David Hanscom, MD – Orthopedic Spine Surgeon, and David Elaimy – Elite Performance Coach
In 2006, I engaged David Elaimy, an elite performance coach, as my surgical performance coach. As he coached my son, Nick, and his close friend Holt in competitive mogul skiing, I realized that surgery is also an individual performance. Over the next year, Holt won the National Championship in 2007, and Nick placed 5th on the North American Circuit. My surgical performance not only improved, but I also reconnected with the joy of being a surgeon. These principles also apply to being a professional at living life, with a focus on building skills to calm and reroute your nervous system. Like attaining any new skill set, it requires repetition.
David, assistant coach with the University of Washington women’s golf team when they won the national championship in 2016.
Performance = Skill – Interference
This approach is well-known in the performance world. It originated in 1974 with tennis coach Tim Gallwey in his book, The Inner Game of Tennis.1 His original wording was ” potential, ” and David Elmy’s rendition is “skill.” However, although surgery is a high-level performance, these concepts are not widely taught in surgical training.
Human suffering is not from a character flaw or personal failure. It is the predictable outcome of an over-activated unconscious survival response operating within a baseline state of Cognitive Fusion. When we spend our lives trying to “fix” ourselves or force life circumstances to conform to our expectations, we often become frustrated, and our nervous system stays locked in a threat loop.
The objective is to transition every participant from reactive, threat-based living (amateur reactivity) into deliberate, regulated mastery: Becoming a Professional at Living Life.
- Performance skills are rarely taught in medical or surgical training. The question is,“How consistently can you deliver a winning performance?”
- Traditional Fallacy: Medical education and standard wellness programs assume that improving outcomes is solely a function of acquiring more Skill (more treatment, more meditation, more effort).
- The Performance Reality: High performers rarely fail due to a lack of skill; they fail because of Interference—the internal noise of anxiety, frustration, rushing, distraction, complacency, and threat physiology that disrupts physical and mental mechanics.
- The Goal: We do not attempt to ” force” performance or pain relief. We systematically identify and minimize Interference, allowing native skill, bodily healing, and regulated performance to manifest naturally.
zhukovvvlad/ AdobeStock
Hardware vs. Software
To navigate high-stakes moments in health, surgery, and daily living, we divide experiences into two distinct domains:
- Hardware (Physical & External Realities): Your physical body, spinal anatomy, nerve tissue, politics, diagnostic scans, external schedules, weather, hospital systems, unwanted thoughts, and otherpeople’ss opinions.
● Software (Internal Mindset & Reactivity): Your intra-operative/daily focus, mental interpretations, automatic stress reactions, perspective, and emotional reactivity.
In other words, stress, almost by definition, refers to unpleasant thoughts and experiences that are out of your control. Your reactions to stress determine your physiological state and your capacity to enjoy life. You cannot control the initial reaction of anxiety and anger. They are hardwired in. However, you can regulate the response.
The 6 Rules of Hardware & Software:
Rule #1: Software Runs Hardware. Panic, anger, or rushed software directly alters physical hardware—increasing muscular tension, elevating stress hormones, sensitizing pain pathways, and degrading motor mechanics. Threat physiology also downregulates thebrain’ss neocortex (thinking centers).
Rule #2: You Cannot Directly Control Hardware. Trying to forcibly control external hardware (symptoms, other people, unwanted thoughts, uncontrollable schedules) in the moment creates immediate internal friction and threat.
Rule #3: With Awareness, You Can Generate Any Software Program at Any Time. While you cannot force hardware to change instantly, awareness allows you to intentionally select your internal software. Many ways can create a physiological shift from threat to safety.
Rule #4: You Are 100% Responsible for Your Software. External circumstances (hardware) do not cause your internal reactivity; you fully own your internal reactions and programming.
Rule #5: You are Your Software, but youdon’tt have to be. Battling unwanted thoughts keeps you enmeshed in them. You are your thoughts (identity). However, you do not have to be your software. You can use somatic and cognitive tools to separate from your thoughts and calm your stress response.
Rule #6: Software is Contagious. Calming your internal software regulates those around you, making you a “Great Playing Partner” in your family, workplace, and healthcare team. It works through mirror neurons in the brain.
Five Interferences
Interference is not an abstract external stressor; it is a specific, internal software state that degrades execution. Human interferences fall into Five Core Categories:
- Anxiety (Including Past Trauma & PTSD): Sympathetic fight-or-flight hyper-arousal. Driven by the ghosts of past medical setbacks or life traumas and fear of future failure. It is simply a very loud, unpleasant alarm that says, “danger.”
- Anger (Including Perfectionism): An aggressive fight response that acts as “gasoline on the fire” of threat physiology. Perfectionism is an angry demand that external hardware conform to an ideal.
- Rushing: Reactive, threat-driven urgency that bypasses safety protocols, narrows visual/spatialawareness, and degrades physical actions. FOMO is a classic issue in life. Where are we all rushing off to?
- Distracted: Fragmented attention; losing presence at the point of execution (worrying about the future or past while executing a current move).
- Complacent: Lowering vigilance during routine situations.
The Biological Root of Suffering: Cognitive Fusion & Threat Equivalence
Why do the 5 Interferences hold such destructive power over human health?
- Cognitive Fusion is Humans’ Default State: Cognitive fusion happens when you fight unwanted thoughts, establish an identity, and label yourself, and you become entangled with unwanted thoughts because you fight them. We don’t just have anxious thoughts; we become them. “I am broken.”This pain is destroying my life””). The more you fight them, the more powerful they become.
- The Brain Cannot Tell the Difference: The unconscious survival brain operates at lightning speed to control autonomic functions, muscle armor, vascular tone, and pain signaling. It has no mechanism to distinguish between a physical threat (a predator or bodily injury) and a mental threat (an intrusive thought, financial worry, or self-critical story). Anxious thoughts trigger the exact same high-amplitude adrenaline and cortisol cascade as physical danger.
- Why Active Tools Are Required: Because fusion is our biological baseline, conscious willpower, logic, or “forced positive thinking” cannot overpower powerful active threat physiology. Trying to argue with a fused threat program is like whispering over a jet. This is why concrete, physical practices—such as Expressive Writing, “Name it to Tame it,” Defusion, CBT, and Somatic Safety—are mandatory to disrupt fusion, create space, and down-regulate the survival brain.
“Every Move, Every Pitch”
High performance is not achieved in broad, vague strokes. It is executed in real time, move by move, pitch by pitch:
● The AIR Protocol
- A — Awareness: Pause and inhale deeply; explicitly label the active interference.
- I — Intention: While inhaling, choose the intention of your next move. Connect with it in the”safe zone.”
- R — Respond: During the exhale, execute the move or response from a position of awareness and visualization. Eventually, operating in the safe zone becomes automatic and routine.
Operating in the Safe Zone
- Visual Safety: It is easy to cut the exposure a little short and make definitive moves with full appreciation of the anatomy. Overexpose!! It might take a little longer, but it’s much easier than moving without 100% certainty.
- Tactile Safety: Monitor bodily tension; consciously drop your shoulders, unclench your jaw, and focus on creating the lightest touch on your instruments.
- Kinetic Safety: Vector your choices so that even if a setback occurs, your baseline safety remains. For example, in spine surgery, you never push an instrument – ever. You have control only while pulling.
Use Complications as Your Feedback
There are four levels of complications.
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- Type 1 – a given move is less than ideal, and there is no potential for harm. For example, you pull a little too hard on an elevator, and it slips toward you and away from critical structures.
- Type 2 – the same as Type I, except there is potential for harm. For example, your curette slips toward the vertebral artery during an ACDF (anterior cervical fusion), but no harm occurs.
- Type 3 – a minor complication, such as a small dural tear. There are no significant sequelae.
- Type 4 – a major complication with damage to an organ, vessel, or neurological structure. The sequelae are
The key is to look for Type 1 complications and use them as feedback. You should be aware of at least 5-10 per case.
Type 2 complications are undesirable, and a few usually occur in a given case. Again, no damage, but you are on higher alert.
Type 3 and 4 complications become rare as you keep yourself in the safe zone by monitoring Type 1 and 2 complications.
Use the AATW Performance Model and Calm Your Body, Heal Your Mind as guides and embrace challenges and adversity as chances to practice your skills; our view of suffering shifts from victim to opportunity. You will step up as active, elite performers in the high-stakes arena of the operating room and life. One of my more influential mentors taught me,””Never waste a crisis”” The next question is,””What is the opportunity”” He taught me to stop wallowing in my pain.
Let’s wake up. Go from reaCtive to Creative and watch your life expand without limits.
Repeated positive action creates meaningful change, not positive thinking. Lean into living life on your terms with highly developed skills. You can create the life you want in and out of the OR, even in the face of significant adversity.
Primary Book Resource
Calm Your Body, Heal Your Mind by Dr. David Hanscom
References
- W. Timothy Gallwey, The Inner Game of Tennis (New York: Random House, 1974).