As a marathon runner, I am here to tell you: Covid-19 is not a marathon.
Marathons have discreet starts and finishes and, beginning with Phidippides, are about victories. In their current form, they celebrate athletic art authored by elite athletes. For citizen runners, they celebrate personal achievement and intentional risk taking. The extended lightning strike of Covid-19, in contrast, is something we are all subjected to.
That said, insights from marathon running and other sports do offer lessons on human performance that might help people — especially health care leaders and workers — think about how they address the big bucket of issues referred to as burnout and the related ideas about resilience. These insights come from my own experiences as a 2:25 marathoner and my research interests on the limits of human performance.
The first lesson is that elite and serious recreational runners run their fastest times at a pace near the lactate threshold. This means the level of lactic acid — a byproduct of energy production — in the bloodstream has risen and reached a plateau, and has not begun to rise exponentially, as it does when a runner goes a bit faster than this threshold. The take-home lesson here is that workload matters.
The fact that so many experienced and well-trained marathon runners compete at a pace close to their lactate threshold — and not faster — indicates that there is more to fast marathon running than simply being mentally tough and gutting it out. Pacing matters, and messages that some sort of internal mental reframing can defeat fatigue are at best oversimplified and at worst received as a counterproductive “You are a wimp” finger-pointing.
When I see the outrage and irony on Twitter from fatigued health care workers about on-line resilience training and self care, the parallels are inescapable. The real issue is that the Covid treadmill has been going too fast for too long, and not that doctors, nurses, other health care workers, and many researchers lack resilience and don’t know how to take care of themselves.
The second lesson is that hitting the wall and dramatically slowing down, at say the 20-mile mark, actually comes on gradually but is followed by a catastrophic collapse. Marathon runners tend to hit the wall when their blood glucose and muscle glycogen get too low — they run out of fuel — and/or they get too hot. These physiological responses can have warning signs, but again the main issue is pacing along with paying attention to early symptoms and adjusting one’s pace to account for environmental conditions. There are ways to prevent hitting the wall, but they require recalibration of effort, not trying to push through.
In the bad old days, it was thought that denying athletes water during practice would toughen them up and allow them to push through the inevitable performance decrements 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 that life-threatening practice, but it took decades to get there.
How long can health care leaders wait to preempt the burnout problem with organizational Gatorade versus get-resilient-and-power-through-it messages? Hasn’t getting through medical, nursing, or graduate school selected for resilient people to begin with?
A third lesson is that while people can train and adapt for a marathon or other sport, this is usually done 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 is asking for trouble via injury or overtraining — the sports version of burnout. Any athlete, or sports fan for that matter, knows that load management is the big thing at the elite level.
A brief survey of pilot fatigue and workload-related issues indicates that the people who staff ICUs are under far more prolonged and intense stress than pilots, with fewer and more limited mitigation options. Given the stakes, shouldn’t health care and research workers have something like the load-management guidelines that air crews have?
What do the coaches and managers of elite athletes know that health care leaders don’t know? Legendary coaches like John Wooden, Vince Lombardi, and Bill Bowerman kept practices short, paid attention to recovery, and were constantly asking what they could simplify and stop doing. They also saw themselves as teachers who turned the actual competition over to the athletes and did not micromanage from the sidelines.
Many people find it especially shocking that Lombardi, an innovative offensive coach, did not routinely call plays during games, preferring instead to collaborate with quarterback Bart Starr. Wooden did not scout opposing teams, believing that practice time was better spent on improving his players’ abilities to execute what they wanted to do.
How many health care leaders see themselves as teachers who empower their charges? How many are caught up in an arms race mentality with “the competition,” or try to catch the wave of the next hype cycle? How much better would things like quality of care and professional satisfaction be if the focus was on marginal gains instead of transformation-of-everything narratives that inevitably come up short? After all, real innovation is a mysterious thing. Would a central planning initiative have generated the Fosbury Flop?
I wonder what a person like Bowerman, who made his runners more efficient by personally making them faster shoes and lighter uniforms, would have to say about inefficient, time consuming, and distracting electronic medical records systems. His efforts to personally create better equipment for his runners almost certainly increased their trust in him. Imagine if the current “data is the new oil” mantra of health care organizations was replaced with a single-minded focus on a user-friendly, labor-saving electronic medical record that improved patient care and facilitated medical research. It’s a safe bet that morale would improve, burnout would decline, productivity would go up, and trust in leadership would rebound.
I’m 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 performers. If doctors, nurses, and researchers were seen as performers, they would be offered routine access to things like training tables and concierge services to ease the routine burdens of life. The vanishing home-field advantage in the National Football League shows what happens when the performer is the focus: teams have the logistics so perfectly calibrated that players aren’t distracted by travel.
So what is the ask, or maybe the solution? See the biomedical and health care worlds as being served by skilled performers rather than staffed by a workforce. Once that fundamental insight is adopted, it can be acted on systematically. Actions large and small focused on performers can lead to broad-based improvements in performance that will, in turn, lead to better outcomes and improved professional satisfaction — and institutional financial scoreboards will do just fine, if not better.
But as Wooden reminded his players, “Play your game and your plan. Don’t look at the scoreboard.” That’s hard to do in the short run. But for health care workers and researchers, it is either that or repeatedly hitting what someone will surely describe as the post-pandemic marathon wall.
Michael J. Joyner is an anesthesiologist and physiologist at the Mayo Clinic. The views expressed here are his own.