emDOCs.net Emergency Medicine (EM) Podcast · emDOCs.net EM Crew

Episode 122: Performing Under Pressure

·28 min·2 clips

Research shows clutch performers don't exist—even NBA players shoot worse under pressure.

This episode explores the psychological and physiological effects of high-stress situations in emergency medicine and presents evidence-based techniques to improve performance. Hosts Britt Long and Manny Singh are joined by Zachary Ost, who synthesizes concepts from human factors experts like Scott Weingart, Mike Loria, and Cliff Reed. Ost challenges the popular concept of a "clutch performer," citing data showing NBA players shoot worse under pressure and CEOs make poorer decisions. He explains the body's threat response triggers fight, flight, or freeze reactions, with vasoconstriction and diverted blood flow. A 2018 article by Chris Hicks and Andrew Petrosoniak details how stress degrades fine motor skills, attention, time perception, and working memory. The discussion introduces the "optimal performance zone," a state slightly above resting heart rate where cognition is enhanced, contrasting it with the "black zone" of extreme stress. A key insight is that performance under pressure depends on the level of one's training, not innate ability. The episode breaks down "just-in-case preparation," which includes breaking procedures like intubation into reproducible microsteps, a concept from Rich Levitan's airway work. It warns of the dangers of overlearning incorrect sequences, illustrated by a story of a police officer who disarmed an assailant only to hand the gun back due to muscle memory. The hosts recommend using checklists and drug reference cards for cognitive offloading and developing "emergency reflex action drills," like "cart, epi, hack" for hypotension, as fixed action patterns. For in-the-moment regulation, the episode details a four-step sequence from an *Annals of Emergency Medicine* article: breathe, self-talk, visualization, and a focus word, summarized by the mnemonic "Beat the Stress Fool." Ost personally recommends an exhale twice as long as the inhale for breathing control. He emphasizes the importance of a post-crisis reset to avoid a parasympathetic backlash and loss of situational awareness. The tone is highly educational and conversational, blending research summaries with practical clinical examples and light humor. Emergency medicine providers at any level seeking to improve their resilience in codes and procedures would find immediate value. Listeners interested in applied psychology or performance science in high-stakes fields would also appreciate this episode. Those looking for a pure clinical review of specific disease management might find the focus on human factors less directly relevant.

As heard by us

A practical look at staying steady when pressure rises.

This episode treats pressure as a skill that can be trained, not just a burden to carry. It moves from what stress does in a crisis to how clinicians can prepare ahead of time and keep adrenaline from taking over once things get tense.

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Why you'd press play

You want a calmer hand when the airway gets ugly.

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