Performance Under Pressure

How well do you perform when the pressure is high? This is one of my favorite emergency medicine topics. Emergency personnel pride themselves on thriving under pressure. Doctors like to think of themselves as perfect, maybe even god-like. Combine the two, and you can imagine the ego of the average emergency physician. But underneath all that bravado, we are all human. We all experience stress, and we all respond to stress in distinctly human ways.

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Mental Practice

I just finished reading a paper on the use of mental practice for resuscitation, and I couldn’t wait to write a post. Usually when I find an interesting paper, I put it aside to include in my collection of “articles of the month”, but I just had to give this paper its own post. This paper epitomizes the raison d’etre of First10EM.

First10EM is fundamentally about mental preparation. True emergencies are rare, so it is difficult to develop and maintain excellence. Medical education has turned to high fidelity simulation to help with this problem, but simulation requires time and resources frequently unavailable to emergency physicians practicing in the community. However, the human brain has an amazing intrinsic capacity to simulate real world scenarios. These authors define mental practice as “the cognitive rehearsal of a skill in the absence of an overt physical movement.” In other words, you can participate in high fidelity simulation while relaxing on your couch, on a beach, or even while in the shower.

First10EM is meant to be a guide for exactly that kind of mental practice. As I describe my approach to various time sensitive emergencies, the idea is to visualize exactly how you would act in the same scenario. Where is the equipment stored in your resuscitation room? How many people are normally available to you, and how will you interact with them as team leader? What will you do during those first 10 minutes?

The paper I am talking about is:

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)

This was a randomized, controlled trial comparing mental practice to usual ATLS training in a group of 78 residents (from anesthesiology, surgery, or emergency medicine). The structured mental practice consisted of 20 minutes of quiet mental rehearsal following a trauma script. They were specifically instructed to visualize how they would behave and function as a team. The control group was given 20 minutes of didactic ATLS teaching.

Right after the teaching or mental practice, everyone participated in a high-fidelity trauma simulation that was video taped. The mental practice group scored significantly higher (21.5 vs 19, p<0.01) on a previously validated scale (the Mayo High Performance Teamwork Scale). To be fair, I am not sure whether a 2.5 point difference is important on this scale, but they certainly did not perform worse. The authors conclude that mental practice led to improvement in team based skills as compared to traditional training.

My Bottom line: (With a very high degree of personal bias.) Mental practice is obviously a valuable way of preparing for high stress situations in emergency medicine. It is something I think we should all be doing throughout our careers.

The specifics of this paper don’t matter too much to me. (When you already believe something works, you are never too harsh in your critical appraisal.) I am not sure if mental practice is better than usual teaching. I don’t know if this study proves that it is. However, this is a free tool that can be used anytime, anywhere.

Any form of education can be done poorly or well. We often attempt to assess simulation as a whole, but all recognize some scenarios and teachers are amazing, while others are lacking. Similarly, we all still remember some outstanding lectures from medical school, but most slipped from our minds before we were even out the door.

Mental practice cannot guarantee great outcomes on its own. One could practice poor technique or mentally simulate in an evidence vacuum. There will always have to be educators or coaches to guide us, but once we have a solid foundation, I think the benefits of mental rehearsal are obvious.

We have an important job. We have a stressful job. We have a job that requires us to be ready for absolutely anything at all times. How you prepare for that job matters.