Get into Gritflowness

Renowned neurosurgeon John Boockvar, MD, strides into an operating room at Lenox Hill Hospital and greets members of his surgical team as they gather in a loose circle. "Let's take a moment to be mindful," says Dr. Boockvar, one of the stars of the Netflix docuseries Lenox Hill, a compelling look at the everyday lives of four physicians who work at the storied hospital on Manhattan's Upper East Side.

"Everyone relax and close your eyes," instructs Dr. Boockvar, who radiates a sense of calm. "Wiggle your toes and roll your shoulders back. Be here in the present. Take a deep breath in, hold it at the top, exhale."

Dr. Boockvar pauses in the middle of the now silent room. He's entered flow state, the heightened awareness needed to perform difficult tasks effortlessly and with complete focus. It's time to remove a worrisome growth from the patient's right frontal lobe and Dr. Boockvar is emotionally, physically and mentally present. He's ready to cut. "OK, let's roll."

Flow state is the culmination of grit and mindfulness — the three principles of "gritflowness," a term Dr. Boockvar coined to describe the techniques he uses to remain focused and calm when faced with the unimaginable stress of performing complex brain and spine procedures where the line between success and failure is measured in microns.

"It takes grit and mindfulness to develop the muscle memory needed to reach flow state," says Dr. Boockvar. "You need to commit to making mindfulness a part of your life, and dedicate the time and effort to accomplish it."

Grit involves deliberate practice and single-minded commitment to master a skill. Michael Jordan shot thousands of jumpers so he could drop 55 points on the Knicks in Madison Square Garden. Tiger Woods wore out practice ranges on his way to winning his first U.S. Open at Pebble Beach by 15 strokes. ?Dr. Boockvar spent endless hours in cadaver labs during medical school performing new surgical techniques under a mentor's watchful eye before eventually becoming one of the best neurosurgeons in the world.

"In order to reach peak performance, you have to practice a skill until it essentially becomes unenjoyable," says Dr. Boockvar. "Over time, you develop a high enough skill set to meet any challenges that come your way."

Mindfulness is being fully present in the moment, without worry of past events or future possibilities. It's an essential skill for managing the inevitable stress of everyday life inside and outside of the OR.

"Dwelling on past failures, or thinking about all the responsibility we're given and feeling like we have little control over situations are the daily challenges to mindfulness," says Dr. Boockvar.

He refers to three universal possessions when describing how to become fully aware. "My phone is a problem and my wallet can cause stress, but my breath can help me," says Dr. Boockvar. "Focused breathing is a tool that's always available."

Practicing mindfulness, even for a few minutes each day, is scientifically proven to prevent burnout caused by the cumulative effect of chronic stress. The amygdala, the brain's center for emotional behavior, is "hot" when you're anxious or depressed and "cold" when you're calm and relaxed. "Mindfulness and meditation are proven ways to cool down the amygdala," says Dr. Boockvar.

The 4-7-8 breath — inhaling through the nose for four seconds, holding it in for seven seconds and exhaling slowly through the mouth for eight seconds — is the ideal initial step on the path to mindfulness. "If you do it for two minutes a day, you're well on your way," says Dr. Boockvar.

He came up with gritflowness about five years ago as a way to remind himself of the grit and mindfulness needed to enter flow state as a husband, father and surgeon. His interest in the philosophy's core concepts began much earlier when he developed a fundamental knowledge of neuropsychopharmacology and a passion for cognitive neuroscience as an undergrad at the University of Pennsylvania in the early 1990s. But it wasn't until fate handed him a copy of "Full Catastrophe Living," the bible of mindfulness teaching, that he fully embraced mindfulness — long before the concept became a boardroom buzzword and social media hashtag.

Dr. Boockvar has added mindful moments to surgical time outs to build team unity and create a sense of group calm. He asks his colleagues to focus on their breathing for 10 or 15 seconds before procedures begin. "We check the patient and confirm the details of the operation, but we also need to check in on the well-being of the staff," he says. "It introduces the concept of mindfulness to members of the team, and hopefully inspires them to begin training, even for just a few minutes a day."

Being centered and fully present in the moment have never been so important. Dr. Boockvar points to the 60% burnout rate among surgical professionals and says the COVID-19 pandemic has only increased the professional and personal stress they face on a daily basis. "We come to work with human emotions, and we all need a little help," says Dr. Boockvar. "It's important to acknowledge stress and understand there are simple ways to manage it. When you integrate the three concepts of gritflowness, you end up in the perfect state of mind." OSM

Summer Logan has spent the last four years as a certified surgical tech at a hospital in Portland, Ore., working what many providers would consider a cakewalk of a schedule: four 10-hour days a week. But when COVID-19 hit and elective surgeries shut down, Ms. Logan and many of her coworkers were redeployed to the COVID-19 intensive care unit. Her agreeable schedule ended in April, replaced by a graveyard shift: three 12-hour nights in a row.

"It was a huge adjustment, but you make the best of the situation," says Ms. Logan. "I actually found some lifelong friends in the ICU, so it was a blessing in disguise."

How can someone who treated patients for a disease that has killed more than 200,000 Americans still see the good in the world? Ms. Logan made self-care a priority. She began working out a gym that offered meditation and mindfulness classes, and scheduled spa treatments once a month. She went for long walks and cooked meals at home. She also relied on her coworkers to keep her mentally strong. Some days were harder than others, but she persevered.

Ms. Logan returned to the surgery department in the middle of June when elective procedures resumed, but her memories of the ICU stick with her. One of the hardest to process is thinking back to the families who couldn't see their loved ones. "When I'm at work, I'm very good at compartmentalizing, because I'm hyper-focused on what needs to be done," she says. "You just have to put all of your needs aside."

That attitude cuts both ways. The dedication healthcare professionals show toward patient care is inspiring, but can come at the expense of their own mental well-being.

"If you care for yourself and put yourself first, you have the availability to be present for your patients," says Alyson McLean, CRNA, a nurse anesthetist at Boston Children's Hospital. "It's the same at home. If you're whole, you have the strength and resiliency to be present for your loved ones. We don't have those abilities when we're burned out."

Burnout is multifaceted — physical, mental and emotional — and caused by the immense amount of additional work surgical professionals are having to endure just to maintain pre-COVID levels of productivity. Everyone has been forced to think differently and pivot to new protocols and restrictions in their personal and professional lives. There's been no let-up.

"It's mentally exhausting," says Dr. Murray. "Healthcare professionals are on a learning curve they likely haven't experienced since medical or nursing school, when they were much younger and able to adapt much easier."

A constant churn of underlying stress impacts people in different ways, points out Dr. Murray. "They might have trouble sleeping, fall into unhealthy eating habits or become more agitated than normal," she says. Dr. Murray recommends prioritizing sleep and adding as much structure as possible to your professional and personal lives in order to regain a sense of control and comfort in routines. "There are a lot of effective ways to manage stress, but it takes time and effort," she says. "You have to work at it and change whole systems in your life to see meaningful improvement."

During the height of the pandemic's initial wave, Ms. McLean had to learn how to establish an airway while outfitted in full PPE and trying to breathe calmly through an N95 mask. At the time, there was very little trusted information about the risk of exposure to the coronavirus, which only added to her anxiety. "The biggest stress was from coming home to my family," says Ms. McLean. "There were so many unknowns about the virus and I was petrified of hurting my husband and kids. The stress level every day during the peak of the pandemic was heavy. Things have returned to some semblance of normalcy, but we still have moments of high stress."

Ms. McLean teaches mindfulness and yoga, and relies on both to remain centered. "I have a lot tools in my mental toolbox and would be a mess if I didn't meditate in the morning before work," says Ms. McLean. "I often wonder how people without the tools they need to cope are faring."

She's passionate about the power of being present and is known for running surgical teams through a series of breathing exercises before cases begin. She recalls teaching a meditation exercise to fellow surgical team members during a morning meeting. Hours later, they faced a life-threatening emergency in the OR involving an infant patient. Ms. McLean caught the eye of a surgical nurse who was in her meditation group and told her to reset, take a breath and realize she knew what to do.

"Focused breathing lets you unhook from stress and move forward," says Ms. McLean. "Awareness disempowers the fight or flight response. It calms the chaos."

If you feel your day beginning to spiral out of control and stress beginning to build, find time to walk away to regroup and recenter. You don't have to sit cross-legged in a healing garden to remove yourself from the constant churn of moving from task to task. Ms. McLean keeps earbuds in her pocket and pops them in to listen to relaxing music when she needs to escape the stress of a busy day, even for just a few moments. "Stare into space, pray, meditate, walk outside — it doesn't need to be involved," she says. "Research shows it only takes five minutes to center yourself."