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2. Pregame Like a Pro


We can't immediately change the process of medicine, the stuff that is kind of a drag and wears us down. What we can change, however, is our mindset. In this episode, we dissect several practices for shift preparation with a common goal of operating at a peak level of performance and experiencing more joy in what we do. Today we learn how to pregame, like a pro.

We discuss:

How when the process of practicing medicine becomes your purpose for being a doctor, you’re at risk for burnout, if not worse. [00:30]

  • We are trained to be grinders, functioning as if we’re a cog in a machine.

  • Our time is spent being EMR jockeys, juggling consultants, taking call for decades, and fearing lawsuits.

  • This transforms us in a negative way. But it doesn’t have to be permanent.


The system will not adjust to what you need right now. You have to adjust yourself. [1:45]

  • There are some things that we cannot immediately change about the process of medicine, but we can change our mindset.

  • One tool is to pregame -- mentally preparing yourself at the beginning of each day to help you keep sight of your purpose.

  • By pregaming, you can set yourself up to operate at a peak level of performance and to experience more joy in what you do.

How accepting gratitude, and other small changes in mindset, can have a logarithmic return on investment. [4:50]

  • Before each shift, Rob does a gratitude exercise. He thinks or writes: “I am open to accepting gratitude from my patients.”

  • When he receives gratitude, he pauses, engages, and graciously accepts it.

  • This is one of many ways to engineer a positive mindset.

The ways that many elite-level performers pregame. They rely on their rituals for peak performance. [07:15]

  • Actors dedicate time before a show in solitude, getting into character.

  • Swimmer Michael Phelps sits in a chair, headphones on, mentally preparing for races.

  • Sprinter Usain Bolt hops and skips around the track, building up energy.

Physicians are elite-level performers who rarely have the time to mentally prepare for each day. And the stakes are high if performance suffers. [8:40]

  • Why don’t we pregame? We accept that we exist in this tumult. We’re just too busy. And it’s not part of our culture.

  • Ross Fisher shares: “I am intrigued at how we are elite performers, but we have a lot of things affecting our performance...When I’m getting battered...that’s putting me off my game...I think medicine has got something it needs to learn. We do not respect the performers and get them into a position to perform as well as they might do.”

How some doctors pregame (or not)


Mike Weinstock [12:06]: “This is a confession of a total loser...The fact is, I don’t pregame.“

  • That’s how a lot of us feel. Work is just part of what happens in the course of your day. You don’t give much thought to the transition before going into it.

Clay Smith [13:20]: “My pregame is to think about other things. --It takes my mind off work, which is good for me because I get a little anxious if I’m thinking too much about work...There’s always a feeling of, ‘Can I actually do this? What if there’s something that comes in that I can’t handle?’”

  • Rob relates to Clay’s anxiety state, negative self-talk, and feelings of inadequacy, having felt the same way for 15 years of his career.

  • But if we start our day like that, are we preparing ourselves for peak performance and experiencing joy in what we do?

Joshua Russell [15:10]: “I break the elements of preparation into 2 categories. One is, how do I get my brain in a place that it’s going to perform optimally from a cognitive standpoint? Secondly, how do I deal with the mental and emotional aspects of practice and, more importantly, be aware of the emotions that are going to have ill effects on my ability to rationally approach patient care?”

  • His pregame involves making sure he’s well-rested, well-fed, and gets a few minutes of high intensity exercise.

  • On his way into work, he listens to medical education to get into the emergency medicine mindset.

  • He creates the frame of mind to attack the day by doing the following ritual before entering the hospital: he meditates for 2 minutes, he does a simple breathing exercise, and then he visualizes performing a critical procedure.

Sabrina Adams [18:00]: Sabrina quickly switches to doctor mode when she looks at her license plate which says, BAFERD (Badass, F-ing ER Doctor). It reframes her identity and motivates her to do her best in taking care of patients.

Jaime Hope [19:10]: As she’s going into work, Jaime thinks of her 4 professional identities: public safety officer, resuscitationist, diagnostician, and patient advocate. This helps distinguish herself as an owner, not a renter, of her job. “When you are truly the owner of your career, you want it to be amazing. You’re going to take care of (it), because you worked really hard to get here.”

Mizuho Morrison [21:40]: Mizuho has a sequence of 3 steps of self-talk: admitting, agreeing, and gratitude. “I go through a mental thought process on the drive to work of admitting and agreeing. ‘Am I nervous?’ I am, and that’s okay. I think it’s a healthy respect for the illnesses you’re about to see and it keeps you humble. I remind myself, ‘You are capable. You are well-trained.’ Finally, I remember that this is a privilege to be a physician...to be in a position to help people.”

Ran Ran [24:20]: “I always bike to work, and that’s my most Zen part of the day. I feel invigorated by the bike ride, and then I just feel fresh and ready to go. That’s my coffee.”

Joe Dubois: “I walk to work. It gives me time to collect my thoughts for the day.”

Chris Nickson walks to work and uses that time to get into a certain headspace. He checks in with himself about how he’s feeling. “So when I do walk through the door at work, I’m the person as close as possible to the person that I want to be...Sometimes I give myself a bit of a reminder self-talk about being kind to people, because when I step out on the floor there, I really want my team to feel ‘I’m glad to be here.”

Ross Fisher has a 90 minute commute: “On the motorway, I am in a happy place. I’m quite calm. I’ve got music playing on the stereo and that is part of the buildup for the day.”

Haney Mallemat: “As I’m driving to work, I listen to podcasts...Listening to education on the way in gets me into educator mode and inspires me to teach others during my shift...And as I’m walking into the building, I start my mental rehearsal phase of me pre-shift ritual. I visualize procedures that I do infrequently...I walk through each step just to be sure I know what’s going on...Going through this mental visualization allows me to get into the mode of resuscitator.”

Luz Silverio [28:40]: Luz’ pregame ritual is to arrive to work 15 minutes early to “chit-chat” with members of her team. “Those 15 minutes are incredibly valuable, because during a shift I can get tunnel vision and end-game focused. I lose perspective of the people I’m working with. If I’ve taken the time ahead of the shift to catch up, check in, and make some jokes...I have a little bit more leeway if later I’m ‘more directive.”

Alan Sielaff [29:30]: Alan’s pregame is to allow sufficient time before the shift to get prepared. He takes time to eat, to drive in, and to get ready.

Dan McCollum [31:00] Dan starts the day mentally preparing with the 5 Minute Journal. In this, he chooses his intention for the day, writes things he’s grateful for, and reflects on what he could’ve done better the day prior.

Reuben Strayer [32:50] “I mentally prepare for a shift by practicing mindfulness, which is to say being aware of what my brain is doing to my mood and my performance.”

Salim Rezaie [35:30] Salim isolates himself from social media and email for at least 1-2 hours prior to each shift. This increases his ability to provide undivided attention to his patients and work.

Mike Mallin [37:15] Mike uses intermittent fasting to improve his focus, attitude, and endurance at work. He skips breakfast before morning shifts and doesn’t eat at all during his shifts. He finds it liberating to not have to worry about food while he’s busy at work.

Rich Hamilton [38:30] Rich treats a shift like it’s a competitive sport. “I get mentally ready with a positive mindset, using some mental imaging to think through various scenarios that I might encounter...Very important is nutrition. I have tremendous concern of not having the proper nutrition to finish the race.”

Rob Orman [41:10] Rob has 2 pregame exercises. First, he does a breathing exercise which is calming. Second, he thinks of 3 things that he’s grateful for: gratitude for his teachers, his skills, and the opportunity to help others.

Jocko Willink’s Good” [44:06]

Show Notes by Melissa Orman, MD

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