Today, I interview Mike Lauria on the concepts of toughness and resilience.
The Rationale of Selection Courses/Indoc
80-90% Attrition for the PJs Indoc
One of the things that people, I think, find distasteful about selection programs in the civilian word is that it uncovers fundamental weaknesses and shortfalls. This is no commentary on the intrinsic worth of the individual. It doesn't necessarily mean that they are smart or dumb. But it is indicative of some inability or failure to meet a standard. While it is hard for many civilians (and military members for that matter) to swallow, perhaps not everyone is cut out for a particular discipline. Maybe we shouldn't be forcing training, pushing people along, coddling individuals to maintain the outward appearance that a program is “successful” if an individual can't make it through some sort of initial pipeline. Perhaps a benefit of selection is making sure that the right people are there to begin with and the individuals that were simply not made for it are directed elsewhere.
I lost the source for the above quote, but I think it describes the process well. If anyone has it, please send me the attribution.
Builds an innate Espirit de Corps and a common thread of self and team-reliance
Residency as the Pipeline
Should we have culmination tests and exercises at the end of residency?
Stress Inoculation/Cognitive Tempering
Mike discusses four stages to do this right:
- Conceptualization-give a background of stress responses, why they happen, and what to expect.
- Train and educate on the skills and tasks we want to see performed under stress. Then give the tools to deal with the expected stress. The latter is where we may be failing our learners
- Do a dry run to train in simulation without added stressors
- Run the same training with stress inoculation
How can we make #4 work in EM/CCM?
Sound, distractions, equipment failures, and deliberate poor communications
So what tools can we offer for #2?
Mike offers an acronym: Beat The Stress, Fool
- B is for Breathe. Breathe tactically. See the On Combat Podcast for a description (and there is an app for that too: Tactical Breather App)
- T is for Talk. Self Talk. Positive self-talk is used by athletes and any elite performance group.
- S is for See. Visualization. Visualize yourself performing the task exactly how you want to see it done.
- F is for Focus. A key word to activate the state you want. Mike has chosen “focus” as his word. We then had a brief discussion of the book, the Art of Learning by Josh Waitzkin. The author creates an entire relaxation and mindset ritual that eventually gets boiled down to a key word or short set of actions. You'll be hearing more about this book on the podcast.
When Mike asked if I had anything to add to this excellent set of tools, I discussed this TED Video by Dr. Amy Cuddy:
So maybe…Beat the Stress, Foolish Padawan with a P for posture??
Too Much Macho Militarization?
Mike posted a Youtube Video Addressing this question
Cliff Reid's Resus.me Post on Self-Defense
During the intro, I discussed the contentious self-defense post on resus.me
First10EM Magnum Opus on Performance Under Pressure
Update
Some Anesthesia programs are already doing a modified interview process–thanks Lauren!
Here is the article: (non-tech-skills-interview-process)
Additional New Information
More on EMCrit
- Imperturbability: William Osler, Resilience, and Redefining Mental Toughness by Mike Lauria(Opens in a new browser tab)
- Enhancing Human Performance in Resuscitation Part 1: Going With The “Flow”(Opens in a new browser tab)
- MotR – Mike Lauria on “Making the Call”(Opens in a new browser tab)
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thanks Scott for delving into this topic in more detail and exploring the complexitiies further. I am not sure its ready for prime time as some of the concepts I think the general medical/health community find difficult to grasp or uncomfortable to accept. Until we can prove with some reasonable certainty that the stress inoculation and mental toughness training concepts, will in fact lead to improved clinical outcomes and do not have unexpected negative consequences i.e increased mental health issues, then this will remain an interesting controversy but be regarded with general disbelief I believe the general feeling is that… Read more »
Hey Minh, Thanks for listening and thank you very much for your feedback. I recognize the burden of mental health both in the medical field and in the military. My contention is this: by performing stress inoculation training (SIT) as a preventative measure it will not only enhance performance but DECREASE these mental health issues. I think one of the reasons that incidences of PTSD is high in the military is because SIT is not widely adopted by conventional forces, at least in an effective manner [opinion with anecdotal evidence, no data yet]. If we better prepare individuals to deal… Read more »
Minh & Mike re: PTSD. I agree Minh that this is a good field for future research. However, the question I have is this: is the PTSD from the training or the combat? So as applied to EM/CC: is the PTSD from stress inoculation or the daily working the trenches of a busy ED?
Hello Minh and Mike, About research. Is performance during Blue Code better after training? I would think so. Can you call the Mock code Stress Inoculation Training? I would think so. I would really appreciate to have this training as a routine part of our hospital life, every week or so. The more you practice, the easier it will become during a real situation. Plus it allows to build team communication. About PTSD in military. I would think that there is a large part of a real thing (Afganistan, Vietnam) that causes mental issues in our veterans. Plus bullying. The… Read more »
I’m with Michael on this one (COI I have no martial prowess whatsoever). Whilst I acknowledge that clinical training in itself is stressful and tough (as Minh outlines), my feeling is that the long hours and postgrad exams prepare the clinician in different ways. The long hours for the slow assimilation of skills (apprenticeship); the exams for knowledge-base. I think stress-inoculation training does have something to offer, particularly for managing critical illness in a challenging environment (which may be an argumentative colleague, in a crowded nightclub with rowdy revellers, or in an austere rural location). Better to include a degree… Read more »
absolutely agree
thanks Mike
I challenge you to prove your theory! Such is the nature of scientific discourse!
If a colleague 7 yrs ago never challenged me to prove my theory that giving ketamine to acutely agitated psychiatric patients was safe and effective for aeromedical retrieval sedation, then I would never have progressed to where I am today, 2 papers published, 2 pending peer review and 2 book chapters written.
So please take my feedback as encouragement not discouragement.
Cause God you will need it to get through all that biochemistry, anatomy and biostatistics 😉
That others may live!
Minh, Thank you very much. It’s an honor and a pleasure to discuss this topic with such articulate, intelligent, and passionate people from around the world. I sincerely appreciate the encouragement and gladly welcome the challenge. That others may live…you bet. I was thinking about altering the Pararescue creed a little bit: It is my duty as a FOAMed enthusiast to spread ideas and challenge dogma. I will be prepared at all times to perform these assigned duties with poise and integrity, aligning them with my professional goals and substantiating them with sound evidence. These things we do, that others… Read more »
Scott and Mike, Brilliant stuff. Thank you. I’m a believer. For the past five years, every flight nurse and flight NP job interview we’ve conducted at UC Health Air Care & Mobile Care has involved a high-fidelity sim case of a critically ill patient, and it has most definitely been an extraordinarily useful tool in building our team. We incorporate some humor to take the edge off the stress, and we focus on a team debrief with education of the entire team (not just the interviewee) afterward, such that the purpose isn’t felt to be solely the evaluation of the… Read more »
Bill that is amazing! So glad someone has put this into action.
Thanks for the discussion. For me this appears to directly impact “performance enhancement”. Using visualizations; sim training/stress inoculation; meditation; physical exercise; nutrition; caffeine; mindfulness are all included in this discussion on how to optimize performance. Mike, as a former SF Medic myself I feel you are spot on with using culmination exercises as a way to form/test the ability to act. Also, testing itself is shown to be a large part of the learning process. It may be of interest that an army psychologist who was studying Special Operations soldiers told me that a lot of the people who made… Read more »
thanks Neil. As I am raising my son, I am wrestling with some of these issues: should I coddle and protect him from everything or let him muddle through sometimes to develop resilience. The latter is soul-wrenching.
Scott you should Malcolm Gladwell books: David and Goliath and Outliners on that subject. I believe younger you learn to deal with difficulty, better you get with it.
Neil, Thank you very much. I am aware of research that demonstrates SOF operators have a particularly high levels of certain neuropeptides that are thought to modulate and inhibit the activity of catecholamines and certain stress hormones. I have seen additional data that suggests in children that have been exposed to traumatic acute stressors also express these or similar neuropeptides. I have been investigating the connections here. If would appreciate it if you would be willing to share the contact information of any of the military personnel (including the army psychologist you referred to) you know of that are familiar… Read more »
Mike, I think Eric Potterat at Navy Special Warfare has to be the first point of contact. This is exactly the stuff he is doing.
I have a question for the gang: Can you teach situational awareness, and if so, can you teach it quickly and remediate it? I ask this as I have a good friend who used to hold a position as the head of a fairly large law enforcement field training program, and part of her job was to be very involved in the students that we’re failing out. In this particular program, many students had previous law enforcement experience (some had years), and had just gone through about half a year of an academy. They were sent out to the field… Read more »
… In a concise way, before residency, especially to those who seem not to be inclined to be able to do so…
I guess that is the crux. Because if we can teach it then we don’t need to screen for it. What Mike and I were talking about screening/testing for is less the situational awareness and more a strong sense of willpower and resilience. I am not sure those two can be taught.
Love that topic. Way before i got into nursing I was into first aid. Always love the unexpected and how to deal with it. That is one other reason I love the outdoor ( another place you learn resiliency). After hearing the talk I realize i had the type of personality you discuss to come out of those testing. Way before I had the critical care knowledge. So i believe it make totally sense to test people that enter the profession. I actually always wonder why MD get to specialize in their training but nurse don’t. Why can’t we have… Read more »
As i think more that concept I have a few more questions to add. If we go with the example of the army, can you train a large group as an elite? Example, can the same concept of special forces be applied to regular army? Cause if the goal is to improve the quality of emergency can it be expect to train the number of ER required for the system. I can see appying those concept to group of health professional with high acuity but just as the special forces require the regular army and can the concept be appied… Read more »
Daniel, I love the thoughts of zen koans as a mental test. That would make a great interview question just to see the reaction of the interviewee.
Dr. Weingart, I am a 4th year medical student going into EM and listened with interest to your thoughts on how it might be possible to select better residency candidates by observing how they perform under stress, perhaps through a simulated code. With interview season just around the corner for me, I have to say this idea provoked a fair bit of angst. These are my thoughts. As medical students, we are taught to absorb a great deal of information, do well on multiple choice tests (namely our board exams), and to learn the basic aspects of general medical care.… Read more »
Dylan, all great comments. I’ll respond to the last piece. You are absolutely right about EM–that is why on the show we separate out resuscitationists–docs from all specialties that take care of the critically ill as a large chunk of their work.
Dylan I would agree partially with your comment. When i started my career in critical care I was like you nervous and anxious and all. But i remember that in nursing school in front of a problem i would act differently then some other student. And most if the student that was like me became or had an interest in emergency medicine. So I believe there is a component of personality attach to learning the skills. The frame before decorating the house. I believe that could assess during interview. Actually even in the last few years I notice how new… Read more »
Dylan, Good thoughts. While I agree that we should teach stress coping skills to residents, where I would disagree is the comment regarding high stress only applying to critical patients. Most of the job of an EP is handling stress many other specialties don’t face as consistently. We deal with multiple patients with multiple complaints, in a loud, chaotic environment filled with interruptions and a minefield for error. The patient who appears non-critical could be a time bomb. Sometimes the non-critical patients cause more stress than the sick ones. Residency itself is stressful as well, for reasons both related to… Read more »
fantastic, Bob. Maybe we should have 7 interviewers asking their ?s at the same time to truly simulate Monday in the ED.
Hey Bob, Thanks for your thoughtful comments on my post. You are all bringing out an interesting perspective which really was not even on my radar (but probably ought to be, as interviews are right around the corner!). I am starting to recognize what a difficult job you have in selecting those residents that you feel are best suited for the specialty and your particular program. I think I am by nature fairly skeptical of the ability of interviews to get at the intrinsic qualities of applicants that we most desire, but perhaps I’m wrong about this. I imagine that… Read more »
Scott and Mike, Great discussion! I particularly like the part about the pre-selection process. While I agree with Minh that medical school in and of itself is a significant indoc process it is only part of the process for EM/CC, since this is small subset of the house of medicine and requires a particular skill set that is not required of an internist, surgeon, etc. I have thought about this recently as I have transitioned from being a resident to now being faculty teaching residents. However, I feel that residency is not the time for an indoc process. The selection… Read more »
Yes! It would be so much better to go poaching in the 3rd year and early accept these folks into your EM program and grab the right rotators as well. This kind of beauty is prevented by the match, unfortunately. I’d love to run the megacode during the med school rotations and offer the spot there and then.
Scott you did ask for feedback on the idea of a military style selection process for EM/CC residency, using simulation under stressful condition. I am glad Dylan provided comment on this already so will add my own now. EM is not just about resuscitation as Dylan points out. I accept though that using a simulation exercise as one component of a selection process may help find better suited candidates for one element of EM practice like resuscitation but the whole picture needs to be considered and is why I suspect your selection panel colleagues protested at your use of the… Read more »
Minh, you know I don’t want to turn every ED into an ICU; I want every ED patient to have immediate access to ICU care both in terms of equipment and the doc caring for them. Whoever that doc is and whatever specialty they are from–they are the person we are talking about in this episode. If that means we need a separate specialty from EM for the reasons you mention, I have no problem with that at all and it probably must inevitably happen. EM is currently a specialty created around a physical location rather than a specialization.
Really awesome talk!! As a paramedic who also spends a significant time teaching, my experience has been that there are some similar deficiencies in EMT and paramedic training. One of the things I’m struggling with in thinking how I can apply the principles of an indoctrination process is finding non-medical assessments for the attributes we think should define an EMT/paramedic. I would personally love to see something similar to the PJ indoc for my EMT classes, but I think the students (and the department chair) would be less than enthralled 🙂 I also found Mike’s 4-phase stress inoculation plan very… Read more »
fantastic comment Ben, I love it
Hello Dr. Weingart and Mr. Lauria, Thoroughly enjoyed the podcast! Just wanted to add in my two cents: I am still in the “pre” phase of my medical career at USF in Tampa, Fl, but I am very fortunate to have a job in the ED and ICU at a trauma center. I have been exposed to, and involved in to a minor extent, resuscitation situations and procedures and have done my best to learn them and try and take away skills from them. To that, personally I would LOVE to have Dr. Weingart as my interviewer asking me to… Read more »
Absolutely agree–can’t spring it on them-that would be horrible! I have heard about interviews where the interviewer fakes a heart attack, but these may be apocryphal.
Thanks guys for your thoughts and feedback. Having A) not been through the interview process and, therefore, B) certainly not conducted an interview I am curious and I have a question for everyone: Do you think that it’s reasonable to ask an interviewee to do something that they have on their CV that they are qualified to do or explicitly denote they can do. So, if someone has an ACLS card do you think it’s reasonable to ask them to walk through a scenario? I’m not talking about a stressful scenario, nothing crazy…AHA style (for better or for worse). If… Read more »
I completely agree with this. If you put something on your CV, or claim to be able to do something, then it should be no problem to be able to perfom it if called out. One wouldn’t put “fluent in Spanish” on a resume and then be surprised if they are talked to in Spanish, I’ve seen it happen. Same thing goes that if someone says “I do central lines all the time,” thb it should be no problem to walk through the procedure of asked to.
yep
Hello all,
I am an anaesthetic trainee (anaesthesiologist!) In the UK. For my last two positions, I have undergone an OSCE type selection process. These have involved structured interviews, 5-minute presentations, and sim station. For my most recent interview, I was asked to simulate providing an anaesthetic to one patient, who suffered a cardiac arrest whilst also being asked to help in another theatre where a patient had airway problems. Moderately stressful! They attempted to validate this interview method with follow up interviews and reviews: http://m.bja.oxfordjournals.org/content/105/5/603.full
holy crap, thanks so much for sharing that Lauren–I am bumping the article up to the shownotes right now!
Lauren,
Thank you very much for sharing. It sounds like an intense and very challenging selection program.
If you don’t mind me asking, how do you feel about your peer group? In your opinion, do you think this was an effective tool? What, if anything, would you change about the program? Finally, is this relative common practice for programs in the UK?
-Mike
Thanks for your interest. Certainly I look around at my colleagues and I cannot find the “joker in the pack” (so it’s probably me!) I remember leaving both interviews feeling as though, if I hadn’t gotten the job, then it wasn’t because the process was inequitable- I felt that all aspects of my skill and mind-sets had been tested. I am not sure exactly how common this process is, but it appears anecdotally to be gaining popularity especially in UK anaesthesia. No reason it couldn’t be extended to EM, and may already be happening. I shall enquire of my EM… Read more »
Mike, As to your question about what is fair game in an residency interview, I think everyone will have a different take on this, and I also have very little experience in this area, having had just two so far. I don’t think that it’s unreasonable to ask someone to walk through a procedure that they are familiar with, but I’m also not sure it’s super high-yield, either. Most interviews are limited to about 20 minutes, so there’s only so much that can be discussed. I have run into this as a member of the admissions committee at my med… Read more »
Dylan, the thing you may see when you contrast residency level interviews with med student interviews is that your goals and yields are entirely different. The questions you mention serve no purpose in residency interviews. By this time anyone you will find anything useful with questions like those have already been screened out by the med student selection process. All of these folks are already legitimately skilled in these areas or more than articulate enough to say what the interviewer wants to hear. That form of interview is virtually worthless and decisions made by it inevitably turn out wrong. I… Read more »
Scott, Great topic and Mike is a fantastic guest, yet again. I think it’s important to address stress coping skills and how to function efficiently under pressure. The part that worries me is the discussion about putting applicants / med students through a stressful “indoc” process. I would have certainly FAILED! I went to LAC+USC for undergrad and never took ACLS, as it was not required. My residency program (MetroHealth / Cleveland Clinic, Case Western Reserve) encouraged us to wait to take it as interns so they could cover the cost for us. I had no background in medicine whatsoever… Read more »
Jess-totally agree; this couldn’t be something sprung on med student the day of. If anyone was to actually do this, they would have to let it be known well in advance so everyone has a level playing field. In fact, I don’t think the benefit would be diminished by telling them the exact scenario ahead of time. It would be the reaction to stress you want to see, not the ability to remember the drug regimen for vfib.
I think this can be boiled down to sensitivity and specificity of the “indoc” process for the outcome of, lets say a competent EM resuscitationist at the end of three or four years of training. My hunch is that it would be specific, but not sensitive ie. it would exclude some med students who do have that potential. I think this is particularly true for medical students (as opposed to say, PA school) as prior clinical experience is not typically required or even encouraged. Similar to what is described in On Combat, some of these folks will have had their… Read more »
Mitch I hear you. We were just discussing this very topic at Levitan’s airway course this weekend. My focus is I do not want to solely draft the 5% of medical students that are already stress-hardened and ignore the other 95% (which is probably what the Pararescue Indoc is trying to do). Instead, I want that 5% and the 90% that are trainable. What I am looking to weed out is the 5% that will never get there through residency. In the past 10 years that percentage is pretty close to my experience. 1/20 will not make it, not because… Read more »
Scott and Mike, Another excellent podcast because, as usual, it keeps me thinking outside the box. As a PEM doc I realize now that my indoc process was pediatric residency itself. It’s where I understood my love for resuscitation and where my mentors (attendings) could evaluate my ability to work under pressure. EM docs don’t have this and therefore the issue with selection of qualified medical students has bubbled to the surface. Perhaps EM should have a one year internship in IM as its indoc process. (Throw tomatoes now…) Second point is realizing that not all of us have the… Read more »
peter-fantastic
do u have his contact info?
Thank you Scott and Mike for a fantastic talk/interview. I really enjoyed listening . I used to be a paratrooper medic in the German army before I studied medicine. The resilience and mindset I was taught as part of my military training have certainly helped me in my chosen profession as ED doc. I completely agree that stress inoculation can be a great tool to improve performance in high stress situations. The saying that in a stress situation you fall to your level of training is certainly true and therefore you have to train under the most stressful conditions you… Read more »
cheers, Andi
Maybe should call it more critical thinking vs just ” working under fire”. As many mention we are in not always in resus bay but we always need to think on our feet and be creative. What i hear people say is it take certain type of person do deal with what we see. Just as in the ” regular” army an see a lot despite been the ” 90%” not chosen by the elite. They still need some skill and stress induce in their job. Maybe what all training( paramedic,nursing,md) need people that can handle that better and that’s… Read more »
Hey all, I can say that, after many years in EMS education, as well as several years in the 101 ABN Div , I absolutely agree with you, but man is it a hard sale to our policy makers and bean counters. I would like to share with you what I am rather proud of as a small weeding out process and completely atypical for the industry. it is easy to do , easy to evaluate objectively, and remarkable effective in picking up some behaviors we would never otherwise see. It hits probably 99% of your points. I am going… Read more »
I followed and holy crap that is great–just perfect Steve!
There is a new article in the August 21 edition of Academic Emergency Medicine which attempts to formulate a consensus on medical student milestones during the 4th year. They assembled a research team including clerkship directors, assistant deans, and a medical student who compiled a list of 39 milestones which were then reduced to 24 through consensus building using a modified Delphi technique. Interestingly, they did not identify any milestones relating to stress response or working in high-pressure situations. From what I’m hearing in this discussion, this may be a major omission. Acad Emerg Med. 2014 Aug;21(8):905-911. doi: 10.1111/acem.12443. Epub… Read more »
Dylan-great ref and thoughts.
Scott and Mike First I was never at Mike’s level and not a physician, I was a Navy Corpsman, Flight Marine Force, Paramedic then attended nursing school and worked PICU, ICU, ED and Pre Hospital. I tended the University Of Texas Emergency Nurse Practitioner Program in 2003. My interview included 3 scenarios – not asking much for advance knowledge but with 8 years of various experience they were testing my thought process and as Elda continued to fire more information I ended with a elderly female in rural area hospital with DKA, AMI and head bleed. I thought at the… Read more »
William, thank you for sharing this!
I am a PGYI EM resident at NYHQ in Flushing. With regard to 1) a hands-on interview process for emergency medicine residents, and 2) models of mental toughness and resilience that do not involve the military: 1) Prior to entering medicine I was a high school and middle school English teacher. I began teaching with Teach For America (TFA) and taught 9th grade English for two years at Malcolm X Shabazz High School in Newark, NJ. After listening to Mr. Lauria describe the selection process to become a PJ, and the pipeline of training after the selection, I saw many… Read more »
fantastic, non-military example. Thanks Myles
Dr Weingart & Mr Lauria – fantastic podcast & show notes. Tons of great advice & things to think about… I’ve thoroughly enjoyed listening & reading through the comments about the validity & potential for various ways to test medical students prior to applying for EM residency programs. As a means to help med students prepare for the rigors of a career in medicine (of any discipline) or for an interview process like the ones being discussed, I would point them to NOLS’ Medicine in the Wild course. First, I will say I’m completely biased as a wilderness medicine instructor… Read more »
fantastic resource
Thank you for the fantastic article and thoughts – there seem to be a number of inter-related issues: Is coping with stress / resilience teachable or inherent? There are some interesting comments about children with adversity/ people in prior stressful careers that have already developed resilience. I have no evidence but Scott’s figures above sound good (5 % inherent, 90 % teachable, 5% do not seem to get it). I suppose the main point here is that a certain amount of people do not have the ability – without an intake screen these people get to the end of their… Read more »
excellent. must admit, I am definitely not tough enough to cave dive. scares the heck out of me.
Great discussion. I liked Mike’s comment about progressive desensitization (I’m not sure if he called it that exactly). I have experienced this in a very basic way when becoming an Urban Combatives Instructor (my instructor is the chap in the “contentious” self protection blog posted by Cliff Reid) and have tried to translate this to our regional simulation program. We use RSI and airway management as the common thread to teach many critical care techniques. The key I think is incremental change. We start the sim sessions by refreshing people’s knowledge, and then refreshing skill with stations or OSCEs. The… Read more »
Scott, Mike, Great podcast. I am currently an ultrasound director and ED attending, but in a former life was an Army Ranger with combat and peace keeping tours in Afghanistan and Kosovo. I can appreciate the discussion about indoctrination and the mental toughness required to do ED and critical care. There is a mental switch that you need to turn on in order to operate in combat, turn it off when done, and have the mental strength to deal with the experiences. I was able to draw on my experiences and inner strength that I used while deployed and on… Read more »
thanks Scott. Wonderful to hear real world perceptions of the concepts.
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… Read more »
Beat The Stress, Pity the Fool?
C
Oh…snap. I can’t believe I didn’t think of that one. Funny how it takes witty and intelligent Australians to point these things out when I grew up watching the A Team. Thanks, Chris.