I have a confession to make: I have blood on my hands. My actions have led to the death of children. Now, that sounds extreme, and in reality, it is. Not in the course of everyday life, of course. But as a pediatric otolaryngologist (ENT) and airway surgeon, I have had to make near-instantaneous decisions with life-or-death consequences for the patient. Fortunately, the vast majority of the time, things go well. In many cases, decisions are made ahead of time in the preoperative planning process and are not spontaneous actions in the heat of a stressful “life or death” moment. But there are a few cases where the wrong decision in the wrong moment still haunts me. Given the nature of the profession, I am here to live with the ramifications of those decisions, while the patient may not be any longer.
Everyone wants to be the “clutch” player—the one who drains a three-point basket to win the game, delivers the game-winning hit, or sinks a miraculous putt on the 18th hole to win the tournament. But in reality, no one performs better under pressure. Stress creates a cascade of physiological impairments that, while they may provide a temporary adrenaline benefit via the fight-or-flight response, do not allow us to perform complex tasks at our peak in a stressful environment. While people often point to the Michael Jordans and Tom Bradys of the world, studies have shown that fourth-quarter free-throw shooting and late-game batting averages are no better than average, even for the best players.
So, what allows some to perform their best when it matters most? The key is not the stimulus but the response. More specifically, can an individual ignore the physiological impacts of stress and perform a task as if it’s just another routine? Viktor Frankl, in his book Man’s Search for Meaning, probably stated it best. Frankl, a physician and Holocaust survivor, endured unimaginable horrors in concentration camps during World War II, yet survived and thrived post-war. “Between stimulus and response is a space. In that space is our power to choose.” In essence, we must separate stress from our reaction. Easy to write, but harder to do when the room around you is on fire. Frankl survived the war partly due to luck, but his outlook on life allowed him to maintain composure and thrive afterward.
Performing Under Pressure by Hendrie Weisinger examines this phenomenon and how it impacts high performers. The authors also suggest ways to help readers handle pressure-filled situations better, many of which apply to medicine. Yet, the life-and-death drama that medicine entails does not always lend itself to solutions such as meditation, listening to a favorite song, or squeezing a rubber ball. So, when the clock is ticking, oxygen saturations are dropping, and the patient is counting on you, how do you respond?
In truly critical, life-or-death situations, how can one improve? I believe there is a path forward, but as with most worthwhile things in life, it is neither easy nor straightforward. Some factors can be controlled (like preparation before an event), while others (like gaining experience) take time. For simplicity, I’ve identified ten key actions to help perform your best under acutely stressful situations and divided them into two phases: preparation and mindset.
Preparation includes everything that can be done before finding yourself in a critical situation.
Communicate and plan. Communication and planning are critical. Fortunately, most events provide at least a short window to assess the situation and think of a plan. In the operating room, communication with your team is imperative. We often talk of “sharing the airway” with the anesthesiologist. Discussing each airway case ahead of time with the anesthesia team is critical. What is the patient’s likely diagnosis? How will the patient be ventilated and oxygenated? What equipment is needed, and is it available? Does that equipment work as intended? If the ideal option fails, what is Plan B or Plan C? Talking through these steps forces everyone on the team to think aloud, engage in group problem-solving, and remind each other of the process.
Take notes. For complex and difficult surgical cases, I have made it a habit to write down notes and reflections afterward. What went right, and what went wrong? What could I have done better? Was there a better way, or more useful equipment we should have had on hand? I file these notes away and have referenced them often throughout my career. This practice forces me to consciously think through the smaller details of challenging cases and aids in future preparation.
Experience counts. Sometimes, experience is irreplaceable. Erick Erikson’s work on peak performance emphasizes that not just pure repetitions, but deliberate practice, are critical to developing mastery. In surgery, doing 1,000 procedures alone doesn’t make you a master. But reviewing your techniques, analyzing complications, consulting mentors, taking on progressively harder cases, and adjusting based on lessons learned may.
Just do it. In a time-sensitive crisis, the outcome doesn’t need to be perfect. In my work, a tracheotomy incision may be too large, the dissection off-midline, or the tube size less than ideal. Yet as we often say after difficult airway cases, “At least you got the airway.” The process may not be textbook-perfect, but reaching the outcome builds confidence for future cases.
Focus on the task, not the outcome. I recall a radio interview with Tiger Woods, in which he discussed a critical putt during a Grand Slam tournament. Asked what he was thinking, Woods replied, “Twenty-five feet, with a slight break to the left.” His sole focus was on the task at hand, not the potential outcomes. In surgery, my cue to focus similarly occurs during the prepping process—when the patient is covered in towels and drapes, and only the surgical field is visible. This is my signal to lock in on the procedure and exclude distracting thoughts.
There are many tricks to prepare, but when the moment arrives, you must perform. This is where the “clutch” mindset comes in.
Tough cases are a challenge. To get better at something, you must challenge yourself. Just as you won’t get stronger lifting the same weights daily, you won’t improve as a surgeon without progressively harder cases. Though more stress accompanies difficult cases, viewing them through a growth mindset allows surgeons to develop greater skills and confidence. Even now, certain cases wake me up at night, but seeing these challenges as growth opportunities keeps me focused.
Lose your fear of failure. The worst outcome for a surgeon is losing a patient on the operating table. As a young attending surgeon, that was my biggest fear, especially if I had erred. But after losing my first patient, I became a better, more confident surgeon. The cloud of failure no longer loomed. Losing that patient, as difficult as it was, gave me the maturity that has likely helped me save additional patients.
Control what you can. In surgery, as in life, we make decisions with incomplete information. Annie Duke’s book How to Decide highlights this. Surgeons face many factors impacting outcomes, including the ever-present “patient disease.” If I’ve prepared properly and executed a sound plan, an adverse outcome is easier to accept. Sometimes patients are too sick to recover, but knowing I’ve done everything in my power helps me sleep at night.
Block out emotions. Just as I prepare and drape a patient, I block out emotions to focus. In a life-or-death scenario, I cannot afford emotional distractions. My mental and physical energy must be entirely focused on the task at hand, not on external concerns.
Laugh. In pressure-filled situations, projecting calm and appropriate levity can lighten the room’s tension, helping everyone focus better. As the leader in a crisis, even small doses of humor can make a difference in reducing stress.
These concepts are easier said than done. My mind still wanders at times, and my physical skills sometimes waver. But with practice, preparation, and experience, anyone can improve in the clutch. Just remember to:
Preparation:
- Communicate and plan
- Take notes
- Use your experience
- Just do it
- Focus on the task
Mindset:
- View tough cases as a challenge
- Lose your fear of failure
- Control what you can control
- Block out your emotions
- Laugh
William O. Collins is an otolaryngologist.
