Reaching Peak Performance in Medicine

Brian Ferguson (1s):
This idea of the service archetype. If you look at people who go into the military, people who go into the front lines of health care as nurses or physicians and people who go to serve as teachers, those are people who again, want to impact the world, save lives and do hard things. That is a very rare and beautiful archetype that is critical to any flourishing society. The problem is that if those people are not around an institutional architecture and leaders who protect them against the better angels of their nature, they will give of themselves and give of themselves until there’s nothing left to give. And some ways we’re not doing anything particularly profound here, what we’re doing is bringing thinking that has been proven in the hard lessons the military learned in the last 20 years of combat and what is laid out in terms of PTSD and a lot of challenges.

Brian Ferguson (51s):
We’re bringing the same tools that work there into medicine.

Announcer (54s):
Welcome to Difficult Conversations Lessons I Learned as an ICU Physician with Dr. Anthony Orsini. Dr. Orsini is a practicing physician and president and CEO of the Orsini Way. As a frequent keynote speaker and author. Dr. Orsini has been training healthcare professionals and business leaders, how to navigate through the most difficult dialogues. Each week you will hear inspiring interviews with experts in their field who tell their story and provide practical advice on how to effectively communicate. Whether you are a doctor faced with giving a patient bad news, a business leader who wants to get the most out of his or her team members or someone who just wants to learn to communicate better, this is the podcast for you.

Dr. Anthony Orsini (1m 40s):
Well, welcome to another episode of Difficult Conversations Lessons I Learned as an ICU Physician this is Dr. Anthony Orsini and I’ll be your host again this week. Today, we’re going to talk about high performance medicine and you may be asking, okay, how does that fit into the Difficult Conversations theme of this podcast? Well just listen, and in no time you’ll see what I mean. Today, I have the pleasure of speaking with Brian Ferguson, who is the founder of Arena Labs, a company that has pioneered the field of High Performance Medicine. Before founding Arena Labs, Brian served in the military as a Navy SEAL Officer, where he deployed to Afghanistan and various parts of the middle east.

Dr. Anthony Orsini (2m 21s):
Aside from his duties at the tactical level, he worked with senior leaders to understand the impact of accelerating technology on the modern battlefield. Brian spent his career working in high performance organizations, learning from leaders and decision makers in the US national security, the military and technology. He has used those experiences to build the Arena Labs. Brian and Arena Labs are on a mission to reimagine healthcare by training doctors and nurses as elite performers. By investigating clinicians with the same training tools and technology as Navy SEALS, Olympic athletes and creative masters Arena Labs believes hospitals can reduce burnout and provide healthcare teams with the ability to flourish in the face of a demanding stressful career.

Dr. Anthony Orsini (3m 7s):
Brian serves on the boards of Battelle, Seatrec and The Honor Foundation. He lives in Nashville, Tennessee, and is most proud of being a father to his daughter, Wynn Valentine. Brian, thank you so much for coming. And I really appreciate you taking time out of your busy schedule to be here.

Brian Ferguson (3m 23s):
It’s a pleasure Dr. Orsini, thank you.

Dr. Anthony Orsini (3m 27s):
This is a really great, it’s been a long time coming. I think we first, I checked my notes. Some we are first introduced by a mutual friend, I guess we spoke that was in September. We finally did a zoom call in October, and then your schedule has been so busy mind. So we’re finally here. This is end of December that we’re recording this and hopefully we’ll get this out as soon as possible. So it’s been a long time coming, but I think it’s really going to be worth it. And I think this episode fits perfectly into our theme and it melts nicely, frankly, in into, I’m going to say about five or six episodes now that we did on physician burnout and really the problems facing healthcare. But before we get into that, want to hear about really let them get to know you build some rapport.

Dr. Anthony Orsini (4m 9s):
Tell us about Brian Ferguson, how you became a Navy seal and how you really decided to get into this whole work with you’re doing with Arena Labs.

Brian Ferguson (4m 18s):
It’s funny. I guess life is always clear in retrospect, but my current work in healthcare is really, I think a product of a long narrative that started where I grew up in before we hit record you and I were talking about the large ethnic families of where I grew up, Cleveland, Ohio, and your Italian heritage. My mom was from a large Irish Catholic family, and that had a lot of influence on me, but ultimately my mom came out of that out in a minute. As we kind of moved through our own discussion here, one of the things I come back to a lot in healthcare is that if the service archetype. People go into healthcare because they want to do hard things, save lives and impact the world. And that was certainly my mom, my mom was a nurse. So I grew up around healthcare, had a massive impact on me.

Brian Ferguson (5m 1s):
I often tell the story of our, our kitchen table. I vivid memories of my mom bringing home both amazingly positive energy from a great day in the operating room where she was a nurse. And the inverse was true, a tough day where she either lost a patient or something adverse happened. And so that was a huge framework in my life. I grew up in a pretty quintessential Midwestern town outside of Cleveland. And for a long time thought I was gonna go into healthcare, but I in 1998 was fascinated by the Kosovo war and the idea of geopolitics and statecraft and international relations. I think as a kid who had never really left where he grew up, the world was really intriguing to me. And so I went to college in Ohio at Miami university, and that began for me that the study around international relations and led me into a world of really my first career was in national security.

Brian Ferguson (5m 47s):
As you said in the intro, I was fortunate to work initially in the white house and then in the Pentagon, this was right after 9/ 11. So a really consequential moment in American history and to have sort of a front row seat was pretty extraordinary. We can talk in a bit, you know, most people would say, how is that relevant to healthcare? Interestingly, a lot of what I saw in terms of a struggle to move from the 20th century into the 21st century, which in the national security space was really marked by 9/ 11. That was a very consequential moment where suddenly there was this shift into a whole new world. I think we’re seeing a lot of that right now in healthcare, both because of COVID and also just because of some external forces on healthcare. So a lot of what I learned in that time has served me today, but then I really decided my brother had served in the military.

Brian Ferguson (6m 31s):
He was a special operator in Green Beret and inspired me to really want to go into uniform and where my story is probably a little more unorthodox. I didn’t join the military till I was 28. And then I had the honor of going into the Navy and ultimately into the world of special operations in the seal teams where I really stood on the shoulders of giants. And that was for me, I had a pretty unremarkable career as a seal given most people of that time. But what was extraordinary for me was learning about human performance and more importantly, human potential. And that opened my eyes to the power of the human mind and spirit to accomplish things well beyond what we’re capable of. And that can sound cliche. But for me, I was living at 29, 30 years old and training, and then I had this amazing time of getting to deploy and just work with some of the most capable men I’ve ever been around in my life.

Brian Ferguson (7m 17s):
But the reason that brings us to our conversation here, and I think the framework is that my last job was collaborating with a whole bunch of external partners outside of the seal teams. And I ended up at the Cleveland clinic, heart and vascular Institute with a cardiothoracic surgeon named Doug Johnston. I was at the time trying to understand performance in small teams. And so that led me into the cardiothoracic OR at the Cleveland clinic. And in a very basic way, what surprised me, whether you work in the cardiac Orr and the ICU, the ER, in internal medicine, modern clinicians have an extraordinary amount of stress and pressure on them. And what amazed me was that there was an obsessive focus on technical proficiency, how a nurse scrub tech or perfusionist or surgeon did his or her technical job.

Brian Ferguson (7m 59s):
And there was an obsessive focus on patient outcomes and patient quality. But there was zero focus on the clinician and how he or she takes care of himself. And how do we provide them with the tools to manage a stressful high consequence environment? And that is the bedrock of training, not just in the seal community, but in most high consequence fields, whether you’re a professional athlete, an Olympic athlete, you work in the creative arts, this human factors and performance training is vital because you’re only as good with a technical skill as your ability to perform that skill in high consequence environment. That led me on an odyssey over the last five years to found Arena Labs and get to work with thought leaders like you to really think about what does a healthcare world look like if we start up equipping physicians and nurses and technicians with this toolkit.

Dr. Anthony Orsini (8m 47s):
Yeah, the last time we spoke the parallels between the Navy seal, the military and the physicians, especially the physicians who are in high stress specialties, such as trauma surgery, emergency medicine. What I do neonatology where, you know, one minute you are writing a note and talking to a parent casually and the next minute you’re in the middle of a code. So the parallels are very similar before we continue. I do want to thank you on behalf of the audience for your service. It’s something that we appreciate, but don’t say enough. So thank you so much for that.

Brian Ferguson (9m 19s):
I appreciate it, but let me just put a quick mark in that. One of the things that excites me, and I think one of the reasons we have been our team loves the work we do, and we’ve been really fortunate to attract world-class talent is I think again, for the first time in a while, we’re seeing the narrative of the hero shift from that of the military over the last 20 years to that of the frontline clinician. And I think one of the things, I don’t say this just as an obligatory response, but truly one of the things that we don’t do well in domestic society is thank the people who are carrying the burden of low during COVID and just generally in stewarding societal health. And COVID has changed that.

Brian Ferguson (9m 58s):
And we’re seeing people start to thank clinicians in the same way that the military was thanked. And it’s just, I think in general, for American society, it’s a really extraordinary development.

Dr. Anthony Orsini (10m 8s):
We are on the tipping point right now, and I’m glad Arena Labs is involved in this because we’re really on the tipping point very early on in recognized. And as you said, the stress that’s involved in being a frontline clinician, there’s been a lot of lip service in the last five, 10 years. The word resilience seems to be popping up all the time. I’d like your opinion on that word. But right now, in most institutions we say to the nurses and doctors are under incredible stress. Here’s a free pizza for lunch and a chart that goes up on the wall that said, if you’re feeling stressed and burned out, I was in one hospital because I visit hospitals a lot to work on their patient experience. And they had a chart up on the wall that said, you know, if you’re feeling burned out, here’s the things you should do.

Dr. Anthony Orsini (10m 50s):
Do yoga, take a day off. And I overheard two nurses laughing at the chart going well, if I had time to do yoga and I had time to take off, I wouldn’t be forgotten the first place. You know? So I think that the work that you’re doing is so important because we really need to draw that parallel between the stress and clinical outcomes, but more importantly to the hospital administrators, it’s important to draw that parallel to the return of investment. And that’s one of the things that I’ll ask you about later. But in the meantime, tell me about the stress involved in that high-performance job. Let’s say trauma surgeons for now.

Dr. Anthony Orsini (11m 31s):
Cause I think you’ve worked with them. And how do you define stress and how do you decide who’s under stress? I know you’re doing some work with whoop, but how do you really define stress?

Brian Ferguson (11m 42s):
So one thing that’s very important to us where we’re doing clinical research right now and, and just research in general is around a I, well, let me back up. So if we’re saying that stress is an upstream marker of burnout or the inverse, that burnout is really a downstream indicator. Someone who has been chronically stressed, the question is how do we measure stress? One of my humble critiques of medicine right now is there is no commonly accepted definition of burnout as it relates to a set of physiological biomarkers in the human system. So it is mainly subjective and it is subjective in the sense that someone fills out a survey maybe once a year and says they are now burned out at which point for the most part, it is too late is very difficult to reverse engineer burnout.

Brian Ferguson (12m 27s):
And so the question is one of our radical folks at Arena Labs is putting data and a definition around biomarkers related to stress. So we look objectively at heart rate in part rate is not as profound, but over time, someone who’s chronically stressed, we do see a slow elevation in heart rate, resting heart rate. Over time, we look at heart rate variability and we teach people what heart rate variability is as a marker of the autonomic nervous system and not only physical health, but equally important emotional health. We look at sleep and how fragmented somebody’s sleep is meaning when someone is in bed, whether they’re on call or they’re at home, are they getting deep restful sleep?

Brian Ferguson (13m 13s):
Because we know through a lot of study of sleep, that people who are in a hyper activated state, because they’re just so focused in trauma or the ed or in just the workload of the ICU, it’s hard to deactivate the nervous system. So their sleep is fragmented, which means they’re not as rested. So those are some of the biomarkers we look at that are objective and we put together a physiological profile through. So you mentioned Whoop, which is W h o o p should give a shout out to our friend Ellen Riley who introduced us. Ellen is the head of healthcare at Whoop. We have partnered with Whoop as a wearable sensor for a number of reasons. The first of which is that they are excited about doing work in healthcare with frontline medical teams.

Brian Ferguson (13m 56s):
The second is their form factor allows the device to be worn on the bicep. So clinicians who have to take off their wrists and rings during when they’re scrubbed in and still monitor their own biomarkers. But we use that sensor to capture that objective marker of stress. Now in holistic health, I would say we can get into sort of how we define stress later, but then the other thing that’s equally important is we have subjective measures. We have a daily check-in on our platform where a clinician reports, how stressed they feel, how prepared do they feel for that stress? How much resources do they have, meaning if you’re really stressed, but you’ve got a toolkit that says, Hey, I can handle this stress.

Brian Ferguson (14m 36s):
Then that variance is important to understand. And then we want to know how focused people are. Again, because this is where to your earlier question. We want to make the link between stress and performance as an important connection into patient outcomes. And ultimately the things that hospitals measure. So the short answer to your question is much of our work is putting a data-driven picture to stress at the individual clinician level. And then we aggregate that across a healthcare system or a hospital department to provide for the first time in history, an actual picture of where people sit in terms of their reported levels of stress and overwhelm.

Dr. Anthony Orsini (15m 13s):
And where do you see this going? Like right now? One of the things that I’ve been pushing hospitals, and a lot of people have been pushing gospels for the last 10 years or so is we know for instance in neonatology that if a nurse has a baby die on them during their shift data shows us very strongly that the next baby that they take care of that day, they are in four to 10 times more likely to commit a medical error. And so there are some hospitals, but very few who now say to that nurse, and it’s more than nursing a doctor because the doctor’s got several patients, but that nurse had been sitting with that baby, watching that kid die for the last six hours. There are some hospitals that are saying, okay, Cindy, after you’re done helping the parents leave, the baby’s taken care of you’re going home because we don’t want to take that risk.

Dr. Anthony Orsini (16m 2s):
Most hospitals, which is absurd to me would say, Cindy, would you like to go home without pay? And the answer is almost invariably. No, I’m fine. Because doctors and nurses kind of feel like they need to wear this S on their chest. And I assume Navy seals are the same way. Dr. Robert Pearl, who wrote a great book called uncaring was on our podcast maybe six months ago and talked about this. How do you foresee this data going? Because you talked about subjective, right? Number one, are they going to be honest? Is it anonymous? Are they honest with themselves? And number two, these, see that we’re getting to a point where this is mandatory, Dr.

Dr. Anthony Orsini (16m 45s):
Jones, your biomarkers, your reports are saying that this is not a good day for you to do surgery. You need to go home. Do you ever see that happening? And is that your goal?

Brian Ferguson (16m 56s):
So, our long-term goal at Arena Labs, we talk about ourselves being healthcare’s first performance coach. And I would love to see a world where healthcare sees us as a trusted, necessary partner for every clinician in the world. Because the toolkit, the training and the technology we are providing frontline clinicians is empowering them for the first time in their career to understand themselves as it relates to their work and performance and how they take care of patients. And because they know that on our platform, we call ourselves a trusted teammate. Any data that they provide is going to be blinded in anonymized, beyond them and the coach on our team they’re working with.

Brian Ferguson (17m 36s):
So what happens is someone gets on our platform. They begin, you know, we ingest this data from their sensor. We ingest their daily subjective check-in data. And we start to build that profile. And then they’re able to check in with our coach and start to learn, how do I understand these biomarkers? How do I improve my sleep? How do I think about some tools to distress? So we believe, you know, a world where that’s feasible is how we start to change the arc of healthcare. Now, two things you said that are important. One is the S on your chest for that nurse who loses a patient, or excuse me, a baby, or in this case, certainly a patient. What is incredibly profound. And I think often in healthcare, again, I say this respectfully, but it’s underappreciated is what I said in the front end.

Brian Ferguson (18m 17s):
This idea of the service archetype. If you look at people who go into the military, people who go into the front lines of healthcare as nurses or physicians and people who go to serve as teachers, those are people who, again, want to impact the world, save lives and do hard things. That is a very rare and beautiful archetype that is critical to any flourishing society. The problem is that if those people are not around an institutional architecture and leaders who protect them against the better angels of their nature, they will give of themselves and give of themselves until there’s nothing left to give. And so the reason we’re not doing anything particularly profound here, what we’re doing is bringing thinking that has been proven in the hard lessons the military learned in the last 20 years of combat and what is played out in terms of PTSD and a lot of challenges.

Brian Ferguson (19m 6s):
We’re bringing the same tools that work there into medicine, because we’re seeing right now, even before COVID, we’re seeing that same load play out in a lot of different perverse ways around stress and turnover, but especially with COVID, that’s been elevated. And so where we go to that nurse to say, rather, Hey, you should go home. Of course, that’s where we’d like to be. We play it right now, a lot more humbly and saying, anytime we work with a new hospital system, I say, the first thing we’re going to do is give you a set of data. You always wish you had, but never did. And that is actual data around stress and upstream of burnout. Now it will be blinded in anonymized. So you can’t say, Hey, Dr. Orsini, you need to take a day off, but you can see in neonatology how that team is doing and how stress they’re reporting on particular days of the week, particular months.

Brian Ferguson (19m 52s):
The second thing we’re going to do is help you see blind spots in that data. And then the third is help you think through what should policies be that are practical, because I recognize, especially given shortages and personnel right now, you can’t necessarily give everyone a day off. But the question is, where are you willing to take risks? In terms of, if someone loses a baby, is it worth the risk of keeping them around? Because you’re, short-staffed knowing there’s a higher likelihood of medical error. And as long as people have that data, that’s the job of medical leaders and administrators, to be smart about how they make decisions. But right now, I would say for the most part, most medical institutions are flying in the blind.

Brian Ferguson (20m 31s):
They have zero understanding and data around the actual health and wellness of their clinicians.

Dr. Anthony Orsini (20m 37s):
It’s so important, because I loved the data part of it, not only for the hospital, but I think it takes the subjectivity out of it. So I think out of a hundred times that you asked that nurse that they want to go home, maybe once they’ll say yes, because it’s a sign of weakness. You’re not tough enough buck up and start working. But if we get to the point where the hospital says, listen, I hate to reduce hospital and medicine to dollars and cents, but that’s, what’s important to the administrators. And that’s, what’s important to the insurance companies. If we could ever get to the point where that data says, listen, keeping me an extra nurse on per shift is going to cost us $300,000 a year, but it’s going to prevent one medical error at $16.5 million lawsuit kind of makes sense that we should probably keep the extra nurse here so we can send the one home as a clinician.

Dr. Anthony Orsini (21m 27s):
It would be very freeing for me, for my boss to say, Hey, Tony, you’re biomarkers horrible today. I’m not asking, I’m telling you, you need a day off and get a good night’s sleep. And then that takes the shame out of it. Does that happen in the military with the Navy seals? Do they I’m sure. Navy seals never want to say I can’t deploy. I’m not feeling good, right? I mean, what how’s that work in the Navy? When a seal looks like they’re burnt out or tired or exhausted.

Brian Ferguson (21m 57s):
So the outcomes here in terms of, again, how people make decisions about human capital management are widely variable within reason. Now, if we zoom out, I think what is more important that we see not just in special operations, but certainly in pros sports is modern technology and data have made us smarter in understanding the human system. And so now it’s, I mean, you see this in pro sport. When coaches make a decision to rest a player, I mean, there’s now data around someone being in a state where there’s a higher likelihood of injury, or we’re playing a long game here. And we know we’ve just been through a really tough set of games or a period of training. And so in the military, you see this first is how do we empower people with data to think smarter about performance in one of the things that is a cultural norm in both pro sport and in the military that we are pushing hard to make a cultural norm in medicine is we want to reframe this, not as you’re broken and burned out, but you as a clinician who is a service archetype, you take extraordinary pride as a physician or a nurse in being the best version of yourself possible to provide world-class patient quality and care.

Brian Ferguson (23m 5s):
Right now that narrative is driven through this mantra of just endure go harder, go longer. Don’t ask questions and grind. To be very clear, grinding and doing hard things is the bedrock of all of these fields, whether we’re in the military or professional sport. The question is how do we use data to be smarter about the approach to grinding and when people rest and recover. So at the end of the day, yes, as an example, think about concussion protocols in pro sports there are red lines that say, look, we know there’s a set of biomarkers that show that neurologically you’ve been impacted and you are required to take this amount of time off. There are similar protocols in the military, and then there are other protocols that are more subjective. How do you want to handle this? We know you’re showing that you need real rest and recovery, but instead of someone mandating and saying, Hey, Brian, take the week off.

Brian Ferguson (23m 52s):
The onus has been put on. If you want to be, world-class a high performer, it’s on you to understand how to manage yourself. And that’s the elevated approach, what we call high-performance medicine. And so we take a lot of pride in giving clinicians this bedrock and foundation around performance and data. So they can start to think of themselves as high performers, because at the end of the day, again, stewarding society through a pandemic right now, every single person in health care is in some way, an extraordinary performer that the average American is not. And that’s powerful.

Dr. Anthony Orsini (24m 23s):
Yeah. The concussion analogy is perfect because if you watch sports in the old days, there were football players who were obviously concussed, who literally had to be tackled because they were going out on the field and the coach would say, I think you should sit down. There were times I remember where the protocol was to hide the helmet because an athlete, a world-class athlete is going no matter how much they’re dizzy or feeling nausea, they’re going to go out there. And I think that’s a great analogy.

Brian Ferguson (24m 48s):
The other thing you brought up, which is really important, our number one value at Arena Labs is humility. Meaning we are not medical experts, but we get the privilege of working in healthcare. And we work with physicians like you, I’m not going to come in and say, Dr. Orsini, here’s how you do your job instead. How do we paint a picture around the way other disciplines that have an equal amount of stress and pressure have navigated the same challenges you’re going through? So where there’s a real deficiency you brought up a couple of times is sort of the tone-deafness of resilience and wellness and healthcare. And I would say there’s two narratives that are insidious. Well, the first is a narrative. The second is a sort of how healthcare has evolved. The first is this narrative around the obsession around patient quality and care.

Brian Ferguson (25m 29s):
And I always say the least important part of patient safety is the patient. If we were to get every clinician to understand himself or herself in a deep sense of data and rest and recovery and how to manage stress, I suffice it to say that I think we would see improvements in patient outcomes and quality. Because there’s an emotional attachment. There’s a whole bunch of things to your earlier than yet about losing a child in neonatology. It’s very similar when people have impactful emotional experiences and they don’t know how to handle it. And they’re obsessed with an extra analogy like the patient, they’re not taking care of themselves. So the first thing we want to do, we call it radically reprioritizing the clinician. How do we get the clinician to focus on himself or herself?

Brian Ferguson (26m 9s):
The second is the sort of tone-deafness of putting up flyers to do yoga or take a day off that comes out of this obsession or what is an understandable evolution in healthcare around a focus on the macroeconomics of a hospital. How do we keep this place open and ensure that in an age of rising costs, we can get enough marginal revenue out of the case in order to, to get the money we need or macro efficiencies, how do we run this place where we can improve patient throughput, improve turnover times or first case on time starts by definition, macro diminishes the micro. And so what has happened over time is this obsession on macro has, you know, when a hospital has time to focus on the micro, the individual clinician, they try to do it at scale through a macro approach.

Brian Ferguson (26m 53s):
We’re going to put these flyers up and everyone’s going to do yoga it’s well-intended, but it’s tone deaf. So our focus at Arena Labs is to invert that paradigm and radically focus on the individual radically focused, because if we can get each person to understand stress and pressure in the context of their own lived experience in healthcare, that’s how we start to give a more sophisticated approach to performance like the NFL concussion protocols or special operations.

Dr. Anthony Orsini (27m 21s):
Brian, and as a clinician, it’s freeing to me to know that I can almost say, I know that I’m burned out. I know that this is not a good day. I know I’m not at my peak performance, but there’s a shame to saying it. And it would be totally freeing to me to be able to say, Hey, my data is saying that I shouldn’t be here. And now I’m altruistic because I have hard data to say that I’m putting my patient at risk. And therefore, so I go from an embarrassed clinician who’s not tough enough to a caring physician who says, Hey, my data says it’s not good for my patient. And therefore, so it totally changes the narrative. And as a clinician, I think it’s so freeing.

Dr. Anthony Orsini (28m 3s):
And I hope we can move towards this. I’m so excited about the future of this.

Brian Ferguson (28m 7s):
Yeah. One of the things we talk about there is we say, number one, we’re not going to make medicine less stressful. We’re not naive, but what we can do is provide clinicians with the toolkit to feel more agency in the face of stress. And ultimately what we hope is a world where you don’t have to make this sort of dramatic decision between going into work and not because you’re so burned out. Those extremes have emerged from a world where people don’t have the tools and you get enlightened thought leaders like you who recognize the craziness of it and are trying to figure it out and be leaders. But what we want to do is if we think of the teaching, someone, if 20 years ago in your career, you were given a toolkit that you started to play with and you figured out what worked for you, whether it was a breathing exercise or an evening wind down, or just some basic stuff to improve your sleep.

Brian Ferguson (28m 54s):
Even if you’re on call over time, the compounding effects of that small toolkit implemented each day would give you some of that agency. So you don’t get those acute moments where you’re like, I might not even be able to go into work today. Then instead we’re releasing a little bit of pressure every day. So the compounding effects is feeling more of that agency and you, and to your point, that freeing nature of, Hey, I understand my job is hard, but I feel an ability to manage that stress and be smarter about how I go about not only my life as a clinician, but my home life.

Dr. Anthony Orsini (29m 24s):
Yeah. And you mentioned something last time we spoke, I think he showed it to me about data, which surgeons and the amount of sleep that they got. I think you, you determine just from your very simple thing, that probably Mondays are probably the safest time to why is that because of the sleep I think, right.

Brian Ferguson (29m 42s):
Yeah. And, and this is highly variant across specialties, but we now have about 8,000 nights collected of sleep in cardiac surgeon populations. That’s because of our early work started with cardiac surgeons, both attendings and residents. And what we see in that specialty as it, this is a generalization, but again, 8,000 nights of sleep because most of those cases are elective they’re done during the week. So surgeons are most well rested on Sundays and that by most well rested, that is a report of time in bed, quality of sleep. We also look at stages of sleep. So percentage of sleep that is rapid eye movement and deep or slow wave sleep.

Brian Ferguson (30m 21s):
It’s also a marker of reported levels of stress and reported levels of readiness and rest moments. So that is highest on Sundays. And what we see is a linear degradation over the course of the week, where by Thursday and Friday, those surgeons are in a deep state of deficiency, as it relates again to reported levels of stress and physiology. So their heart rate is elevated. They’re getting less sleep and their heart rate variability is significantly lower. And so what that begs the question again, where we go back to our earlier conversation, it is not our job nor expertise to tell a cardiothoracic program when they should be doing cases. But we can ask the provocative question, which is if you have an elective case that is particularly complex, that maybe your institution does not do frequently, are you going to schedule that on Monday or on Friday?

Brian Ferguson (31m 12s):
Because we can tell you that on Friday that team, your attendings and your residents are going to be physiologically degraded and reporting higher levels of stress and lower levels of focus. So just from a human capital management perspective, rather than, you know, we’re not saying reorganize all the deck chairs, maybe we start with some basic decisions around when we’re scheduling to difficult elective cases.

Dr. Anthony Orsini (31m 32s):
I think that’s great. And after I spoke to you, I going for a hip replacement, even though I’m relatively young, I’m going for hip replacement next month. And I had you in my mind, this other receptionist like, oh, the orthopedic surgeon, he does surgeries on Tuesdays and Fridays. When would you like, and I go Tuesday

Brian Ferguson (31m 50s):
And tell him to rest up on the weekend, make sure he’s not out late.

Dr. Anthony Orsini (31m 55s):
You were talking about stress, some tips for the doctors. So as I said, we go from zero to 60. Neonatology is like that, ER, trauma, you’re doing the surgery. Things are going really well. All of a sudden the patient codes. And one of the best advice that I got when I was really early on is one of my mentors said to me, during a code situation, the higher up on the ladder, you are the softer you should speak. And I’ve always followed that. And I’ve gotten many compliments on that. What’s some advice that you can give to people that you’ve learned during your period while you were in the Navy seals and during your time here to help them get through that stressful situation when it happens like lightning, are there any tips that you can give us the deal with?

Brian Ferguson (32m 38s):
I think the first is start with an understanding of yourself and this is where in our platform we deliberately, because your question is coming from that of a leader, which is so important, how do I lead in a crisis? What is interesting is that without an understanding of yourself, and then ultimately you understanding as a teammate, it’s hard to really understand how to lead in a high consequence, high pressure environment. So we start with the individual, which is in there’s two core components of our individual curriculum, which are energy management and self-awareness. The self-awareness side is what do you feel like when you’re stressed? How does your body respond? So for me, when I’m really stressed out, my thoughts will race.

Brian Ferguson (33m 21s):
I will often see some sort of galvanic skin response, my palms sweat, and then there’s an inability to focus. Some people feel their heart rates significantly elevate. So the first is understand for yourself, what does stress feel like? And then learn, what are the protocols or the interventions you can use to get back into a place of calm. That might be a breathing routine that might be a quick visualization exercise, or just a fast reset physiologically. Dr. Andrew Huberman who’s at Stanford university on our platform, teaches something called the physiological sigh, which is to inhale through the nose. The first one being longer than the second followed by a long exhale. His lab has done a deep research around the impacts that has at lowering heart rate and lowering stress.

Brian Ferguson (34m 2s):
So understand those protocols for yourself. So that’s step one and then understand in a team environment, how does in a team environment, what leads to an effective response? I think some of the more exciting work being done here is by Dr. Dworkis out of USC, he’s an emergency room physician. You’d be a great future guest on the podcast, but he’s got his own podcast called the emergency mind. And what Dan has looked at is how do we get teams and crisis environments beat in the ICU, be it in neonatology, in a code situation to understand collective response. And how do we teach that? Because when people understand themselves and their own energy management and stress response, and then they understand how to communicate in a crisis in a team it’s taught as a protocol.

Brian Ferguson (34m 45s):
And so people need to have a common framework. So when they show up at your hospital and they’re on Dr. Orsini’s team, they understand in a code where to go. And we condition that because one of the things that special operations and I think most high consequence teams do well is they just practice to a point of failure. And so we fall back to our highest level of practice in a crisis. And so, you know, if your team has never practiced these codes and they don’t understand their role as a teammate, it’s hard to know where they go. And if someone moves through that sort of progression, by the time they get to be a leader, and they’re now responsible for a code, they understand everything from their own energy management, how they project that energy to how to, you know what I always say for a physician or someone leading a code, the highest order of performance for a leader is you are expected to be able to manage yourself from an energy perspective, into your point to use a calm voice and be directive.

Brian Ferguson (35m 40s):
What is more impressive is when you can look at the people around you and see that someone is teetering on the edge of melting down, and you can pull them back into a state of focus. And that is expected of leaders in special operations and military combat that’s expected of leaders on any elite level of sport. And it should be taught and expected of leaders in medicine. But right now people sort of like you, they have a good mentor that gives them piece of advice and they get lucky, or they kind of just meander through. And so seeing the work that Dr. Dworkis is doing, and then there’s also an organization called the mission critical teams Institute. We work with Dr. Preston Kline. He does a lot of work in mission critical teams. And what are the protocols that lead to effective management of crises?

Dr. Anthony Orsini (36m 20s):
And there’s all the Italian saying that I speak about all the time called the fish rots from the head, which basically means the leader is falling apart. Everything else does, whether that’s a large fortune 500 company, or it’s a small team during a code. And, you know, I’ve seen so many times where I’ll walk into a room and there’s people screaming in chaos. And I just walk in, I go, what’s going on? And everybody comes down and I saw an interview. You did back in 2018 where he told a story about a scrub nurse that would totally got debilitated because of the surgeon. Tell us about that quickly.

Brian Ferguson (36m 51s):
Close it, the tail of two operating rooms. And it’s, I think a common vignette for anyone working in modern healthcare. And I think one of the things, again, this sort of legacy thinking that you talked about the old days and on the football field of concussions, where people just were expected to tough it out and play through, certainly have those versions in the military. One of the insidious sort of cultural legacies, I think of you see in the operating room and in parts of medicine is this idea that like screaming and losing your temper as a way to control the room. And so we were in what we call the operating room B, we watch an orthopedic surgeon do an extraordinary case. His team was in flow, they were playing music. They were communicating well, the music came down during points of intense focus. And so we left that room at one of my partners. And I went into another room to observe in this particular room as another orthopedic surgery.

Brian Ferguson (37m 34s):
And we were standing at the scrub sink and the surgeon asked who we were and what we were doing. We talked about our working performance and he said, oh, you want to know about performance? And he proceeded to just talk about how terrible this place was and how bad the team was and how ineffective people were. And then he turns, and he kicks the operating room door in, right? So literally kicks the door in and he’s got both of his hands he’s scrubbed, and he’s holding his hands up and imagine the energy of just exploding into a room by kicking the door. So the people on the other side of you, and here’s the thing better than me, th the thing about energy, you can always ramp up. It is very difficult to ramp down. So when you set the tone of the beginning of the case, by kicking the door in, people are already in a heightened state and people who are not sophisticated and understanding energy management, it’s hard to come back from that fight or flight response.

Brian Ferguson (38m 17s):
They’re now in a sympathetic state that is hyper. And so the case proceeds, he initially starts diving in and really going after the anesthesiologist about it was technical information beyond my knowledge, but just hammering the anesthesiologist and eventually, you know, so it turns that IRAD bend to the resident. The resident to his credit was fairly stable, but eventually turns to the scrub tech and proceeds to really ride the scrub tech to a point where the scrub tech starts to clearly start to tremble and so much so that she loses dexterity and is no longer able to handle the instruments and what was fast. So, first of all, like for me, that’s the equivalent of shooting someone in your own team in the foot. I mean, it’s just ludicrous to me, that’s even thought of as reasonable behavior.

Brian Ferguson (39m 0s):
But what was interesting is that the entire scenario was salvaged by a device rep in the room who was particularly seasoned. And he came over and talked her through what instruments were needed to finish the case. But that for me became a higher order vignette of how we have to reframe this idea of high performance at an individual level, the team level, because any high-performing team in the world, be it in sport, in the creative arts, if you’re in Cirque de Solei and you deliberately let someone hit the floor, because you’re upset with them, you have taken them out and you’ve permanently injured them. It’s no different in the, or if you’re saying to me that patient quality is your number one outcome, then why would you ever diminish the capacity of your team by screaming at someone in a way that causes them to lose their ability to do their core job?

Brian Ferguson (39m 40s):
So we focus a lot in, and here’s the thing. This is not about that individual surgeon, because what I always tell institutions is he was behaving rationally. If that is a culture that has been normalized, where screaming at people allows you to get work done, then it’s actually very rational to, you know, until it’s been clear what the standard of behavior and conduct is. People will behave in a way that gets them, what they need until they’re told to do otherwise.

Dr. Anthony Orsini (40m 4s):
In that book on caring, which I highly recommend for you to read. I think you’d love it by Robert Pearl. He talks a lot about that and people respond different ways. I coached football for awhile. My oldest son played quarterback in high school and college. And one of the things that I noticed between good coaches and bad coaches is the inability to understand how people respond. I’m a big fan of coaches Shefsky, and I’ve read all his books. And there are some on the football field who will respond to a coach who’s yelling at them and say, you need to get tougher. And then there’s other players who are their hardest critics on themselves. And that there are some players that you need to say, okay, well, you threw three touchdown passes, but that was an interception.

Dr. Anthony Orsini (40m 47s):
So relax. And if you yell at that player, they’ll shut down much more quickly. So I think that’s the biggest problem. And as a coach, and also as a leader, that you have to understand how people respond that end in an operating room or in a code situation, nobody responds to being yelled at nobody because they’re all they’re trying to do the best thing that they can. So, Brian, before we go to the last question, just take me through this when you get a client and how does this work, where I think you’ve got some pretty big clients, right? Cleveland clinic, there’s some big clients that you have someone wants to do a program with you. Doctors have to wear this thing on their biceps for a long period of time.

Dr. Anthony Orsini (41m 28s):
Is it just the whoop that you’re using a how’s it work? Yes.

Brian Ferguson (41m 31s):
So anytime we go into a hospital, whether we right now are working in all parts of medicine, as I mentioned, we started cardiothoracic surgery, but at a basic level, if an institution is interested in bringing high-performance medicine, thinking into either the hospital writ large or particular division, we’ll come in, meet with those leaders. Talk about rather than just diving in. Let’s talk about why we do what we do and how we can be seen as a trusted partner. And then we do, we roll out. So we’ll typically meet with the key leaders of that institution and key influencers in both the nursing space or whatever space we’re working so that people feel bought in. And then we put them on our platform. And so it’s a six month learning journey. Part of which is digital content. So videos from Olympic athletes, creative masters seals, fighter pilots, people who do high consequence, high-pressure work, teaching you those skills initially in an individual bucket, then a team bucket.

Brian Ferguson (42m 18s):
And then as a leader and manager. And we require five to 10 minutes a day to absorb either a single video and then to do a check-in on how you’re feeling. And then you do wear a device. And so it is optional people opt in. We like to see them wear it for at least eight weeks on the front end, and then another eight weeks on the back end of that experience and that device, all of that data is blinded and anonymized. But it’s used for you individually to understand yourself in the context of stress rest, and ultimately performance, and then why you’re on our platform. You work with a coach. And so that coaches is helping you understand your data and understand how you’re relating to your own cohort and your colleagues. And so, again, six months experience. And then about two months in, we started to provide the hospital with high level data analytics around what we’re seeing as it relates to rest recovery performance reported levels of stress.

Brian Ferguson (43m 6s):
All of that is blinded anonymized, but it’s a dashboard that allows hospitals instead of having to put up flyers about yoga and pizza parties, to have real data, to help clinicians understand everything from how do we think smarter about our schedule to, to managing our human capital. And at the end of that six months, we can get into more sophisticated one-on-one coaching and work, depending on where an institution wants to go. And our partner on the data side, is indeed whoop and they provide us those analytics.

Dr. Anthony Orsini (43m 31s):
I think I’m so excited about this, Brian, I didn’t warn you on our conversation last time. Although I do usually warn people, the title, this is a difficult conversation. So I end every podcast episode asking a guest the same question. What is the most difficult conversation that you ever had to have? And how did you navigate through that?

Brian Ferguson (43m 52s):
Yeah, I think two quick ones. One is my brother, my brother, very close to him. He was also in special operations. And one of the reasons I’m very passionate about this work is because I do believe these things have a universality that we’ve seen in the military, and you’ve seen another service archetype professions. My brother served for 10 years in special operations and he had his own struggles. I won’t go into that, but that unfortunately led to him passing away in 2017, but a number of really difficult conversations that I did not manage as well as I would have liked because I was, there was so much emotionality in it for me. And it’s one of the reasons I think it’s so important to give people data and equip them with tools so that they’re not just leaning on emotion when people who you care about and who are working hard and doing their best, start to go down a path where they’re burned out and their work is taking a toll.

Brian Ferguson (44m 44s):
And so there was series of our conversations in there. And if I’m being honest, I think one of the challenges and why I’m so passionate about this work is I, I wish I could tell you I handled them better. And I had a better understanding of how to navigate the very emotional side of someone you care about struggle.

Dr. Anthony Orsini (45m 0s):
So sorry about the loss of your brother and thank you for sharing that. And yes, Difficult Conversations are, is something that I’ve dedicated my life to. It is very hard about the emotionality of it. And I think there’s a lot we can learn about that and I’m working on healthcare, but it’s something that I think everybody can learn both in their professional and personal lives. And again, I’m sorry for your loss. So I appreciate it, Brian, right now, I’m just so excited about your work. I really am. I was excited the first time we spoke, but now as time goes by, and as I’m doing more and more work in the burnout field and experienced some of the things that you’re talking about, we have in a couple of weeks, a guest here is going to talk about physician burnout, how she calls it moral injury and how that ties into this.

Dr. Anthony Orsini (45m 45s):
But to me, there’s this little glimmer of hope in the end, because some people are so pessimistic about healthcare and where we’re headed. But I think this is there’s a glimmer of hope. I can’t be more excited. I want to thank Ellen Riley from Whoop to introduce Ellen was my across the street neighbor for 15 years and we still keep in touch. And so, but now we’re in Orlando. Brian, thank you so much. That’s the way to get in touch with you. And we’ll put it on the show notes just for everybody else.

Brian Ferguson (46m 13s):
Yeah. Dr. Orsini again, thank you so much for elevating this conversation. I’ll tell you our team takes that comment. There’s nothing. I tell you more central to our work that gets people motivated than hearing from you. That there’s a glimmer of hope in what we’re doing. And I think we believe that we see it in the work we get to do with clinicians like you. And it’s, there’s nothing more fulfilling than getting to do something that’s meaningful. And for folks who want to know more about us Arena Labs.global is our website. And if I want to reach out and work with us, there’s a form on our website where you can get us at hello at Arena Labs.global. And we’ve got a lot going on right now and are looking for people who like you are thought leaders in the field and want to do this kind of work in their institution. So please reach out.

Dr. Anthony Orsini (46m 50s):
Thank you, Brian. If you enjoyed this podcast, please go ahead and hit, subscribe or follow on apple. Please let your friends and families know and download previous episodes that we talked about today. If you’d like to get in touch with me, you can reach me at Dr. Orsini Way@theorsiniway.Com or just go to the website, contact us. Thank you, Brian. Appreciate everything. And this has been really exciting and I can’t wait for my audience to hear this. Thank you so much.

Brian Ferguson (47m 16s):
Thanks’ Dr. Orsini.

Announcer (47m 16s):
If you enjoyed this podcast, please hit the subscribe button and leave a comment and review your contact, Dr. Orsini and his team, or to suggest guests for future podcast, visit us at Orsini Way.com. The comments and opinions of the interviewer and guests on this are their own and do not necessarily reflect the opinions and beliefs of their present and past employers or institutions.