Wow, what an honor: a conversation with the author of my favorite book about performing under pressure! Dan Dworkis is the Chief Medical Officer at the Mission Critical Team Institute & Assistant Professor of Emergency Medicine, Keck Medicine of USC. Dan wrote the a great book, The Emergency Mind: Wiring Your Brain for Performance Under Pressure. We talked about performance under pressure in emergency medicine and the lessons from martial arts. We talked about what writing the book taught him and what he would add in the next edition of his book. And I asked him about the most important skill in crisis situations and of course about his 1- 3 favorite books on performing under pressure that every doctor should read!
What is your experience / affinity with martial arts and acute medical care?
I was lucky enough to start training martial arts at eight years old – a very early age – and fortunate enough to be able to continue training throughout my life thus far (and hopefully far into the future!). These days it’s mostly Brazilian jiu-jitsu with some muay thai mixed in. Obviously, I came to emergency medicine later than eight years old, but I was really drawn to it early in my medical training. I did my emergency residency training with the Harvard Affiliated Emergency Medicine Residency at Massachusetts General Hospital/Brigham and Women’s Hospital in Boston. Prior to that I did my medical and doctoral studies at Boston University School of Medicine, and these days I’m in attending physician and assistant professor of emergency medicine at LA County (LAC+USC), one of the busiest emergency departments in the United States. I also serve as the Chief Medical Officer of the Mission Critical Team Institute, which focuses on exploring best practices with elite teams working in the military, aerospace, medical, and related fields.
Why did you write your book and what did it bring you (in a non-commercial sense)?
Many times, especially in critical cases at the beginning of my training in emergency medicine, I would struggle to perform at the level that I wanted to. I had trained in the theory of medicine, and I had a deep fund of knowledge, but I found it extremely challenging to overcome the chaos and stress of a situation to bring that knowledge to the patient where and when it was needed. I kept asking what does it take to perform at the level that I wanted to, what does it take to deliver my skill under stress? Over time, I came to realize that this idea – how to apply our knowledge under pressure – is its own skill, separate from, but equally important too, the other skills we learned in training like intubation, laceration repair, or splinting.
I wrote The Emergency Mind to help individuals, teams, and structures develop that skill – I wrote it because it’s a book I wished I had when I was laying awake at night after challenging cases wondering how to perform better under stress and pressure. I see The Emergency Mind as establishing a common vocabulary around applying knowledge under pressure – something that we can use to understand and explore the scope of this problem and begin to develop solutions to it.
I think the most important thing it’s brought me is connection to the wide array of other people who are working in and out of emergencies. These people are struggling to do the best they can in suboptimal circumstances, and it’s been an absolute joy getting to connect with them and work side-by-side to figure out how all of us can do better applying our knowledge under pressure.
What is not in the book that you would definitely like to add in a new edition?
There’s so much – I am constantly learning and improving my ideas around applying knowledge under pressure and there’s a lot of evolution that has taken place in the last year since the book has come out. Two things particularly come to mind, both of which have to do with zooming out.
First, the majority of The Emergency Mind is focused on the point of performance – that is at the actual moment of applying skill. The more I’ve studied the problem of applying knowledge under pressure, and the more diverse set of teams I’ve worked with, the more I’ve come to understand that the actual moment of performance is really just one part in a larger cycle—what we now call at The Emergency Mind Project the cycle of Prepare, Perform Recover, and Evolve. So, from that perspective the next version of the book will incorporate a lot more mental models around the moments before and after a crisis as well as on the slower and deeper timeframes of recovery and learning.
Similarly, The Emergency Mind focuses primarily on individual and small-group team level skills. I think there is a lot of deeply important factors at the larger teams and structural/cultural levels that I would want to add in to really expand out the whole picture of performance under pressure. These are things like building a psychologically safe culture, understanding safety-II, and exploring how human factors and behavioral economics and nudges play into intelligent defaults and making excellence the most-likely outcome of a situation. There’s a lot, so definitely stay tuned for an updated version, or, more likely, a second book soon.
What is the one thing that impacted you the most from making your podcast?
At the risk of being slightly cliché, I think the most impactful piece has been the amazing network of people I’ve gotten a chance to talk to with a podcast. I truly feel fortunate to be able to sit down with elite individuals in and out of the world of emergency medicine from across the world who are pushing the edge of human performance. Cross pollinating ideas and bringing together diverse opinions complex problems like how to apply knowledge under pressure is just absolute magic.
What is the value of Martial Arts / BJJ training for working as a emergency physician?
Certainly, there’s a self-defense/personal safety aspect to it but I think the value runs a lot deeper than that. Studying martial arts is really studying yourself – it’s learning how to find inner calm in difficult, stressful, and even antagonistic environments. It’s learning how to slow your heart and your mind and make high quality decisions in rapidly changing, uncertain environments. It’s also learning how to be uncomfortable, how to sit with things that initially are unfamiliar or even frightening and make those situations places where you can perform. Obviously, there are a lot of crossovers between your ability to handle uncertainty and pressure and your success at performing in resuscitation. I also think there’s a very important thread about learning to read people – martial arts training helps you learn to observe posture, movement, and nonverbal sources of communication, all of which are critically important when evaluating a patient or communicating with your team and high-pressure scenarios. Finally, I think the discipline of pivoting from an intended course of action to back up plan is something in martial arts teachers you particularly well – attack chains in jujitsu for example. If you get stuck on your first idea about how to do something and can’t successfully pivot to your back up plan, your struggle both on the mat and in the resuscitation bay.
Which (mental) skills from working in acute medical care are reflected in BJJ / Martial Arts?
Personally, I think I’m a substantially better emergency physician than I am a martial artist, so take this with a grain of salt. That said I do think there are multiple parallels in both directions.
First practicing a sense of calm in stressful scenarios obviously works in both universities. Second, I think there’s a lot that martial artists can learn from the way that emergency providers debrief and post-process challenging cases. Often on the jiu-jitsu mat, if something doesn’t work or you struggle in a certain position, it’s tempting just to muscle your way through it or ignore it and go onto the next round. In emergency medicine, we often don’t have that kind of option – we really need to develop the discipline of consciously and intelligently dissecting what happened and learning what our individual teams and structures can do to respond to a similar case in the future. In that way, I think that perhaps we capture more learning in emergency medicine then at least I do in martial arts. So yes, lots of opportunities to learn and improve in both directions.
If you had to choose the most important skill in crisis situations, which one would you choose?
Averaged across multiple emergencies—assuming we’re playing a repeating game, not just performing in a one-off crisis—I think the most important skill is introspection. One of our fundamental jobs as emergency providers is to learn from a situation and evolve in order to be able to perform better the next day. This type of evolution and learning requires a feedback loop that involves us evaluating ourselves, our actions, and our teams. Ultimately, learning how to get better requires running experiments on ourselves, and evaluating these experiments requires introspection. Certainly, there are a lot of other important skills—things like handling uncertainty, processing risk across complexity and higher order effects, managing teams in volatile and emotional situations, etc. Improving at these skills though really requires us to be able to run experiments and that requires introspection, so I think that’s really one of the foundational skills.
What are your 1- 3 favorite books on performing under pressure that every doctor should read?
I’m going to cheat and recommend four books.
First, Peak Performance Under Pressure Lessons From A Helicopter Rescue Helicopter Doctor, by Dr. Stephen Hearns. This book is an excellent introduction to the overall theory of human performance under pressure and does a great job diving into individual techniques that you can use to improve your own performance. I wish I had read this book when I was just starting out my training.
Second, Thinking in Bets, by Annie Duke. Duke is a former world-champion poker player turned decision making expert, and this book is a phenomenal analysis of decision making in the face of uncertainty. The sections on learning from mistakes and studying decisions you have previously made are especially excellent and changed the way I post-process my own work. Plus, it’s a really fun read.
The third and fourth suggestions are really a pair of books that should be read together: Thinking, Fast and Slow, by Daniel Kahneman, and Sources of Power, by Gary Klein. Kahneman’s book is probably the more famous of the two and explores the system one / system two thinking that earned him the Nobel prize. Basically it talks about the systematic biases and predictable errors that our brains make when we try to make decisions in areas in which we have limited information. Klein’s book, by comparison, focuses on the way in which experts make decisions in areas of their expertise – things like chess masters making decisions about chess or experienced fire captains making decisions about fighting fires. Gather these books do an amazing job of exploring the ways in which we make decisions as human beings – more junior learners should start with Kahneman, and then go on to Klein when they have trained more.
Which documentary or film has made the most impression on your work as a emergency physician? (think of ‘just a routine operation’)?
Might be sort of a strange answer, but “Jiro Dreams of Sushi,” which is a documentary about one of the best sushi chefs in the world and his family. It has nothing to do with emergency medicine, but it has everything to do with mastering oneself and one’s craft. There’s so much in there about doing the little, seemingly boring things correctly and about constantly trying to improve and learn, both of which translate directly to resuscitation.
What are your favorite 1-3 podcasts (episodes) other than your own podcast?
I’m a huge fan of The Knowledge Project by Shane Parish—I think it does a great job of exploring reusable mental models across a variety of disciplines and challenging me to think in new ways. I also routinely listen to the Finding Mastery podcast by sport psychologist Michael Gervais. I really enjoy the way that he moves beyond the purely technical concepts of mastery to consider what it really means to become an expert in your field and in life in general.
Suppose it were possible to travel through time to be able to talk to everyone – living and dead or from the future – about your profession: who would you most like to talk to on your podcast?
This is such a cool question – I’ve always been fascinated by teams that have come together to produce previously unheard-of results. I’d love the chance to interview some of these legendary teams – people like the 300 Spartans at Thermopylae, the complete mission control team that first put a human on the moon, folks like that. Ideally, I would want to interview multiple members across the teams with different viewpoints, and then interview them all together. That way I could get a sense not only of what was going on in their individual minds but also what the shared mental model (the hive mind) of their team was like when they were immersed in it. I think there would be so much to learn from that kind of experience.
Bio
Dan Dworkis, MD PhD FACEP is the Chief Medical Officer at the Mission Critical Team Institute, a board-certified emergency physician, and an assistant professor of emergency medicine at the Keck School of Medicine of USC.
He performed his emergency medicine residency with Harvard Medical School at the Harvard Affiliated Emergency Medicine Residency at Massachusetts General Hospital / Brigham Health, and holds an MD and PhD in molecular medicine from the Boston University School of Medicine. Dr. Dworkis is the founder of The Emergency Mind Project, and the author of The Emergency Mind: Wiring Your Brain for Performance Under Pressure.
Photo credit: chris shinn.