It can be hard enough managing critical tasks in even the best of times but, when things start to go awry, you need to focus even more to keep moving in a positive direction. Back by popular demand, Dan Dworkis (our guest on episode 57) walks us through: Navigating uncertainty when under situational pressure, powering down at the end of the day, managing the physiologic response to stress, the most thoughtful procedural time out we’ve ever heard, and transparent team communication.
Guest Bio: Dan Dworkis MD, PhD is an emergency physician who is a clinical professor of emergency medicine at USC Keck School of Medicine. He’s also host of the Emergency Mind podcast that focuses on helping individuals and teams perform better under pressure and the author of The Emergency Mind: Wiring Your Brain for Performance Under Pressure.
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How Dan’s approach to resuscitation or stressful situations has changed since he started The Emergency Mind project [02:30];
- Knowing how to apply knowledge under pressure is a mission critical skill for anyone in emergency medicine. Historically, trainees have learned this in bits and pieces and unconsciously through experience.
- “The single biggest thing that’s changed after having spent time with world experts on performance under pressure across a variety of domains is understanding how much the moment of performance exists within a broader context – both a personal context and an environmental, team and systems context.”
“Previously I would think of performance as its own thing. I was ultra focused on the moment. Now I think of it as a stage within the cycle of preparation, perform, recover, and evolve. I spend my energy trying to work on the system that supports me. How do I get ready to do this? How do I recover? How do I learn from what I’m doing and get better?”
Applying the core principles of prepare, perform, recover, and evolve to the scenario of a difficult intubation [05:20];
- It is common for emergency physicians to have a failed 1st attempt at intubation. This is a highly stressful situation where, within a couple of seconds, you have to diagnose a new problem that you didn’t know existed, design a new solution, execute that solution, and recover the patient from the hole that you’ve helped put them in.
- That moment of realizing you might be on the path to a failed airway can be ameliorated if you better understand what’s happening within yourself and what you can do to offset some of the stresses that emerge.
- Many people respond to that stressful moment by quickly moving to make a decision, “because making a decision is better than making no decisions”. Dan resists the urge to just act in any direction and reflects for a second. “I take a beat to prepare and to come up with a plan.”
“Being able to identify what problem you’re actually facing, to sit in that pocket of discomfort for another second, really helps steer you towards the right direction.”
Breathing techniques to manage the physiologic response to stress [07:40];
- A physiologic sigh, which Andrew Huberman talks about, can bring calm in a moment of pressure. The double inhale exhale pattern triggers the vagus nerve and helps slow the heartbeat.
Being cognizant of the other people in the systems around you and communicating what you think you might need next [09:00];
- Think out loud. Let your team know what you have planned and how they can help you.
How to build a high-functioning culture [10:55];
- The key is empowering your team in the days and months before the moment of a stressful situation. Have you built up a culture and a team that believes that you’re there for the best interest of the patient? If so, then when you feel stuck, you can communicate that honestly and ask for help without worrying it is a sign of weakness or incompetence.
- For Rob, a personal culture change with a complex patient was to have a “chalk talk” with his team, reviewing on a white board what they knew was going on and sharing ideas about what to do next. It was all about empowering, delegating, prioritizing and bringing everybody into the same conversation.
“You live or die with your team in those moments. Your ability to work together, to create an instance where you’re all operating on the same problem in the same shared mental model and where you’re all helping each other get better, where you have this common sense of purpose and passion about it – that’s magic when that works.”
Leave no trace emergency medicine and tale of the squeaky door [15:30];
- Part of Dan’s sense of victory when he leaves a shift is to walk out knowing he left the patients, the hospital, the team, and the physical space better for him having been there. Even if it’s a small thing like repairing a squeaky door, he tries to leave things a little bit better than when he found them.
“If you have a culture of making small things better, over time your team will outperform at big things too, like resuscitation.”
The drama triangle: victim, villain, and hero [17:15];
- Often in medicine, we get to be the hero and we have the hero perspective. But many times we see ourselves as the victim – the victim of administration, the victim of poor infrastructure, the victim of our systems. The secret is to get outside of it and be none – be someone with agency who is neither hero, victim, nor villain.
Altering the principles of behavioral economics when doing a timeout in the ED [19:15];
- Behavioral economics teaches us that when we’re in the middle of a high pressure situation, we’re less likely to want to speak up when there’s a large power gradient or when we are not feeling psychologically safe, even though we might have important information. This tendency to withhold usable ideas especially occurs when those ideas go against the grain of what’s happening.
- In a procedural timeout in the ED, how do we create a circumstance where people are likely to feel psychological safety, to understand what we’re looking for, and to deliver usable information when we need it the most?
- Instead of asking your team, “Everybody good with this procedure?”, flip the question and ask everyone individually if they see a reason why it might be unsafe. “Tell me where I’m wrong. Help me understand how I’m broken. What do I not see that you do?”
“Asking for disconfirming evidence is a big step forward in terms of getting that psychological safety in place and getting people able to speak up.”
David Marquet’s fist to five [24:15];
- After sharing the plan with your team, ask everybody in the room to hold their hand up and give a number of fingers. Five fingers is full go ahead, love this plan. Fist (or zero fingers) is a full stop, terrible idea. Some number of fingers between fist to five expresses an amount of certainty/uncertainty about what you think is about to happen.
- Fist to five gives you several pieces of information. First, you get a quick snapshot of the temperature check of everybody in the room and you see a diversity of opinions. The heterogeneity is itself a signal.
“The goal is to create a culture that allows the best things to happen naturally, removes obstacles, understands how people’s brains work under pressure, and creates an environment where you’re able to deliver your best self and the best care.”
Cognitive load theory and where trainees struggle when it comes to knowledge under pressure [27:40];
- Cognitive load refers to the amount of things you’re able to do at a given moment. There are different forms of cognitive load: intrinsic cognitive load (the cognitive load devoted to doing the task at hand), extraneous cognitive load (the extra cognitive load of distraction, such as noises), and germane cognitive load (the energy it takes to take experiences and build schema out of them).
- Trainees tend to struggle when there are high levels of extraneous things going on, unrelated to the task at hand. This creates a moment where the level of mental effort spikes. And if the task at hand is already hard for you, because you’re a novice, and you have this spike on top of it, you’re more likely to hit overload. A solution is to apply gradual pressure and use wedge practice. If you are able to train a skill and employ it under low wedge conditions, you have a better success rate at getting it done.
- An antidote to some of the fear of performance under pressure We can help trainees by expressing clearly, coherently, and in front of people that we are works in progress.as an attending, as a senior, as a leader, continuing to work on yourself and evolve yourself. And I think that’s part of the antidote to some of the fear that comes with performance under pressure, If you’re constantly held to an impossible standard, then you’re going to be afraid of not making it. So one of the thing that I try to do is to express when I am uncertain express, when I don’t know the answer and express what I’m working on and what I’m struggling with.
- Recommended reading: Sweller’s Cognitive Load Theory.
Managing task saturation with systems and structure [31:30];
- If you anticipate task saturation, put systems in place to offload the overwhelm.
“Don’t fight the way that human brains are designed. Try to improve on it. But also try to create structure that supports you when you need it the most. Accept your own fallibility as a human and design structures, cultures and teams that support you.”
Powering down after a shift [32:45];
- Dan parks far away so that he is forced to walk over a bridge that has beams and pillars on it. He imagines the beams of the bridge stripping some of the residue off of him. He doesn’t look at his phone or talk to anybody until he’s through that bridge.
- Other ways to power down: parasympathetic breathing, mindfulness meditation, sequential walkthrough of the day, evoking gratitude.
“Prepare and recover are two sides of a coin. How you set yourself up matters greatly for what you can do and also how you can recover. Making good choices throughout the day before the shift may allow for continued good choices after the shift.”
The fact that some days a win is simply not “throwing gas on the fire” [40:12];
- We can talk about ideals, techniques and routines for being our best, but the job we do is hard. And sometimes, all we can hope for is to not make things worse by responding to things with anger, frustration and blame.
Algorithmic vs creative thinking and the shape of uncertainty [42:20];
- Often in medicine when you’re uncertain and feel like you’re in uncharted water, you must switch from algorithmic to creative thinking. The key is communicating to your team how you plan to approach the workup. And also ask for everyone to “be on the lookout for things that tell us we’re pointing in the wrong direction”.
- When uncertain, it’s helpful to explore the shape of uncertainty. Typically, if we don’t know the answer to a clinical question, we have an idea which direction the answer lies on either side (if we had to guess). Also, we have a sense of the consequences of making the right or wrong choice. We can use that “shadow knowledge’ to help us make difficult decisions.
Dan’s recommendations for new listeners to his show [50:47];