Ed – We are delighted to publish a guest post from a great friend of St Emlyn’s, Joke from Belgium. She is one of a number of superb Belgian emergency clinicians that we have had the honour to meet in recent years. This post is based on Joke’s work on how we perform and lead in the clinical environment (which is related to her PhD work, but with a special focus on the difficult circumstances we currently face during the pandemic). You can read more about Belgian EM here.
JOKE: Emergency medicine and elite sports have much in common. When the stakes are high, whether this is treating a crashing patient or performing on an international competition, both the physician and the athlete need to perform under acute pressure to the best of their abilities. They do so by pushing their physical and mental skills to the maximal capacity. In order to raise our potential or to stay balanced during difficult times, much can be learned from the training of athletes.
Firstly, athletes are fully aware of the importance of mental skills for achieving peak performance and are trained and coached in it. Secondly, much attention is given to rest and recovery. Due to the consequences of overtraining or injury, they allow themselves time and planning in order to recover fully as in the long run it will make them stronger.
This pandemic is challenging us all, in one or more ways. If you haven’t figured out how to give your mind and body what it needs during this intense period then this is the time. Mental training as well as rest and recovery are essential parts of your functioning and thriving as an emergency physician. Good self-leadership lets you optimize your performance and manage your energy levels to make your day flowing. It’s even an important starting point for leading others and creating a high performance culture at your emergency department. Start with caring for yourself first. Today.
Read my suggestions below and pick out what resonates with you. Make time for it, practice and reflect.
1. Cultivate a growth mindset
During his captivity in a concentration camp in Auschwitz, Viktor Frankl lost almost all his family as they were murdered in the gas chambers or died due to exhaustion. In his horrible living circumstances, he gained insight into ways to achieve a more fulfilled and meaningful life and wrote his book ‘Man’s search for meaning’. He believed meaning could be discovered by the attitude we take toward unavoidable suffering, and that everything can be taken from a man but one thing: to choose one’s attitude in any given set of circumstances.
“Between stimulus and response, there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”
This attitude could have many different forms, having a growth mindset is an important one. Carol Dweck, an American professor of psychology, invented the terms growth and fixed mindset to describe the underlying beliefs people have about intelligence and learning. A growth mindset is defined as the belief that intelligence is malleable and improvable. The world is about learning and growth, and challenges and setbacks are seen as being helpful in the learning process. The fixed mindset, on the contrary, beliefs that intelligence cannot be changed and every challenge is a potential threat because it could reveal a lack of skills or weaknesses. People with a fixed mindset show helplessness responses when faced with setbacks.
These mindsets can lead to us creating our own personal psychological worlds which act as a perceptual lens through which we perceive ourselves self and our environment.
What’s your mindset?
Consider a recent situation in which things did not go well. How did you react?
“Failure is an opportunity to grow”
“Failure is the limit of my abilities”?
In the global population, the growth versus fixed mindset is equally divided. Our team recently studied (paper will be published in 2021) these mindsets in Flemish emergency medicine residents and found that 90% of them have a growth mindset. This is even associated with a lower perceived stress score which is not illogical as a growth mindset promotes to interpret a stressful situation as a challenge instead of a threat. As a challenge appraisal is known to promote cardiovascular indices and even performance, a growth mindset could be helpful in coping with or even thriving due to daily stressors. It will reframe difficulties and setbacks towards personal and professional growth.
Almost nobody has a 100% growth mindset for 100% of the time. We are often a mixture of both, depending on the context. It is, however, possible to train our brains to cultivate the growth mindset more often. The key to change this is self-awareness as it enables you to actively identify situations that trigger a fixed mindset while it is happening. Remind yourself that you do have a choice in the way you respond. While in that moment, put on your ‘growth sunglasses’ and take a second look to the situation. It will be different.
When situations are hard, new or intense, it could be necessary to retrospectively reframe the obstacle toward a growth perspective. Take a daily moment to reflect on the demanding situations you faced today. Look back on what you have learned, are learning now or could still learn, ranging from a difficult intubation of a hypoxic patient in full personal protective equipment to showing humility, gratitude or other values you resonate with.
From a long-term time perspective, ask yourself:
“How do I want Covid-19 to change me?”
“What is helping me get beyond this?”
Take time to clarify who you currently are and where you are going. Define your goals. The clearer they are, the better you will be able to handle difficult situations. You’ll approach difficult situations with more motivation and focus.
“Your goals will show you the way, your growth mindset will drive you forward.”
2. Breathing for performance
We continuously need to adapt to a changing environment and our stress system gives us the necessary drive to do so. This means that stress is not necessarily negative, provided it is used to our advantage. If however, stress levels are excessively high or chronically raised, we remain in a fight-or-flight mode too often with many negative physiological and psychological consequences.
Fortunately, we can influence a unbalanced autonomic nervous system by our breathing, as this is the only part of it we can control. Through controlled breathing, we can activate the parasympathetic part, which allows us to rest and digest. Before reviewing some breathing exercises, check your regular breathing first. After all, we breathe about 20,000 times a day.
Become aware of your own breathing while you are reading this. Are you breathing slow or fast, shallow or deep, regular or irregular and into your chest or your belly?
Our breathing is far from optimal as acute stress, chronic tension, wrong body posture and the use of personal protective equipment make us breathe shallow, fast and high in the chest. Almost all of us are breathing wrong (TEDx Belisa Vranich) which makes it more difficult to cope with long-term daily stress.
For a moment, relax all your muscles and be aware of how air goes in and out of your lungs. Let your breathing return to its natural rhythm. When you inhale, your diaphragm goes down and your belly expands. On an exhalation, the diaphragm relaxes and rises, the belly becomes smaller again.
With this proper breathing in mind, breathing exercises are one step further. There is no definite proof that one method outweighs another but here are some good options:
- Breathing with long expiration
- 4/7/8-breathing: inhale for 4 seconds / hold for 7 seconds / exhale for 8 seconds
- You can use an app to guide you: Paced Breathing (Android) or Breath Pacer (iOS)
- Cardiac coherence breathing
- Breathing frequency is generally 6/min, inspiration and expiration time are equal (5/5)
- You can use biofeedback devices: Inner balance trainer (Heartmath)
- Box breathing
- 4/4/4/4-breathing: inhale for 4 seconds / hold for 4 seconds / exhale for 4 seconds / hold for 4 seconds
- This one is probably less useful as an exercise at “rest” but may be especially helpful during periods of acute stress when a rapid mental reset is required
In stressful situations, your physiology might make it impossible to breath as slowly as mentioned above. One solution is to keep the rhythm (4x4x4x4), because that is what you will be familiar with, but perhaps speed up the counting so you go round same cycle but maybe with less than 4 second cycles.
If you want to introduce controlled breathing in your life and work, I would recommend the following familiarisation/preparation program:
Find out which breathing technique suits you best. Try different methods and pick one out.
- Try this breathing exercise on a consistent basis for 6 weeks. Aim to practice for 10 minutes every day, this could be 2×5 or 1×10.
- Introduce your breathing exercise during stressful events at work and with a variety of different scenarios.
- When you do notice rapid shallow breathing and a stressed feeling: practice your breathing exercise for at least 2 breathing cycles
- If you are not aware of your stress response during high-performing events: try to build in a routine for your breathing exercise at predetermined points in resuscitation, for example after every rhythm check or while auscultating the patient.
This sequence is a form of self-guided stress inoculation training, which is a proven technique in sports or other fast-paced, physically or psychologically intense disciplines such as military training. These exercises will help you optimize your performance under stress levels, can accelerate recovery and may lower baseline stress scores.
In 2021 there is no doubt that the research project regarding feasibility of implementing controlled breathing techniques during clinical work will be a challenge in our emergency department. In my personal experience, training with the Inner balance trainer during a peak performance course was a real game changer.
Because breathing makes you more calm and at rest, it is useful to combine it with meditative practice. Meditation in this context can be seen as a form of secular mental training. During our shifts at the ED, our brain is continuously performing at high speed. Switching between tasks, intense cognitive processing and high environmental attention are some of the many skills we use. Moreover, we live in a distraction epidemic and are constantly bombarded with emails, tweets, reminders and all kinds of other things that demand our attention. The more effort we put on our brains, the more we should take care of it.
As meditation affects many brain regions, the benefits are multiple. It increases body awareness, emotion regulation, introspection, complex thinking and many more. Therefore, it should no longer be considered a “nice to do”. Many would say that is is a “must do” as a way to keep our brains healthy, to slow down racing thoughts, to increase focus and to support effective decision-making capabilities.
If you haven’t meditated before, it’s nice to introduce the breathing into a mindful breathing meditation (just google this term) or sign-up for an online course (many online resources, eg Headspace). For biofeedback fans, there are devices that measure the brain activity. I had good experience with the Muse headband.
Ed – you might also want to visit this great post from Scott Weingart from SMACC
But, meditation can also be as small as being present in a single moment, for example being fully aware of your senses while drinking your coffee between two patients or noticing small beautiful things while commuting.
Learn the ability to turn off and you will recover more deeply. This will lead you to preload your system and you will be more ready for the next challenge.
3. Stop. Think. Plan. Act. Then reflect
As with New Year’s resolutions, introducing new and lasting habits in your daily life is more difficult than creating the intentions to do so. Whether you lead with one of the ideas listed earlier or other ones that were already on your to-do list, you can use some practical advice to make the implementation of better self-care and self-leadership successful and sustainable.
A. Don’t skip the planning and reflecting
Taking a moment to sit down is a powerful starting point. It means you can make time for your plans and progress by consciously investing in yourself. One very powerful aid in planning is a (bullet) journal. Writing down your plans and reflections has many advantages:
- It will encourage you to pay attention to aspects that you may not have thought much about before.
- It will invite you to list your thoughts and feelings. That takes your reflection to a higher level than if you only thought about it.
- It will stimulate your daily progression. By registering what you did (or not), it helps you think about what works for you (and what doesn’t).
B. Set up of an implementation plan
- Anchor new habits: You need to anchor your new habit on an existing one, the anchor habit. This last one is something that is already happening whether you have a good day or not, and is the base for the new habit. Come up with a system that works for you. For example, if you want to practice meditation, do this every day after taking a shower. Or, if you want to reflect about challenges and opportunities for growth, take a daily moment to write in your bullet journal, while drinking the morning coffee.
- Take baby steps: If your goal is to start meditating, start with an achievable starting point. Don’t expect yourself to meditate every day for 30 minutes as aiming high will give you soon an experience of failure. Then you will need a big portion of willpower to push through. Instead, set the timer to 2 minutes and increase it slowly. It will make you experience small wins that will give you instant motivation and confidence to persevere.
- Practice in easy or peaceful circumstances first: Start with changing habits when you need it the least, because you will have more energy for it. This makes your new habit a routine when you need it the most. For example, don’t start to reshape your thoughts toward a growth perspective during or after an emotional exhausting day. Instead, start in easier circumstances with smaller obstacles or difficulties and make the habit your own by the time the more intense days arrive. Or, although it would be extremely useful to meditate after a hectic day, it can be better to start with it on days off.
- Bypass your willpower: Willpower is an exhaustible resource that is often fully consumed at the end of the day. Be aware that it is like a muscle, it fatigues. For making new habits, use it as little as possible otherwise, you might fail. Beside the suggestions above, also consider your environment. Reshape this by removing things that conflict with your new intentions and install other ones that enable it. If you want, for example, to eat more healthy at work, buy lots of healthy snack bars and store them more nearby than the candy machine.
C. Set up of an escalation plan
Despite your excellent implementation plan, there will be moments that you fail to keep yourself balanced. When your energy levels drop, good habits are easily lost as well, and you might go down the spiral of mental and physical exhaustion. The deeper you go, the more difficult it will become to get yourself out of this.
To prevent this, it is crucial to think of an escalation plan before you even enter this spiral.
What actions might help you in case your energy levels drop below baseline?
Eg: going for a walk in nature with a positive friend
Next, think of alarm signals that trigger you to start your escalation plan.
What changes in your behaviour might indicate that you’re going down?
Eg: drinking more coffee, having less patience with your children,…
Write this down and share it with someone you trust and knows you well, in case you might not be aware of it or need a friendly push to take action.
The suggestions above are examples of the many possibilities for progressing on the path toward better self-management and peak performance. Although these are my experiences, ideas and suggestions I hope that by sharing what has helped me, I hope it might inspire you as well. In these tricky times, showing some vulnerability and sharing our experiences is one step further in helping ourselves and others getting through this pandemic and beyond. This is my journey and I hope it helps, but I’m very curious to hear your thoughts and experiences too. Please comment.
References and further reading
- Simon Carley, “Belgian EM at BeSEDiM 2018.,” in St.Emlyn’s, January 28, 2018, https://www.stemlynsblog.org/beligian-em-at-besedim-2018/.
- Robert Lloyd, “An Englishman in South Africa: Robert Lloyd at St.Emlyn’s,” in St.Emlyn’s, May 7, 2016, https://www.stemlynsblog.org/englishman-south-africa-robert-lloyd-st-emlyns/.
- Robert Lloyd. ‘My Mental Toughness Manifesto’ Part 3: PERFORM. https://blogs-bmj-com.manchester.idm.oclc.org/emj/2017/05/09/my-mental-toughness-manifesto-part-3-perform/
- HBR Emotional Intelligence Series: Mindfulness. 2017.
- Benjamin Hardy. Willpower doesn’t work. 2018.
- Carol Dweck. Mindset: Changing the way you think to fulfil your potential. 2006.
- Scott Weingart, MD FCCM. Podcast 182 – Kettlebells for the Brain – Meditation from SMACC 2016. EMCrit Blog. Published on September 19, 2016. Accessed on January 20th 2021. Available at [https://emcrit.org/emcrit/kettlebells-brain/ ].