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Flow, Deliberate Practice, and Renewal Are the Keys to Peak Performance

Watson, Nicholas C. MD

doi: 10.1097/ACM.0b013e31826d557b
Response to the 2012 Question of the Year

Dr. Watson is assistant professor, Department of Anesthesiology, Division of Critical Care, and Department of Surgery, UMass Memorial Medical Center and University of Massachusetts Medical School, Worcester, Massachusetts.

Correspondence should be addressed to Dr. Watson, Department of Anesthesiology, University Campus, 55 Lake Ave. North, Worcester, MA 01655; telephone: (508) 856-3343; e-mail:

The most effective ways to ensure that those who work and learn in medical schools and teaching hospitals can develop to their full potential are through the adoption of methods that yield peak performance at the personal and institutional levels. Evidence from psychology, business, and sports informs us of the principles employed by individuals who develop full capability and repeatedly function at a maximal level. Implementing these strategies in our personal lives and institutions can help us achieve increasing capacity and higher levels of performance.

Several evidence-based techniques are available for the development of personal potential. These interventions target three time periods: the present, the near future (days to weeks), and the long term (years). In our moment-to-moment self-management at the hospital or medical school, we should aim for full focus of our cognitive energy to achieve a state of concentration called “flow.”1 Flow is experienced as a period of focus in which the individual operates at full capacity. Not only is flow a pleasurable experience, but a good life has been described as “one that is characterized by complete absorption in what one does.”1 Flow is most easily achieved when the difficulty of a task matches an individual’s existing skills, the proximal goals are clear, and progress can be detected through immediate feedback. We must not simply hope that we will encounter flow by luck; rather, we must actively seek ways of creating the conditions that allow for flow. Daily self-training and professional interventions can enhance this ability.

Of course, such a state cannot be maintained perpetually, and for this reason we must look for optimum methods of budgeting our energy over daily and weekly cycles. Schwartz et al2 argue for 90-minute cycles of intense productivity followed by periods of renewal, such as one minute of deep, rhythmic breathing, a short nap, or up to 45 minutes of exercise. Over days and weeks, our chronic habits can maintain and even expand our capacity for sustainable high performance. Without exception, the ways that we care for our bodies through diet, exercise, intermittent relaxation, sleep, and vacation have tremendous effects on every aspect of our professional and personal lives.2 When we keep our bodies at peak, so too do our emotions, thoughts, and productivity come to full capacity.

Taking a long-term view, it would seem logical that day-to-day focus and renewal would lead to the development of full capability at one’s professional and personal endeavors. Ericsson and colleagues’3 work on the acquisition of expertise supports this notion: Engagement in deliberate practice with concentration on improving performance, when sustained over periods of 10 years or more, has been linked with the attainment of expertise in many fields.

Once we accept that the above mechanisms foster peak performance at the individual level, we must examine how these methods can be leveraged at the institutional level to invest in the individuals who work and learn in medical schools and teaching hospitals. There are two stages in this process: (1) gaining institutional awareness of the importance of these mechanisms and (2) implementing strategies that capitalize on these mechanisms. How can we gain institutional awareness? Any cultural change in an institution the size of a hospital or medical school requires support from the leadership, who must be open-minded and willing to experiment with methods outside the traditional means of governing. There is only one fact they must recognize to make this happen: Valuing people within an institution will improve the organization’s long-term performance.2 With respect to implementing the above strategies, valuing people who work in a medical school or hospital starts with investing in their health. Providing easy, 24-hour access to on-site workout areas, discounted memberships at local gyms, call rooms with beds and showers, and healthy, affordable food in the cafeterias and vending machines demonstrates a baseline commitment to the health of employees and students. Importantly, these represent basic mechanisms that allow individuals to move toward optimal performance on a daily basis.

To address more complex mechanisms of achieving peak performance, institutional leadership should invest in professional consultants’ services. The traditional model of pairing a student, resident, or junior faculty member with a more senior mentor still holds value; however, professional performance advisors, similar to the business consultants used by executives or the sports psychologists used by professional athletes, can play a crucial role in coaching employees and students in advanced techniques such as achieving flow, deliberate practice, and personal budgeting of energy.2,3 They can also help identify personal lifestyle changes that may improve capacity and performance at work, leading to greater professional happiness as put forth in “flow” theory and resonating in happier personal lives outside medicine.1

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1. Nakamura J, Csikszentmihalyi MSnyder CR. The concept of flow. Handbook of Positive Psychology. 2002 New York, NY Oxford University Press
2. Schwartz T, Gomes J, McCarthy C The Way We’re Working Isn’t Working. 2010 New York, NY Free Press;
3. Ericsson KA, Nandagopal K, Roring RW. Toward a science of exceptional achievement: Attaining superior performance through deliberate practice. Ann N Y Acad Sci. 2009;1172:199–217
© 2012 Association of American Medical Colleges