Dr. Meaghan Keville is an Active Duty EM physician stationed at CSTARS Baltimore at the R. Adams Cowley Shock Trauma Center. Graduated USU in 2010 and then completed EM Residency at Wright Patterson AFB/Wright State University 2010-2013. She has been forward deployed with CCATT, TCCET and with a field surgical team in support of USSOCOM.
In this lecture, she discusses the importance of mindset and mental fitness in medicine and as she has recovered from injury.
For access to the slides and to view the whole lecture, visit:
https://pheedloop.com/GSS21/virtual/?page=sessions§ion=SES77CTYP9E0I4MOC
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Episode Transcript
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Meaghan Keville (00:01):
Hello again, everyone and good morning. For
those of you that I may havemissed yesterday, I'm making
Cavill, an active duty Air Forceem physician at sea stars in
Baltimore. Here to share withyou today a bit more of a
personal topic, a look intowellness and cognitive
performance.
Unknown (00:55):
On February 20 2020, my team was on alert at a small FOB
when a 107 rocket round impactedabout 30 meters from my
aircraft, and a small fragmentfrom that round came through the
wall where I was seated.
All I remember from that momentis feeling like someone had hit
me in the back with a baseballbat full swing. This small
(01:18):
fragment struck the body armorthat I was thankfully wearing. I
didn't know it at the time. Butthat event would change a lot of
things for me. I woke up thenext morning in a fog with a
pounding headache. My head hadbeen leaned against the skin of
the aircraft when the blast hadoccurred. And I was feeling the
(01:41):
effects of the TBI later thatmorning, and not came on the
team tent door, and a wellrespected Senior Chief from the
Special Operations team thatwe've been supporting, asked to
speak to me. He'd heard aboutthe incident the day prior and
had come to see if I was doingokay. I told him I had a bit of
(02:01):
a headache, but I would be fine.
He looked at me sort of doubtingLee and said, I know you're
physically okay. But are youreally okay? I told him that
things would heal. And I knew Iwas lucky. Things could have
been far worse. If I hadn't beenwearing my body armor. Since we
(02:23):
were inside the house goes onFOB. Or if the frag had been
just slightly higher above myplates. This guy knew better and
asked me if I'd go for a walkwith him. He told me he'd been
here before in the world of nearmisses. He told me about how he
thought he was fine too. Untilabout four months later, when he
(02:47):
found himself drinking heavilydaily, constantly angry at odds
with his wife and yelling at hiskids. He told me how he finally
realized how the Near Miss hadaffected him. And he'd found
some help. I was humbled to hearthat someone I considered far
braver and tougher than I wouldever be had struggled. But I'm
(03:08):
grateful that he told me when Iarrived back to the US a few
weeks later, I was still havingheadaches and struggling with a
bit of a post concussivesyndrome. I followed up with my
primary care doctor and begantreatment at the National
Intrepid Center of Excellence.
(03:31):
And then COVID arrived, I foundmyself working q3 Call in the
ICU watching young, otherwisehealthy people die on ECMO. Once
again, working in a job that washigh risk. Everyone was tired,
and I was no different. Exceptthat I'd never really adjusted
to the time change of being backhome, nor the sympathetic
(03:54):
overdrive that would keep meawake after I'd come home from a
call, not really allowing me tosleep when there was finally
time for it. I was stillstruggling with post concussive
syndrome, persistent headaches,short term memory loss, and I
was downright exhausted.
isolated by the virus from thepeople I cared about, and that I
(04:14):
knew cared about me. I foundmyself one night, curled up
alone and sobbing on my bathroomfloor. It was in that moment
that I knew what that operatorhad been telling me. I knew that
if I didn't do somethingdifferent things were going to
continue to get worse. And Ididn't know what that might look
(04:37):
like.
It was terrifying. I spoke withmy leadership, and for the first
time that I can really recall, Iasked for an accommodation and
for some help. I removed myselffrom clinical duties for a
couple of weeks, and I began avery long road to recovery with
(04:59):
a fair amount of health I beganto learn about how our brains
work, and began to investigatehow to improve the performance
of my own. Along the way, Ifound myself learning a few
things that I wished I'd knownbefore I'd ever been injured. So
I'd like to share a few of thosethings with you. You might tell
yourself, you haven'texperienced any specific trauma,
(05:21):
and you're pretty well adjusted.
Why does any of this matter toyou? This image is an important
reminder that over 45% ofphysicians and 43% of em
physicians reported havingsymptoms of burnout in 2020. And
the evidence has linked onepoint changes in burnout scores
with meaningful differences inadverse outcomes. Although the
(05:42):
things we'll talk about todaywon't change your crappy EMR,
difficult leadership orchallenging patients, hopefully
they will help you to deal withall of those things in just a
little bit of a better way. Manyof you may be familiar with
Lieutenant Colonel DaveGrossman's interpretation from
the book on combat of ourphysiologic response and ability
(06:03):
to perform a task when understress. As stress on the human
psyche increases, there is apoint of optimal functioning for
any given situation. However,too much stress results in poor
performance, it is an excellentmodel of how the mind and body
will behave at a single point intime. However, I argue that this
model is incomplete, as it onlylooks at the problem in the two
(06:26):
dimensions one point in onetime, and is unfortunately not
how we live life. In order togive some depth to the mental
model and incorporate the thirddimension, time, I figured I'd
start with one I assume asemergency physicians you're all
familiar with. Not sure how therate of D saturation has
(06:49):
anything to do with stress andwellness. Allow me to explain.
You'll have to pardon mydrawings. But stick with me for
a moment and hopefully it willmake sense. Consider your
personal wellness as the greenline here. Whether you want to
believe it or not. Each of us ishuman and has a point where
performance and wellness can'tstand up to stress any further
(07:11):
and it begins to deteriorate.
Much like Colonel Grossmanreferred to getting into the
black. However, one mustconsider how long it takes to
get to that point in any givensituation, and how steep the
drop will be once things beginto compensate. For example, here
(07:33):
you are plotting along on yourgreen line, a rather high
performance individual. When youget some short notice orders to
deploy, you travel across ninetime zones, lose the daily
support of having your family byyour side, and begin to worry
about your kiddo who's hadtrouble in school that sits in
(07:54):
the back of your brain all thetime, you're still likely to be
able to perform at your normalcapacity. But some of your
available cognitive bandwidthhas already been utilized. And
your views may be just a littlebit shorter. What is this
cognitive bandwidth thing youmight say? It refers to our
cognitive capacity, our abilityto pay attention, make good
(08:16):
decisions, stick with our plansand resist temptations. Think of
it like the internet bandwidththat may run through a cable
like this one. There's a fixedamount of information that can
be transmitted in any giventime. Keep too many things
running in the background andyou can overwhelm the system.
More on that later. But let's goback to you on your deployment.
(08:40):
You're now midpoint through yoursix month deployment. You never
quite adjusted to the timechange and operations have been
busy. It's been over 100 degreesevery day. And let's face it,
your fuse is just a little bitshorter. In addition to pay
really has not started off well.
There were three rounds of IDFovernight, the Wi Fi is down.
(09:01):
The shower is cold and someonepeed in your Cheerios. Turns out
the likelihood that you willmove more quickly from Colonel
Grossman's condition red tocondition Black is pretty darn
high. And the chances that thiscould affect your performance on
(09:22):
this afternoon's mission, alsopretty high. The question then
becomes how do we move the curveto the right and dare I say,
flatten the curve?
And is there a way to climb backup once we've started to slide
off the edge? Can we buy backcognitive bandwidth? Well, logic
(09:49):
would say there must be or weprobably wouldn't be here
talking about it. But it turnsout like climbing any height it
takes some work. I will prefaceby saying that in this talk
Today, we'll probably only havetime to scratch the surface on
the continually growing amountof available information on
cognitive performance andpersonal wellness, which in
(10:09):
truth go hand in hand. Andadditionally, I am not a formal
expert on either merely a personwho learned some valuable
lessons the hard way, andthought there might be someone
in the room who could benefitfrom those things I learned. So
let's begin. First is probablyimportant to have a baseline
understanding on the inputs thataffect overall peak performance.
(10:31):
Remember that cognitivebandwidth I mentioned? Well,
here's your fiber optic cable.
All of these factors play a rolein allowing us to perform at our
best, and we can influence themall in different ways. As we
move forward, we'll look at someof the things we can do to
influence the amount ofcognitive bandwidth we have at
baseline, and how to try to buysome back when it's limited.
Let's start by looking at movingthe curve to the right. We're
(10:56):
increasing our baselinecognitive bandwidth. How do we
build our ability to cope withlong duration stress, often
referred to as resilience. Weused to think that it was done
by repeated exposure to longsleep deprived periods with
intense stressors and embracingthe suck. It turns out what that
builds is people who are brokenand burned out. Now don't get me
(11:21):
wrong here. This is not mesaying that we shouldn't flex
our bravery muscles, do hardthings, take risk, fail and
grow. This is me saying we'vegot to be smart about the way we
do it. In order to createlasting improvement. We've got
to utilize Ernie ability torewire the brain to adapt in a
(11:41):
positive way, neuroplasticity.
But buyers beware. This is slowchange managed by hormones such
as cortisol, building neuropathways, and it takes effort
and time. In order to make achange, though, the first step
(12:01):
is to recognize that our brainscan be trained. Attitude is
everything. This concept isadapted from the book Mindset by
Carol Dweck. In it she exploresthe idea that adapting a growth
mindset, a mindset thatunderstands the abilities and
success can grow with hard work.
She introduces the concept ofnot yet the idea that success is
(12:22):
not necessarily in having theright now right answer and not
in perfection. But in the ideathat if you don't have the right
answer yet, you can reach it.
And that success comes from thejourney. That difficulty and
effort don't mean that a personis not capable or not smart
(12:43):
enough, just that they haven'treached the endpoint yet. Take a
moment to ask yourself, Arethere areas of your life where
you've accepted that somethingjust is as it is, and that
you'll never never be able to doit? When is the last time that
you challenge yourself to dosomething hard? Something that
(13:04):
you could possibly fail. Thisbrings me to my first
recommendation. The idea of amindfulness practice may sound a
little hippie. However, evidenceis mounting that mindfulness
practices can help you performbetter, be more confident,
improve your mood and reduceanxiety. mindfulness practice
(13:27):
allows a person to be more awareof where their cognitive
bandwidth is focused at thepresent moment, to engage with
the task at hand and to be ableto recognize the things that may
be pulling us away and shiftingattention. Taking the time to
allow the mind to wander givesit space to struggle with things
that are important, but notnecessarily active. It creates a
(13:48):
window for the exploration ofthe past formation of memories,
connecting learning experiencesand dealing with residue. More
on that in a moment. Inaddition, in the medical world,
mindfulness practice has beenshown to be successful in
improving pain management,treating depression, anxiety,
(14:09):
and improving coping mechanismsfor patients with chronic
disease. Understanding your ownmind will help you to learn how
to use it to perform to itsmaximum potential.
There are many options to starta mindfulness practice, if
you're willing to give it a try.
There's little harm and it cantake less than five minutes of
your day. Here are a few greatapps that can help. Many are
(14:30):
free, including the PTSD Coachand CBT eye which have been
developed and produced by the VAand have specific tools designed
for people dealing with PTSD.
You know that case? The one youwill never forget the child that
died. The baby you delivered themistake you made. The woman
(14:55):
whose husband shot her in thehead, or the soldier whose life
you saved That is residue. Thepieces of intense experiences
that we carry with us, we'll alldemand to be recognized at some
point. If processed well residuecan create meaningful stories
and memories to carry forward,share and learn, if not dealt
(15:18):
with, these things can become anightmare that plays on repeat,
slows cognitive, bandwidth andneeds of the soul. Consider a
journal where you can process atthe speed of handwriting, a
standing meeting for coffee witha friend who has similar shared
experiences, or scheduled timeat the end of the workday. Five
minutes before you get out ofthe car when you get home, to
(15:41):
spend with the intense momentsof the day. As mammalian
primates we are designed to haveincreased levels of oxytocin
when we are supported and haveconnection with our tribe. As it
turns out, oxytocin does a bitmore than stimulate lactation in
mamas, all mammals demonstrateoxytocin receptor expression in
(16:02):
the mesolimbic social decisionmaking centers of the brain or
the social survival region ofthe brain. These regions
ultimately mediate aggressive,emotional and sexual behaviors,
and attribute social salience tospecific sensory or
environmental stimuli.
Additionally, animal and humanresearch has also demonstrated a
role for oxytocin in improvingwound healing following
(16:26):
traumatic skin injury. MostRecent studies have shown that
stress induced increases andoxytocin levels may act as a
feedback regulator to enhancerecovery from stress related
symptoms. And that socialconnections that increase
oxytocin levels can promote bothcognitive and physiological
resilience. If you don't likeany of those points, and you
need one more good excuse towork on your connections with
(16:49):
family and your tribe. Know thatadministration of oxytocin in
rodents and primates leads tosustained weight loss by
reducing food intake, increasingenergy consumption and promoting
promoting lipolysis. Yep, that'sright. Improving your connection
can help you lose weight aswell. Gratitude is one of the
concepts most commonlyassociated with well being from
(17:12):
an empirical point of view.
Despite this, we seldom use thisconcept, possibly due to a lack
of dissemination of itsscientific basis and clinical
applications. At an anatomicallevel, the expression of
gratitude is relatedconsistently with a medial
prefrontal cortex, and then amolecular level again, with none
(17:36):
other than oxytocin. Gratitudehas been associated with better
physical health parameters suchas decrease in pro inflammatory
markers, better cardiovascularfunction with decreased blood
pressure and improved heart ratevariability. It also is
associated with better sleepquality. From a mental health
(17:58):
perspective, it has beenassociated with results such as
higher levels of positiveemotions and life satisfaction.
Gratitude has been demonstratedto decrease anxiety and
depressive symptoms, substanceabuse and suicidality. In
addition, it has been associatedwith better quality of life, and
greater adherence to treatmentand patients with chronic
(18:20):
disease. Not sure where tostart, consider taking a moment
each night before going to bed.
Try to think of three thingsyou're grateful for. Challenge
yourself to find the smallestthings possible. Pro move, write
them down. Many of us are wellaware of the physical and sleep
(18:40):
related benefits of exercise,but often forgotten are the
cognitive benefits. Multiplestudies have demonstrated that
exercise has beneficial effectson cognitive performance,
executive function, workingmemory, self esteem, mood and
motivation. So if you're readyto take over the world, you can
get started with a few push ups.
(19:05):
It wasn't until a few years agothat I recognize the importance
of the third thing. The thirdthing is the thing that
separates work life and homelife. The icing in the middle of
the Oreo cookie, you know, thatis the best part. Research has
shown that military memberstransition out of their active
duty career. The people who tendto handle the transition best
(19:27):
are those that have some sort ofidentity and meaning that isn't
linked to the military. Itreminds me of an anecdote a
friend of mine shared with me.
He'd gone on vacation to NewZealand and found himself
chatting with a stranger at abar. He asked the stranger what
he did. The man replied, I'm asurfer. Now this man did not
look like a professional surferby any stretch. And apparently
(19:51):
this was written all over myfriend's face as the gentleman
looked at him and replied, allof you Americans have got it
wrong. Yes, I have a day jobthat pays the bills. But it's
not what I consider as the thingI do, or who I am. How you
define yourself matters. If allyou are is your title, you will
have a challenge when you nolonger have that title. You may
(20:13):
be thinking, Oh, this soundsgreat, but it also sounds like a
lot. How do you really have timefor all of these things?
Creating a battle rhythm issomething that the military is
sometimes excessively good at.
But as individuals, not all ofus are, and yes, I get it as em
(20:35):
physicians, we rarely have theluxury. But if we once again
reach back to our primal rootsas man mammals, we can learn
that we truly are creatures ofhabit. Our circadian rhythms
appreciate some predictability,allows our body to know predict
and manage the timing of hormonerelease, and how and when to
manage and conserve energy. Inaddition, having a battle rhythm
(20:58):
frees up cognitive bandwidth,you might ask how? Well we each
have a finite amount of mentalenergy that we can expend on
decision making before our brainstarts to look for a shortcut.
It at least partially explainswhy weekend shoppers impulse buy
and elite athletes makeunaccountable decisions at the
end of a game. decision fatigueis also a well recognized reason
(21:21):
behind poor clinical decisionmaking, decision avoidance and
as a precursor to burnout. So ifyou're able to be efficient
about the number of decisionsyou need to make in a day, if
the questions about when to wakeup when to workout I went to
meditate are already answered,then there is more energy
available for your brain to workon the more important questions
(21:41):
like whether or not to giveanother unit of blood. There is
very little objective data onthis concept for deployment.
However, anecdotal informationindicates that developing a
consistent battle rhythmdownrange as soon as possible,
helps transition occur morequickly and improves both
physical and mental performance.
We've now touched on a few waysto move the curve to the right.
(22:02):
Let's take a few minutes to talkabout some tools to help you
climb out when you're runningout of bandwidth. The stress
response to the body wasdesigned to protect us from
predators and danger. Butsometimes it can be less than
helpful. The amygdala is thepart of the brain that signals
danger to the sympatheticnervous system. When the
stressor is great enough, it canoverride the compensatory
(22:25):
rational brain that keeps it incheck. This is considered to be
an evolutionary response to theenvironment where there is no
time for rational thinking.
However, in most situations weare exposed to this is an
inappropriate response toprotect our well being when our
physical well being really isn'ttruly in danger. The best way to
(22:47):
buy back some cognitivebandwidth is to get the amygdala
back in check. Here are somesimple ways to save your day.
The first thing I'd recommend istake five. If you can take a few
minutes to step away fromwhatever is the triggering
situation. Go for a walk,breathe some fresh air. The
(23:09):
University of Maryland where Ispend most of my time has even
developed the T five programwhere staff members can come and
grab a take five bag forthemselves or a friend. They've
got a small bottle of water anda healthy treat. As it turns out
your basic training ti hadsomething right by forcing you
to drink water all the time.
Besides not becoming a heatcasualty hydration status has
actually been linked in somestudies to both cognitive
(23:30):
performance and mood. Who wouldhave thought that those guys
could have been doing anythingthat might improve your mood?
Speaking of improving your mood,did you know that the
neurotransmitter dopamine ismost commonly associated with
reward and happiness? Findingthe things that trigger dopamine
release will help to dial downthe sympathetic nervous system
(23:50):
and help to improve feelings ofcalm and focus to things
integral to performance and highrisk situations like the recess
Bay. What's the best way to findsome dopamine? Well, what do you
do for fun?
A surprisingly small amount ofadults actually have an answer
(24:11):
to this question. And the numberis even smaller within a
military culture that places astrong value on pulling up your
bootstraps and giving 100% ofyourself to whatever your
country needs. However, playlaughter and joy are an integral
piece to managing stress isreported that in ancient Sparta,
the second most valued skill ina man after his martial prowess
(24:32):
was his singing ability. Thinkback for a moment when you were
a child, or think about what youtell your children. When things
are stressful. What does a goodparent do? Well, they kick their
kid out the back door and tellthem to go play of course. So
why don't we do the same? Ifplay isn't your thing, tell a
joke. If you think about it fora moment, you can remember being
(24:54):
in a tough situation that seemsto be falling apart. When
someone cracks the perfectlytimed joke. You'd better believe
it. That's dopamine to thefeeling of warm sunshine on your
face. Dopamine, listening togood music, dancing, dopamine,
(25:14):
is it starting to sink in yet?
The last tool that I have foryou is an old one, an easy one,
an oft forgotten one. Ask anysniper and they will tell you
that the best way to dial backthe sympathetic nervous system
and activate the parasympatheticis to breathe. Emotions have
been documented to changebreathing patterns, and
(25:38):
breathing patterns have beendocumented to change emotions.
Controlled patterns ofbreathing, thus can serve as a
powerful tool to impact andshift emotional states. There
are many ways to utilize thistool. And the best part is, no
one in the room has to knowyou're doing it. As far as how
to do it. There are a lot ofdifferent methods. The one most
(26:01):
commonly referred to in themilitary populations is called
the box method that can be seenhere. Another method that is
even simpler and focuses on thelong exhale, which is more often
associated with parasympatheticactivity is to take two short
inhales through your nose, andthen a long exhale. Give it a
(26:21):
try. I'll wait. I promise, noone's looking.
As I come to a close, you'llhave to forgive my blatant
(26:42):
plagiarism of my currentfavorite podcast, the mission
critical team Institute teamcast, we're at the end, the
narrator Coleman Ruiz talksabout what to do on Monday.
Here, we'll circle back to thefirst steps you can take to
improve performance and wellnessand the mission critical
environments in which we alloperate. I'll remind you that
this is only a brief glance, andthat there are many different
(27:06):
ways to train your brain toperform at its peak. Number one,
be vulnerable. have thedifficult conversations. And
remember that a person can drownin six inches of water just as
easily as they can drown in sixfeet. That's why I'm here today.
(27:26):
Because I know that I had theperson who shared his struggles
with me, not taking the time outof his day to check in and tell
me about his experience. I maynever have realized that it's
okay not to be okay. And thatasking for help is not a sign of
weakness. So I encourage you toshare your story. You never know
(27:47):
what it might change for someoneelse. Number two, balance, self
career family. All three requireintentional focus and too much
energy on any one of the threeand the other two will suffer.
Number three, do something foryour brain and your body every
(28:11):
day. This does not have to becomplex for the brain. Take five
minutes to meditate. Learnsomething new, that doesn't have
to do with work. Write in yourgratitude journal. For the body.
Go for a walk, or a hike, ride abike or play with the kids.
(28:31):
Number four, have a third thing.
Work workout and what? For meit's putting my head in the
clouds. What will it be for you?
And finally, don't forget to Briif you're intrigued by today's
discussion and want to look intothese things further, here are
(28:52):
some places I'd suggeststarting.
Thank you all for your timetoday. I'd be happy to answer
any questions now or feel freeto send me an email
Hello again, everyone and good morning. For
those of you that I may havemissed yesterday, I'm making
Cavill, an active duty Air Forceem physician at sea stars in
Baltimore. Here to share withyou today a bit more of a
personal topic, a look intowellness and cognitive
performance.
Unknown (00:55):
On February 20 2020, my team was on alert at a small FOB
when a 107 rocket round impactedabout 30 meters from my
aircraft, and a small fragmentfrom that round came through the
wall where I was seated.
All I remember from that momentis feeling like someone had hit
me in the back with a baseballbat full swing. This small
(01:18):
fragment struck the body armorthat I was thankfully wearing. I
didn't know it at the time. Butthat event would change a lot of
things for me. I woke up thenext morning in a fog with a
pounding headache. My head hadbeen leaned against the skin of
the aircraft when the blast hadoccurred. And I was feeling the
(01:41):
effects of the TBI later thatmorning, and not came on the
team tent door, and a wellrespected Senior Chief from the
Special Operations team thatwe've been supporting, asked to
speak to me. He'd heard aboutthe incident the day prior and
had come to see if I was doingokay. I told him I had a bit of
(02:01):
a headache, but I would be fine.
He looked at me sort of doubtingLee and said, I know you're
physically okay. But are youreally okay? I told him that
things would heal. And I knew Iwas lucky. Things could have
been far worse. If I hadn't beenwearing my body armor. Since we
(02:23):
were inside the house goes onFOB. Or if the frag had been
just slightly higher above myplates. This guy knew better and
asked me if I'd go for a walkwith him. He told me he'd been
here before in the world of nearmisses. He told me about how he
thought he was fine too. Untilabout four months later, when he
(02:47):
found himself drinking heavilydaily, constantly angry at odds
with his wife and yelling at hiskids. He told me how he finally
realized how the Near Miss hadaffected him. And he'd found
some help. I was humbled to hearthat someone I considered far
braver and tougher than I wouldever be had struggled. But I'm
(03:08):
grateful that he told me when Iarrived back to the US a few
weeks later, I was still havingheadaches and struggling with a
bit of a post concussivesyndrome. I followed up with my
primary care doctor and begantreatment at the National
Intrepid Center of Excellence.
(03:31):
And then COVID arrived, I foundmyself working q3 Call in the
ICU watching young, otherwisehealthy people die on ECMO. Once
again, working in a job that washigh risk. Everyone was tired,
and I was no different. Exceptthat I'd never really adjusted
to the time change of being backhome, nor the sympathetic
(03:54):
overdrive that would keep meawake after I'd come home from a
call, not really allowing me tosleep when there was finally
time for it. I was stillstruggling with post concussive
syndrome, persistent headaches,short term memory loss, and I
was downright exhausted.
isolated by the virus from thepeople I cared about, and that I
(04:14):
knew cared about me. I foundmyself one night, curled up
alone and sobbing on my bathroomfloor. It was in that moment
that I knew what that operatorhad been telling me. I knew that
if I didn't do somethingdifferent things were going to
continue to get worse. And Ididn't know what that might look
(04:37):
like.
It was terrifying. I spoke withmy leadership, and for the first
time that I can really recall, Iasked for an accommodation and
for some help. I removed myselffrom clinical duties for a
couple of weeks, and I began avery long road to recovery with
(04:59):
a fair amount of health I beganto learn about how our brains
work, and began to investigatehow to improve the performance
of my own. Along the way, Ifound myself learning a few
things that I wished I'd knownbefore I'd ever been injured. So
I'd like to share a few of thosethings with you. You might tell
yourself, you haven'texperienced any specific trauma,
(05:21):
and you're pretty well adjusted.
Why does any of this matter toyou? This image is an important
reminder that over 45% ofphysicians and 43% of em
physicians reported havingsymptoms of burnout in 2020. And
the evidence has linked onepoint changes in burnout scores
with meaningful differences inadverse outcomes. Although the
(05:42):
things we'll talk about todaywon't change your crappy EMR,
difficult leadership orchallenging patients, hopefully
they will help you to deal withall of those things in just a
little bit of a better way. Manyof you may be familiar with
Lieutenant Colonel DaveGrossman's interpretation from
the book on combat of ourphysiologic response and ability
(06:03):
to perform a task when understress. As stress on the human
psyche increases, there is apoint of optimal functioning for
any given situation. However,too much stress results in poor
performance, it is an excellentmodel of how the mind and body
will behave at a single point intime. However, I argue that this
model is incomplete, as it onlylooks at the problem in the two
(06:26):
dimensions one point in onetime, and is unfortunately not
how we live life. In order togive some depth to the mental
model and incorporate the thirddimension, time, I figured I'd
start with one I assume asemergency physicians you're all
familiar with. Not sure how therate of D saturation has
(06:49):
anything to do with stress andwellness. Allow me to explain.
You'll have to pardon mydrawings. But stick with me for
a moment and hopefully it willmake sense. Consider your
personal wellness as the greenline here. Whether you want to
believe it or not. Each of us ishuman and has a point where
performance and wellness can'tstand up to stress any further
(07:11):
and it begins to deteriorate.
Much like Colonel Grossmanreferred to getting into the
black. However, one mustconsider how long it takes to
get to that point in any givensituation, and how steep the
drop will be once things beginto compensate. For example, here
(07:33):
you are plotting along on yourgreen line, a rather high
performance individual. When youget some short notice orders to
deploy, you travel across ninetime zones, lose the daily
support of having your family byyour side, and begin to worry
about your kiddo who's hadtrouble in school that sits in
(07:54):
the back of your brain all thetime, you're still likely to be
able to perform at your normalcapacity. But some of your
available cognitive bandwidthhas already been utilized. And
your views may be just a littlebit shorter. What is this
cognitive bandwidth thing youmight say? It refers to our
cognitive capacity, our abilityto pay attention, make good
(08:16):
decisions, stick with our plansand resist temptations. Think of
it like the internet bandwidththat may run through a cable
like this one. There's a fixedamount of information that can
be transmitted in any giventime. Keep too many things
running in the background andyou can overwhelm the system.
More on that later. But let's goback to you on your deployment.
(08:40):
You're now midpoint through yoursix month deployment. You never
quite adjusted to the timechange and operations have been
busy. It's been over 100 degreesevery day. And let's face it,
your fuse is just a little bitshorter. In addition to pay
really has not started off well.
There were three rounds of IDFovernight, the Wi Fi is down.
(09:01):
The shower is cold and someonepeed in your Cheerios. Turns out
the likelihood that you willmove more quickly from Colonel
Grossman's condition red tocondition Black is pretty darn
high. And the chances that thiscould affect your performance on
(09:22):
this afternoon's mission, alsopretty high. The question then
becomes how do we move the curveto the right and dare I say,
flatten the curve?
And is there a way to climb backup once we've started to slide
off the edge? Can we buy backcognitive bandwidth? Well, logic
(09:49):
would say there must be or weprobably wouldn't be here
talking about it. But it turnsout like climbing any height it
takes some work. I will prefaceby saying that in this talk
Today, we'll probably only havetime to scratch the surface on
the continually growing amountof available information on
cognitive performance andpersonal wellness, which in
(10:09):
truth go hand in hand. Andadditionally, I am not a formal
expert on either merely a personwho learned some valuable
lessons the hard way, andthought there might be someone
in the room who could benefitfrom those things I learned. So
let's begin. First is probablyimportant to have a baseline
understanding on the inputs thataffect overall peak performance.
(10:31):
Remember that cognitivebandwidth I mentioned? Well,
here's your fiber optic cable.
All of these factors play a rolein allowing us to perform at our
best, and we can influence themall in different ways. As we
move forward, we'll look at someof the things we can do to
influence the amount ofcognitive bandwidth we have at
baseline, and how to try to buysome back when it's limited.
Let's start by looking at movingthe curve to the right. We're
(10:56):
increasing our baselinecognitive bandwidth. How do we
build our ability to cope withlong duration stress, often
referred to as resilience. Weused to think that it was done
by repeated exposure to longsleep deprived periods with
intense stressors and embracingthe suck. It turns out what that
builds is people who are brokenand burned out. Now don't get me
(11:21):
wrong here. This is not mesaying that we shouldn't flex
our bravery muscles, do hardthings, take risk, fail and
grow. This is me saying we'vegot to be smart about the way we
do it. In order to createlasting improvement. We've got
to utilize Ernie ability torewire the brain to adapt in a
(11:41):
positive way, neuroplasticity.
But buyers beware. This is slowchange managed by hormones such
as cortisol, building neuropathways, and it takes effort
and time. In order to make achange, though, the first step
(12:01):
is to recognize that our brainscan be trained. Attitude is
everything. This concept isadapted from the book Mindset by
Carol Dweck. In it she exploresthe idea that adapting a growth
mindset, a mindset thatunderstands the abilities and
success can grow with hard work.
She introduces the concept ofnot yet the idea that success is
(12:22):
not necessarily in having theright now right answer and not
in perfection. But in the ideathat if you don't have the right
answer yet, you can reach it.
And that success comes from thejourney. That difficulty and
effort don't mean that a personis not capable or not smart
(12:43):
enough, just that they haven'treached the endpoint yet. Take a
moment to ask yourself, Arethere areas of your life where
you've accepted that somethingjust is as it is, and that
you'll never never be able to doit? When is the last time that
you challenge yourself to dosomething hard? Something that
(13:04):
you could possibly fail. Thisbrings me to my first
recommendation. The idea of amindfulness practice may sound a
little hippie. However, evidenceis mounting that mindfulness
practices can help you performbetter, be more confident,
improve your mood and reduceanxiety. mindfulness practice
(13:27):
allows a person to be more awareof where their cognitive
bandwidth is focused at thepresent moment, to engage with
the task at hand and to be ableto recognize the things that may
be pulling us away and shiftingattention. Taking the time to
allow the mind to wander givesit space to struggle with things
that are important, but notnecessarily active. It creates a
(13:48):
window for the exploration ofthe past formation of memories,
connecting learning experiencesand dealing with residue. More
on that in a moment. Inaddition, in the medical world,
mindfulness practice has beenshown to be successful in
improving pain management,treating depression, anxiety,
(14:09):
and improving coping mechanismsfor patients with chronic
disease. Understanding your ownmind will help you to learn how
to use it to perform to itsmaximum potential.
There are many options to starta mindfulness practice, if
you're willing to give it a try.
There's little harm and it cantake less than five minutes of
your day. Here are a few greatapps that can help. Many are
(14:30):
free, including the PTSD Coachand CBT eye which have been
developed and produced by the VAand have specific tools designed
for people dealing with PTSD.
You know that case? The one youwill never forget the child that
died. The baby you delivered themistake you made. The woman
(14:55):
whose husband shot her in thehead, or the soldier whose life
you saved That is residue. Thepieces of intense experiences
that we carry with us, we'll alldemand to be recognized at some
point. If processed well residuecan create meaningful stories
and memories to carry forward,share and learn, if not dealt
(15:18):
with, these things can become anightmare that plays on repeat,
slows cognitive, bandwidth andneeds of the soul. Consider a
journal where you can process atthe speed of handwriting, a
standing meeting for coffee witha friend who has similar shared
experiences, or scheduled timeat the end of the workday. Five
minutes before you get out ofthe car when you get home, to
(15:41):
spend with the intense momentsof the day. As mammalian
primates we are designed to haveincreased levels of oxytocin
when we are supported and haveconnection with our tribe. As it
turns out, oxytocin does a bitmore than stimulate lactation in
mamas, all mammals demonstrateoxytocin receptor expression in
(16:02):
the mesolimbic social decisionmaking centers of the brain or
the social survival region ofthe brain. These regions
ultimately mediate aggressive,emotional and sexual behaviors,
and attribute social salience tospecific sensory or
environmental stimuli.
Additionally, animal and humanresearch has also demonstrated a
role for oxytocin in improvingwound healing following
(16:26):
traumatic skin injury. MostRecent studies have shown that
stress induced increases andoxytocin levels may act as a
feedback regulator to enhancerecovery from stress related
symptoms. And that socialconnections that increase
oxytocin levels can promote bothcognitive and physiological
resilience. If you don't likeany of those points, and you
need one more good excuse towork on your connections with
(16:49):
family and your tribe. Know thatadministration of oxytocin in
rodents and primates leads tosustained weight loss by
reducing food intake, increasingenergy consumption and promoting
promoting lipolysis. Yep, that'sright. Improving your connection
can help you lose weight aswell. Gratitude is one of the
concepts most commonlyassociated with well being from
(17:12):
an empirical point of view.
Despite this, we seldom use thisconcept, possibly due to a lack
of dissemination of itsscientific basis and clinical
applications. At an anatomicallevel, the expression of
gratitude is relatedconsistently with a medial
prefrontal cortex, and then amolecular level again, with none
(17:36):
other than oxytocin. Gratitudehas been associated with better
physical health parameters suchas decrease in pro inflammatory
markers, better cardiovascularfunction with decreased blood
pressure and improved heart ratevariability. It also is
associated with better sleepquality. From a mental health
(17:58):
perspective, it has beenassociated with results such as
higher levels of positiveemotions and life satisfaction.
Gratitude has been demonstratedto decrease anxiety and
depressive symptoms, substanceabuse and suicidality. In
addition, it has been associatedwith better quality of life, and
greater adherence to treatmentand patients with chronic
(18:20):
disease. Not sure where tostart, consider taking a moment
each night before going to bed.
Try to think of three thingsyou're grateful for. Challenge
yourself to find the smallestthings possible. Pro move, write
them down. Many of us are wellaware of the physical and sleep
(18:40):
related benefits of exercise,but often forgotten are the
cognitive benefits. Multiplestudies have demonstrated that
exercise has beneficial effectson cognitive performance,
executive function, workingmemory, self esteem, mood and
motivation. So if you're readyto take over the world, you can
get started with a few push ups.
(19:05):
It wasn't until a few years agothat I recognize the importance
of the third thing. The thirdthing is the thing that
separates work life and homelife. The icing in the middle of
the Oreo cookie, you know, thatis the best part. Research has
shown that military memberstransition out of their active
duty career. The people who tendto handle the transition best
(19:27):
are those that have some sort ofidentity and meaning that isn't
linked to the military. Itreminds me of an anecdote a
friend of mine shared with me.
He'd gone on vacation to NewZealand and found himself
chatting with a stranger at abar. He asked the stranger what
he did. The man replied, I'm asurfer. Now this man did not
look like a professional surferby any stretch. And apparently
(19:51):
this was written all over myfriend's face as the gentleman
looked at him and replied, allof you Americans have got it
wrong. Yes, I have a day jobthat pays the bills. But it's
not what I consider as the thingI do, or who I am. How you
define yourself matters. If allyou are is your title, you will
have a challenge when you nolonger have that title. You may
(20:13):
be thinking, Oh, this soundsgreat, but it also sounds like a
lot. How do you really have timefor all of these things?
Creating a battle rhythm issomething that the military is
sometimes excessively good at.
But as individuals, not all ofus are, and yes, I get it as em
(20:35):
physicians, we rarely have theluxury. But if we once again
reach back to our primal rootsas man mammals, we can learn
that we truly are creatures ofhabit. Our circadian rhythms
appreciate some predictability,allows our body to know predict
and manage the timing of hormonerelease, and how and when to
manage and conserve energy. Inaddition, having a battle rhythm
(20:58):
frees up cognitive bandwidth,you might ask how? Well we each
have a finite amount of mentalenergy that we can expend on
decision making before our brainstarts to look for a shortcut.
It at least partially explainswhy weekend shoppers impulse buy
and elite athletes makeunaccountable decisions at the
end of a game. decision fatigueis also a well recognized reason
(21:21):
behind poor clinical decisionmaking, decision avoidance and
as a precursor to burnout. So ifyou're able to be efficient
about the number of decisionsyou need to make in a day, if
the questions about when to wakeup when to workout I went to
meditate are already answered,then there is more energy
available for your brain to workon the more important questions
(21:41):
like whether or not to giveanother unit of blood. There is
very little objective data onthis concept for deployment.
However, anecdotal informationindicates that developing a
consistent battle rhythmdownrange as soon as possible,
helps transition occur morequickly and improves both
physical and mental performance.
We've now touched on a few waysto move the curve to the right.
(22:02):
Let's take a few minutes to talkabout some tools to help you
climb out when you're runningout of bandwidth. The stress
response to the body wasdesigned to protect us from
predators and danger. Butsometimes it can be less than
helpful. The amygdala is thepart of the brain that signals
danger to the sympatheticnervous system. When the
stressor is great enough, it canoverride the compensatory
(22:25):
rational brain that keeps it incheck. This is considered to be
an evolutionary response to theenvironment where there is no
time for rational thinking.
However, in most situations weare exposed to this is an
inappropriate response toprotect our well being when our
physical well being really isn'ttruly in danger. The best way to
(22:47):
buy back some cognitivebandwidth is to get the amygdala
back in check. Here are somesimple ways to save your day.
The first thing I'd recommend istake five. If you can take a few
minutes to step away fromwhatever is the triggering
situation. Go for a walk,breathe some fresh air. The
(23:09):
University of Maryland where Ispend most of my time has even
developed the T five programwhere staff members can come and
grab a take five bag forthemselves or a friend. They've
got a small bottle of water anda healthy treat. As it turns out
your basic training ti hadsomething right by forcing you
to drink water all the time.
Besides not becoming a heatcasualty hydration status has
actually been linked in somestudies to both cognitive
(23:30):
performance and mood. Who wouldhave thought that those guys
could have been doing anythingthat might improve your mood?
Speaking of improving your mood,did you know that the
neurotransmitter dopamine ismost commonly associated with
reward and happiness? Findingthe things that trigger dopamine
release will help to dial downthe sympathetic nervous system
(23:50):
and help to improve feelings ofcalm and focus to things
integral to performance and highrisk situations like the recess
Bay. What's the best way to findsome dopamine? Well, what do you
do for fun?
A surprisingly small amount ofadults actually have an answer
(24:11):
to this question. And the numberis even smaller within a
military culture that places astrong value on pulling up your
bootstraps and giving 100% ofyourself to whatever your
country needs. However, playlaughter and joy are an integral
piece to managing stress isreported that in ancient Sparta,
the second most valued skill ina man after his martial prowess
(24:32):
was his singing ability. Thinkback for a moment when you were
a child, or think about what youtell your children. When things
are stressful. What does a goodparent do? Well, they kick their
kid out the back door and tellthem to go play of course. So
why don't we do the same? Ifplay isn't your thing, tell a
joke. If you think about it fora moment, you can remember being
(24:54):
in a tough situation that seemsto be falling apart. When
someone cracks the perfectlytimed joke. You'd better believe
it. That's dopamine to thefeeling of warm sunshine on your
face. Dopamine, listening togood music, dancing, dopamine,
(25:14):
is it starting to sink in yet?
The last tool that I have foryou is an old one, an easy one,
an oft forgotten one. Ask anysniper and they will tell you
that the best way to dial backthe sympathetic nervous system
and activate the parasympatheticis to breathe. Emotions have
been documented to changebreathing patterns, and
(25:38):
breathing patterns have beendocumented to change emotions.
Controlled patterns ofbreathing, thus can serve as a
powerful tool to impact andshift emotional states. There
are many ways to utilize thistool. And the best part is, no
one in the room has to knowyou're doing it. As far as how
to do it. There are a lot ofdifferent methods. The one most
(26:01):
commonly referred to in themilitary populations is called
the box method that can be seenhere. Another method that is
even simpler and focuses on thelong exhale, which is more often
associated with parasympatheticactivity is to take two short
inhales through your nose, andthen a long exhale. Give it a
(26:21):
try. I'll wait. I promise, noone's looking.
As I come to a close, you'llhave to forgive my blatant
(26:42):
plagiarism of my currentfavorite podcast, the mission
critical team Institute teamcast, we're at the end, the
narrator Coleman Ruiz talksabout what to do on Monday.
Here, we'll circle back to thefirst steps you can take to
improve performance and wellnessand the mission critical
environments in which we alloperate. I'll remind you that
this is only a brief glance, andthat there are many different
(27:06):
ways to train your brain toperform at its peak. Number one,
be vulnerable. have thedifficult conversations. And
remember that a person can drownin six inches of water just as
easily as they can drown in sixfeet. That's why I'm here today.
(27:26):
Because I know that I had theperson who shared his struggles
with me, not taking the time outof his day to check in and tell
me about his experience. I maynever have realized that it's
okay not to be okay. And thatasking for help is not a sign of
weakness. So I encourage you toshare your story. You never know
(27:47):
what it might change for someoneelse. Number two, balance, self
career family. All three requireintentional focus and too much
energy on any one of the threeand the other two will suffer.
Number three, do something foryour brain and your body every
(28:11):
day. This does not have to becomplex for the brain. Take five
minutes to meditate. Learnsomething new, that doesn't have
to do with work. Write in yourgratitude journal. For the body.
Go for a walk, or a hike, ride abike or play with the kids.
(28:31):
Number four, have a third thing.
Work workout and what? For meit's putting my head in the
clouds. What will it be for you?
And finally, don't forget to Briif you're intrigued by today's
discussion and want to look intothese things further, here are
(28:52):
some places I'd suggeststarting.
Thank you all for your timetoday. I'd be happy to answer
any questions now or feel freeto send me an email
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