Category Archives: Leadership

Mental Mastery in Medicine

 

 

You are the crème de la crème.

You are élite human beings. You have completed one of the most sought after and toughest apprenticeships in the world.

The-Doctors-Travis-Stork.jpg

You have mastered multiple fine and gross motor skills, you are adept at managing multiple patients, you are able to translate from English to Medical and back again, many of you are able to do this in several other languages as well. You can reassure, trouble shoot, talk down and mediate in some of the most stressful moments of people’s lives. You have acquired a vast body of medical knowledge.

And you will continue to develop all of these skills for the rest of your careers.

You belong to an amazing, rapidly evolving, international, altruistic, knowledge sharing profession that work seamlessly with multiple other highly skilled professions.

And on this background we are now going to start developing another group of skills which has been touched on here and there in your training, but not to any significant depth. We are going to work with you to develop your mental mastery. Mastery of your greatest asset – your mind, and mastery of your patients and colleagues’ minds.

In various posts we will look at metacognition: the way we think about our thinking, positive psychology – the study of a well functioning mind (instead of psychopathology) and what is called mindfulness – the higher awareness that occurs beyond or without thinking (being mindful, similar to careful, not have a full mind).

These are areas that are in their infancy in medicine, but are rapidly growing and will transform the way we do medicine before the end of my career.

http://roadtoawakening.net/wp-content/uploads/2010/02/meditation.jpg

For the last few years I’ve been promoting mindfulness as a stress management tool, and a way to better listen to our patients. But in the last few years we have learned a lot, largely from military and business psychology. In the last couple of years some of the international emergency and critical care medicine gurus have been saying that meditation and mindfulness are essential skills to help us be good doctors. If we can be cool, calm and connected during a resuscitation, it is much more likely we are going to make good assessments and decisions and communicate these well with our teams.

Here’s a useful analogy. I’m testing a “Virtual Desktop” for IT. The Virtual Desktop is a new computer system that should speed a lot of our computing up. The get me to test it because it has to be fool proof. Most of the time it was working brilliantly, some times it would grind almost to a halt. As I typed there would be a time lag before anything appeared on the screen. The boffins had a look and found that there was one little programme using 99% of the computing time of the server. It turned out it was Adobe Reader. Sometime in the past Adobe had asked if it Reader could report back to Adobe how I was using Reader. Being a good eCitizen I ticked the “yes” box. It turned out that anytime I opened a PDF Reader starting reporting to Adobe non-stop “Oh, he’s rotated that ECG, and now he’s copied that, and now he’s enlarged the image, and now he’s doing nothing” etc, non-stop using 99% of the server’s brain power. The boffins disabled that programme and Virtual Desktop was fast again.

Our minds are very like this. A kid comes in with a febrile seizure.

Grand_mal_seizures

We think “shit, it’s a kid, will I be able to get a line in” “Oh god, Cresswell’s on, he’s useless as tits on a bull, I wish we had good seniors here” “I can never find decent paeds IV lines in this department” “Oh no not that nurse, she drives me nuts” “Oh no, I’m crap at paeds” “This is going to be time consuming – what time does the café close?” “What’s the dose of midazolam for a kid” “Look at that mother’s teeth, she obviously doesn’t look after herself, she’s probably neglected this kid too” “Oh, what model iPhone has she got? Nice case” “Shit it’s a kid, will I be able to get a line in” “Oh god, it’s Cresswell on ….

And that stuff uses up 99% of our brain power. And then we only have 1% left to work on the medical stuff “Should I move him to resus?” “Should I suction him first or get the midazolam in” “Oxygen by mask or nasal prongs” …. and that 1% of brain that we have left free can’t make a friggen decision. And we see that. We see doctors freeze, we see them rock backwards and forwards between the IV gear and the suction. I’ve done 2 laps of a bed without doing anything useful because I didn’t know where to start.

A lot of the time in medicine we are suffering from information overload. There are a lot of patients, a lot of bosses, a lot of nurses, lots of relatives, lab results, X-Rays, medication lists, obs … a lot of data. And then we have to fit in our real lives: socialising, keeping our partners happy, sports, exploring NZ etc.

We also believe we should be able to multitask. We can focus on multiple patients, multiple jobs and keep all those balls in the air. Multitasking is a myth. We can only focus on one thing at a time. When we focus on many things we sequentially focus on one at a time. If we focus two things our ability to do deal with each of those things diminishes. With each thing added to our attention our performance decreases more.

Our brains are easily overloaded. We have endless questions calling for an answer. Our brains behave like a 2-year-old, throwing tantrums when it doesn’t get it’s own way or enough attention.

 

We are going to help you get rid of some of that mental crap.

“The empty space within a cup is what makes a cup useful”

Lao Tsu

We need to create some empty mental space within you to give you space to see the child, to think clearly, to see the parents, to see your staff, to see the big picture, to say to the health care assistant “this case is going to take a while, can you ring up the café and get them to send me a meal” and then focus back in the room again, to have space to be able to say a few words to the parents to reassure them, to have the space and humility to ask for help when you need it.

For most of us the best way to deal with a 2-year-old throwing a tantrum is not to yell “Will you shut up!”, rather it is to turn our attention to something else and wait for the 2-year-old to calm down and then give it a big hug when it has settled. Brains are similar.   We and ignore the mental chatter and focus instead on what we need to be focusing on – the patient in front of us and how our team can best help them.

A very simple, very real, exercise you can do this afternoon is to listen to a patient for one minute. Go and see a patient and ask them how they are and listen for 1 minute. Don’t try and problem solve for them, don’t try to diagnose, just listen. Just listen. If another thought pops up, just notice that, don’t try to suppress it (don’t yell at the 2-year-old), and turn your attention back to your patient.

If a nurse is telling you about a patient, stop what you are doing and just listen to what the nurse has to say, without trying to problem solve, without thinking about what else you are meant to be doing. Now after a minute if the patient is telling you about Tiddles last trip to the vet you can then disengage. If the nurse has given her or his handover, you can consider the matter and give a full attention reply.

If you do this, most of you will be surprised at how hard it is to stay focused on that one person in front of you. You may notice that you miss big chunks of that persons story. And for many of us this is how you get diagnoses very wrong, we go into a room after seeing a STEMI on the ECG and don’t hear the actual story that the patient tells us that doesn’t actually sound like cardiac chest pain and thrombolyse the STEMI mimic.

To start with the effort of focusing on the person may get in the way of actually listening, but that will quickly pass.

You may start noticing the same thing in other parts of your life. You may find that you only half listen to your partner most of the time. But that is another story.

With practice the distractions will become less intrusive. The commentaries will become less noticeable. You will find that you have 90% of your brain power available to make the key medical decisions, and you will make them quickly and move on to the next question. You act more quickly and decisively. And you will make less mistakes. And you will communicate better with your patients, their families and with your workmate.

Most of us find we need to do some special time outside of work to help us keep our mental cup empty. For some of you that may be your music, for some it will be your religious practice, for some it will be exercise, for some it will be walking on a beach.

I strongly recommend to all of you that you also do some specific training to help you be able to focus your mind on one thing at a time, one thing of your choosing. This type of mental training is commonly known as meditation, but is seen in probably all cultures in various forms: chanting, prayer and other contemplative practices.

http://images.psxextreme.com/wallpapers/ps3/stillness_891.jpg

Please try a simple meditation with me now, just for a few minutes

Please focus on your breathing. I want you to close your eyes and just focus your attention on your belly and feel the changes in sensation as you breath in and out quietly and naturally in your own time. And just gently keep your attention on your belly. If a pager goes off, unless it is an arrest pager, just notice it and turn your attention back to your belly. If any thoughts come along just notice these and return your attention back to your abdomen. etc …

If nothing else, this sort of exercise helps most people see that there is a lack of space in their awareness. For many people meditation helps to create some space in our minds.

Meditation can be particularly good to help us switch off at sleep time. When it is time to go to sleep focus on one thing. It might be your breathing, it might be the sensations in your body, starting at your feet and moving up your body, it might be listening to the sounds around you. And if any thoughts come along, work, disagreements, plans for the weekend, anything, just notice them, let them be, don’t try to suppress them, and turn your attention back to your chosen focus. Until … you wake up. If after 10 minutes the exercise is driving you nuts, stop it and go back to what ever you normally do at sleep time, but try it again the next night.

With these simple exercises: listening to one person, spending 5 minutes a day observing your breathing, and observing one thing as you go to sleep, and with much practice, you will transform yourselves from good doctors to medical masters who walk into a resus bay with an empty mind and mindful awareness and create calm. “Ah, Dr Bhatra is hear, everything will be OK”

 

If you can be present with that patient, not flitting off into fears or worries, if you can be present in the present, not fearful for the future, angry about the past, if you can be present in that space, and be spacious enough to hold all that is in that room, to listen, to look, to touch and really hear and see and feel, to take it all in, that will be the presence you will have.

And that will be a present, or gift or tonga [Maori word which approximately translates to “a treasure”] from you, and from your medical predecessors, to all those in the room.

This is how we will change the practice of medicine.

Enjoy your practice.

 

 

Images from

http://www.zap2it.com/blogs/the_doctors_travis_stork_hopes_to_save_your_life-2012-09

http://roadtoawakening.net/wp-content/uploads/2010/02/meditation.jpg

http://www.drvl.org/parenting/toddler-tantrums-advice/

http://images.psxextreme.com/wallpapers/ps3/stillness_891.jpg

http://cartoonnetwork.wikia.com/wiki/Master_Splinter

 

Obstetric Emergency Communication and Teamwork

 

Audio

 

Phone image from http://mobilephones.pk/reviews/emergency-calls-now-free-from-all-networks-%E2%80%9Cthe-number-allocation-and-administration-regulations-2011%E2%80%9D-issued-by-pta/

Panic face image from http://tamlynn75random.blogspot.co.nz/2012/02/panic-face.html

Music: Mr Wendle. Arrested Development.

Own the Resuscitation Room – Cliff Reid

Cliff Reid from Resus.me gave this talk at Essentials of Emergency Medicine in Las Vegas today.

He discusses mastering your team, yourself and the patient.  He advocates training in resus for resus, having systems to manage stress like RSI checklists

Here’s the one we use in Whanganui:

It looks complicated – because it’s a complicated process – and there is a lot to prepare and do right to make sure it goes smoothly. It also provides great documentation of what actually happened when.

Sneaky little screen shot of Cliff’s causes of shock:

[Hmm.  Still gotta get sepsis, anaphylaxis and toxins in there some where.]

We need to encourage our teams to help us / challenge us / remind us of things we may have forgotten or when we are heading down the wrong track.  The team leader should keep their hands off the patient and avoid becoming task focused.

Control the environment.  Don’t allow the environment to control you.

We need to control the mob of helpers.  Get everyone on the same page by regularly verbalising assessments and plans.  We need to ask individuals to do tasks not just float a request out into the room.  Different teams will be focused on their “bits” eg the surgeons on the belly.  We need to keep the over view.  We need to learn graded assertive techniques and to learn the science of human persuasion.  Cliff sagely notes this doesn’t work well at home.  Give annoying people a job eg ask the surgeon to do a cut down (while one of your team puts in the IO in a fraction of the time) ;-)

We need to be comfortable with allowing patients to die with dignity when this is appropriate.

We need to learn from the cases that don’t go well.  Weingart: “A good resuscitationist agonises.”

Ah, a man after my own heart.

Emergency Medicine Tutorials