This comment was left on the Mike Lauria Toughness podcast by a gentleman named Francisco Norman:

Dr. Weingart and Michael Lauria,

Thank you for the podcast and for your insight into this topic, as I don’t think I have ever heard it discussed in this context.

I would first like to comment that I don’t believe the stress applied to these operators/candidates can be simulated in an interview. If I could suggest a process that might simulate the stress, it would require a rotation through the program to further understand the personality of the applicant. This has to be done BEFORE the resident is accepted into the residency program, and it must be voluntary. Remember, the situational stress is applied to these military candidates so that their core values can be exposed. Are they good team mates? do they have endurance? do they work well under pressure? A 4 week volunteer rotation prior to residency, would be helpful in the selection process.

Secondly I would like to suggest that instead of trying to select candidates for a residency/fellowship that may be mentally tough, why not make an effort to find these candidates that have already been selected.

Dr Weingart, if you could have two Mike Laurias join your organization every year would you? Would your organization benefit from a couple of candidates that have Mikes experience, maturity, humble confidence, and direction? Why try to identify them yourself, when they have already been identified by the military?

This comment is really directed at medical school faculty, Physician assistant programs, residency and fellowship program directors and other “shot callers” in the medical world. I would also put into this category leaders of hospital medical staffs and ER group leaders.

I don’t know Michael Lauria but I will bet my stethoscope that a guy like Michael Lauria will bring to your program:

1. Leadership and Leaders that lead by example, often choosing the “hard right over the easy wrong”. Others in your organization will mimic their approach and improve the overall performance of your unit.
a. Operators want to work in an organization that is elite, they will therefore work to make you organization better, doing things like training their replacements (less experienced members of your team… an excellent example is everytime that operator uses the ultrasound to start a peripheral line, he will take a nurse with him to show them how).
2. a tremendous work ethic that make them great teammates. They “embrace the suck”, work well under pressure and take responsibility for their actions. Now I want you to think very hard about a colleague you have worked with in the past. What percentage of colleagues possess all of these traits?

3. A desire to be Best among their peers. These Operators chose their path for many reasons, but they all have one thing in common. They want to challenge themselves and be part of the best. These are the people that climb Mount Everest… because it was there. They don’t get paid more, don’t get rich and are almost all guaranteed to have harder more austere lives.

I don’t think the point is to make all practitioners as mentally tough as Mike Lauria, but to identify the Mike Laurias of the world to place them in a position to succeed.

Now I am going to respectfully disagree with ketaminh. He should focus not on how the military prepares operators for combat and compare that to how we educate practitioners, but focus on the very process that Special Operations use to select their personnel and improve their performance.
Here are some ways medicine could mimic Special Forces in their performance improvement measures.

1. Rehearsal- there is a team element approach to executing your task that includes repetitive rehearsals where the movement of every individual is choreographed to improve timing, execution, and to memorize responsibilities and measures. Operators rehearse their mission, job, and task until they can literally do it with their eyes closed and know where their teammates are without even having to think about it. (have you ever had a code where the chest tube tray couldn’t be found? or CPR is being done with one hand? rehearsals eliminate this problem by doing number 2.

2. After Action Review- What went right, what when wrong, what can be done better. This is a question that is posed to every individual from the lowliest private to the commander. Everyone must participate and everyone is open to criticism. It can sting but it answers many questions as to the why something is done. This is a highly valuable tool that improves performance. In the hospitals I have worked in this consisted of a group huddle where the members of the code team said “great job everyone”, but did little to improve the performance of the group.

3. Ranger Peer System- this is a system where the students of a Ranger school class rate each other numerically. This helps to identify members of the group that may do well with their interaction with the Ranger Instructors, but do little to help out their peers. These “fair-weather Rangers” will conserve their energy, not help the weaker or injured students and generally do not make good team mates. These are the Eddie Haskels of the world, people generally like them but they are not thought of as great workers. They know how to turn it on when the spotlight is on them, but generally will not make your organization better. You have them in your organization and you have not identified them.

4. Change of Duty station-Have you ever wondered by the military changes duty stations every 2-4 years? They don’t want individuals becoming too comfortable in their environment. Have you ever met anyone in medicine or nursing who “had just been around forever and thats just the way they do it?” They may benefit from this tenant.

So in conclusion how does this long and likely boring statement help those “shot callers”?

1……First I would say if you have decision making ability in your organization, school, program, or group I would encourage you to actively seek out those operators who have already been vetted and come down the pipeline and welcome them into your organization. While these are incredibly humble individuals that will not show up to the interview wearing a “Navy SEALs” baseball hat or a pararescue tattoo on their neck (if they do please raise an eyebrow) they are proud of their service.

2…. If you have one in your organization already and want to try something “out of the box”…. these are the guys to try it with. Do you have paramedic that was an operator and want to find out if 15hrs of training in ultrasound can make a difference in how trauma is handled? this is the guy to do it. Do you want to know if a fellowship for physician assistants can be developed in Critical Care to augment your ICU and have more coverage? The Michael Laurias of the world are the guys to do it.

thanks for listening and please keep the FOAMed coming, and more Michael Lauria. I’m proud of this kid and of others like him, he will be a winner wherever life takes him.
respectfully,
Norm

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Scott Weingart

Editor-in-Chief, EMCrit.org at EDECMO LLC

An ED Intensivist from NY. No conflicts of interest (coi).

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