Performance Under Pressure with Emergency Physician Dan Dworkis

 

Dan Dworkis, MD PhD, is an emergency physician, an assistant professor of emergency medicine at USC’s Keck School of Medicine, and the author of The Emergency Mind: Wiring Your Brain for Performance Under Pressure. Dan’s work at The Emergency Mind Project focuses on human performance under pressure, especially in times of emergency and crisis.

In this conversation, we share techniques for improving your decision-making and becoming a great leader in critical situations. We explore mental preparation, navigating risk and uncertainty, creating high-performing cultures, and much more.

See above for video, and below for audio, resources mentioned, and conversation transcript.

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Topics:

  • (01:26) A passion for performance under pressure

  • (08:44) Determining the level of emergency

  • (12:22) Training and preparation for high-pressure situations

  • (27:49) Reframing and staying calm when something bad happens

  • (44:23) Developing effective ways to communicate and offer feedback

  • (52:40) Infinite depth is prioritization and “The Emergency Mind”

  • (01:04:25) Practices for powering down after a shift

  • (01:16:39) Using systems to improve

Conversation Transcript:

Note: transcript slightly edited for clarity.

Chris (00:05): Welcome to Forcing Function Hour, a conversation series exploring the boundaries of peak performance. Join me, Chris Sparks, as I interview elite performers to reveal principles, systems, and strategies for achieving a competitive edge in business. If you are an executive or investor ready to take yourself to the next level, download my workbook at experimentwithoutlimits.com. For all episodes and show notes, go to forcingfunctionhour.com

I'm very excited to have Dan Dworkis on the show today. Dan's an emergency physician, an assistant professor of emergency medicine at USC's Keck School of Medicine, and the author of The Emergency Mind: Wiring Your Brain for Performance Under Pressure. At The Emergency Mind Project, Dan focuses on human performance under pressure, especially in times of emergency and crisis. Could not think of a better person to have on today. We're gonna explore the topics of mental preparation, navigating risk and uncertainty, creating high-performance cultures, and much more. So stay tuned for techniques for improving your decision-making and leadership so you can have it in the critical situations where it counts most. Thank you so much for joining us, Dan. It's a real honor to have you here.

Dan (01:20): Thank you so much for having me. That intro was awesome. I'm like super excited to hear our own conversation now. This is gonna be great.

Chris (01:26): Well, let's set the stage for the conversation today. How did you end up in the ER? Where does this passion for performance under pressure come from?

Dan (01:35): I love that usually when you ask somebody how they ended up in the ER, it's like a car crash or getting shot or something, but thankfully that's not actually my origin story in this case. So I started out in the sort of science and engineering world and got really fascinated by like finding the hardest problems to solve that I could. Right? And so for a long time that was around physics and math, drifting sort of into biology, and then, you know, the more you poke at real life, the more you realize that's like the hardest problem you can possibly come up with. And followed sort of a real natural passion for that.

And I actually went to med school thinking that I—I went to med school on an MD-PHD, thinking that I was going to really sort of just use the medicine part to understand what type of medical devices to build. In my mind, I was an engineer really focused on actually biophotonics and optics, which is a totally sidebar super cool thing, getting to shoot lasers at stuff. And really thought that's what I was going to do, until I started actually doing a lot of the medicine. And you realize that most of what humans need is not, in a lot of ways, new machines. Most of what humans need is the understanding of how to deliver knowledge to them where and when they need it most. Right? Because we have a bunch of knowledge that we can't actually deliver.

There's probably like a great thread in terms of like why we think that is and where those blocks are coming from, 'cause that's a pretty universal thing, right? How do you get the knowledge that you have to the position in time and space that it needs to be? But the more I sort of went down that path, the more I started to fall deeply in love with emergency medicine. Because more than almost any other field, emergency medicine is about the reality. Right? It's about where the rubber hits the road, it's about the dirty, gritty, bloody, you know, craziness of the absolute edge between the system of care that we have and the reality of what people face.

And you know, I recall this time sort of in the middle of the night—and I actually wasn't even on an emergency rotation—and it's like three in the morning and I'm wandering around the hospitals, a med student, like you do. Sort of like a ghost. And I just had this overwhelming—Like, I have to go down and see what these people are up to. And somewhere on the way down, I realized that it had changed from "these people" to "my people." And I was like, oh my, man, I want to do this. This is me. Like, this is where I feel like I'm at home.

And thankfully, you know, however many years later, that feeling has only intensified, that the emergency department and the emergency room is really the space that I come alive when you think about performing under pressure and building teams and everything else that I do.

Chris (04:00): I love this phrase, "the edge between systems and reality," where the things that you learn in the classroom quickly just need to face up to not having the information that you'd like, not having the resources that you like, certainly not having the time that you like. Clear, suboptimal conditions. Maybe put us in the room. You walk into some form of emergency that's happening, you need to quickly get up to speed, figure out who else is in the room, what your role is. Kind of put us there and just give us a sense for what you have to deal with, how you have to orient yourself in this type of situation.

Dan (04:39): Yeah, absolutely. So I will happily drop you into my life and put you in my shoes and run you through some problems, but I actually think there's one conversation we need to have before that, which is sort of the hidden conversation that happens. And it seems like it's an obvious question, but it's really not, which is, "What is an emergency?" Right? What actually is an emergency? Because a lot of what I spend my time doing is designing individual team and structural solutions to emergency problems, but if you don't take a second and realize where that fits, you're going to be using a hammer as a screwdriver, and that doesn't work in any way. So most of what I do as an emergency physician, even when I'm in an emergency department, is not an emergency. That's sort of like a little bit counterintuitive, right? You'd think like most of what I do is emergencies, but that's actually not true in any way. And to me, when I think about what an emergency is, it has a couple of structural components that we need to identify.

So, first it's a mix of pressure, uncertainty, and impact. Meaning that I don't know what to do, I don't understand the situation, there's things I don't know, there's an incredible high-impact result of this decision or set of decisions I'm gonna make, often life, limb, or catastrophic loss. And there's pressure in the sense that the resources that I have often don't match the requirements of what I'm supposed to be doing.

And then separate from those three things (pressure, uncertainty, and impact), you have complexity. Right? It's a complex adaptive system with interlocking, nonlinear parts. And then it exhibits what you'd call liminality, which means that once you go into it, you've crossed over some threshold and you can't easily extricate yourself from it. You really have to drive all the way through. Right? So pressure, uncertainty, impact, complexity, and liminality. Like this spicy, beautiful mix of chaos that comes together to make an emergency. Right?

So, most of what I'm gonna be able to talk about in terms of this sort of decision-making under pressure and applying knowledge under pressure really fits those emergencies. And a lot of what I do—treating a sprained ankle, helping somebody set a bone, even doing certain types of resuscitative care—isn't really an emergency. Does that make sense, to start with?

Chris (06:39): Absolutely. It seems like a critical skill is to recognize what level of engagement you need to have. Not that you aren't fully engaged when you're doing something that's lower pressure, lower urgency, but that presumably there's a little bit more room to breathe, and the opportunity to have more of a systematic lens, more of a step back, versus when—I love this way you've put it, of liminality, that the only way out is through, that you just have to push forward regardless of those conditions. And something that I see often in my work is the tendency to just be at this kind of anxious seven all the time, versus recognizing when you need to be at the ten and when you don't need to be at the ten, allowing you to navigate not being more engaged than the situation calls for.

Dan (07:28): Yeah, absolutely. So there's an internal sort of intersensory interoceptive component to what you're describing, right? Like how was the balance of your parasympathetic and your sympathetic nervous system? How ramped up are you? Where are you on the Yerkes-Dodson curve? And we can talk about that in a second too. There's also a tool perspective to it, right, which is that if I ask you, like, "Hey, man, what's two plus two?", I don't need you to run a like multivariate Taylor series expansion to sort of figure out what that is, right? You run the risk of overfitting and wasting time and energy, as opposed to just, "Oh, this is a simple problem, it needs a simple tool." Right?

So there are things that are emergency problems. They often need emergency tools. And if you apply non-emergency tools to this complex, adaptive liminal system, you're gonna fail, and people might die. Right?

Conversely, though, if you apply emergency tools to non-emergency situations, you run the risk of burning yourself and your team completely to a crisp, wasting resources, and also doing things that are really wrong. Right? Like, in an emergency the right answer is sometimes "cut the person's chest open." Whoof. If it's not an emergency, you probably should not cut their chest open. Right? Now I said I won't give medical advice, but I'll stick to that one. Right? Like, don't cut people's chests open unless you have a really good reason to.

And I think there's like this fitting problem of like, are you using the right frameworks and tools for the right situations?

Chris (08:44): Yeah. Thank you. I think that's really helpful to differentiate. So we're setting the stage, we're stepping into the room. Maybe we start there. Determining what level of emergency or not we're dealing with, and based upon that what's the next moves.

Dan (08:59): Absolutely. All right. So now, let's drop you into my shoes. So you're gonna be the ER doctor for a second, right? We're gonna swap roles for a minute. So you walk into a room, and the CMED radio, which is the ambulance sort of connection system goes off and says, "Hey, we've got incoming ETA three minutes, older gentleman, not breathing well, looks kind of blue, he's hypoxic"—meaning his oxygen level's really low—"his heart rate's through the roof, and we don't know what's going on, but whoa, Doc, we're worried." Right? And you think to yourself for a second, "Eh, uh, nothing good is happening here." Right? Like, these are really concerning sets of vital signs, the report they're giving you says there's some chaos coming, and more importantly, these folks who are experts at what they do out in the world in ambulances and pre-hospital setting, they're telling you they're worried. They're communicating, like, things are coming in hot.

And so maybe in that time, as a realistic version of this scenario, you know, you'll say, okay, coming into room three in you know, four or five minutes. Okay. So, what do you do? Right? What do you do for those four, five minutes? And what I'll say is that there are some individual factors and some team factors, and those factors exist within the larger structure of everything you've done before that moment. Right? So the real answer to this story happens days, weeks, months, years before you get there to that moment. But actually this is you now, so it's just you for these four minutes, and you don't have the luxury of all of my training, so like, here you go. Right?

So there's a couple things that we can do. And what you said was quite intelligent, which is that, do we think that this is an emergency? And often the answer to that is like, strong yes until you figure out it's a no.

Jocko Willink, through the book Extreme Ownership, talks a lot about this idea of default aggressive. Right? Like, you should default to aggression in action. We have a version of that, which is that you default fast, then move slow. Right? You move fast, then you move slow. So I assume it's an emergency. I assume the person is sick. I set up as if things are gonna go bad. And then once I'm ready to go, then I can slow myself down and go for a second, slower loop. So, "fast and then slow" is usually how we describe it.

And a lot of what I do when I'm training teams and training doctors to be emergency doctors is to teach them that mindset, of "move fast and then slow down and take a second loop again." And there's a bunch of super rich, interesting things in here about how we lever our system one and system two thinking and take advantage of the best of both of those things in that fast loop and then slow loop. 

But what I'm going to do in those minutes is I'm gonna set up to move fast. So I'm thinking about what the worst-case scenario things are here. Okay. This person, it sounds like they're not breathing well, and they maybe have a heart problem. All right. I've gotta set up for both of those things. I'm gonna think ahead about what some likely scenarios are, I'm gonna gather tools, I'm gonna spend some of those minutes setting up my equipment, I'm gonna spend some of those time internally on myself, calming myself down, and then I'm gonna spend some of those times galvanizing my team and putting everybody in the same space and the same mental model for those couple of minutes.

And often, that part will be us getting together in a room and sharing what we know and what we don't know. So it'll literally be some version of, "Team, we have incoming. Dude sounds sick and probably not breathing well. Let's prepare for intubation," (which is placing a breathing tube and putting somebody on a ventilator), "and let's get ready if this converts into a cardiac arrest." And then my team will sort of go and set those things up and we'll be able to plan for that.

But there's really those parts, right? There's like gathering equipment, readying yourself, and readying your team.

Chris (12:22): Thinking about the vein of readying yourself, you mentioned so much of the preparation is part of the training, is part of having an idea of what to expect or what to look for for things that could take an unexpected turn. Talk to me about some of the simulation or the visualization that you'll do before you'll go into the room, not even at the day at the hospital. Maybe the weeks, the days before that allow you to maximize your mental bandwidth, your sense of calm, that you've gone through this before.

Dan (12:56): Yeah, yeah. So there's immediate tools that we use at the moment, right, and then there's sort of like structures that we've set up a long time in advance to prepare us for that. And I think this gets us to a concept that we use a lot in The Emergency Mind Project, which is this continuing cycle of prepare, perform, recover, and evolve. Right? And we run that cycle in multiple ways. And so the preparation for this person incoming, right, we're about to perform, we have this moment to prepare, you're right that it really starts ahead of time, as we've gone through multiple cycles of prepare, perform, recover, and evolve setting ourselves up for this approach.

A key concept along that lines that we use to really get better under pressure is to apply graduated pressure. Right? Whenever possible we try not to jump into the deep end of things. We try to set ourselves up through a really gradual approach. And we like to call this the wedge. Right? Sort of a wedge concept. So high-wedge is super high-impact and life-or-death scenario, it's putting you in the center of that room having to run this resuscitation. Medium-wedge is doing that on a simulated patient with your colleagues around you where you can run the case back and forward and get thrown some curve balls by your instructors. And then low-wedge is maybe mental visualization, or maybe it's practicing a particular technique, like a mental technique, to slow your heart rate down but practicing it when you spill your coffee on yourself in the morning. Right? Taking advantage of all of the stress that you get exposed to, all of the suffering you get exposed to, to sort of walk yourself along that wedge.

I think the beauty of that is if you throw yourself into high-wedge scenarios—In my experience, this is true whether you're talking about being an emergency doctor or doing martial arts or any other elite teams that I work with, things fail and you don't know why. Right? If you're in too high pressure, things fail and you don't know why. You don't know if it failed because you don't know how to open the kit the right way, because you don't know how to use the kit, or because you misused the kit to begin with. Right? There's so many different points of failure that if you don't really explore that landscape and that edge of failure on the way, you're setting yourself up to fail and not learn anything from it, which is a cardinal sin, really.

Chris (15:04): Yeah, this concept of never wasting suffering really resonates. Of all the time in our daily life, we're facing stressors, we're facing things that don't go as we would like, and the reframe that, "Hey, here's an opportunity to practice." Dealing with the unexpected, calming ourselves, making the best of a bad situation, that anything that we encounter is the path in this sense, and this beauty of the graduated pressure is that we slowly introduce difficulty in variables, being able to control for those variables, as you said. We can know what in our process has failed. Versus if we just completely dive off the deep end. Like you said, that's the cardinal sin, when we fail but we don't learn from it. That we continue to pay tuition from the same lesson over and over again.

How do you identify where we are in this wedge? What's the correct amount of pressure or difficulty given where we are?

Dan (16:09): You know, that is a great question, and I don't think there's a simple answer to that. Let's divert very slightly to cognitive load theory, 'cause I think it's gonna take that to really answer this question right. So, cognitive load theory says that in your brainpan up here you have limited capacity. No knock on you, I have limited capacity too. Everybody does. Right? And what we know is that that limited capacity gets taken up by various things. So the cognitive load that I'm experiencing, the total mental work, the total mental effort that I put out, is intrinsic load, which is the mental effort it takes to perform a task. Extraneous load, which is the load that is taken up by other things not directly related, so like screaming people and flashing lights, and buzzing noises, and stuff like that. And then germane cognitive load is the load it takes as I'm learning and trying to build schema and mental models and consolidate knowledge.

All of that goes into one pot, and that pot I only have a limited amount of energy in. Right? So it sort of depends. Because you can ask the question about where do you train on a wedge, and if you made me answer one thing, I would say, "To the point where it is slightly but not overwhelmingly uncomfortable." Unless you are trying to train specifically for discomfort, in which case you should push yourself slightly farther. Right? So if I have a skill I'm doing, and I'm really a novice at it, right, I'm learning to put a central line into somebody's neck, or I'm learning a kimura lock in jiu-jitsu, whatever it is, if I'm really, really new at it then I should expect that I'm gonna have to use a lot of energy in germane cognitive load, and there's gonna be a lot of things that distract me, so my extraneous cognitive load is gonna be really higher, and so I'm not gonna have a ton of energy left over to do the stuff I really need to be practicing. So as a result, I'd want to train lower on the wedge, I'd wanna minimize that extraneous cognitive load, and I wanna set things up to be easy for me in order to prepare.

If I'm better at it, and I want to start applying it under close to real-life situations, then I'm gonna practice that higher up in the wedge.

Chris (18:12): That's really interesting, because it just reminds us that life has a variable difficulty level, and that we have the power to increase that difficulty level in order to continue our training. And that this is a multi-dimensional opportunity, that we can control for how many variables we have to face, we want to have more extraneous pressure, as you put it, more things we have to deal with, or is this we actually want to just increase the difficulty of the task itself, or perhaps both. But thinking about what variables we have control over, and what dimension we're looking to train upon. It's really well put.

Dan (18:50): Yeah. And it also speaks to the fact that, like, all of us are learners. Right? I'm training at some point on my own wedge for techniques, you're training at some point on your wedge for techniques, that's honestly part of the reason that we're sitting here having this conversation, right? We both have a growth mindset when it comes to developing better ways to make decisions and applying our knowledge in and out of high-pressure situations. And because we believe that, we're out there seeking out circumstances that are hard and challenging and enable us to really grow our skillset like that.

Chris (19:18): It also reminds me of the Josh Waitzkin concept of training at altitude. The one I always give is, for baseball if you're facing a pitcher who's throwing seventy miles per hour, first start at the ninety-mile-per-hour cage, and then seventy won't feel so bad. So if you train in these situations which are far from optimal, then when you face a real-world situation, oftentimes it will feel less challenging by comparison, and that'll bring an extra level of confidence and conviction in what you're doing.

Dan (19:47): Yeah. There's an important caveat to that, which is one, not all things work to be trained that way. Right? So if I'm training to do an emergency cricothyrotomy, like, surgical front of neck access, things have failed and I have to cut somebody's neck open and put a tube into it, you know, that logic would say, "Well, just do it blindfolded, 'cause it's harder." And like, you can't, right? You can't do that. The person needs you to get it right. And so there's some things where you can't overtrain, and you have to figure out other ways to really get the same sort of, the benefit that Waitzkin talks about in that sort of process.

The other thing is, like, sometimes it's not safe to train at ninety miles an hour. Right? If your goal is seventy, you really have to work up and make sure it's safe to hit that ninety miles an hour, and there's a tendency to overtrain and to throw ourselves into situations where we're really either not safe physically or we're wasting suffering in the sense that we're training in a space that gives us such a high failure rate that we're unlikely to know why we fail.

So you sort of have to balance that in there a little bit. But otherwise, yes, I completely agree, and I love Waitzkin.

Chris (20:51): Something that you talk about in The Emergency Mind that really resonated with me is the power of ritual to put yourself in an intentional state. You talk about the way that you enter the hospital, the way that you leave the hospital, taking very specific routes in order to remind yourself. We'd love to have you share a few more details about how you're able to kind of create this sealed container for performance.

Dan (21:15): Yes. Ritual is really, really important. And I think I've only started to understand that as I've gotten further along in my career and in what I'm doing. You know, there's sort of the idea always of like the psyche up, right, or you're like getting yourself ready to go, you're throwing on the music that makes you feel good. And that's like a pretty reasonable one to it. But to me, I always started asking the question, like, "Who do I want to be when I show up today?" Right? Not just can I be like pumped up and psyched out and ready to go, but who do I wanna be? And if this is the day that I get to try to take care of my fellow human beings, what do I wanna bring with me?

And that made me answer some slightly deeper questions than like what music do I wanna pump myself up with. Not that there's anything wrong with that, 'cause I think that that's crucial. But if what I wanna be is creative and flexible and giving and present, what are the things that help me achieve those goals? And so I started tinkering with that a little bit, and sort of designing some different roots to it. And it started when I was in residency training, and frankly, it started 'cause I was really nervous when I was first going. You know, when you first get into, in Mass. General Hospital, where I did a lot of my training, there's this area called "Acute," which is where the sickest patients in, arguably, the world go, and it's really, really high-stakes, high-pressure, it is the, you know, the paragon of emergency. And to train there is an honor and a privilege and an incredible challenge, and people's lives are in your hands even from pretty early on in your residency training. 

And so when I started working there, I was very nervous. I knew what I wanted to do, but there is often this incredible gap between the knowledge that we have and the ability we have to apply that knowledge into these high-pressure, high-stakes scenarios. And I was concerned about that, because I knew the stakes were real humans. Right?

So there's this long hallway, and it's got brick everywhere, and I remember walking down this brick hallway, and realizing, like, "Okay, I'm gonna walk down this space, then I'm gonna open this door, then I'm gonna go in there, and I'm gonna do the best that I can. I'm gonna do the best that I can. And I don't know what that's gonna be, I'm not gonna be able to fix everything, I'm not gonna be able to save everybody, but I want when I walk back out in this brick hallway to look at myself and know that I damn well tried my best." And the thing that got me sort of started in that mindset was—It's actually part of the Hippocratic Oath, which I rarely ever think about, to be totally honest, but there's a part that says, "Into whatever house you enter, may it be for the good of the people within." And I would think about that as I walked down that hallway. Right? I'd say to myself, "All right, I'm gonna enter this house, and I know I'm gonna do it for the good of the people in there. And if I meet that standard, if I throw the best I have into it, I do my best for the people that are in there, and I walk out and get better for the next day around, that is everything I can muster as a human."

So it starts with who do you wanna be, who do you wanna show up as. And then it starts getting into what are the things that will help you get there. And it's less important to me what you say and what you do, and more that you practice putting the meaning into those things.

Chris (24:33): It's really powerful, and especially when you're facing frequent failure and challenge and there are many things outside of your control, bringing it back to “what can I do, how can I prepare myself to face whatever is coming?” And I love this question, "Who do I want to be when I show up today?" Coming with that intentionality, and having that intention to come back to as a sense of training, as a sense of practice, where you walk in the door and you know what you're there to accomplish. And something that I come back to often is that a life of no regret is knowing that you've given it everything you've had. You tried your best. So thinking about, when you zoom out, when you perform well, what conditions were in place? When you are able to show up, what else was going on? How can you make those conditions happen more often? That those are the things that are within your control. These stoic themes seem to recur in your work, of there are so many things that are happening that are outside of your control, and this wisdom of knowing the difference. I would love to just hear a little bit about how this philosophy has helped you keep level-headed and calm in these situations.

Dan (25:50): Yeah, man. I—You know, for better or worse, and I think it's better, emergency doctors get to go up to bat against life and death and suffering so many times, and so many more times than most humans get to. Right? Most of us maybe see death once or twice, or we see like severe suffering a very small number of times, unless we're, you know, a member of a mission critical team or somebody operating in sort of the extraordinary world of incredibly high-stakes decision-making. But we get to go up against the edges of the human condition and watch what happens over and over again.

And Seneca, as a Stoic, has a quote that says, "A person, like a gem, is not polished without friction, a person is not polished without trials." I think I got that backwards. But that's the right idea, right? And you have a choice at some point when you see this suffering, you know, when you go up to bat with these life and death scenarios of, do you run away from it? And that's either, do you pretend it's not happening or are you crushed by it, are you incredibly depressed, do you drown it out one way or the other? Or do you step forward and try to process it?

And I think that I was very lucky to be able to be exposed to Stoic philosophy from a younger age. My parents are really into philosophy, and it was a sort of frequent topic growing up. And growing up in the martial arts as well, there's a lot of sort of stoic themes in martial arts. So being exposed to that was really useful, 'cause it gave me a framework to understand and sort of approach some of these life and death things. Right?

And the Stoics do such a good job about talking about that death is part of life and that suffering is part of life and that our approach to that is within our control and that our focus on that dichotomy of control really gives us the ability to alter ourselves and our environment.

Chris (27:49): So, we've been talking a little bit about failure and changing our relationship with failure and discomfort. All the time in the emergency room, I imagine, you're trying to make the best out of a bad situation. Accepting reality. I love your phrase, "Well, this is sub-optimal." Talk to me a little bit about something bad happens, and you're able to reframe that, keep a cool head, and continue playing from that bad position.

Dan (28:20): Yeah. So, I think again it's worth approaching this as sort of, "What do you do in that moment?" And then what do you do after, and the next day, to set yourself up for success afterwards? 'Cause both of those things are true, and both of those things are different.

And you know, if you get—Like a lot of sort of the popular literature around there about how to handle a failure or a mistake often starts with the idea of, "Okay, take time out." Like, go on a walk, have a cup of coffee, divorce yourself from the situation and really start to let the emotion wash out and process. Then you'll sort of do a root-cause analysis and get back into figuring out why it happened. And, like, that's awesome. But if I did that, people would die. Right? If you miss placing a breathing tube, and you divorce yourself from the situation, there is still a human there that desperately needs to breathe that doesn't have a breathing tube in. We don't have the luxury, a lot of times, of doing the slow-step process right at the beginning. You have to continue to work while the fire is still hot, so to speak.

So dividing it that way, I think, is pretty useful. And when you look at the beginning there, you can ask yourself, "Okay, well, how do I rebound from failure or a miss," or even (to put it in a slightly more positive way), "How do I pivot from Plan A to Plan B, when Plan A doesn't work?" Right? We have this whole theme about Plan B being part of the plan. It's not a failure, it's just an alternate route to success. Right?

But okay, so I need to do something different than what I did at a really fundamental level. To me, that's where this idea of, you know, "Well, this is sub-optimal" comes in. 'Cause I need some balance that allows me to acknowledge the gravity of the situation, and the frustration and the disappointment and the feelings and the everything, without being totally swept away by it. Right? So I'm sure you know people, I think we all know people, that when something goes wrong, they just lose their head. They're screaming, they're yelling, they're throwing things. That is a way to handle that emotion, a challenging emotion, but it's not a particularly useful way, especially when somebody needs us to still be sharp. We also probably know people that run away from it entirely without acknowledging it, that just pretend everything is fine. You know, are Pollyanna about it. And that's also really not a good way to handle things most of the time.

So, there has to be this middle ground. And I've sort of experimented and tinkered with this phrase until I could get something that felt like not too tight and not too lose for me. And that's where "this is sub-optimal" comes in. 'Cause it's just sort of hilariously understated. Right? Like the person is dying, there's fire everywhere, there's blood, there's, you know, things happening. And to look at that and be like, "Eh, this is sub-optimal." Right? It just produces this like slight smile on my face where I'm like, "Yeah, okay, yeah. It is sub-optimal. You're right. It could be better than this. It could also be worse."

And that sort of allows you to acknowledge the situation and take a mini-reset. Take just like the smallest possible pause in there. Often that's just a breath, right? And then pivot your team into what you're gonna do next. And I think that's crucially important. It's not just you. Right? Unless you're operating where there's no one else around you, which is pretty rare, most of the time you're operating within the context of a team, and that team is relying on you to make that pivot smoothly. So if you fly off the handle, they're gonna fall apart. If you are the one who's able, you know, to say, "Hey, this is sub-optimal," take a breath, and then pivot, it's incredibly useful and you'll galvanize the team back around you.

And structurally, that tends to take an actual specific shape, which is to say, you know, "Oh, man, that was sub-optimal. Deep breath. Okay, team. Priority is readjusting. To use this plan I need my bougie," (which is a backup tool that we use), "And I need this other tool on standby for Plan C." Right? You're able to sort of reorient everybody to what's coming next.

What you don't do is dive into a deep root-cause analysis while everything is still spicy (for lack of a better word) and people need you to actually be performing. You really have to decouple what you're doing in that exact moment from your ability to retroactively analyze and learn from what happened in that moment.

And there's sort of a thing in the middle, which is a hot wash idea—to use a term I borrowed from some military teams—where you think about a really quick evaluation of what happens sort of right after the fact.

Chris (32:31): Three things—fantastic—that I really want to highlight there. I'll kinda go in reverse order. First, there's going to be lessons happening in real-time, and the temptation is going to try to solve it, like, "Hey, the next time this happens, we're going to do it differently." But the situation is already happening, and the way that you create that separation is that you have that time set aside afterwards when the dust is settled, like, "Hey, we're gonna go back, and presumably this is going to happen again or something similar, we're going to have the opportunity to do a retrospective and see what we're going to be doing next time." But when the situation is still critical, putting those aside for the time being. That's one failure mode that often happens: already chalking something up as a failure and moving on to the next one when it's still in process.

Dan (33:18): Can I tell a story about that, actually?

So, as a really concrete example of that, so, I was working in a relatively small hospital and we had a case where we needed to put a breathing tube in for somebody and provide anesthesia, put 'em on a ventilator, and it was way more challenging than I had anticipated from the get-go, as sometimes happens. And I had already had to pivot to my Plan B, which involved me using this thing called a bougie, this like backup tool. And the person that I was working with and I had never worked together before. This was our first time intersecting in this highly critical life and death moment. And the way that we communicated was totally sub-optimal. Right? We just weren't on the same page, nothing was synced up, so I got handed this tool and I got handed the tool upside down and backwards. And it also was wrapped in a way that I had never seen before or since in any other hospital. I don't know how it happened like that. So you picture, this person is sort of dying, I'm looking at this thing, it's not at all what I was expecting, it's upside-down, backward, and wrapped weird. And you have to do a second pivot in the middle of your first pivot, and unwrap the thing, turn it upside-down, and you know, do what you're gonna do with it.

And I remember having this flash of frustration that I was in this situation, because this is a preventable error, an unnecessary error, which are very concerning in the setting of emergencies. But like you're saying, there wasn't time or space in that moment to be like, "Why did this happen? Why did you hand me this this way? Why is this wrapped this way?" And there's a human tendency to focus on that, which really draws us away from what actually needs to happen. So what I said was, you know, I took the thing, flipped it upside-down, put it into the person who thankfully lived and did great, but what I said was, "This is strange. Let's talk about it later." That's it. "This is strange. Let's talk about it later." And then afterwards went back and revisited it. 

And I think that what that allowed me to do, other than actually, you know, save the person, was to cool off and create a psychologically safe space for this other person and I to have a conversation about what happened. Because if I didn't, if I'd gone in hot, "Why were you doing this? What's wrong with you? How could you hand me this upside-down and backwards? Have you never seen one of these?" (Which, like, maybe they hadn't seen one of these. Right? I don't know.) But I would never have figured out what the actual issue was if I didn't have the time and space to create that psychological safety first.

Chris (35:42): It's such a great example, because it brings to light that we are constantly narrativizing our experience, and if we're not careful we can easily create a narrative that makes us feel good about our role in the scenario but isn't actually productive towards the scenario itself. So it's very easy to start casting blame or to look for excuses. "Hey, this would be going so much better if," rather than accepting the situation as is and working from that.

I really like what you were saying around that you have this handle that's not too loose, that's not too tight with this phrase, "This is sub-optimal." Because there's a need for a gentle touch. And if we are too myopic on how things could be better, that becomes a distraction. And at the same time, if we deny what's happening, we can't incorporate this new information. On a somewhat less high-stakes situation, when I'm playing poker, a common failure mode could be a card that you don't want to have comes on the river, and all of a sudden a hand that you were very confident about winning about, maybe you were already starting to count the other person's chips and imagining them sitting in front of you, all of a sudden with that one turn of a card, everything has changed.

And so there's this tendency to root for good cards, and to pray, hope, "Please not an ace, please not an ace, please not an ace." And this rooting, that, hey, there are good outcomes and bad outcomes puts us in this frame of judgment and closes us off to information that is less convenient for us.

So this mindset of committing to accept whatever comes and works with it, again, puts us in the best position to deal with what comes, because that way we're open to new information in a dynamic situation.

So I think that there's a lot of subtle power in committing to these practices, to recenter, to accept, to work with what's there knowing that things are going to go wrong in unexpected ways that you can't necessarily prepare for, but being mentally prepared for that sense of surprise.

Dan (38:00): Yeah. And it's so important also to say that, like, it doesn't mean you like it. Right? Like, you can be angry that like that card turns over the way that it does. That's okay. You just need to get through it. You just can't be so angry that you are completely swept by it and throw the next three hands as a result. Right?

Chris (38:19): You put it so well in that, "Plan B is not an obligation but an opportunity." It's very easy to, again, create this narrative of, "Hey, things aren't quite going the way that you'd like," instead of, "Hey, here's an opportunity to try something new."

Dan (38:33): Yeah. Of which there are no shortage in the emergency room.

Chris (38:38): A common theme of what you were saying is recognizing that we are often in team situations where everyone's bringing different backgrounds, different sets of experience, different levels of context to the situation, and that often particularly in high-pressure situations there can be communication gaps or information that's not shared or information in this case, you know, how to put the bag upside down, that sort of thing, that people just don't know and make their best guess. What have you learned about having clear communication and understanding in these critical situations?

Dan (39:19): Oh, this is so absolutely important and under-taught, at least in my universe, and something that I think we're starting to get better at. The framework of view of sort of how to perform under pressure—This is gonna get us back to communication in a second, but the framework of view of sort of how to perform under pressure when I was coming up was entirely or nearly entirely doctor-focused. Right? It was looking at the doctor, looking at yourself, looking at what you do on-shift, and how to, you know, perform better in those one or two critical moments. And the more that I have worked with The Emergency Mind Project and also my work with the groups at the Mission Critical Team Institute, looking at crosscutting teams with Special Forces folks and NASA and a variety of other folks that have to perform in these elite environments, what I now understand is a much more sophisticated structure of how we think about human performance in general.

And I've actually—I've been working on this yesterday and today, so I'm gonna toss it out there as a work in progress, but now the way that I think about it tends to be this matrix, right? So, three by two matrix, and the levels are individual, team, and structure. Right? And structural. And then the conditions, or the columns, are on and off. So, on-target, off-target, on-shift, off-shift, whatever it is. And really that you have all of these things working in concert. So you have the things you do as an individual off shift that allow you to perform under pressure, the structures you build on shift to function, and all of these things sort of working together. And it's a bit of an unformed thought, 'cause I'm sort of just starting to organize things into this way, but my suspicion is that that will give us a much broader and more real version of the world of things out there that help humans perform under pressure.

Now, to bridge that back, and by the way, like, if anybody listening to this—I would love your thoughts on that, 'cause it's, like I said, a work in progress. But bridging that back to communication, a concept that we work with a lot is routine versus critical communication. Right? And again, some of this comes from the work in the Mission Critical Team Institute. So when you and I are going through a day-to-day normal scenario, we are at a dog park, talking about whatever, or we're having this conversation, we expect a certain way of communication. We expect a certain frequency of words and tone of voice and body posture and way of delivering content back and forth. When we're in a critical situation, right, when life or death is on the line, or as you're saying, right, when you're really, really deep into the math of a complicated problem in a poker game, you're going to expect information to be structured in a very different way. Somebody chatting you up about your dog is going to be really uncomfortable, because it's so incongruous with what needs to happen. Right?

What needs to happen is clearcut, direct communication. And there's some stuff that we use in those critical moments, right? So, information-rich, focused, directed, usually with eye contact and names, if you can do it, and then with clear, closed-loop communication. Right? So somebody might say, "Dan, I need you to place an IV in the right arm." And I'll return, "Copy that. Placing IV, right arm." And then when I place an IV, I'll say, you know, "Team lead, IV placed right arm, eighteen gauge." Back and forth, closed loop communication. If I can't get it, "Team lead, struggling with IV. Consider alternate site." Right? You're just ultra, ultra-focused passing of communication like that.

One of the big strengths of this is that it allows us to focus our minds in these moments and focus our team onto the most important problems first. And we can talk for a second about sort of like the ADC structure of resuscitation and the sort of underlying hierarchical approach of decision-making, which I think is fairly useful. But one of the problems with this is that it works when everybody is doing it. And it struggles when there is a mismatch in terms of expectations. So if you have seen a saber-toothed tiger bearing down on us in this conversation, you see one circling behind me over here and it's about to eat me, and you start yelling at me, "Dan, turn around, you're in danger," and I'm still in a routine mode, I'm like, "Man, why is he a jerk? Why is he yelling at me?" Right? There's a disconnect between our mental models of, "Are we critical or are we routine?" And that's when a bunch of friction happens. And it happens in both directions, right? As we're going from routine to critical, as we're going from critical to routine.

You talked earlier about rituals. Right? We need to have rituals and ways set up that we're able to communicate, "Hey, folks, we're going into a critical environment." And often those are sort of very focused things. In the ER, you'll see everybody really loose and relaxed as we're sort of setting up for what's about to happen, we're joking with each other, we're laughing. And then the patient will come around the corner and somebody, whoever sees the person first, whoever's the team lead, will say, "All right, here we go." And that's it. Dead quiet in the room. Right? Because we know when we hear, "All right, here we go," we are ramping up and moving forward into that critical environment, and everything is critical until it's no longer critical, and then you can sort of go back and laugh at each other again.

Chris (44:23): The common failure mode that happens across all organizations, but I certainly see it a lot within startup companies, within small firms, is how to both give constructive feedback, but also to collect conflicting views, where often what you'll see is particularly if there's any sort of hierarchy, whoever the most powerful person in the room is, they'll speak the most, everyone else's views tend to conform there, even though people who might be on the ground floor have important context, that context might not get heard or taken into account. It seems like you have some really good kind of subtle differences to questions to bring out those conflicting views or ways to communicate feedback, perhaps in that situation that you discussed before. Would love to learn more about some of the things that you've developed over the years.

Dan (45:16): Yeah. I'm sort of, I'm in the middle of compiling this into an article about how to gather more effective feedback, so this is a great chance to sort of dig into it and talk about it a little bit. So I think you're right. So first off, like, why are we—Hmm. Let's take one step back. As an axiom, the room is smarter than you are. All right? The room is smarter than you are. It doesn't matter how good I am as a doctor, the room is smarter than I am. There are multiple points of view, they see different things than I do, they have different sources of information, and what I need to do is get the entire room together facing this same problem set that we're working on. Right? So I have to do that. My patients need me to do it, their lives depend on me being able to gather the information from the room.

That's a huge impetus to do that. Right? Incredibly important. So, you might ask why do we suck at it so much? Well, you nailed one of them, which is that we exist in a hierarchy, and the hierarchy in medicine is incredibly rigid and well-established, even though it's less in emergency rooms often, because we tend to be a bit of a more informal, fast-moving culture than other parts of the hospital, which we pride ourselves on, being a little bit weird. But still, we have a very rigid structure compared to a lot of things. So there's a resistance to speaking up if you're a junior in a hierarchy. There's also resistance to giving counterfactual information. Another way to say that is we all have sort of confirmation bias. We look for information that confirms what we already believe. And when you combine those things, when you combine hierarchy and difficulty and friction in speaking up, and you combine that with difficulty in providing dissenting views, you get this sort of like two-hit thing where it makes it really hard for people to speak up and give you information that they might not think you want to hear.

So, I remember being a medical student, and I was watching a cardiac catheterization going on in the cath lab. This is somebody that was actively having a heart attack, they were in there with some wires trying to feel around with it, and I was like three or four rows back watching through a screen, and I remember seeing one of the wires had broke in the sterile field. Okay, now, I knew that was a problem. I had enough training to know that was a problem. But I had no idea what to do at that moment, about passing that information to people. I was petrified. I was petrified that I would have to speak up and tell somebody else that this mistake had happened, even though I knew that doing that might save this person's life. I remember, I was like sweating profusely thinking about how to do this, because there's that much of resistance, and that much of a hierarchy. And ultimately I ended up sort of like tugging on the sleeve of somebody higher up than me in the hierarchy, and being like, "Excuse me, I think maybe this happened." 

You know, what I wanted to say was like, "Yo, you broke the sterile field, we gotta stop this." But it's hard. We create these frictions in there, right, which is—And that relates to everything. That's individual team and structure. That's on me to figure out how to do it, that's the team dynamic of how you communicate, and that's the structure of the hierarchy all playing together, in this place negatively synergistically for that patient.

So there's a lot of problems, in summary.

So, what do you do about that? Right? Well, one thing is I think that you have to when you're not in crisis mode before you're in crisis mode, when there are—You're just going about your day, as the leader of a team you need to go out of your way to explain how valuable everybody's opinion is, right? You can't be a jerk ninety-nine percent of the time and then one percent of the time expect everybody to volunteer useful information for you. No. They're gonna assume you're a jerk, 'cause you've been a jerk the entire time. Right?

So all of the time when you're off-crisis, when you're off-target, whatever it is that you wanna say for that, you wanna be really conscious of how you're seeking out feedback and information from everybody. Asking for opinions, answering questions, and challenging people to come to you with really hard problems and questions that maybe you don't know the answer to. Right? You're aligning yourselves together on one side of the problem.

The other thing is when you're actually on target, I think it's really crucial that we pay attention to how we ask for information and ask for dissenting opinions. So, to counteract confirmation bias, I used to ask, "Hey, I'm gonna do Plan X. Everybody on?" And people nod, right, they're like, "Yeah, I'm on, sure, whatever." But it's really hard to speak up against that. So instead, what I literally ask is, "I'm intending to do Plan X. Who sees a reason why X is unsafe or wrong?" And you invite everybody to actually say, "Actually, you know what, I'm confused why we're doing X and not Y." Right? Like, and if there's space and time, I'll actually say, "Hey, I really need you guys to prove me wrong. I need your minds on this. What do I not see that you do?" Ask for that counterfactual. And when you superimpose that on a background of valuing people's opinions, that is a really rich, fertile ground for getting more information.

There's some other stuff you can do for hierarchy. You can ask the people lowest in the hierarchy first. You can ask people to vote all at the same time about things. David Marquet, who wrote Turn the Ship Around!, has an amazing thing that he does, the fist to five, where he asks everybody to vote all at once, right, like, "Five fingers is full go, fist is full stop with the plan. And okay, on the count of three everybody raise your fingers." And then if you get a couple of ones or twos, you're like, "What do you know that I don't?" Right? "Why is that?" And voting all at once tends to break down some of the hierarchy and confirmation bias that we talked about, also.

Chris (50:25): It's so subtle, but small changes to the way that we ask these questions really have powerful differences. And part of what I'm hearing is just the acknowledgement that people are humans and respond to incentives. So something that is often said, but in my opinion not followed as much, is to really be conscious of what behavior you acknowledge and reward. That the systems that you create, the culture that you create, what you point out, what you celebrate, all of that is communicating a message about what's valued, and people will naturally respond and conform to that. So thinking about if you prioritize having a high-performance culture, are you incentivizing, are you recognizing, rewarding new opinions, new perspectives, divergent perspectives, or are you creating a system that is going to result in consensus? Because that is what's rewarded, that's what's incentivized.

And it comes down, like you said, you can't just wait for, you know, the really big decisions, you know, "What project are we gonna go on?" It comes down to all the small decisions as well—

Dan (51:46): Absolutely.

Chris (51:47): —And how that communicates with the organization values.

Dan (51:48): Absolutely. And I think, you know, if folks are listening to this and they're in the startup and entrepreneurship world, or they're running a team and they're looking at a culture that they have that maybe doesn't match what they want to, right, this is really an invitation to see how you can evolve that culture and become more of an elite performance culture. And a really sort of straightforward way to start that process is just to start asking that right now, to be like, "Hey, the next time we have a decision, I would really love for some dissenting points of view. I tend to overestimate X, Y, Z, and I really need some help finding where I'm blind. I'm gonna ask you for stuff. It might feel a little uncomfortable at the beginning, because that's not what we're used to doing, but we're all in this together, and we're gonna sort of bend the culture to be more like what we want it to do."

Right? A friend of mine, Preston Klein, says, you know, "There's no passengers here. Only crew." Right? We're gonna all together sort of work to bend this culture as we build it.

Chris (52:40): A concept at Forcing Function that we think has infinite depth is prioritization. So, recognizing what's most important and making sure that that comes first. That I don't think there's often a lot of opportunity to get more done, but what we can do is that we can work on things of higher average importance and make sure that those things come to the forefront. I'd love to read a quote that really, really jumped out at me from The Emergency Mind and kind of use this as a jump-in point for talking about prioritization and triage, which is a really key part of your role in the emergency room.

Dan (53:14): Yeah, absolutely.

Chris (53:15): "See this guy in front of you with the minor chest pain? Behind him in the waiting room are five other people who are waiting to be seen. Behind those folks are other people with chest pain or ambulances or even just thinking about calling 911. Your job is not just to take care of this one guy. Your job is to do the best you can to take care of him in the context of the entire cone of people spreading out behind him. Those people, the ones you can't see yet, they're your patients too." 

I thought that was just such a well-put way of thinking about opportunity cost, that the thing you are doing, the person you are treating, comes at the expense of all the other places those resources could be going. I know you think a lot about triage and how to make the most of your limited resources, time, et cetera. How does this quote jump out at you?

Dan (54:00): Yeah. So, that quote's actually from Erik Antonsen, who's an ER doctor that has done an enormous amount of work with NASA. And that's something he told me when I was just starting. And it's interesting, 'cause that's sort of like still a lot of what he does. Like he in a lot of ways has helped build the human system part of NASA, right, where they have to make these incredible trade-offs that are really micro-level on a space flight between, "Do you add another type of medicine or do you add more water or do you add a second set of, you know, CO2 scrubbers, or more thrust to the engine, or whatever it is?" And all of us exist—I would assume all of us exist in these spaces where the decisions we're making come with these trade-offs. Right?

And so how do we start approaching really complicated decision-making where there are these real, like, very serious trade-offs between what you're doing? And ironically, the first answer is like, is that true? Right? Like actually, are there trade-offs between things? 'Cause there's a whole host of decisions that we sort of invent trade-offs for that don't actually have trade-offs, and I think that finding places where we don't have to make decisions is actually an incredibly important skill. Right? Going back to our example of using a Taylor series to figure out what two plus two is. Right? Sometimes we make things way too complicated and we invent a reality that doesn't exist, and we want there to be a crisis when there isn't one.

So, let's put that aside for a second. Right? Because we do exist a lot of the times in spaces where there are real serious trade-offs between that.

There are no easy answers for this. And you can move pretty quickly from a complex theoretical problem to a real-life heart-wrenching ethical problem in kind of the blink of an eye in a lot of times in the emergency department. Right? And you know, we saw that as we are sometimes rationing access to care that we might otherwise want to be able to give but can't because of a lack of resources.

I remember a truly heart-wrenching case when I was working in Haiti and I had these two young men with life and limb-threatening infections in their leg, and I only had one dose of antibiotic in the whole hospital, and I remember looking at them and trying to be like, "Who do I give this dose of antibiotic to?" Like, there's no good way to answer that kind of a question, and there's a lot of structural work that needs to be done to make those decisions less frequent and less possible.

Thankfully, most of the time that's not the types of decisions that any of us are making, right, and we're making decisions in these middle grounds, where we have some resources, we have some requirements, and we're sort of doing a complex multi-dimensional optimization problem in terms of how to get there.

One of the things that we take advantage of a lot in emergency medicine to address that sort of reusable tool that we have is the idea of dependent hierarchies. So, we try to ask the question of what relies on what, and are we doing the most important first things first?

So, as a pretty good example of that, resuscitative care tends to follow this path line of A, B, C: Airway, Breathing, Circulation. Right? And that reflects the underlying reality of how the human body, the human system is put together. So we need oxygen in our brain to keep our brain alive. Right? And that's my second point of medical advice. Keep oxygen in your brain. Don't cut people open unless you have a reason to, and keep oxygen in your brain.

So, in order to get oxygen, you have to have oxygen that comes in through your airway, and then it has to make it into your lungs, and then it has to pass into your blood and be circulated to your brain. But that's a hierarchical dependency set. If your airway is blocked, if you're choking on a piece of eggplant Parmesan, which was a very real patient that I had not too long ago, and your airway is blocked, it actually doesn't matter if your lungs are working. And it actually doesn't even matter if your heart's working to circulate blood, because there's no oxygen getting in. Right? So what you have to do is fix that first problem. Only then can you go on to fix the breathing and the circulatory problems.

And although it's a little bit counterintuitive, any energy spent fixing that person's heart is kind of useless, 'cause it won't ever matter, 'cause you really have to have the first things coming first. So you're sort of operating in a "don't pass Go" mindset, which is a slightly different way to put that, a "don't pass Go" mindset.

So I think the question becomes how do you find and take advantage of these hierarchical dependencies in your organization, and how do you get a sense of where you can use that "don't pass Go" mentality to sort of balance these multi-dimensional optimization problems.

There's not an easy way to do that, right? It took us a long time to develop the ACLS algorithms that allow us to understand how to do A before B, then C. And we still have to remind ourselves of that really at the point of the spear when things are going South, to really concentrate on A, then B, then C. 

But again, right, how do we make those kind of decisions? Well, we go low-wedge first before we go high-wedge. So if you're looking at making a really important, multidimensional optimization problem for your organization, is there a more simple, lower stress, lower-wedge model that you can build out that maybe explores some of the same underlying reality and tries to look for those hierarchical dependency sets?

Chris (59:08): That's great. I think this is a good time to transition to the moments between emergency situations, or the time after you've left the room. There's a lot of research and documentation that our decision-making quality plummets when we're under pressure. And you share the ABC framework. I'm sure there are many more, you know, checklists, processes, systems, algorithms that you use in these situations to minimize cognitive load, to synchronize with the team. "Here's the order of operations, here's how we make decisions." I always like to approach these processes at a habit level. That the critical thing isn't the creation of them, it's that they continually iterate, they update over time and become more and more dialed in with the benefit of experience.

I would love to hear how your team improves these processes over time. Maybe if you do some sort of post-mortem. How do you separate the process from what actually happened?

Dan (01:00:11): Yeah. There's a ton of really cutting-edge work on how to do the most effective possible post-hoc debrief to get the most out of it. And I'll tell you, I spent quite a bit of time in the last week or so in sort of the first annual High Performance Resuscitation Team's Conference, which is a joint task force between Stanford, Mayo Clinic, and Mission Critical Teams Institute trying to study partly this problem of how do we as we come out of resuscitations learn the most out of it in the most psychologically safe way that leverages all of the suffering that all of us just went through?

So, there are open questions around this. One thing that I think we do know is that it's useful to do it in loops and stages. Right? So there's the immediate, "Are you okay?" Right? The immediate question is, "Are you okay?" Right? "You and I just went through this incredibly intense scenario together. The guy came in, I don't know if you remember him, he's been sitting there having trouble breathing this whole time. We put a breathing tube in him, we put him on a ventilator. Thankfully, he's been doing fine. We've been off in the corner talking about human performance. And so now, we've gotta regroup and say, hey, are you okay? That was hard." Right? Like, we just watched somebody really suffer, and that has to be our first move. Right? The zeroeth move is, "Is there another person around the corner that needs us before we can even check in with each other?" But let's assume that's not true. The first move has to be some version of that. Like, for me, and my team, are we okay.

Sometimes, the answer to that's "no." And what you really need to do is spend a minute mourning what just happened. And that's actually probably the best thing you can do, if you take that integral over time, that's actually gonna make you better more so than doing some sort of an after-action report would be. You know, once you make it through that piece of it, the next step is often what you'd call like a hot wash, which is just a really quick version of, "Hey, what just happened?" And we go through in as non-judgmental and open a way as possible what just happened.

Again, the success of our team to do that relies on the culture we have built before that point. So if we're a culture that is angry and vicious and undercuts each other, going to be really hard to do an effective hot wash. Right? So all the little decisions we make over the course of the day that set up that culture is what allows us to do that well.

And then after the fact, you can do sort of a more in-depth brief on a couple of cases, probably not all of them, 'cause it takes a lot of time and energy to be like, "All right, what did we learn from this, and what can we reflect back to everybody else?"

There's different versions of that. So, one of the ones that I really enjoy is one of the ones used by the Navy EOD folks, the bomb squad folks. So what they do is after a team defuses a device, one of their immediate next responsibilities is to go back and build a simulated device of that thing. To put everything they've learned into a sim case that they can then pass off to the other teams around them, so as much of that knowledge as possible gets captured for all the other folks out there. I really like that. I think that's elegant, I think it gives the team a chance to process what they went through, and also gives you a chance to push knowledge outward, laterally, vertically, and horizontally to your other teammates.

Some teams do automatic triggers for evaluation. Right? So when I was training at Harvard, anybody that had an unexpected upgrade in care within twenty-four hours, so if I admitted a patient to the hospital and I thought they needed to go to the floor, and within twenty-four hours they decompensated and required intensive care, that would trigger an automatic review, which is an interesting system if you have enough resources to do that kind of thing. Not everybody does, though.

But I think that again, when you look at the structure of individual team and structural levels, part of what you're doing is asking the questions of what occurred in each of those levels, and what can we pull from that as a reusable resource for next time? Incredibly, like, cannot stress this enough, incredibly important is the underlying reality that everybody who is doing that is a learner. There is no one person that knows the answer that's just teaching everybody else. Right? When I go through that with my team, I'm not the voice of reason and they're all the wrong peons that screwed this case up, but we're all together trying to get better at our craft collectively. And I think that that's an incredibly important piece of culture that really underlies the ability to do that well.

Chris (01:04:25): I'd love to be thinking about this at the individual level. It seems like a key trait of high performers is their ability to leave the performance in the arena, to create that separation between work life and personal life. I'm curious, Dan, like, how do you process some of the experiences that occur to you? Do you have practices that you find helpful to be able to power down after a shift, to step back, recover, and not let some of the things that happened at the hospital affect in your personal life?

Dan (01:05:01): When I think about the prepare, perform, recover, evolve cycle, "recover" is probably the piece I am the worst at at a personal level. It's just the thing that I am experimenting the most at, and I have the most growth to do in that domain. I picked up a lot of really unhealthy habits when I was training. A lot of compartmentalization, which is sometimes necessary but only for short bursts, and a lot of difficulty in communicating around what I feel, experience, and go through for it. And I think I've started to, through therapy and through really deep conversations with other folks who are operating in these types of worlds, come to realize the strength of being able to discuss what we go through and what we see. There is no magic bullet for this, especially when you operate in the types of spaces that I do, but there are certainly ways that it doesn't work. Right? There are definitely ways you can make it worse on yourself, and a lot of us choose those ways because we don't know what else to do sometimes.

And so the first thing I would say out of all of this is that if that strikes a chord in you, reach out. To me, to somebody else in that world, and sit there and as much as you can talk to them about little bits and pieces of it. And my challenge for you if that's you is to ask yourself what good might come if you took that path. You know what's happening on the path that you're on when you're not doing that. So what good might come if you took that other path?

But I'll step away from that for a second, and at a more tactical level, we talked about ritual, and I think that the ritual of creating a space between things is a great way to start. So I will never, unless there is literally no way to avoid it, I won't pick up the phone and call somebody as I'm walking out of the hospital, because I just—that just—bad things happen. Right? Like nothing good's gonna happen, unless there's really no way to avoid it. Ideally, I will take the space and time to shower and eat and drink some water and stretch and start to reset myself as a human, and I'll be conscious about that. You know, "I am resetting myself as a human." And then I'll pick up the phone and, you know, talk to whoever I need to talk to or get to talk to.

I will do some journaling about stuff that I find particularly challenging, especially if it's a decision that I'm struggling with my performance in, where I want to think through how I could perform better and maybe try to dissect a little bit about what I could have done to set up a better structure and team around me.

I'll often engage with a group of other people whose opinions I really trust, most of whom are non-medical, as it just happens to be the makeup of my close friend group.

Then I'll also employ professionals. Right? Like, I've a therapist that I really enjoy talking to, because I think it really helps me get at some of the underlying stuff that's hard to talk through and talk about. You know, there was certainly a time when, like, old versions of Dan would have been like, "Dan, there's no way you're going on a podcast and telling people you're in therapy." Right? Thankfully, this version of Dan is like, "I'm in therapy, this is really important, you need to talk about things, you need to like get better at what you're doing." Like, you have to get better at what you're doing. And if you approach it with that growth mindset of, like, "I want to get better, I want to be better than I am now," I think it's really a powerful tool in our arsenal as we recover from stuff like that.

And then I think it's also worth like taking some time and space different from your day-to-day stuff. 'Cause most of what I just talked about is sort of like day-to-day like tactical applications. So you know, when I'm thinking about a really challenging case or a very challenging outcome, I'll often batch process that while hiking. I'll take a hike by myself and work through a couple of things that have been sitting around on the back burner, and you know, really try to take a deeper stab at some of those things. Especially if they're people, right? Especially if they're patients that suffered or died that I'm holding onto. I'll take that as an opportunity to honor them as I go hiking and to, you know, take a couple breaths of fresh air in their memory.

Chris (01:09:14): Thanks. That really resonates, and I appreciate your vulnerability in sharing. The recognition that we are all continually evolving and that we all have growth edges and a lot of times we know something works from us and it falls off for any number of reasons and we can always return to that well, return to the things that we know that work, that will always find something anew. It reminds me of a piece of advice that I received around meditation, but I think that in this way it can really apply to exercise or self-care or any number of practices that allow us to step back, be objective, recover, do what's necessary to put ourselves in a position to succeed the next day, is that we prioritize these activities and we treat them as if they're the most important. So, treating sleep as the most important. Treating recovery as the most important. Treating journaling or meditation as the most important. Not because the other things in our life, our patients, our clients, our business are non-important, but because those are so important, and thus like it is so important for us to show up for them, that we do these things for those other people in our lives.

And that really resonated for me, is when I work with a founder, it's often they can have the weight of the world on their shoulders, and a lot of avoidance response, and a lot of almost self-punishment, in a way, of avoiding exercise or destructive patterns online or staying up late, and the sort of justification is, like, you know, creating a narrative. "I'll push through it, I can get through this, I can handle anything," that sort of thing, back up against the wall, et cetera, but just recognizing, hey, you put yourself into a position to succeed for the other people on your team, for the other people who are gonna be on the table in front of you, and this recognition that self-care is not selfish I think is a really important message.

Dan (01:11:22): Yeah, I like that a lot. I like that a lot. I've certainly gotten better at that as I've gotten older, and as my view of what it means to perform has expanded. And I feel very fortunate about that.

Chris (01:11:34): I'm curious, because I don't think a lot of us have had this type of experience—I mean, something in poker that happened often is I think I'm playing for three hours and then it ends up being thirteen. I imagine you've had many of these experiences where you sign up for a ten hour shift and twenty hours later you're walking out all bleary-eyed, the sun blaring in your face, saying, "How did I get here? What just happened?" Any things that you've learned over the years to sustain performance, sustain good decision-making across a long and unpredictable shift?

Dan (01:12:08): Thankfully, that exact scenario is pretty rare for us. We have a good rotation of folks that come in, and overlapping support structures, and everything. But you're right, that there's always like, you know, there's always the time when things go way later than you think they are, and there's this unpredictable nature to it. You know, there's also the times when you have a shift that starts at 7:00, and you walk in at 6:45 and there's somebody in cardiac arrest and you start. You know, you walk in the room, you throw your backpack down, you don't even have anything on, your coffee's in the corner, and you're going. And you don't get to choose when an emergency happens. Right? None of us do. I think that's part of the nature of its unpredictability and its liminality, which is that you walk into this space, and then all of a sudden you're there, and all you have, all you have is what you've prepared ahead of time. You don't get to rebuild your tools in front of you as you're going.

So how do we keep our decision-making as robust as possible in the face of applied pressure over time? Right? One is my patients need—They don't only need me to make good decisions, they need me to make the right decisions well. That's a subtly different but incredibly important thing. Right? I need to make sure I'm devoting my mental energy to where it is differentially useful and important.

What that means functionally is that as many decisions as possible, I need to not make them. I need to conserve my decision-making ability for where it makes the most difference for somebody. Right? So if there is equipoise, I love that. It's a great thing to take advantage of. Right? So maybe there's equipoise, for example, there's a lot of debate—And this is sort of a kind of a dry topic, but there's a lot of debate about should you give somebody antibiotics for five days, seven days, or ten days within a particular type of thing. And for many versions of that question, the answer is it probably doesn't matter. There's probably not definitively important evidence in one direction that it makes a bigger difference one way or the other. So you could say, "Well, I'm gonna give everybody five days, 'cause that's less, and that's less, you know, reorientation of the gut bacteria, which we're starting to learn how important it is." You could say, "I'm gonna give everybody seven, 'cause that's the middle." You could say, "I'm gonna give everybody ten, 'cause I don't think they'll take ten, and maybe if I say ten they'll take seven, and that's probably better."

I don't care. Right? That's actually my answer, is like, you should probably not care. You should identify places where there's equipoise, and as much as possible offload decision-making into some intelligent default. So, what's predictable, you should make intelligent defaults. What's less predictable, you should design behavioral economics-informed bumpers around you to try to make the best decisions as possible. Right? So doing things like asking the room for better feedback, that's actually a protective mechanism in terms of decision-making over pressure and time. It allows you to harness the wisdom of everybody else, and not just rely on your own facilities.

There's some other stuff that I'm a little less sure about. There's a subset of ER doctors that tend to become more conservative toward the end of their shift, and take less risk. I think that's probably a good idea. Sometimes I operate like that. I don't know from—You know, if you make me put on my like "What Do I Know As A Doctor" hat, I can't tell you I know that, 'cause I haven't really seen an actual definitive study of that. I'm not even really sure how a definitive study of that would work, as a scientist. But if you take off that hat for a second, I still think it's probably the right thing to do, because we do tend to make worse decisions over time, and so can I be more—Can I handle risk with larger buffers as I maybe get worse at making decisions? I probably should do that. 

You know, we know that humans, as they get hungry and tired and thirsty, make poorer decisions. Right? If you read the judge's lunch study, right, like an incredibly seminal piece of work that's worth reading—So what do you do? Well, you should probably snack during the course of your shift. You know, you're a human, right? You're not a robot. Like, you need food. At one point when I was a resident, I decided I would really jump into the keto diet, and intermittent fasting, and I—No comment at all about the utility of those things, but I straight passed out on a shift. I just hadn't done the homework, hadn't done the legwork, set myself up for failure. Not my best moment. You have to think about how to support yourself as a system. You have to think about the human system as you're doing that work.

Chris (01:16:39): So many places we could go with that. I think what really comes across as you speak is your commitment to growth and mastery, that you are continually iterating, experimenting, trying things, see what works, trying to do more of that, if something doesn't as planned trying to deconstruct, look for Plan Bs. I would love to hear more about your personal approach to growing as a doctor or as a human. You mentioned at some point that you track your personal values, that that's something that's new for this year, how tracking how you act on a particular day, the habits that you do, the way that you go about in your life seeing what correlates with being better at your role, living a good life. Like, how do you use these systems, personal and otherwise, to continue to improve?

Dan (01:17:39): I have a deep belief that I can change and grow as a human, and I have a deep belief that it's my responsibility to do that, and I have a deep belief that it's a joy to do that. And when you sort of mash those things up, right, you can change, you need to grow, and it's awesome, it's pretty cool, right? Like, there's a lot of possibility that emerges from those three pillars.

I tend to be very value-driven in my approach to stuff, so I spent a lot of time at the beginning of the pandemic, for example—I sorta thought I was gonna die. A lot of us did. We didn't know what we were facing, we didn't know how virulent it was. We'd seen some of those stuff that happened with Ebola, and we weren't really sure. So you know, a lot of us wrote wills and a lot of us volunteered for shifts for other people who had families, and you just sort of went in thinking, like, "Maybe this is it." And to do that, to keep going back being like, "Maybe this is it," it really helped me clarify—This is the retroactive silver lining that it only sort of felt like at the time, but it really helped me clarify sort of what a day well-lived would look like.

So, I tried to boil it down to like, "Well, okay, what am I gonna do such that if I blink out of existence tomorrow, I will blink out of existence feeling like I did a pretty damn good job?" And that question, which is a sort of more grown-up version of, "Who do I wanna show up as today?", is a question that I continue to wrestle with and continue to think about. And I keep cycling through what I think it means to be a good version of Dan, and to then be a better version of Dan tomorrow, and I keep trying to make that a constant thing for me, to make it less of a special thing that I do and more of a normal thing that I do, which is, "Am I living lined up with what I think the best version of Dan would do today?"

Sometimes I find it useful to track habits for that. Sometimes I don't. To me that's more of a tool. And I have friends that love tracking habits, and go down this rabbit hole of how to design their habit trackers in a way that's most effective. And sometimes that's important to me, and sometimes that falls off the radar, but that idea of, "Am I living my life coherent with what I think the deepest things are, and am I evolving those deepest things?" is a pretty constant thread throughout my existence.

Implicit in that is the sense of growth and personal development being a really important thing. So I'm always reading, and always talking to my friends about what I'm reading, and have groups of people that I share ideas back and forth with about, like, "What do you think about this? What are you guys working on? What are you struggling with today?" And that being part of the joy of it.

On a technical level, at work, I always tell my teams that they should be able to ask me at any point in time what I'm working on right then, and that I should be able to answer them. And I had—Right after I said that, this was almost a year ago now, one of our brand new interns, I had just sort of given them some feedback about, "Okay, hey, I need you to tweak this thing you're doing like this because of X, Y, Z. Do you understand where I'm coming from on that? How does that feel?" And they were like, "Yeah, I get it. Also, what are you working on?" I was like, "Ha, ha, ha! All right. Calling me out." And it's great. And I think that's a really important piece of it, like, knowing that I am a work in progress, and that's a really good thing. That I'm lucky to be able to be a work in progress today.

Chris (01:21:07): Thank you so much for sharing that, Dan. It's something that I come back to over and over again, is what is that critical mindset that really separates the top performers? And for me it just comes back to this commitment to continuous improvement. That there's always a new dimension for growth, and that this is an opportunity. That things are always going great for us, and there are opportunities for things to grow even better. So coming back to, you know, who am I trying to be, who do I need to be in this moment, and where is that gap? Where is the dimension that I can train, creating this deliberate practice as you've put so eloquently, what are you working on, that there's always something to be trained. And having fun with it, even when the situation isn't fun, that this is a blessing. That we have all of these things that we can be doing to improve ourselves.

And Dan, I think the work that you're doing is just so incredibly important for the world, the medicine and otherwise, and you know, I'm so grateful for you coming on and sharing your hard-earned wisdom with us. For anyone listening, highly recommend Dan's book, The Emergency Mind. I think there is a wealth of actionable knowledge in that book whether you work in medicine or otherwise for managing teams, for managing yourself in high-pressure situations and coming into these types of situations prepared so you can be confident and act judiciously.

Dan, is there anywhere that you'd like to send people listening, anywhere you'd like to direct them in terms of websites or resources?

Dan (01:22:49): Yeah, absolutely. You can go to emergencymind.com, and sort of more importantly you can find me at dan@emergencymind.com, and just reach out. I'd love to hear the challenges that you and your teams are working on and what you're going through with that, and if there's any way that we can help.

Chris (01:23:05): Dan, it's been an honor and a privilege to talk to you today. Thank you so much for joining us.

Dan (01:23:08): Thanks so much, man. Thanks for having me.

Tasha (01:23:11): Thank you for listening to Forcing Function Hour. At Forcing Function, we teach performance architecture. We work with a select group of twelve executives and investors to teach them how to multiply their output, perform at their peak, and design a life of freedom and purpose. Make sure to subscribe to Forcing Function Hour for more great episodes, or go to forcingfunctionhour.com to sign up for our newsletter so you can join us live.

EPISODE CREDITS

Host: Chris Sparks
Managing Producer: Natasha Conti
Marketing: Melanie Crawford
Design: Marianna Phillips
Editor: The Podcast Consultant

 
Chris Sparks