For years gone by, pre-hospital care has looked to the aviation industry for a model to fix the inconvenient challenge that faces all specialities of medicine – human factors. But change is afoot as medicine opens its eyes to not just industries, but those individuals who can produce elite performance under extreme pressure.
The Performance in Psychology Medicine symposium hosted by London's Air Ambulance at the Blizzard Institute on the 24th June embraced this challenge, as a packed schedule aimed to impart lessons from top comedians, Olympians, sports psychologists and some of the leading names in pre-hospital, emergency and critical care. Everyone present agreed it was a conference like no other.
The day started with Cliff Reid asking why clinicians should care about performance, and highlighted how the Greater Sydney Area Helicopter Emergency Medical Service (HEMS) had managed to create a climate of elite performance in a world-renowned service. The approach was multi-faceted – direct involvement of senior clinicians in the training, a rigorously structured induction and a culture that every tasking should produce an elite performance. He went on to highlight his service's ‘zero-point survey’, a process that is performed prior to the primary survey but can be at multiple points throughout the incident in order to focus the team at crucial points of the job cycle. He highlighted the point of tasking, on route to the job and approaching the patient side as crucial times to do this in order to incorporate a check of Self, Team, Environment and Patient. To me, it raised an important point in our practice. When tasked to a critical incident where you know your knowledge is going to be stretched, do we as a profession have a model or structure to ensure we are mentally prepared? I have seen experienced clinicians do this very well. Could such a model help focus our students or more junior clinicians when facing such pressure?
He finished with one of the most powerful questions of the day for me, questioning what played the biggest role in his service's high standards – great trainees or great trainers? Reflecting on this, I feel it highlights a real challenge to our profession. When learning from these elite teams and performers, do they already have a head start on achieving elite performance due to the baseline with which individuals enter their teams? If so, how do we ensure we create a climate within our profession where we attract future paramedics that have a solid baseline to build from?
Welcoming the first of many experts from various sports disciplines, James Harris, Chris Shambrook and Mel Wilson explained how the women's Olympic rowing 8 went from a failing boat to winning a silver medal. As the trio discussed mind-set to achieve elite performance, Mel highlighted how a positive mind-set does not equate to a positive performance. Negative mind-sets can also drive a positive performance. She highlighted the fear of failure as a personal driver, and I recognised identification of failures or substandard care acknowledged during a debrief as being a personal negative driver towards my future positive performance.
James Harris also produced one of my standout comments of the day when offering his input on Kate Kellogg's research on the effect of doctors being interrupted mid-task in the Emergency Department (ED). As Kate highlighted the detrimental effect of Doctors being interrupted to complete other tasks and the consequential effect on performance, James highlighted how, if something regularly happened and affected performance in sport, athletes would explore a way to use this as a trigger to drive performance. Considering the paramedics' role at a critical incident when interruptions are plentiful, from other services, EOC, members of the public and colleagues, the consequential effects on performance, I feel are relatable. However, exactly how we use these to drive performance is something I am uncertain about.
Returning after the lunch break, Milton Jones and Sally Phillips took the stage and were predictably hilarious with Milton Jones's opening comment explaining he felt ‘humbled although out of place to be talking at a medical conference… a bit like a pigeon at an airport’. Although this could have very easily been an interlude, to what on paper was a very heavy day, some of the greatest learning points came from this session as the pair explained how they managed pressure when things went unexpectedly wrong; for example, managing the heckler.
Surprisingly, both seemed to come to the same conclusion without being prompted. Milton Jones highlighted that 98% of the time when things have gone wrong for him, it was through ‘self sabotage’ – the idea that he had become complacent and let that scenario develop. Sally Phillips highlighted similar experiences in her role and the need to always remain focused on set and as I reflect on my clinical practice, the times when things have spiralled out of control is often when I was complacent.
In terms of how to manage the heckler. Address it early, meet it head on, and as I translate this to the unexpected deterioration or a challenging relative in our practice, I feel the technique translates. For me, the final highlight of the day addressed how we meet the challenges of educating our future paramedics and current students in the unique environment of pressure and stress – specifically through simulation. The idea was simple; Professor Marc Jones explored the effects of stress and emotion on performance and learning. As he talked about this in the context of simulation, he managed to draw together many other talks from the day as he highlighted the effect of emotional response on performance. Challenge vs threat was the key theme and a mantra I have already mentioned many times this week at the University. Simulation and learning needs to challenge the student but not appear threatening and this will require an approach that will be unique to each individual student.
Predictably, the failure to achieve an emotional response was associated with the lowest level of performance. Meanwhile, a threatened response would improve performance, but the highest levels of performance were achieved when challenged, but not threatened.
For me as an academic, this highlighted something we as a profession need to explore in order to achieve student education and paramedic CPD that creates an emotional response that challenges, but does not create an environment that threatens. As paramedic education evolves and a greater number of students are completing level 6 pathways, the academic education that a paramedic receives has evolved significantly from the IHCD course that was completed historically. However, as the day drew to a close, I questioned whether how we educate our students in practice has evolved as drastically, even with the addition of formal mentoring courses and simulation-based practice in the University.
What has the day meant for my practice? I used to feel that learning took place during the simulation or when the student is out in practice. In reality, it appears that the pre-brief and de-brief are essential in order for this to occur. This will in turn allow us to challenge rather than threaten our students and in turn leads to higher stimulation and greater learning. This will in turn start to address Cliff's dichotomy – great trainees or great trainers because in my opinion, elite performance sits at the top of a triangle with great trainees and great trainers sitting at either point on the base – truly elite performance cannot exist without both being present.
A star studded panel with experts in Emergency, pre-hospital and Critical Care form around the world drew close to the day and as they highlighted where they felt their teams currently were and also needed to be, I was humbled by the humility of the panel; comprised of individuals who are elite performers in the medical setting but still chasing ever greater results and performance.
They all concluded medicine still has to learn and although everyone in the panel had their own highlights of the day, they all agreed on one thing. None of them were in services that had nailed performance psychology within their teams, and as I reflected on how both my academic and clinical colleagues embrace this challenge, a common theme emerged: both need to embrace this culture by implementing performance education as a cornerstone of student paramedics' education and annual Ambulance Service CPD.
In my opinion, we have only scratched the surface of human factors in pre-hospital care. Using checklists or looking for ‘marginal gains’ can no longer be viewed as satisfactorily addressing this issue. Recognition that the paramedic role requires individuals to perform under pressure, and finding processes to address this cannot be the role of a few elite teams or individuals, and needs to be embedded throughout pre-hospital care education and CPD. This can only be achieved through a climate and culture that looks to promote elite performance spanning the range of clinical grades within pre-hospital care, and such a process must start from day 1 of a paramedic's training.
Gareth Davies summed up the day best highlighting virtuosity – performing the common, uncommonly well and the danger of skipping past the fundamentals in order to perform more elaborate and sophisticated techniques. The flaws in the fundamentals become apparent at a later stage and if you take a step back from some of the big topics of discussion in paramedic practice at the moment, virtuosity is something that probably warrants greater recognition.