Maintaining high performance in times of stress

Join us for a conversation with Jason Brooks, a performance psychologist who works with physicians, to learn some ways physicians can sustain their energy − both mentally and physically − during times of crisis.

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About Jason Brooks

Jason Brooks is a performance psychologist who has done extensive coaching and consulting with physicians and other high-performance professions. Through this work, he has gained valuable insight on how to help physicians sustain themselves – mentally and physically – during times of crisis. He incorporates lessons from research on mindfulness, stress management, leadership development and reflective practice.

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COVID-19 wellness resources Stress

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Maintaining high performance in times of stress

Dr. Jillian Horton:

Welcome to the COVID-19 Physician Learning Series brought to you by Joule and the Canadian Medical Association. I'm Dr. Jillian Horton. I'm a general internist, medical educator, writer, and podcaster. And I'm your host for this series. We know this crisis is going to play out over months, if not years. There may never have been a time in our history as a profession when so much rested on our ability to perform under challenging circumstances.

In this webinar, it's our intention to help you focus on the criticality of having, and implementing personal strategies for fatigue and stress management. Joining me is Dr. Jason Brooks, a PhD performance psychologist. And long time performance coach to acute care physicians and others in high pressure professions. Jason, thank you so much for making the time to join me today.

Jason Brooks:

Thank you Jill, pleasure to be here as always.

Dr. Jillian Horton:

So Jason, you've infiltrated the psyche of our profession, and you have a very deep understanding of what drives us as performers. Can we start by talking about the characteristic parts of the physician mindset that are going to be strengths versus weaknesses when it comes to our personal and organizational approach to getting through the pandemic.

Jason Brooks:

Well, I think obviously the logistical analytical nature can be useful in terms of the fast and the furious way in which procedures and policies are changing. People being very apt at adapting to that and making sure that they stay on top. I suppose that I also can get in the way. The idea of just consuming too much information to the point where it might impact on recovery and detachment time for people away from that.

I think that we have great teams in place that are very good at following instructions and working well together. But I think the emotional climate has changed significantly with this COVID crisis. And so, perhaps the teams and the communication needs to be strengthened even more. I mean if ever there's been a time in the history of being a medical professional where collegiality, and encouragement, and civility, and overcommunication are absolutely essential. I mean, I think this is the time.

So I think those are skills and attributes that people can learn quickly on the fly. Because I think as much as anything, it's just about being consciously oriented to bring that. So we're going to have to make sure that we are stepping into our shift each and every single day perhaps motivated and anchor to do a few different things. Making sure we take care of one another, making sure we slow down. And perhaps those are things that aren't quite as common as we'd like to think day to day.

Dr. Jillian Horton:

Just to follow up on that. We know that there are aspects of the physician identity that can go from adaptive to maladaptive very quickly. When you look at the situation, what do you identify as some of those personality issues?

Jason Brooks:

I think one of the biggest things is when you consider that so many professionals are in this profession because they want to provide care. And with some of the decisions, and some of the new wave policies that might be forcing people to make decisions that are against the grain. Of the way that they would want to do things ideally, that can be a source of tremendous fear and anxiety for people who care and are so compassionate for what they do and the way to which that they serve people.

So I think getting ahead of some of those feelings and having a plan, and making sure that we stick together. And there's sort of a united front to support one another, is going to be absolutely vital to ensure that we get through. And we heal effectively in the process while we're going through this together, supporting one another. And I think that's going to be really important consideration.

Dr. Jillian Horton:

So Jason, you've worked with a lot of physicians already around issues of performance anxiety. And under normal conditions, what's your approach to dealing with physician anxiety in the workplace? And how do you see that translating in the face of this crisis?

Jason Brooks:

Well, it's interesting. I mean, if you had let's say fear and stress on a scale, a Richter scale. On any given day, there's a lot of that that physicians and medical professionals have to face, but we're dealing with something unprecedented now. I think in any given day, always risk. There's always the possibility of poor outcomes, there's always the possibility of errors that can lead to deaths.

The difference though, is that now that might actually impact the medical provider his or herself. So that's a whole different ballgame when it comes to fear, and stress, and anxiety. And so again for me, the thing that I would advocate then, that I would advocate now, is there are certain things that we can do with fear to get in front of it. To allow it to become something that we can utilize for its value.

I would not want to be in this COVID situation and not have some degree of fear. Fear mobilizes you. Fear is an emotion that can keep you sharp. And keep you safe, and keep you from making mistakes. But of course, if it's at too high of an intensity, it does the opposite of that. It can impair us, it can sap our energy, it can destroy our ability to make effective decisions. And so, we have to meet fear by doing a few certain things.

The first thing that I would recommend is-- and people might accuse me of recommending a split personality, I'm not. Talk to your fears. Talk to it, it's part of you. OK. It's part of your personality. We have this built in defense system to keep us safe, it's just doing its job. So we can help ourselves by when we see fear as the signal that it is. Just pause, have a conversation.

I've even encouraged people at times to put it in the image of something. Put it in the image of an imaginary friend or one of your kids or something that's a part of you, but outside of you because now I can have a conversation with it. And let me ask you this. If you had fear, that signal, let's say in the image of someone you love. What would you do to someone you love if they were afraid? You'd show compassion. You'd ask them what it needs.

So have that conversation with your fear, what does it need? Fear needs two things for it to dissipate or reduce in terms of its intensity. It needs to know that you hear it, that's its primary job to keep you safe. And that it needs to know that there is some reason that you can provide to allow it to feel a little bit more at ease with whatever the threat is that it's picking up on.

So that's the second thing that we can do to meet our fear is, can we add some certainty to in this case, an incredibly uncertain set of circumstances. We will not be able to come up with answers to the global questions, when will this end? can I be certain that we're going to all be OK? And that sort of stuff. And that's the questions that we wish we had answers to. We can't.

But there's a lot of things that when we're in a fearful state we're not focusing in on, that if we did, would bring a lot more certainty and a lot more confidence. These are basic things. Your experience doing what you do. The COVID situation is intense, but the actual doing of the job has not changed. The tasks, the procedures, they're still the same. And everybody who's doing this is very well trained and has a ton of experience.

We have different procedural things we have to be mindful of for safety and such, but the tasks in the job at hand is the same. And we're good at what we do. Think of the team that you have around you, people who are bringing great energy and supporting one another. There's so many things. Think of the experience of getting through tough times and facing fearful experiences in the past. We've all been there, we've all found ways to navigate through.

So when you start to meet fear by shifting your attention towards certain things that you can be certain of. And that in the bringing and creating of those things, it does increase our degree of confidence, it does increase the degree of safety that we can assure for ourselves. That's another huge step.

Another thing we do with fear is plan. Fear does not like a plan. And yet that's what it's asking for, right? So when you step back and you consider, what are the things that I'm really fearful of? I know in talking to so many physicians over the past couple of weeks. Primarily, it's their own safety and of course their family's safety. And still, have those conversations.

Don't allow the what if? What if fear's to predominate? Work the what-ifs through to a resolution. I was having a conversation with a physician not that long ago, who was concerned about the risk of exposure for their family-- obvious-- and I said OK, well let's process that. Let's work backwards.

Do you know the point at which that it would be too much for you and you'd have to pull away? And they kind of had a sense of what that was. I said OK, in the worst case scenario, what would that look like? What would you do? What would be the plan? Would you leave with your spouse and kids leave? Where would you go? And you don't want to think about these things, but guess what happens when you start to think about these things?

You reduce some of the anticipatory anxiety. Astronauts do this all the time, that's their job. They spend the worst possible situations and figure out solutions in advance. Such that if and when those things were to occur, they respond, they don't react. And secondly, I don't have to worry about them as much in the lead up.

So with this person, we just worked backwards and we got to a point where they were still concerned about here and now. And I said well, what could you do? And they thought, they started getting creative. I could set up a bed in the basement. I could practice different ways in which I'm served my food, et cetera. And all the while you just saw this person feeling a little bit more at ease, why? Because they had a plan.

And the other thing that fear doesn't like is facts. Fear, it doesn't look too far beyond itself. It senses danger, and it does not want to look at the other facts that are counter to that. So it's very helpful to increase a sense of confidence and peace of mind to inject some of the facts. You know, you've heard of the saying "Facts Over Fears." It's a great concept. Look at some of the facts that are happening all around us in lightning speed.

We have so many companies that are volunteering to produce the absolutely essential PPEs. So we can say with some certainty that there is a movement coming down the wire to ensure that you have the stuff that you need. There's been changes globally in places that have had the outbreak before us, New York notwithstanding, that are beginning to show some measures. We have had some at this time here in Canada, in comparison to other places to get plans in place.

All of these things, all of these things some degree as a [AUDIO OUT] what we do. And that's not even considering our individual capacities. Like I said, our personal experience stepping in, and doing this job under very challenging circumstances before. We're not coming into this thing completely unarmed. Everything that we would need to stay safe, as effectively as we can, we can leverage.

And I think the final thing Jill, with the fear of uncertainty is focus on what you can do. Right now the mind is racing and focusing on the stuff that we wish we had and isn't in place, and what about this? And if you cannot answer those questions effectively, you're just creating undue suffering for yourself.

So step back. Again, reel it in, put your attention in the directions of the stuff that you can do and you can bring every single day. That contributes to effectiveness. Contributes to safety of you and your team. And when we start to put our energy there, days feel a lot better. And I think it's sort of a practice … and the art of acceptance, this is a stoic philosophy principle. When you accept the situation as it is, and that doesn't mean we like it. Of course, not. But when you accept that as it is, there's an efficiency there.

I need that extra bandwidth. I need that extra emotional energy for the long haul. This is going to be a marathon, not a sprint. And so, if I'm not attaching and resisting to things that no amount of spinning them in my head can help resolve, what a difference for you mentally and emotionally to release from some of that.

And again, focus on the things that matter that you can bring. Good attitude, good energy. Good teamwork, good communication. Being safe. There's a lot more that we can do here to step in front of and get ahead of the feelings of fear of uncertainty that when we're in that state, our mind isn't [INAUDIBLE]. We have to shift our attention to those things.

Dr. Jillian Horton:

Jason, long before simulation was popular in medicine, you and your colleagues were talking about rehearsal. So can we talk about the role of rehearsing. Not just in the same lab, but rather the role for mental rehearsal in what we're facing right now? And what that looks like when an individual tries to use rehearsal.

Jason Brooks:

Sure. I mean, I think the role right now is primarily for safety sake. And I'll tell you why. Again, when you think of all the policies and procedures around PPEs, this is new to people. We're not used to having to take the extra time and consideration to follow very specific protocols. So we need to ensure that we're getting as many mental reps doing that as is possible because we have not had the luxury of doing a lot of training with this.

So we can take advantage of as you alluded to the simulation center that we were born with, the one that floats between our ears. And so, if I use that particular example. The way that that would look to me is I would imagine myself stepping into a situation whereby let's say it's hectic and chaotic, and I am bouncing from one thing to the other. So there's the possibility I could be distracted.

In the first wave of playing that scene through, I just want to gather the data. I get a sense as to what I would [AUDIO OUT] might be interfering with my ability to be more present and focused because that is what's my enemy. If I'm either aroused or if I'm too distracted, it might make the difference between a moment's error with putting on or taking off something properly.

So I collect the data, and then I get a sense. So now when I'm playing that scene through again in my mind, priming my mind to respond rather how I want. I anticipate as I'm going from one week to another, that I might be experiencing some internal distraction. And so, I visualize seeing myself slow down. Seeing myself take a moment's pause. Maybe I cue it with a word that says just [AUDIO OUT]. Something along those lines.

I see myself putting the equipment on properly. I see myself ensuring it's fastened and secured in whatever way it should. I see myself executing a procedure and then at the end I see myself take pause and doing the same routine in reverse. And maybe just maybe to add additional safety. I would visualize having a reflective statement that I say to the team that just says look, before any of us do anything, let's just take a moment. Let's take a breath and think about what we are about to do as far as taking off this equipment.

And so, when I create this mental image, this story in my head. And play that seen through, the mind doesn't know whether what I'm doing is "real," air quotations, or perceived. And so, I'm getting those valuable mental repetitions. I'm training the mind to respond, and to behave, and to execute in a very particular kind of way.

And if I spent two minutes doing that at the beginning of my day, before I step into a situation. Or maybe at some break in my day. I'm getting that valuable mental repetitions that's going to strengthen that neural pathway to remind me and to cue my mind to do the thing that I need to do to stay safe and be effective.

Dr. Jillian Horton:

Jason, let's talk about transitions. So, you see these as other found moments in the day that can help us create intentional change. So, tell us how we can use transitions to help us work through this pandemic?

Jason Brooks:

Well, I think the transitions in the moment, during a shift let's say, that just allow us to ensure that we are not allowing an otherwise busy mind to do something without the forethought that could put us at risk. So, taking a breath. Moving slower than normal, ensuring that we are mindful, that if we feel heightened in some way. Distracting thoughts, a bit more fear than usual. That should be a signal that says, hang on a sec, I need to take a little proverbial mental time out right now.

And so, I step back. I take a deep breath. I quickly observe what it is I might be thinking or feeling. If there's some solution, I can bring to that at the moment, terrific. If I have to put it away for later fine-- later fine. But just taking that pause, I want some of that initial anxiety or intensity of emotion to drop down ever so slightly, which means I have more presence, more bandwidth available for the task.

Those are the moments that you can happen 100 times a day during your shift. I also think it's important to manage the transitions in terms of leaving work and going home, and conversely going back to work. When you go home, I think the ride home is a great opportunity to do perhaps some of the processing of the day.

And when you get home, I would encourage people to alert the team that is their family, whoever is going to be receiving them at home, as to what it is that they need to transition [AUDIO OUT] and emotionally. You might find that people want to be received in a certain kind of way. Maybe they need 15 minutes to vent about all of the challenging, difficult things that they experienced in the day.

Maybe they want the exact opposite. They want to just be left alone for 15 minutes. Whatever the case is, if we have those conversations ahead of time and your family can actually support you in making the valuable psychological transition from the stress and strain of the day to be able to immerse more effectively and fully into our personal time. That's going to make [INAUDIBLE] in terms of long term recovery. So have those conversations.

And I think be very careful with where you put your attention. I think part of ensuring that we recur at the end of a tough shift, especially under these conditions. I'm concerned about the flow of information. All the physicians I've talked to, their emails are beeping every 5 seconds with some new update as to way they should be doing things. You know what? If you're going to spend your entire evening glued to your phone waiting for the latest update, that will interfere with your ability to transition.

Set aside a time for that. Let that thing buzz to its heart's content. If you're not working until the next day, I only have to be ready for the most current update when I start my shift. So, if you give yourself a half hour at the end of your evening just to check in. And then get up. And a little bit earlier the next morning to ensure that you can go sort of through the backlog of updates. They're going to be changed anyways.

So we don't want to make sure that we're allowing the constant change to interfere with our time. And as I said to you in the morning, the transition to work. Get up and get ahead of the thoughts and feelings. Imprint to your subconscious what it is that I need and want to feel today. What do I need to bring that will be helpful to my team? What am I a little bit scared and anxious of solving? And can I do something with those thoughts and feelings right now.

When we do that, we sort of put fear behind us to mobilize us. And we can be much better than at starting the day with better focus and better energy because we have a plan, that's like a mental warm up. If you went to the gym you would warm up your body physically before you put it under tremendous stress and strain.

Now [AUDIO OUT] more than valuable strategy to do when we start our day, to make sure that we're switched on and dialed in as effectively as we can because that's what's going to ensure safety and effectiveness.

Dr. Jillian Horton:

I'm going to ask you to talk about contagion as it applies in your world. So can we spend a few minutes talking about how it lift's up or brings us down?

Jason Brooks:

Well, and it's just so interesting given that we are dealing with a global contagion if you will. And it functions in much the same way psychologically. If you think about the attitude and the energy, and the communication that we bring to our work, it in and of itself it has a contagion effect.

So I think it's a just a simple approach, you step back and you ask yourself what is it that my teams need? That all of us are going through this same thing together. What can I do just by virtue of the way that I communicate, the support that I bring, the empathy, the understanding, the civility, et cetera. When I bring that and make a conscious effort to be that, that's the kind of energy that's helpful. Especially, as people are stressed, and tired, and with no end in sight and with all the anxiety.

Conversely, the opposite is true. If I bring negativity, and anxiety, and panic and fear. That is what's going to infect if you will, the emotional climate of the environment. So ask yourself what is the energy that is optimal? And for me, the two things we need right now more than anything. We need calm, and we need courage.

And so, if I can make a pointed effort to be and bring that every single day, that is the energy that is uplifting. And I'll tell you what, given that this is going to be such a long and arduous process, we need to be doing anything we can to ensure that we're optimizing and sustaining our energy for the long haul. And something so simple as bringing the right emotional currency that helps people. If we all did that, that in and of itself can be so uplifting and help increase our sustainability factor.

Dr. Jillian Horton:

So Jason, the last question I want to ask you for today. You know, and I know that physicians hate generic prescriptive wellness advice. But what would you like to see front line providers doing for themselves when it comes to both fatigue management and self care in the months ahead?

Jason Brooks:

Well, I mean again. I think that if you look at the idea of recovery, it is absolutely essential when you connect the dots. If we are fatigued and distracted, we are at a greater risk of making errors. Errors right now impact not only patient safety, they impact provider safety. So anything that we can do to recover effectively is going to contribute to better safety and better performance.

So some of the things are the most basic things. And it's so interesting because it's all the things that all of us should be doing a better job of in non-COVID times. Making sure as best as possible we get as much rest. Making sure as best as possible our nutrition and hydration is well. Making sure as much as possible we get some form of exercise. And I think specifically, exercise that involves movement.

I'm a big believer in under stress, stretching, yoga, Pilates, movement based exercises. Because again, just the way in which stress manifests physically in the body as muscle tension, people will be clenching their jaws a lot at night. So, allowing some physical release from this is incredible to ensuring that we can stay sustainable. I think finding moments for stillness. And I say stillness as compared to meditation because meditation is but one option that one can do to practice stillness.

I feel that there would be just as much a benefit for someone listening to their favorite rock music while they vacuum their carpet. I mean that in and of itself is a form of stillness. We're not having ourselves attached to all things, stress and strain of this crisis. And I think simple strategy to help let's say with sleep, conscious breathing. I've heard many instances where this is a sleep aid that has been really beneficial for people under stress.

So in essence, it's just thoughtfully breathing through your nose for a count of let's say two or three. And the key here is the exhalation also, through the nose just needs to be twice as long. Now, the physiology and the neuroscience behind that is quite clear. When we exhale, that is cuing the parasympathetic nervous system. That's the relaxation response.

So we are literally bypassing whatever we are thinking going straight to the brainstem, and cuing it to begin to relax. Less physical tension, less mental tension et cetera. And feed your mind what's going to help. We have to be really mindful of what we're allowing into our subconscious right now. And I would suspect that most of the thoughts are not on the positive, and the encouraging they're on the fear from the anxious.

So, make sure that you spend some time looking at some of the encouraging developments that are also happening at the same time. And what an opportunity this is to lead, and to serve, and to literally bring your skills and talents to the world in a way that matters more than ever before. And I look at some of the things that are happening in other centers. You get goosebumps seeing people applauding medical providers from their balconies in New York and in Vancouver.

And I was speaking with an emerge doc in New York City just the other day. And that was the thing that he said to me more than anything he wanted to make sure that a message is being sent that says, look, we also, there's some good things happening here. The amount of recoveries, the amount of people being together. The way in which teamwork and collegiality has never been higher at the hospital.

He says these are things that we also need to be talking about because there are a lot of another side of the story. And I suppose another key wellness thing then would be-- this might sound funny, but avoid CNN or news of that type. If you've been on the front lines of this crisis all day, the last thing you need to do when you come home is to be looking at ticker counts of deaths and cases and listen, I'll summarize the mainstream news media for you. It's not good, the number's on the rise et cetera, et cetera. We don't need that. We need to make sure that we detach and recover.

Dr. Jillian Horton:

Well, I want to end today by thanking you, Jason, for spending time sharing your knowledge and your expertise around performance with us today.

Jason Brooks:

Thank you Jill. I appreciate what you're doing here so much. It's so invaluable for those folks. And everybody who's out there facing this thing, thank you so much. I mean, I've said it before. The 1% of you are facing this thing while the 99% of us are silently sitting in the background. Sending every ounce of love and support we can. So thank you so much.

And thanks for everything you do to support us.

Thanks Jill.

Dr. Jillian Horton:

I'm Dr. Jillian Horton. Thank you for joining us for this COVID-19 webinar series powered by Joule. Take care of yourselves. Thank you for all that you do. And I'll see you again soon.

Maintaining high performance in times of stress

About Jason Brooks

Topics

Strengthening Mental Health and Wellness During COVID-19

Perfectionism in Perspective

Vicarious trauma: Signs and strategies for coping

Medical students’ well-being and identity formation

Keeping well and self-care

CMPA podcast: COVID-19 – physician moral distress

Are you in distress? Get help now.

Maintaining high performance in times of stress

About Jason Brooks

Topics

Related resources

Strengthening Mental Health and Wellness During COVID-19

Perfectionism in Perspective

Vicarious trauma: Signs and strategies for coping

Medical students’ well-being and identity formation

Keeping well and self-care

CMPA podcast: COVID-19 – physician moral distress

Are you in distress? Get help now.

Maintaining high performance in times of stress