As a marathon runner, I’m here to tell you: Covid-19 is not a marathon.
Marathons have discrete starts and finishes and start with Phidippides, is about victories. In their current form, they pay homage to athletic art written by elite athletes. For citizen runners, they celebrate personal achievement and conscious risk-taking. The prolonged lightning strike of Covid-19, on the other hand, is something we are all exposed to.
That said, insights from marathon running and other sports offer lessons on human performance that can help people – especially health leaders and workers – think about how to solve the large bucket of problems referred to as burnout and the related ideas. about resilience. These insights come from my own experiences as a 2:25 marathon runner and my research interests at the limits of human performance.
The first lesson is that elite and serious recreational runners run their fastest times at a pace near lactate threshold. This means that the level of lactic acid – a by-product of energy production – in the bloodstream has risen and reached a plateau and has not started to rise exponentially, as it does when a runner goes a little faster than this threshold. The homework here is that the workload matters.
The fact that so many experienced and well-trained marathon runners compete at a pace close to their lactate limit – and not faster – indicates that there is more to fast marathon running than just being mentally tough and cleaning it out. Pacing means something, and messages that some form of internal mental reframing can defeat fatigue are oversimplified at best and received as a counterproductive “You’re a slut” fingerprint at worst.
When I see the indignation and irony on Twitter from tired healthcare workers about online resilience training and self-care, the parallels are inevitable. The real problem is that the Covid treadmill has been running too fast for too long, and not that doctors, nurses, other health professionals and many researchers lack resilience and do not know how to take care of themselves.
The second lesson is that hitting the wall and dramatically slowing down, by e.g. The 20-mile mark, in fact, comes gradually, but is followed by a catastrophic collapse. Marathon runners tend to hit the wall when their blood sugar and muscle glycogen become too low – they run out of fuel – and / or they get too hot. These physiological reactions may have warning signs, but again, the main problem is to go along with paying attention to early symptoms and adjusting one’s pace to take environmental conditions into account. There are ways to prevent hitting the wall, but they require recalibration of the insert, not trying to push through.
In the bad old days, it was thought that refusing athletes water during training would sharpen them up and allow them to penetrate the inevitable performance impairments that come with dehydration. The development of Gatorade at the University of Florida (home of the Gators) and better hydration practices more generally put an end to the life-threatening practice, but it took decades to get there.
How long can health leaders wait to anticipate the burnout problem with organizational Gatorade versus get-resilient-and-power-through-it messages? Is it not to begin with getting through medical, nursing or continuing education selected for resilient people?
A third lesson is that while people can train and adapt to a marathon or other sport, this usually takes place outside of competition. A general rule of thumb from one of the founders of sports medicine, orthopedic surgeon Stan James, is that more than five hard efforts every two weeks prompt problems through injury or overtraining – the sports version of burnout. Every athlete, or sports fan for that matter, knows it load control is the big thing at the elite level.
A brief study of pilot fatigue and workload-related problems indicate that the people manning intensive care units are under far more prolonged and intense stress than pilots, with fewer and more limited options for remediation. Given the effort, health and research workers should have nothing like it guidelines for load management which air crews have?
What do coaches and managers of elite athletes know that health managers do not know? Legendary coaches like John Wooden, Vince Lombardiand Bill Bowerman kept the exercises short, were aware of improvement and constantly asked what they could simplify and stop doing. They also saw themselves as teachers who left the competition itself to the athletes and not micro-controlled from the sidelines.
Many people find this particularly shocking Lombardi, an innovative offensive coach, did not call routine play during matches, but instead preferred to work with quarterback Bart Starr. Wooden did not scout opposing teams as he felt the training time was better spent improving his players’ ability to perform what they wanted to do.
How many health leaders see themselves as teachers who strengthen their accusations? How many are trapped in an arms race mentality with the “competition”, or trying to catch the wave of the next hype cycle? How much better would things like care quality and professional satisfaction be if the focus was on marginal gain instead of transformation-of-everything-narratives which inevitably falls short? After all, real innovation is a mysterious thing. Would have generated a central planning initiative Fosbury flop?
I wonder what person like Bowerman made his runners more effective by personally making them faster shoes and lighter uniforms, would have to say about inefficient, time-consuming and distracting electronic record systems. His efforts to personally create better equipment for his runners almost certainly increased their confidence in him. Imagine if healthcare organizations’ current “data is the new oil” mantra was replaced with a targeted focus on a user-friendly, labor-saving electronic journal that improved patient care and facilitated medical research. It is a sure bet that morale would improve, burnout would fall, productivity would rise, and trust in management would return.
I am struck by other lessons from the human performance world. One is the ability of elite coaches and sports organizations to reduce the overhead of life and distractions for their artists. If doctors, nurses and researchers were seen as artists, they would be offered routine access to things like training tables and concierge services to ease the routine burdens of life. The disappearing advantage at home in the National Football League shows what happens when the athlete is in focus: The teams have the logistics so perfectly calibrated that players are not distracted by travel.
So what is the question, or perhaps the solution? See the biomedical and health professional worlds as serviced by skilled artists rather than staffed by a workforce. Once the basic insight is adopted, it can be traded systematically. Large and small actions with a focus on performers can lead to broad-based performance improvements, which in turn will lead to better results and improved professional satisfaction – and institutional financial scoreboards will perform fine, if not better.
But as Wooden reminded his players, “Play your game and your plan. Don’t look at the scoreboard.” It’s hard to do in the short run. But for healthcare professionals and researchers, it is either that or repeatedly hitting what someone would certainly describe as the post-pandemic marathon wall.
Michael J. Joyner is an anesthesiologist and physiologist at the Mayo Clinic. The views here are his own.