The science behind 'flow' and how it can help you be a better clinician

Have you ever been so engrossed in an activity that your sense of time vanishes? Hours pass, and all the while your senses are fully engaged. Regardless of what you’re doing, the next step seems to appear to you effortlessly.

This is the flow state, elucidated and named by positive Hungarian-American psychologist Mihaly Csikszentmihalyi in the 1970s. His discoveries demonstrate that under the right circumstances, flow states are accessible to us. These states hold the potential of personal and professional transformation for healthcare providers.

What is flow?

Flow researchers call flow states autotelic experiences. Autotelic originates from two Greek words: autos (self) and telos (end or goal). Autotelic experiences are intrinsically rewarding. Whether it’s a climber scaling a rock face, a surfer gliding through a barrel, or a monk chanting a mantra, the performer does these things for their own sake, divorced from external reward or outcome.

In a 2004 TED Talk, Csikszentmihalyi called the resulting experience clarifying and ecstatic. This feeling is what propels us forward in flow states, despite hunger or fatigue.

“You know exactly what you want to do from one moment to the other,” Csikszentmihalyi said. “You forget yourself. You feel part of something larger.”

 This isn’t an experience reserved for adrenaline junkies. A clinician might achieve a flow state navigating a crowded emergency department, connecting with patients in meaningful conversation, or handling a difficult procedure.

Michael S. Mulligan, MD, described his surgical experiences with flow states in a 2016 presidential address to the American Association for Thoracic Surgery. He said that in part, it’s the challenges of surgery that put surgeons into flow.

“Practicing a variety of dissection sequences will allow one to encounter an unanticipated challenge and ‘flow’ to an efficient, safe, and optimal completion,” Mulligan said.

 Flow isn’t exclusive to surgery, however.

How to reach flow states

According to researchers, achieving flow states is a matter of prime conditions and practice—both of which you can cultivate at work, regardless of specialty, and in your personal life. If pursuing flow states, chosen activities should meet or support the following criteria:

• Clear goals: The participant knows what they must do at all times. They focus their attention on each step, not the outcome. They are cognizant of the experience and its quality, not a successful performance.

• Feedback: Feedback underscores the notion that what the performer is doing matters. It can be external, such as from a colleague, but it’s better if the feedback comes from the activity itself. Think of playing a video game. It’s self-evident when you’re playing well.

• Balanced opportunity and capacity: First, the performer must believe that the task is within their grasp. Then, their skills must be on par with the challenge. As they improve, the challenge must also increase in difficulty to maintain their interest.

• Concentration: A loss of sense of self occurs. There is no longer separation between the activity and the performer.

• Presence: The present moment, and the demands of the challenges, are the only focal points of attention. Past and future are no longer relevant.

• Control: Performers must feel as though they have internal control over their performance. External factors do not matter.

• Time distortion: Performers may experience a slowing-down or a speeding-up of time. Sense of time scales to suit the task.

• Egolessness: The intense focus causes the performer to forget themselves. There no longer appears to be a self, just the activity and the experience of the activity.

 A 2011 BMC Nursing study found that “being involved in medical care was positively related to flow situations.” Researchers pointed to Csikszentmihalyi’s findings that work produces flow states more often than leisure. They noted that if flow is a priority for clinicians, administrators must emphasize medical care, not administrative tasks.

 Outside of work, channeling flow is a matter of pursuing activities and hobbies that meet these criteria. Possibilities include playing an instrument, participating in a sport you enjoy, or even video games. These activities, and others, have proven benefits.

The benefits of flow

Burnout among clinicians has proliferated during the pandemic. Pursuing flow states may be one way to diminish its impact.

A 2018 Journal of Affective Disorders study examined 10,000 sets of Swedish twins, assessing them for their proneness to flow states. The researchers found a “(partly) casual relationship between flow and work-related depression and burnout,” suggesting that flow may limit emotional problems at work.

Flow also may prove beneficial in easing periods of anxiety. A 2019 Emotion article examined three studies that sought to determine whether flow states can ease the anxiety of waiting. In the first study, law students awaiting bar exam results said they felt less worried, experienced fewer negative emotions, and more positive emotions while in flow. The second study replicated these results among doctor-level students searching for jobs. In the third study, undergraduate students who played Tetris while waiting for peers to rate their physical attractiveness experienced more positive emotions and fewer negative emotions—but not less worry.

“Engaging in flow may boost well-being during a period of uncertainty and make waiting a little easier,” the researchers concluded.

Flow may even promote better emotional regulation, according to a Psychology Today article. It’s difficult to be anxious when you’re completely focused, time has lost its relevance, and the only salient thing is a flow-producing activity.

Sources

1. 11 activities and exercises to induce a flow state(+ 6 examples). PositivePsychology.com.

2. Bringsén Å, Ejlertsson G, Andersson IH. Flow situations during everyday practice in a medical hospital ward. Results from a study based on experience sampling method. BMC Nursing. 2011;10:3.

3. Can flow experiences be protective of work-related depressive symptoms and burnout? A genetically informative approach. Journal of Affective Disorders. 2018;226:6-11.

4. Csikszentmihalyi M. Flow, the Secret to Happiness.

5. Lőrincz K. Flow conditions – Csikszentmihalyi’s summary. Leadership & Flow.

6. Mulligan MS. Achieving flow in surgery. The Journal of Thoracic and Cardiovascular Surgery. 2016;151(6):1435-1439.