It is often assumed that doctors have a natural ability to deal with pressure. Their popular image is generally one of calm professionalism under extremely challenging conditions, especially at the moment.

And if your job also involves treating seriously ill and injured patients by a roadside, on a remote island or even halfway up a mountain, you expect to encounter high pressure situations every day. But Dr Stephen Hearns had not seriously considered what it takes to maintain peak performance, until he saw himself on camera.

But this is neither realistic - nor helpful - for those who are charged with providing critical frontline care, according to Stephen, a consultant in emergency and aeromedical retrieval medicine and mountain rescue doctor. He believes that performing under pressure is an important skill that needs to be better understood, in the interests of doctors and patients.

Human factors

"There is an absence of teaching about human factors, human behaviour and performance under pressure at medical school and in post-graduate training programmes," Stephen says. "Undergraduate and post-graduate courses concentrate on factual knowledge and technical skills, so someone with the ability to retain lots of information and get good marks in academic examinations can progress a long way into their career without necessarily having the aptitude or emotional intelligence to perform in a very high-pressure situation. And I also have to say that people's insight into their own ability is often not very accurate."

Stephen has extensive experience of working under extreme pressure in his demanding role as a doctor within Scotland's Emergency Medical Retrieval Service, which he helped establish in 2004. This sees him flying by helicopter to attend emergencies in remote areas with limited resources and a mission to stabilise the patient and oversee their safe transfer to hospital.

Even so, it was only about five years ago, when he and his team agreed to wear badge cameras, that he recognised the impact that pressure could have on his own practice. "We were carrying out anaesthetic procedures at the scene of a road accident," he remembers, "and it was a real lightbulb moment for me when we got back to base for debriefing and viewed the footage. It turned out that the paramedics and nurses I worked with described the look that I could give them if things were going wrong as being 'herniated'. When I saw the badge camera footage I could see from my facial expression and the look in my eyes that my own ability to perform under pressure, to communicate and lead the team, was not as good as it could be at times.

"I suppose it then became a bit of a personal journey to try and improve my own performance and that of the team. I was really interested to find out why I was behaving like that and how to avoid this response when the pressure became excessive."

Stephen's research, which included visiting other organisations such as the RAF and Search and Rescue services, has given him a deeper understanding of how the brain responds to stress and the different pressures that doctors experience. Typically these include limited time, the amount of information that your brain has to process (cognitive load), environmental pressures such as noise and interruptions, and the strain of knowing that a mistake could have catastrophic consequences.

Stephen emphasises that pressure is not necessarily a bad thing. Too little pressure carries the risk of boredom and disengagement; too much can tip us into a state of 'frazzle' that prevents us functioning effectively and can eventually lead to burnout. But in the right circumstances, pressure can be a positive motivational force that actually enhances performance. "If the pressure is high - but not excessively so - and you reach what I call a 'zone of high-performance flow', then that is a really pleasurable place to be. For example, a surgeon in the operating theatre who is about to carry out a difficult procedure but who knows they have the knowledge and skills to overcome the challenge. That feeling is one reason that doctors are attracted to high-pressure specialties."

The key to maintaining the balance between pressure and performance, explains Stephen, is to identify the human factors and situations that can make doctors more vulnerable to frazzle, and to develop strategies to manage these more effectively.

"Fatigue is a big issue," he notes, "both in terms of prolonged periods of working and shift work. Fatigue has a considerable effect on our ability to communicate, to make judgements, to make decisions, and to carry out complex practical tasks. Another factor is communication. When we are under pressure our ability to both transmit information and to receive and process information is severely compromised in time-pressured situations."

One important way we can become more attuned to the warning signs is by having open and honest conversations with colleagues. Stephen advises: "Ask nursing and medical colleagues, 'How did I come across there?' or, 'Are there any learning points for me?' Some hospital services encourage filming and I think that can be really beneficial, but you need to get ethical approval and to have robust systems in place. In our service, recordings are encrypted and deleted in 24 hours and the footage can only be viewed by the team concerned."

Pressure in a pandemic

Of course, it is impossible to consider the impact of pressure without discussing the way the coronavirus pandemic has magnified the challenges, particularly for those in critical care roles. "The pressure on us is huge," says Stephen. "There is the constant anxiety about becoming unwell because of our exposure to infected patients. We've got real challenges with communication between colleagues and with patients because we are wearing masks and eye coverings which make it difficult to understand what people are saying and we can't see facial expressions. And the sheer weight of demand versus capacity adds to the pressure and stress considerably.

"In Scotland, a quarter of a million people have no direct access to intensive care within one hour of where they live so our helicopter retrieval services are flying out to islands like Shetland, The Orkneys, Arran, Islay, to move very unwell patients while wearing really quite complex and uncomfortable PPE for up to ten hours a day. In the past 12 months I have been involved in high pressure incidents that luckily haven't resulted in a negative outcome for the patient."

There are practical measures that can help address some of the challenges, such as the use of cognitive aids to support communication while wearing PPE and checklists. However, Stephen warns that poorly considered interventions can bring their own difficulties. "Hospitals are developing guidelines to help doctors and nurses treat significant numbers of patients with a new condition, but often those have been produced by someone with no training in writing guidelines. So we have tired junior doctors at 2am trying to read a document that is too long, poorly-designed and not user-friendly."

In the current health crisis, the focus really has to be supporting the resilience and wellbeing of healthcare professionals. "We are in this for the long-haul and we are all vulnerable," he says. "The big thing for me personally in terms of self-preservation is making good use of my downtime for exercise and relaxation. I've just read a really good book called Why We Sleep and now I've made it a priority to ensure I get sleep which is of good quality and duration. It's so important and I've found it really helps."

Even so, Stephen worries about the damaging consequences if healthcare staff continue to work under excessive pressure for such a prolonged period: "We can't afford to go into work day-after-day and shift-after-shift with high levels of cortisol and adrenaline because our bodies and brains cannot deal with that and it leads to chronic stress and burnout. But that is what a lot of acute hospital staff and the ambulance service are facing at the moment. I have seen the impact on colleagues already, and unfortunately I think we are going to see the results long after the pandemic is over."

Nor will the fallout be confined to clinicians. As Stephen points out, doctors who are struggling to cope with pressure have always been more likely to make mistakes. "I act as an expert witness for the GMC and the defence unions, I'm an ombudsman adviser in Scotland and I work for the procurator fiscal, so I spend a day or two each week looking at cases of alleged medical error and fitness to practise. Human factors play a role in almost all misdiagnoses and medical errors, whether that is communication problems, fatigue, or the pressure of demand versus capacity. In my view, encouraging doctors to have specific training in human factors and performance under pressure would go quite a significant way to reducing medical error."

More broadly, he would also like to see more progress towards an open, learning culture within NHS organisations so that problems that hamper performance are promptly and effectively addressed. "Incident reporting in the NHS is sometimes viewed as a punitive process, which is quite wrong," he explains. "We need people to feel safe to speak up if the care provided to a patient is sub-optimal, for events to be reviewed in a safe and supportive manner and for learning to be shared where changes are made. There should be a much lower threshold for reporting and it should be clear who is responsible for looking into the matter. We are getting there but there is still a long way to go. I work alongside quite a few pilots and it's quite fascinating to contrast the open culture in aviation compared to that within healthcare."

Stephen is now on a mission to push these issues up the agenda of the NHS, medical schools and his fellow professionals. He has just started teaching an undergraduate course at Glasgow University Medical School and wants non-technical skills like human factors training to be a regular part of CPD for practising doctors. He has written a book about his experiences, Peak Performance Under Pressure: Lessons from a Helicopter Rescue Doctor, published in 2019, while more than 700 people have signed up for his online course on improving performance under pressure.

"I've been really pleased with the response," he reflects. "I'm very fortunate that my work and interests bring me into contact with people with completely different perspectives on safe systems and performance, from ex-military pilots to individuals on remote expeditions and mountain rescue. These insights have helped me look at doctors' performance under pressure from outside the box."

INTERVIEW BY SUSAN FIELD