Reflections on an ass-kicking

cliff-mullered-sm

 

Last weekend I got my butt handed to me and I’m feeling really good about it. I entered my first Brazilian Jiu Jitsu competition, and was beaten unequivocally, having had to submit to avoid having my arm broken after about three minutes into the fight. So what’s to be so cheerful about? Essentially, the whole endeavour was an experiment, and the experiment was a success. I learned a heap about learning, and about myself. Lessons that can be applied to learning resuscitation medicine, or learning anything.

The 10000 hours fallacy: not all hours are created equal

I’ve been doing Brazilian Jiu Jitsu (BJJ) for about a year, and am not very good at it. I started it because my (then) five year old son started it, and I thought it would be nice if we could share an interest in something healthful and useful for self protection. For most of that year I made 1-2 sessions a week, usually rushing to class after an emergency department or retrieval medicine shift and not really having my ‘head in the game’. Turning up. Just like it’s possible to turn up to work, get through your shift, and go home and forget about it.

I noticed something interesting about the people who started around the same time as me. Those who were entering competitions – as inexperienced and ill-prepared as they were in the beginning – progressed much faster than me. They would break down techniques and work on specific movements or positions they knew they needed to improve because of their competition experience, and they’d ask targeted questions of the coaches, aimed at maximising feedback for them to work on. It dawned on me that I was witnessing something I’d described in a lecture on Cutting Edge Resuscitation performance at the Royal College of Emergency Medicine Conference last year:

What seems to be apparent is that although many hours of practice are important, pure exposure or experience alone does not predict those who will master their subject. We may have all encountered colleagues who have many years under their belt who lack that spark you’d expect of a cutting edge expert. So merely turning up to work every day doesn’t make you better, it just makes you older. You reach a certain level where you can manage the majority of cases comfortably, after which more exposure to the same experience fails to improve performance expertise.

What differentiates the cutting edge performers from the majority in all these domains (studied areas such as chess or sports or music) appears to be the amount of deliberate practice, or effortful practice, in which individuals engage in tasks with the explicit goal of improving a particular aspect of performance, and continue to practice and modify their performance based on feedback, which can come from a coach or mentor or the results of the performance itself.

“Competence does not equal excellence” – Weingart

 

With this realisation, I decided to enter a competition I was extremely unlikely to win. I knew that committing (publicly) to a deadline would force me to improve my game, and I turned up more, studied the notes I’d made, and started asking more questions. In the space of a few weeks I felt that my BJJ was progressing faster than before.

The powerful combined forces of deadlines and public commitment

There’s nothing like a deadline or a high stakes test or exam to focus the mind. I’ve done several postgraduate fellowships and diplomas by examination, some of which were optional, and I’m sure each one raised my knowledge and clinical ‘game’ more than any other educational intervention I can think of.

The reality of the competition day approaching forced me to tackle my training, fitness, diet and timetable in a way I otherwise would not have found the motivation for. I had a strange moment when I took off my teeshirt in the changing rooms prior to the match and caught sight of my reflection in the mirror. I barely recognised how different my physique was compared with months earlier. Previously, I’d exercised for its own sake and not made much progress losing the middle aged paunch. But the public commitment to a BJJ fight, in a certain weight category, instilled the drive to exercise and monitor my diet. Commitment to this deadline physically restructured me!

Stress exposure training WORKS!

I’ll be 49 this year. The only people available in my weight category to fight me were aged 36-40. Age can make a big difference. Injuries are not uncommon and a significant one could put me out of training or out of work. My wife and son and friends were going to watch me, and I didn’t want to let them down or put on a pathetic performance. All my buddies who had competed before warned me of the overwhelming nervousness that can disorientate you and cloud your concentration. There were plenty of potential negative outcomes to focus on, but I ignored them all. I knew the simple formula. Breathe. Talk. See.

This basic mantra, assisted by the mnemonic ‘Beat The Stress’ (BTS) developed by Michael Lauria, is something we teach and apply in the training department of Sydney HEMS. Breathe means control and pay attention to your breathing, allowing you to reduce sympathetic hyperactivation and be ‘in the moment’. Talk means positive self-talk: a silent internal monologue that reminds yourself of all the preparation you’ve done and the potential positive outcomes of the task about to be performed. See means visualise: run through in your mind a successful performance, imagining yourself overcoming any anticipated obstacles – a practice which prepares your mind and body for effective task execution.

Less than a week ago I was running workshops on human factors for Sydney University Masters of Medicine (Critical Care) students, and covered how we submit our new HEMS clinicians to stress exposure training in order for them to practice Lauria’s BTS approach. Throughout these workshops I couldn’t wait for the opportunity to test what I teach.

On the day, my only interpretation of my adrenal surge was excitement. Even in the ‘holding pen’ after weigh-in where you wait with other competitors to have your bout, there was no anxiety, no fear. I couldn’t wait to get on the mat. The whole thing was an exhilarating buzz, and even when the can of whoopass was being unloaded on me I felt cognitively ‘available’: aware of my surroundings (and predicament!) and able to control my breathing while I self-talked my way through my limited and ever dwindling options.

Conclusion

It might be slightly unusual to be singing from the rooftops about a defeat, but the educational principles I’m re-learning are worth re-sharing. I took myself out of a comfort zone, and made a public commitment to be tested. This focused my learning and made me practice in a different way and more proactively seek feedback. I no longer was ‘turning up’, I was training towards a goal. This renewed sense of ownership of my training transformed my level of engagement in the learning process, instilling an enthusiasm and craving to understand and test principles rather than rote learn techniques.  I had an opportunity to test ‘Beat The Stress’ in a non-clinical setting and this mindware tool proved itself yet again. And despite the uninspiring outcome on the day, I was back sparring the following evening, with an even greater hunger for specific answers from the coaches, and with senior students remarking ‘you’ve got better’.

Further reading and listening:

Sydney HEMS training (Reid)

Achieving mastery (Weingart)

Cutting edge performance in resuscitation (Reid)

Stress exposure training (Lauria)

Martial arts and the mind of the resuscitationist – do it like you f***ing mean it’.

Sydney Jiu Jitsu Academy

12 thoughts on “Reflections on an ass-kicking”

  1. Interesting article, Cliff. Let me expose you to an interesting intersection.

    I’ve been helping fearful flyers for more than twenty years, applying good old fashioned exposure-based work (including flights) with cutting edge technologies such as Virtual Reality and Heart Rate Variability-based biofeedback.

    Patients really enjoy the HRV feedback delivered via inexpensive equipment which shows the effect of diaphragmatic breathing on HRV where we can look at maximising Respiratory Sinus Arrhythmia via reference to the Power Spectrum chart. The software itself (emWave) uses proprietary algorithms to reference what it calls “coherence” and renders a red-blue-green set of bars, where we want more green, and it aligns with better vagal tone, which is also reflect ed in the Power Spectrum chart.

    Most anxious patients with no formal breathing training are around 80% in red most of the time when they first start.

    A few years ago I once had a young man of 25 visit me form Sydney (he drove) to work on his fear of flying. After taking a history, I hooked him up, and took some more notes only to turn back to the screen (I use a data projector for greater patient immersion) and saw he was 100% in green. So what to do – there goes a major intervention aide! The other question was: how was he in 100% green and still presenting with strong anxiety?

    On a clinical hunch, I put him in my airline seats, and showed him a video of a rather bumpy take off (and rattled the seats too) and lo and behold, he shot off into red very quickly, suggesting high levels of sympathetic arousal.

    Ah, we had some work to do! I needed to help him take advantage of his naturally occurring “green” vagal tone, when it really mattered on the flight. He actually held his breath unwittingly during his scary moments on the plane.

    But how was he in green during rest, when most patients are in red? Well it turns out since the age of 15 he had been practising Brazilian jiu-jitsu! And had been taught after a brief bout, breathing and visualisation techniques in preparing for his next bout. This breathing technique had become a way of life for him. And I’ve since seen the same results for other “professional” breathers, such as singers, certain athletes, and marine salvage divers. All go into green, except when confronted by their scary triggers, in which case they depart into red!

    Hope this is of interest!

    Les Posen FAPS
    Clinical Psychologist
    Brighton East, Victoria.

  2. Wonderful post! You continue to inspire me, my friend. I can’t wait to see what you are going to do when 60 years.

  3. Thanks for sharing Cliff.

    Im not so sure im filled with excitement yet when I go out there though. I feel it’s the aftermath of the whole competition I enjoy the most (so far anyway), when I can reflect and feel proud of having stepped up to a challenge most walk away from and tried my best to win.

    See you soon

  4. Its my observation that young guys (<30) take the longest to acclimatise the fear of competing with most never going beyond that single first competition. Inversely the +35 year old, while questioning their sanity, enjoy that moment as life itself. My opinion; what the younger guys fear most is the humiliation of loss. Its stifling where we don't care……Go well young fella…..MikeyJ.

  5. PERFECTION IS THE ENEMY OF GOOD

    It is human nature not to appear ignorant, foolish or lazy. Unfortunately this can work against a medical student or junior doctor:

    For instance they might:

    a) Exhaust valuable time moving backwards from textbook to textbook trying to develop a comprehensive overview rather than establish a general understanding from one reference and then filling in gaps or reconciling contradictions later from other sources
    b) Have trouble sticking to one approach when exercising their clinical skills e.g. cardiovascular examination and end up confusing themselves by employing an inconsistent technique
    c) Constantly searching for the elusive ‘best way’ or ‘new way’ of approaching a learning challenge or clinical problem before trialling a conventional tried and true way that is easily taught, remembered or employed
    d) Be hesistant to be engaged in patient assessment or management because they fear their lack of experience and knowledge will be revealed
    e) Withhold the fruits of their efforts or opinions when the opportunity to present their cases appears

    Furthermore, students often translate criticism as some form of permanent mark on their ability or reputation. But nothing could be further from the truth. Contrary to popular belief, perfection is rarely expected of our embryonic students. However, diligence and application always is. The reality is that your mentors will be even more suspicious about your motivation and learning ability if you aren’t seeking out, practising and actively demonstrating knowldge at every opportunity.

    In most situations any genuine attempt is appreciated. It does not mean teachers won’t pass comment or criticise. But again it must be remembered that these occasions are not a personal attack. Your response to criticism is also telling. Being immediately dismissive or defensive suggest that a desire to improve is not important to you. Aggressively challenging or questioning may not give enough regard to the important of experience and knowledge in medical practise. Neverthless, a considered and respectful question is usually answered by reasonable teachers in an appropriate manner.

    This is the timeless nature of academic medicine which is constantly reflective – always seeking to improve, refine and challenge existing knowledge so that the best outcomes can be achieved for our patients. A clinician can be said to have matured when they can bravely accept this confronting challenge without external pressures to do so.

    “Dans ses écrits, un sàge Italien
    Dit que le mieux est l’ennemi du bien.”

    Voltaire, La Bégueule

    “He who asks a question is a fool for five minutes; he who does not ask a question remains a fool forever”

    Chinese Proverb

  6. Hey Dude!
    Great to see your training in Jits. I get my arse kicked every week….at the end of each class, my ego is so compressed it’s at risk of forming a singularity…..see you in Dublin!

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