The Power of Stress – Stress Inoculation in Procedural Training

Hello, hello, hello and welcome to the SimKit podcast and our conversation of stress inoculation in medical training.

The first question we should be asking ourselves is why? Why do we need to inoculate stress in our medical training, particularly when it comes to procedures?

In my opinion, there are two clear and very tangible reasons.

The first can be titled simply practice like You Play. In the high stakes arena of the Emergency department performing a HALO (high acuity, low opportunity) procedure like cricothyrotomy, we want to be used to a certain degree of stress when training because bet your bottom dollar it will be stressful in real life. We need to be comfortable being uncomfortable by exposing ourselves to and familiarizing ourselves with stress. We get better at mitigation of stress when we have to perform to save a patient’s life.

The second reason is cognitive science teaches us that stress is a powerful memory aid.

Adding stress to learning helps anchor the memory for long term retention.

So how do we do this in actuality? How do we bring stress to our training?

The first thing to recognize is the power of your own mind. Use your powerful mental simulator when training in a procedure.

The most effective way to do this is to create a case around the training. Make it very real. Think about the sounds in the room, the alarming telemetry, the inflation of the blood pressure cuff, the nurses chatter in the background. Think about smells. If there’s a burn or vomitus in the room, what effect will that have on you? Maybe there’s a family member in there asking questions, praying or crying in the corner, hoping their significant other makes it. The more detail you can add the higher the stress level and the better the stress inoculation.

When doing this, think about a specific nurse you’d want to have in the room with you. What are you asking that person for? What consultants are you requesting to be paged? The more detail you can add, the better.

Now, how about other tricks? In addition to our mental simulator, there are several additional simple things we can do to inoculate stress. I break them down into 3 categories.

The first is timing yourself. While this sounds almost too simple to be effective, think about the following scenario. I walk up to you with a stopwatch and tell you your shoe is untied, tied as fast as you can, and click the stopwatch. Boom. A nice little shot of adrenaline enters your bloodstream. Timing yourself and particularly setting a target time for the training is a nice way to add some stress and allow you to work on your smooth and purposeful movements to avoid wasted time.

The next trick is audio cues. Adding audio to the background of your training is a great and sometimes fun way to add a little stress. To do this, you have to know a little bit about yourself and what gets your heart pumping. For example, we are all clinicians for the most part, so alarming telemetry, particularly with tachycardia, is often a very irksome sound in the background. Use that to your advantage and add this stressful audio cue to your training. And you can have a little fun with it, too. I’m a father, so I know that the sound of a crying baby gets my heart rate up. How about a crying baby and alarming telemetry?
Here’s an example of an audio cue I used for my procedural practice. If that does not get your heart rate going, I’m not sure what will.

And the third and final way for us to add stress to our training simply is to perform in front of an audience. This is one of my favorite ways to add stress because it also hits on this idea of deliberate practice. While we’ll have a separate podcast on deliberate practice in and of itself, this is a very feedback driven process. I see three unique ways to use an audience to add stress.

Number one – family. For many of us, myself included, we generally leave work at work and home life at home. This is important given the career we have and the things we see. So for me to ask my partner to watch me do a cric, or perhaps time me doing a cric and giving me feedback on it would be an intensely stressful experience.

Number two – colleagues. Find someone equally devoted to bringing their procedural game to the next level as you are, and practice the procedure with them. Take turns being the operator and the evaluator.

The third way to practice in front of an audience, and definitely my favorite, is with a learner.
If you have access to learners, I highly recommend bringing them into your procedural training.
We talk all the time in medicine about being lifelong learners, but rarely are we able to put that into practice. What a great way to show a learner that you are fallible, that you have to continue to work on your skills and how that that learner is an important part of the process. This is a fantastic way to build rapport with that learner.

Okay, let’s do a quick summary before we wrap up.

First, we talked about the why we recognized why we need to add stress in our procedural training in medicine. We have to practice like we play. If stress is going to be present in real life with these HALO procedures, and it definitely is going to be there, we need to become comfortable with stress and learn how to mitigate it.

We also recognize through cognitive science that stress is a powerful memory aid. Adding stress will help anchor this learning in our long term retention.

We then talked about some practical ways to add stress to our training.

We talked about our very powerful mental simulator and how creating a case around the procedural training is a fantastic use of this simulator. Be very specific, using many senses. Think about the sounds in the room, the smells, the people, the resources you need, family presence. Adding these great degrees of detail will make the training more real and therefore add to the stress.

The three other tricks we talked about for stress inoculation include timing yourself, using audio cues, and performing in front of an audience, which can be your family, colleagues or learners.

I highly recommend incorporating these simple and effective techniques in your procedural training.