What is "Flow" and how does it contribute to Physician Engagement?

This month we’re beginning a new series on the blog exploring physician engagement. As we know from our excavation of problems in the healthcare industry last fall, lack of physician engagement is a serious issue many organizations face. It leads to increased rates of burnout, high physician turnover, and low job satisfaction, among other related issues.

Unlike our previous series, this month we’ll start to look at solutions for low levels of engagement, instead of bogging ourselves down with the problems. Since we’re already well-versed in why low levels of engagement are a problem, let’s move on to what’s needed to create engagement, i.e. flow.

Engagement at an individual level has been studied for nearly five decades and there is significant research to bolster this claim. Positive psychology has contributed the most to studying the connection between engagement and flow. Mihaly Csikszentmihalyi popularized the concept of flow as he researched creativity and productivity and conducted interviews with people who were successful in a wide range of professions. He discovered that the secret to people’s optimal performance was their ability to enter a state he called flow. Flow is so named because during these interviews several people described their "flow" experiences using the metaphor of a water current carrying them along (Csikszentmihalyi 1975).

What is flow?

Csikszentmihalyi defines flow as, “…being completely involved in an activity for its own sake. The ego falls away. Time flies. Every action, movement, and thought follows inevitably from the previous one, like playing jazz. Your whole being is involved, and you’re using your skills to the utmost” (Geirland 2017). Flow is characterized by complete absorption in what one is doing, and results in a loss of sense of space and time.

Consider this on an individual level. When immersed in certain activities, people often report completely losing track of time. Perhaps participating in a beloved activity like playing music or a sport where hours pass by without notice. Times like these are not passive, leisurely, or relaxing, but they are not unpleasant. Instead, they are active moments when body and mind are stretched in pursuit of achieving something difficult and worthwhile. Those experiencing a flow state may not describe it as fun or happy. In fact, the sense of enjoyment is an after effect during which one recognizes the time as essential for growth and mastery. They don’t have to be unpleasant, but they are active moments when our body and mind are stretched to their limits in active pursuit to achieve something difficult and worthwhile. 

This altered state, colloquially termed as being in the zone, is accurately described by one of the participants interviewed in the earliest stages of flow research: “My mind isn’t wandering. I am not thinking of something else. I am totally involved in what I am doing. My body feels good. I don’t seem to hear anything. The world seems to be cut off from me. I am less aware of myself and my problems” (Csikszentmihalyi and Csikszentmihalyi 1992).

How is flow related to engagement?

Data collected by Daniel Goleman shows that most people are either bored or stressed at work, where “15% never enter a state of flow on a typical day and only 20% enter flow at least once per day” (2013). Note that flow-producing situations occur more than three times as often when people are at work, as compared to during leisure time. This is because, as previously stated, flow is most easily accessed when engaged in a challenging activity. In this particular study, Goleman recorded any time that participants scored above their personal average in both the challenge faced and skills being used at the time of study (2013). Another important element is that flow experiences at work occur at all levels of employees: managers, clerical staff, and blue-collar workers (Csikszentmihalyi 2009).

The phenomena of flow and engagement has a few major elements. Across many studies, people reflecting on experiences of flow mention at least one, often all, of the following building blocks.   

Elements of Flow

But how do physicians achieve a state of flow in the workplace? 

Flow requires both challenge and skill.

The match between one’s skills and challenges creates an optimal state where flow can occur. This is also the state of engagement where active and effortless activities happen. It’s necessary to balance challenge and skill in order to achieve flow. Enjoyment and engagement are experienced precisely when the opportunity to tackle a challenge is equal to an individual’s skill level. If the challenge exceeds an individual’s skill level, they will experience anxiety. And if their skills exceed a particular challenge, boredom sets in. Engagement occurs just in between boredom and anxiety, when challenge and skill are perfectly in sync.

Let’s look at an example, a resident in early training may have anxiety when asked to engage in individual patient care, since they have little experience and skill in that area. However, the same physician may feel bored with the same work after ten years of doing the same thing. The challenge has become too low and their skill set has exceeded it. When and where a flow state occurs necessarily shifts and changes over a person’s career.

Flow merges action and awareness.

When an individual has all the relevant skills, their attention is absorbed by the activity. People become so involved in what they’re doing that their actions APPEAR automatic. Additionally, they are not aware of themselves as separate from their actions, which take place seamlessly and without doubts of self-questioning. From the outside, the experience appears to be effortless, when in reality it requires stamina, hard-earned skill, and focused mental energy. Like a pathologist absorbed in interpreting valuable information from what look like blobs of ink to an observer.

Flow offers clear goals and feedback.

People experience flow when given clear and immediate feedback. Even if goals are long-term and take months or years to accomplish, short-term goals and feedback are extremely important. Unfortunately, clear goals and immediate feedback are not always available at work and physicians often must use their own experience and support to develop this feedback internally.  

Short-term feedback that a surgeon receives during surgery is a different experience than a psychiatrist who seeks long-term functional improvement. The surgeon may consider the blood, the incision, or the vital signs to be the most important feedback, while the psychiatrist considers small changes in the patient’s mental status to be significant feedback. Without this feedback, over time, the work becomes meaningless and lacks engagement. When comparing the surgeon and psychiatrist above, it is clear how individualized feedback and goals must be in order to be effective.

Flow ensures concentration on the task at hand.

When the mind is engaged, it requires complete focus that leaves no room for irrelevant information. During day-to-day life, the mind is preoccupied with multiple thoughts, worries, and other distracting unwanted drains on concentration. When experiencing flow, the mind has exquisite focus that improves the quality of experience by diminishing interference of chaos. At any given moment, a great deal of information is available to every individual. Yet, psychologists have found that the mind can only attend to a certain amount of information at a time, about "110 bits of information per second" (Csikszentmihalyi 2008). That may seem like a lot, but simple daily tasks, like decoding speech, take about 60 bits of information per second, over half an individual’s capacity! For the most part people decide where they want to focus their attention. When in a flow state, the mind is completely engrossed with the task at hand and, without making the conscious decision to do so, loses awareness of all other things: time, people, distractions, and even basic bodily needs. According to Csikszentmihalyi, this occurs because all of the attention of the person in the flow state is on the task at hand. There are no more attention resources left to be allocated (2000).

Flow provides a heightened sense of control.

We can infer that as the practitioner’s skill set grows, they develop a sense of mastery about it. Then, they take on a new set of challenges and gradually with practice and training, gain more control over more difficult challenges. At a certain level of expertise, resetting a broken bone feels like the height of achievement, and as expertise grows, a triple by-pass feels like a no-brainer. The important thing is that while in the state of flow, there is a sense of being in control and an awareness of exercising that control.

Flow creates loss of awareness of self.

Typically, people spend a great deal of time thinking about themselves. It is human nature. This preoccupation with the self absorbs much of a person’s time and energy, especially when one perceives a social or physical threat to the self. As mentioned, flow invokes an intense focus, allowing the rest of the world to disappear from awareness. Simultaneously, there is also an obliviousness to the sense of self. This loss of self is sometimes described as a feeling of oneness with the environment. “One feels more together than before, not only internally but also with respect to other people and to the world in general” even after such an episode is over (Csikszentmihalyi 2009). Stress is a common threat that exposes our vulnerable self to constant worries. During flow, especially if the activity has clear goals and challenges are well-matched to skills, there is no threat to self.

In Flow, one’s sense of time changes.  

Subjectively, people sense the passage of time in different ways. The Greek language explains this phenomenon by using two words for time: Chronos and Kairos.  Chronos refers to measurable, objective time, while Kairos refers to the subjective experience of time (Liddel and Scott 2007). Sometimes this subjective experience is forced upon us. For example, “my whole life flashed before my eyes”, is a common statement made after near-death experiences. Individuals often describe a slowing sense of time doing this ordeal. That, obviously, is not a flow or engagement experience. An individual experiencing flow has entered such an experience voluntarily and, if the conditions are suitable, may repeat the experience again and again. During a procedure, a fully engaged physician still knows how much time has passed and how much longer they still have. They are aware of time, and yet simultaneously outside of it.

The key element of the flow experience is that it is an end in itself. The activity is intrinsically rewarding. Csikszentmihalyi describes it as an autotelic experience (2009). Auto, meaning self, and telos, meaning goal. It is an activity that is not done with expectation of some external benefit but because the doing is the reward. While seeing patients and helping them get better is not necessarily autotelic, seeing patients because one enjoys seeing them and interacting with them can be. 

During a flow experience, the person is focused on the activity for its own sake, and not on its consequences. Throughout it all, people describe experiencing flow as a highly pleasurable event. They enjoy being in control of a task, the ongoing feedback they receive, and find what they are doing highly self-rewarding. An engaged employee is one who has the opportunity to experience flow at an individual level at regular intervals during their work.

As a physician leader, how can you contribute to helping the physicians on your team experience flow more regularly? How can you on an individual level find flow in your work more often? 

If you’re ready to maximize your leadership potential and provide opportunities for your team to thrive in the workplace, I invite you to participate in my 5-Day Challenge: Coach Yourself! Becoming a leader is not an overnight process, but a slow and steady commitment to create and fortify a culture of learning and growth in the workplace -- starting with you. 

Next time on the blog, we’ll continue our exploration of physician engagement by looking at the differences between engagement on an organizational level and on an individual level. See you then!

References and Resources:

Csikszentmihalyi, Mihaly.

1975. “Beyond Boredom and Anxiety.” San Francisco: Jossey-Bass Publishers. Retrieved 3 September 2020.

Csikszentmihalyi, Mihaly, and Isabella Selega Csikszentmihalyi.

1992. “Optimal Experience.” Cambridge: Cambridge University Press.

Csikszentmihalyi, Mihaly, and Isabella Selega. Csikszentmihalyi.

2000. “Optimal Experience: Psychological Studies of Flow in Consciousness.” Cambridge: Cambridge University Press.

Csikszentmihalyi, Mihaly.

2008. “Flow, the secret to happiness.” Filmed October 2008 in Long Beach, CA. TED video, 18:55, https://www.youtube.com/watch?time_continue=15&v=fXIeFJCqsPs& feature=emb_title.

Csikszentmihalyi, Mihaly.

2009. “Flow: the Psychology of Optimal Experience.” New York: Harper Row.

Geirland, John.

2017. “Go With The Flow.” Wired. Conde Nast, June 4, 2017. https://www.wired.com/ 1996/09/czik/.

Goleman, Daniel.

2013. “Focus: The Hidden Driver of Excellence.” New York: HarperCollins, 2013.

Jain, Saurabh.

2018. “Education Needs Flow.” Medium. Medium, January 13, 2018. https://medium. com/@skjsaurabh/education-needs-flow-bdc08c659baa. Used with permission from Saurabh Jain. fun2dolabs.org.

Liddel, Henry George, and Scott, Robert.

2007. “A Greek-English Lexicon.”  London: Simon Wallenberg Press. http://www.perseus.tufts.edu/hopper/text?doc=Perseus%3Atext%3A1999.04.0057% 3Aentry%3Dkairo%2Fs1. Retrieved 3 September 2020.

Maslach, Christina, and Michael P. Leiter.

2014. “The Truth about Burnout: How Organizations Cause Personal Stress and What to Do about It.” San Francisco: Jossey-Bass Publishers, A Wiley Imprint.

Scott, Susan.

2017. “Fierce Conversations: Achieving Success at Work and in Life, One Conversation at a Time.” London: Piatkus.

Seligman, Martin.

2018. “PERMA and the building blocks of well-being.” The Journal of Positive Psychology. DOI: 10.1080/17439760.2018.1437466

McCambridge, Jim, Witton, John, and Elbourne, Diana R.

2014. “Systematic review of the Hawthorne effect: New concepts are needed to study research participation effects.” Journal of Clinical Epidemiology. March 2014.

Medical Group Management Association (MGMA).

2018. “Practices are slow to adopt staff engagement programs.” Post: February 20, 2018. Accessed August 3, 2020. https://www.mgma.com/data/data-stories/mgma-stat-poll-practices-are-slow-to-adopt-staff.