Intentional practice

As an anesthesiologist with 30 years of practice, I didn’t think I could improve my performance in simple procedures like iv line insertion. I was wrong. I reduced my failure rate 5-fold using the power of intention.

Robin Youngson reflects on a novel strategy to improve healthcare practice

Many of us know the true story of the heroic airline pilot, Captain ‘Sully’ Sullenberger, who landed his aircraft on the Hudson River after catastrophic engine failure caused by bird-strike shortly after take-off. His decisive actions and extraordinary skill saved the lives of every single passenger and crew member. The dramatic story is told in the feature film, ‘Sully’, with Tom Hanks playing the lead role.

Even more interesting to me is the back-story. Shortly after we saw the film, my wife Meredith bought me a copy of Captain Sullenberger’s autobiography, a very inspiring read. I identified strongly with Sully’s story. He was a top-notch military pilot and a pioneer in aviation safety before he began his career in commercial aviation. I grew up in a military family and was an engineer before I was a doctor. For many years I was a leader in patient safety and healthcare quality, taking lessons from aviation and applying them in healthcare.

Aviation is a high-reliability industry with an astonishing safety record, considering the millions of passengers who fly without injury. In contrast, healthcare is a low-reliability industry where we accept high rates of error and failure. International research shows that at least 10% of patients admitted to hospital are accidentally harmed in the course of their care – the true number is probably far higher. Of course, patients are not machines, we can’t engineer out all the modes of failure, and healthcare is infinitely more complex and uncertain than aviation. But, reading Captain Sullenberger’s life story, I was inspired to apply some of his approaches to my own clinical practice.

Sully describes the incredible precision with which he conducts each flight. For instance, he calibrates his final approach and landing to achieve perfection in terms of minimal fuel consumption. For Sully, nothing is routine. Could I emulate his approach and improve the performance on procedures I do with every patient?

As an anesthesiologist, one of the tasks I have to do for every patient is insert an iv line. On average I get the cannula successfully placed in a vein for about 90% of my attempts. The other 10% I miss the vein, cause a haematoma, can’t advance the cannula, or penetrate the back wall of the vein. Usually it’s because the patient has ‘bad veins’ or those constricted by cold or nervousness. By the standard of Sully’s practice, a 10% failure rate is a very poor standard. In medicine we do some of the complex things really well but we’re bad at getting the simple things right 100% of the time.

My first attempt to improve my performance used a technical approach. I wanted to understand exactly how a vein behaves when it’s punctured by the needle and entered by the cannula. What were the risk factors for the cannula accidentally penetrating the back wall of a vein, or rupturing a valve? I spent hours with an ultrasound scanner examining the detailed anatomy of peripheral veins in my forearm and hand and trying to observe the needle penetrating the vein wall. I learnt almost nothing useful except that it’s difficult to visualise superficial veins when they are flattened by the touch of the ultrasound probe! I was also unable to visualise or located valves within the peripheral veins. My technical studies didn’t make any difference to my success rate, I needed a different strategy.

I decided to take a consciously intentional approach to the insertion of iv lines. Rather than trying to improve my performance, I just held a powerful intention that the cannula would be correctly placed in the vein and I visualised the end result as I performed the procedure. This approach yielded impressive results. I missed only two veins in about 100 consecutive patients over a six week period. I had reduced the error rate 5-fold, as shown in this cumulative error chart.
Cumulative error chart On reflection I noticed something odd: not one of these 100 patients had vaso-constricted or ‘difficult’ veins even though the study period ran into winter weather when patients more commonly have cold hands and hard-to-find veins. My newfound success rate wasn’t just owing to my improved technical skill, the patients and their veins changed too! It’s as if the veins became open and receptive to my intention.

If that sounds fanciful, consider this lovely story told by a colleague and friend in the USA. Julie is a nurse specialist who is often called to do iv lines in patients, when others have failed. As I do for difficult cases, she uses an ultrasound scanner to find bigger veins deeper in the arm and then inserts the iv line under direct vision, steered by the ultrasound image. On this occasion, she was called to help a teenage patient who was very anxious and needle-phobic. The patient’s mother was sitting at the bedside. Julie scanned the forearm and found a vein that was adequate but not very big in cross-section. Keeping the scanner on the arm, she asked the patient what reward she would like, after the iv line was inserted. ‘What’s your favourite food?’ she asked.

The patient said ‘ice cream’ so Julie asked her to describe her favourite ice cream, type of cone, best toppings, and so on. As the girl imagined her treat, Julie kept her eye on the ultrasound image. The vein doubled in diameter as the patient relaxed. Even the patient’s mother saw the change and exclaimed in surprise.

So my belief that my conscious intention influenced my patients and changed their veins, as well as my skill in the procedure, is not so far-fetched. Maybe there is some subtle change in my attitude that is allowing my patients to relax and the veins to become dilated?

When I bring powerful intention and consciousness to my work, extraordinary things happen.  Conversely when I try to improve performance by trying harder, my success rate falls rapidly. The day after I began composing this blog, I missed two veins out of four!

We know that emotional and psychological factors powerfully influence the course of an illness or injury and that compassionate care is great medicine, achieving much better clinical outcomes.

Perhaps if we add powerful intention to our care, we can help patients be more open and receptive to our treatments? I’d love to hear if other practitioners have adopted this approach.

8 Responses to “Intentional practice”

  1. Ian Paterson says:

    This is so true Robin – I’ve been a Consultant Anaesthetist for 20 years now and agree totally. Spending an extra few minutes just chatting to the patient as an individual before they come to theatre makes a huge difference, as does having relaxing music in the background in the anaesthetic room.

    If the IV cannultation / arterial line etc. looks difficult I often say a prayer (silently) first and am genuinely amazed at how much difference that makes too. Perhaps this could be phrased as ‘positive intention’ but I’m sure there’s more to it 🙂

    Thank you for the wonderful book – I’ve given copies to several of my colleagues who have really enjoyed reading it too.

    Very best wishes,


  2. Great blog, Robin, and lovely responses. Keep up the good work!
    Love. Dad.

  3. michael godfrey says:

    Robin, your intentional experiment was much appreciated as having given over 50,000 I/V infusions over the past 50 years, I would certainly agree with the frightened needle-phobic patient being a potential problem. Even a hot water bottle doesn’t help much however,I’ve found that a few minutes sitting down alongside and holding their hand whilst having a chat helps.
    I learnt a good lesson in humility in ’63 when working in the A&E Dept Middlesex Hospital, London that I’ve never forgotten. A middle-aged Canadian businessman was brought in with a fractured femur and as I was drawing up some morphine he asked if he could have heroin instead. Sure, I replied as it is also a good analgesic and was readily available. However, his well-used veins were like hardened rubber and the needle just skidded and bounced off. The man looked up and said “give me the needle Doc” I handed it over and watched as he tied his scarf round his arm as a tourniquet held by his teeth. He then plunged the needle vertically into the vein. There’s both intention and visualisation whilst I was thankful that the curtains hid my red face!

  4. Richard Egan says:

    Great post, thanks Robin. Seems to me you’ve also named and very explained a component of compassionate / spiritual care. We’ve done lots of work on spiritual care and you include many of the key factors in your account above.

  5. Robin says:

    Note from the author:

    One Facebook follower wrote, “Not sure what he saying! Think about the outcome more?? Intentional approach. In my job I always have an intentional approach. I hate missing a vein. I want one of those scanners!!”

    This was my response:

    ‘OK, I will try to explain. Most of my career, my work was just a job. I cared for my patients, I was kind and nice to them, and I did my job with skill. An iv line was just a trivial task I did repeatedly through the day. My intention didn’t go much beyond the physical actions required to get the job done.

    An intentional approach means that you are in service to the patient. You recognise that what is a trivial task for you is a big deal for many patients. You focus powerfully on the human connection, building a bond of trust, putting the patient at ease, and then performing the iv line insertion like it’s the only thing that exists in the world. You bring 100% of yourself, heart and soul, to the task. In a way, it’s a sacred act of service (and I quite often kneel on the floor when I’m doing it).’

  6. Barb says:

    I love this. I’m just a medical student, but after reading this I am determined to also take a consciously intentional approach to the procedures I have to do/learn. I’m sure it will yield good results! Thank you for sharing your experience!!

    • Angela says:

      Hi Barb, I am just a GP of 30 years experience and I can assure you, you are not JUST a medical student, you are our future. I bring compassion to work every day and since I attended my first workshop with Robin 3 years ago my work satisfaction has increased 100 fold, with a daily focus of “how can I help” every human being before me. If you are finding your way now, you are in for an awesome future!

      • Robin says:

        What a lovely comment, Angela! Thanks for supporting our medical students – it’s our favourite work too, spending time with students and young professionals. They are our future.

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