REBEL Cast

🔑 Key Points

• 🎮Gamification in medical education can deeply engage learners and improve clinical skills.
• 🕹️Rapid Sequence alternates between game blocks, where learners act in clinical scenarios, and teaching blocks, where insights are shared.
• 📈True expertise is about developing effective cognitive strategies, not just accumulating knowledge.
• 🧠Building mental models involves not just learning, but practicing decision-making in complex environments.
• 🌐The learning environment should foster psychological safety and encourage growth through reflection and feedback.

📝 Introduction

Welcome back to Rebel MIND, the podcast where we sharpen the person behind the practitioner. MIND stands for Mastering Internal Negativity during Difficulty. This series emphasizes productivity, provider performance, and team optimization to ensure we are at our best during high-pressure situations.

In this episode, we introduce an innovative teaching tool called Rapid Sequence, aimed at revolutionizing how clinicians learn critical care through gamified experiences. With host Dr. Mark Ramzy, we invite Drs. Sarah Crager, and Ryan Ernst, to explore what it takes to become an expert and how gamification can transform learning in the medical field.

🤔Cognitive Question

What does it truly mean to be an expert in emergency and critical care medicine?

⁉️What Is Rapid Sequence??

• It's a gamified clinical case simulation tool consisting of different "blocks" where you have individual learners that can work through cases in non-multiple choice format.
• You're basically working on shifts, seeing multiple patients with your team.
• There's a cast of characters, interruptions, distractions, and you enter orders just like you would as if you were on shift, and then the cases advance to see the outcome of your decisions, good or bad
• For more information check it out the Rapid Sequence website here. Use the following Promo Code: REBEL2026 at checkout page to receive a 20% off coupon

🏃🏽‍♂️‍➡️Learning Must Be An Active Not Passive Process

• An important part of the process when acquiring new skills or information is making it an active process
• It is not just passively listening, but actively participating, providing answers that aren't multiple choice, and then responding to the outcome
• This provides the engagement, and increases both the comprehension and retainability of new concepts
• When you then apply those same concepts in future times of questioning (or in Rapid Sequence's case "Blocks") it helps expedite active recall through spaced repetition

🏥How This Applies to the Emergency Department or ICU?

In high-stakes environments like the ED or ICU, clinicians must make fast, informed decisions often without complete data. Rapid Sequence provides a simulated space where clinicians can make mistakes without risk to real patients, receive feedback, and build the cognitive resilience needed for actual shifts, mirroring the chaotic nature of these departments.

⏩Immediate Action Steps for Your Next Shift

1. **Embrace Gamified Learning**: Engage with or seek out platforms like Rapid Sequence that offer a practice ground for real-world medical scenarios.
2. **Develop Mental Models**: Start by breaking down complex cases into mental models that you can refer back to during your shift.
3. **Prioritize Feedback and Reflection**: After each shift, allocate time to reflect on decisions and seek peer feedback to refine your cognitive strategies.
4. **Foster a Safe Learning Environment**: Encourage open discussions in your team where all members can express uncertainties and learn from one another.

💬Conclusion

Embracing innovative teaching methodologies such as gamification can lead to significant improvements in clinical education and practice. By integrating tools like Rapid Sequence in training, healthcare professionals can not only enhance their skills but also foster a culture of continuous learning and psychological safety.

🚨Clinical Bottom Line

Effective medical education isn't about rote memorization—it's about developing the ability to think critically and adapt rapidly in ever-changing environments. Gamified tools offer an engaging path to achieve true expertise, ensuring clinicians are well-equipped to provide the best patient care possible.

📌 Key Points

• 🧠 Mastery Learning: A unique educational framework focusing on achieving high competence with minimal variability among learners.

• 🔍 Deliberate Practice: Involves learner-driven improvement, guided by expert feedback and breaking skills down into micro steps.

• 🦺 Psychological Safety: Essential in mastery learning, allowing open feedback without fear or shame, enhancing growth. Embrace the productive struggle!

• 🔁 Practice to Prevent Skill Decay and Improve Clinically: Application of mastery learning principles helps maintain high proficiency levels in both common and rare procedures.

📝 Introduction

Welcome back to Rebel MIND, the podcast where we sharpen the person behind the practitioner. MIND stands for Mastering Internal Negativity during Difficulty. This series emphasizes productivity, provider performance, and team optimization to ensure we are at our best during high-pressure situations. In this episode, host Dr. Kim Bambach chats with master educator Dr. Jennifer Yee about the science of performance through mastery learning and deliberate practice.

Jennifer Yee, DO is an associate residency program director for OSU Emergency Medicine, the OSU EM director for assessment and evaluation, and an associate professor of emergency medicine. She is from Akron, Ohio and earned her bachelor degree from Ohio University and her medical degree through the Ohio University College of Medicine. Her residency training was completed through Summa Akron City Hospital. After serving as chief resident, she completed a simulation medicine fellowship at Summa.

She completed Northwestern's Designing and Implementing Simulation-Based Mastery-Learning Curricula, as well as Ohio State's Master of Art's program in Biomedical Education. She established a mastery-based procedural curriculum for OSU's EM residency program before creation of an institution-wide mastery-based central venous catheter (CVC) curriculum for all housestaff expected to place CVCs during their clinical training.

🤔 Clinical Question

How can mastery learning and deliberate practice transform traditional medical training to improve both competency and confidence in clinical settings?

🏥 What is Mastery Learning?

Unlike traditional clinical training, which is time-bound (e.g., "you are competent after a 3-year residency" or "after 10 chest tubes"), Mastery Learning is outcome-bound. The goal is to get every single learner from their unique baseline to an identical, objectively high level of performance with minimal variation. In this framework, learners start with a pre-brief, followed by baseline assessment, targeted debrief, deliberate practice, and a final evaluation using a checklist with a strict minimum passing standard (often set via methods like the Mastery Angoff). The mastery learning framework has been shown to improve patient safety.

• The Northwestern Central Line Study: Research demonstrated that requiring residents to achieve a set benchmark on a simulator prior to clinical performance led to fewer needle passes, a decrease in mechanical complications (such as accidental arterial punctures), and a subsequent reduction in catheter-associated infection rates in the intensive care unit.

• High-Acuity, Low-Occurrence (HALO) Procedures: Studies have demonstrated that for rare, critical procedures like emergency cricothyrotomies or transvenous pacing, baseline testing shows that very few trainees can meet a standard passing score initially. However, following targeted simulation training and deliberate practice, 100% of participants successfully achieved the minimum standard required to perform the procedure competently.

🎯 The Anatomy of Deliberate Practice

• We often assume experience or confidence equals competence, but humans are notoriously poor self-assessors (plug for our Dunning-Kruger episode!). True deliberate practice isn't just repeating a task for 10,000 hours; it is purposeful, learner-driven micro-skill improvement guided by an expert coach.

• High-Quality Feedback: Avoid vague phrases like "good job" or "read more." Effective coaching relies on strictly objective, real-time observations (e.g., "I am watching your needle angle. If you enter the skin more steeply, you will hit the vessel faster").

• Embrace a Growth Mindset: Stripping away your ego to be silently watched and critiqued is inherently awkward. Normalize deliberate practice to create psychological safety. Overcoming this requires building an environment centered on patient safety, where baselines are treated as data points rather than judgments. True growth happens with the "productive struggle".

• Adaptive Expertise: True mastery means moving past a rigid checklist. It requires learners to understand the reasoning behind their actions and anticipate next steps, complications, and plot twists in real time.

✨ How this Applies to the ED/ICU?

In high-stakes environments like the ED or ICU, where quick, accurate decision-making is critical, mastery learning transforms training. Unlike traditional methods that rely on quantity of practice, it emphasizes quality, ensuring practitioners can handle rare, complex procedures proficiently. This method encourages breaking down tasks into manageable steps with feedback from expert educators, moving beyond the "see one, do one, teach one" approach.

⏩ Things You Can Do on Your Next Shift

1. **Reflect on Personal Goals**: Identify specific clinical skills you wish to improve and set objectives.

2. **Seek Expert Feedback**: Find a mentor or coach for guided practice and objective feedback on your skills.

3. **Cultivate Psychological Safety**: Foster an environment where discussing mistakes and receiving feedback is viewed as growth rather than criticism.

4. **Practice Adaptively**: Introduce scenarios with atypical anatomy, complications, plot twists to better prepare for real-world complexity.

💬 Conclusion

By focusing on specific skill improvement and welcoming constructive feedback, clinicians can build competence and confidence, ultimately improving performance and patient safety. Effective mastery learning hinges on creating psychologically safe learning environments, engaging in focused deliberate practice, and leveraging expert feedback. This approach can be applied to clinical procedural excellence as well as many other skills, including communication and team dynamics.

🚨 Clinical Bottom Line

Mastery learning is an outcome-bound framework to reach a high standard of performance and deliberate practice is the tool that can help you achieve that high performance through expert feedback.

📚Further Reading and References

1. Barsuk JH, Cohen ER, Potts S, et al. Dissemination of a simulation-based mastery learning intervention reduces central line-associated bloodstream infections. BMJ Quality & Safety. Sep 2014. PMID: 24632995

2. Klein MR, Loke DE, Mitchell ME, et al. Developing simulation-based mastery learning curricula for emergency medicine skills training. AEM Education and Training. Jun 2025. PMID: 40521339

What Is Nitrous Oxide?

Nitrous Oxide (N2O) is a colorless, odorless inhaled anesthetic that has been used for centuries, particularly in the surgical world. Mechanistically, it can induce euphoria, anxiolysis, and intoxication via NMDA receptor antagonism.

During the late twentieth century, nitrous oxide was increasingly used recreationally due its accessibility and perceived benign nature.

The modern day slang term for nitrous oxide is "whippets" – which tends to refer to the canisters that contain this agent and are frequently used as whipped cream foaming agents.

Despite the legal nature and benign perception of nitrous, frequent use can lead to lasting and permanent neurologic effects.

How Nitrous Oxide Causes Toxicity

Nitrous oxide toxicity results from its ability to oxidize the cobalt moiety in Vitamin-B12, thus leading to a functional B12 deficiency, despite adequate consumption and absorption.1

Functioning B12 is needed as a cofactor for methionine synthase.2 This enzyme has two critical roles:

The conversion of 5-methyl tetrahydrofolate to tetrahydrofolate; tetrahydrofolate is essential for the synthesis of our DNA.

And the conversion of homocysteine to methionine; methionine is needed to maintain the integrity of the myelin sheath of our axons.

As a result, nitrous toxicity leads to: a megaloblastic anemia and demyelination of both the dorsal columns and the lateral corticospinal tracts (also known as subacute combined degeneration).

Clinical Manifestations of Nitrous Oxide Toxicity

These patients will have a combination of both upper and lower motor neuron symptoms due to demyelination of the dorsal columns, lateral corticospinal tracts, and peripheral nerves. As a result, the following may manifest:

Dorsal Columns: diminished sense of proprioception, vibration, and fine touch.

Lateral Corticospinal Tracts: upgoing plantars, hyperreflexia, weakness of voluntary distal muscle control

Peripheral Nerves: numbness/tingling and weakness in a glove and stocking pattern (symptoms that start initially in the feet and hands that progressively spread proximally to the ankles and wrists)

Taking all of this into account, patients may present with difficulty ambulating, positive Romberg sign, dysmetria (difficulty with finger to nose or heel to shin), upgoing Babinski reflex, and decreased strength and sensation in a glove and stocking pattern.

How to Diagnose Nitrous Oxide Neurotoxicity

History is key! As with a lot of pathologies in toxicology, identifying the exposure will expedite management.

A thorough neurologic exam will narrow the differential – with a particular focus to fine, peripheral motor and sensory deficits, dysmetria, proprioception, and ability to ambulate.

Magnetic resonance imaging of the spine may identify enhancement and/or edema of the dorsal columns, specifically on T2 weight axial imaging – sometimes referred to as the "inverted V" or "inverted rabbit ears appearance."3

Serum B12 concentrations may be normal as the issue is with a functional deficiency as opposed to a vitamin absence. However, patients have elevated concentrations of both homocysteine and methylmalonic acid, both of which are metabolized in the presence of functional B12.

Management of Nitrous Oxide Toxicity

First and foremost, cessation of nitrous oxide abuse is crucial to limit/prevent toxicity.

While there is no universally agreed upon treatment regimen, supplementation with intramuscular B12 is recommended.

Approaches vary from daily or every other day injections until symptoms improve at which point injections can be spaced out to weekly and then monthly.

Physical and occupational therapy may be needed depending on the degree of functional debility.

It is important to note, that depending of the severity and chronicity of toxicity, some proportion of patients may not fully return to their baseline.

Take-Home Points

• Though legal and seemingly benign, nitrous oxide abuse can lead to permanent neurologic dysfunction.
• Nitrous oxide toxicity can affect the dorsal columns, lateral corticospinal tracts, and peripheral nerves.
• Thus leading to a constellation of both upper and lower motor neuron deficits, particular in a glove and stocking pattern: deficits in proprioception and fine motor skills, positive Romberg, upgoing Babinski, peripheral numbness, tingling, and weakness.
• Magnetic resonance imaging may identify symmetric high signal intensity in the dorsal columns.
• Treatment includes B12 supplementation and physical/occupational therapy as needed.

References

1. Long H. Chapter 81. Inhalants. In: Nelson LS, et al. Goldfrank's Toxicologic Emergencies. 11th ed. New York: McGraw-Hill; 2019
2. Shah K, Murphy C. Nitrous Oxide Toxicity: Case Files of the Carolinas Medical Center Medical Toxicology Fellowship. J Med Toxicol. 2019 Oct;15(4):299-303. doi: 10.1007/s13181-019-00726-x. Epub 2019 Aug 6. PMID: 31388940; PMCID: PMC6825085.
3. Schmitz ZP, Hoffman RS. Magnetic resonance imaging in a patient with nitrous oxide-induced subacute combined degeneration of the spinal cord. Clin Toxicol (Phila). 2023 Nov;61(11):1006-1008. doi: 10.1080/15563650.2023.2286205. Epub 2023 Dec 19. PMID: 38060330.

🔑 Key Points 🧩 Human Factors: The unseen behaviors, distractions and considerations critical in emergency medicine and the ICU, influencing patient care beyond just medical knowledge.

🎯 System Design: Effective system design directly impacts team performance by creating environments that facilitate optimal decision-making.

🏥 Real-world Application: The application of human factors in healthcare leads to better team dynamics, reduced stress, and improved patient outcomes.

👷🏽‍♀️It's Everyone's Job: Building a culture of adaptability and openness to change can lead to better healthcare delivery, communication and interprofessional relationships

🛠️ Practical Solutions: Start the conversation in departments for actionable and pragmatic changes to current healthcare environments to enhance practitioner efficiency and patient care quality.

📝 Introduction Welcome back to Rebel MIND, the podcast where we sharpen the person behind the practitioner. MIND stands for Mastering Internal Negativity during Difficulty. This series emphasizes productivity, provider performance, and team optimization to ensure we are at our best during high-pressure situations. In this episode, host Dr. Mark Ramzy chats with special guests and master educators about the concept of human factors.

Dr. Chris Hicks is an emergency physician and trauma team leader at St. Michael's Hospital in Toronto, Assistant Professor in the Department of Medicine at the University of Toronto, and co-founder of Advanced Performance Healthcare Design, a physician-led simulation and design group. Dr. Andrew Petrosoniak is an emergency physician and trauma team leader at St. Michael's Hospital, and Medical Director of the Unity Health Toronto Simulation Program. He's an Assistant Professor at the University of Toronto where his research focuses on simulation for systems and design improvement and optimizing the care of the bleeding patient. Along with Dr. Hicks, he's also President of Advanced Performance Healthcare Design, a consulting firm that works with high-performance teams and uses simulation to enhance and design better healthcare spaces

🤔Cognitive Question How can the integration of human factors improve decision-making and performance in emergency medicine and critical care environments?

⁉️What are Human Factors? In the context of healthcare, human factors encompass the interplay between humans, the systems they work within, and the effectiveness of their interactions. It includes elements like communication, system design, environmental conditions, and behavioral patterns affecting individual and team decision-making processes. It's the collective impact of individual behaviors, team dynamics, and the physical environment on performance and outcomes. The aim is to eliminate issues arising from human error by creating systems and environments that naturally guide and support optimal performance.

🏥How This Applies to the Emergency Department or ICU? - Efficient integration of human factors in high-pressure settings like the Emergency Department (ED) or Intensive Care Unit (ICU) helps mitigate the risks associated with stressful and chaotic environments. - By focusing on system designs that account for human behavior, healthcare professionals can reduce errors, enhance team coordination, and ultimately improve patient care. - This is crucial as teams are often required to make rapid, life-saving decisions in these environments - The design of clinical spaces can either hinder or help efficient care. Poorly arranged equipment or cluttered workspaces increase stress and impede decision-making. - Implementing structured design principles, such as dedicated equipment zones and clear visual cues, can streamline workflows and enhance team coordination - It actually helps pave the way for more efficiency because you end up "working smarter instead of harder". - It speaks directly to the Daniel Kahneman's theory of Type 2 Thinking – which is a slow, analytical cognitive process requiring deliberate thought - We'll likely create a whole dedicated episode to this but if you want to read more ahead of time on it, check out his book Thinking, Fast and Slow ⏩Immediate Action Steps for Your Next Shift **Assess Your Environment**: Take note of any clutter, noise, or layout issues in your workspace that could hinder optimal performance. Identify problem areas that could be optimized.

**Recognizable Hard-Stop** – Implement a "Stop-Point" Check for areas or issues that involve more than just patient safety (ie. workflow inefficiencies, sign-out, throughput, etc). Use predefined benchmarks during procedures to ensure clarity and efficiency.

**Foster Open Communication** – Encourage an environment where every team member feels comfortable discussing their thoughts and decisions without fear of judgment.

**Prototype Solutions** – Work with colleagues to identify problems and brainstorm quick, cost-effective solutions that could be tested in your department.

**Role Clarity and Preparation** – Ensure roles are clearly defined and team members are prepared with necessary resources readily available during high-stakes scenarios.

**Test and Refine** – Conduct quick pilot tests of new setups or processes during quieter times and gather feedback from your team. 💬 Conclusion Human factors play a critical role in shaping healthcare outcomes. Through structured system designs and attention to team dynamics, it is possible to reduce inefficiencies and enhance both patient care and provider well-being.

It requires a shift in perspective from seeing design and systems as separate from human behaviors, to seeing them as intricately linked. By incorporating these principles, healthcare professionals can create environments that inherently support better, safer, and more effective patient care.

🚨 Clinical Bottom Line Incorporating human factors into healthcare isn't just about preventing errors—it's about creating an ecosystem where the healthcare team is empowered to perform at their best, even under the most challenging conditions. Implementing small, iterative changes can create a meaningful impact, paving the way for improved systems and processes.

This starts by redesigning systems and environments with human factors in mind, which can significantly improve both the efficiency of care delivery and the safety of the healthcare environment.

📌Key Points

🧠Parallel Tasking: Transitioning from junior to senior roles in medicine involves both personal growth and the development of leadership skills, often simultaneously.

🚀Psychological safety: Creating this within teams is critical for fostering an environment where all members feel empowered to speak up and share insights.

🔎 Big and Small Picture View: Effective leadership requires the ability to zoom in on specific tasks and zoom out to manage the big picture, ensuring comprehensive patient care.

⌚Timing is Everything: The act of asking the right questions at the right time can significantly enhance team dynamics and patient outcomes in high-pressure situations.

🗣️Talk the Talk: Creating and practicing clear, structured communication strategies can assist in smooth transitions and effective leadership during medical emergencies.

👀Previously Covered and Related Content:

• REBEL EM: Titles Don't Make Leaders
• EM Cases: Four Key Learnings from a Career in Emergency Medicine Leadership

📝Introduction

Welcome back to Rebel MIND, the podcast where we sharpen the person behind the practitioner. Hosted by Dr. Mark Ramzy, with special guest Dr. Dan Dworkis, an emergency physician and author of "The Emergency Mind," this episode dives into the complex journey from junior to senior leadership in medical settings.

You can learn more about Dan's work and the Emergency Mind Project here

He has a phenomenal book called "The Emergency Mind: Rewiring Your Brain for Performance Under Pressure" that you can purchase here!

🤔Cognitive Question

How do medical professionals effectively transition from junior to senior roles, and what mental shifts are necessary to manage these evolving responsibilities?

🏥How This Applies to the Emergency Department or ICU?

• • Transitioning from a junior to a senior role in the emergency department or ICU is akin to stepping onto a new stage where the performance demands are higher, and the stakes significantly greater.
  • While juniors focus on learning their craft and understanding themselves, seniors are expected to manage and lead entire teams, often making life-saving decisions under pressure.
  • This transition challenges not only their clinical skills but also their ability to lead effectively and maintain psychological safety within their teams.
  • By fostering an environment where every team member feels valued and heard, senior leaders can harness the collective intelligence of the group, ensuring better patient outcomes and a more effective response to emergencies.

⏩Immediate Action Steps for Your Next Shift

1. **Exercise Intentional Questioning**: Start your next shift by focusing on how you ask questions. Aim to frame queries in a way that invites discourse and challenges assumptions.
2. **Develop Peripheral Awareness**: As you conclude critical tasks, practice expanding your focus from the immediate to the wider context, considering broader departmental needs.
3. **Promote Inclusive Participation**: Encourage junior team members to share their observations and insights by specifically inviting their input during debriefs and planning.
4. **Conduct Leadership Experiments**: On your next shift, try altering your leadership approach—whether it's how you communicate or delegate—and reflect on its effectiveness with colleagues.
5. **Create Psychological Safety**: Work towards fostering a safe environment for open communication, ensuring that all team members feel comfortable speaking up without fear of retribution.

💬Conclusion

Transitioning from a junior to a senior leadership role in the medical field is not just about honing your clinical skills but also about growing as a leader who can guide a team under intense pressure. By focusing on intentional communication, fostering psychological safety, and keeping an eye on both the details and the bigger picture, you can enhance your effectiveness as a leader. Continuous reflection and feedback are essential to mastering these skills, ensuring that both you and your team provide the highest level of care for your patients.

🚨Clinical Bottom Line

Leadership in medicine is about more than making decisions—it's about creating an atmosphere where every voice is heard, ensuring optimal functioning of the team. As you grow into your senior role, remember that fostering psychological safety and practicing strategic communication can make all the difference in patient outcomes and team dynamics.

📚 Further Reading

1. Collins-Nakai R. Leadership in medicine. Mcgill J Med. 2006 Jan;9(1):68-73. PMID: 19529813
2. Chen TY. Medical leadership: An important and required competency for medical students. Tzu Chi Med J. 2018 Apr-Jun. PMID: 29875585

🔑Key Points

• 🌱 Growth mindset transforms learning – Residents and students who believe skills can be developed are more open to feedback, more resilient after failure, and more engaged in practice.
• 🧠 Language matters in feedback – Simple reframes such as "You're developing procedural skills" instead of "You're not strong at procedures" encourage persistence and normalize the learning curve.
• 🤝 Mindset shapes team culture – Growth mindset leaders foster psychological safety, invite input, and create collaborative teams. Fixed mindset hierarchies, on the other hand, silence voices and can compromise patient care.
• 🔥 Growth mindset protects against burnout – By reframing mistakes as part of the process, clinicians reduce perfectionism and shame, bolstering resilience and wellness.
• 🔍 Practical steps start with self-talk – Add the word "yet" to limiting beliefs ("I'm not good at X…yet") and shift feedback questions toward improvement ("What's one thing I can do better next time?").
• 🛠️ Embracing mistakes with a growth mindset – Leads to more effective feedback loops and improvement do this by building a culture of psychological safety is crucial for growth and reducing medical errors.

👀Previously Covered and Related Content:

• • REBEL EM: The EM Mindset
  • REBEL EM: Titles Dont Make Leaders
  • REBEL EM: Mind of the Resuscitationist with Scott Weingart
  • EM Crit: Making Things Happen with Cliff Reid

📝 Introduction

Welcome to this episode of REBEL MIND, where MIND stands for Mastering Internal Negativity during Difficulty. Here we sharpen the person behind the practitioner by focusing on things that improve our performance, optimizing team dynamics and the human behavior that embodies the hidden curriculum of medicine.

Mindset shapes everything we do in medicine—from how we teach and learn to how we show up for patients at the bedside. Drawing from Carol Dweck's influential book Mindset, this episode of REBEL MIND explores the critical difference between a fixed mindset (believing abilities are innate and static) and a growth mindset (seeing skills as things that can be developed through effort and feedback).

We sat down with Dr. Kim Bambach, an emergency medicine physician and medical educator, and Dr. Frank Lodeserto, a dual-trained intensivist and internal medicine program director, to unpack how mindset influences medical education, bedside performance, and physician wellness. In this episode, we delve into how the mindset of clinicians can profoundly influence their performance, professional growth, and ultimately patient care

🤔Cognitive Question

How does adopting a growth versus a fixed mindset influence clinical performance, medical education and patient outcomes?

🌱What is Growth vs Fixed Mindset?

• • In Carol Dweck's research, two primary mindsets are highlighted:
    • Fixed mindset: Which sees intelligence and skills as static
      • In the medical field, adopting a fixed mindset might lead a clinician to avoid complex cases due to fear of failure.
      • Growth mindset: Which views abilities as improvable through dedication and effort.
        • In contrast, a growth mindset encourages embracing challenges as opportunities for learning and development.

🏥How This Applies to the Emergency Department or ICU?

• • In high-stakes environments like the ICU or the ED, the mindset adopted by healthcare providers can distinctly shape patient care and team dynamics.
  • A fixed mindset might lead to defensive behaviors and a reluctance to engage in challenging cases, potentially stunting personal and professional growth.
  • Conversely, a growth mindset not only fosters resilience and adaptability but also enhances team collaboration and patient outcomes by encouraging open communication, continuous learning, and acceptance of constructive feedback.

⏩Immediate Action Steps for Your Next Shift

1. **Monitor Self-Talk**: Notice your internal narrative when faced with challenges. Replace negative, fixed-mindset thoughts with growth-oriented ones like "Not yet" or "What can I learn from this?"

2. **Promote a Culture of Inquiry**: Challenge yourself and your team to engage in constructive questioning and explore alternative diagnoses or treatment plans to encourage a growth-centered environment.

3. **Model Vulnerability**: Share personal learning experiences and mistakes with colleagues to normalize the growth process and reduce the stigma of imperfection.

4. **Reframe Feedback**: Instead of broadly asking, "How did I do?" inquire, "What's one thing I can improve on next time?" This shift helps maintain focus on growth rather than performance validation

• • Feedback is a whole another topic that we plan to have dedicated episodes and blog posts. This is an area where sometimes faculty struggle and often learners are asking for more/improved feedback.

💬Conclusion

Cultivating a growth mindset in medicine isn't merely about staying positive; it's about embracing continuous learning in the face of challenges. It involves creating supportive environments that encourage vulnerability, experimentation, and resilience. By adopting these practices, clinicians can improve not just personal competencies but also enhance patient care quality and safety.

🚨 Clinical Bottom Line

Clinicians who embrace a growth mindset not only enhance their skills but also contribute to a more dynamic, adaptive, and error-resilient healthcare environment. Remember, the best clinicians are those who never stop learning, not the ones who never make mistakes.

📚Further Reading and References

1. Claro S, Paunesku D, Dweck CS. Growth mindset tempers the effects of poverty on academic achievement. Proc Natl Acad Sci U S A. 2016 Aug 2. Epub 2016 Jul 18. PMID: 27432947
2. Hopkins SR, et al.Trainee growth vs. fixed mindset in clinical learning environments: enhancing, hindering and goldilocks factors. BMC Med Educ. 2024 Oct 23 PMID: 39443909
3. Memari M, Gavinski K, Norman MK. Beware False Growth Mindset: Building Growth Mindset in Medical Education Is Essential but Complicated. Acad Med. 2024 Mar 1. Epub 2023 Aug 30. PMID: 37643577

Cite this article as: Mark Ramzy, "REBEL MIND – Growth vs Fixed Mindset in Medicine", REBEL EM blog, November 28, 2025. Available at: https://rebelem.com/rebel-mind-growth-vs-fixed-mindset-in-medicine

🔑Key Points

☕ Try the coffee nap! Where you combine caffeine and a 30-minute nap to then have that boost energy and alertness by the time it kicks in.

💤 Sleep isn't optional—it's crucial for memory, mood regulation, and physical recovery. It is fundamentally different from rest

❌ Replacing sleep with caffeine isn't effective and can have negative health impacts. Make getting enough sleep a priority

🌞 Sunlight exposure is important for maintaining circadian rhythms and sleep quality. This applies even if you work as a nocturnist

💡 Creating a personalized sleep system enhances quality and consistency. It gives you back control of a schedule that you may feel like is out of your hands.

🧩 If you've tried these strategies and you're still struggling, consider true sleep pathology (insomnia, shift work disorder, sleep apnea) and get help—this is not a "be tougher" problem.

🩺 Better sleep isn't just about feeling good; it's directly tied to error reduction, patient safety, and longevity in EM/ICU careers.

👀Previously Covered and Related Content:

• REBEL Core Cast: Sleep Hygiene
• REBEL MIND: Rest Is Not Sleep: The Seven Dimensions of True Recovery
• Rebellion in EM: Care For Yourself – Sleep Hygiene
• First10EM: Some Evidence For Working Night Shifts
• REBEL MIND: Dunning Kruger Effect

📝 Introduction

Welcome to this episode of REBEL MIND, where MIND stands for Mastering Internal Negativity during Difficulty. Here we sharpen the person behind the practitioner by focusing on things that improve our performance, optimizing team dynamics and the human behavior that embodies the hidden curriculum of medicine.

Today we are exploring the imperative topic of rest and why it's not just about sleeping. The second of a two part series, hosted by Dr. Mark Ramzy with guests Dr. Maureen Aiad and Dr. Amil Badoolah, continue our discussion but this time on the multifaceted nature of sleep, how it serves as medicine and how we can use our tools deliberately to get more of it!

🤔Cognitive Question

How would your clinical performance, patience with families, and long-term career sustainability change if you treated sleep as a non-negotiable clinical intervention rather than a flexible "nice-to-have"?

💤How is Sleep Different From Rest?

1. Rest reduces load; sleep repairs systems

• • We previously talked about the 7 types of rest and you can check that out here
  • Examples of physical rest include: pausing tasks, stepping away from the monitor, taking a walk, stretching, breathing, journaling, connecting with a colleague. This lightens your cognitive/emotional burden.
  • Sleep is fundamentally different in that it's an active biologic process that helps:
    • • Consolidates memory and learning (yes, including the tough cases from last night).
      • Regulates mood, impulse control, and emotional reactivity.
      • Supports immunity, metabolic health, and cardiovascular function.
      • Repairs tissue, replenishes neurotransmitters, and fine-tunes neural networks.
  • You can have "rested but underslept" days (you took breaks but got 4 hours in bed), and "slept but unrested" days (you got hours, but all junk sleep). Both matter, but they are not interchangeable.

2. Sleep architecture vs. "knocking out"

• • True restorative sleep cycles through NREM and REM in predictable patterns.
  • Alcohol, late caffeine, and fragmented nights may help you fall asleep faster but:
    • Suppress REM.
    • Shorten deep sleep.
    • Increase awakenings and light sleep.
  • The result: you technically slept, but your brain didn't get the "software updates" it needed.

Biology isn't built for your schedule

• • Circadian rhythms were designed for light-day / dark-night cycles, not:
    • 10 pm–7 am ED shifts.
    • 24-hour calls.
    • 6 nights in a row followed by days.
  • Your body can adapt partially, but not instantly and not perfectly. That's why:
    • You can feel "jet-lagged" even when you haven't traveled.
    • Sleep before and after nights feels odd and fragile.
• Recognizing that "this is biologically unnatural" is key: you're not weak; you're fighting physiology.

🏥How This Applies to the Emergency Department or ICU?

1. Performance & safety
   • Sleep deprivation:
     • Slows reaction time and increases error rate.
     • Impairs risk assessment and complex decision-making.
     • Drops your frustration tolerance with consultants, families, and staff.
   • In both emergency medicine and critical care, that translates into:
     • Anchoring on the wrong diagnosis.
     • Missing subtle clinical changes.
     • Snapping at a tech, nurse or resident and damaging team culture.
2. Chronic health for chronic shift workLong-term sleep disruption is associated with:
   • Hypertension, diabetes, obesity.
   • Depression, anxiety, burnout.
   • Arrhythmias (e.g., AFib) and increased stroke risk.
   • Possibly increased all-cause mortality.

   You're already in a high-stress, high-exposure specialty. Chronically poor sleep amplifies that risk profile and can end a career early—or make you miserable while you're still in it.

3. Culture of "heroics" vs. health

   • Skipping sleep to pick up extra shifts, late meetings, or "just one more note" is often praised.
   • We rarely celebrate:
     • The attending who says "no" to a 2 pm meeting post-nights.
     • The resident who defends their blackout-curtains-and-earplugs routine.

🛏️Different Ways to Improve Your Sleep

• • Clarify your "sleep non-negotiables"

    • Decide how many hours you realistically need to function (e.g., 7–9 on off days, realistic blocks on nights).
    • Treat those hours as you would a procedure time—blocked, protected, and respected.

    Use caffeine like a drug, not a reflex

    • Aim for ≤ 2 cups equivalent on most days.
    • Avoid caffeine within 4–6 hours of your planned sleep time (remember: it can hang around up to 12 hours).
    • Consider scheduling caffeine for:
      • Early in the shift for alertness.
      • Strategic "coffee naps" (see below), not late-night chugging.

    Respect alcohol's impact on sleep

    • Recognize that even small to moderate doses degrade sleep architecture.
    • Avoid using alcohol as a "sleep aid"—you'll fall asleep faster but sleep worse.
    • If you do drink, separate it from bedtime and keep it modest.

    Optimize food and fluid timing

    • Hydrate consistently on shift, but taper fluids ~4 hours before bed to reduce nocturnal bathroom trips.
    • Avoid heavy, spicy, or large meals within 2–3 hours of sleep to decrease reflux and discomfort.
    • Plan a light, balanced "pre-sleep" snack if going to bed hungry keeps you awake.

    Move your body (but not right before bed)

    • Regular exercise improves sleep depth and latency.
    • Try to avoid intense workouts within 2 hours of bedtime.
    • On shift: micro-movement (stairs, brisk walks between pods, quick stretch sessions) can help alertness without wrecking sleep later.

    Control light exposure

    • Maximize sunlight or bright light after waking (even if that's 3–4 pm after a night).
    • Minimize bright light and screens before sleep:
      • Dim lights.
      • Use night mode/blue-light filters if you must scroll.
    • For daytime sleep:
      • Use blackout curtains, tinfoil, cardboard, or sleep masks.
        • Yes seriously use tinfoil if you have to, we talk about it on the podcast episode!
      • Aim for "I might be blind" darkness—so dark you can't see your hand in front of your face.

    Dial in your sleep environment

    • Cool room temperature (fan or AC if possible).
    • White noise or sound machine to mask household/traffic noise.
    • Earplugs and eye masks as needed.
    • Bed used primarily for sleep (and sex)—not for charting, doom scrolling, or email.

    Strategic power naps

    • Keep naps ≤ 20–30 minutes to avoid sleep inertia.
    • Prefer early-afternoon or pre-night-shift naps.
    • Coffee nap strategy:
      • Drink a small coffee.
      • Immediately lie down for a 20–30 min nap.
      • Wake up as the caffeine kicks in, combining nap benefit + stimulant.

    Thoughtful melatonin use

    • Remember melatonin is a hormone, not a vitamin gummy.
    • Lower doses often work as well as (or better than) large OTC doses.
    • Use it intentionally and intermittently, not as a crutch every night.
    • Over-reliance may reduce your own natural production and its effectiveness over time.

    Build pre-sleep rituals

    • Repeated, calming habits signal your body it's time to downshift:
      • Warm shower, gentle stretching, or yoga.
      • Guided breathing or body scan.
      • Brief journaling or "brain dump" of tasks to get them out of your head and onto paper.

    Protect from pathologic patterns

    • If despite consistent effort you:
      • Snore heavily, stop breathing, or gasp in sleep.
      • Feel excessively sleepy driving home or at work.
      • Cannot fall asleep or stay asleep for weeks to months.

    Consider evaluation for sleep apnea, insomnia, or shift-work sleep disorder with your physician or sleep specialist.

⏩Immediate Action Steps for Before/During/After Your Next Shift

1. **Before the Shift**:

• • Plan a 20–90 minute nap before your first night shift (many clinicians find 3–5 hours earlier in the day is ideal).
    • I treat ED and ICU shifts very differently. I always sleep 3-5 hours before my night shifts aiming for the full 5 (sometimes 6 or more) hours for my ED shifts because you always have to be "on". Depending on the ICU I'm working in, I may have a bit more downtime so 3 to 5 hours is plenty.
  • Set a caffeine plan: decide in advance when your last dose will be (e.g., none after 2–3 am if sleeping at 8–9 am).
  • Tell your household, "This is my sleep block" and agree on a plan for kids, pets, deliveries, etc.
• On my calendar, I completely block off time called "Pre-call sleep" so no meetings can be scheduled and then put my phone in airplane mode

2. **During the Shift**

• • Hydrate early; taper fluids in the last 3–4 hours of your shift
  • Eat something light but adequate; avoid "last-minute" heavy meals right before sign-out.
  • Build in micro-breaks and movement: one or two short walks, a few stretches, even a quick stair run if safe.
  • Get outside or near a window for a few minutes of light exposure if possible.

3. **After the Shift**

• • On the way home:
    • Use sunglasses to reduce bright morning light if you're aiming for sleep soon.
    • Avoid "just checking" email or messages; shift into wind-down mode.
  • At home:
    • Do a brief, calming decompression (shower, light snack, 10–15 minutes of low-stimulation TV or reading).
    • Make your room cold, quiet, and dark (blackout curtains, tinfoil/cardboard, white noise, fan).
    • Put your phone on Do Not Disturb and physically place it away from the bed.
      • On my calendar, I completely block off time called "Post-call sleep" so again no meetings can be scheduled and then I personally don't just put my phone on Do Not Disturb but rather in airplane mode and WIFI OFF
  • If you can't sleep after ~20–30 minutes:
    • Get out of bed, do something calming in dim light (breathing, gentle stretching, journaling).
    • Return to bed when sleepy—this trains your brain to associate bed with sleep, not frustration.

💬 Conclusion

Rest and sleep are both critical—but they're not interchangeable. Rest helps you step out of the constant "on" of our jobs, while sleep is the biological intervention that restores your ability to show up safely and sustainably. Rest ≠ sleep. Rest reduces load; sleep repairs your brain and body. You need both, on purpose.

As EM and ICU clinicians, we're trying to perform formula-one-level medicine with engines that often only see half their maintenance. You won't fix shift work. You can build a sleep system that respects your biology, your schedule, and your life at home.

That system starts with valuing sleep, then prioritizing it, personalizing it, trusting the process when it's imperfect, and actively protecting both your routine and your mindset.

🚨 Clinical Bottom Line

Sleep is medicine. Shift work is biologically unnatural. Struggling does not mean you're weak; it means you're human fighting physiology. Use your tools deliberately. Caffeine, naps, light, food, movement, melatonin, and environment can be leveraged—or can quietly sabotage you. Build and defend a personalized sleep routine. Communicate it, normalize it, and protect it from casual encroachment. You can't control every trauma, code, or admission—but you can control how seriously you take your own recovery. Your patients, your team, and your future self all benefit when you do.

📚 Further Reading

1. Espie CA. The '5 principles' of good sleep health. J Sleep Res. 2022 Jun; PMID: 34676592

2. Solodar, J

   "Sleep hygiene: Simple practices for better rest." Harvard Health, 31 January 2025 Link is Here

3. Suni, E.

   "Mastering Sleep Hygiene: Your Path to Quality Sleep." Sleep Foundation, 7 July 2025, Link is Here