Lessons from surgeons and athletes on making better decisions under pressure
Hi,
Today I’m feeling very grateful...
I’m unbelievable happy and honored to have been part of a new publication that came from my working relationship with Mount Sinai Hospital. Working with NYCs top medical doctors I’ve learned that there is such a deep level of expertise in neurosurgery that is crafted through many years of intense apprenticeship style learning, commitment to overcoming challenge and adversity, sacrifice, pressure, risk and an enduring will to be of service to others in need. And yet, after their many years of service and reaching an expert level, many neurosurgeons continue to strive to perform better and advance what we believe is achievable. So the focus of this post is on exactly that: what we can learn from experts including surgeons and athletes to help us make better decisions under pressure. Read on for some thought provoking concepts and practical step-by-step practical strategy.
An exercise on gratitude and performance
So, before I dive in to the main article here, I thought it would be timely to reflect on something that you (the reader) have personally been creating, working on, building or developing for quite some time. Maybe you’re writing a book or article, training for an event or competition, running a research investigation, studying a course, developing a new skill, starting a business, pursuing a particular career path. Can you take your mind back to the moment just before you began? Did you or someone else conceive of the idea? Why did you begin? Where were you when you got started? Who influenced your decision to dive into the project? What about actually doing it got you excited? What does it say about you that you chose to start it? Does your ability to begin this ‘thing’ mean you are daring, courageous, brave, decisive, adventurous, crazy, wild, spontaneous, curious? Just take a moment and think about the progress you have made since you started? Perhaps there was uncertainty about if you could pull it off. Perhaps you questioned if you were able enough to make it happen. But, in spite of those you got to work. Consider all of the road blocks and unexpected challenges you have overcome since then. Think about any new learnings, unanticipated results and small wins you have achieved along the way. The process of making something is really quite beautiful isn’t it? You start with nothing but a figment of imagination of what could be and then slowly, surely, progressively it manifests into something that is real. Something that you can see, touch, put to use and feel. Isn’t that cool? That we can do that. Does any sense of getting better and progression seem worth all the challenge, difficulties and pain in pursuing it? Is the process of building in itself something special? I think that whenever we are building anything we owe it to ourself to enjoy our own unique process. We must try with every ounce of energy and will power we have to enjoy our process, because that is what will not last. Yes, we will have the result one day, but then the process is gone - it’s transformed into what we have made and at that point the process is a memory. Once the result is achieved, we are no longer in the thick of creating, learning, growing - we have grown: we have achieved. Whether we have achieved more, less or exactly what we anticipated, we have achieved. And then it is done. Then we can be still. Then we can have some peace, even just for a moment before the next effort, a new cycle, the next idea, the next phase of growth.
The process of creating, working, developing or learning can be very special. Every day you have an opportunity to decide whether your process is enjoyable and fun or painful and exhausting. Every day you can transform any ounce of uncertainty into a strategy that leads to improvement. Everyday you can realize that you, the creator of whatever it may be makes you extremely special. Because it is you that is putting in the effort against all of the potential personal challenges which you face, that no one else will quite understand, in the way that you do.
So please continue with whatever path of achievement you are on. Please enjoy it. Please take a moment to be grateful for the expected and unexpected gifts, rewards and setbacks that appear along the way. Because you will only be on this part of your journey once. And then it will be gone. And you will have the finished product. Then you can see what it’s worth to others. What impact it creates. What return on investment it gets. But you will know what it’s worth to you first - a value that represents all of your effort, before any subsequent result. And that’s what matter most to feeling grateful about what you have built. To savor the process of creating as much as or more than the final result. And then, from that moment onwards, you can decide what you will do next.
Diving in: Expert Decision Making Under Pressure…
This post was inspired by two scientific articles. The first of which I am honored to have played a role in writing. The second being one of my all time favorites for many reasons that I won’t bore you with.
Neuromonitoring Correlates of Expertise Level in Surgical Performers: A Systematic Review (link)
Theodore C. Hannah, Daniel Turner, Rebecca Kellner, Joshua Bederson, David Putrino and Christopher P. Kellner
Application of Decision-Making Theory to the Regulation of Muscular Work Rate during Self-Paced Competitive Endurance Activity (link)
Andrew Renfree • Louise Martin • Dominic Micklewright • Alan St Clair Gibson
So, let’s dive in to some chatter about surgeons, athletes, how to become an expert, decision making and thriving under pressure.
What we can learn from expert surgeons and professional athletes to achieve more
Surgical expertise does not have a clear definition and is often culturally associated with power, authority, prestige, and case number rather than more objective proxies of excellence. Frontiers, 2022
So what is it that makes a surgeon elite? What is it that sets a surgeon apart from others who seem to already be so high performing? And, they are all so high performing, precise and reliable - there is such little room for error in this world where the slip of a scalpel can dramatically change or end a human’s life. Our recent publication is all about just that and it’s a question which I imagine I will spend a lifetime being curious about. When I consider how complex the answer is to this difficult question is, I cannot help but draw some parallels between my experiences coaching some of the world’s greatest athletes. Comparing notes between athletes and surgeons is a fun way to shed some light on how we can all perform better. And what I mean by that is there are some interesting qualities and circumstances that are shared between athletes and surgeons, and many other types of high performers. I could probably write a book on this (maybe I am - wink wink?!) but for now I’d like to share just a few thoughts on such a (wild!) idea…
The ability to make appropriate decisions under pressure separates experts from novices
In surgeons, it is demonstrated that the brains of experts function differently when compared with non-experts. Specifically, we found across the literature that the part of the brain that is involved in decision making functions at a higher rate in experts when they perform under pressure when compared with novices. Almost like there’s a lot more rapid and accurate decisions being made in expert brains. Almost like the expert brain has another gear, where more precise decisions are made, faster, like a turbo mode if you will.
We found substantial evidence that surgical expertise can be delineated by differential activation and connectivity in the prefrontal cortex (PFC) across multiple task and neuroimaging modalities. Specifically, novices tend to have greater PFC activation than experts under standard conditions in bimanual and decision-making tasks. However, under high temporal demand tasks, experts had increased PFC activation whereas novices had decreased PFC activation. Frontiers, 2022
Now, this might seem pretty logical that experts have a neurocognitive turbo mode where they can make quicker, better, faster, smarter decisions - sure! But, trust me when I say that there’s a useful lesson to be learned here. So, let’s consider some interesting insights from studies on what separates winning athletes from novice athletes to understand more so how we perform under pressure.
What we anticipate will happen influences our ability to perform
In sport science, St Clair Gibson studied the makings of athletic greatness and his research suggests that:
Human performance is a central teleoanticipatory processes which cycles between periods of uncertainty and certainty. A period of uncertainty occurs immediately following any change in effort (eg. physical exercise). And because biofeedback and environmental conditions continually change throughout the effort, assessment of this information must also occur continually. Article here
Basically, what Gibson is saying is that us humans are anticipatory creatures, who are constantly running predictions about hypothetical scenarios which may happen to us and to others in the future. When we perform, we continually scan the environment (e.g. competitors, patients, equipment, team mates etc.) alongside our bodily state (e.g. heart rate, physical sensations, breathing patters, visual clarity, taste, feelings of fatigue, etc.). And while doing these scans, we sort of fluctuate between a state of higher and lower certainty. We question more and less as to whether our predictions of the future will manifest in reality. And we hope that the reality and ensues is in agreement with one of our predictions - this would give us confidence most likely. In this way, while we perform, each time we make an effort or move our level of certainty is open for negotiation as it were. Isn’t that kinda cool? Performance is the act of negotiating with ourself about what might happen? So, perhaps the best performers are the best negotiators?
Winning the negotiation
When performing whether it be in sport, business or the operating room, if we make a move and gather some information that supports our current anticipated ideas of the future then we become more certain but if we gather information that is different to what we anticipate then our level of certainty reduces - we become less certain or uncertain. So each time we perform a procedure, change our level of effort or detect some change in our scans of the environment we can become more certain, less certain, or stay the same, and this in turn can affect our ability to perform. To crystalize this, we’ve all had those moments like in a race, during a project or event or maybe even in the operating room when what we predicted would happen, happens. And what happens next? Damn... we feel good, even just for a moment. Similarly, we’ve all had those moments when something happens while we perform that we did not expect. In that moment we have to negotiate with ourself not only what we will do but we must overcome any uncertainty or change in our emotional and mental state that arises with this as well. Then we have to go back to our drawing board and rethink what we can do next. And this is all happening in fractions of seconds. So, if you’re onboard with this and interested in better understanding how you can better negotiate with yourself to make better decisions when in those critical moments then I’d like you to consider working through the following exercise with me.
Side note | Certainty, confidence and performance
I’d just like to point out that (1) less certainty (or uncertainty) does not necessarily mean poor performance, and (2) the feeling of certainty is not necessarily a conscious felt-state especially when we might find ourself completely present and absorbed in our task or performance. Often certainty is a hidden subconscious motivator. But, uncertainty tends to be a little more conscious as are many difficult emotions. Uncertainty is sticky and likes to hang around. But uncertainty does not mean we lack confidence. Many humans immediately jump from feeling uncertain to lacking confidence. This in my opinion is a form of scarcity (which I learned all about from the magnificent neurophysiologist and founder Dr Rose Perry). When we lose confidence due to uncertainty, it is not the uncertainty per se that is causing us to lose confidence. It is usually that we have forgotten that we are resourceful or how to be resourceful. An emotional strategy like encouragement from a peer or positive self-talk can help us feel better, but what we are truly in need of is a technical strategy. Uncertainty can make us feel lost. If you imagine being lost - sure you can make yourself feel better about it, but reality is you need to find a tool that’ll help you navigate. I think the following exercise will help with this. And I’d like to remind you that many humans have conditioned themself to thrive in when experiencing uncertainty. For some, uncertainty almost breads confidence rather than fear because it’s encouraging us to realize what we are capable of. Uncertainty can motivate us if we know how to leverage this state.
An exercise to help almost every working professional make better decisions under pressure
Start this exercise by bringing an upcoming high pressure event or high stakes circumstances to the front of your mind. Take a moment to imagine yourself working, performing or participating in this event. Use your imagination to transport yourself there. Can you make a still picture of the most critical part of this event that’s in your mind? Imagine yourself in this event, and you have now paused it. You’re in the thick of the challenge, the pressure is high, the stakes are higher, but time has stopped and so have you and everyone else. With this still image of being under pressure, please work through the following steps...
Step 1. What are you anticipating might happen when you hit play in your image and continue performing?
Write down 10 possible future scenarios of what you anticipate might happen in this critical moment that’s in your minds eye. Now, 10 potential scenarios might actually sound like a lot but it’s important that you dig deep and get creative. If 10 is easy then write 20. Creative thinking is the backbone to high performing decision making. Aim for an even balance between things that might happen to you (e.g. spontaneous cramp, shaky hands) versus things that might happen in the environment with your equipment, teammates or competitors. Be as specific as you can.
Next, order the potential scenarios from most likely to least likely going to happen, in your critical moment. Once you’ve done this I’d like you to begin thinking about how you might deal with the least likely scenario, working progressively through your scenarios until you get to the most likely scenario. We start at the least likely scenario because this is widening your experiential considerations for things you don’t usually consider while being cognitively fresh. Most of the time the most likely scenarios do happen so we get a fair amount of repetitive real-life practice with those. Take your time to work through building a strategy for each scenario. If you want to spend more time on this engage your coach, mentors, partner or teammates in the conversation to get their opinions. Tell them you have a hypothetical scenario and you are curious how to best deal with it. If you want to do it quickly then please do so. Jot down a few words about your hypothetical strategy for each anticipated scenario. I’m going to bet that once you complete your list you’re going to feel much more confident to perform than when you started. And that confidence is not just based on positive affirmations - it’s based on critical and creative thinking about how you make decisions under pressure.
Step 2. Anticipate how you might feel when you hit play and continue performing?
Anticipating how we might feel emotionally in our mood and sense of self can be an extremely powerful awareness tool. When we anticipate emotional reactions we learn how to use and take command of the emotion as opposed to the emotion using and commanding us. Renfree et al published this beautiful model (Fig.2 above) when exploring great athletes, that shows us what types of events in our high pressure moment result in positive versus negative emotions. Basically, feeling good about what we are doing is largely dependent on our ability to (1) find value in what we are doing and (2) reduce our perceived risk. This means that when we perceive high levels of risk or low levels of potential gain/reward/value in what we are doing, we tend to experience difficult emotions. The reminder here is to (1) always be clear on what you have to gain in any moment of high pressure, (2) develop strategies to change how you perceive risk - that’s what we are doing in this exercise and (3) accept the risk. This is a large part of what I do in my coaching and we will discuss more of how to do this in future articles.
Next, for each of your hypothetical scenarios I’d like to write down a one word emotion of how you might feel if it were to happen. You can use this emotional wheel (below) to help. Now, for each of your scenarios you should have a strategy and potential difficult or uplifting emotion. I’d like you to think about the idea that no matter what emotion you experience you can still engage your will power to action your strategy. This is key to performing under pressure. Many performers that I work with will go through a visualization exercise of rehearsing the scenarios with the emotional reactions. You can definitely do this on your own! Go on give it a try!
Emotions Chart
Use this to help anticipate how you will feel under pressure, as described in step 2.
Step 3. Is what you anticipate known and understood by others?
This question refers to what you will do in the moment of high pressure, other than engage any part of the planned actions you have created so far. There’s a couple of considerations in this step of the exercise: Are you performing on your own versus are you performing as part of a team? When you’re performing on your own it’s 100% worthwhile discussing your plan for dealing strategically and emotionally with various scenarios with your team before you go off on your solo mission. As you can imagine, it may not be helpful for your competitors (if you have those) to know your anticipated plans as this may in fact be something that gives you an edge over others. However. in team environments it’s usually best to over communicate not just what is happening but what you expect might happen, especially in the exact moments when you are under pressure. This helps others track progress, anticipate, contribute and reduces overall team uncertainty as there is more intelligence in numbers and more power in team cohesion.
So, your simple job for this part of the exercise is to write down 1 to 3 people that you will discuss your plan with. If you’re in a team then I encourage you to identify whom you will communicate your anticipated outcomes with. A second step here is to also communicate the anticipated outcomes alongside how you are feeling while you perform in your critical moment. In reality, this opens us a cohesive discussion of how to deal with scenarios with a higher level of empathy. Practice this while you visualize to become more familiar with this process. Then, practice in real life with the people on your list.
Step 4. Finally, who is influencing your decision making while you perform?
As we mentioned, decisions are made based on the assessment of relative risk and benefit associated with our own actions. Whether we are in a team environment or against our rivals, our decisions can be influenced by other decision makers. For example, many individuals tend to do what others do, even when private information to which only ‘the others’ have access to may not be the optimal personal strategy. When we feel uncertain and are without a previously rehearsed strategy, this is when others have the most amount of power to influence our decisions, and at the same time we can become less responsive to our own information (scans of the environment and bodily sensations). In fact, according to the research discussed earlier, many competitive endurance athletes are likely to select levels of effort based on the behavior of their rivals whilst giving less weighting to their own information relating to their personal body status and circumstances (Renfree et al). Conversely, those who tend to pioneer, set world records and establish new levels of human potential, are those who are able to consider the strategy of others but retain their agency by deciding whether they will follow the other person’s strategy, even when the experts feel uncertain. So expert decision making means during moments of uncertainty being open to and considering the strategy of others but remaining critical by avoiding being “hijacked” or overly influenced by these strategies and ultimately engaging our own personal strategy.
So, the final exercise is to bring your critical moment back into the front of your mind. Review your list of strategies and feelings for each scenario, and now... I’d like you to identify who’s feedback and suggestions you are willing to act on. To do this make a list of as many people as you can think of that may influence your decision making in your critical moment. Next, assign 1 of 3 categories to each person.
Category 1: People who’s decisions and suggestions I will most likely follow without questioning or debate
Category 2: People who’s decisions and suggestions I may follow with questioning or debate
Category 3: People who’s decisions and suggestions I am very unlikely to follow
This is an important exercise to do on a regular basis as what can happen is we can sometimes become better and more experienced in ourself yet continue to follow the decisions and suggestions of others despite that our own personal abilities are better or more suited to us or the situation. Similarly, others can improve and we should frequently evaluate whether someone’s ability and credibility has changed so as we are not blocking potentially very helpful new suggestions about how to deal with pressure. Now in the real life scenario, what’s important to consider is that you want to initially focus your attention on category 1 then category 2 people. Category 3 people are going to be most disruptive to how you perform so no matter what they do it’s likely that you will ignore them or give them much less time or attention.
And there we have it, a systematic technique to enhance your ability to make decisions under pressure that are more in agreement with our personal capabilities and situational demands. After all, that is a major skill that sets apart experts from novices.
If anything in this post has got your attention and you’d like to learn more then feel free to drop me a message. Likewise, if you think this will be of value to someone you know then please share.
Warmly,
Dan
As always, my guidance is not designed to replace professional medical advice or treatments. In many cases my thoughts, opinions and recommendations are crafted by peer-reviewed scientific research and/or hands on experience trial and error working with thousands of high performing humans. My methods and opinions are my own. Everyone’s journey of success, healthy living and search for longevity is unique. So it is in the space between science and real-life scenarios that we must forever forage for new discoveries and challenge ourself with new perspectives, ideas and approaches. Doing so will pave the way for new levels of human performance in ourself and others. Should you find my writing controversial and/or of value I encourage you to reach out and share it with someone you know. :)
