Performance under pressure, mental practice and how to use First10EM

mental practice title

I love emergency medicine, but I have to admit that it sort of scares me. We truly get to see the best parts of every speciality, but we also must be ready to face the very worst things that can happen in each of those specialities. We have to know all of medicine. And we have to know it in such a way that the information is immediately available, at 4am, in the midst of swirling chaos.

I was never sure that I knew everything I needed to know. I remember walking up to the hospital for my first few shifts after residency and dreading what might come in. Would I have to perform a procedure I had never seen before? Manage an illness I had only read about? Or worse, manage an illness I somehow hadn’t ever read about?

So I started practicing. Unfortunately, for the rare but deadly conditions that worried me, there aren’t a lot of opportunities to practice, especially in a community hospital. Simulation might have helped, but we don’t have a lot of sim programs for staff doctors, and simulation is time and resource intensive. My only readily available resource was myself, so like a lonely child with an imaginary friend, I practiced in my mind. In the shower, in the car, at the gym (these visits might also be imagined), I would be rehearsing. I would picture the knife sliding through the skin, followed by a bougie and endotracheal tube in my plan for a bougie-assisted cricothyrotomy. I would imagine organizing my team into two resuscitation rooms as I completed a perimortem c-section and prepared to manage both the neonate and the mother in a single coverage emergency department. In large part, First10EM is just a written record of those rehearsals.

I started this blog having never heard of ‘mental practice’. It was just something that I did; something that made sense to me. It turns out, mental rehearsal is actually supported by some evidence. Today’s post is a brief review of our performance under pressure, mental practice, and how I think First10EM is best used.

Performance under pressure

A much more extensive article on performance under pressure has been added to this site, and can be found here.

Stress and emergency medicine go hand in hand, but how well do we perform under the extreme demands of this job? The emergency department is a frequent scene of heroics under extreme pressure. However, I imagine many of us have also seen individuals freeze in the face of overwhelming stress.

There is a lot of evidence that high levels of stress can impair performance. (Evidence specific to medicine is limited, so we must extrapolate from other fields.) Stress can overload our cognitive resources, impairing our attention, working memory, decision making strategies, and communication. (LeBlanc 2009)

Our response to stress involves two rapid assessments. First, we assess the demands of the situation – what is required of us to achieve a goal. Next, we assess the resources we have to achieve that goal. When resources are sufficient to deal with the demand, we frame the situation as a challenge, and generally perform well. When demands outweigh resources, we see a threat, and performance suffers. (Weisinger 2015)

A lot has been written about managing stress in the moment. Control of your breathing, positive self talk, re-framing threats into challenges, using anchor words or scripts, and focusing on what you can control are a few of the techniques described. For a more indepth discussion, I would suggest reading Performing Under Pressure by Hendrie Weisinger or On Combat by Dave GrossmanFor an emergency medicine perspective, the various posts by Mike Lauria on EMCrit have also been amazingUpdate: I have a much more extensive write up on performance under pressure here.

In moments of extreme pressure, your performance is not going to magically improve. Despite the prevalent myth of the ‘clutch performer’, you are unlikely to ‘rise to the occasion’. You are going to sink to the level of your training. Luckily, emergency medicine training is pretty damn good. However, emergency medicine is a broad subject, and the majority of my residency was spent learning topics like the differential diagnosis of abdominal pain, how to cast, and when to consider a head CT in trauma. Even when focused on resuscitation, education tended to be broad and theoretical, whereas I wanted specific and practical. When the shit hits the fan at 4am, I want to be sure that I know what to do, but more importantly, I want to be sure that I know how I am going to get it done. The tool that I use to ensure that this happens, and really the reason for First10EM’s existence, is mental practice.

Mental Practice

What is mental practice? There are a number of different definitions, but the essence seems to be cognitive rehearsal of a specific skill without physical movement. That lack of movement really appeals to the sloth in me, but it doesn’t mean you can’t be moving at all. I go through the steps of mental practice while running (yeah right), eating, and showering. The lack of movement, for me, just means you aren’t physically performing the task you are practicing.

Physiologically, mental rehearsal activates the same neurons as actually performing the task. (At least, every study I’ve read says so – I haven’t actually seen basic science research I could cite here.) Multiple studies, of mixed quality, seem to indicate a benefit of mental practice in sports and music. (Weinberg 2008, Driskell 1994) In medicine, mental practice has been shown to enhance surgical and procedural skills. (Arora 2011, Komesu 2009, Sanders 2004, Sanders 2008) More recently, mental practice was also shown to improve performance in team based trauma resuscitation simulations. (Lorello 2015) However, not surprisingly, considering the many possible interpretations of mental practice and the breadth of medicine, there are also studies that show no benefit. (Hayter 2013) Furthermore, mental practice is probably less effective than actual physical practice. (Driskell 1994) However, we don’t always have children around in the middle of a TET spell to practice on, and simulation, although a fantastic tool, is time and resource intensive.

Overlearning has been suggested as an effective method of enhancing performance under pressure. (LeBlanc 2009) Overlearning involves continuing to deliberately practice a skill after achieving proficiency, and could be achieved through mental practice. Under pressure, complex thought is most impaired. Overlearning can help simplify our approach. Overlearning skills can make them automatic, freeing up working memory. Furthermore, mastering skills can increase our sense of control in pressure situations. (LeBlanc 2009)

It is difficult to assimilate this literature into a single, simple answer. It is reasonable to guess that the effectiveness of mental practice may vary depending on the type of activity (mental or physical), the user (novice versus expert), the method of practice, and the time spent practicing. However, it makes sense. Mental practice is cheap, easy, and can be done basically anywhere and anytime. I want to make sure I always have the resources I need to meet the demands of emergency medicine, and mental practice works for me. First10EM exists because I hope it will work for you as well.

How to use First10EM

So how does this mental practice stuff work? How do I use First10EM?

The core content of First10EM is a series of approaches to life threatening presentations in emergency medicine. The blog posts represent what I think is the best approach – after reviewing multiple textbooks, publications, and FOAM resources – for me, considering my skills and the resources available to me at my hospital. The approaches I publish are not meant to be universal. They are guides. Hopefully, they are useful, but to be used properly, they should be adapted to your own skills and setting.

Mental practice is different that just reading and trying to commit facts to memory. It involves setting the scene in my mind; imagining not just the patient, but my actual resuscitation room and the other people in that room. For each step in my approach, I picture how I will make it happen. If the asthmatic patient needs oxygen, bronchodilators, an IV, and to be placed on the monitors, I specifically think about who is going to do what, and in what order. (I can take care of the monitors, while my nurse starts an IV, and my RT looks after the nebulizer and oxygen.) If I need to start BiPAP, I know our machines are stored in a different hallway, and I will have to send my RT away to get one. I rehearse that timing. If I plan to perform a finger thoracostomy to deal a pneumothorax, I actually picture where in the resuscitation room we store scalpels and chlorhexidine, and exactly where and how I will make the cut. The blog posts guide me through this practice session, and provide a simple frame that helps me to mentally organize my approach, but I think the real value comes from the mental simulation.

This sounds like a lot of work, and honestly, the first time you try it, mental practice can be time consuming. However, each practice session becomes quicker and more efficient. When I started, I was usually sitting quietly, doing nothing other than running through the scene in my head, but eventually it becomes second nature, and you can practice skills while driving to work.

I have noticed other benefits as well. Quite frequently, when mentally practicing for emergencies, you will notice some deficiency in your own skills or your department’s set-up. When reviewing how to deal with shoulder dystocia, I realized I didn’t know where our department stored obstetric equipment. The nurses probably would have been able to help, but what if I am working with a new nurse the day I need it? At the start of my next shift, I found the equipment, and can now get it for myself if whenever needed. When practicing my approach to local anesthetic toxicity, I discovered that our department did not stock intralipid. It was in the pharmacy, a minimum of 30 minutes away. Now it’s in our resuscitation area.

Although this is often thought of as an individual exercise, I find it also works well in groups. Many people have experience the “what if” teaching method – what if you can’t see the cords, what if there is blood in the airway, what if the bougie will pass but the ETT won’t? Thinking through these scenarios is an important form of mental practice that can be done as part of bedside teaching. This also works in small group seminars – rather than simply lecture, have the group think through the steps of management, and really focus on the logistics of getting things done.

I think First10EM is best thought of as a guide for mental practice. The posts may teach you something if read once. But to truly benefit – to ensure that you will be able to manage those first 10 minutes of extreme pressure – these posts should be seen as a framework to be adapted to suit your own skills and the resources available to you, and then reviewed repeatedly until the skills become automatic. Then you can be sure that you will be ready, no matter what comes through the door next.


I don’t think I can possibly do as good a job discussing performance under pressure as Mike Mallin did in his amazing talk “The day I didn’t use ultrasound” from Blood and Sand 2015 (hosted on EMCrit). I would suggest watching that now, if you haven’t already:

Another great mechanism for enhancing performance under pressure is a cognitive behavioral technique called “stress inoculation training”. Honestly, I am no expert. However, if you happen to be attending SMACC this year, there is a pre-conference workshop (that I will also be attending) put on by Chris Hicks, Chris Nickson, Anand Swaminathan, Jesse Spurr and Tom Evens that I would strongly suggest checking out.

Finally, for a brilliant piece on a related topic, check on this post at St. Emlyn’s on deliberate practice. Also, if you ever get the chance, listen to the real expert, Chris Hicks, talk about mental practice.

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Performance under pressure

LeBlanc VR. The effects of acute stress on performance: implications for health professions education. Academic medicine : journal of the Association of American Medical Colleges. 84(10 Suppl):S25-33. 2009. PMID: 19907380

Weisinger H, Pawliw-Fry JP. Performance Under Pressure. New York, NY: Crown Business; 2015.

Keinan G, Friedland N. Training effective performance under stress: Queries, dilemmas, and possible solutions. In: Driskell JE, Salas E, eds. Stress and Human Performance. Mahwah, NJ: Lawrence Erlbaum Associates; 1996.

Grossman D, Christensen LW. On Combat: The psychology and physiology of deadly conflict in war and in peace. Warrier Science Publ, 2008.

Mental Practice

Weinberg R. Does Imagery Work? Effects on Performance and Mental Skills. . 3(1). 2008. [article]

  • A review article. Bottom line: mental practice and imagery seem to improve sport performance as well as mental skills.

Driskell JE, Copper C, Moran A. Does mental practice enhance performance?. Journal of Applied Psychology. 79(4):481-492. 1994. [article]

  • Another review. Bottom line: mental practice has a positive and significant effect on performance.

Arora S, Aggarwal R, Sirimanna P. Mental practice enhances surgical technical skills: a randomized controlled study. Annals of surgery. 253(2):265-70. 2011. [pubmed]

  • A RCT showing better scores by residents performing laparoscopic cholecystectomy following mental practice.

Komesu Y, Urwitz-Lane R, Ozel B. Does mental imagery prior to cystoscopy make a difference? A randomized controlled trial. American journal of obstetrics and gynecology. 201(2):218.e1-9. 2009. [pubmed] [free full text]

  • A RCT  of residents performing cystoscopy, that demonstrated better surgical ratings after mental practice

Sanders CW, Sadoski M, Bramson R, Wiprud R, Van Walsum K. Comparing the effects of physical practice and mental imagery rehearsal on learning basic surgical skills by medical students. American journal of obstetrics and gynecology. 191(5):1811-4. 2004. [pubmed]

  • A RCT showing similar outcome for suturing when comparing 3 physical practice sessions to only 1 physical practice and 2 mental practice sessions among second year medical students

Sanders CW, Sadoski M, van Walsum K, Bramson R, Wiprud R, Fossum TW. Learning basic surgical skills with mental imagery: using the simulation centre in the mind. Medical education. 42(6):607-12. 2008. [pubmed]

  • A RCT, again in second year medical students looking at suturing, comparing mental practice to textbook study, and the mental practice group performed better

Lorello GR et al. Mental practice: a simple tool to enhance team-based trauma resuscitation. Can J Emerg Med 2015;10:1-7. PMID: 25860822 (Free open access article here)

Hayter MA, Bould MD, Afsari M, Riem N, Chiu M, Boet S. Does warm-up using mental practice improve crisis resource management performance? A simulation study. British journal of anaesthesia. 110(2):299-304. 2013. [pubmed] [free full text]

  • RCT looking to evaluate CRM skills in a simulated anesthesia environment showed no difference in scores. (Sounds like scenario heavily prompted to blood loss, and goal was to get residents to order just 1 unit of blood)
Cite this article as:
Morgenstern, J. Performance under pressure, mental practice and how to use First10EM, First10EM, March 23, 2016. Available at:

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