310: Wiring Your Brain for Performance Under Pressure

This week’s conversation is with Dr. Dan Dworkis, an attending emergency physician and professor at USC’s Keck School of Medicine, where he works at the Los Angeles County+USC Medical Center (one of the largest and busiest emergency departments in the country).

Before that, he did his training with the Brigham and Women’s Hospital / Massachusetts General Hospital Harvard Affiliated Emergency Medicine Residency.

ER doctors or not, we all face emergencies in our lives– times when we are called on to make a decision to act, or not act – whether that’s in an environment of uncertainty, pressure, or even intimacy.

Dan believes deeply that all of us can improve how we function under pressure and in doing so perform at our best when we are needed the most

He’s the founder of The Emergency Mind project which helps individuals and teams perform better under pressure both in and out of the emergency department – and that sets the tone for this conversation.

“A person comes in, and then you have that one moment to use everything you’ve studied your whole life to learn, to try and save that person.”

In This Episode:

Why Dan was drawn to the ER

I love the fact that emergency doctors don’t say no to anybody. It doesn’t matter what your insurance is. Doesn’t matter who you are, where you’re from, what your details are. If you show up whether you need a sandwich and a pair of socks, or whether you are shot in the chest and about to die, whatever that thing is you need, I and my team are going to do the best we can to take care of you. And I love that. I love that idea of what I’ve come to learn about what it means to really hold the line in that moment and to be part of humanity, that’s sort of up there holding the line in that minute. I didn’t really understand that at the time I just had this feeling of like, wow, this is crazy and chaos. And the grit and dirt and blood of what’s happening. And this is where I want to be.

The gravity of every situation in the ER

So say a person fell off of something. They have seriously injured their head. It’s quite obvious and they’re not breathing and you have three minutes, go. And in three minutes that you’re going to be in a room set up, that they’re going to bring in this person, that you’re going to not really have any idea what’s actually coming in. And then in three minutes, you’re going to have to make life or death decisions that alter this person’s life – decisions that alter every person who’s in that person’s life, that alter maybe the entire community that that person’s a part of. And also that alters your life and everybody else in that room. And you’re going to have to do it to the best of your ability, no matter what else is happening. If you’re sick, if your family’s sick, if you’re hungry, if you’re tired, if you’ve been on for 12 hours, if you’ve been on for one hour, whatever it is, you’re going to be called upon in that moment to hold the line.

Never waste suffering

This is the thing that sort of got me down this whole path on the Emergency Mind project and on thinking about how to get better under pressure and all of this, was this understanding that if my patient suffers and dies, which happens, it doesn’t matter how good you are as a doctor or how good you are at anything else, people are going to suffer and die. But the question is, what do you do with that? You let it sort of dissipate in the universe or do you try to use it as fuel to get better for the next thing? And so this concept of sort of never wasting the suffering that you’re exposed to tends to be one of the biggest pieces of it. And I think that being exposed to that over and over again has shaped me and polished me and hopefully made me a better human as I go through it.

The evolution of his compassion and empathy for patients

I certainly don’t feel the same way that I did when I first started. Right. And I think a great example of that is, I have this very vivid memory of the first time I ever did CPR for somebody. Right. And you know, there’s this person and their heart stopped and I’m the one closest to them. So I’m going to start doing the chest compressions. And I will never forget what it feels like to break that man’s ribs when I’m doing CPR and to feel that just sort of crush under my hand and to know that that was human to human, the best thing I could possibly bring to that person was to crush his ribs and do CPR. And I don’t even remember how many years ago that was, but I never forgot the color of his skin or the color of the glove I was wearing or just burned into me. Now when I do CPR, I don’t absorb that level of detail from it. I do think about that question of, “Am I bringing the best I have to bear the best humanity has to bear for this person in this moment?” But they probably don’t need me to feel the same way about it.

Fierce optimism and purpose

On the best days, I’m able to think about and to bring together this idea of kind of a fierce optimism, this sort of reality that suffering and death is part of existence that they go through. I watch them go through it. I know it’s going to be my turn on the table at some point and the turn of everybody that I love. And if that’s true, if that’s part of the inevitability of what we’re doing, then we’re left with this question of sort of what is the purpose, right? And man, does that drop you into know what is the purpose really quickly to watch that level of chaos and suffering and to be able to approach that with a joy of, and this fierce optimism of, okay, well, I’m going to do what I can, and I’m going to try to stand here and hold the line well, and I’m going to try to do it tomorrow better than I do it today. And I’m going to try to do it because I think it’s right. And because it’s my way of honoring that other person as they’re going through it.

The human aspect of medicine

You try to bring the best that you have to bear to everything, but I’m also a human. Which means that I am an imperfect human, I practice in imperfect science of emergency medicine and I practice it imperfectly. And that’s the reality of everything that we do. And I think I can always aspire to be my best at it and to bring everything I have, but man it is hard. It’s hard and it’s chaotic.

Not becoming a robot

When you go through medical training, often you come out or many of us come out feeling like a bit of a robot because in order to do what you have to do, you can’t bring to it sort of the normal human skillsets and the normal human interactions. Right. In normal life, it is inappropriate to stab somebody in the chest and cut their chest open right. In my life in certain times, that’s the most humane, wonderful giving thing you could possibly do. That’s a really weird disconnect. Right. Hey, welcome. I don’t know you, I’m going to cut all your clothes off and stab a hole in your chest. Oh, that’s weird. Right. Like that’s really outside the normal realm of human experience. So to get to the point where you’re like, yeah, not only is that what I’m going to do, I’m going to do it right now and I’m going to do it smiling and be like, Hey, I’m here for you. Right? Like to actually sort of cross that gap, you have to really reprogram the way you understand how you interact with other people. And that gets to this idea of, well, what is compassion and what is empathy for most of us that turns off at the beginning because that’s the safer way to do it, and safer being in enormous air quotes here. It feels safer to just not handle any of those deeper pieces, and instead act a little bit robotic.

Mental imagery and practice

When I go running, there’s this hill outside my house. And when I charge up that hill at the end of it, I practice that sentence at the end of it when I’m out of breath. I practice running through skill sets in my mind about intubating people, about dropping chest tubes in people, about doing these skills. I practice it when I’m out of breath so that I can walk in that room and have every single thing ready to bear. And I come with the weight of everything that humanity has ever invented about medicine, all behind me, every other person whose shoulders I stand on. I run in that room and I do everything that I can to make that person better. And where that confidence comes from is me knowing that I have trained and continue to train, to be able to bring all that humanity has to bear, to that patient.

Pressure training, and ‘The Wedge’

When I’m learning a medical skill, like putting a central line into the neck, I learn it on a skills trainer. Then I learn it on a skills trainer under pressure. Then I do it on an easy patient as an assistant. Then I do it on a really challenging person in a full fledged thing. That graduated pressure is a pretty universal concept in terms of knowledge under pressure… we tend to visualize it as a wedge, right? So, low wedge practice is easier, friendlier environments. High wedge practice is unfriendly, maybe even antagonistic things. And a couple of truths that come out of that is basically, you’re not better at a high wedge than you are at a low wedge, generally speaking. So, if there’s a thing that you need to practice, and maybe that thing is instead of putting a central line in it’s how to talk to your partner when you’re angry and when you’re upset, how to communicate hurt … not something I’m always particularly good at, but I’m trying to get better at. And I know I won’t be better at it, high wedge than I am at low wedge. So, if I’m really invested in trying this, how can I find low wedge ways to practice things? Whether that’s a side control escape, or a central line or talking to my partner. And then how do I do that consciously as a student, as a scientist and be like, “Well, I don’t know. Did this work? How do I know if it worked? What am I going to do differently tomorrow to try it again?”

Intrinsic vs. extraneous cognitive load

If I’m trying to do a task, like put a central line or intubate is usually the one I think about, you put somebody to sleep, you put a breathing tube in. The intrinsic cognitive load is what it takes to actually execute the skill, so the physical parts of putting a tube in somebody, the thinking through the thought process of what medicine I’m going to use and why, “How do I map this huge knowledge base onto this patient right here to do the best I can?” Understanding probabilistic things and running multiple different scenarios in terms of what might or might not happen and planning for backups and things like this. And then there’s the extraneous part of the cognitive load, which is all of the stuff that it takes that’s not directly related. So, the patient is screaming and coughing blood everywhere. The person who is their family member is trying to punch you.

Sometimes all you can do is learn

So that moment of this person’s dying and let’s say I can’t get there in time or I get there in time but no matter what I do, they die anyway. What do you do in that moment? So one of the things that I was taught that stuck with me through my whole career that I deeply value is to say this, is to put your hand on this person’s body, after they’ve gone and to say some version of, “Thank you for teaching me, sir. I’m sorry all I could do for you today is to learn. I’m sorry all I could do for you today is to learn.” Because sometimes that’s all we can do for each other. We can’t stop the suffering. We can’t stop the chaos. We can’t protect them from the barnacles and the reefs or the Covid or whatever it is. Sometimes all we can do is learn and come back and be like, “Well, what did I learn from this?”

You can’t win every time

How do you handle knowing that there are times when you’re going to do the best you can and it’s not going to be enough? Yeah. Part of my answer to that, is that you have to, in some sense, consider the integral of your effort over time, right? Are you bringing good things to the rest of humanity over time? Are you winning on net? Because you can’t win every time. Nobody can win every time.

The importance of microchoices

First off, you must understand that what you can bring to bear on any day is influenced enormously by all of the choices you make on the days before that. And so, what you do on your day off influences what you can do when you’re on your day on. It’s a little of a clumsy construction, but I think you get the idea, right? And so part of my backstop against risk is trying to make really intelligent choices when I’m not under pressure. And setting up systems that support me to perform better, that are capable of supporting me despite my shortcomings.

The Emergency Mind

In The Emergency Mind Project, when we talk about performance, we talk about this cycle of prepare, perform, recover, and evolve. And when I was coming up, when a lot of us were coming up, that cycle was perform, perform, perform, perform kind of prepare, perform, perform some more. There wasn’t this focus on, what does it mean to successfully come home, right? What does it mean to find your way through a lot of the suffering and death and come out human on the other side. If you do not pay attention to that, you will break. Period. I think we’re just starting to really pay enough attention to that kind of thing to be like, what do we need to support ourselves as humans?

Separating work from life

That is an active area of experimentation for me. I’m practicing that a lot. I purposely park in a far away spot from the entrance to the ER, because it allows me to walk back and forth across this one bridge. And it’s this really long bridge to the parking structure. It’s a space, and I did this in residency too. There was this long hallway that leads in sort of to the ER in Mass General, it has these old bricks that are there and they’ve been there forever. You sort of feel the weight of the people as you walk through it. I use it as a sense of, when I’m going in, it’s this sense of leaving the outside world behind me as I’m walking in. It’s an idea of I’m setting my intention. I’m moving closer to my intention. I’m getting ready to be there. Now, I’m going to be the one on the line. And then on the way out it used to be, I’d get out, I’d be on my phone. I’d be talking to people. I’d be sort of like, just pretending none of that ever happened. Now, I try to be a lot more conscious about stepping down from it, especially as I walk over that bridge. I try to think about every pillar of the bridge I pass is like me getting scrubbed a little bit from what happened. And then whatever is still there at the end of that scrubbing process, okay, how am I going to think about that?

Prepare, perform, recover, evolve

You have to set yourself up for success. And that prepare, perform, recover, evolve, that’s not just me getting into a shift or me putting a breathing tube in. That’s all of us for anything we want to do, right? We prepare to get ready to do the best that we can. We do it. We come home and recover. And then if we really want to spin the cycle, we sit down and ask what the hell just happened and what does it mean? And how do I get better at it? And what am I going to do differently? And that cycle over and over and over again is like, I mean, that’s where the magic comes from, whatever that is that you’re trying to do.

Doctors should be working with you, not against you

We have to own our health right now, but sometimes all of us or some of us get hit by a disease that we cannot manage on our own. And that’s what we are here for. We’re here to help. And when I do my job correctly, I want it not to feel like you are here and I’m on the opposite side of the table from you, looking against you. But rather, I am right next to you facing whatever the hell this problem is together and bringing the best that we can put into it from it. And I want it to feel like that because that’s what it should be. That’s what we should be doing as physicians. That’s what our job is, it’s to help people heal and get better.

Study yourself

You have to study yourself. You know, we talked about advocating for yourself, but you really have to study yourself because I can point you towards the direction of mental models and frameworks that historically function well under pressure. And I can give you ideas, but the ideas rot on the page, unless you put them to practice. You have to study and experiment with yourself to get better at pressure, under pressure. The corollary to that is that you can’t expect just to jump into the deep end and have everything work. You have to practice it if you want it to be well, when you need it.

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