Professionalism and performance

Wellness week – Emergency Physician performance over a career span

Performance as told by a mid career (not old) emergency physician


Charley McNabb
Dr Charley McNabb – Emergency Physician Princess Alexandra Hospital, Brisbane


Disclaimer – Maths and physiological concepts prerequisite to interpret this blog.

Context: In considering performance whether on my own or in discussion with colleagues, I use a personal model that helps me visualize my perspective. Note there are seven discrete possibilities of context within this model (which I will discuss in more depth in another blog).


Performance = Potential – Interference (Tim Gallwey, The Inner Game of Work)

Strength based learning = Strength (Talent) + Development (Effort)

Old = Your age + 10 years

Frank Starling Curve – relationship between stroke volume and end diastolic volume with respect to cardiac contractility. This is assimilated to a relationship between (actual) performance and the potential/interference ratio with respect to quality (assessment) of performance

There is a conversation developing around performance quality throughout our career particularly for the ‘older’ emergency physician. Given my above formula for old, I have at least another 10 years…. I prefer to think of myself as ‘mid career’.

Performance in clinical care is still tricky to measure and most literature would exist around outcome measures in the context of process. There is a small body of work on patient related outcome measures and clinical performance, but we are yet to effectively objectively study performance in the practitioner context. The following is subjective and biased to my own experience, in the absence of appropriate literature to review.

Performance assessment is simple (not easy) during training (retrospectively speaking). There is a set standard to attain, an ever-changing curriculum on the science of humanity and validated assessment tools that assure the standard. Then it is a less defined process to reflect, review, maintain or improve your performance as an emergency medicine clinician in the wilds of practice.

More than 10 years out from fellowship I have reflected on my own performance as I build and coach the performance of my trainees and colleagues. I have adopted a strengths based learning approach. This does not neglect knowledge or skills gaps in performance which must be attended, but does provide a positive cognitive start point and inroad to develop performance and approach performance gaps which, in learning science, is effective and also reflects my personal and departmental values of integrity, wellbeing, balance and resilience (again, a discussion for another time perhaps).

The following is one approach that I have applied to myself and discussed with anyone willing to do so. I have worked publicly in a large group and privately in solo practice. My clinical performance has varied throughout my years of practice with so many factors to consider at any one time that I have tried to simplify consideration of performance by going to one of our basic physiological models.

Could emergency physician performance follow the Frank Starling Curve? If yes, we could consider in reference to time blocks.

Career long – When is the right time to pull back from clinical practice or retire?

Within a shift – Our performance can start to flounder if our internal and external resources are overstretched; our reserve can’t fill effectively and the quality and quantity of our performance can dip.

Within a single case…etc. When should we ask for help?


What are the factors that improve performance quality (shift the curve up and to the left)? Like cardiac contractility, sympathetic drive is important, but cannot be the long term solution.

Equally down time (allowing the curve to come down and to the right) may be appropriate to allow recovery or to place the peak performance where it best matches where it is needed in order to maximize efficiency of resources.

Instead of factors related to hypoxia and acid base status, with performance, we need to consider intrinsic factors like reflective practice, commitment to practice (investing time), goal setting, risk propensity, resilience and self-empathy; and extrinsic factors like clinical experience, resources and structure, expectations from other system stakeholders (patients, institutions), accountability to the workplace and team and pharmacology (for me – serum caffeine level!).


In closing here is a methodology to succeed in maintaining and improving your performance, irrespective of stage of career:

Develop situational awareness

Set goals and be able to map them

Put your attention where you want to deliver your energy

Repeat your actions

Establish patterns

Set habits

Observe and measure results

If you’re interested in developing or reviewing your performance, no matter what stage of career or practice you’re at, then reflect, talk with a peer or a supervisor, chat with a mentor, and get yourself a coach.  Discover what maximizes your potential and what minimizes the interference?

Start today.


About Charley McNabb

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