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We explore the high-stakes world of life-and-death decisions in medicine with William O. Collins, an otolaryngologist and airway surgeon. Drawing from personal experiences, he shares the challenges of performing under pressure, the importance of preparation, and the mindset needed to thrive in critical moments. Learn how resilience, teamwork, and reflection shape his approach to saving lives and coping with the consequences of those decisions.
William O. Collins is an otolaryngologist.
He discusses the KevinMD article, “Performing in the clutch: lessons from a pediatric airway surgeon.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Bill Collins. He is a pediatric otolaryngologist. Today’s KevinMD article is “Performing in a Clutch: Lessons from a Pediatric Airway Surgeon.” Bill, welcome to the show.
Bill Collins: Thank you, Kevin. I appreciate the opportunity to be on here and also appreciate everything you do to amplify the voices of those in health care. It is really valuable.
Kevin Pho: All right. Let’s start by briefly sharing your story and journey.
Bill Collins: Certainly. As you mentioned, my name is Bill Collins. I am a pediatric otolaryngologist, a pediatric ENT surgeon by training. I have been here at the University of Florida in Gainesville, Florida, since 2006, during which time I have been the division chief for pediatric otolaryngology, and over the last almost three years, I have also been the department chair for our Department of Otolaryngology here as well.
Kevin Pho: All right, and what led you to write this KevinMD article, “Performing in the Clutch: Lessons from a Pediatric Airway Surgeon?” I can only imagine that, as a pediatric otolaryngologist, you have a lot of life-and-death decisions that have to be made or performed within seconds.
Bill Collins: Yeah, you know, a lot of what we do is elective outpatient things. Fortunately, knock on wood, the vast majority of the time, things go well and smoothly. But every once in a while, we get thrown into unfortunate situations, particularly regarding the pediatric airway for me. So really the genesis of this article is a few years back, we were doing a fairly difficult procedure. It was an EXIT procedure—an ex utero intrapartum procedure—where we plan those in babies if we anticipate that they are going to need ventilatory support right at birth and also anticipate that there is going to be trouble getting an airway, you know, difficult intubation.
I did this case with one of our residents. It was a little tricky, a little dicey. Ultimately, things went well. It took a little while to get the airway, but since the baby was still only partially delivered and attached to placental support, we had a little more time than usual to intubate the baby. Afterward, the resident commented, “That was awesome. It was so much fun. How did you stay so calm during that?” My first thought in my head was that inside, I really was not that calm, as the clock was ticking. But it got me thinking about this concept a little bit because I know earlier in my career I certainly would have felt that pressure more, and it would have affected my performance. Some of it is that I grew up playing sports. I have three boys who have grown up playing sports, so watching them over the years and their teammates—how they react to pressure situations in their respective sports—got me thinking about what makes a clutch player and translating that into health care, certainly in our own field. How does a surgeon learn to perform better under pressure when needed most?
Kevin Pho: Now, before talking about some of those tips, what is it like to intubate a newborn? Take my audience into that situation and just play out that scenario. Even as a physician myself, I cannot imagine that. So tell us what it is like to be in that scenario.
Bill Collins: Yeah, you know, I will tell you early in my career, my approach was a little different. At first, I had a lot of extraneous thoughts going through my head, thinking, “Oh, this is such a cute little baby” or “The parents are going to be so mad at me if we cannot get this procedure done.” As I have evolved over the years, I have become much more focused on the task at hand, and I have taken a lot of that emotion out of it. So it has become, for better or worse, a much more technical procedure for me by taking those emotions out of it.
I really just focus on the task at hand: Do I have the right equipment? If we are talking about intubating a baby who is desaturating, for instance, I am not as focused on listening to that sat monitor drop. I know it is dropping. I have to fix it. So instead of focusing on the desaturation and that “doo-doo-doo” monitor that wakes us up in the middle of the night, I really focus on whether I have the right laryngoscope, why I am not getting good exposure, if the tongue is in the way, if the patient is positioned properly, and sort of take it step by step, very technical and analytical. That approach has allowed me to handle those situations better and more effectively over time.
Kevin Pho: Now, you talk about that and other tips in your KevinMD article, “Performing in a Clutch: Lessons from a Pediatric Airway Surgeon.” So tell us more tips and lessons that you have learned over your career.
Bill Collins: Yeah. In my mind, I think there are two types of emergencies or pressure situations. There are the planned situations: you have a difficult case or a difficult patient scheduled for next week, so you know what day it is, what time it is going to be, and you can put preparation into it. Then there are the unplanned emergencies or pressure situations that you cannot plan for. For us, the dreaded phone call is, “Is there anyone from ENT in the room?” because they do not care who it is—they just need someone to come help.
For me, I break it down into what I can do ahead of time, what I can do in preparation before these moments, whether I know that moment is coming or not. Then I break it down into what I can do when I am in that moment, what my mindset is. Usually it is in the operating room. The preparation part is, for us, we talk about “sharing the airway,” so planning ahead, communicating with the anesthesiologist or whoever we may be collaborating with. It might be other surgeons. It could be a dual-team approach. Spending that time ahead of the procedure, before the situation, ensuring you have everything you need. Does everybody have all the equipment they need? Is it ready to go? Is it functioning?
I look back a lot on previous cases that I have had, and for me, it helps to take notes. I have binders full of notes from difficult cases—some that might seem small, such as what suture I used and what approach worked or did not. It is important with all of these things to take note of what did not work so you do not keep repeating the same mistakes. Another big consideration is that you just have to do these cases. There is really no shortcut—experience matters. If you learn from your experience, that really advances you. And if you can help other people learn from your experience as well, I think it advances the quality of care in your field.
Kevin Pho: One of the things that you mentioned earlier was removing emotion from pressure situations and looking at it more as a technical procedure. Of course, it is easier said than done. How does one go about doing that?
Bill Collins: You know, for me, one of the biggest things—it is a tough subject to talk about—was losing my fear of failure. In medicine, failure is often death. I had one particular case early in my career with a baby with a difficult airway. Things did not go well in the operating room. We lost the airway, and ultimately the baby died on the OR table. After that happened—and that was always my biggest fear—having it actually happen and then learning from those mistakes and maybe some of the decisions I made intraoperatively, that loss of that one patient probably translated into saving fifty or a hundred or more lives from the lessons I learned.
Getting over that fear of failure allowed me, in those moments, to really focus on the task and the patient and what I needed to do, rather than having those emotional thoughts flooding my mind: “What is going to happen? Am I going to get in trouble? Is this child going to die? Am I going to get sued?” Those are all things you cannot be thinking about in the heat of the moment.
Kevin Pho: As you know, how people respond to pressure can come from who they are initially, and there is a spectrum of people who are innately able to deal with pressure. You have been in academic medicine for a while. Can performing under pressure be taught, even for someone who is the most anxious coming out of training? Can that person be taught to perform under pressure?
Bill Collins: I think that is a great question. That is the million-dollar question. My current opinion is that you can get better at it. I do think some people are just wired differently and in how they approach things, and that may lead them to self-select a specialty that frequently involves these emergency situations, whereas if you do not like those types of situations, then maybe being a trauma surgeon is not for you. But I do think you can improve. There are some studies that have looked at athletes and free-throw percentages in the fourth quarter of basketball games or late-inning batting averages, and there is not a clear statistical answer. Even the best hitters, even Michael Jordan, missed a lot of game-winning shots. But I do think for certain people, if they are inclined to put themselves in a role that is going to face those situations, they can get better.
Kevin Pho: Now, you mentioned sports a few times, and there are very few scenarios that are more pressure-packed than some sports situations. These athletes often go to sports psychologists and use various techniques to help them perform under pressure. Are you seeing these techniques in medicine? Perhaps seeing some type of psychologist or any other psychological approaches to help physicians perform in pressure-packed situations?
Bill Collins: You know, I really have not. I think one of the glaring deficiencies in medicine is that we do not get a lot of time to practice. By practice, I mean training. Once you get out of residency and fellowship and you are out taking care of patients, we do not really spend a lot of time in simulators or learning whether it is visualization techniques or meditation, whatever those things might be, compared to, say, an astronaut or a military special-operations soldier who spends a lot of time in training. The vast majority of our time is spent on the job, taking care of patients, with a very small portion dedicated to ongoing training. I hate to use the term CME, because that implies doing online training or something, but I think as physicians, there is so much financial pressure in the modern era and the corporatization of medicine that we are not able to spend as much time on self-improvement and ongoing training once we are in practice.
Kevin Pho: Now, do you specifically talk about managing pressure with your fellows and residents as you mentor and train them while they rotate with you?
Bill Collins: I do. We always teach them anatomy, physiology, and surgical technique. In the last five to ten years, I have spent more time teaching them about the mentality and the philosophy of being a surgeon, the different phases you go through over the course of your career, the art of medicine, how you practice, and how you deal with, in my field, families and their patients. It is something I am more deliberate about discussing with our residents.
Kevin Pho: So what is an example of that? What is the mindset or the approach of being a surgeon? What are some pieces of wisdom that you share with your residents?
Bill Collins: Again, since I am in a pediatric field, a lot of what we do is elective, and it is not necessarily life or death. I talk a lot with our residents about shared decision-making in the office setting. If we are talking about putting ear tubes in a child or taking out the tonsils and adenoids, really how you explain that to families and outline the pros and cons, the risks and benefits, and the alternatives. In many cases, it is a quality-of-life decision, so do not come at it with a heavy hand and mandate surgery. What are the non-surgical options? What are the success rates? It really is a partnership with the families and these children, and I want the residents to understand that process.
Kevin Pho: We are talking to Bill Collins. He is a pediatric otolaryngologist. Today’s KevinMD article is “Performing in a Clutch: Lessons from a Pediatric Airway Surgeon.” Bill, let us end with some take-home messages that you want to leave with the KevinMD audience.
Bill Collins: Sure. Three things come to mind. Number one, I mentioned this earlier: there are really no shortcuts. People turn to self-help books, podcasts, and different platforms, but you just have to get the experience and learn from it. Do not just go through the motions. I hate to break the news, but there are no shortcuts.
Number two, it is important to understand that for a variety of physiologic reasons, nobody performs better, especially with cognitive or fine technical tasks, when they are actually feeling the pressure.
So, number three, the key is to separate your response from that stressor, from that pressure situation. Learn to create some distance so that you may be in a pressure-filled situation, but you are not feeling it yourself.
Kevin Pho: Bill, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.
Bill Collins: Appreciate it. Thank you, Kevin.
