AANS Neurosurgeon | Volume 28, Number 4, 2019


Gritflowness: Using Grit, Flow and Mindfulness to Reduce Stress

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“Everyone, let’s take a moment. Close your eyes, stand still. Breathe in, breathe out.”

These words echo through the neurosurgery operating room at Lenox Hill Hospital whenever John Boockvar, MD, FAANS, and David Langer, MD, FAANS, are working. It was my very first day at Lenox Hill, and the mantra was all around me.  “Breathing,” I thought to myself, “It’s such a basic human instinct – why should we need a reminder?”

Neurosurgery is clearly one of the most demanding specialties, producing burned-out physicians at a clip of ~50 percent.1 For trainees, learning how to manage stress may be as essential to lasting career success as mastering fundamental surgical skills. As medical students, we are trained (and tested) to build rapport, express empathy, diagnose illness, titrate medications and write notes; however, lessons on self-care and mental balance are often skipped altogether. For me, the cornerstone of my own balance comes from grit, flow and mindfulness.


Angela Duckworth, PhD, who delivered a keynote address at this year’s AANS Annual Scientific Meeting, has studied the importance of grit in many different high-stress professions. According to Dr. Duckworth, grit is the tenacity and passion that one brings in the pursuit of long-term goals. Duckworth’s research has consistently demonstrated that grit is a strong independent predictor of sustained career satisfaction and achievement. However, maintaining grit for years or decades is not easy. Grit requires deliberate practice under the mentorship of a leader in the field. It requires extreme focus and constant feedback to the mentee to allow her to constantly improve.


Deliberate practice and grit helps to develop muscle memory to enter the “Flow state.” Mihaly Csikszentmihalyi first described this state of complete concentration, during which the highly challenging task at hand feels effortlessly completed.2 For an aspiring young neurosurgeon, flow states may be found in the operating room or classroom and any activity, such as playing sports. This requires being able to assume a focused mental state in which one is unaware of the distractions. Setting aside the chaos is important in all aspects of life in order to continue achieving challenging goals. Csikszentmihalyi further developed a chart depicting a ‘flow channel’ that describes the relationship between the level of complexity and challenge of a task versus skillset. The flow channel is intended to be the optimal state in which the difficulty of the activity matches one’s skillset. When the challenge is too great for the given skillset, we experience anxiety – the state above the flow channel. Below the flow channel lies the state of boredom, which signifies that a person is too skilled for the task at hand and will thus be disinterested. 


Mindfulness maintains one’s alertness and attention, filtering the constant stream of potential distractions. Not only does mindfulness have psychological benefits, but neuroimaging studies have also shown that mindfulness can engage mechanisms of neural plasticity. In one study, MRI images of participants who practiced mindfulness for eight weeks showed an increase in gray matter density in brain regions implicated in learning, memory and emotion.3 Another study showed that those who practiced mindfulness had decreased amygdala activation in response to emotional stimuli, which suggests that people who meditate can have more regulated reactions to fear and stress.4

The synergy of grit, flow and mindfulness, Gritflowness, allows a gritty individual, such as an aspiring neurosurgeon, to enter a focused state of motivation while staying calm and centered on the task at hand. As early trainees, we are still learning how to leave external problems outside of the operating room, especially during medical school, when an endless list of stressors can confound us. Developing an appreciation for Gritflowness, and a consistent approach to entering this focused state, can be one way to promote a sense of self-balance, awareness of stressors and calm in the face of adversity.

Every aspiring neurosurgeon has been subject to the pressure to do extremely well on the USMLE exams. We all go through the dedicated study period and endure high levels of stress for weeks on end. As the exam approaches, students may start experiencing insecurity, fear, self-deprecation and ultimately ask, “Can I really do this?” A good medical student must use deliberate practice to adequately prepare for the exam. The student can use mindfulness to manage anxiety by always returning to her breathing and maintaining a mindfulness practice daily. With mindfulness and grit, she can stay motivated to continue studying and enhance her skillset, to balance the level of complexity of the exam, indicating that she has entered the flow channel. If the student knows the material in its entirety well before the exam, then she will get bored and burn out on test day. Similarly, if the student knows too little, then her skillset will not match the difficulty of the exam and anxiety will cause her to underperform. Mastering the essence of entering the flow channel will allow for self-doubt to diminish and ultimately, disappear.

This is the essence of Gritflowness. Grit leads to flow and mindfulness gets you out of negative ruminating thoughts. By choosing to break the vicious cycle of negative emotions and maintaining focus in the flow state, the student can apply the knowledge gained from studying most effectively. At the end of the daunting dedicated study period, many students feel extremely burned out, and the start of clinical rotations is the next challenge. However, this is where deliberate practice and grit come back into play; it’s a self-derived elixir that drives the young neurosurgeon-to-be and keeps her ready to take on any stressors that come her way.

Here are some simple steps for achieving calm in a state of panic:

Step 1: Close your eyes, take a deep breath in through the nose, hold on to the breath and exhale out through the mouth.

Step 2: Acknowledge the negative and anxiety-provoking thoughts. See them and let them go. Do not suppress your thoughts!

Step 3: Repeat the breathing exercise as you achieve calm.

So now, take a moment. Close your eyes; stand still. Breathe in and breathe out. You will be happy you did.


I would like to thank Kevin Kwan, MD; Nitesh Patel, MD; Kay Kulason, BS; David Langer, MD, FAANS; and John Boockvar, MD, FANS; for editing this piece.


1. Mcabee, J. H., Ragel, B. T., Mccartney, S., Jones, G. M., Michael, L. M., Decuypere, M., . . . Klimo, P. (2015). Factors associated with career satisfaction and burnout among US neurosurgeons: Results of a nationwide survey. Journal of Neurosurgery, 123(1), 161-173.

2. Csikszentmihalyi, M. (1990). Flow: The psychology of optimal experience. New York: Harper Row.

3. Hölzel, B. K., Carmody, J., Vangel, M., Congleton, C., Yerramsetti, S. M., Gard, T., & Lazar, S. W. (2011). Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Research: Neuroimaging, 191(1), 36-43.

4. Desbordes, G., Negi, L. T., Pace, T. W., Wallace, B. A., Raison, C. L., & Schwartz, E. L. (2012). Effects of mindful-attention and compassion meditation training on amygdala response to emotional stimuli in an ordinary, non-meditative state. Frontiers in Human Neuroscience, 6.

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