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Enjoy Studying, Score Higher, and Have More Energy: How Flow Can Help

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by Alec Palmerton, MD in Plan
Med School Flow

How do you feel at the end of the day? Do you feel run down, like a candle scorched at both ends? Mentally sluggish, struggling to concentrate? Do you feel irritable, like a porcupine ready to send spikes to an unsuspecting passerby? Or unmotivated, losing every battle-of-wills against Youtube and Netflix?

Ever wonder WHY you feel that way? Do you wonder if there is a way to make it better?

What if things were different? What if, at the end of the day you slipped into bed, happy and contented. You congratulate yourself on how much you did. You note how challenging the day was, and how enjoyable it was to overcome the challenge. Your test scores are higher, and your sense of purpose greater.

This article is for you if you:

  • Struggle to get through the day, then dread the next day;
  • Want high scores on the USMLEs or other standardized exams; or
  • Want to find more enjoyment and rejuvenation in your work

Specifically, I will discuss the transformational concept of “flow.” Then I will explain how it can improve both performance and meaning for medical students.

(This is Part 3 of a 3 part series on motivation in medical school. You can read Part 1, and Part 2 here.)

What is “Flow”?

Have you ever been so engrossed in playing a game that you lost track of time? Or felt so engaged in what you were learning that you forgot to eat lunch? Or got so into writing a paper that you missed an important appointment?

If so, you were experiencing “flow.” Mihaly Csikszentmihalyi used “flow” to describe the experience of losing yourself in an activity. It came from his research on people who “were so enthralled in what they were doing that they seemed to be in a trance.” It’s behind when musicians “feel the music” or athletes are “in the zone.”

Intrinsic motivation means the activity itself is the reward. Flow is how we feel doing it.

Med School Flow

Flow is losing yourself in an activity. Flow is rejuvenating.

Flow Rejuvenates

What happens if we were to take flow out of our lives? That was the subject of an experiment from the 1970s by Csikszentmihalyi. In it, he told participants to record all the “non-essential” things that gave them flow.

Some people loved to exercise. Others found pleasure in day-dreaming while washing dishes.

Then he told them to remove the flow from their lives.

The instructions: “We would like you to act in a normal way, doing all the things you have to do, but not doing anything that is ‘play’ or ‘non-instrumental.'”

(Side note: does this sound eerily like the culture of sacrifice we embrace in medicine?)

The results were astonishing. By the end of Day 1, participants already felt “sluggish.” Most reported problems with concentration. Someone said their “thoughts wander[ed] round in circles without getting anywhere.” “Some felt sleepy, while others were too agitated to sleep.”

The DSM-V criteria for generalized anxiety disorder (GAD) require 3 of the 6:

  1. Restlessness, feeling keyed up or on edge.
  2. Being easily fatigued.
  3. Difficulty concentrating or mind going blank.
  4. Irritability.
  5. Muscle tension.
  6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

Within 48 hours, many of the participants met these criteria for GAD. It was so bad that the researchers stopped the experiment early. After TWO DAYS.

Think about that for a moment. Normal, everyday people took flow out of their lives, and within 48 hours many met criteria for GAD. That is astonishing and points to the importance of flow.

How Can We Achieve Flow?

Wouldn’t it be amazing to control our experience of flow? To engage ourselves more, for greater focus and performance?

For decades, researchers have studied what elements are necessary to promote flow. They’ve found that flow requires three components:

1) Flow Needs Clear Goals

Ever tried to go on a hike without a good map/clear directions? You’re always wondering if you’re going the right way. Instead of losing yourself in the activity, you wonder if you’re merely getting lost.

Flow is similar. Without clear goals, it is challenging to achieve flow.

Take studying for instance. For many med students, “studying” may mean “keep reading until I can’t read anymore.” Or taking copious “notes” of lectures/videos/textbooks. Without a clear goal, studying has no chance of achieving real flow.

Instead, clearly defining what you want to accomplish at the outset can help you achieve flow.

2) Flow Requires Immediate Feedback

Have you ever worked on something, and had no idea if you were doing a good job or not? What you were lacking was the second ingredient to flow: feedback.

Let’s continue our hiking analogy. If we lack clear directions (i.e., goals), flow is challenging. However, now let’s say that it is dark out, and there are no clear landmarks. We can’t see anything in the distance; we’re unsure if we’ve passed the same trees or rocks before. In other words, we’ve lost all forms of feedback of whether we are going in the right direction.

How would you feel? Overwhelmed? Scared? Definitely not a sense of flow.

Having immediate feedback will help you lose yourself in your studying.

3) Flow Requires Challenges Well Matched to Our Abilities (Not Too Hard, Not Too Easy)

This is the Goldilocks rule for flow: the activity should be challenging, but not too much, and not too little.

Once in middle school, I procrastinated on a paper that was assigned weeks before. I hadn’t even read the prompt. The night before, I realized that I needed not only to research but write an entire paper. The challenge overwhelmed me. I couldn’t concentrate and felt a constant panic as I banged out a seriously deficient term paper.

I wasn’t feeling any sense of “flow.”

Unrealistic Expectations Kill Flow

Have you ever felt overwhelmed with how much you had to do? (Umm…yeah?). If you’re a med student, then this feeling is likely constant.

Trying to do too much is also likely to be a significant reason why you lack flow and feel tired all the time.

Let me explain. Most med students are extreme hard-workers. We got here by working harder and more extended hours. Sacrifice is part of the game.

However, that same mentality plants the seeds for stress and burn-out. Most med students carry around a deep sense of guilt. Have you ever felt like you should be doing more? Taking more notes? Watching more videos? Shadowing more? It’s a never-ending stream of “should’s” and “ought-to’s.”

However, by always trying to do more, we are creating a situation that is WAY too challenging. Remember, to achieve flow, the challenge has to be matched to your abilities. Too hard and no flow.

It’s like asking me to play basketball against Michael Jordan in his prime – I don’t stand a chance. By continually adding to our “to-do’s” we create a list we couldn’t possibly do.

For example: you decide you want to do Anki cards. Then a friend mentions they’re doing UWorld questions already – you start to add Qbank questions to the mix. Then you decide you’ll start doing the latest online lectures (Pathoma, B+B, OnlineMedEd, etc.). Before you know it, your to-do’s are overwhelming. Instead of getting all these things done, you are overwhelmed, and accomplish little to nothing.

The solution? Aim to do less. If you find yourself overwhelmed with how much you have to do, cut back on your to-dos. Identify the one or two most critical activities, and focus on those. (I advocate for mastering of topics + doing Anki cards for retention).

Remember, flow requires a reasonable challenge. Giving yourself more than is possible will only worsen your exhaustion and performance.

How to Achieve Flow in Leisure

It’s the end of a long, grueling week. You’ve been pulling all-nighters, cramming for your last exam. Or you’ve been at the hospital for all hours. What is the best way to recuperate? Do you:

1) Binge-watch Netflix as a way of doing as little thinking as possible, or
2) Find a leisure activity that will engage and challenge you?

We work so hard that it’s tempting to think that to recuperate we should shut off our minds. If work = energy-drainer, then no work = energy-giver. The rationale? Working hard uses energy, so to regain strength, I should minimize effort.

Flow research suggests, however, that we don’t refresh ourselves with the absence of work. Think about it: how do you typically feel after a Netflix binge? Energized, alert, and ready for more action? Heck no! I’m usually MORE tired. I certainly don’t feel better.

Why?

As Csikszentmihalyi’s experiment suggests, it’s not the absence of work that refreshes us. Instead, it is the experience of flow that we achieve by work or play.

I’ve started to re-think my leisure time. In residency, I would watch TV as a reward for getting through a long week. (Sometimes with an alcoholic beverage.) I took my exhaustion afterward as a sign that I needed to work even less, NOT that Netflix was a poor way to recharge.

Now, I’m not so sure.

Near the end of my residency, I started reading books instead of watching television. I was still working as hard, but I found that after a good book, I had substantially more energy. Anecdotally, flow recharged me, even though I was working “harder.” My reading of research on flow would seem to support that, as well.

Flow Allows Studying to Feel Like Play

“Once we realize that the boundaries between work and play are artificial, we can…begin the difficult task of making life more livable.”
– Mihaly Csikszentmihalyi

You may be thinking, “but I don’t have time to ‘play’ in med school!” “Medicine is all about personal sacrifice – I’ll sleep when I’m dead.” Au contraire, mon ami.

It’s astonishing to note that without flow, we may become irritable, sleep-deprived zombies. What’s even more surprising is that flow is more accessible to achieve with work than it is with leisure.

Say what? Can I turn work into something enjoyable and rejuvenating? Studying doesn’t have to be an all-consuming, soul-crushing experience?

Yes, my friend.

Work Can Fulfill the Three Requirements for Flow

Recall the three requirements for flow: clear goals, immediate feedback, reasonable challenge.

Think about your hobbies for a moment. What are the things that you do that engage and refresh you? Gardening, sports, outdoor activities, board games, reading? They likely have these three characteristics.

Know what else can have the three elements of flow? Studying!

I loved studying during medical school. I didn’t have the words at the time, but every day, I used the elements of flow to engage and energize myself.

Clear goals? Every day, my goal was to master the Boards-relevant material presented in class.

Immediate feedback? I knew I had done an excellent job if I a) understood it, and b) had made it into Anki cards.

Challenge matched to my ability? It wasn’t easy, but I knew if I was efficient and woke up earlier, I could accomplish those goals.

I’m sure I’m not the only successful student who enjoys studying. Every student I’ve ever known who scored 250 or 260+ on a USMLE enjoyed studying. You can tell when you speak with them. They are genuinely interested in learning and love applying that knowledge to vignettes.

Contrast that with students who typically struggle to pass. If you’re at risk or have failed a USMLE, it is almost never an issue of intelligence. Instead, it is nearly always an inability to study effectively. Rather than engaging with the material, they’re always worried about how much (or little) they’re doing. Instead of diving right in, they procrastinate because of exhaustion and perfectionism.

Concluding Thoughts

Most med students struggle to reconcile the desire for wellness with their professional ambitions. Or more accurately, we sacrifice wellness to pursue higher USMLEs and more residency options.

My surprising takeaway having read numerous books on motivation, flow, and expert performance? The goals of wellness and professional success can be complementary. Nowhere is this truer than the concept of flow.

Feel exhausted at the end of the day and dreading the next? You likely lack flow. Can’t concentrate on your UWorld block? Try making flow your aim. (And sleep more).

There is an entire branch of psychology devoted to understanding how we can work at our peak and enjoy doing it. You can read more about this in books like Daniel Pink’s Drive (affiliate link).

Or you can add more flow to your routine.

What do you think? How much flow do you have in your life? Do you think that adding more flow is realistic, and what kind of changes do you think you could achieve?

Reference:
Pink, Daniel H.. Drive: The Surprising Truth About What Motivates Us. Penguin Publishing Group. Kindle Edition.

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Want FREE Cardiology Flashcards?

Cardiology is key for impressive USMLE scores. Master cardiology from a Harvard-trained anesthesiologist who scored 270 on the USMLE Step 1 with these 130+ high-yield flash cards. You’ll be begging for cardio questions - even if vitals make you queasy.

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