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
What do you think?
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A wonderful comment. Lots of personnel coming out of military service recently with experience and attributes that will make them excellent Drs/practitioners. Exactly the approach to practice that I hope to achieve, however I have no military background so would not fit into Norm’s criteria for recognition.
thanks to Francisco Norman for this considered comment. I think he and I agree to disagree on some points, which is fine. Does medicine need tough people? Do we need to be all warrior mind set? Does the resuscitationist need to be like a Navy Seal or Pararescue operator? Maybe..maybe this is all opinion. we dont really know if it will help. it makes sense but then again last night on Australian TV, there was a documentary on the rates of psychiatric casualties in Australian soldiers returning from Afghanistan. PTSD does and will happen to anyone subjected to trauma. Intriguingly in the documentary , a psychiatrist specialising in PTSD, claimed that in fact the indoctrination and stress training used to prepare elite soldiers (Australian Commando regiment members) actually makes it more likely that they may develop PTSD. HIs point ( albeit controversial) is that separating emotion from action and rapid decision making, in fact makes it much harder to process the trauma/stressful event, after it has occurred. This has been my caution all along. with stress inoculation training, may we be setting future resuscitationists up for more burnout and stress related illness? Maybe..we just dont know. Medicine is not the… Read more »
Minh,
Not sure of the brush you are painting these guys with. i might have a non-representative sample, but all of the special ops military i have associated with have been nuanced and delicate folks who just happen to have an extreme degree of mental resilience and a plasticity of thought that seems ideal for critical care. I would not eant to fill my residency or fellowship with solely these folks, but to have 1 per class, I can only see as a huge boon.
Now as to the ptsd comments, i need to have a long think on that before i respond. Very intriguing…
this is the article that is making me think:
http://www.ncbi.nlm.nih.gov/pubmed/15656996
so the ? is would a change in training minimize of increase this already present issue.
good question. we dont know, is the true answer for now. and I would caution using military analogies and research to extrapolate to medicine, even resuscitation medicine. everything requires context.
certainly the OZ psychiatrist on the TV documentary proposed that training to deliberately create the warrior mindset may predispose to PTSD. becoming emotionless, robotic in action, is great to get things done in crisis, but not so great when you return to non crisis, civilian mode of living.
One ex Commando interviewed said on return from Afghanistan he was utterly unable to emotionally connect with his children
and personally I think being a physician is more than about being great in a crisis. I am not discounting the benefits of mental and psychologic training. I am pointing out there should be a balance. everything has a cost.
Minh, As always, I appreciate the comments. I am humbled by your words of support as well. I think, however, there is a fundamental difference between developing skills to cope with stress, and elevate performance, perposefully programming emotional indifference to enable taking life. These are very different concepts. Although a somewhat necessary union exists between areas to prepare one for combat, I agree, it would certainly inappropriate (and likely detrimental) include this in any sort of medical training. In my modest opinion, it should be quite to the contrary: enable emotion and compassion that would drive a provider to work harder, dig deeper, and arrive at an unparalleled level of performance. As to observation of your Australian colleagues and their observations on soldiers, I would be interested to listen more carefully to their contention. Again, programs that develop resilience and strength of mind are different, although sometimes used concurrently, from training explicitly designed to kill. While I cannot deny that anyone exposed to trauma may be subject to PTSD, I have to say that some of the data that I have seen (unpublished) suggests that soldiers that didn’t have the same selection and training as special operations forces were perhaps… Read more »
Great post
Great comment Minh! We should also not forget that every team needs different members. 10 warriors does not make a good team. You need people that are complementing each other, with different qualities
Before an operator can get into the ED or ICU, he or she must first make it through academia which is often antithetical to pretty much everything the operator has stood for in their first career. If they can succeed in an operational environment, and then succeed academically, they will be able to fit into any team.
Dr. Minh – there is a big difference between being tough minded, and being the tough/rough guy in the room. Furthermore, while PTSD is currently a hot-button topic for veterans and therefore the subject of numerous studies, I would suggest many (non-military veteran) ED providers and nurses also suffer from PTSD as well. Perhaps you are right that the “indoctrination and stress training” that military operators receive may predispose them for PTSD, but if so, couldn’t the same be said for the indoctrination and stress training of emergency physicians/providers?
Fortunately the recent wars have given us many new therapies to help manage PTSD. I certainly would not let the “risk” of hiring a vet with PTSD stop you from adding him/her to your team.
While I agree that approaches from the military might be applied to evaluate and develop mental/emotional resilience, I am concerned that this paradigm of the “tough” resuscitationist leaves women behind.
Is a more collaborative leadership approach less valued? Is the softer spoken but no less capable physician less valued? Stereotypes of “strong” leaders are frequently gendered and an avenue for perpetuating gender inequity in medicine.
All- I’m a prior service enlisted Army Ranger Medic and am currently about to complete my first year as an EM resident. Part of my residency requires me to lecture and work with medical students (which I love) and as an avid reader of emcrit I had to comment. As a Ranger, I was also a senior medic and trained new Ranger Medics as part of my job description which I again loved doing. The difference in my experience is that the Ranger Medics were held to a significantly higher standard than med students and even residents. Yes, we were required to manage very sick patients in austere environments; however ultimately, in my opinion, I’m more hesitant to send a family member to a med student/intern than I would a Spec Op medic for basic care. It’s sad that a newly minted medical graduate is less capable, but ultimately it’s the truth. My concern is that by not challenging medical students/residents to a higher degree, they will ultimately graduate as an attending and eventually hurt someone because we don’t create these pseudo-stressful enviornments for them to succeed later on. Training while in the contiguous US gave you the ability to… Read more »
This whole Comment stream has provoked some interesting thoughts. Having never been in the military I can not comment on or begin to understand the training. I kinda agree with the original comment posted regarding the benefits of military training in respect to overcoming the task at hand. I also share Minh’s comments regarding the necessity of this kind of training. I think PTSD is PTSD regardless of cause. The sexually assaulted are equally prone to PTSD as my grandfather who watched his friends split in half by heavy rounds from Mitsubishi A6M zeros at Pearl Harbor. The military is just more in the spotlight because these guys come home and the second one snaps it makes Fox News or CNN. Most spec ops guys I have met are humble and likely could survive and overcome the task at hand with wits and determination that most of us don’t realize they are capable of. That being said, history shows that the common less trained adversary against all odds can usually overcome the best trained militaries of the world. If the task at hand is to take a room with a suspected terrorist….then training becomes paramount and the rehearsal is the… Read more »
Craig,
If you ever get a chance to visit the Shock Trauma Center in Baltimore, you will find what you are looking for in any of the trauma critical care units. It is a center entirely devoted to only one thing: what is the best move for the patient. I never found a single instance in 2 years where this was not the case.
Thanks For the response…
Sometimes I feel like I am that lone little voice advocating from my ICU. Every now and then the stars line up and care goes in the direction of optimal….I need to get up there and check it out….
Dr. Rosebrock, For “most” people with military experience your concerns with them requiring a high level of top-down direction/leadership/management is valid. But operators, especially those who are more specialized, are used to functioning in environments with little to no direct supervision. A spec ops team may be told that their target is supposed to arrive in this town sometime tomorrow…go get him. A SAR team will launch on a mission and receive no further direction from above. Furthermore, while the rank structure still exists in such teams, there is more credence given to situational leadership rather than positional leadership, and team members effortlessly shift between following the directions of the “senior” person to following the directions of the person most knowledgeable/experienced in the situation at hand. In these teams it is not uncommon to have an junior enlisted man directing the actions of a senior officer. However, when you get outside of specialized operations teams (not just spec forces) there certainly is more reliance on top-down, rank-based command and control. Your experience in wanting more resources for your patients is very much the same that every operator has had in the field. We identify the need for additional resources, make… Read more »
Boatswain2pa, Sorry man, I should have been more clear. I understand that the spec ops guys when deployed are given more operational latitude. My point, which I didn’t really make well, is that to get to that position they have first move though the basic and then more advanced training. Boot camp, BUDs, and then the more special weapons, demolition, halo training etc is done before they can have the ability to think more freely…. make their improvised tactical plan after their strategic plan has been made for them. In order to be that special operator though there has been years of training…..all of which required a senior operator who has been there done that. During this movement they have learned and understand rank, orders and discipline. What it means to take orders to get things done. I think this is the difference in military training and medicine. We dont have this system in medicine…and therefore there is some difficulty with getting people focused in a team environment. The backbone of rank and duty is infused early into the military personnel. It can be hit or miss in medicine. Physicians get training but we don’t get good teamwork training in… Read more »
[…] Scott Weingart and Michael Lauria’s podcast on mental toughness? A beautifully nuanced comment was made following it, and it’s worth reading for all present and budding resuscitationists. […]
Thanks for the clarification. I think today’s MD/DO education process is so academically focused that many of those who make it through it do so to the detriment of some other developmental processes. Not many pre-med students on college varsity teams.
Your comment about the mil-ops guys spending years following more senior guys who have BTDT (been there done that) is true. I’m not a MD/DO (went to PA school after 20 years of operations), but isn’t that analogous to a residency? I guess the obvious difference is the team-based focus with military training/operations vice the individual (and potentially competitive) focus of residency.
This may be a reason for Dr. Weingart to have more than just one ex-military operator on his team, because the followership/leadership these guys bring to the team are contagious and will “wear off” on the “traditionally educated” team members. Leadership is contagious, whether it is good or bad.
Great discussion.
what a remarkable thread of commentary! brilliant stuff from Craig and Boatswain Medicine is like the Hunger games but more ruthless. we are indoctrinated to be lone wolves, top of the game. Graduating from medicine, gives you the sense of entitlement. as Craig points out, its great until you actually have to work as a team! but I still maintain medicine does not and should not turn into a military hierachical warrior culture. Medicine is far more holistic than that. The psychiatrist who is called in to consult on ICU case is a classic example. ICU patient on ECMO for strep sepsis with bilateral forequarter amputations. ICU team want to withdraw Rx but NOK refuses. despite many ICU family meetings, impasse continues. So head of psych is called in to review mental state of NOK. the Psych is an old fella, balding, doesnt look any different to average joe with glasses. ICU doc has drawn up graphs of survival for strep sepsis on the blackboard in the meeting room. Psych guy asks for some more comfy chairs and glass of water. NOK comes in. he sees the pSych guy as being new face. sits away from him. ICU guy starts… Read more »
Great discussion guys as said above… When I got into medical school I was so excited. I was a biology major, and a duel minor in chemistry and ancient history…..stuck around five years in college. Worked as a synthetic organic chemist for two years and then squeaked into medical school. I thought I was going to meet folks interested in deep discussion and play chess till three am in between our studies. Oh boy what a shock….I felt like I was in a class where everybody was striving for A’s so they had choices ….. Not entirely because they wanted to be the best and smartest. Now I am sure that most everybody has good intentions….but it gets lost somewhere along the way. The individual mentality starts to consume you and you realize that you need to make an A or you are gonna have poor choices when you apply for residency…it becomes like learning so you can pass your boards and not learning because it’s gonna save a life one day. Some of the guys with the most life exp. do the worst simply because the old school methods of learning are obviously antiquated to them…we had a few… Read more »
[…] Scott Weingart and Michael Lauria’s podcast on mental toughness? A beautifully nuanced comment was made following it, and it’s worth reading for all present and budding resuscitationists. […]