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‘My Mental Toughness Manifesto’ Part 3: PERFORM

9 May, 17 | by rlloyd

‘Practice’ is about building a skillset, and fostering a way of life (via ‘immersion’) that serves to strengthen perception of one’s available resources when crunch time arrives.

However, reality dictates that certain scenarios are impossible to prepare for, particularly in the emergency medicine arena. The more chaotic the workplace, the higher the frequency of unavoidable threat appraisals.

Therefore, it is crucial to utilise strategies which stabilise one’s level of emotional arousal in the heat of battle. Namely tactical breathing and cognitive reframing.

Tactical Breathing

“Feel breath filling every cell of your body. This is our ritual. We master our breath, we master our mind. Pulling the trigger will become an unconscious effort. You will be aware of it, but not directing it. And as you exhale, find your natural respiratory pause and the space between heart-beats.”

American Sniper

In a high stakes game, where your next move (performance) has implications for the survival of another human being, it is a guarantee that your sympathetic nervous system will be working overtime. We know, of course, that this can work in our favour if challenged (perceived resources > demands); indeed, we’ll feel ‘pumped’ and ‘ready for action’. On the other hand, this heightened physiological arousal can be the architect of a catastrophic blunder if threatened (i.e. demands > resources; see MMTM Part 1 for a full explanation).

The only component of the autonomic nervous system that we can override and take conscious control over is our breathing [1, 2].

Deliberately slowing respiratory rate in a moment of crisis has the effect of preventing further escalation of other features of the sympathetic surge, such as tachycardia and hypertension. This feeling of control over our physiological arousal induces a prevailing sense of clarity and calm. It serves to psychologically detach the conscious self from the stressful moment, allowing an imaginary reset button to be pressed with subsequent restoration of mental bandwidth. Visual and auditory perceptions widen as the mind is released from the paralysing effect of the cortisol dump. Professional presence in the moment is re-established.

square breathing

‘Tactical breathing’ (or ‘square breathing’) describes the four-second method pioneered by Lt. Col. Dave Grossman, of On Combat fame [3]. One must breathe in for four seconds, hold for four, exhale for four and then hold again for four, on repeat until the desired effect is achieved. Whilst this provides the stressed individual with a mental model to follow, it is not essential to adhere rigidly to the timings. The crucial task is committing to a conscious slowing and deepening of one’s breathing cycle.

This idea is nothing new or revolutionary. Breathing techniques have been utilised by elite soldiers, martial artists, professional athletes, and a host of other world-beaters for generations [4]. Underestimate this tool at your peril.

Cognitive Reframing

A salient feature of the threat mindset is a thinking pattern polluted with self-doubt and persecution.

‘I can’t do this’ 

‘I don’t know what to do’ 

‘My mind is blank and my patient is dying’

Naturally, this has a devastating effect on performance. If you are telling yourself that you’re not up to the job, it is highly unlikely that you will prove yourself wrong.

Pressing ‘control/alt/delete’ on these thoughts, and inserting useful content, is therefore critical. This process is called cognitive reframing, and it can be achieved via positive self-talk and an ‘incrementalsteps’ approach.

Positive self-talk

This is the process of forcing one’s internal dialogue to suggest something positive. It can jolt the mind out of a persecutory spiral, if sufficient commitment/buy-in is present [5, 6].

It can be generally motivational:

You have trained well for this’

You’ve been in this position before and succeeded’ 

‘Relax and focus’

Or be used as a method for directing cognitive resources to something specific:

Slow is smooth, smooth is fast’ 

You have plenty of time, just bring the epiglottis into view’ 

Positive self-talk synergises well with tactical breathing, providing, in effect, a two-pronged intervention on physiological and cognitive over-arousal.

An ‘incremental-steps’ approach

During a crisis or particularly demanding scenario, it is always a bad idea to look at the big picture.

Break down the required process into its component parts, and focus only on your first step. Upon completion of that step, allow yourself to contemplate the next, and so on. This will modify your perception of the situational demands by reframing the scenario into a series of manageable challenges instead of one giant threat, and in doing so, hold off any detrimental physiology [7].

For example, if confronted with an unconscious head injury patient who is obstructing his airway and gargling blood, do not allow yourself to contemplate the overall objective (i.e. getting the patient safely anaesthetised and intubated). First focus solely on applying high-flow oxygen, appropriate monitoring, and allocating team roles. Next, focus on achieving intravenous access, followed by readying the airway equipment and drugs, then instrumenting the airway, thereafter ‘epiglottoscopy’, and so on. A state of panic is warded off by a refusal to allow the mind to wander too far forwards.

If you avoid looking at the mountain peak, and focus exclusively on the first obstacle lying in front of you, you will arrive at the summit in no time.

Use positive self-talk to encourage and guide you through each incremental step.

Summary

  • Threat appraisals are an unfortunate inevitability for all acute care clinicians.
  • Taking conscious control over your respiratory cycle grants you the ‘keys’ to the rest of your autonomic physiology.
  • Positive self-talk intervenes on persecutory thought pollution, and can redirect cognitive resources to specific tasks. It can synergise with tactical breathing as a method for ‘resetting’ in a moment of high stress.
  • An incremental-steps approach converts a significant threat into a series of manageable challenges.

In the fourth and final instalment of My Mental Toughness Manifesto, I’ll be discussing a healthy and progressive methodology for PROCESSING a highly stressful clinical encounter after the event.

I’ll leave you with NAVY Seal Commander Jocko Willink’s take on cognitive reframing:

References

  1. Mike Lauria. Enhancing Human Performance in Resuscitation Part 3 – Performance-Enhancing Psychological Skills. EMCrit Blog. Published on November 22, 2015. Accessed on May 5th 2017. Available at [https://emcrit.org/blogpost/performance-enhancing-psychological-skills/].
  2. Seppala, E.M., et al., Breathing-based meditation decreases posttraumatic stress disorder symptoms in U.S. military veterans: a randomized controlled longitudinal study. J Trauma Stress, 2014. 27(4): p. 397-405.
  3. Grossman, L.C.D., On Combat: The Psychology and Physiology of Deadly Conflict in War and in Peace. 2008: Warrior Science Publications.
  4. Weisinger H, Pawliw-Fry JP. Performance Under Pressure. New York, NY: Crown Business.
  5. Scott Weingart. Podcast 177 – Chris Hicks on the Fog of War: Training the Resuscitationist Mindset. EMCrit Blog. Published on July 11, 2016. Accessed on February 24th 2017. Available at [https://emcrit.org/podcasts/chris-hicks-fog-of-war/].
  6. Tod, D., J. Hardy, and E. Oliver, Effects of self-talk: a systematic review. J Sport Exerc Psychol, 2011. 33(5): p. 666-87.
  7. Rob Orman, Rich Levitan, ERCast – Psychology of the Difficult Airway, 2014

‘Why tomorrow’s patient needs a digital NHS’

6 Apr, 17 | by rlloyd

On February 22, the EMJ blog team were well represented at . This was the one-year ‘summit’ of DigitalHealth.London, an organisation (funded in large part by NHS England) designed to accelerate the uptake of digital technology in the NHS. It was part-conference, part-showcase of some potentially game-changing innovations/innovators that are starting to gain traction in global healthcare. The event was hosted by the Royal College of GPs, and it brought together NHS leaders, senior clinicians and digital entrepreneurs. I had the great honour of compèring proceedings.

The event sizzled with excitement and ambition. Conference delegates were talking about the future of the NHS in positive, expansive terms with an up-beat chirpiness that starkly contrasts the doom-and-gloom-ridden water cooler discussions currently reigning supreme across UK hospitals. The air of possibility and optimism was utterly infectious. I had a great time.

I am a now a fully-fledged digital health believer, and adoption of new technologies discussed at the event can’t come soon enough in my opinion. Interventional virtual reality? Artificial intelligence-augmented clinical decision-making? Healthcare provision to every human being on Earth via smartphones? Yes please.

I met some great people, including the inspirational Molly Watt (one of the most accomplished public speakers I’ve heard; if you haven’t heard her story, check out her website – phenomenal stuff), director of digital experience at NHS England Juliet Bauer, and the amazing Dr. Keith Grimes – a GP from Eastbourne and digital health evangelist, whose work I have admired for a while now. He gave a typically superb talk on the application of virtual reality in medicine, and has since written an insightful blog post reflecting on the artificial intelligence panel discussion. Watch this space for a future collaboration between Keith and the EMJ blog team.

DigitalHealth.London have put together a neat full write-up, and produced a couple of beautifully shot videos of the summit, which I happen to feature in! Here they are:

Needless to say, you can count on some future EMJ blog posts exploring digital transformation in healthcare!

Thank you DigitalHealth.London (in particular James Somauroo, Yinka Makinde, Rebekah Tailor, and Hannah Harniess) for inviting me to be involved in your fantastic event.

It’s a great time to be a doctor.

Rob
@PonderingEM

‘My Mental Toughness Manifesto’ Part 2: PRACTICE

15 Mar, 17 | by rlloyd

Screen Shot 2017-03-06 at 15.55.21

In MMTM Part 1, two-step cognitive appraisals were explained. This process dictates whether one enters a challenged or threatened mindset in the event where an immediate performance is required under acute stress.

Feeling challenged, of course, is one of the two chief components of a mentally tough individual.

“I am 100% committed”

“I feel challenged”

In this post, we will explore principles which must be incorporated in one’s ‘practice‘ (i.e. training) regime, to increase a sense of confidence in one’s skillset. The confident individual will always be more likely to appraise a scenario as challenging as opposed to threatening.

Paradigm shift alert: When practicing, specific skill development must be prioritised over knowledge-base widening. This, of course, sharply contrasts with the traditional approach to medical training. New theoretical concepts seem less abstract and will always be absorbed more rapidly when they fit into the mental scaffolding built by focusing on skill development.

In an ideal world, all clinicians, across the spectrum of specific role and geographic location, would get regular high-fidelity simulation training sessions, supervised by master educators. Of course, this isn’t feasible in even the richest healthcare systems; and the reality is that all types of supervised training (other than weekly death-by-PowerPoint didactic teaching) become increasingly rare the more senior you become.

Therefore, one must take ownership over one’s own practice, and be relentless in the pursuit of ultimate confidence in one’s skillset. This will be achieved through immersiondeliberate practice, and visualisation.

Immersion

“Discipline equals freedom”

Jocko Willink, Navy SEAL Commander

My definition of professional ‘immersion’ is regular engagement with one’s craft outside of working hours. The abundance of free online medical education (FOAMed) resources makes this process exceptionally easy and enjoyable. With availability/access to excellent content no longer an issue (unlike the olden days where you had to sift through dusty textbooks, and YouTube hadn’t yet been invented), the only obstacle standing in the way of adequate immersion is having the discipline to allocate time to it.

Too often, clinicians assume they are advancing their expertise, and fine-tuning performance standards, purely by attending work – clocking in and clocking out, going through the motions on the shop floor, and then completely disengaging during free time. This is occupational autopilot. And it is dangerous.

Screen Shot 2017-03-14 at 20.33.35Occupational autopilot predisposes clinicians to flounder during a crisis, because the mind stiffens when seldom fed new information. For example, the disengaged anaesthetist who rarely ventures far from uncomplicated elective orthopaedics will be flummoxed by the surprise grade 4 intubation. Despite being entirely competent enough to weather the storm, he/she will fall easily into the clutches of the threat mindset and spectacularly fail the patient in that rare moment, largely because of their lack of engagement with the broader landscape of their chosen pursuit.

The ability to think laterally, employ techniques that might be ‘rusty’ or never performed before (e.g. surgical cricothyroidotomy), and trust one’s own clinical judgement, can only occur seamlessly if you have adequately immersed yourself in the educational resources and evolving narrative of your vocation.

Of course, immersion in specific resources to improve an isolated skill is crucial if weakness is identified (a principle of ‘deliberate practice’ – see below). But it’s the habitual (daily) general immersion, with no specific agenda, that is a key characteristic of the dedicated professional whose identity is embedded in his or her craft. Immersion isn’t a training methodology – it is a lifestyle decision. It ensures currency is maintained, and nurtures a fertile cognitive environment, mandatory for yielding the acrobatics and improvisation required during a crisis.

Deliberate Practice

“Skill is only developed by hours and hours of beating on your craft.”

Will Smith, actor

Deliberate practice describes a common set of principles which should form the framework of every training session [1].

Every time you practice, your sole mission is to improve. You should constantly be asking yourself the question: “How can I do this better?”.

A specific component of a chosen skill is isolated – one that you are poor at or can’t do – and then subjected to specific training exercises and repetitions (‘drilling’).

The core principles of deliberate practice:

  1. specific, measurable goal must be established for the session. Vague overall performance targets like ‘succeed’ or ‘get better’ mean nothing.
  2. Be maximally focused on improvement during practice. It must be intense and uninterrupted. Put your electronic device away.
  3. Receive immediate feedback on your performance. Without it, you won’t be able to figure out what you need to modify or how close you are to achieving your goal.
  4. Exit your comfort zone. Push yourself to the edge of what you are capable of. Don’t be afraid of failure – it signposts the path to progression.

IdScreen Shot 2017-03-14 at 20.35.09eally, a supervisor should be present to guide training, and give immediate feedback. When this isn’t available (which will be most of the time for the majority of clinicians), video footage of the skill being performed/taught is a decent substitute. You can compare your own repetitions to the video subject, and ‘self-police’ your training progress. The plethora of FOAMed video content makes this comfortably achievable.

Human nature dictates that we gravitate towards training skills that we are already proficient at, and neglect areas outside our comfort zone. Why? It’s much more satisfying to feel like you are ‘nailing’ something. DO NOT be enticed into that trap – the significant gains exist where there is most discomfort and least enjoyment. What is enjoyable, is the feeling that you are moving forward and advancing your overall proficiency.

Regular re-visiting of skills that have laid dormant for a while (either in practice or in the field) is essential for avoiding skill fade. This habitual ‘spaced repetition’ deeply embeds a skillset into our mental scaffolding, and makes it far more likely to be retrievable under acute, severe stress.

Here is a previous blog which covers deliberate practice in a little more detail.

Visualisation

“In my view, the answer is to use the highest fidelity simulator in the universe – the human brain”

Cliff Reid, Emergency Physician, Sydney HEMS

Despite it being our most powerful and adaptive weapon, we routinely fail to utilise our brain as a training gadget. When physically practicing, our minds are engaged, but (naturally) we conceptualise the process as being entirely external. Our conscious focus is largely zoned in on body positioning or equipment handling, making it easy to forget our brain is the anatomical structure in the driving seat.

tigerwoodsvisualization

Visualisation (or ‘mental practice’/’mental rehearsal’/’imagery’) is the process of consciously playing a mental ‘video’ of a task or scenario from the perspective of one’s own eyes. In other words, one thinks about doing something, step by step. Despite no physical engagement, one is activating the very same neural circuitry as when performing the skill for real, and if done effectively, it reinforces skill-related mental scaffolding, just like deliberate practice [2, 3]. It enhances clarity and speed of thought during the moment of truth.

Much like the concept of mental toughness itself, visualisation can get routinely dismissed as a vague, abstract, somewhat hippyish concept, with little scientific credibility. If that is your opinion, you are sorely mistaken and missing a huge opportunity. The evidence-base is abundant across a wide spectrum of human endeavour, with perhaps the most high profile examples found in the results-driven world of elite sport [4, 5, 6]. Desperate for the edge over equally motivated competition, you would be hard pushed to find an upper echelon-worthy individual or team not dedicating a considerable portion of their training schedule to mental practice. Put simply, it is considered pivotal to producing the goods by folk who earn their living making us say ‘WOW’. When the Federers, Mcilroys, and Bradys of this world consider it indispensable, then frontline healthcare, an equally performance-centric game, should be paying attention.

Vivid realism is crucial for the process to be effective. You need to feel it as well as see it. The PETLEPP mnemonic is a useful guide [7]:

Physical – What are you holding? What are you wearing? What are you smelling?
Environment – What are your surroundings? It is essential to imagine yourself in the environment where you will be performing (i.e. your usual workplace).
Type –Imagery must be specific to your role and responsibility.
Timing – Given the time critical nature of acute care, imagery must take place in ‘real time’.
Learning – Content should evolve with learning. The cognitions and feelings experienced will change as the individual improves.
Emotion – Imagine yourself acutely stressed, but in the challenge mindset. Total ‘calm’ is not realistic and, therefore, not useful.
Perspective – Feel and see from your own perspective (i.e through your own ‘eyes’).

The unique selling point of visualisation when compared to other practice modalities is its malleability. Using your imagination to conjure up potential curveballs and banana skins is a very effective method for finely sharpening routine skills and processes where there may be a tendency to get complacent. Play the ‘what if’ game:

“What if I had to perform an RSI on a 300kg patient with a receding chin? What extra precautions should I take?”

“What if whilst I was putting in a right IJV central line, the patient became hypotensive and the oxygen saturations dropped to 70%? What should my next steps be?”

“What if I was the trauma team leader for a penetrating chest trauma case and suddenly the patient lost output?”

It’s also a perfect strategy for shoring up one’s procedural routine for exceptionally rare events, such as the emergency thoracotomy or perimortem Caesarian section. Procedures like that would be uneconomical, and logistically impossible, to repetitively practice on mannikins/cadavers. Regular and structured mental practice is therefore a must for emergency providers who genuinely want to be able to tackle everything thrown at them. It is impossible to predict what is coming through the resus doors, but when you have seen it all in the simulation lab between your ears, you will be ready.

This technique isn’t limited to skills training; it can be applied on a broader, more personal level as well. It can galvanise the spirit, and ignite the passion for positively affecting the world through your job – a trait abundant in all of us deep down. Regularly visualise yourself returning home at the end of a shift, mission, or deployment with that beautiful sense of victory and euphoria that washes over when you know you’ve performed well. See yourself overcoming every obstacle thrown at you on duty, and always able to access clarity of thought, and the best of your ability, when it really counts.

Capture yourself in the career trajectory exactly as you have always dreamed it, regardless of how far away you currently feel. If you have the imagination to dream, and the courage to believe that your vision is possible, it will make you hungrier to strive for it. Every training session will be laced with boundless intent, and in time, your mental movie will become a reality.

Summary

Effective practice is about building confidence, so that when a performance is required, the challenge mindset is achieved.

Immersion in your craft safeguards against occupational autopilot, and fosters a healthy cognitive environment for high performance.

When training specifics, fully embracing the principles of deliberate practice is the only gateway to expert-level skills.

Visualisation, when maximally vivid and performed in a structured fashion, can prepare you for anything. Never underestimate the training-tool that is your mind.

Building mental toughness isn’t easy, but your patients deserve it. No-one will do it for you. Get after it.

References

  1. Peak: Secrets From the New Science of Expertise. Anders Ericsson and Robert Pool.
  2. Weisinger H, Pawliw-Fry JP. Performance Under Pressure. New York, NY: Crown Business.
  3. Mike Lauria. EHPR Part 5: Using Mental Practice and Visualization Exercises by Mike Lauria. EMCrit Blog. Published on February 21, 2017. Accessed on March 13th 2017. Available at [https://emcrit.org/blogpost/ehpr-part-5-using-mental-practice-visualization-exercises-mike-lauria/].
  4. Feltz DL, Landers The effects of mental practice on motor skill learning and performance: A meta- analysis. Journal of Sport Psychology. 1983;5(1):25-57.
  5. Mental Training for Peak Performance. Steven Ungerleider and Nick Bollettieri.
  6. Sports visualisation: how to imagine your way to success. Mark Bailey, The Telegraph.
  7. Holmes PS, Collins DJ. The PETTLEP Approach to Motor Imagery: A Functional Equivalence Model for Sport Psychologists. J Appl Sport Psychol. 2001; 13(1): 60-83.

‘My Mental Toughness Manifesto’ Part 1: Understanding Cognitive Appraisals

5 Mar, 17 | by rlloyd

It has been an exciting period for me recently. Last month I was at the International Special Training Centre (ISTC) in Pfullendorf, Germany, where I had the honour of speaking to a group of Special Operations Combat Medics in-training from eleven nations across NATO. Staying at the base, meeting the guys, and contributing to their fantastic 26-week course was an unforgettable experience, and without a doubt my most proud achievement to date.

Why me? Last year I blogged/podcasted for St. Emlyn’s about my lively experience working in a South African Township Emergency Department, at Khayelitsha District Hospital. Luckily for me, a course faculty member from the ISTC stumbled across this work and thought I might have something to offer a group of warrior medics.

If you haven’t read the original blog, I would advise that you do before proceeding; the credibility of what follows hinges on its predecessor.

I was tasked with providing a session that tackled human performance optimisation. Through four separate 20-minute lectures, I delivered a package of strategies for ‘Building Mental Toughness’.

This post is a summary of my first lecture at the ISTC, and is the first instalment of a four-post series. I am making a call-to-arms: frontline healthcare providers must start prioritising performance optimisation strategies.

This is my ‘Mental Toughness Manifesto’.

What is Mental Toughness?Roger-Federer-of-Switzerl-007

Traditionally, it’s a term synonymous with the sports world. It is therefore often ignored or laughed off as meaningless cliché, particularly by performers in healthcare – a ‘serious’ field. In my opinion, this represents a glaring missed opportunity.

A mentally tough individual is consistently able to produce desirable performances during moments of high stress; an undeniably crucial trait for those operating in high octane environments, not least the resus room, prehospital environment, or the realm of combat.

By accurately identifying the specific components of mental toughness, we can work on strengthening it through focused training and attitude adjustments. During a stressful, high stakes scenario where a performance is immediately required, (having interrogated the literature [1]) I believe you are mentally tough if able to state the following:

“I am 100% committed”

“I feel challenged”

Commitment to one’s overall goal is critical, but should be a foregone conclusion. A trauma team leader, flight paramedic, or special operations combat medic, should be inherently committed to their job because what they do is of indisputable importance – they deal in the currency of human life. Also, they will have had to demonstrate commitment whilst climbing their respective professional ladders, via examination and selection processes. So, the first half of the battle – ‘being 100% committed’ – is the easy bit.

Feeling ‘challenged’, as opposed to feeling threatened by a stressful scenario, is more complicated. This requires confidence in one’s skillset, and a feeling of control over one’s emotional arousal.

Cognitive Appraisals

It is imperative to appreciate the nuances of acute stress, and how it influences our physiology and cognition.

When an individual is faced with a situation which threatens an important goal (like staying alive, or keeping someone else alive), an immediate two-step cognitive appraisal takes place [2, 3]:

If personal resources are deemed sufficient to meet the demands of the scenario, the ‘challenge appraisal’ ensues. One feels positively energised (‘pumped up’), there is a sense of high self-esteem, and one will view the situation as an opportunity to capture a victorious moment. It is what athletes call being ‘in the zone’. There is physiological stress via activation of the sympathetic nervous system, but control of task-specific motor skills and cognition remains intact.

If the demands outweigh available resources, a ‘threat appraisal’ takes hold. In addition to the sympathetic nervous system response, the hypothalamic-pituitary (HPA) axis activates, triggering the release of cortisol. This cortisol ‘dump’ is a relic from our days as primal hunter-gatherers. It readies the mind and body for instant, evasive action (like running away from a predator), which is, of course, suboptimal when a skilled and complex performance is immediately required.

Threat appraisals narrow our auditory and visual perception, minimise our mental ‘bandwidth’, increase our sense of fear (via its effect on the amydala), erode our short-term memory (hippocampus), and obliterate our capacity for rational judgement (prefrontal cortex) [4].

Need convincing? Watch the video below for an armchair threat appraisal…

 

The psychological literature has consistently demonstrated that high serum cortisol is associated with impaired performance, over a wide range of human pursuit [4, 5]. What becomes clear, therefore, is that performance optimisation centres around this two-step cognitive appraisal process. By using strategies to modify one’s perception of the immediate demands and available resources, we can convert threat appraisals to challenge appraisals, and in doing so, harness the power of the sympathetic nervous system, avoiding HPA axis-mediated self-sabotage.

I will propose seven strategies, over three phases of the game (the ‘practice’, ‘perform’, and ‘process’ phases), designed to favourably modify our perceptions during the cognitive appraisal process. The aim is to build the challenged mindset, resulting in a mentally tougher performer, better equipped for saving lives.

Stay tuned for the next instalment.

Robert Lloyd
@PonderingEM

References

  1. Mike Lauria. Imperturbability: William Osler, Resilience, and Redefining Mental Toughness by Mike Lauria. EMCrit Blog. Published on February 3, 2016. Accessed on February 24th 2017. Available at [https://emcrit.org/blogpost/imperturbability-william-osler-resilience-and-redefining-mental-toughness/].
  2. Tomaka, J., Blascovich, J., Kelsey, R. M., & Leitten, C. L. (1993). Subjective, physiological, and behavioral effects of threat and challenge appraisal. Journal of Personality and Social Psychology, 65, 248-260.
  3. LeBlanc, V.R., The effects of acute stress on performance: implications for health professions education. Acad Med, 2009. 84(10 Suppl): p. S25-33.
  4. Scott Weingart. Podcast 177 – Chris Hicks on the Fog of War: Training the Resuscitationist Mindset. EMCrit Blog. Published on July 11, 2016. Accessed on February 24th 2017. Available at [https://emcrit.org/podcasts/chris-hicks-fog-of-war/].
  5. How stress affects your brain – Madhumita Murgia, TED Ed

*This post has also been published on the Pondering EM blog.

Are nurses always right?

15 Feb, 17 | by cgray

Are nurses always right?

As a junior doctor, I have had, and still have some fantastic senior colleagues to work with, who generally give important and valuable advice. Over the placements and years, their advice is slowly turning me into the doctor that I aspire to be, an amalgamation of all the good bits from every doctor I have worked with so far along the way. I say doctor, but really I’m talking about all the other people that play a part in the hospital experience. Physiotherapists, pharmacists, health care assistants, porters, and so many more. Most of all, the many brilliant nurses I’ve had the pleasure of working alongside.

When I first started out as a doctor, the single biggest piece of advice that was given to me, and that still holds true today as one that I pass on to those unlucky enough to be my juniors, is to listen to the nurses. Make friends with the nurses. Don’t get on their bad side. Pay attention to what they say. That advice has saved me and saved my patients more times than I can count.

Because, nurses are always right. Aren’t they?

It’s a brave team that would design a study to pit nurses against a scoring tool, but that’s exactly what Allan Cameron and team from Glasgow have been up to. The Glasgow Admission Prediction Score (GAPS) was developed to estimate the probability of a patient being admitted, based on data collected at triage such as the patient’s age, early warning score, and triage category. The tool has been validated with good results, and could be used to help to optimise flow within the ED through early identification of those more likely to need a hospital bed.

This study, published in the January EMJ, aimed to compare GAPS to the triage nurses’ gestalt on likelihood of admission. To assess the latter, a visual analogue scale (VAS) was used, onto which triage nurses would mark how certain they were of patient admission/discharge. Previous studies on the topic have shown that when nurses are confident of the outcome, they’re usually right, and this study was no different. As always, we’d recommend you take a look at the paper itself to draw your own conclusions from the results.

3844 attendances to a single emergency department were studied, however a portion were allocated direct to a minors or resuscitation area, bypassing triage, and further patients were excluded from being under 16 or leaving before treatment was complete. Only 9 patients out of the 2091 that were triaged had insufficient data completion, which is a respectable figure. Of the 1829 attendances suitable for inclusion, 745 were admitted (40.7%), which seems high, however as stated this did not include a large number of minors patients who were more likely to have been discharged.

Nurse gestalt was found to be more sensitive than GAPS (81.2% vs 71.8%) but less specific (77.4% vs 86.6%). There was no correlation between nurse seniority and accuracy of predictions. Whilst the GAPS was more centrally distributed, results from the VAS showed peaks at 0-5% and 95-100% certainty of admission. This was the case for 781 patients. In these patients, nurses performed significantly better than GAPS, correctly predicting outcome in 92.4% (722). Excluding these patients though, GAPS provided a more accurate assessment.

In practice, the team found that the most accurate way to predict likelihood of admission was GAPS, but with the triage nurses able to override the tool where they were confident (>95%) as to whether the patient would be admitted or discharged. The authors admit that more work is needed, but maybe we’ll see admission prediction scores in use in the future.

Interestingly, there is no mention on whether those patients discharged home were followed up to see if any were admitted in the following days. Maybe the nurses’ gut feeling wasn’t wrong after all…

vb

C
@cgraydoc

The ‘Deliberate Practice Mindset’

27 Jan, 17 | by rlloyd

Performance improvement is an interest of mine. I have previously blogged and podcasted about the strategies I employed to lift my game (from rock-bottom) when working in an extreme environment – a South African township ED.

I first became aware of ‘deliberate practice’ after reading an excellent St. Emlyn’s post last year. I had never encountered the concept before, but it resonated with me because it resembles certain aspects of how I’ve approached self-improvement in a professional setting, particularly when desperate to prove myself in South Africa.

The psychologist who originally described deliberate practice, Dr. Anders Ericsson, has recently published a book – Peak. It explores the ‘science of expertise’, for which he is the world’s leading expert – the expert on experts.

I thought I’d discuss a few of my take-home points from the book.

The ‘gift’ fallacy

“I am not talented, I am obsessed” – Conor McGregor, UFC lightweight champion

Too often, wider society’s assumption is that elite performers are naturally ‘gifted’. They have been magically blessed with superhuman ability. According to Ericsson, this is false.

No-one is born with an innate ability to perform at expert level, in any domain. All exceptional performers, regardless of field, have had to push themselves through a very intense practice regime to get to where they are. They have learnt how to be brilliant.

Ericsson repeatedly makes the point that in his 30+ years of studying an extraordinarily wide range of expert performers, from grandmaster chess players to professional tennis players to concert violinists, he is yet to encounter a genuine ‘prodigy’ – somebody born with prerequisite skills for expert performance.

MozartEricsson’s favourite example of the ‘God-given talent’ fallacy is legendary composer Wolfgang Amadeus Mozart. From an astonishingly young age, Mozart wowed audiences in concert halls across Europe with his apparent mastery of multiple musical instruments, and was labelled a child prodigy. Not so much, it turns out. The history books reveal that Wolfgang could barely walk before commencing a comprehensive training regime designed by his father, a pioneer in musical training. Furthermore, Ericsson claims that if he were around today he would barely stand out from the crowd. In fact, it’s been demonstrated that Suzoki Method-trained child musicians are often able to perform to a higher level than Mozart was ever capable of achieving.

A key component of Mozart’s prodigious skillset was thought to be his possession of perfect pitch – the ability to accurately name a musical note upon hearing it in isolation. The assumption was that it spontaneously emerged from birth and was un-teachable. It has since been proven that anyone can be trained in perfect pitch, particularly if they’ve received appropriate training between the ages of 3 and 5 years. Intriguingly, it is now acknowledged to be fairly common for children born in countries where tonal languages (e.g. Mandarin) are spoken to possess perfect pitch if musically trained. No magic involved.

The only exception to the rule that natural talent is bogus is when it comes to height and body size. Specific phenotypes are essential for certain sports – you need to be tall to slam dunk a basketball, and being short confers a big advantage for competitive artistic gymnastics. No specialised training regime will lengthen or shorten your bones.

We’re all endowed with the same ‘gift’ – the ability to adapt and improve if we train ourselves correctly (i.e. effective practice). Excitingly, Ericsson’s key message in Peak is that a common set of general principles lie at the heart of effective practice for any human endeavour… all walks of medicine included.

All practice is not equal – avoid naive practice (and forget the 10, 000 hour ‘rule’)

The most common approach to improving performance is ‘naive practice’.

This is where one spends a significant amount of time engaging in the activity, with the hope that stockpiling experience alone will improve performance, and move them closer to the realm of expertise.

“All I need to do is see 15 Majors patients per shift for the next 10 years and I’ll become a world-beating Emergency Physician” – hapless emergency medicine trainee destined for mediocrity

This is aligned with the 10, 000 hours ‘rule’ as per Malcolm Gladwell in his book Outliers. The proposed theory is that 10, 000 hours of generic practice yields expertise, with emphasis on time spent practicing as opposed to the nature of the practice itself. No specific component of the activity is isolated and focused on (e.g. putting in golf, or needle manipulation in central venous access), one just keeps doing the task over and over again. Outliers has been an immensely popular publication, and the 10, 000 rule a widely-disseminated concept. It sounds cool, and it satisfies the basic human desire for cause and effect.

In reality, this theory is fundamentally flawed. In order to change behaviour (i.e. improve performance), you need to engage in effective training. Ericsson calls this ‘purposeful practice’.

Interestingly, it is Ericsson’s original work, examining concert violinists in training, that inspired Outliers, and he levels a reasonable amount of hostility towards Gladwell in Peak, with accusations of corrupting lessons from the research. The best violinists out of the trainee group had all spent approximately 10, 000 hours by the age of 20 in solitary practice, as compared to the more inferior (but still relatively elite) trainees who had a few less thousand hours on the clock. It was this finding which prompted Gladwell to jump to the conclusion that 10, 000 hours was the magic number, yet the few that went on to win international music competitions did so at 30+, when they had put in 20,000 to 25,000 hours of practice.

“The greats weren’t great because at birth they could paint, the greats were great because they paint a lot” – Macklemore, rapper

It might be mired in controversy, but the 10, 000 hour rule does serve one crucial purpose – it reminds us that a massive volume of practice is required to achieve peak performance. No elite performer in any field has not dedicated a significant slice of their life towards achieving their goal. The path to greatness is not easy.

Purposeful Practice (core of Ericsson’s deliberate practice)

Exactly what it says on tin – this is practicing with a purpose. The mission is to improve, and you are practicing for that sole reason. Every time you practice, you are asking the question: “How can I do this better?”

A specific component of the skill is isolated (a component that one is poor at/can’t do) and then targeted for improvement via training activities. There are four principles of purposeful practice:

1.     You need to establish a (reachable) specific goal. Vague overall performance targets like ‘succeed’ or ‘get better’ won’t cut it.

2.     You must be maximally focused on improvement during practice. It must be intense, uninterrupted and repetitive (‘drilling’). Not particularly pleasant, but highly rewarding.

3.     You must receive immediate feedback on your performance. Without it, you can’t figure out what you need to modify or how close you are to achieving your specific goal.

4.     You must get out of your comfort zone, constantly attempting things that are just out of reach.

Take chest drain insertion for example. You isolate one part of the procedure that you know needs improvement – e.g. surgical hand-ties (to suture the chest drain to the skin):

Goal: Be fast and efficient at single-handed surgical hand-ties by the end of the training session.

Focus: Watch a training video explaining how best to perform the tie a few times; then practice tying knots round a kitchen utensil using the taught technique multiple times.

Feedback: Compare your performance to that on the training video, or ideally get personalised feedback from a supervisor.

Exit comfort zone: Experiment by performing the technique under time pressure or give yourself less suture thread to work with.

A hallmark of purposeful practice is that performance level during training tasks is not initially at the desired level – there is a gap. By the end of a phase of training, there needs to be something measurable that you’ve improved.

Embracing these principles in training squeezes the trigger of the greatest weapon in the arsenal of the human brain – adaptability. Every training session should be viewed as a challenge to refine and improve.

Deliberate Practice

“The most effective (improvement) method of all: deliberate practice. It is the gold standard, the ideal to which anyone learning a skill should aspire.” – Anders Ericsson

Deliberate practice encompasses the principles of purposeful practice, with a couple of additional elements:

1.     The field must be well established, and elite performers easily identified.

2.     A coach or teacher guides training.

A good coach provides constant individualised feedback and designs training activities that target specific areas. They hold the ‘roadmap’ that guides the student through an evolving training regime that hones skills in a specific order. Certain skills can only be taught and practiced once others have been mastered.  This calculated and heavily supervised approach to training always leads to elite performance when the student is motivated. It is tried and tested.

A useful analogy is to think of purposeful practice as trekking through the desert to a specific destination that is out of sight. You know the general direction you need to go, but in order to reach the destination you must walk in a completely straight line – notoriously difficult in the desert. A good strategy would be to use landmarks up ahead such as trees and sand dunes to aim at, so as to avoid walking round in circles. You are progressing with a purpose, but there is minimal guidance.

In this context, deliberate practice can be thought of as that same journey, but instead there is a path marking the route you need to walk, with signposting along the way, and even a camel guide to get you back on track if you veer off the route.

Mental representations

Engaging in purposeful/deliberate practice modifies the structure of our brains. Specific neural circuitry, which fires action potentials when training a skill, get reinforced and increasingly complex. This serves to strengthen the ‘mental representations’ one has of the skill in question.

The human brain is a blank canvas, and learning a new skill is like painting a picture on that canvas – the picture being a mental representation of that skill. With effective training, and as one improves at performing the skill, a discernible image starts to take shape. As the years of effective practice roll on, the picture becomes increasingly detailed and animated, and eventually it correlates with performing the skill at an expert level.

The expert performer, via their mental representations, is acutely aware of how best to perform. By comparing what they are doing in the moment with the perfect picture in their head, they can modify their performance appropriately – self-policing. The quality and quantity of mental representations is what sets expert performers apart from everyone else.

“In pretty much every area, a hallmark of expert performance is the ability to see patterns in a collection of things that would seem random or confusing to people with less developed mental representations. In other words, experts see the forest when everyone else sees only trees” – Anders Ericsson

The perfect example of elite performance correlating with highly sophisticated mental representations is George Koltanowski, a chess Grandmaster who set the world record for simultaneous games of blindfolded chess – 34 games (he won 24 and lost 10)!  His mental image was so strong that he could animate each game in his mind without looking at a single chess piece. It turns out simultaneous-game blindfold chess has been a pursuit of Grandmasters for centuries.

Furthermore, in studies of elite footballers and basketball players, it has been shown that when visual stimulus is suddenly removed, they can accurately pinpoint the position of all their teammates and opposition, and even predict how the game evolves in the seconds that follow. Again, this is facilitated by their mental representations – highly detailed images that come to life in the brain of the performer.

Fascinatingly, if you asked a grandmaster to recall the positions of randomly placed chess pieces on a chess board, or asked a footballer to recall the positions of 22 randomly placed men on a football pitch (i.e. not in position as a result of a game), they would fail because their mental representations are specific for the respective activities. If the arrangement of pieces or players is random, it ceases to be meaningful, in much the same way a set of jumbled up words is meaningless in comparison to a sentence.

The ‘deliberate practice mindset’

To truly reap the benefits of purposeful/deliberate practice, one must reject three prevailing myths:

1.     Your abilities are limited by genetics.

2.     If you do something for long enough you’ll get better.

3.     All it takes to improve is to increase your effort levels.

Once this is done, you are set free; the world is your oyster. However, the road to expertise is long and gruelling, and patience is crucial. The four underlying principles of purposeful practice must be kept in mind at all times, and failure should always be viewed as a precious opportunity to reflect and refine one’s mental representations.

If no coach or teacher is available (i.e. deliberate practice not strictly possible), identify somebody who is at a level that you want to reach (i.e. a mentor), try and understand how they got there, and proceed to purposefully practice.

Intense periods of focus, constant repetitions, and hovering at the edge of one’s comfort zone in training will get pretty miserable and frustrating at times. However, it should be appreciated that when quantifiable improvements start to occur, striving for further gains will become more enjoyable… even exciting.

Remember that a crucial aspect of deliberate practice is that it focuses solely on performance (i.e. how to do it) – it is a skill-based practice, and this must be embraced. By effectively practicing components of the skill and building stronger mental representations, knowledge will build naturally alongside. New concepts will seem less abstract as they are absorbed whilst applying skills (NB: This is in contrast to the traditional approach to medical training which has placed more emphasis on knowledge acquisition than skill development, largely because it is more convenient and less labour-intensive to teach).

In medicine?

An unfortunate reality of most medical specialties is that once a practitioner is fully qualified (i.e. a consultant or attending physician) there are few opportunities for immediate feedback on his/her clinical practice. There are no longer regular mandatory appraisals, and too often, little feedback from the patients themselves (e.g. a radiologist might not be made aware of the outcome of a patient where a cancer was missed on CT scan).

Furthermore, as seniors are no longer being actively trained, it is very unusual for them to be pushed out of their comfort zones, and they will usually deem their own performance level to be ‘acceptable’. You might say that they are particularly guilty of naive practice. This is a recipe for stagnation, and an overall decline in performance. An interesting passage in the book is where Ericsson discusses research into senior radiologists looking at mammograms, and experienced GPs listening to heart murmurs. It turns out their diagnostic accuracy is no better (and in some cases worse) than their junior colleagues, who will have received more recent active education.

As an emergency medicine trainee, much of my daily work will embrace the principles of deliberate practice, but it is variable, and often depends on the boss I happen to be on shift with. Taking ownership is key. It’s up to me to be cognisant of what elements of practice will make me a better doctor, and anchor my training appropriately. Awareness of these principles has also given me a greater appreciation of the utility of simulation training – ‘off-the-job-training’ which focuses on closely supervised skill development rather than knowledge acquisition.

It will be far more of a paradigm shift for senior doctors (i.e. finished all training) to adopt deliberate practice, but the implications for patient outcomes, and indeed medicine’s overall trajectory, will be enormously positive if they do.

I highly recommend Peak to anyone interested in improving at what they do. Doctors, of all grades, should be aware of, and striving to incorporate, the lessons from Anders Ericsson’s masterpiece.

Robert Lloyd
@PonderingEM

*This blog first appeared on the Pondering EM blog

The 4-hour standard. Why can’t you get it right?

10 Jan, 17 | by scarley

please-get-it-right

If you were hoping for a solution to flow in the ED then this is not the post for you. Rather it’s an appeal and a cry of pain from all UK clinicians who work in emergency departments for politicians and journalists to understand what the 4-hour target is.

It is the percentage of patients seen and DISCHARGED OR ADMITTED within 4 hours.

Journalists regularly mistake this as the time that people wait to be seen in the ED which of course is entirely different. Yesterday Jeremy Hunt was questioned in the commons about the current crisis in the ED and even the opposition front bench mistook the 4 hour standard as wait to be seen and not the time it takes for us to completely sort patients out and either get them home or into a hospital bed.

Even Wikipedia is unclear on the matter, and so it’s perhaps not surprising that everyone is confused. The King’s fund does much better and has some excellent research in the area.

Does this matter? Well I would argue that it does. From a public perception if we are failing to even assess people within 4 hours that does indeed sound awful. The idea that we have to complete the ED journey within 4 hours must surely be understood as a more challenging task. If it were just a wait to be seen then in all honesty we’d be running at well over 100% already (if you include triage which you should).

So. An appeal that perhaps no journalist or politician will read. Please get it right and stop emergency clinicians shouting at the TV or radio every time you get it wrong. We’re under enough stress as it is.

vb

S

@EMManchester

https://twitter.com/deanoburns/status/818745470281465856

How to write off your paperwork. EMJ Blog.

29 Dec, 16 | by cgray

how-to-write-off-your-paperwork

Emergency medicine is one of those specialities where physicians of all grades have to make their own notes, even the consultants. Medical and surgical bosses have juniors to scribe at the ward round, secretaries to type up dictated clinic letters, assistants to type op notes (most of the time). EM consultants, like their junior colleagues, still need to put their own pens to paper, or fingers to keyboard.

There are two general ways to make notes in the ED. You can do it whilst talking to the patient, which creates the most contemporaneous notes, allows you to use the patient’s own words, and means you can easily recant the story back to them to confirm details, though can sometimes create the impression that you aren’t giving the patient your full attention. I am a big fan of this approach, writing quickly means I can document almost as fast as I can talk. In my opinion, I forget fewer questions, meaning I can carry on with other tasks without having to return to the patient when I remember later on. It’s an approach that works well for me and my very short attention span, though only really works when I’m in a department with paper documentation. Alternatively notes can be completed after seeing the patient, when you can rearrange everything you have learnt into a sensible and concise narrative. However, writing at the desk puts you in the line of fire of technicians asking you to check ECGs, or other colleagues asking your opinion on their patients, to name a few examples. These interruptions have the potential to cause confusion in the history and examination you are trying to commit to paper, and details can be missed or altered.

I would miss doing my own paperwork in the emergency department – I write small and fast, (and reasonably legible) and my note taking helps to put my thoughts in order to make differentials and come to conclusions. However, I’m sure many of you have wondered how much quicker and efficiently you could work if you had someone to write notes for you. Maybe you even have a scribe – I know of people that do, and it seems to be reasonably popular in the US.

Scribes can help those who adopt either approach, and whether electronic or paper. They allow contemporaneous note taking, so that the clinician can focus on the patient, listening to their answers carefully rather than just planning the next question. It can be easy to miss cues from the patient when you are documenting at the same time. They also mean that time isn’t spent documenting at the nurses station, allowing a better focus on other tasks – not missing that subtle MI on the ECG you’ve been shown because you’re still trying to remember how to spell “Sjögren’s”. However, as I’ve already mentioned, sometimes you need to write the notes yourself, for those more complicated patients where writing it out helps with problem solving.

In this month’s EMJ, Katherine Walker and team from Melbourne have put together an observational study and cost analysis to determine the feasibility of training medical scribes in the ED. They took 10 trainees, put them through a 1 month pre-work course followed by 2-4 months of training and clinical sessions facilitated by emergency physicians. Only 5 trainees became competent, and required 68-118 hours of clinical work to do so. They found training scribes to be a feasible exercise, and crucially did not find any loss of productivity in the physicians who trained them. Medical students became competent more quickly than pre-med or non-medical students, and only medical/pre-medical students made it through the whole programme. There is little information on how scribes were selected to go forward to each part of the scheme, and also what the criteria were for applicants to be offered an interview. There was an overall loss in money from the programme, which had not been recuperated by the end of the study. Longer periods of observation would be needed to identify how long it would take for training costs to be outweighed by productivity savings, if at all.

As always we’d recommend you read the paper yourself to get the full results and to be able to draw your own conclusions. A reply from a senior scribe, Nicholas Rich, also provides a useful commentary and some further reading.

It’s an interesting concept, one that doesn’t appeal to me personally, but maybe it does to you. Have you got a scribe? Do they improve your productivity and patient interaction? We’d love to know.

vb

Chris
@cgraydoc

#FOAMed, credentials and a view from the college (sort of).

10 Dec, 16 | by scarley

156r09lpI found an amazing tweet on my timeline today that taught me many things. Firstly, I was not aware that students were publishing their own theses online and as an open access resource (this is fantastic), and secondly the topic in question is of great interest to me and everyone here, that is the development of #FOAMed.

Chris Walsh is a super chap who is head of e-learning at the Royal College of Emergency Medicine. He is an extremely intelligent man with a strong academic track record, initially in the humanities, and now also in the field of medical and digitial education.

He has now published his MSc thesis online looking at the development, current state and future direction of e-learning resources for the RCEM.

Click here to read the thesis online.

I am very interested in the view from a senior member of the college as my relationship with the college over e-learning has been difficult at times. As an advocate of #FOAMed I’ve always struggled with the requirements to meet the limitiations and restrictions of an overarching organisation whilst maintating the freedom, speed and open discussion that #FOAMed creates. This is a theme in the thesis and I found Chris’s analysis of #FOAMed as a dialogic process fascinating. This work also aludes to the changing relationships between organisations, traditions, curricula, members, technology and delivery. It’s complex and fascinating.Chris has used a mixed methods technique to look at the impact and future direction of e-learning for the College and for #FOAMed. The perspective is clearly from his position, and thus the influence of the College perspective is very clear, but there are many interesting elements for any producer or consumer of #FOAMed.So what are the main themes? Obviously this is my interpretation and you really should read the whole document.

    #FOAMed is here to stay.#FOAMed engages and invigorates elements of the EM community but some are not engaged.There is a desire amongst some for credentialing of activity related to #FOAMed (though the strength There is some confusion between e-learning and #FOAMed type activities and credentialing.The RCEM is developing a system to credential #FOAMed learning.There is a belief and understanding that #FOAMed will be incorporated into formalised learning and continuous professional development.

There are many other questions too of course. This study is based on small samples and almost all the interviews were conducted with those involved in college work. The survey data was sought through social media spaces which is good as they are #FOAMed consumers, but also limits the findings to those who are already engaged in this style of learning. The perspective is thus largely one of the college establishment and as a result may be a self-fulfilling one. However, I’m not sure that matters that much as the project is really aimed at those groups as opposed to those who are not currently engaged with College resources. It does therefore study a specific, but relevant

So. Follow the link above to read the thesis (or at least read the abstract), follow Chris Walsh on his twitter account, and if you feel inclined I’m sure he would be delighted to hear your thoughts.

My final question is in regard to the proposed credentialing of #FOAMed activity into an online CPD portfolio.

The question is whether users will be able to record activity from non RCEM #FOAMed sites, or will it be limited and paywalled by the college. As a #FOAMed advocate I’m clearly keen to support learners to be able to record #FOAMed CPD from any blog or podcast.

That may not be a decision that Chris will personally make, but I’d love to know the answer (and hope it’s the right one).

The bottom line is that this is a great piece of work that takes our understanding of College based learning further and deeper than we have previously seen.

vb

S

 

What do Emergency Medicine and Donald J. Trump have in common?

7 Dec, 16 | by rlloyd

trump-01

Illustration by A3 Studios

*Caution: Emotionally-charged post, pinch of salt required… personal feelings only and not the editorial view of the EMJ/BMJ.

On the morning of the 9th November 2016, I woke up to the earth-shattering news that Donald Trump had been elected President Elect of the United States. It’s a moment I’ll never forget.

Rain pounded menacingly against my bedroom window, all my social media outlets exploded with sentiment of anger and sadness, and my American fiancé lay next to me in floods of tears.

I, like many (urm… all) of my friends and family, and seemingly the majority of the #FOAMed community, am horrified by the Trump phenomenon. His hateful, divisive rhetoric is unlike anything I’ve previously encountered in a public figure, let alone the new leader of the free world. Appropriately, and frighteningly, he has drawn comparisons with some of modern history’s ugliest dictators, such as Hitler and Mussolini. Mind-bendingly hideous stuff.

Throughout his campaign, Trump would verbally decapitate anyone who dared to undermine him. Cutting personal insults and sinister threats (‘I’ll throw her in jail when I’m in the White House!’) were par for the course, and reflective of an insecure man with astonishingly thin skin. Of course most of the time it was his rival Hillary Clinton in the firing line, but even fellow Republicans took some damage if they decided to be critical.

If his foul-mouthed tirades were a shrewd strategic move for diverting attention from his lack of political acumen and poor grasp of the Presidential job description, then arguably, the man’s a genius. Decipherable policy specifics were sparse, but unashamed fascism seemed to be a common theme, exemplified by absurd proposals to build a wall on the US-Mexico border and ban all Muslims from entering the US.

I’ve lost count of how many times I felt convinced of his self-destruction. Whether it was accusing all Mexican immigrants of being ‘rapists’, jokingly inviting a Clinton assassination attempt, or the release of a video where he openly boasted of sexual assault, he somehow kept on surviving. And then he won the keys to the White House. Ugh.

I am no journalist. Nor am I a political analyst. I’m a blogtastic British junior doctor training to be an Emergency Physician, and therefore pretty far removed from the whole debacle (*wipes sweat off brow*). Having said that, witnessing Trump’s ascendancy has triggered an important work-related reflection that I feel the urge to share.

Where is our basic human decency?

The Trump campaign suffered from a disease which stripped it of basic human decency. Depressingly, this reminded me of the alarming regularity that I witness unnecessary rudeness and outright bullying in the ED environment. Unpleasant, heated exchanges are a daily occurrence (certainly where I work anyway). Where does the hostility come from?

We’re bloody busy

The influence of workload cannot be emphasised enough. The ED is inevitably the busiest department in every reasonably-sized hospital, and it remains so 24 hour-a-day, 7 days-a-week (despite what our Health Secretary might have the tabloid newspapers believe).

When you consider that in 2015-16 there were 22.9 million visits to the 136 existing EDs in the UK, I think it’s fair to say overburdened is an understatement (by developed world standards of course) (1). Stress levels can reach fever pitch at the sight of a an overflowing waiting room, a seemingly never-ending list of ‘unclicked-on’ patients on a computer screen, or a growing congregation of paramedics indicating that pregnant ambulances are queuing up.

All of these are inevitable features of working in a UK ED, and with the added pressure to have patients ‘sorted’ in under four hours (i.e. discharged or warded), it’s understandable that some might become irritable and combative. It doesn’t matter if you are a native ED doctor, nurse or visiting specialist, the feeling is contagious; it’s a pressure-cooker workplace, and too often I see people releasing their personal pressure-valves by taking out frustrations on colleagues.

Of course, all of the emotional demands of working in such an over-stretched environment are heightened when dealing with particularly sick and unpredictable patients. As such, the resuscitation room tends to be the arena where I am most stunned by the way colleagues address each other.

False inferiority complex

There is no department where tribalism is more evident than the ED. It’s a bubbling cauldron of inter-specialty and multidisciplinary interaction.

As emergency medicine practitioners, we’re arguably the only nominal generalists in the hospital setting. This means that in the eyes of some of our specialty colleagues, we’re ‘second best’ at managing many of the pathologies we see. We can commence management of acute coronary syndrome, but we’re not cardiologists; we can intubate, but we’re not anaesthetists; we can even crack chests, but we’re not cardiothoracic surgeons.

This, of course, is a total fallacy. Emergency physicians might seem like generalists at surface-level, but the reality is that they ‘specialise’ in appropriately differentiating the undifferentiated. Where neighbouring specialties anchor towards diagnosing familiar pathologies (e.g. the cardiologist quickly labelling a patient’s chest pain as myocardial ischaemia), emergency physicians won’t jump to premature and potentially dangerous false conclusions, and remain open to multiple possibilities until firm evidence presents itself. In the initial phase of managing patients fresh from the community, across the spectrum of acuity, the emergency physician possesses the safest, and most expert pair of hands.

Unfortunately this isn’t always recognised by our specialty colleagues, who can overlook the inherent challenges of the emergency medicine landscape, and occasionally be quick to patronise, condescend, and even ridicule when being referred to, particularly when by a junior person.

In the more vulnerable amongst us ED folk, this can breed a false inferiority complex and erode confidence. Seniors are more likely to react with verbal pugilism if they feel disrespected.

Conflict is further cultivated by the unfortunate reality that much of our job involves giving someone else more work to do, which naturally fosters resentment on their part.

Of course, the outcome of inter-specialty collisions in the ED don’t always end in tears, and I appreciate that I might be painting a overly grim picture. However, in my experience the referral process can turn ugly very quickly, particularly when other stressors are in play (e.g. being particularly busy).

Blame culture

Doctors aren’t supposed to make mistakes. However, it’s undeniable that healthcare (especially the ED) is highly error-prone. It’s an unpredictable, dynamic environment with an extraordinary amount of moving parts.

The hallmark of a good system is a strong culture of learning from failure. The ultimate example is the peerless aviation industry, whose safety model has become the stuff of legend – they jump up and down with excitement when a plane crashes because it represents an opportunity for precious learning (2).

In stark contrast, it’s no secret that the healthcare industry hasn’t exactly covered itself in glory when it comes to promoting patient safety. From the Mid-Staffordshire Enquiry to the Harold Shipman scandal, our history is littered with examples of system failures that should have been thwarted earlier through a healthier culture of incident reporting and institutional change management.

I’m not saying we’ve had no success stories, I’m merely suggesting that there’s an awful lot of room for improvement. There’s the tragic case of Elaine Bromiley, whose death in the anaesthetic room prior to a routine sinus operation prompted an independent investigation which led to a global revolution in patient safety measures around airway management (3). It’s worth noting that the investigation was driven by Elaine’s inspirational husband Martin – a commercial airline pilot.

There are plenty of historical and structural reasons for our suboptimal safety culture, but arguably the most important factor is that society puts doctors on a pedestal, and assumes invincibility. Error is heavily stigmatised in our workplace because the public expects perfection. So when the inevitable mistakes do occur and we fear being implicated, a strategy for deflecting attention is to turn on each other. Even when there is no risk of being implicated, we still can’t resist the urge to point the finger of blame (or gossip about the incident behind the back of the guilty party) because somehow it soothes open wounds from previous public humiliations.

When it comes to mistakes, our institutional focus is on who did it, and not what can be learnt from it. Opportunities for progression usually descend into fruitless professional witch-hunts. And this culture is ingrained in us all from medical school.

The ‘patients lives are on the line’ card

Trump exonerated himself from his revolting campaign narrative by playing the ‘political correctness’ card. He fooled the electorate, and branches of the media, into thinking his verbal excrement was acceptable (even attractive) because he wasn’t a career politician and therefore didn’t ‘play by the rules’. No other presidential candidate in US history would have got away with some of the things he’s said, but he was ‘sticking it to the establishment’, so it was OK.

In a similar vein, I believe that it’s become acceptable for collegiality and decency to be left at the door of the ED because the ‘patients lives are on the line’ card gets played. The stakes are far too high for us to care about the way we treat each other.

This attitude is helped along by our very rigid, arguably militaristic hierarchical structure.

There is no doubt that a hierarchy is crucial for ultimate decision-making accountability, but it gets abused too often in my opinion. Of course some are more guilty than others, but if a senior person is feeling particularly under pressure (or, dare I say it, out of their depth), it’s all too easy for them to take out their frustrations on a defenceless junior staff member – riding the authority gradient. And it’s totally acceptable to do so, because it’s a patient’s life at stake of course.

I’m not just talking about consultants and senior nurses, it spans the entire spectrum of ED staff. I’ve witnessed a rookie doctor rotating through the ED viciously bark at student nurses for taking ‘too long!’ to attach the monitoring to a perfectly stable patient in majors – unacceptable, and an abuse of authority even at the most junior level.

Misplaced self-importance anaesthetises basic manners. We weaponise the inherent moral high ground of doctoring in much the same way that Trump weaponised being ‘un-PC’. We’re getting away with behaviour that we shouldn’t.

The irony of playing this ‘card’ (so to speak) is that our patients ultimately suffer because our multidisciplinary teammates are less willing to go the extra mile for someone they don’t like. Truly toxic stuff. Are we that self-righteous? Are we that arrogant?

Why are we not holding ourselves to a higher standard?

I am not proclaiming to be mightier than thou. I have fallen foul of high stress, surfed the authority gradient and hidden behind the fallacy that I’m making regular life and death decisions as much as the next junior emergency medicine trainee. I can recall multiple times where I’ve been unacceptably rude to colleagues, and even remember an occasion where I made a nurse cry and run out of resus. I was remorseful about those moments, but only transiently. There was always something ‘terribly important’ I could distract myself with, ridding me of the shame I felt for being a b*****d to a colleague for no valid reason.

However, those I verbally abused will not have recovered so quickly, and are now more likely to treat their future juniors as I did them on those occasions. This is the vicious cycle of bullying that I’m sure every doctor reading this post will relate to on some level, whether they can admit to it or not.

Why are we not holding ourselves to a higher standard? As front row spectators to the fragility and preciousness of human existence, surely we of all people should have more respect for each other.

We musn’t be fooled into thinking that just because we have different skillsets or seniority that we aren’t singing from the same hymn sheet. No matter what it says on your hospital name badge, we all have the same job description: help make people better.

We deal in the currency of human life, which in my opinion is the greatest professional privilege that there is. No matter how bad our day seemingly is, or how much pressure we feel under, you can bet your bottom dollar that you need to look no further than the frightened, desperate person staring back at you from the trolley to find someone worse off. That dose of perspective is a gift, and it alone should do the job of warding off Trump-like demonstrations of contempt for our colleagues.

Of course, Americans voted for Trump in their droves (in much the same way that Brits voted for ghastly Brexit). Why? That’s not for me to say; I’ll leave that to the politicos. What I can say with some certainty is that a massive proportion of the Western world feels a potent combination of embarrassment, sorrow and anger that we’ve allowed such a harmful situation to escalate.

Is this not the very same cocktail of emotions that we feel after a hostile exchange in the ED? We must strive to be better at checking ourselves before forgetting our basic human decency and engaging in needless workplace warfare.

We’re better than this.

Do the right thing

As medical professionals, our knowledge-base and skillset give us almost supernatural status in the eyes of the public. Being a doctor is more than a job, it’s a title. But that’s not why they’ll allow us to slice into their bodies, poison them with medications, and have access to their most hidden secrets. They allow us these privileges because we’re supposed to be fundamentally good people who’ll always act in their best interests no matter what the cost. We, more so than anyone else in wider society, are deemed to be the custodians of doing the right thing.

That should be something we carry with us at all times in our workplace, regardless of who we are speaking to, or the nature of the scenario. There is no place for Trumpism in the ED.

Robert Lloyd
@PonderingEM

NB: I appreciate that the content of this post is emotionally-driven, opinion-based, and potentially controversial. Please feel free to commentate/agree/criticise in the comments, it would be great to generate some discussion around the topics brought up.

References

  1. Accident and Emergency Statistics: Demand, Performance and …
  2. Black Box Thinking. By Matthew Syed.
  3. What can we learn from fatal mistakes in surgery. By Kevin Fong, BBC News.

Many thanks A3 Studios for the amazing accompanying graphic.

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