One lesson worth considering.
Even brief consideration will reveal that sports and medicine share multiple commonalities beyond that of many physicians having participated in sports and experienced the benefits of its developmental impact. Professionals in sports and medicine comprise a highly select and competitive group of individuals. Mastery in both sports and medicine requires serious dedication and commitment that is tested through rigorous training. Both athletes and physicians are required to execute their skills at an expert level in public forums where expectations are high for performance and even perfection. Success in both arenas can be associated with considerable respect among peers and from the public.
However, it seems one under-recognized commonality is that the experience and science of sports training can be applied to the training of physicians. In addition to recent interest in optimizing performance, especially under stress, there is at least one other lesson worth considering exemplified in sports conditioning: the need for adequate recovery when intensively training.1
The training of an athlete requires physical and mental preparation. Physically, the athlete requires overload to push the body beyond normal capacity to make gains. Mentally, the athlete must have the proper mindset during training and competition, as well as being able to maintain that particular mindset between multiple events, heats and sets.2,3
One of the foundational principles of sport conditioning for maximal performance is rest and recovery. Without adequate recovery, overtraining can occur leading to decreased performance, profound fatigue, burnout and staleness, mood changes, irritability, and loss of motivation.4,5
In sports, it is accepted the body needs time to recover to fully realize the benefits of training. In the short term (i.e. single practice session) it can be characterized as “rests between sets.” Additionally, careful planning is required for the long term (i.e. over an entire season) to allow recovery and continued peak performance.3,4,6,7 Some of the more well-known means of physical recovery used by athletes include hydrotherapy, cryotherapy, massage, compression, sleep, and electrolyte replacement; and mental recovery has become an expanding area as mental preparation translates into improved competition performance.2,4
What about physicians, especially residents? Residents are regularly required to perform for long durations in clinical and nonclinical tasks under varying degrees of clinical and nonclinical stress.8,9 Stress, physical fatigue and mental fatigue are of such a concern in resident training that the Accreditation Council on Graduate Medical Education has made education and training on these topics as a core requirement for accreditation (www.acgme.org). The opportunity to reset and recover (R&R) may be an important concept and procedure in medical training and, even, practice.
Recovery as an Educational and Performance Strategy
The potential of integrating sport and medical and surgical training has not gone wholly unrecognized. The adaptation of performance optimization techniques from sports is exemplified by the Cooks et al. article: What Surgeons can Learn from Athletes: Mental Practice in Sports and Surgery.10 In fact, early articles promoting the value of integrating psychological skills training in surgery were written by sport psychologists.11,12
The long work hours of residents and physicians demand continuous high-level performance tackling challenging tasks: patient care, paperwork and EMR responsibilities, consultations, meetings and lectures. Based on chronobiology, rest and recovery should occur every 90 to 120 minutes.13 Contrary to this, medical clinical rounds are typically much longer, lasting on average90 to 180 minutes or more.14,15,16 Transitions occur from floor rounds to grand rounds or hour-long lectures and back to clinical work. Rarely, if ever, are regularly scheduled breaks incorporated or even considered in the daily schedule of a resident.
Loehr & Schwartz observed that in athletic training, stress is not the real enemy of high performance; the real enemy is the absence of disciplined intermittent recovery. They note that in the corporate world, “corporate athletes” push themselves excessively and linearly without breaks and often without adequate exercise (sounding much like physician culture).13
Dedicated recovery time has been studied and found to be valuable in military training, as well as being a success strategy for women in STEM professions.5,17 The military use of recovery dates back to the Roman legions where soldiers of higher rank and of aristocratic heritage had a refreshment retreat in their tents which they used when they became tired.18
Related to mental fatigue is central fatigue which refers to fatigue of the central nervous system and is thought to be related to changes in synthesis and metabolism of brain monoamines. These neurotransmitters play essential roles in modulating important brain functions including motivation, arousal, attention, stress response and motor control.6 The need to break from intense attention and concentration is required to avoid exhausting the focus circuits in the brain.19 The sports science literature suggests mental fatigue needs to be evaluated across time and vulnerable individuals need to be identified.20
Central recovery should also be relevant to resident education. Central or cognitive recovery periods have been labeled by terms such as mental detachment and may be composed of just rest, social engagement, positive constructive daydreaming, taking a walk, internet surfing, mindfulness exercises, mental imagery, debriefings, music or visiting restorative environments.5
Beilock recommends “taking a step back” before engaging in cognitively taxing tasks to maximize performance on the task, preserve energy for unanticipated problems or the next task, and to reduce glucose depletion. She proposes an inverse relationship between the ability to perform difficult cognitive tasks and prolonged time, with the performance declining as time progresses, much like muscle fatigue.21
Unfortunately, a full understanding of central fatigue, recovery and means of mitigation still remains elusive.6 Brain fatigue is complex and factors yielding optimal recovery will likely prove to be highly idiosyncratic. Parameters such as individual variations, minimal and maximal recovery periods and structured versus “as needed” recovery sessions are still to be defined.
The Example of Napping as an R&R Performance Strategy
Especially in medical training, napping is probably one of the most discussed, yet also most minimized and ignored, effective measures for cognitive performance maximization and fatigue management. Not so in sports and other fields.
In 2013, sleep expert Dr. Charles Czeisler addressed sleep and fatigue concerns of the Boston Red Sox by suggesting they place a nap room in the club house. Not only was it popular with players, the team won the World Series that year and Dr. Czeisler received his own championship ring.22 In a 28 million dollar renovation of the Louisiana State University Football Training facility, special considerations were taken to promote recovery for their student athletes with the installation of locker seats that convert into sleeping pods to facilitate napping.23
Major companies like Google, Uber, Nike, Cisco, Zappos, Huffington Post, Proctor & Gamble, and Ben & Jerry’s encourage workplace naps and provide accommodations to do so. Federal agencies like NASA and the FAA traditionally have focused on fatigue effects providing opportunities for rest and restoration of cognitive resources.24 Despite a growing interest in strategic napping and mounting data supporting positive performance effects, a continuing cultural bias that equates naps with sloth, weakness and poor productivity extends to medicine and prevents the effective and creative use of napping to mitigate a variety of stresses plaguing medical training.24,25,26,27,28,29
Sports training recognizes the negative impact of overtraining their athletes; and studies show that lack of recovery, especially in chronically stressful and challenging situations leads to burnout and breakdown, ultimately undermines performance, and has consequences that range from “muscles to motivation” and mental decisions.4,13 The need for respite over prolonged intervals, such as vacations, is well-recognized, though also often not heeded in medicine. The sports world is changing and incorporating a multimodal approach to rest and recovery. Perhaps it is time to recognize the need for more frequent recovery periods in medical education and practice with special considerations for individualized requirements and integration of recovery periods on a daily basis.
Dr. Jensen is a member of the internal medicine residency faculty at UPMC Pinnacle in Harrisburg, PA. and trains as a female competitive body builder.
Dr. Asken is the Director of Provider Well-Being at UPMC Pinnacle in Harrisburg, PA.
(1) Asken M. Code Calm: Mental Toughness Skills for Medical Emergencies, 2020: Amazon Kindle Books.
(2) Gee, C.J.. How does sport psychology actually improve athletic performance? A framework to facilitate athletes' and coaches' understanding. Behav Modif. 2010 Sep;34(5):386-402. doi: 10.1177/0145445510383525.
(3) Loch F, Ferrauti A, Meyer T, Pfeiffer M, Kellman M. Resting the mind –A novel topic with scarce insights: Considering potential mental recovery strategies for short rest periods in sports. Performance Enhancement & Health. 2019:6(3): 148-155.
(4) Eichner R. Overtraining: Consequences and prevention. J Sports Sci. 1995:13, Supp 1: S41-48.
(5) Purvis, D, Gonsalves, S, Deuster, P. Physiological and Psychological Fatigue in Extreme Conditions: The Elite Athlete. PM&R. 2010:2(5): 442-450.
(6) Skorski S, Mujika I, Bosquet L, Meeusen R, Coutts A, Meyer T. The temporal relationship between exercise, recovery processes and changes in performance. Int J Sports Physiol Perform. 2019:14(8): 1015-1021
(7) Pritchard P, Grant C. (Eds.). Success strategies for women in STEM. 2015: NY: Academic Press.
(8) Maswadi N, Khader YS, Abu Slaih A. Perceived Stress Among Resident Doctors in Jordanian Teaching Hospitals: Cross-Sectional Study. JMIR Public Health Surveill 2019;5(4):e14238. DOI:10.2196/14238
(9) Issa, B.A., Yussuf, A.D., Olanrewaju, G.T., Oyewole, A.O.. Stress in Residency Training as Perceived by Residents in a Nigerian University Teaching Hospital. European Journal of Scientific Research. 1450-216X Vol.30 No.2 (2009), pp.253-259
(10) Cooks M, Moulton C, Luu S, Tulin C. What surgeons can learn from athletes: Mental practice in sports and surgery. J Surg Educ. 2014;71(2): 262-269.
(11) McDonald J, Orlick, T. Excellence in surgery: psychological considerations. Contemporary Thought in Performance Enhancement. 1994;3:13-32.
(12) Brown, C. (2001). The cutting edge: Performance psychology with surgeons. https://headinthegame.net/resources/library/the-cutting-edge-performance-psychology-with-surgeons/
(13) Loehr, J, & Schwartz, T. The Making of a Corporate Athlete. In HBR’s 10 Must Reads On Mental Toughness Boston: Harvard Business Review Press. January 2001.
(14) Ward, D.R., Ghali, W.A., Graham, A. et al. A real-time locating system observes physician time-motion patterns during walk-rounds: a pilot study. BMC Med Educ 14, 37 (2014).https://doi.org/10.1186/1472-6920-14-37
(15) Stickrath, C.. Noble, M., Prochazka, A., et al. Attending Rounds in the Current Era:What Is and Is Not Happening. JAMA Intern Med. 2013;173(12):1084-1089.
(16) Gonzalo, J.D., Chuang, C.H., Huang, G. et al. The Return of Bedside Rounds: An Educational Intervention. J GEN INTERN MED25, 792–798 (2010).https://doi.org/10.1007/s11606-010-1344-7
(17) Martin K. Combating mental fatigue in soldiers. J Sci Med Sport. 2017:(20): S53-S54.
(18) Scarborough J. Roman medicine and the legions: A reconsideration. Med History. 1968:12 (3), 254-261.
(19) Pillay S. Your brain can only take so much focus. Harvard Business Review. May 2017.
(20) Russell, Jenkins D, Smith M, Halson S, Kelly V. The application of mental fatigue research to team sport performance: New perspectives. J Sci Med Sport. 2019: 22(6): 723-728.
(21) Beilock S. Choke: What the secrets of the brain reveal about getting it right when you have to. New York, NY: Free Press, 2010.
(22) Weisfogel A. & Ross C. Napping: You snooze –you win! CBS News. March 8, 2020.https://www.cbsnews.com/news/napping-you-snooze-you-win/
(23) Naintas D. LSU showcases insane new football facility after 28 million dollar renovation. Sporting News, July 2019.
(24) Alger S, Berger A, & Capaldi V. Challenging the stigma of workplace napping. Sleep, 2019: 48 (8), 1-2 zsz097https://doi.org/10.1093/sleep/zsz097
(25) Smith-Coggins R, Howard S et al. Improving alertness and performance in emergency department physicians and nurses: The use of planned naps. Ann Emerg Med. 2006:48(5): 596-604.
(26) Debarnot U, Castellani E, et al. Daytime naps improve motor imagery learning. Cog Affect Behav Neurosc. 2011:11(4): 541.
(27) Spruit E, Band G, et al. The effects of spacing, naps, and fatigue on the acquisition and retention of laparoscopic skills. J Surg Ed. 2017:74(3): 530-538
(28) White T. For weary physicians and nurses, short naps can make a difference. Stanford Report: October 25, 2006. https://news.stanford.edu/news/2006/october25/med-nap-102506.html
(29) Geiger-Brown J, Sagherian K, Zhu S, et al. Napping on night shift: A two hospital implementation project. AJN: 2016: 16 (5), 26-33. https://nursing.ceconnection.com/ovidfiles/00000446-201605000-00027.pdf