Making Decisions under Pressure

Thursday, 17 October 2019

Medico-Chirurgical Hall

President’s Medal Lecture (2018/19)

Professor George Youngson graduated from Aberdeen University Medical School in 1973.  After research and training in a number of centres and countries (Aberdeen, Inverness, Uppsala Sweden, London Ontario, Hospital for Sick Children Toronto, Canada), he was appointed a Consultant General Surgeon in Aberdeen Royal Infirmary in 1984 and Consultant Paediatric Surgeon at Royal Aberdeen Children’s Hospital in 1988.  He was awarded a personal chair in paediatric surgery in 1999 and became Emeritus Professor in 2010. He was made CBE for services to Child Health in June 2009.

He was previously Council member and Vice-President of the Royal College of Surgeons of Edinburgh.  His major interests are in surgical education, research into human factors and non-technical skills related to surgical performance and patient safety, and service configuration for children's specialist care.  He is also involved in global health initiatives including development of surgical infrastructure in low resource countries. 

This talk will examine some of the factors that influence human performance particularly under conditions of stress and pressure and outline the antidotes which can produce performance enhancement.


The President welcomed everyone to the meeting and noted that the excellent attendance was testament to the esteem in which the speaker is held by his colleagues. Three new members were welcomed to the Society and apologies were noted (see separate sheet).

Dr Reith then formally introduced the new President-Elect, Professor Alison Murray, Professor of Radiology at University of Aberdeen, and the meeting endorsed her appointment. He went on to give the history of the President’s Medal and the qualities required for it to be presented before introducing Professor Youngson as the speaker for the evening and the 2018 recipient. Due to challenging health issues, Professor Youngson’s lecture had been deferred and Dr Reith noted that the Society were delighted to welcome him to deliver his lecture and present him with the Medal.

Professor Youngson began by thanking the Society for the accolade of the Medal. He explained his interest in decision making under pressure and performing in response to stress.

He mentioned several colleagues by whom he was mentored and who influenced his own clinical practice both in Canada, where he spent two years working in cardiothoracic surgery, and in the UK. Those who mentored and influenced him were general and specialist surgeons, anaesthetists and paediatricians. Through their mentoring he learned the value of academic research in clinical practice, surgical discipline, a hard work ethic, holistic care of patients, technical surgical skills and found support for extra-curricular activities as well as generally furthering his surgical education.

Professor Youngson noted four key concepts in decision making under pressure as:

  • Clinical performance
  • Human performance limitation
  • Enhanced individual performance
  • Non-technical skills (NTS)

Clinical performance is often complex and may be influenced by team work, environment, equipment and the organisation people work for. A team should be familiar with each other, have the correct skill set and provide mutual support. Patient factors e.g. size and physiological status, can also affect clinical performance. It is necessary to be aware that clinical performance can be affected by interruptions and distractions, missing equipment or equipment failure, inexperienced staff, poor assessment, slow turnaround, missing results, poor communication, unexpected findings and poor working relationships.

Aspects of self, such as knowledge, attitudes to risk, experience, NTS, confidence, readiness and ageing can all affect performance. In addition, underperformance may be associated with poor training or lack of training. Human factors are the most common cause of adverse events. Adverse events may result from poor communication, poor leadership, unfamiliar teams, lack of “thinking ahead” or lack of NTS. Human factors include, and are influenced by, behaviour, attitudes, codes of conduct, organisational reliability, patient safety, ergonomics, NTS and team performance.

With respect to NTS, many industries are familiar with the need for rapid decision making under stress e.g. aviation, firefighting and armed police. They try to improve performance through training and simulation. Professor Rhona Flin, an industrial psychologist in Aberdeen, is an expert in this field and studied NTS for surgeons with Professor Youngson. NTS for surgeons have been identified as:

  • Situational awareness (gathering and processing of information)
  • Decision making (considering options, selecting and communicating the favoured option, implementing it and reviewing the situation)
  • Communication and teamwork
  • Leadership

A master surgeon noted that the ability “to think on the job” is the most important aspect/quality of a good surgeon. Professor Youngson referred to Endsley’s (1995) situation awareness model and utilised interactive videos to illustrate some of the points in the model. Situation Awareness Model after Endsley

During playing of one “Whodunnit” video twice, the audience were asked to spot changes between the two videos. Approximately five changes were spotted by audience members; there were actually 21. Possible reasons given were people concentrating on other things, not knowing what they were looking for or passing changes off as frivolous or unimportant.

It was noted that the same thing can occur in a work situation where people may ignore seemingly unimportant changes.

In the next video, observers were asked to note the number of passes between members of a basketball team. Not only were there numerous different answers to the question posed, but several other changes were missed by the observers e.g. changes in the number of players, changes in the colour of the players tops, changes in the colour of the backdrop and most notably someone dressed in a gorilla suit running amongst the basketball players.

Level 1 situational awareness is our perceptions. Unintentional blindness, search satisfaction and confirmation bias all affect situational awareness.

Level 2 situational awareness is comprehension e.g. most people can decipher a piece of text even though the letters in the words are in the incorrect order. However, this pattern recognition only comes with experience and would help explain why a junior doctor may struggle to comprehend information in some situations.

Level 3 situational awareness is projecting forward e.g. the reaction of a driver on seeing a child’s ball come in to the stream of traffic.

In general, there is poor understanding of how decisions are made. One model of decision making breaks it in to four categories i.e. recognition primed/rule based/analytical/creative. Recognition primed tends to be used in high risk/low time situations and creative in lower risk/more time situations.

There was a short interactive discussion of model from one of Professor Youngson’s publications illustrated by video and voice recordings from Sully’s 2009 plane landing in the Hudson River.

The dual process theory, documented in the book “Thinking fast, thinking slow” is a cognitive psychology theory that explains the different levels of information processing in individuals. It divides the processing of information into two pathways. 

The first pathway is system 1 processing which is very fast, automatic, involuntary and deals with small chunks of information. It is an unconscious process that we are not in control of. 

The second pathway is system 2 processing which is slow, deliberate, and voluntary. It is a conscious process in that we are aware that the processing is occurring. Working memory is used in system 2 processing and information is explicit and more detailed than in system 1 processing. 

It is known that the following factors degrade working memory:

  • Fatigue
  • Distractions
  • Stress
  • Illness
  • Fasting
  • Bullying

It is also known that situational awareness and decision making are at risk when someone is startled. However, dealing with this is not taught to clinicians.

One of the self-assessment tools used in aviation is “I’m safe; IMSAFE”. Aviation crews can use the tool to assess the factors which may influence their abilities.


It has been shown that two hours less sleep than normal equates to the effect of drinking a small amount of alcohol. Being hungry, angry, late or tired (HALT) makes it eight times more likely that someone will have RTA whilst driving.

Professor Youngson referred to another study which demonstrated the impact of bullying intervention on staff when being assessed in a neonatal resuscitation scenario. The bullied group individually and collectively underperformed.

Decision making traps such as jumping to solutions, complacency and failure to communicate can by mitigated by being given the increased capacity to think. Pilots are trained in distraction management within a “sterile cockpit”, particularly for take-off and landing procedures. There is scope for similar training techniques to be applied in clinical settings.

Professor Youngson noted that work still has to done in relation to the effect of human factors by way of training, improving patient safety and greater emphasis from the GMC.

Professor Youngson concluded his lecture by acknowledging those who have collaborated in his research and by expressing his grateful thanks to his family for their support in his career and life.

There were numerous questions prior to the conclusion of the evening when the President thanked Professor Youngson and presented him with his President’s Medal.


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