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Doctors at Work Podcast.

Episode #56

How to perform under pressure

Mat Daniel


We all face stressful moments in our careers, when we have to perform under pressure. This isn’t just limited to clinical challenges, there are frequent pressures related to time, resources, learning, exams, and interviews. How do you set yourself up for success? In this episode, Adam Nicholls tells me that success starts well ahead of the moment of performance itself. It is wise to think and plan in advance, so that you have already considered possible challenges and obstacles, and have a plan in place for dealing with them. Visualising events in advance can be useful, and visualisation can focus on touch, sound, smell, as well as what you see. When it comes to training others, there needs to be a focus on strengths as well as on development areas, and over time the stressfulness of the situation should be increased in a supportive learning environment. And in the moment of performance itself, a threat mindset when people worry about threats can cause sabotage, but a mindset of challenge focused on what needs to happen is better.

Adam is a professor of psychology within the Department of Sport, Exercise, and Rehabilitation Sciences at the University of Hull, UK. The main focus of his research relates to the psycho-social factors that predict doping among adolescent athletes, along with coping and emotions among athletes.

His research is supported by more than £1.1 million as a principal investigator and £1.5 million including all projects. He has published more than 90 journal articles and written three books. His book, Psychology for Coaches: Theory and Practice has also been translated into Arabic and Hungarian.

In addition to pursuing his own research interests, Adam is the Director of research for the school and also the Research Excellence Framework (REF) lead.

You can also watch our conversation at

Podcast Transcript

[00:00:00] Mat: Welcome to Doctors at Work. My name’s Mat Daniel and this podcast is about doctors careers. Today I’m having a conversation with Adam Nicholls and we’re talking about how to perform under pressure. Now we all face stressful moments in our career and we all have to perform under pressure. That isn’t limited just to clinical scenarios.

There are often pressures related to time, resources, learning. exams, interviews. But how do you set yourself up for success? In this episode, Adam tells me that success starts well ahead of the moment of performance itself. It’s wise to think and plan in advance so that you’ve already considered all the possible challenges and obstacles, and you have a plan in place.

For dealing with such obstacles, it’s no use thinking at the time of the performance about what might go wrong. You want to have thought about what might go wrong well in advance of the situation. Visualizing events in advance can be useful because that allows you to think through all the situations.

You know what might go wrong? What can happen? How do I do this? If X, then Y, who do I call for help? What are my options? So when you are planning something in the cold light of day, think in advance and consider how you would deal with the complexities and the challenges that might arise. And When you are visualizing or thinking or planning for possible future situations, it’s not just about what you can also focus on what touch, what things might sound like, who would be talking, what noises would be in the background, or even smell. And when it comes to training others. It’s important that there’s a focus on the strengths as well as on their development areas. You need both. And over time, the trainer can increase the stressfulness of a situation.

And we know that how somebody performs is very much influenced by how stressful that situation is. So when it comes to training in a safe and supportive learning environment, the trainer over time can gradually increase the stressfulness of the situation to help the trainee learn. At the moment of performance itself, a threat mindset, when you’re worried about what threats can happen and what might go wrong, that actually will cause self-sabotage.

So at the moment of performance itself, you need to adopt a challenge mindset, where you’re focused on what needs to be done and what needs to happen in order for the outcome to be a success. I hope it’s useful.

Welcome, Adam. Tell me a little bit about yourself.

[00:02:39] Adam: Yes, I’m currently a professor of sport and exercise psychology at the University of Hull, where I have engaged in research with elite athletes for the last sort of 20 years now on stress and coping. More recently, I’m researching factors that predict doping behaviours.

And I also have leadership positions at Hull, a director of research. So I’m involved in mentoring staff and sitting on. various university committees.

[00:03:07] Mat: Thank you. And I saw your work around elite athletes and performance. And I thought, what a great thing it would be to talk about how to perform under pressure.

And that’s something that’s relevant to elite athletes as well as it is for doctors and for lots of other professions as well. So what do we know about the psychology of performance under pressure?

[00:03:28] Adam:  , so we know that performing under pressure is, in terms of sport, is a thing that really differentiates between those who make it at the very highest level and those who I guess, fall short.

And there are a multitude of factors of this. Some people have this kind of innate ability or and also a learned ability to perform under pressure to be able to get their best performances out when they’re under pressurized situations. And we know it’s not difficult. In fact, it’s, it’s one of the hardest things and you often hear about elite coaches talking about athletes or players who are There are world beaters in training but can’t translate that performance into a competitive situation.

And as I guess, as a sports psychologist, this is one of my roles to research and to help athletes to be able to try and perform at their best. When under pressurized situations,

[00:04:23] Mat: so let me get this right. So we know that there are people that perform I’ve got things flashing behind me on the screen.

Okay, so we know for anybody who’s listening That’s a weird thing that’s appeared on zoom all of a sudden for those of you that are watching you can have a laugh so we know that People can perform so well in training But whether that translates into winning, that’s determined by how they perform under pressure.

[00:04:50] Adam:  , in terms of, competition situations, and I guess in competition situations, it’s much more riding on the performance. So in training there’s not the crowd there. There’s not the cameras there. The scrutiny is not the same, whereas the athletes know that in a real life match situation, there’s, many of the factors which, which can actually distract them from performing at their best.

When they’re thinking about all these other factors my, my earliest research was with international adolescent golfer. So that’s one thing that came and came out from this research is that they. In a, in practice situations, they’re much more relaxed and because there’s no consequences, but when they got into the competitions, they’ll be thinking about all the factors, the selectors watching, the impact it would have on their career, how they were performing.

And these all the multitude of factors which are prevalent during competition, but not during training.

[00:05:47] Mat: So I guess in a medical world, I can see there that sometimes people will do practice things or they’re going to do stuff on simulators or in the sim suite or on models, and they’ll do things at a certain level.

And then when it comes to actually doing it with patients then it’s for real. And I guess an even more. Extreme example there would be that it may be if you’re doing stuff without a consultant or without a GP watching versus being assessed because all of our doctors have workplace based assessments.

So sometimes they might be doing procedures by themselves and they’ll do it to one standard and then somebody watches them and this assesses them. So that raises the stakes. And maybe even the next level up then would be exams where, people are doing a job day in, day out, but then they are required to demonstrate that in an exam or in an interview setting and that adds.

another level of pressure. What kind of pressures do people typically talk about? And, you mentioned that having to perform or other people watching. So tell me about what is it that makes a situation stressful?

[00:06:51] Adam:  . So I’ve conducted research with quite a lot of international rugby union players.

Some of those are played at the highest level. So within rugby every four years we have the best players in England, Ireland Wales, Scotland, all come together to form what’s known as the British and Irish Lions. So they’re the very pinnacle of the players. And I’ve, been fortunate enough to conduct research with them, players from the New Zealand All Blacks.

The most prominent stressors among these sorts of players relate to mistakes, and we categorize the mistakes into physical mistakes, so that would be throwing a poor pass, missing a tackle, and also mental errors, or well, mental mistakes, so that would be making the wrong selection. And they account for around, I think it’s around 50 percent of all stressors that these athletes encounter.

So we, we monitored the, done several diary studies where we monitor the players for, around the month where they do stress and coping diaries every day. And it’s, these are the biggest stressors. Coach criticism is one of them, but it’s not as high up as the mistakes. It’s the mistakes that really impact them.

As they get more experienced, they’re also less concerned about what their opponents are doing. It’s purely about these mistakes. Okay. And also injuries, but that’s, rugby is a high contact sport, lots of injuries. So  , but that’s, they’re the top three stressors.

[00:08:16] Mat: So it’s interesting because I would wonder that people are particularly worried about what everybody else thinks.

But actually, what you’re saying is people are worried about a mistake that they might make. And presumably they haven’t made these mistakes. They’re just worried about. making a mistake.

[00:08:30] Adam: It’s probably both. There’s some mistakes that have happened. For example, a missed tackle or also there’s a few players have spoken about, when there’s a kick-off, it’s about dropping the ball.

But it does relate to the people though, because In rugby union performance analysis is very big now, team meetings and some of the players have often spoken about they’ll make a mistake that’s occurred and they’ll be thinking, Oh God, I’ve got to go through this team meeting on Monday now or Tuesday now.

I know the coach is going to bring this up. I’m going to have to sit through watching this mistake in front of all my teammates. So I guess they’ll be less concerned about dropping a ball in training because, there’s no cameras, there’s no crowd there. But in the match situation, there’s more on the mistake.

And interestingly, now you hear about, I’m really passionate about listening to high level American coaches in collegiate sport and also professional sport. One thing they talk about now is about being a good teammate and Not letting one mistake impact what you do for the next four or five, plays that you may be engaged in.

So it’s about shutting down and blocking out those mistakes.

[00:09:43] Mat: I was going to ask a little bit more about the role. of the team, because I would have said, the team’s there. It’s a bit of a funny one, because the team’s there to support you, but you’re also accountable to the team, aren’t you? So it’s a slightly strange relationship with the team.

Can you tell me a little bit more about the role of the team when it comes to performing under pressure?

[00:10:03] Adam:  , I think, The role of the team varies depending upon the environment in which you’re playing in. For example, in a, in an environment where there’s a kind of a high task focus, there’s lots of cohesion, then the team is, it can have a much more positive influence.

Where if you’re in a team sport, because if you make a mistake, you’re going to be encouraged by your teammates. You’re going to be supported by your teammates. You’ll be supported by your coaches. However, having done researching with team sport athletes who are not in those environments, actually the fear of making mistakes is much higher.

The anxiety is higher because that they feel, less, less secure in the environment, less psychologically safe. Which then actually can contribute to them making more mistakes because of this, they become more distracted, which is, which can link to reduce performance

[00:10:55] Mat: under pressure. So now I’ve got to ask then if you have two teams, and one’s a really supportive team, and one’s a really judgmental team.

And I’m thinking, okay maybe the supportive team, yes, they’re very supportive and encouraging. But are they really pushing each other? Whereas the team that’s judgmental, they’re really holding to account. They’re pushing each other to deliver. Is there any research out there that’s examined that?

And do we know which of those two teams would actually achieve better?

[00:11:26] Adam: Even though you’re still you’re supporting each other, you’re still pushing each other to improve. So the emphasis, even in a supportive environment, is about pushing each other to improve and putting as much effort in as possible.

Now, we know in elite level sports that The they prefer both the pushing each other, the effort to improve, but also competing against each other. So I don’t think, I’m not aware of any research which has looked at the kind of team performance in those environments but when I work with coaches and performance directors, one thing I’m really passionate about, and one thing I think is important is about the communication between athletes.

And I don’t want, I think it, I don’t think it’s good that teammates are swearing at teammates if they drop a ball or berating them because actually that causes you know negative feeling but also actually distracts them from what they should be doing you know 10 seconds later they might be expected or required to catch the ball again or you know execute a difficult movement so  , I’m very much in favour of this, the supportive approach, but equally, elite level, they are there to perform and they still should be pushing themselves, but just not after having made mistakes.

I think there’s a time and place for that and it’s not in the middle of the performance.

[00:12:52] Mat: I hope you’re enjoying the show. If you are, please click subscribe so you will be notified when new episodes come out. This podcast is part of my mission to help doctors create successful and meaningful careers.

You can be part of that mission too by forwarding this show to any one person who you think might benefit from listening. Thank you. Now on with the show.

So if you’re in the middle of doing something, and maybe if I think of that, say you’re in the middle of an operation or in the middle of a cardiac arrest, in, in a medical setting and somebody makes some mistakes that isn’t the time to have a go at them because then the whole team falls apart and whether you like it or not you still need that team member with you for the rest of the procedure you know because unless you have the capacity to replace them there and there which you won’t you’ve got to have that person with you but the time to discuss performance then is after in the cold light of the day rather than in the middle of you know of a match or an operation or a cardiac arrest.

[00:13:48] Adam:  , and sometimes when you’ve calmed down as well, when everyone’s calmed down, but one thing I really like in terms of this performing under pressure is in training is about creating highly pressurized situations. But also giving the athletes the tools to be able to try and deal with that situation.

So coping strategies. So what I like to do as a sports psychologist when working with teams and players is teach them coping strategies. And allowing them time to practice those in situations which are similar to matches, but they don’t quite have that pressure. And then they can learn. Which things work for them, which things don’t work for them, and then take them into matches.

I call, we call that coping effectiveness training. We found, we’ve tested that with Premier League Academy soccer players. And it’s actually been really effective in helping them. But I think in the past, within sports settings, it was all about creating pressure and intensity. But not giving the athletes the resources to try and be able to manage that stressor and the stressors.

And I think that’s really important in terms of developing mental toughness and resilience. So it increases our ability to be able to perform under pressurized situations, under stressful situations, which is what we want. So

[00:15:04] Mat: How do you then create sort of those pressure situations?

Because I imagine, you’re not going to take in. a 12 year old and put them into an incredibly pressurized environment. So can you give me some examples as to how does that pressure ramp up during the course of somebody’s training career?  .

[00:15:21] Adam: So there’s a really good study with the England under, I think England Academy players, they’ll be under 18 players.

So what they did, they have performance drills and there were consequences for the performance drills if they didn’t perform well. So it’d be. extra fitness training tidying up the rooms extra drills. So they knew if they didn’t perform to a certain standard, they would, there will be a consequence.

Now the consequences aren’t severe. They’re not. It’s something that the athletes would worry about, but they’re still there. they would be scrutinized, so they’d have video cameras on them. So just lots of little things, which actually could be a distraction. But it also gave them an opportunity to use the strategies.

So different increasing concentration strategies, deep breathing strategies, relaxation strategies, and just this being exposed to and trying to handle the stress and handle the pressure on the stressful situations.

[00:16:23] Mat: So in medical world, I can see that that, how we could do that.

Certainly, having a workplace based assessment, that introduces an element of stress. I think that the problem that I think that we do, or maybe some people work differently than me, but if I think how I would work is there’s an assessment and that’s it.

And there’s not. There might, you might be assessed on different elements or different procedures but it’s still exactly the same assessment, whether you’re a brand new doctor or whether you’re somebody who’s about to complete their training. So maybe one of the things that I could do is I need to minimalize the consequences for somebody who’s the beginning and then somebody who’s coming towards the end, I can add in.

additional sort of stresses and that might be patient complexity or it might be, feedback from other team or it might be how helpful, let’s say in a procedural setting, if you have an assistant, how helpful an assistant is, as in a stressful situation would be having an assistant that doesn’t know what they’re doing, who not very helpful.

And I’m wondering something about timing there.  . I am wondering if I could get away with saying that that they have to wash my car if they don’t perform very well but sadly, Adam, I don’t think I’d get away with that!

[00:17:29] Adam: But I fully agree on this, about this increasing the level of challenge and the level of difficulty as the individual, whether it’s a doctor or athlete improves.

So you are constantly We have comfort zones. You’re constantly getting them towards the edge of their comfort zone. Because if you had this, for example, in the sports situation, if we sell the same challenge, difficulty and same consequences for an elite athlete and a, an academy athlete, the academy athlete will be.

really experiencing some level of discomfort, some level of distress, whereas the elite athlete wouldn’t. And the purpose is to increase this level of discomfort and distress in the, in a safe environment. So  , it’s, I think that’s definitely really important to have this increased challenge for the more competent people, whether it’s doctors, athletes, or in any situation, I think that’s so important.

[00:18:25] Mat: It’s perhaps also. articulating that because as I say, maybe there are people out there that do stuff very differently to how I work, but it’s probably, until our discussion, I don’t think that’s a concept that I’ve thought of. But equally, I think it’s something that, that I would need to explain to the people because then otherwise people can think in a second, last time it was easy, when now you throw in all of these things at me and it’s recognizing that’s deliberate, that as you.

as you progress. So if I think people typically they rotate with me for six months and at the beginning they don’t know very much of what I do and by the end of the six months they’re really good at the subspecialty that I do. But it’s also recognizing that during the six months that the challenge is gradually.

Going to ramp up and that’s deliberate.

[00:19:10] Adam: it’s really important to mention that because there’s been some research has shown that within sport settings that if you have these consequences, these challenges, it can be perceived as being bullying.  . So by explaining at the start of the rotation, this is how I work, this is what I’d like to do.

And this is why it would benefit you as a doctor, because I’m going to test you. And as, as you get better, the tests will become slightly more difficult. The challenge would be more difficult, but actually that’s making it much more realistic for when you’re going to practice yourself. And as long as you have that dialogue explaining why and the purpose of that, I think that’s, that’s important.

And it’s crucial.

[00:19:49] Mat:  , you’re right, actually, because otherwise what would happen, there would be an early career trainee that would come and I wouldn’t particularly apply pressure and then there’d be a senior trainee to say You know with the other person, you didn’t do x y and z and you gave them more time And why are you not giving me time?

And if that isn’t explained then people won’t understand that’s actually you know, that’s part of the learning progression that as you are a senior trainee the pressure, the complexity of the procedures and patients increases when it comes to assessments but also the pressures under which you work increases.

So the two different things under, the task complexity, and then there’s the pressure complexity, and they’re not the same thing.

[00:20:28] Adam: And then you as a, as anyone, as a coach, as a leader can manipulate that dependent upon the skills of the individual you’re mentoring and supervising. Some people will be very good very soon and they can increase the task difficulties or the pressures or one or the other.

but I think that’s one thing that’s really important.

[00:20:47] Mat: So tell me a little bit more then about the role of the coach, the trainer, the educator, how do, how can, how did they help somebody develop the ability to thrive under pressure?

[00:20:59] Adam:  , I think So I wrote a book on that, The Psychology of a Sports Coach, and what is it called now?

Theory and Practice, that’s the one. It’s on to the third edition of that, and that’s a book purely for helping coaches apply psychology within the sport environment. And they play a massive role for a number of different reasons in terms of, they can teach their athletes mental skills, so they can teach visualization, they can teach coping, effectiveness, training, mindfulness, or a whole variety of skills.

But also, they can shape the environment in which they work, in which the athletes are expected to perform under. So the thing that, one thing I’m really interested in now is about coaches fulfilling the basic psychological needs of athletes. So we all have needs. And our three needs are the need to feel autonomous, so control over what we do to some extent, the need to feel competent, so effective in what we’re doing, and also the need to feel cared for.

So as coaches, I think it’s important to create an environment in which those three conditions are met because individuals and athletes will thrive under those situations. They’ll be more intrinsically motivated, they’ll perform better, they’ll be happier, higher levels of well-being. And I think this is one thing that.

When I look at a lot of the American coaches and I read and watch videos about their comments, I think that’s one thing they get so, they do so well, or some of the top ones do so well. I’d probably say it’s less so within the United Kingdom. I don’t think we’re quite there yet. And that’s one thing I hope will come in overtime and with education

[00:22:34] Mat: So the. Can I pick up the competence? Yes. So how does that play? Because, if somebody hasn’t got the skills, how can you presumably, the trainee or, whether that’s sports medicine, whatever, they need to feel competent at what they do.  . But if they haven’t got the skills how can I help somebody feel competent if they haven’t got the skills?

[00:22:58] Adam: So I suppose, first of all, it’s about increasing that skill level, and that comes from feedback and communication. I Always think that we do need to enhance people’s competence, that feeling of that, but also we need to be honest as mentors. And that’s one thing I, as a mentor at work, as a leader at work, we do have to be honest about people.

But it’s the way in which we deliver that feedback. I think the feedback should always be constructive. So what is it that an individual needs to work on? Whether they’re a doctor, an athlete, or an academic, what are the things they need to work on to become better? How do we manage that? How do we monitor that?

These are all crucial steps. And then, but then if we’re trying to enhance competence, what are the things they’re competent at? What are the things they’re effective at? Hopefully there’ll be some things that we can pick out that they are good at, but equally still working on our, on the weaknesses to develop those and get better.

[00:23:52] Mat: So what I’m hearing in you is there’s then there’s finding out what they can do as well as what they can’t do because. I don’t know, I don’t know what it’s like in sport, but in medicine, I think largely we look for things that people can’t do. I don’t know whether it’s the same in sport.

.  .

[00:24:07] Adam: And I think, again, that’s another thing that American coaches get right. It’s about what, so you, as an individual. As an athlete, as a person, or you might have these, four or five weaknesses, but actually your strengths are probably what got you selected for the team. Your ability to do X, Y, and Z, your ability to do this.

So we need to work on those as well. So we need to build on strengths because sometimes if we focus too much on our weaknesses, the things that we had as strengths might go or might. diminished. So I think it’s both. It’s about praising people for their strengths, acknowledging their strengths, developing their strengths, but at the same time, working on the weaknesses.

And I think that’s, I’m not sure that’s a UK thing in sport about just working on people’s just a focus exclusively on people’s weaknesses. I know in sports it is when you hear coaches talk about why they didn’t or did select players. And the reasons often is about they just talk about their limitations as a player.

Actually, everyone has limitations, but also what are their strengths? And sometimes I think we should need to be more strength based personally.

[00:25:16] Mat: suspect there is a bit of a cultural element there, because I think, in, in UK, so I didn’t grow up in UK, but my perception of UK is that people are very quick to, people are very self-depreciating and people are very quick to criticize themselves, to point out their own weaknesses.

And as a society, most of us are not very good at showcasing what we’re brilliant at.  . Whereas if I think of the time when I’ve been, professionally, when I’ve been in US I’ve always been. I’ve been astonished by how quick people are to tell you how brilliant they are. And in UK, you’d never been a lift with somebody telling you, I’m the most amazing ex, I have the biggest practice, I have the best, we just wouldn’t have those conversations.

Whereas, in the US, yes, you go into a lift and, and people, straight away, people will tell you, how big the practices are, how much money they earn, how many papers they’ve published, what accolades they have, a thousand medals, every single letter after the name they’ve ever learned features.

So I think there is a bit of a cultural difference.  , there is.

[00:26:17] Adam: I suppose there’s also a balance, isn’t there? But if you imagine if you’re, you’re in that society in America where everyone is it’s unlikely you’re going to have problems. With confidence, isn’t it? Whereas you’re in England or UK or a country where there is this, people get criticized for their weaknesses.

It’s probably always going to be that feeling of never ever being good enough because you’ve always got to worry about something and that can hold you back, I think, as a performer.

[00:26:42] Mat: Though I do wonder in the US, if everybody’s brilliant, or maybe this is the British part of me that’s speaking.

I think I would feel quite inadequate surrounded by everybody else. Who’s brilliant. But maybe that’s a British mentality transposed into American society thinking, gosh, I’m so inadequate and all of these people are amazing.

[00:26:59] Adam: But then you will be brilliant in areas that you just made, I’m sure there’ll be other people who think you are brilliant at this.

You’re brilliant at that. You wouldn’t feel confident saying that.  . And sometimes it is about acknowledging your strengths, not just thinking about, Oh, what am I bad at? It’s actually, these are the things I’m really good at and, I can make a difference in these areas.

And that’s one thing I try and work with the players and get this into them at this, because when you’re in stressful situations, if you’ve got doubts about your own ability to perform, that’s not a good thing. Whereas actually, if you think about, I’m good at this,  , I’m really good at this.

And actually,   that’s a good thing to have

[00:27:35] Mat: So I think what I’m hearing from you is there needs to be a realistic sense of appraisal. This is what I’m good at. These are my strengths and this is what I need to develop. And if you have one without the other, you’re not going to be a top performer.

[00:27:50] Adam: Regardless of what situation you’re in. And if you are, an elite level of any industry, medicine, sport, business. You are going to have super strengths. You are going to be brilliant in lots of different areas. And it’s about,  , thinking about that and acknowledging that and developing those strengths and just, and  , accepting those and, being positive and being grateful for those strengths.

[00:28:14] Mat: Let’s go back to the individual athlete then that, that’s, about to face something that, that’s very challenging. The people that, that struggle, what, what happens? You’re trying to perform under pressure in a competition and it’s just all falls apart.

And I think most of us will have witnessed that it’s usually hits the headlines. So what happens in somebody’s psychology?

[00:28:36] Adam: so generally it can actually start, before the performance has started and we, there are two mindsets, but this is based on the biopsychosocial model and two mindsets.

So we can have a threat or a challenge mindset. So a threat mindset is when the individual focuses or thinks about what can go wrong in a particular sport and performance. So it might be, they’ll be worrying about. So things that could go wrong, not being able to perform at their best, they’ll be concentrating on all the negative things and this has implications for our physiology in terms of cardiovascular output, our blood vessels They, and then also we’re, so I’ll just talk about the challenge state.

That’s when you focus about, think about what you want to make right, what you want to happen, what will go right. And that has implications, so your blood vessels dilate, so the blood flows more frequently around the body to the muscles, to the mind, which has been shown in research. And that’s the mindset that’s associated with superior performance.

There’s lots of studies that have shown that if you can generate the challenge states, then you’re much more likely to perform better. So I participate in Brazilian jiu jitsu. I’ve competed at the British Open a few times now, and I’m aware of these. So in Brazilian jiu jitsu, we have what’s known as the bullpen.

So you stand in this, you get weighed and you stand in this. Cage. It’s not a cage. It’s not caging at the top, but it’s an area where you’re not allowed to leave until you get called out for your match. And now I’m in that area. Now I can generally, I can think about what could go wrong in my up and coming match.

Am I going to get am I going to lose in the first 10 seconds? Things that could go, I could get injured, which would be a threat state. But I know that for me to perform at my best, I’ve got to be creating a challenge day. So I need to be thinking about what I want to happen, what I want to go well.

I need to be thinking about all the times I’ve practiced and things have gone well, and how I’m going to implement what’s gone on in practice to my upcoming competition, which is this challenge day. So it’s so important that we generate these. What’s known as challenge states and the best ways to think about that is or how to do that is to focus on, three or four things that you want to go well, thinking about all your preparation that you’ve done.

And so if you’re a surgeon, a doctor, it’s the number of times you’ve engaged in a particular task and actually not. It’s sometimes, it’s hard to do this is not to focus on the negative but realizing that focusing on the negative consequences is not going to help you. So going back to my Brazilian Jiu Jitsu, it’s not going to help me thinking about, I might get injured in the first 10 seconds.

It’s not going to help me thinking about, I might get tapped out, which is where you submit to the person. That doesn’t work. It’s not. So I need to be shutting out and blocking those negative thoughts out and focusing on, key thoughts and key strategies of a performance plan. And that’s the mindset, which is about performing under pressure.

It’s generating challenge states.

[00:31:49] Mat: So this is fascinating for me, because what you’re saying is that your mindset changes your body physiology. That’s fascinating, isn’t it?

[00:31:57] Adam: it really is. And also, emotional responses,  , it really does.  , there’s been some quite recent studies on that,  .

[00:32:06] Mat: What’s the role of preparing for the worst then? Is the role of preparing for the worst, you do that in the cold light of day, you do that, weeks and weeks in advance, you consider different permutations, what would you do if X, what would you do if Y, but in the moment, isn’t the time to think about all the possible permutations.

[00:32:24] Adam: Because in the moment you’re thinking about, you’ve got a solution for these things. For example, I know if that goes wrong, I’ve got the solution for that. If that goes wrong, I’ve got the solution for that. So you’re still generating a challenge mindset because you’re confident in that whatever happens, you’re going to be able to handle that situation.

You’re going to manage it because of your preparation, because of your, your practice time, your, the drills that you’ve done. And that’s when you should take confidence from all your training because you know that you’re ready for that particular performance.

[00:32:56] Mat: Okay,

[00:32:56] Adam: so it’s hard to do it, it’s not easy to do, I’ve, I’ve done the British Open a few times now and it’s not hard, it’s not easy to do, but I think with practice you get better and better at doing it.


[00:33:07] Mat: the journey then is that there’s some, there’s stuff that’s away from the event itself,  , which is around preparation, around thinking, around practice, around, reading. simulators, considering the different options, thinking about worst possible scenarios, how do I get out of x, y, and z, who are my friends, what do I do if so and then, in, in the moment you’ve thought of all of that, you’ve thought of the different permutations, and then that means that in the moment you then You’re then not worrying what effects because, because you’ve already thought about what effects.

. So in the moment, you can focus on this is what I’m going to do. This is what I need to achieve. And, if it doesn’t work, how, because you’ve already thought about it, you practice your, your things. And, even if one of those in sport, it might be you’re not going to win the competition and, in, in a medical setting, it might be.

You’re going to need to call for help, or that’s going to be everything that anybody can do for this particular patient, because that happens also, or in a surgical setting, it might be that that, that you close and bail out and you say, this is not an operation that can be done.

And they’re not great outcomes but they are outcomes that happen.

[00:34:11] Adam:  . And you’ve got a plan. I heard this coach say pressure is something that pressure is something only felt by people who don’t have a plan or don’t know what they’re doing. If you’ve got a plan, even if they’re not good outcomes, you still know in that situation, you’ve got a plan of what you can do.

And I think it does help you just focus a bit better on what you are doing and focus more on the process. If you’re just worried about these little things.  ,

[00:34:34] Mat: so can you give me some more sort of tips and strategies around how people can prepare, how people can get ready for that moment where all the pressure piles on?

[00:34:47] Adam:  , I think it’s, one thing I would do is, I think is really good is visualization. So if you’ve got a big day as a doctor, as a surgeon, as an athlete is about preparing for that before you go into that scenario. So maybe the morning of traveling to work or the morning when you’re at home is visualizing the situation, visualizing the different things that could happen, but ultimately seeing yourself accomplishing a, Or see yourself dealing effectively with any stressful situations that can occur.

I’m a big believer in visualization and I know a lot of the, the real elite athletes, they all naturally engage in visualization, often without, being told to do that. And it just allows your mind to get ready and prepared for what’s to come up. Michael Phelps, the Olympics, multiple Olympic gold medal swimmer, he would always visualize things going wrong.

But then equally, he would know how to deal with that. And he said about one time he had visualized how his goggles might break. And that did happen in Olympic final or one of the Olympic qualifiers. And it wasn’t a stress for him because he already knew what he was going to do. He’d prepared visually he’d get engaged in visualization, mental imagery.

So actually when it did really occur, it wasn’t stressful. He knew what he had to do. And I think that, that will be a top tip, I think, or a tip.

[00:36:12] Mat: So I’m wondering whether people do that. Cause I think as you described that, so I do that kind of stuff. I think if you’d asked me to explain it, I don’t think I would have had the language quite eloquently to explain it.

Because I would have said, somebody said, how would you do? So I don’t know, I think about it. But you, you’ve made it much more, I would say, why do you do I just think about it, but actually what I do is what you’ve described. So if somebody is out there, let’s say a very early career doctor who’s thinking, I have no idea what they’re talking about.

So how would you instruct somebody in visualization?

[00:36:45] Adam: So what I would do is, they’re all actually different types. So in the past, it would be, you sit down in a bed or a chair and you close your eyes. Actually what they’re saying now is that you should use more of a physical approach to engaging imagery.

So if you’re holding the tools you might use or, and actually planning out what you think could happen, trying to close your eyes and you can see it from your own eye. Of what you’ll be looking at. Or as a camera in the room. And playing out different scenarios and thinking through in your mind.

And it’s also best to try and make the images as vivid as possible. So using as many senses, so not just sights, but also sounds that might be going on the smells of a, of an operate it’s in theatre or surgery, any noises, making it as vivid as possible. Any communications you might have with people and just.

Trying to make the imageries and the sounds as vivid as possible and spending a few minutes at a time going through these different scenarios that you might be worried about. And we know that with imagery, it’s some people have a more of a natural ability than others, but with time and practice, you can get better at it.

better images. I wouldn’t prescribe either, either the internal imagery where you’re looking through your own eyes at a situation, say as an operation or the camera filming the operation. It’s up to you. Some people find the internal imagery easier. Some people find the video camera external injury easier and just spend time practicing it.

It’s not some people, it might not come straight away, but just,  , five or 10 minutes a day, or in the build-up to something that you might be anxious about. One thing we do know is that some elite athletes talk about using imagery up to three months before an Olympic. So Virat Kohli, the Indian cricketer spoke about how he would often use imagery.

At least three months before going on an overseas tour to England or Australia. And he would see himself, out there imagining about against some of the bowlers he would be up against and actually outperforming them in his mind. So that when he came to the matches, he was doing nothing that he hadn’t done before in his mind.

I think that’s the key.

[00:39:01] Mat: That seems like a great place to finish, so I wonder if I could invite you to maybe summarise and try and pick out what your top tips would be for a doctorate work when it comes to working under pressure.  ,

[00:39:13] Adam: I think, so first and foremost is to create this, the challenge mindset, which we’ve spoken about today.

Perform, when you’re going through simulations, practicing, training, try and have this element of pressure there. So you get used to performing under pressure, deploy coping strategies. Logically analysing situations, deep breathing techniques. And again, use those in training situations.

Don’t be afraid to speak to your mentor and ask for advice. Ask how you can improve. And that’ll probably be, that’ll probably be it really.

[00:39:48] Mat: Wonderful. Thank you very much, Adam.

[00:39:50] Adam: Thank you. Cheers. Thank you.

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