Preparing for the unknown: mental readiness lessons from the military

Building on her crisis care experience in the Canadian Forces, resident Dr. Stephanie Smith will explain the mental readiness model she learned in the military, and how it can be used to manage the stressors facing physicians today.

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About Dr. Stephanie Smith

Dr. Smith is a family medicine resident and graduate of the Cumming School of Medicine (University of Calgary). Before medical school, she worked for 12 years as a critical care nursing officer in the Canadian Armed Forces, completing two deployments in Kandahar, Afghanistan, and a DART (Disaster Assistance Response Team) mission to the Philippines following Typhoon Haiyan. She has a master’s degree in Disaster and Emergency Management, and served as president of the Canadian Federation of Medical Students, where she led the introduction of the STRIVE (Simulated Training for Resilience in Various Environments) program.

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Preparing for the unknown: mental readiness lessons from the military

Dr. Jillian Horton:

Hello, and welcome to the COVID-19 physician learning series brought to you by Joule and the Canadian Medical Association. I am Dr. Jillian Horton, a general internist, writer, and podcast, and I'm the host of this series. We know that COVID-19 is pushing many physicians into the unknown. Working in new ways, under extreme pressure, against a virus that we have never seen before.

Today we're going to take a page from the Canadian military and learn how its program to plan and prepare for the unknown can help reduce the stress of crisis care. Joining me is Dr. Stephanie Smith, a resident doctor in Calgary with personal experience in crisis care.

Before medical school, she spent more than a decade as a critical care nursing officer in the Canadian armed forces, serving two deployments in Afghanistan and one in the Philippines following Typhoon Haiyan. Stephanie, thank you very much for joining me today.

Dr. Stephanie Smith:

Thank you very much, Dr. Horton. It's a pleasure to be here.

Dr. Jillian Horton:

So you have just started your residency. And I actually can't imagine a more challenging time to be entering this profession. What are you hearing from your fellow residents about coping during COVID-19?

Dr. Stephanie Smith:

That's a really good question, Dr. Horton, and it certainly has been impacting residents as it has been impacting many health care providers. I would say some of the stresses that have been impacting residents have been related to the unknown not knowing if they will get the clinical placements, they need to be prepared when they're going to be finished residency and going into practice, and concerns about when exams will be written.

And also some stresses related to the finances associated with the situation as many others are going through when your children can't be in school, and you need to get a daycare or a nanny to help look after your children and adds a financial burden. And certainly, residents are in a unique situation where they are impacted by this like many others, but there is a bit different unknown for sure.

So I think that the residency programs are trying their best to help keep us informed. I know my residency program is offering wellness sessions every week to make sure we have the opportunity to talk about what our concerns are. We also have opportunities to talk with our program director to let them know our concerns from a clinical competency standpoint.

We understand there are challenges, and there are certain things that need to be done to both keep patients safe and to keep residents safe, but certainly, that does impact our day to day function from what it was only six weeks ago. So I think we've been doing a lot of collaboration with one another to really help support each other, and we know we're all in this journey together. But it certainly has been an adventure, to say the least.

Dr. Jillian Horton:

So I wonder if we could talk for a minute about how your previous training and your deployments in the Canadian Forces prepare you for what we are dealing with here today?

Dr. Stephanie Smith:

I would say that my experiences in the military have taught me to be comfortable with being uncomfortable. And often, I've been in situations where we have had limited resources. We've had limited individuals or clinicians available to provide the care. There's been a lot of unpredictability with the patient injuries that we would see, the volume of patients that we might see, and often there's a lot of responsibility for collaboration with New individuals that you might not have worked with in the past.

So I think it taught me that you have the opportunity to really pull together and try to make the best of a really challenging situation, recognizing that everybody is also going through the struggles, but it's better to do it together and work together as a team. I would say my experiences on deployments have taught me that the camaraderie and the teamwork is certainly something that I really value from my experiences with the military.

But it's also something that I see day to day working the health care field. So I think that ability to continue working together and recognizing that if we work together, this will be better to get through it than getting it done on your own.

Dr. Jillian Horton:

In medical school, you worked to take a model that was developed by the military called STRIVE, and you adapted it for medical school training. Can you talk a bit about why this model is so valuable to medical students?

Dr. Stephanie Smith:

I think that the program is really valuable because when I got to medical school, I realized that medical students were being exposed to some pretty traumatic events very early on, and I think it was unique to my experiences I had as a nursing student in the past because I wasn't expected to shadow as a new nursing student, but as a medical student, I'm trying to find out what specialty I want to work on or apply for in residency.

So very early on, people are trying to get exposure in a variety of areas. And often with very little understanding of what that clinical experience might be like. So many of my peers in medical school would come to me and talked to me about their traumatic events, maybe experiencing death for the first time or witnessing something very traumatic from an injury and just trying to figure out how to process that.

And so I found taking my experiences from the military and understanding that I was never 100% prepared for what I had to deal with, but I found my chain of command and the leadership always said that they were there to help prepare us the best that they could, and to give us the resources that would help us through that journey.

And the military had provided me with resiliency training based on the road to mental readiness program. And so taking that model and bringing it to medical school through STRIVE really allowed me to take the experience I had from the military and help my peers work through those challenging events, give them an opportunity to be exposed in a simulated experience, where they could experience those emotions and learn how they would deal with them, and potentially talk about what they were feeling, and also develop a plan of action to help manage what they were going through. So I saw it as an opportunity to give back a little bit of the skills I had learned along my journey in the military.

Dr. Jillian Horton: 

So the model itself has some key elements, and they are referred to as the big 4 plus. So I wonder if you could walk me through them one at a time. And maybe we could start with box breathing.

Dr. Stephanie Smith:

Sure. So box breathing or arousal control, sometimes, is another word used for this. I find is a really easy one for people to use. It's something that many of us are taught by our parents when we're younger, when we feel really overwhelmed, we're told to take a nice deep breath in and to calm down, and it can be very helpful.

With box breathing, in particular, it uses a cycle of four where you take a nice deep breath in for four seconds, then you hold that breath in for four seconds, then you breathe out for four seconds, and then you hold the breath out for four seconds. And the goal is that you will do that four cycles in a minute, and so 16 seconds a cycle. And then ideally you do that for two to four minutes.

And what that can do is really help calm down our sympathetic nervous system. When we get that flight or flight response, we're feeling anxious or overwhelmed by the environment we might be in, whether it's a direct clinical experience in the moment or just the overwhelming situation as a whole.

Having that ability to take some deep breaths and actively bring down our heart rate, calm us down, and our breathing rate can be really therapeutic. And I find that this is something that's very easy to do regardless of the setting and it doesn't take a lot of concentration and I also find it really good to help us fall asleep at night. So it's a bonus as well.

Dr. Jillian Horton:

And how about now if we move on to goal setting and to talking about that?

Dr. Stephanie Smith:

I really like the goal setting portion because it can be broken down into two different ways. So there can be the smart acronyms so the specific, measurable, attainable, realistic, and timely goals that can be developed, which many people are familiar with. And you can use those for big picture goals on how you're going to make it through this challenging time and thinking about what things are going to look like in the future. Or you can use another acronym that's called win, what's important now.

And they find that it's very easy to use in thse clinical environments when we know a patient's coming in. And we're anxiously preparing for that if they're significantly injured or, in the case of COVID, not really knowing what that experience will look like and how others are going to respond. Having the ability to really narrow in on what is most important and then trying to take away all the external things that really don't have any bearing on what really needs to be achieved.

So whether it is a short term or an immediate goal that you want to take on or a long-term plan, I think goal setting is something we do day to day. In a way, it's even a mental checklist that's often something we've developed over time to achieve a task that we do regularly, but we might not even know that we're doing it. So I think the more you practice doing that skill, the easier it is to implement it in practice.

Dr. Jillian Horton:

And perhaps now we could talk about visualization. How do you employ that?

Dr. Stephanie Smith:

Well, Dr. Horton, I would say that visualization is probably one of my favorite of the big 4 plus, and as a competitive athlete, this is something that I have used many times in preparing myself to achieve the task. And, for example, in a triathlon, where I can think through every specific task that I have to do and how it's going to feel. And that's easily reproducible, specifically when you're going through a process in the health care environment.

So if I wanted to visualize a patient coming into the emergency departments and then them having symptoms that I was suspecting could be COVID related. How would the team respond? How would we activate that? What would that look like? What would that feel like for me? And how would I respond to that? And I think visualization is a really great skill that you can use going through everything going well.

But then the more comfortable you get doing visualization, you can challenge your brain to take different routes and going through it not working out optimally, and then how do you troubleshoot that challenge so that you can get back on the right track to have the positive outcome.

We know in health care, we don't always have positive outcomes. But having the chance to go through those experiences in advance and being able to walk through, talk through those things and imagining how you might respond or helping yourself learn the best way that you could respond, I think gives a bit of peace of mind to help you prepare for those types of things in the future.

Dr. Jillian Horton:

And as we move our way through the elements of the program, I wonder if you could bundle up self-talk and attention control and talk about both of those?

Dr. Stephanie Smith:

If there was one more that was my favorite, it would be self-talk, as we can say many things to ourselves in our heads about the challenges that are coming our way. And maybe we don't think we're prepared enough or capable of taking on the challenge in the moment, and it's easy to really talk ourselves out of it. But I think really focusing on a positive mantra one for me has been, you are so enough, something my father taught me.

And saying that can get me back on cue and remind me that I can accomplish what I need to do. Maybe I don't have the training or the skills that I wish I had or maybe have been exposed to this more, but given this situation, if I say to myself positively, you can get through this, I'm more likely to have a better experience and more likely to get through it feeling that I've done the best that I can.

And then using that with attention control, we have very challenging environments in the clinical setting, we have our internal monologue, which I just mentioned and many natural characteristics that impact us and even how our bodies feeling, I'm I tired, sleep deprived, hungry, do I need to go to the bathroom? All these internal things are impacting me and my ability to maintain my focus.

But then there's the external factors as well. How upset is the patient or the family that I'm dealing with at the time? Is it very loud? Is the lighting not easy to see the technique that I'm doing? Is the environment I'm working in safe? Am I concern that I might potentially be exposed to a pathogen that could get me sick or my family sick?

So I think the importance of attention control is recognizing there are all these competing demands that impact my ability to maintain my attention. So being able to recognize those different factors can allow me to have a sense of control, and recognize which of the factors I have the ability to change, and then recognize which ones I don't have the ability to change so that I can then take that off my plate and recognize I can do the best with the things that I control.

And often, we have to shift from a very focused perspective. And then do a specific skill. And then sometimes we need to take a step back and see the big picture and evaluate how multiple patients are being evaluated. So attention control takes a few different domains of you being able to adapt in the different environments that you're exposed to, depending on the expectation of the situation.

Dre Jillian Horton

And then I think there's one final element of the program that we haven't come to yet, which is progressive muscle relaxation.

Dr. Stephanie Smith:

So this a specific skill, in addition, to attention control, were the two newest to the big 4 plus. They are the pluses. And the progressive muscular relaxation allows us to recognize what tension feels like in our bodies. So when we're getting stressed, our body might manifest in a way of bringing on that tension. So if we can practice the skill in advance, we can recognize that our body is feeling stressed and use some of the other queues we've already discussed today to help you work through and manage that stress.

So a really simple way to do it is even just grabbing your hands and squeezing them really tightly for five or 10 seconds. You can even look at the color change in your hands, and then relax, and then looking at your hands and seeing as the color changes and comes back. You can then go through your arms, your chest, down through your legs, and you can use this just to recognize. That's what it feels like to have tension for me.

Many people will experience tension in their upper body and their shoulders, but some people will feel it in other locations. So doing a body scan by doing the muscle contraction for 5 to 10 seconds, and then a release where I actually feel like a release the catecholamines response and a flush that happens, this can be very therapeutic when you're doing it outside of a stressful event, but it really does help recognize our body's response in those types of events and allows us to be able to respond in a more positive way.

Dr. Jillian Horton:

Both in terms of the literature and your own experience, are some of these techniques more useful in crisis situations than others?

Dr. Stephanie Smith:

I think to best answer that question. It has to do with which ones connect with you the best? We all are going to be drawn to some-- more than others. We'll find them easier to remember or easier to utilize. I think for me, it's very easy to do deep breathing and positive self talk on the fly because I notice my breathing go up, or I notice my handshake or my heart starting to beat faster.

So then saying, OK, take a couple of deep breaths and try to calm yourself down. I'm easily cued. And also the self talk if I recognize myself saying, Oh, no, I don't know if I'm ready for this situation. It's a lot easier to cue myself to do those things. I think for some people, visualization is a skill they use on the flight every time they're going to go in and do a specific skill set. I've met surgeons that say, when they're scrubbing, that's their time to do visualization as they prepare for the case they're going to encounter.

So I think a big thing is practicing all of them, seeing which ones resonate best for you, and then trying those out, and recognizing that others might like different ones more than you do, but I don't think there is a right or wrong answer. I think it's really about what connects best with you and makes you feel is most beneficial.

Dr. Jillian Horton:

So we both know that there's a difference between theory and practice. How do you think that individuals can best ensure that they're able to deploy these techniques when they need them the most?

Dr. Stephanie Smith:

That's a really good question, Dr. Horton, and it's actually come up in the many times that I've taught this course in the past. People have said things like having on their name tag. Putting little cue notes can be there, like take a deep breath. Or that positive mantra I had mentioned earlier, it's just do it, or something a smiley face on-- on the back of their name tag can be helpful.

I think practicing it more regularly will make it easier to pull on the skills in the moment, but I also think if the culture itself is supportive of doing these types of things, it will become more natural. So if the team says is there preparing to transfer a patient, if they were a code team or respond to a code, for example.

If the team says to each other, everybody just take a nice deep breath, remember that we're going to do the best that we can do, and just think through in the next couple of minutes while we're getting prepared, the positive response that's going to happen.

Maybe even make some specific goals of what you want to accomplish during that time, and then remember that doesn't matter what's going on in your life right now, anything else in your head, just try to put it to the side and focus in on the job that needs to be done. And I think having those cue statements can really help us in the moment because as we know, many other things are happening as we're feeling overwhelmed.

It strikes me that in the military, it was probably an advantage that everyone had this training. So what advice do you have for physicians who are trained to use these types of techniques when the people around them don't necessarily have the same skills.

I think the military has done a great job at teaching me how to manage my own personal stress response. And I don't think there is one perfect solution, but I do think we all need to develop a tool kit of skills. And many other people might use a different approach to managing their stress. I know we can all think of that one person that's always cool as a cucumber in a stressful event, and we often think, how are they doing this so well?

And afterwards, they might say, you have no idea how stressed I seemed inside, but I have an ability to show on the outside that I'm managing this well. I don't think there is one perfect approach, but I do think what the military has taught me is that we have to have some approach. You have to talk about the realities of what you're going to be experiencing.

You need to sometimes even talk about the worst case scenario, maybe not even the probable scenario, but just thinking through if it got really bad, how would we handle this? So that you can feel safely prepared in the process. I think creating that environment where everybody has an approach to deal with stress and supporting people in that role is really important, especially from a leadership side. That's something the military has taught me that you can't prepare everybody the same way.

You can have a general approach to do this, and that's something the military has tried but by implementing the road to mental readiness training and resiliency training within our basic training now, something that I actually didn't have initially in the military and did get later on. I've since learned that it's such a helpful strategy to get through the challenging times.

There are many things I've been asked to do that I have absolutely no technical skills in doing, like develop a rope bridge. That's not something I have technical skills in, but when you're given the task, and the military gives you a timeline to achieve it, and they're evaluating you, you have to try your best, so having skills that can help you work through a challenging situation, regardless of the resources that you might have at hand.

I think just having that mental fortitude and that ability to recognize that you might not always have the experience, but you will have the support. And I think that is something that helps people sleep at night knowing that they're doing the best that they can and that it is the responsibility of the organizations working to really loyally support us and prepare us the best they can for the jobs that we have to do.

Dr. Jillian Horton:

Well, I want to thank you for spending time with us today, sharing your knowledge and experience with crisis care, and providing such an excellent roadmap to the STRIVE technique.

Dr. Stephanie Smith:

Thank you very much for the opportunity, Dr. Horton. It's a pleasure to do this today, and I'm hopeful that the things that I've discussed today will bring some positive light towards individuals going through challenging times right now and just knowing that we're all in this together, and we're all having to be comfortable with being uncomfortable, thank you.

Dr. Jillian Horton:

I'm Dr. Jillian Horton. This has been a webinar in the COVID-19 learning series powered by Joule. Take care of yourselves, and I'll see you again soon.

Preparing for the unknown: mental readiness lessons from the military

About Dr. Stephanie Smith

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Preparing for the unknown: mental readiness lessons from the military

About Dr. Stephanie Smith

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Related resources

The buddy system: What it is and why it is important

Wellness at Canadian medical schools

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Mindfulness for Physicians During COVID-19

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Are you in distress? Get help now.

Preparing for the unknown: mental readiness lessons from the military