Olympians and Comedians #PerformanceLDN

perf sympTraditionally, human factors and performance psychology are low down the priority list (or non-existent) in medical training. Students graduate from medical school with ‘academic-style’ mindsets, arguably ill-prepared for the practical, performance-dependent branches of medicine. In short, our training predisposes us to the yips.

But change is afoot. On 24th June, I attended the London Performance Psychology Symposium at the Blizard Institute, close to the Royal London Hospital. Organised by the London Air Ambulance Service, it was the world’s first medicine-specific performance psychology conference. For a Kool-Aid drinker like me (I’ve blogged on mindset and performance here at PonderingEM and over at St. Emlyn’s), it was unmissable.

The line-up included a Who’s Who of thought-leaders from the EM/critical care/prehospital community, along with elite performers in distant disciplines. All were united in their quest for performance optimisation. The day was jam-packed full of pearls, but my favourite take-home points came from the worlds of sport and stand-up comedy.

‘Focus on your processes’

The audience was inspired and riveted in equal measure when Olympic rower Mel Wilson delivered a TED-worthy presentation on the performance culture of the GB Women’s VIII at Rio 2016. Her message was beautifully simple:

Focus on your processes, not the outcome

She kept returning to this mantra. You have no direct control over the outcome of a rowing regatta, much like you have no direct control over patient survival from life-threatening illness or injury. There is always the chance, whether racing a boat or team-leading a paediatric cardiac arrest, that winning will elude you, despite performing at your maximum. The only controllable elements are how diligently you approach the steps required, and how well you sync up with your team. By placing all your focus on real-time practicalities (processes), as opposed to the overall goal, the result will usually take care of itself.

Fascinatingly, when Mel started to feel stressed or overwhelmed by the moment, it would physically manifest as a specific hand/grip position on her oar. When she noticed that happening, she would use it as a trigger for re-directing her attention to her basic processes and nothing else, which nipped any potential cognitive or physiological self-sabotage in the bud. This strategy can be applied to resuscitation. When a case becomes chaotic and unmanageable for the team leader, it should trigger a cognitive stop-point. That moment is an opportunity to summarise the case thus far (sharing his/her mental model) and to focus the team’s attention on crucial basics – e.g. good quality CPR, rhythm and pulse check logistics, a recap on interventions performed and when the next is due (e.g. next adrenaline push) etc. Reigning in the team from a state of entropy is achieved by getting back to basics. Once order has been established, more nuanced performance and clinical reasoning can be layered on top.

Team-GB-621915The reality for athletes, particularly in Olympics-centric sports such as rowing, is that 4-year training cylces culminate is as little as 6 minutes’ peak performance time. That is pressure of unmeasurable magnitude, and the danger of choking is real. In the 2016 Olympic final the crew were in last place until past the half-way mark and Mel described how she resisted the temptation to fixate on their position or obsess about how much time and energy she had invested in that short moment. Instead she focused only on her processes. She felt the team’s collective processes ‘strengthening’ as the race progressed, and in the final stretch they managed to pip the Romanians into third place and seize a historic silver medal. By taking complete ownership of the basic practicalities of their jobs and focusing on nothing else, they achieved sporting immortality.

In medicine, we do not have to wait four years for a big performance to be required – it is an everyday occurrence. But the same rule applies. We must take full ownership over our performance and never allow personal standards to drop because of perceived external pressures. If we resist the urge to dwell on how high the stakes are, how busy the department is, or the implications of a poor patient outcome, and remain doggedly focused on our processes, we will be better doctors.

Mel’s source of inspiration was her teammate and role model, five-time Olympian, Fran Houghton. Fran always claimed that rowing was an ‘art form to be mastered, not a series of races to be won’. Focusing on processes was such a core of Fran’s race mentality, that she is on record as saying she would rather lose with processes intact than win ugly. For an individual whose career will largely be judged on the number of medals won and nothing else, her attitude speaks volumes. Fran has recently retired as one of Great Britain’s most decorated female rowers, and her influence on Mel’s career was palpable.

Perhaps medicine is an art form to be mastered, not a series of patients to be saved. Whilst I am sure that reflection might not jive with how many doctors feel about their jobs overall, I firmly believe that the more we focus on our processes, as opposed to saving lives, the more lives we will save. We must recognise that medicine is a performance-dependent pursuit, particularly on the frontline, and our focus must be on ourselves before the patient, so that we can serve them to the best of our ability.

At the end of my career, I hope I will be able to reflect on a consistently diligent and disciplined approach to my performance at work, and an insistence on respecting the crucial basics, rather than on specific patients with good outcomes or any accolades won/prestige posts earned (still pending obviously!). I would like to think Mel and Fran would approve of that intention.

Best of luck to Mel who is now an FY1 (first year intern) at Hillingdon Hospital. It will be fascinating to see where she ends up.

‘Learning stand-up is like learning to play piano with a live audience’

Another standout moment of the day was when Dr. Tom Evens (London HEMS consultant, and Symposium Convenor) interviewed comedians Milton Jones and Sally Phillips. They were predictably hilarious, with my favourite gag being Milton’s opener:

I’m humbled to be here… a bit like a bird at an airport

I loved the contrast of having professionally funny people talking to a room full of serious types at a serious conference! They made the event feel beautifully light on its feet, whilst making hugely valuable contributions to the overarching conference themes of innovation and exploration.

My take home message from this session is that failure is important, and must be embraced, no matter how painful. Junior stand-up comedians spend night after night failing to make people laugh, but each of those failures is critical for eventual success. A poorly executed delivery or subject matter that falls on deaf ears provides invaluable guidance for iterating the following performance. Eventually, a hilarious session of comedy will have been sculpted from rubble.

I’ve blogged before about ‘Black Box Thinking’, and how healthcare has much to learn from the staggeringly brilliant aviation industry in terms of institutional attitudes towards failure and near-misses. The world of stand-up comedy might provide equally poignant insights. Comedians have nowhere to hide when they are bombing on stage, and it must feel like the loneliest place imaginable. I’ve heard it is the only job in the world where you are judged every five seconds. And yet they keep dusting themselves off and getting back on the horse, knowing that each tumbleweed moment, hurtful heckle or stuttered punchline, is a rite of passage and necessary self-harm en route to mastery. Without constantly putting themselves in a position to fail, and then honestly and actively reflecting post-failure, a comedian’s career would never get out of first gear.

milton jonesThe unfortunate reality of medicine, unlike the comedy club, is that there are plenty of places to hide when we fail, and so precious learning opportunities are frequently squandered. If elite performance is what they seek, junior doctors must take a leaf out of the stand-up comedy playbook and actively chase after moments of failure. Wrong decisions, bodged procedures and impossibly stupid questions should be celebrated for their lessons, and never be deemed unforgivable by supervising senior colleagues, the inherent nurturers of this process.

A novel way that Milton demonstrates mistake-ownership during his routine is to lead a collective ‘boo’ from the crowd when a gag falls flat (‘on three, everybody boo… one, two, three…’). He says it puts his audience at ease, and earns him a sure-fire laugh. What a pro. Mind you, I’m not sure I’ll adopt that strategy the next time I intubate the oesophagus!

Many thanks Dr. Evens and his team for a fantastic day of learning and inspiration. I’m already excited to see who they line up to speak next year.



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‘My Mental Toughness Manifesto’ Part 4: PROCESS


Everything in aviation we know because someone somewhere died… We have purchased, at great cost, lessons literally bought with blood… We cannot have the moral failure of forgetting these lessons and have to relearn them.”

Sully Sullenberger
Pilot of Flight 1549, ‘The Miracle on the Hudson’

All frontline healthcare warriors will bear scars from emotionally distressing experiences in the workplace (e.g. major incidents with multiple casualties, unsuccessful paediatric resuscitations, personal mistakes resulting in patient harm). For the most part, members of the public will only rehearse being exposed to these flavours of horror by watching movies or having nightmares. For us, it is a potential reality every shift.

In the aftermath, the way one processes these events heavily influences future commitment to similar causes and cognitive appraisals (challenge vs threat mindset) – the key determinants of mental toughness.

Adaptive processing should incorporate ‘Black Box Thinking’ and self-compassion. 

‘Black Box Thinking’

BBT betterConsider the aviation vs healthcare discussion for a moment – arguably the two most safety-critical industries in the world.

On average, just one commercial flight goes down for every 8.3 million take-offs worldwide. In the US alone, there are approximately 400, 000 avoidable medical errors every year, which is the equivalent of two jumbo jet crashes every day [1, 2]. That is a gargantuan discrepancy in passenger versus patient safety.

Of course, it is well documented that the two industries are not directly comparable. There are far more reasons for a patient to die than there are varieties of plane crash, and medics do not yet have the option to switch on a mental bandwidth-sparing machine that’s able to mop up routine tasks. Nonetheless, the statistics illustrate an indisputable point – we have a huge amount to learn from our aviation counterparts, whether we like it or not.

Why is aviation such a staggeringly high performance industry? The answer is simple: there is an institutional culture of learning from failure. Every plane is equipped with two sturdy black boxes which record conversation in the cockpit, and electronic decision-making (i.e. which buttons were pushed). In the case of an accident, the black boxes are promptly retrieved from the battered fuselage, opened, and the contained data interrogated. Every aspect of the crash gets the fine-tooth-comb-treatment to identify exactly what went wrong. Protocols are subsequently modified so the same mistake can never happen again. Error is not viewed as a sign of weakness or inadequacy – on the contrary, it is treated as a precious (even exciting) learning opportunity for everyone who might benefit.

Healthcare culture is largely the polar-opposite. Failure is stigmatised because doctors are supposed to be infallible in the eyes of the public. Mistakes get ‘swept under the carpet’ by the guilty to avoid being held accountable and where that is not possible, the blame-game ensues [3]. When one’s professional credibility is at stake, a successful escape from the situation is higher up the priority list than learning from the failure; and the omnipresent threat of litigation only serves to further entrench this defensive, maladaptive institutional culture. The immediate gratification of reputation-preservation trumps the potential for professional growth that naturally follows acknowledgement of personal failure. We routinely blind ourselves to the best possible signposting for getting better at our jobs – our mistakes.

Whilst this growth-stunting phenomenon will vary in severity across the spectrum of healthcare environments, you would be hardpressed to find a doctor, anywhere in the world, not regularly exposed to this embarrassing peculiarity of our profession.

Be a black box thinker. Own your mistakes. Share your lessons. Interrogate every performance with the curiosity and tenacity of the Air Accidents Investigation Branch. Re-conceptualise your relationship with failure so that it no longer represents an existential threat, but acts as a guide for your ‘practice’ phase.

‘Reflective practice’ is an overused and misunderstood term in medical training (in my opinion). Often, written evidence of it is a requirement for career progression, and when one ‘reflects’ for that reason alone, it ceases to be useful. Furthermore, documented reflections will too frequently centre around what went well – a less lucrative training exercise.

Apply the black box philosophy to your reflective practice and force yourself to face potentially ugly truths. Embrace being criticised and never back down from asking a ‘stupid question’ – it tees you up for focused training and subsequent accelerated improvement. Have the bravery to be the detective leading the warts-and-all investigation on yourself.


In frontline healthcare, we are routinely exposed to life-changing injury and acute illness. If we take our workplace goggles off, and dare to view the worst aspects of our jobs through the eyes of a ‘normal’ person, it can be intensely disturbing. Furthermore, subscribing to the highest professional standards can make us prone to gratuitous suffering as we’ll mistakenly convince ourselves that we could have done more for unsalvageable patients. Our keenness to take full responsibility can render us vulnerable to unnecessary self-punishment.

Without appropriate perspective and personal support, our view of the world, and indeed of ourselves, can become warped. Long-term self-neglect in our line of work will eat away at our commitment to the job, potentially invite long-term psychological damage (PTSD), and ultimately, harm our patients.

When a particularly traumatising incident occurs, many institutions will employ a ‘critical incident stress management’ (CISM) protocol, which encompasses a range of supportive interventions aimed at preventing PTSD [4]. This includes a formal group debrief, led by an outside party (usually a psychologist) within 72 hours of the event. Despite being widely practiced, this approach is controversial as no definitive benefit has been demonstrated in the literature. However, widely accepted to be of critical importance for psychological wellbeing in the immediate aftermath of an emotionally traumatising incident is a ‘defusion’ process [4, 5, 6].

‘Defusion’ is a team get-together where thoughts and feelings are shared in confidence. When threat appraisals drench our brains in cortisol and distort our perceptions, defusion allows for piecing together the chronology and specifics of the event through organic, informal discussion with team-mates. It is an opportunity for emotional support, having a collective laugh/cry at the absurdity of the job, and an accurate information gathering exercise in a safe environment. The team pull together in the aftermath, are honest about their emotional frailties, and find strength in each other. It lacks the rigidity and intrusion of an uninvited formal debrief led by an ‘outsider’.

Pain shared = pain divided

Joy shared = joy multiplied [7]

In the hospital setting, it can be as simple as insisting on a chat in the coffee room after a big resus, or a quick get-together after work. It might seem minor, but unnecessary guilt, anger, confusion and other damaging emotions can be thwarted by this process. However informal and insignificant it might appear on the surface, it is of fundamental importance, and must be sought out, however logistically difficult.

In more extreme environments, such as combat or the prehospital setting, sitting down to defuse should also be used as an opportunity to regain a feeling of physical safety, get warm, hydrate and refuel (eat something).

Self-compassion via defusion is a critical strategy for building mental toughness. Taking care of yourself and your team after an acute insult preserves commitment to the job, and prevents lasting psychological scars that will render you less able to cope emotionally with the inevitable acute stress that lies in wait.


Use mistakes as signposts for self-advancement as opposed to sources of embarrassment. Own your failures instead of hiding them, and use them to guide your ‘practice’ phase.

Always remember to ‘defuse’ with your team after emotionally challenging cases/incidents. Share the pain, and multiply the joy. Never underestimate the therapeutic value, and heavy dose of perspective, that humour offers.

‘My Mental Toughness Manifesto’ Roundup

You are mentally tough if able to state the following (Part 1):

“I am 100% committed”

“I feel challenged”

To build and maintain mental toughness, I propose seven strategies over three phases of the game:

‘Practice’ (Part 2)

  • Immersion
  • Deliberate Practice
  • Visualisation

‘Perform’ (Part 3)

  • Tactical Breathing
  • Cognitive Reframing

‘Process’ (Part 4)

  • ‘Black Box Thinking’
  • Self-compassion

Own your performance.

Robert Lloyd


  1. Black Box Thinking. Matthew Syed.
  2. 2017 Royal Society of Medicine Easter Lecture: Creating a high performance revolution in healthcare. Matthew Syed.
  3. What do Emergency Medicine and Donald. J Trump have in common? Robert Lloyd, EMJ Blog.
  4. Mental health response to disasters and other critical incidents. BMJ Best Practice.
  5. Debriefing and Defusing. http://www.davellen.com/page21.htm
  6. Shoes, Sex and Secrets: Stress in EMS. Ashley Liebig. SMACC Chicago lecture.
  7. Grossman, L.C.D., On Combat: The Psychology and Physiology of Deadly Conflict in War and in Peace. 2008: Warrior Science Publications.

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‘My Mental Toughness Manifesto’ Part 3: PERFORM

Arousal‘Practice’ is about building a skillset, and fostering a way of life (via ‘immersion’) that serves to strengthen perception of one’s available resources when crunch time arrives.

However, reality dictates that certain scenarios are impossible to prepare for, particularly in the emergency medicine arena. The more chaotic the workplace, the higher the frequency of unavoidable threat appraisals.

Therefore, it is crucial to utilise strategies which stabilise one’s level of emotional arousal in the heat of battle. Namely tactical breathing and cognitive reframing.

Tactical Breathing

“Feel breath filling every cell of your body. This is our ritual. We master our breath, we master our mind. Pulling the trigger will become an unconscious effort. You will be aware of it, but not directing it. And as you exhale, find your natural respiratory pause and the space between heart-beats.”

American Sniper

In a high stakes game, where your next move (performance) has implications for the survival of another human being, it is a guarantee that your sympathetic nervous system will be working overtime. We know, of course, that this can work in our favour if challenged (perceived resources > demands); indeed, we’ll feel ‘pumped’ and ‘ready for action’. On the other hand, this heightened physiological arousal can be the architect of a catastrophic blunder if threatened (i.e. demands > resources; see MMTM Part 1 for a full explanation).

The only component of the autonomic nervous system that we can override and take conscious control over is our breathing [1, 2].

Deliberately slowing respiratory rate in a moment of crisis has the effect of preventing further escalation of other features of the sympathetic surge, such as tachycardia and hypertension. This feeling of control over our physiological arousal induces a prevailing sense of clarity and calm. It serves to psychologically detach the conscious self from the stressful moment, allowing an imaginary reset button to be pressed with subsequent restoration of mental bandwidth. Visual and auditory perceptions widen as the mind is released from the paralysing effect of the cortisol dump. Professional presence in the moment is re-established.

square breathing

‘Tactical breathing’ (or ‘square breathing’) describes the four-second method pioneered by Lt. Col. Dave Grossman, of On Combat fame [3]. One must breathe in for four seconds, hold for four, exhale for four and then hold again for four, on repeat until the desired effect is achieved. Whilst this provides the stressed individual with a mental model to follow, it is not essential to adhere rigidly to the timings. The crucial task is committing to a conscious slowing and deepening of one’s breathing cycle.

This idea is nothing new or revolutionary. Breathing techniques have been utilised by elite soldiers, martial artists, professional athletes, and a host of other world-beaters for generations [4]. Underestimate this tool at your peril.

Cognitive Reframing

A salient feature of the threat mindset is a thinking pattern polluted with self-doubt and persecution.

‘I can’t do this’

‘I don’t know what to do’

‘My mind is blank and my patient is dying’

Naturally, this has a devastating effect on performance. If you are telling yourself that you’re not up to the job, it is highly unlikely that you will prove yourself wrong.

Pressing ‘control/alt/delete’ on these thoughts, and inserting useful content, is therefore critical. This process is called cognitive reframing, and it can be achieved via positive self-talk and an ‘incrementalsteps’ approach.

Positive self-talk

This is the process of forcing one’s internal dialogue to suggest something positive. It can jolt the mind out of a persecutory spiral, if sufficient commitment/buy-in is present [5, 6].

It can be generally motivational:

You have trained well for this’

You’ve been in this position before and succeeded’ 

‘Relax and focus’

Or be used as a method for directing cognitive resources to something specific:

Slow is smooth, smooth is fast’ 

You have plenty of time, just bring the epiglottis into view’ 

Positive self-talk synergises well with tactical breathing, providing, in effect, a two-pronged intervention on physiological and cognitive over-arousal.

An ‘incremental-steps’ approach

During a crisis or particularly demanding scenario, it is always a bad idea to look at the big picture.

Break down the required process into its component parts, and focus only on your first step. Upon completion of that step, allow yourself to contemplate the next, and so on. This will modify your perception of the situational demands by reframing the scenario into a series of manageable challenges instead of one giant threat, and in doing so, hold off any detrimental physiology [7].

For example, if confronted with an unconscious head injury patient who is obstructing his airway and gargling blood, do not allow yourself to contemplate the overall objective (i.e. getting the patient safely anaesthetised and intubated). First focus solely on applying high-flow oxygen, appropriate monitoring, and allocating team roles. Next, focus on achieving intravenous access, followed by readying the airway equipment and drugs, then instrumenting the airway, thereafter ‘epiglottoscopy’, and so on. A state of panic is warded off by a refusal to allow the mind to wander too far forwards.

If you avoid looking at the mountain peak, and focus exclusively on the first obstacle lying in front of you, you will arrive at the summit in no time.

Use positive self-talk to encourage and guide you through each incremental step.


  • Threat appraisals are an unfortunate inevitability for all acute care clinicians.
  • Taking conscious control over your respiratory cycle grants you the ‘keys’ to the rest of your autonomic physiology.
  • Positive self-talk intervenes on persecutory thought pollution, and can redirect cognitive resources to specific tasks. It can synergise with tactical breathing as a method for ‘resetting’ in a moment of high stress.
  • An incremental-steps approach converts a significant threat into a series of manageable challenges.

In the fourth and final instalment of My Mental Toughness Manifesto, I’ll be discussing a healthy and progressive methodology for PROCESSING a highly stressful clinical encounter after the event.


  1. Mike Lauria. Enhancing Human Performance in Resuscitation Part 3 – Performance-Enhancing Psychological Skills. EMCrit Blog. Published on November 22, 2015. Accessed on May 5th 2017. Available at [https://emcrit.org/blogpost/performance-enhancing-psychological-skills/].
  2. Seppala, E.M., et al., Breathing-based meditation decreases posttraumatic stress disorder symptoms in U.S. military veterans: a randomized controlled longitudinal study. J Trauma Stress, 2014. 27(4): p. 397-405.
  3. Grossman, L.C.D., On Combat: The Psychology and Physiology of Deadly Conflict in War and in Peace. 2008: Warrior Science Publications.
  4. Weisinger H, Pawliw-Fry JP. Performance Under Pressure. New York, NY: Crown Business.
  5. Scott Weingart. Podcast 177 – Chris Hicks on the Fog of War: Training the Resuscitationist Mindset. EMCrit Blog. Published on July 11, 2016. Accessed on February 24th 2017. Available at [https://emcrit.org/podcasts/chris-hicks-fog-of-war/].
  6. Tod, D., J. Hardy, and E. Oliver, Effects of self-talk: a systematic review. J Sport Exerc Psychol, 2011. 33(5): p. 666-87.
  7. Rob Orman, Rich Levitan, ERCast – Psychology of the Difficult Airway, 2014

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