How does 23-time gold medalist Michael Phelps prepare for an Olympic race, an event so rare it happens only once every 4 years? According to his long-time coach, “He mentally rehearses for two hours a day... He smells the air, tastes the water, hears the sounds, sees the clock.” Can medical trainees do the same? 

With the overall drop in patients, procedures, and hands-on experience in the COVID-19 era, the foundational experiences that comprise the bulk of medical training are becoming rarer. To help remedy this, we need a simple, effective, high-fidelity training tool that can be accessed from the comfort of one’s own socially-isolated home. I suggest we use the highest-fidelity trainer available - the human brain - to train our learners using structured mental practice.

Mental practice, originally defined as “symbolic rehearsal of a physical activity in the absence of any gross muscular movements,” has been studied and lauded by performance psychologists for decades. Recently, the body of literature for its use in medical education has grown and expanded to include rehearsal of skills that are not strictly motor. There are studies showing that visualization and mental practice are associated with improvement in the performance of cricothyroidotomy, cystoscopy, laparoscopic cholecystectomy, and team-based skills in trauma resuscitation. Though not yet specifically studied, we should also use mental practice at this time to rehearse a variety of other scenarios - from simple physical exam maneuvers (e.g., the performance of a complete neurologic exam) to more complex skills (e.g., the resuscitation of a crashing neonate) to critical procedures (e.g., the performance of a thoracotomy during a traumatic cardiac arrest). Recently, even posted a fantastic video and script for mental practice of donning and doffing personal protective equipment.

The challenge for medical educators is in designing effective visualization exercises for trainees, as imagery works best when it is vivid and reflective of the environment in which the skill will be performed. To this end, written, audio, and video scripts can be used as guidance for learners. To maximize the imagery in these scripts, performance psychology research supports utilizing the PETTLEP framework

P: focus on the Physical aspects of performance as much as possible

E: perform the mental practice in the right Environment, such as a quiet space in one’s home that allows for vivid visualization of the desired environment without distractions, or in an isolated part of the floor/ED/ICU surrounded by the beeps and alarms that will be present when the skill is actually performed

T: choose a Task that is appropriate for the skill level of the trainee

T: emphasize the Timing of individual steps, aiming to eventually complete them in “real-time” (though future research may reveal value to slow-motion imagery)

L: update the imagery content as Learning occurs and skill advancement is needed

E: tie in Emotion, perhaps by cueing the learner to experience the emotion he or she will be feeling at the time, visualize the sight of blood filling the sterile field, or feel the gaze of the crowd of people watching the resuscitation

P: convey the intended Perspective of the learner, noting that the first-person (internal) perspective is often best, but the third-person (external, as if watching oneself performing a skill) may also be valuable in the right circumstance

As one example, consider this written mental practice script for cricothyroidotomy that I have used at our institution. This was distributed as an audio recording to allow learners to visualize the scenario with their eyes closed. With time and practice, the exercise will be memorized and the script will no longer be needed. 

“Imagine you are in the resuscitation bay of the emergency department. A patient is wheeled in by EMS who has a disfigured face and is gasping for air. The EMTs are attempting to bag the patient without success. When you get him on your monitor, you see his sats are in the 60s and dropping rapidly. You are unable to reposition his airway or open his mouth, and you decide it is time for a surgical cricothyroidotomy. You feel your heart racing as you announce your plans to the crowded room. Take a deep breath to relax. Stand up, close your eyes, and imagine yourself standing beside this patient. If you cut with your right hand, position yourself on the patient’s right. If you cut with your left hand, position yourself on the patient’s left. Put your non-dominant hand in front of you, as if it were resting on the patient’s chin and upper neck. Imagine yourself grasping and stabilizing his larynx between the thumb and middle finger of that hand, leaving your pointer finger free to palpate his cricothyroid membrane. You first feel the prominent thyroid cartilage, so you know you’re near the right spot. You slide your finger down until you feel the membrane between the thyroid and cricoid cartilages. Now, in your other hand - your dominant hand - you pick up your green #11 blade scalpel. Moving your pointer finger from the membrane you just found, you easily slice through the skin and subcutaneous tissues with a long, 3 to 4 centimeter vertical incision in a head-to-toe direction over the area you just palpated. Blood immediately covers your surgical field. At this point, you know the procedure will be blind from here forth. You immediately re-palpate your landmarks and find your finger resting on the thin cricothyroid membrane. Turn your scalped 90 degrees in your dominant hand so you can make a horizontal stab incision. To ensure you do not injure the finger on the membrane, remove it just before you proceed. You effortlessly stab through the cricothyroid membrane, feeling the loss of resistance as the scalpel enters the lumen of the larynx. You do not remove the scalpel. Instead, quickly cut laterally all the way to one side of the cartilaginous cage that bounds the cricothyroid membrane. Once you feel resistance, you turn the scalped 180 degrees and cut all the way to the other side until you again feel resistance. At this point, you remove your scalpel. Immediately upon removing the scalpel, you place the pointer finger of that non-dominant hand resting on the neck into the incision you just made. You feel the relief of knowing your finger is in the hollow tube of the larynx and trachea, so you keep your finger exactly where it is. With your dominant hand that just put down the scalpel, grab the long, blue bougie. Take the angled tip and feel it slide alongside your finger into the lumen, keeping your finger in the lumen until the bougie passes. Feel the bougie advance easily until you meet the resistance of the distal tracheobronchial tree. Though your heart is still racing, you know the only obstacle left is inserting the endotracheal tube into the trachea. Imagine yourself grabbing the 6-0 tube handed to you by your respiratory therapist. He has lubricated it to make passage easier. Slide the tube over the bougie into the trachea just until the cuff enters the lumen so as not to insert it too far. You inflate the balloon with 5-10cc of air and breathe a sigh of relief.”

Have you used mental practice for your own training or for your trainees? How could this tool be best utilized at your institution?


Did you know that the Harvard Macy Institute Community Blog has had more than 220 posts? Previous blog posts have explored topics including students as partners, promoting collaboration and teamwork among medical students, and empowering residents to teach.

Joshua Ginsburg

Joshua Ginsburg, M.D. is a medical educator and emergency medicine physician. Josh currently holds a position as Clinical Instructor of Emergency Medicine at the University of Virginia, where he is completing a fellowship in medical education. Josh’s areas of professional interest include clinical reasoning, decision making, and the application of psychology to medical training. He can be followed on LinkedIn.