My Mental Toughness Manifesto – The Talk

I recently spoke at the fantastic AGN 2018 conference in Graz, Austria. My talk was a slightly modified version of “My Mental Toughness Manifesto”.

The talk was live streamed, and a youtube video has since been uploaded (see above).

It’s been quite a journey getting to this point. The blog posts, podcasts and talks I’ve given about my experience in Khayelitsha have become a huge part of my career, and I owe Sa’ad Lahri and his team an enormous debt. It will always be the most important professional experience of my life.

It started off with this blog post covering my initial reflections on the experience.

That led to an invite to speak at ICEM 2016, where I delivered the first iteration of the talk which has evolved into “My Mental Toughness Manifesto”. The original title was “Lessons From the Western Cape”. Professor Simon Carley was in the audience, and we recorded this podcast after I spoke that day.

That podcast led to a follow up guest blog post for St.Emlyn’s – “An Englishman in South Africa” – which I’m proud to say is one of their most popular posts to date.

Since that St.Emlyn’s post dropped things have escalated somewhat. I have now spoken on the topic of performance psychology all over the UK to a wide range of audiences including foundation and core trainees, GPs, anaesthetists, military medics, prehospital docs, Hospital Grand Rounds and senior educators at Health Education England. I’ve also spoken at international EM conferences in South Africa, Germany, Denmark and now Austria.

My proudest achievement is delivering an extended version of “My Mental Toughness Manifesto” at the International Special Training Centre in Pfullendorf, Germany, to a group of Special Operations soldiers from nations across NATO. The guys I spoke to were all training to be Combat Medics. I first went over in January 2017, and was honoured to be invited back earlier this year. That experience prompted me to write four accompanying blog posts:

“My Mental Toughness Manifesto” Part 1: Cognitive Appraisals

“My Mental Toughness Manifesto” Part 2: PRACTICE

“My Mental Toughness Manifesto” Part 3: PERFORM

“My Mental Toughness Manifesto” Part 4: PROCESS

This journey will continue. I will always be a student of performance optimisation and acute stress management in the context of delivering acute healthcare. The content of my blog will keep mirroring those interests in the years to come. I’ve got big plans!

I would like to take this opportunity to thank those who have helped me get to a point in my career where I am being invited to speak regularly on a topic I am truly passionate about. To have have my session at in Graz live streamed (AND live translated in German) was a huge bonus! In particular I’d like to thank Simon Orlobb for the invitation to speak in Graz, my mentor Simon Carley, and of course Sa’ad and the team at Khaye. I should also mention James Kingston and Jocko Willink as their incredible work is featured in the talk.

Exciting times.


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PonderMed #3: Nick Adkins, creator of #pinksocks

About Nick

Nick Adkins is a healthcare executive and serial healthcare entrepreneur from Nashville, Tennessee. He is the creator of the exponentially growing #pinksocks movement. #pinksocks is a global community trying to the positively affect the world, largely through a variety of missions within healthcare and #digitalhealth.

Nick used to wear a suit and tie to work. After a life-changing experience at Burning Man Festival in 2010 he started wearing a kilt every day and moved to Portland, Oregon.  He now spends his time keynoting at conferences around the world about the importance of human connection (usually in the context of healthcare), and focusing on the abundance of love that exists in our world as opposed to media-fuelled fear. He also serves on the advisory board at Cloudbreak Health, a leading telemedicine company in the US.

The Burning Man principle of Gifting gave birth the #pinksocks movement.

Our conversation

00:24 – How I became exposed to Nick’s work

03:46 – Telemedicine

14:05 – Poor uptake of new technology in NHS hospitals/more on telemedicine

28:42 – US healthcare politics

49:15 – Love More Fear Less

51:38 – The #pinksocks story

Want more from Nick?

Find him on twitter – @nickisnpdx

I hope you enjoyed the podcast!

Until next time.


#pinksocks #LOVEMOREfearless

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Simulation Training in Virtual Reality

Recently I’ve been thinking a lot about how new technology will affect my life as an ED doctor. It’s 2018, and the un-ignorable hype surrounding #MedTech is reaching fever pitch. In my opinion, the big players are machine learning, telemedicine, and virtual reality (VR). Their impact promises to be unprecedented across the spectrum of medical environments, with patient outcomes and reported patient experience set to be the key beneficieries. Of these three technologies, the one that feels closest to becoming a part of my daily working life (at a midsized District General ED) is VR. There will need to be some pretty seismic infrastructure improvements before the other two hit the mainstream in the UK.

It is hard to believe anybody reading this won’t have heard of VR, but for those that haven’t: it is an artificial 3D environment that the user experiences through visual and auditory stimuli. Visually, the experience is delivered via head-mounted display (HMD/headset), and the audio is delivered via headphones connected to the HMD. Head motion is tracked so that the user seems to move naturally around the virtual space (full 360-degrees). Audio is also simulated in 3D, so the user can locate sound at a real location in the environment. The result is that the user becomes so immersed in the simulation, that rationality is overridden and a sensation of genuine presence in the virtual world is experienced.

There is a hugely noticeable difference between the physical world and the abstract, packaged versions of reality that we routinely experience through multisensory media like movies and videogames. We always know we’re not experiencing something that is immediately ‘real’. When immersed in VR, that difference is far less easy for the rational mind to discern. At the touch of a button, our subconscious might be genuinely fooled into thinking we are swimming with sharks, flying through space, or living in a cartoon world full of teddy bears.

Strictly speaking, it’s incorrect to call VR a ‘new’ phenomenon, as the technology has been around for several decades. The reason it’s picked up steam recently is the exponential growth of computing power, and because HMDs are now comfortably affordable for consumers. They are lighter, transportable, and standalone – you can just slot your smartphone in and you’re all set. VR has gone from lab experiment to consumable, and it’s as user-friendly as putting on a pair of ski goggles.

Historically, VR has been limited to the entertainment and gaming industries. However, the recent explosion of public interest has prompted experimentation with the latest iterations of the technology across multiple domains, including healthcare.

How might VR be utilised in the ED? The answer to this question will evolve in parallel with the technology of course. Clearly though, it already represents a huge opportunity for education and training.

Experiential learning via simulation training is now well established as a mainstay of any reputable EM curriculum, but high-fidelity manikins and simulation labs are expensive and labour/equipment intensive. As such, sim opportunities for trainees are all too infrequent. In-situ simulation, the fashionable cousin of high fidelity sim, is an even rarer occurrence as it requires wide-scale hospital buy-in and, of course, a quiet department.

VR simulation represents a cheaper, more versatile alternative to traditional sim. When one considers the quality and variety of virtual environments that have been designed in other industries, it seems pretty feasible to design a range of virtual scenarios that would simulate the practical curriculum of the emergency physician in-training.

The same thought processes and (more challengingly) practical skills could tested and honed, and all that would be required is the trainee putting on an HMD and pair of headphones. The breadth of sim scenarios that could be accessed in a VR library would dwarf the offerings of even the most impressive sim lab, as the limit of what could be trained would be reflected by the imagination of the VR software developers as opposed to the practical constraints of the lab. It’s conceivable that trainees could run through sims in the comfort of their own home, and then debrief with their supervisor via Google Hangout at a convenient time afterwards.

To many, the unsung hero of sim training is the ‘stress inoculation’ element. Whilst crucial to test scenario-specific knowledge-base and decision-making, it is the rehearsal of having to put on a performance in the presence of heightened emotional and physiological states (‘being under pressure’) that is most useful to the trainee the next time they are in a real resuscitation room managing a real crashing patient. When deliberately increasing stress levels mid-scenario to challenge the trainee, surely the immersive and artefact-free nature of VR will be vastly superior to traditional sim. It’s a digital treasure trove of potential scenario modifications and curve-balls, as opposed to the clunky, frankly un-human manikin and predictable supporting cast found in a sim lab. VR will be simulation training 2.0.

Not confident managing major trauma? Download a few appropriate scenarios onto the VR Sim app on your smartphone, and then spend an evening ‘playing’ them as many times as required. VR will gamify quality medical training, and make it available on demand. Perhaps the future will bring us an artificial intelligence algorithm that will be able to supervise a trainee’s performance during the virtual sim, and give constructive feedback, negating the need for human supervision.

Self-directed training optimised.

Robert Lloyd

Want more VR stuff?


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