The Flow State
An optimal state of consciousness
The experience of flow is universal and has been reported across all classes, genders, ages, and cultures. It can be experienced during many types of activities, from playing an instrument to climbing a mountain or doing a medical procedure. If you’ve ever heard someone describe a time when their performance excelled and they were “in the zone,” they were likely describing an experience of flow. Flow occurs when your skill level and the challenge at hand are equal. Flow is one of life’s most highly enjoyable states of being, delivering us entirely in the present, and helping us be more creative, productive, and happy. It is a peak state of being. Rarely it can be a group phenomenon rather than just a personal one. This is documented in chamber quartets or team sports, or pilots.
Technically defined as an “optimal state of consciousness where we feel our best and perform our best,” the term takes its name from the sensation it creates. In flow, every action, every decision, arises seamlessly from the last. In this state, we are so focused on the task at hand that all else falls away. Action and awareness merge. Our sense of self vanishes. Our sense of time distorts. And performance excels.
Flow produces potent neurochemicals that have a huge impact on our ability to acquire new skills and knowledge. DARPA, for example, found that military snipers trained in a state of flow learned 230% faster than normal. Scientists at Advanced Brain Monitoring in Carlsbad, California, ran a parallel civilian study and found that flow cut the amount of time it took to train novice marksmen up to the expert level in half. In flow, the brain releases norepinephrine, dopamine, endorphins, anandamide, and serotonin. All five of these hormones affect performance. Norepinephrine and dopamine tighten focus, helping us shut out the distractions. Endorphins block pain, letting us burn the candle at both ends without burning out altogether. Anandamide prompts lateral connections and generates gestalt insights far more than most brainstorming sessions. Serotonin goes beyond making us feel good; it’s been found to effectively bond teams.
I published a commentary on this topic in The Journal of Vascular and Interventional Radiology with my student Taryn J. Rohringer in 2019, a modified version of the text of which is below. The idea came to me at the racetrack when I played back in my mind a moment when, in less than a second, I had to avoid a bouncing wheel that had just come off a crashing car. I saw in retrospect that time had slowed down. After the race, we drivers chatted about this and realized we had all experienced this. It happens in crisis moments in procedures too. I can still see some of them in my head and feel them. These are visceral memories.
Your Focus Is Your Reality: Helping Interventionalists Achieve the Flow State
The flow state, first described by the psychologist Mihaly Csikszentmihalyi in 1975, is an optimal psychological state that occurs in an individual when completing a challenging task for which they have the requisite level of skill. In this state, such a great degree of focus and concentration is attained that the individual becomes completely engrossed in the task – suspending self-consciousness and employing minimal effort but simultaneously experiencing great confidence and enjoyment. This concept of the flow state has been primarily analyzed from the lens of elite athletes. In this context, scales have been developed to assess both a person’s propensity to experience flow, as well as to assess a person’s flow experience in each scenario utilizing nine dimensions of flow originally described by Csikszentmihalyi. The attainment of peak performance for elite athletes has been illustrated to be correlated to the experience of the flow state, and athletes describe the feeling as being in “the zone.”
Ross Bentley, professional race car driver and performance coach, describes the paradoxical phenomenon of racing in the flow state – physically reaching your fastest speeds but mentally feeling as though time is elongated as though you have endless time at your disposal to reach this moment’s goal. Extrapolate this feeling to an impending crash during a race. Or further, to a patient crashing during a procedure. Feeling completely in control and focused, and experiencing time as slowing down, such that you can optimally navigate these situations. Is the flow state something we can measure beyond self-reported surveys? Can the flow state be applied to proceduralists in medicine? Moreover, can we adopt practices to facilitate interventionalists’ experience of the flow state?
Positron emission tomography (PET) studies have implicated dopaminergic pathways in the striatum with an individual’s proneness to the flow state. Specifically, a higher availability of dopamine D2-receptors is positively correlated with an increased proneness to flow. These neurobiological correlates are in keeping with the phenomenology of the flow state insofar as it involves the reward pathway, specifically dopaminergic transmission in the striatum, as well as impulse control – a necessary trait in achieving the focus required for the flow state. Functional magnetic resonance imaging (fMRI) studies of individuals in purported states of flow while playing video games implicated midbrain reward structures and complex cognitive and sensorimotor networks as having increased activity in the flow state. Another study utilized functional near-infrared spectroscopy to analyze oxygenated hemoglobin concentration changes in the brain in university students in the flow state while playing video games. They found a significantly increased concentration of oxygenated hemoglobin bilaterally in the ventrolateral prefrontal cortex and concluded that high prefrontal cortical activity is associated with the flow state. These neurobiological correlates not only validate the subjective experience of this internal state but may also allow for objective measurement of both how prone an individual is to experience the flow state as well as whether they are actually experiencing it.
Though the areas in which the flow state has been described are diverse – from chess and video game playing to baseball and rock climbing – the terms used to describe it have been remarkably consistent. Can it be applied to surgeons or interventionalists radiologists or cardiologists as well? The state of complete focus on and absorption into the task at hand, with the adequate skills and confidence to complete said task, seems particularly well-suited and significant for the interventionalist in the angiography suite. It may improve physician success rates, as the associated feelings of concentration, confidence and lack of time pressure lend themselves well to the interventionalist who encounters an unanticipated complication during a procedure.
Is there a way to increase the likelihood of interventionalists achieving the flow state? Ensuring that skill level corresponds to the challenge of a procedure, whether individually or amongst the healthcare team, is paramount. Additionally, focusing on one task at a time during a procedure may aid in reaching the necessary level of focus. Being in tune with feedback both from yourself in how you feel during a variety of different tasks, as well as from your team members around you, can help individuals understand the types of tasks that allow them to near or reach flow. This is a strength-based and goal-directed form of professional development that may prove quite advantageous for both physician and patient well-being. Due to the similar emphasis of focusing on the present moment and experiencing time as elongated, mindfulness practices have been implicated in discussions of flow. One study indicated that athletes with high levels of mindfulness had greater flow disposition and adoption of mental skills. Another study demonstrated that mindfulness training increased the attainment of flow state amongst elite baseball players. In addition to the aforementioned strategies, mindfulness training may similarly benefit interventionalists in achieving the flow state.
Increasing awareness of this positive psychological state, its neurobiological underpinnings, and strategies to achieve it is crucial in the setting of interventionalists, for whom extreme focus and optimal performance are of immense importance. Achieving this state and the enjoyment and superior performance associated with it may allow for efficient and optimal use of physician skills, higher job satisfaction, and improved patient outcomes. It is our goal to urge interventionalists to endeavour to “go with the flow” and reach their flow states.
The paper was unexpected by my fellow interventional physicians, but it resonated with them. They recognised the sense of calm, self-integration, clarity, vision. Pure signal, no noise.