Fitness from the Inside Out: Kristen Holmes on Joy and Burnout in Medicine

  • Alexa Miller
  • September 15, 2020

An elite level athlete, coach, and teacher, Kristen Holmes has spent her career studying and testing scientific principles related to physiology and psychology in high performance environments. One of the most successful coaches in Ivy League history, having won twelve league titles in thirteen seasons and a National Championship at Princeton University, Kristen now serves as Vice President of Performance Science at WHOOP. She works with hundreds of the best tactical, professional, surgical teams, and NCAA Athletes/Teams in the world helping them interpret WHOOP data to optimize training, recovery, and sleep behavior.

You’ve had a particularly dynamic career path through sports, physiology and the learning sciences, and tech. What’s driving you? 

It’s evolved over time, but what I’m after at my core is living my values with joy and energy. My day is set up so that I can just kind of… back into that.

Happiness, for me, is peace: feeling content that what I’m doing in the present moment is what I’m meant to be doing, a level of acceptance. How to get into that state consistently has been the subject of both my research and my energy on the applied side. If I want to have peace, what does my day need to look like?

How do you know when you’re in that state?

I’m not wanting. I’m able to actually be truly present. My mind doesn’t wander. I have control over my attention and my thoughts.

I’ve kind of given up on this idea of problems in general. There will always be unlimited external problems. When you give up on the whole idea or concept of problems, all of a sudden you start to recognize that inside there is actually quite a bit of peace.

That is so…peaceful. How for you does peace reconcile with times at work or life that require a lot of intensity?

My path to peace is really the degree to which I’m able to live my values.  Identifying what it is in my heart that I really care about, and then aligning those values with my daily actions.

What are the core values on your shortlist?

Tolerance is at the top. Having tolerance and an open heart leads to less judgment. I don’t ever want to be in a scenario where I think I have the answer. Every person, every event, comes with context that I can’t possibly understand. Approaching everything with that kind of lens is really important to me.

Innovation. I want to feel like I’m doing something that’s unique and contributing to society. I think from first principles, and I want to be able to take those principles and layer original thinking. My current role affords me innovation in pushing scientific boundaries and finding new ways to solve problems in the area of human performance, which is something I love thinking about.

Presence. It is easy to get pulled out of reality, to get caught up in future planning or ruminating on the past too much.Long range strategic planning is important, but I’m talking about turning off the ridiculous voices that lead to the incredibly unproductive states of fantasy and judgement. I work to bring awareness to my thoughts and attention and keep myself in check. I know that in order to bring state of peace to my relationships, be present in my work, I need to be in control of my mind. 

Internal fitness. I can look great on the outside but what is actually going on inside me? That is the real scorecard. How I eat, what thoughts I allow, how I apply my attention, the food I eat, sleep. They all contribute; they are all related.

We talk a lot about performance. What does performance mean to you?

I think of performance as your ability to intentionally behave at a level equal to your physical, mental and emotional potential. It’s easy to just kind of drift through life, but if you’re really interested in fulfilling your potential and in getting the most from your life mentally, physically, emotionally, and spiritually, there needs to be intention behind your actions.

Performance is being aware of how your behaviors contribute to your overall happiness. It’s doing that internal work to understand what it is you care about, what that means for how you spend your time, and ensuring that is how you’re spending your time. I am a sum of my actions and there are no neutral actions. Performance is about human thriving.

Is there an example of that that stands out?

The context of decision-making stands out. Decisions should generally be fairly easy if you know your values. If you don’t have clarity there, you end up kind of flinging yourself in all sorts of directions. It’s so micro, but clarity on values sets up whether you’re going to have a happy fulfilling life, or not. Does this path give me the opportunity to action my values or does it not?

How did you first start innovating with the concepts of whole-day consciousness and athletic performance?

Coaching field hockey, I noticed that the two daily hours of training yielded no prediction on how my athletes would show tomorrow. So I asked: how do we quantify the other 22 hours? What are the variables and factors that we need to be thinking about in order to design the day in a way that would enable us to have more control over next-day capacity? Sleep bubbled to the surface quickly as a factor influential to overall mood, energy level and propensity to hit training effect during practice consistently. The other big factors were hydration levels, nutrition and mental factors, such as how much control they felt they had over living purpose and efficacy.

It was an incredible moment because up to that point–we’re talking 2013-2016–it was really all about external load. We were not adequately considering internal load. And we certainly weren’t thinking about the other 22 hours. Suddenly, we were able to quantify that in a meaningful way that could direct behavior.

Coaching Princeton University, against Penn State

Technology aside, it’s such a powerful principle, that idea of time outside of training and its profound impact on craft. 

Yeah. It’s counterintuitive, but the principle is that your downtime is your competitive advantage. The time that you are away from your craft is the time where is going to dictate how you re-engage your craft, depending on how you spend it.

I love that concept of re-engagement because it recognizes the presence of the gestation time between engagements with craft. 

Yes. Every time becomes an opportunity to go in fresh, with a new lens, as a different person. I truly believe the ability to consciously de-activate is the path to innovation, creativity, and accessing one’s highest self. 

What do you think that means for medicine? For frontline medical teams who have a craft?

The skill of deactivation is the critical element for anyone in a fast paced, high-stakes environment.

Maintaining an activated state comes at a significant cost. Even in chaotic environments, you don’t have to be in a state of hyper vigilance all the time. You need to be activated when you’re engaged in your craft, and then you need to toggle out of that state. Understanding how and when to deactivate is just as important as being able to activate. I think this might be the key to maintaining consistent high-level performance.

So: After six hours in the Emergency Department, when there was a 50-car accident, how do I go home? How do I come down from that? What are the skills that I need to have in order to be able to put myself in a situation where I can deactivate and put myself in a position to be present enough to go to sleep, to read a book to my child before bed? This is not easy. But longevity, both career and health, rests here. 

I think that’s the most important next step for medicine: ensuring that there’s education to help people understand the tools to toggle between these two states.

Where are the places you see innovating with this?

WHOOP is collaborating with Dr. Doug Johnston at the Cleveland Clinic, Drs Jamie Coleman and Mitch Cohen at Denver Health. I believe doctors looking at burnout in an intentional way like this are going to help facilitate change at scale.

I see good trends happening in Naval special Warfare. Special forces are starting to think about what happens when the war fighter goes home. How do we help him understand how to deactivate? And, are there opportunities to deactivate within the environment? What does that look like?

In sports, this informs the time on the bench when athletes are taking a breather. They intentionally deactivate: doing diaphragm breath work, bringing their heart rate down in an intentional way, taking a mental break. They still have a soft focus on what’s happening in the game, but they are resting with the intention of being able to reactivate at a higher level.

So I see it happening across military and Sports and Medicine, but not at the scale that we need it to be. These skills need to be baked into their education in medical school.

Can you talk a bit more about the physiology of burnout?

I look at burnout in light of lack of energy for replenishment. Not being able to access the energy that’s required for your job is what leads to depression, and to all the negative repercussions that happen when you just don’t feel like you have the energy you need to do your job effectively. There is also the feeling that the cost of what you do doesn’t equal the reward. When sleep isn’t where it needs to be, that layers on living in a sympathetic state where you just can’t come down enough to get in a state where you can actually have consolidated sleep.

Biologically, your body always has this drive for autonomic balance. The result of prolonged energy mobilization forces phenomena to occur such as allostatic load (the cost of chronic exposure to stress), irritability, and exhaustion. Feeling stressed or burned out from work is the result of a complex interplay between the brain, spinal cord, and the autonomic nervous system in which the neural system becomes aware of the physiological state of the body. It’s going to force behaviors that put you back into a feeling of “ balance,” but unless you have the tools to understand how to do that in a healthy way, our default isn’t to choose the healthiest path. Our brain will choose whatever is easiest, whatever feels most pleasurable, but oftentimes that isn’t in line with what’s healthy. So you end up using medication or alcohol to help you deactivate. Obviously, that’s not a good long-term strategy. Eventually someone is going to bear the brunt of that constant activated state, whether it’s your family or you are engaging in destructive behaviors just to try to feel you know, some sort of balance.

We are doing quite a robust study with Denver Health, with 250 trauma surgeons. We’re in the analysis phase right now. But we see that these folks are simply not getting the sleep they need, to the degree that they are basically operating in a cognitively drunk state for a majority of the day.

This lack of energy is at the core of the issue. The actual exhaustion that these people feel is something that we don’t really understand or fully appreciate. Severe energy depletion influences attitudes toward the job as well as professional efficacy. At a policy level, it’s a problem.

Could you talk about how a coach approaches a roster, and what that means for medicine?

A coach cares about their athletes’ capacity, and looks at it in a very strict light. In other words, the coach looks at trends and understands how their athletes are coping with external stress in order to understand what their capacity is for that day. Coaches now have ways to measure the capacity of their athletes–what the athlete is capable of–and puts them in the game based on that data.

Let’s say that for a couple days in a row, my athlete is run down. If I put that athlete in a position where they have to compete,  the chances of them getting injured or injuring someone increases exponentially. In field hockey, you’ve got sticks and balls and people running at really high speeds as the context for a lot of decisions being made. I would never put an athlete in a position where they can’t compete effectively, where they could injure someone else or themselves. 

In medicine, people are performing surgeries with life or death consequences, and we don’t know that person’s capacity. It seems really clear that you wouldn’t want to put a surgeon in a position to perform where the statistical probability that a medical error can occur increases.

And that just seems like…. an opportunity, really. How are we not thinking about a roster of folks who perform surgery in the same way that we think of a roster of athletes who are going to perform in a game? It is just mind-blowing. We have the technology now. At a policy level, we have to start to rethink how we’re assigning folks to these different jobs.

What if frontline staff treated themselves more like athletes?

I think that would allow them to come to their jobs with more energy, more stamina, and more joy, and to engage with craft on a more meaningful level. We need to think about this as a long-term game with the physical, mental, and emotional health of our frontline staff at the center. 

USA vs Japan, Champions Challenge. Virginia Beach, 2005

What is your response to those who say that self-care is “selfish”?

That is a highly ignorant statement. You can’t possibly show up for others–mentally, emotionally, physically, spiritually– when you’re not able to take care of your own needs. If you don’t take care of yourself in a way that actually, truly feels really good, your access to your patience, resilience, and leadership get diminished. Prioritizing your own health is the ultimate form of respect and love. How else can you be available and present for the people that you love?

Interview by Alexa Miller, High Performance Medicine® Correspondent