Want to perform better under pressure? Learn to make better decisions

Author: Dan Dworkis, MD, PhD (@TheEmergMind, Assistant Professor of EM, USC) // Reviewed by: Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

Great. But how?

Learning to make better decisions, especially better decisions under pressure is neither simple nor straightforward. Many individuals and teams working in emergency medicine struggle to find concrete ways to improve their decision making that go beyond saying “don’t do that again” when the result of a decision is a suboptimal outcome.

Fortunately, there are a variety of resources available from other domains to help those of us in the world of emergency medicine improve our ability to make decisions under pressure. In this article, we look at five key books that anyone wanting to improve their ability to make high-stakes decisions under emergency conditions should read.

Collectively, these books take us on a path exploring how the hardware and software we work with – as well as the environment we work in – alter, support, and often frustrate our ability to make high-quality decisions under pressure.

-John Coates

Coates is a former Wall Street trader turned neuroscientist who does an amazing job exploring the physiology and neuroanatomy of how stress affects us and our abilities to effectively make complex (or even simple) decisions.

Where most of the books on this focus on the “software” or mental tools we use to make decisions, Coates’ work focuses more on the “hardware” built into us from earlier evolutionary periods. As such, I think it is an excellent foundational book that should be processed early in training, though even reading it later as an attending I found its extremely helpful to process what I was feeling and experiencing under pressure.

Some of what Coates describes about how humans function at core levels is probably not directly changeable, but the more we understand how we function, the more we can adapt and build systems that support us.

-Daniel Kahneman

No surprise that Kahneman’s seminal work on cognitive biases makes this list. Even if you don’t explicitly work through this book as part of your training, chances are high your team talks about the strengths and weaknesses of System 1 (fast, intuitive, and prone to stereotypical errors) vs System 2 (slower, methodical, mentally costly) thinking and decision making.

Knowing about the cognitive biases that Kahneman explores is probably our best defense against making them, and many teams employ a System 2 style slow down and double check process as part of their high-stakes decision making as a result.

Not officially on the list but also excellent is Kahneman’s other work Noise: A Flaw in Human Judgement, which he wrote with Olivier Sibony and Cass R. Sunstein.

Especially when read with Thinking, Fast and Slow, Noise does an excellent job exploring some of the features/bugs of the underlying “software” our brains typically use to make deciding under stress. At least one of these books should be read early on in training to develop a healthy sense of humility around making high stakes decisions.

-Gary Klein

How do chess masters make decisions about what move to make in chess? How do experienced firefighters seem to know exactly what to do when responding to fire? If you’ve ever asked an expert how they made a seemingly supernatural or prescient decision and received a shrug as a response, this book is for you.

Where Kahneman’s work on cognitive biases explores how humans make decisions in areas where they are relatively uninformed or novice, Klein’s work on naturalistic decision making explores how humans make decisions in domains where they are an expert. It turns out these are vastly different things.

Understanding how expert decision-making works is hugely important for working in emergencies, but, in a somewhat circular way, it requires a degree of expertise to understand. As such, this book should be read later in training, after the more fundamental work by Kahneman has been read and processed.

A particularly useful arc would be Thinking, Fast and Slow, then Sources of Power, then this paper which Kahneman and Klein co-authored contrasting their beliefs about decision making.

-Annie Duke

Duke is a former champion poker player turned expert in decision-making, and this book is a phenomenal analysis of decision making in the face of uncertainty and incomplete information. Where the other books on this list focus on how decisions are made in general, this book digs into how to prepare to make an individual decision and how to learn from decisions which have already been made.

The process of working backward from a result to determine if you made a decision well – and how you could do better next time – is critical for working in emergency medicine, and I often formally go through the performance-outcome matrix Duke describes in my after-action reviews and debriefs.

A close runner up for this spot is Duke’s second book, How to Decide, which focuses a bit more on the process of making decisions and slightly less on learning from the results of decisions. The sections on free rolling and deciding about deciding, are particularly useful in emergency situations.

I’d also recommend my 2020 Emergency Mind Project podcast with Duke, which occurred right as How to Decide was being released and describes a great deal about applying these principles to emergency medicine.

-Richard Thaler and Cass R. Sunstein

Rounding out the list – which is primarily focused on the universe within us as we make decisions – is this excellent book looking at how things external to us can “nudge” us into making different decisions. Specifically, Thaler and Sunstein look at how subtle changes in the way decisions are formed and posed to us can drastically change the choice we make, even as we are totally unaware of (or even in direct denial of) their influence.

Nudge is an excellent introduction to the field of behavioral economics and covers important topics like decision design and intelligent defaults that we all should be aware of as we work in emergency medicine. It’s also a truly humbling book to read – along with Thinking, Fast and Slow it can really hammer in the point of how much of decision making is outside our conscious control. But, forewarned is forearmed, and reading Nudge can pave the way for systems-level change in our emergency practice.

There is an enormous fund of knowledge in these books and working with and reflecting on the material they cover is a worthwhile and seriously challenging endeavor. Thankfully, I believe the overall message of these works is one of hope. With individual and systems-level effort, we can improve how we make decisions, even under severe pressure.

I hope studying these bring you as much joy as they have me, and I’d love to know what else you think should be on this list.


One thought on “Want to perform better under pressure? Learn to make better decisions”

  1. Thank you for these recommendations and the summaries. They all sound fascinating. I’ve added all those books to my Amazon to-read list. If and when I get through all of these books, I’ll be sure to get back to you about them. I’m a “seasoned” EP (30 years in practice) and would still love to learn more about decision-making in high-stress and high-risk environments, both the conscious and subconscious pathways. I love what you said, “forewarned is forearmed.” That’s QA and debriefing in a nutshell.

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