The history fitted. The findings of her examination seemed to fit. I had already started thinking about treatment before I’d finished examining her. It felt like knew, no guessing.

Then I did something very ordinary. I wrote out the problem list. Partly for the notes, partly for whoever saw her next. Mostly from habit.

A few lines in, I stopped. I noticed two of the findings were sitting there next to each other on the page, and they didn’t make sense together. In my head, they had been part of one neat story. On paper, they clearly weren’t. I had missed that.

She didn’t have what I was about to treat her for.

I had simply moved the thought from my head to the page. And once it was there, I could see the problem.

That moment has stayed with me.

We tend to think that thinking happens in the head and writing comes afterwards. First you work something out, then you write down the answer.

But often the writing is the thinking.

Your mind is good at making things feel complete. It joins the dots, fills in gaps and quietly drops whatever doesn’t fit. Most of the time this is useful. We couldn’t function if we had to examine every thought from scratch.

When under pressure, that shortcut becomes risky.

When you’re tired, rushed or worried, you don’t usually experience your reasoning as messy. You experience the result of it and it’s easy to feel certain.

You can’t see what your mind left out.

This is one reason I keep coming back to Cognitive Oxygen®, the buffer space needed to think carefully. Pressure reduces that space making our thinking faster, our view becomes narrower. We jump from problem to answer without seeing much of what happened in between.

Putting a thought on paper gives some of that room back.

It has to slow down, once it becomes words, you still need enough time to look at it.

And then you can ask: does this actually make sense?

That’s also the point of Red Team Thinking®. It sounds more complicated than it is. At heart, it means trying to find the weakness in your own idea before the world finds it for you. What have I assumed? What haven’t I checked? What would make this plan fail? What am I not seeing because I want to be finished?

These are hard questions to ask of a thought that still lives entirely inside your head where it can change shape too easily. When in writing on the page, it has fewer places to hide.

I once watched a senior team discuss closing a service and moving its work somewhere else. By the end of the meeting, the decision seemed settled. Everyone was nodding. There was a sense that we had talked it through.

Maybe we were also just tired. Then someone went to the whiteboard and wrote four headings: What do we know? What are we assuming? Who is affected but isn’t in the room? What would show us we’re wrong?

That was it. Nothing clever.

Under “What are we assuming?”, someone wrote that the other service had enough capacity to take on the work. The room went quiet. Nobody had checked.

We had all been treating it as a fact, but only because nobody had said it clearly enough for the rest of us to question it.

It took about nine minutes to understand the plan was not going to work.

The whiteboard let us see what we had actually not been thinking.

You could say this is just note-taking, and sometimes it is. Writing things down doesn’t automatically make them thoughtful and smart. You can fill a page with tidy headings and still avoid the difficult part.

The question is whether the writing changes anything. Did it reveal a gap? Did it make you uncomfortable? Did you notice that something you called a fact was really just an assumption? Did it change what you did next?

If not, you may only have recorded the decision you had already made.

There is something strangely convincing about a thought that feels finished. Sometimes it just means your mind has done a good job of hiding the rough edges from you and it’s not a proof.

At three in the morning the problem list helped me see them.

So this week, try this with one decision you feel sure about. Put it on paper under four headings:

• What do I actually know?

• What am I assuming?

• Who or what is missing?

• What would prove me wrong?

Give it nine minutes.

You may end up making exactly the same decision.

But at least you’ll have had a proper look at it first.

By Wednesday it was gone. Nothing dramatic happened. No scene anybody would remember. The resolution simply wore away somewhere between the bed shortage and a bleep that would not stop. By Thursday I was, more or less, the same man I had promised myself on Sunday I would no longer be.

So the next Sunday I tried again. This time I made the promise more precise. Gave it sharper edges. A proper commitment, I told myself. More serious, less vague.

And it dissolved on schedule. I did this for years. Years.

It is uncomfortable to admit that, because I would like to think I am someone who is able to learn. But I kept doing the same thing: making promises in a quiet room about how I would behave in a noisy one.

And when the promise failed, I blamed the promise-maker.

I had not wanted it enough. I had not been disciplined enough. I had let myself off the hook. So I reached for the only lever I seemed to know.

Push harder.

This is one of the traps in how we think about change. We treat it as a problem of insufficient will. If something has not changed, we assume we cannot have tried hard enough. The answer, therefore, must be more: more resolve, more vigilance, a better system, another notebook, a sterner conversation with ourselves.

Sometimes that works. Of course it does. Some things really do need practice, repetition and effort. But effort is most useful when you can see the problem in front of you. When the wall is visible and you simply have to find a way over it.

It is much less useful against the walls you keep walking into without knowing they are there.

And, under pressure, a great deal of what runs us is invisible in precisely that way.

I could not become calmer on a Wednesday because I had never actually seen the moment I stopped being calm.

It did not announce itself. There was no internal alarm. I did not hear a little voice saying, Here it comes, you are about to become clipped and impatient.

It just happened.

I was too busy being the thing to notice myself becoming it.

That, I think, is the part I missed for so long. You cannot correct a moment you never catch. And no amount of Sunday-night sincerity can reach into a Wednesday afternoon you are not fully present for.

The change began, not all at once, and certainly not neatly, when I became able to notice a little earlier.

First, I noticed afterwards. Usually much afterwards. Then I noticed as I was doing it, which was awful in a different way. There is something particularly dispiriting about hearing yourself give the clipped reply and being unable, or perhaps unwilling, to stop halfway through.

Eventually, occasionally, I caught it just before. Not every time. Not even most times. But sometimes there was a fraction of a second in which another response became possible.

That fraction mattered more than all the promises.

This is part of what sits underneath the framework I have been building here. Change seems to follow seeing. Or perhaps, more cautiously, seeing gives change somewhere to begin.

The headroom I call Cognitive Oxygen® (COx) is not just what careful thinking runs on. It is also what allows us to watch ourselves while we are acting, rather than reconstructing everything later, once the damage has been done.

When there is enough of it, you may catch the clipped reply as it forms. You may feel the pull of the shortcut before you take it. You may notice that the thing in your head is still an assumption and has not yet earned the status of a decision.

When that headroom disappears, the watcher seems to go with it. You do not simply become less thoughtful. You become less able to see that you have become less thoughtful.

I wish this were not true. It would be much more convenient if pressure merely made us worse while leaving us perfectly able to observe the decline. But that is not how it has felt in my own life. The blindness and the behaviour arrive together.

Then, afterwards, effort volunteers to clean up.

Try harder next time.

Be more careful.

Do not do that again.

But effort spends something too. Sometimes we use so much of ourselves gripping the behaviour that there is nothing left with which to notice it.

Red Team Thinking® is, for me, the same basic move pointed outward: trying to see what is actually there rather than what the tidy picture in my head says ought to be there.

The assumption I would rather not discover I have made.

The plan that works beautifully, provided three untested things all happen at once.

The awkward detail everyone has quietly stepped around.

We often miss these things not because we are stupid or careless, but because seeing them takes a quality of attention that pressure quietly confiscates. Then we try to make up the deficit with grip.

More focus. More vigilance. More effort.

It feels responsible. That is partly why it is such a convincing trap.

I once watched a department being told to try harder for the better part of a year.

Things kept being lost at handover. The response was reminders, posters and a stern email about focus and personal responsibility.

Be more careful.

As far as I could tell, nobody involved was careless. They were tired. They were interrupted. And they were trying—genuinely trying.

Still, the same things kept falling through the same gap.

Eventually, one registrar did something almost embarrassingly simple. She stood at the back of several handovers and watched.

Not to correct anybody. Not to produce another rule. Just to see what was happening.

The handover took place in a corridor. Everyone was standing. Interruptions came constantly. Nobody quite owned the list.

The gap was not inside a person. It was built into the room.

Once that became visible, the changes were almost mundane: a table, a door, one named person responsible for holding the list.

None of this required the staff to care more. They already cared.

We had spent months aiming effort at the people when the problem was sitting in the environment around them.

There is a fair objection here.

Does change not take work?

Yes. Obviously.

I am not suggesting that we glimpse the truth once and are remade by teatime. Seeing is not the whole of change. New habits still need to be practised. Structures have to be built. Sometimes we have to do the difficult thing repeatedly, badly at first, before it becomes any easier.

But seeing tells the work where to go.

It turns effort from a punishment into a response. It lets us spend energy on the thing that is actually happening, in the moment it happens, instead of throwing more determination at a picture we made on Sunday night.

Effort with its eyes open is a different animal.

Effort without sight is often just exhaustion with better branding.

So, the next time you hear yourself resolving to try harder at something you have already tried very hard to change, pause.

Not forever. Just long enough to become a little suspicious of the resolution.

Ask what happens in the actual moment. Where are you? What has happened just before? What does it feel like in your body? What becomes unavailable to you? What are you unable to see from inside it?

You may not be ready to fix it.

That is all right.

For now, perhaps, just try to be there when it happens.

Awake enough to see it.

Not judging. Not promising. Not already turning the moment into a lesson about what sort of person you are.

Just watching.

Change may still ask a great deal of you. But it may not be waiting for more effort.

It may simply be waiting for your attention.

This week, choose one behaviour you keep promising to fix. Stop promising for a while. The next time it appears, see if you can catch it happening—even if you do nothing differently. Seeing it once, from inside the moment, may be the first honest step.

It was an MDT meeting discussion about a frail woman in her late eighties. There was a lot going on and we had to decide whether to put her through a procedure. It might help. It might also be too much for her. The consultant explained the plan. Clear, calm, already fairly settled.

Then the nods started. Sounds sensible. Agree. Yes. Someone said, “No concerns,” which is a phrase I have grown increasingly suspicious of.

Twenty or thirty seconds later, we moved on to the next name. A decision about the rest of someone’s life had taken less time than making a cup of tea.

I nodded too.

I need to say that because it would be easy to tell this story as if I were the one person in the room who could see what was happening. I couldn’t. I went along with it and felt that small sense of satisfaction you get when a meeting is moving well and everyone seems to know what they are doing.

There was a physiotherapist sitting in the corner. She had met the woman at home. She had actually been inside the house. At one point I saw her open her mouth. Then she stopped.

I can’t know exactly what she was thinking, but I have seen that pause often enough. The room had moved on emotionally, even if we were still talking about the same patient. Everyone had agreed. Speaking now meant pulling the whole thing backwards. It meant becoming the difficult person in a room that was pleased with its progress.

So she stayed quiet.

Weeks later, the thing she nearly said turned out to matter. The woman could not cope at home in the way our plan assumed she could. The plan looked sensible in the meeting. It came apart in a house most of us had never seen.

I keep returning to that meeting because it changed how I hear agreement. A room full of nodding people feels reassuring. Nobody is arguing. The decision sounds reasonable. We move through the list. It feels efficient and competent.

But a nod tells you very little. People nod because they agree. They also nod because they are tired, because the senior person has already made their view clear, because lunch was twenty minutes ago, because there are twelve more names on the list, or because speaking up now feels like more trouble than it is worth.

From inside the room, all those nods look the same.

That is what makes fast agreement risky. You can’t tell whether the plan has been properly tested just by looking at the faces around the table. A good decision can feel smooth. A weak one can feel exactly the same.

Somebody has to put pressure on the plan. Somebody has to ask what could go wrong, what we are assuming, and what we might be missing. If nobody does that, all we really know is that the plan sounded acceptable for thirty seconds.

There are understandable reasons why people stay quiet.

Doubt takes effort. You have to reopen a discussion that everybody else wants to finish. You have to risk being seen as awkward. You have to hold your ground while people look at you with that tired expression that says, please don’t make this take longer.

That needs a kind of mental and social energy. I call it Cognitive Oxygen®, or COx.

When people are running low on it, disagreement becomes expensive. Going along with the room is easier. The meeting moves forward and everyone feels relieved.

Relief can feel a lot like agreement when you are tired.

There is also a point in every discussion where the first few nods begin to gather momentum. Each nod makes the plan feel more settled. It also makes speaking against it harder. Disagreeing early might look thoughtful. Disagreeing after eight people have said yes can make you look like a nuisance. Most people don’t want to be the nuisance. I don’t blame them. I didn’t want to be one either.

So sometimes the person with the most useful information says nothing. The room leaves believing it has reached a sound decision, even though one of the facts that mattered never made it into the conversation.

That thought still bothers me. A meeting can end with less useful knowledge than it had at the beginning.

Red Team Thinking® is one way of dealing with this. There are tools and methods involved, but the basic idea is simple. Make disagreement part of the process. Give someone permission to question the plan before the meeting begins. Better still, make it their job.

Then they don’t have to decide whether to become the difficult person. They are simply doing what the room asked them to do.

You can ask: What would have to be true for this plan to fail? What are we assuming here? Who has seen something the rest of us haven’t? Who hasn’t spoken yet?

These questions need to come before the agreement has hardened. Once everyone feels the decision has been made, a question can sound like an attempt to derail things, even when it is exactly the question the room needs. Of course, you can’t pull apart every decision.

A ward, service or board would grind to a halt if every item became an hour-long debate. Some meetings already suffer from the opposite problem. Everything gets questioned, nothing quite gets decided, and one confident person can keep the whole room circling forever.

Sometimes quick agreement is genuine. People have considered the options. They understand the risks. They really do agree.

The useful test is to make space for a challenge and see what happens.

Ask someone to argue against the plan. Invite the quietest person in. Ask what has been left unsaid. If the plan still holds, good. You probably have something solid.

If it begins to fall apart as soon as one person feels able to speak, the earlier agreement wasn’t worth very much.

That physiotherapist had been inside the woman’s home. She knew something the rest of us didn’t, and she almost told us.

The failure was sitting there in that small pause. The information was available. The person holding it decided, probably quite reasonably, that saying it aloud would cost more than staying quiet.

None of us noticed. We had made the conversation so quick and easy that the most important fact couldn’t find a way into it.

So now, when an important decision goes through unusually fast, I get uneasy.

Perhaps everyone genuinely agrees. Perhaps the plan is obvious. But it is worth waiting another minute. Look around the room. Who hasn’t spoken?

Then ask what would make it easier for them to tell you what they know.

A few years ago. Friday afternoon, acute take, the list far too long. I was at a computer trying to hold nine sick people in my head at once. An FY1, three weeks into the job, caught me as I passed. “This is probably nothing,” she said, “but Bed 9’s obs are a bit off and something about her doesn’t sit right with me.” I didn’t look up from the screen. “Chase the bloods, put it in the notes.” Flat. Efficient. Back to the list.

I didn’t snarl. Didn’t slam anything. By any reasonable account I was perfectly professional. But the tone said what the words didn’t. Not now. Not you. Not worth my full face. And she heard it. I know she heard it, because three weeks later I noticed she’d stopped bringing me things. She’d learned. She took her doubts to the registrar instead. Or worse, kept them to herself. I only clocked it because a patient I should have heard about sooner turned into a phone call at two in the morning.

Here’s what we get wrong about pressure and what it does to people.

We picture the villain as the shouter. The consultant who throws the notes trolley. The manager who humiliates someone in a meeting. The one everyone can name. So we watch for volume. And we reassure ourselves: I don’t do that. Never have. I’m one of the good ones.

The shouter is the easy case. You can hear him coming.

The dangerous version is quiet.

It arrives as a clipped reply. Eyes back to the screen while someone’s still talking. “Just do X” instead of “what are you seeing?” A little warmth pulled back from the people who bring you problems, and handed to the ones who bring you agreement. Nobody would call it contempt. From the inside it doesn’t feel like that. It feels like focus. It feels like a busy person being sensible with a limited resource, which is exactly what it is, except the thing I was rationing was my regard for another human being, and I was spending it on the spreadsheet instead of on the person who’d just told me something true.

This is the drift. And it isn’t a character flaw. It’s an oxygen problem.

The steadiness thinking runs on, the headroom I keep calling Cognitive Oxygen® (COx), is the same headroom curiosity and patience run on. Same supply. When it’s full, I’m the version of me I’d want be on the take: interested, unhurried in the way that matters, glad to be interrupted by someone who’s spotted what I missed. When it thins, that version goes first. What’s left is faster. Colder. More certain. And a lot harder to argue with. I don’t decide to become that. Nobody schedules a Friday to be dismissive. The drift builds itself out of a hundred reasonable moves to keep going, and here’s the frightening bit. The person doing it is the last to know. Because the room stops telling them.

That’s the mechanism to stare at. The information you most need under pressure. The “this is probably nothing, but.” The half-formed doubt. The have-we-considered. It all travels along one particular wire. The same wire your sharpness just cut. A cold room doesn’t get calmer. It gets quieter. And quiet is not agreement, it’s the sound of people deciding you’re not safe to be honest with. So you make your next call with less truth in the room than you had an hour ago, and you feel more in control than ever, because control is what a depleted system hands you instead of clarity. That is universal, happens 100% in any area with pressure on, not just in healthcare.

There’s a discipline built to keep that wire open. It’s what Red Team Thinking® is really for. Not the tools. What sits underneath them. The habit of treating dissent as a safety system rather than a nuisance. Asking out loud: what am I not being told, and what have I done to this room that stopped them telling me. Rewarding the person who says “I think you’re wrong about Bed 9” instead of taxing them for it. You cannot run that habit while you’re drifting. Drift is the exact state that makes challenge feel like insubordination. Which is why the first move isn’t a technique. It’s noticing.

There is a fair objection to all this. Standards matter. In a resus, on a ward, in a boardroom, there are moments when somebody has to say the hard thing clearly. Being kind cannot become an excuse for being vague. But I think we sometimes confuse coldness with rigour. They are not the same. Making people smaller rarely makes the work better. More often, it makes them quieter. The harder skill is to keep the standard high without pushing the person down. To say, “This isn’t good enough yet. Talk me through what happened.” Or, “I disagree, but I want to hear what you’re seeing.” Clear about the work. Decent with the person. Both at the same time.

I’ve been on the other side of this too. Years ago, as a junior doctor, I worked under a consultant who became very quiet when the pressure was on. Not angry. Just colder. I remember standing there with a question or a concern and doing the calculation in my head: Is this worth bringing to him? More than once, I decided it wasn’t. He probably never knew I was making that calculation. He certainly never knew he had taught me to make it. And that, really, is the problem. He never knew.

So the question isn’t “am I a good person.” Useless question. Everyone answers yes. The sharper one stings: what is the pressure turning me into in this particular room, and who has already gone quiet because of it. You won’t feel the answer. The drift is silent from the inside. Always. But the room knows. And if you’re willing to look, the room will show you. The person who used to interrupt you and doesn’t any more. The doubts that now arrive too late. The meeting where everyone agrees a bit too fast.

Pressure won’t make you shout. That was never the risk. It’ll make you someone people manage around. And the day they start managing around you is the day they stop telling you the one thing that would have changed your mind.

So this week, in the room where the pressure runs highest, ask the question you least want to. Not “am I being fair.” Who has gone quiet around me lately. And what did their quiet cost me that I haven’t noticed yet.

The arrest had been running more than ten minutes, and the room had never been busier.

Compressions going, someone drawing up adrenaline, a second nurse hunting for a vein, a junior reading the rhythm aloud, a porter wheeling in the trolley, three conversations at once. Every pair of hands in that bay was doing something. From the door it looked exactly like a team working. Noise, movement, purpose. The kind of scene that makes an observer think, they’ve got this.

They didn’t have it. The rhythm hadn’t been checked properly in two cycles. Nobody had said out loud what they were treating, or why. The drugs were going in on habit. There was motion everywhere and direction nowhere, and the two look identical until you stand still long enough to tell them apart.

What changed it was a registrar who stepped back from the patient and put her hands behind her back. Deliberately. It’s the first thing they teach you about running a resuscitation and the hardest thing to actually do. The person leading takes their hands off the patient. Not because there’s nothing to do with them. Because the moment your hands are busy, you’ve joined the motion, and the room already has plenty of motion. What it’s short of is someone looking at the whole thing and saying where it goes next.

Here’s what we get wrong, and we get it wrong everywhere, not just at the bedside. We read a busy room as a working room. Activity feels like progress. When the hands are moving and the diary is full and the meeting ran the whole hour, something is surely happening, and it’s uncomfortable to ask whether any of it was going anywhere. So we don’t ask. We let the motion stand in for the direction, because motion is visible and direction is not.

It is easy to keep moving. The harder question is whether you are actually getting anywhere.

Move the same pattern from the resus bay into the meeting room and it looks far more respectable.

Some standing meetings seem to exist mainly so the organisation can prove they happened. Tickbox. There is an agenda, a list of attendees and a set of actions carried forward from last month, many of which will be carried forward again next time.

The meeting continues because it is in the diary. People leave with the dull satisfaction of having attended something. Another set of minutes is filed. Nothing important has shifted.

Six meetings like that can fill a senior leader’s week while barely moving the work forward at all.

This is governance theatre. After you have sat through enough of it, you begin to recognise the different kinds. Some meetings are almost comic. Occasionally, they become genuinely tragic. Most are simply overlong dramas, packed with issues that nobody in the room has the authority to resolve.

We discuss them anyway. We record the discussion. We carry the same actions into next month. Then everyone leaves with the vague sense that something has happened, even though very little has changed.

I have chaired that meeting, so I want to be fair to the people in it. They are not lazy, and they are not foolish. They are busy. Genuinely busy. Expensively busy. That is part of the problem. Busyness starts to feel like the work, even when it has quietly become a substitute for it. Nobody entered the room intending to perform a piece of theatre. It emerged from a hundred sensible decisions to keep things moving, until movement itself became the point.

There is a reason tired systems reach for activity.

Direction is harder. It asks people to stop, look at the whole messy picture and make a choice before everything is clear. Choosing one path also means letting other possibilities go. That takes steadiness, attention and enough mental space to think. It takes what I call Cognitive Oxygen®.

When that oxygen is running low, stillness can feel almost unbearable. Activity is easier. You can keep answering emails, attending meetings and moving actions forward even when you are exhausted. It feels like coping. Sometimes it even feels like progress.

Meanwhile, the move that might help most is the one nobody has the capacity to make: stepping back from the immediate task long enough to see the whole board.

The more we keep moving, the less space we leave ourselves to work out where we should be going.

Even a well-rested team can drift, because once something is in motion it begins to feel real. A meeting moves through its agenda. A team follows the protocol. The process gathers momentum, and that momentum starts to look like authority. Stopping it means being the person willing to ask, “Wait. Where is this actually taking us?”

Red Team Thinking® is designed to make that question routine rather than heroic. It gives people permission to pause a room that is busily agreeing with itself and examine what the activity may be hiding.

What are we trying to achieve, rather than simply get through? If this meeting disappeared tomorrow, what would genuinely be lost? How would we know that we were making progress rather than merely keeping busy?

These questions separate movement from progress while there is still time to change direction.

There is an honest objection to all this. Sometimes movement is exactly what the situation needs. A major bleeding does not need a strategy session. It needs people to act, quickly and well. A leader who stands back reflecting while someone is bleeding has misunderstood the moment. The same is true of some meetings. Their purpose is simply to pass information from one person to another. Trying to turn every one of them into a strategic conversation can waste more time than it saves.

The real skill is recognising what kind of situation you are in.

Some problems are clear enough to reward fast action. Others are still taking shape. In those situations, more activity can make things worse. A team can be working flat out and still have no idea whether it is heading in the right direction. Worse, the busyness can hide that uncertainty from everyone in the room.

Movement becomes dangerous when the situation needs direction first. The difficulty is that, once everyone is moving, it can be remarkably hard to notice which kind of room you are standing in.

The registrar took her hands off the patient, and within thirty seconds the room had a direction it had been missing for two minutes. She didn’t do more. She did less, on purpose, so she could see. That’s the move, and it’s counterintuitive to the point of pain, because every instinct under pressure says do something with your hands, and the most useful person in the room is often the one who won’t.

I spent part of last week learning this again on a motorbike in North Devon, probably riding a little harder than wisdom would recommend. The roads were steep and narrow, with blind bends and hedges that hid what came next. Often, you could see only a few metres ahead. At some point, you had to choose your line and commit. Waiting for the whole road to reveal itself was never an option.

The lesson is simple, and every rider knows it: look where you want to go. Keep staring at the pothole, the verge or the stone wall, and you will begin to drift towards it. The bike follows your attention. Your hands merely make the small adjustments.

It reminded me of teaching a registrar during a difficult procedure: eyes up, hands quiet. Perhaps that is the question to take into the week ahead.

Count the movement. The meetings attended. The emails answered. The hours that were unquestionably full. Then ask the quieter question, the one a full diary makes so easy to avoid: how much of that movement was taking me somewhere? And how much of it was simply movement, because I had not stopped long enough to choose a direction?

A full day can feel remarkably like a good one. They are not always the same.

So this week, once, in the middle of something busy, take your hands off it. Ten seconds of doing nothing, so you can see where it’s actually going. Motion will not miss you. Direction might.

Subscribe now

Share The School of Cognitive Oxygen

Picture a boardroom. Long table, a screen, and on the agenda a set of minutes from six months back. A decision had aged badly. A pathway redesign that looked sensible in spring was quietly hurting people by autumn: longer waits in the wrong place, a rota that leaked staff, a saving that turned out to cost more than it saved. So the chair asked the obvious, fair question. Why did we decide it this way?

And nobody could quite say. One person offered a fragment. Another remembered it differently. A third just went still, because they’d had a doubt at the time and hadn’t pushed it. The decision was right there in black and white. The reasoning that produced it had evaporated.

The minutes, meanwhile, were immaculate. Who attended, what was proposed, that it was agreed, by when. Everything except the one thing the room now needed, which was the why. That reasoning had left the building the moment the meeting ended, because it had never lived anywhere except inside a few people’s heads.

Let me be fair to that group, because I’ve sat in it. Sometimes a room decides badly for reasons no checklist would ever fix. Ego. Turf. A voice in the corner nobody fancies crossing. And often enough the decision was perfectly reasonable for what those people could see that morning, and it went wrong anyway. Those are the ones I want to talk about. When they go wrong, we tend to put the decision itself on trial. We pore over the outcome and hunt for the person who should have known better. Now and then that’s justified. More often the choice was sound and the thinking behind it has simply gone, so we can’t examine it, can’t correct it, and we hand the same trap, intact, to the next capable group working under the next round of pressure.

There’s a name for the kind of thinking that never leaves the skull. Fast, private, compressed, coloured by whatever mood the room was in. Under pressure it’s the setting we all default to, because it’s cheaper than the alternative. Saying “here’s what I’m assuming, and here’s what would change my mind” out loud takes time you don’t feel you have, and it leaves you exposed. Far easier to reach the answer quietly and table the conclusion. So the conclusion goes in the minutes and the reasoning goes nowhere.

There’s a condition in my own field that behaves almost exactly like this, and it’s worth being precise about rather than reaching for a tidy metaphor. Silent ischaemia. The heart muscle is short of oxygen, but the alarm that normally drives a patient through the door, the chest pain, never sounds. It’s commonest in the people you’d least want to miss it in, the diabetic, the elderly. Damage builds with nothing to announce it, and then one day it announces itself as an event that looks sudden and wasn’t. The danger was never the shortage of oxygen on its own. It was a shortage that arrived with no warning attached.

Hidden reasoning is the organisational version of that. Judgement running short of oxygen, with no pain to tell you it’s happening. The meeting feels productive. The minutes look complete. Most people file out satisfied, and the one who isn’t keeps it to themselves. The deterioration only turns up six months later, dressed as a mistake, when really it was a symptom of thinking nobody could see back when there was still time to question it.

So why does the reasoning stay buried? Not for one neat reason, whatever a tidy article would like you to believe. I keep running into two, and I’ll be honest, neither of them has a product conveniently stapled to it.

The first is that the room has no room. A thinker runs on Cognitive Oxygen® (COx), the steadiness and headroom that judgement actually needs, and when that thins out, thinking curls back into its most private, compressed shape. A depleted room stops showing its working. It jumps to the answer, because spelling out the reasoning feels like a luxury when there’s no margin to pay for it. You cannot make exhausted people think aloud. Protect their oxygen and you make the rest possible. You don’t get the rest for free.

The second is plain speed. Even a well-rested room thinks too fast. The answer turns up before the reasoning has been laid out, and we mistake how quickly it arrived for how strong it is. This is where a deliberate bit of slowing earns its keep, the discipline Red Team Thinking® is built around. What are we assuming here? What would have to be true for us to be wrong? Who’s not in this picture? What would actually change our minds? Questions that drag the private reasoning into the light while it can still be looked at, and while there’s still a decision left to change.

Notice those two aren’t the same problem. One is about capacity, the other about pace. A room with oxygen to spare can still gallop. A slow room with none still hides. That’s why there’s no single lever to pull, and why this is harder than it sounds once you’ve written it down in a sentence.

The fix itself is small, and I won’t pretend it’s free. Before the minute gets written, before everyone stands up, sixty seconds. Those seconds cost you something real. They hold a room that badly wants to be finished, and they ask people to show reasoning they’d rather keep to themselves. That cost is precisely why they almost never happen on their own. Is the evidence actually visible? Are the assumptions? Is the disagreement out in the open, or did the quiet ones stay quiet? Did we name the trade-offs, or pretend there weren’t any? And is there a date in the diary when we’ll come back and find out whether we were right?

Here’s the fair objection, and I raise it because I’d raise it against anyone else selling this. A sixty-second check is indistinguishable from governance theatre right up until the moment it changes an outcome. Ticked, filed, forgotten: theatre. The only thing that separates the two is whether an answer moved the room. One real assumption named. One genuine disagreement admitted. One date fixed for a proper second look. Miss all three and what you’ve got is decoration, and decoration is just hidden cognition in a lanyard. The point was never asking the questions. It’s whether the answers change what you go on to do.

Six months from now, someone’s going to sit at a table, look at a decision you’re about to make, and ask why. It’s the fairest question in leadership and the one we’re worst prepared for, because we hoard the conclusion and let the reasoning burn off. The minutes will survive. The thinking won’t, unless you put it somewhere it can be found again.

The quiet decisions are the ones that catch you out. The loud ones can hurt too, of course. But the quiet ones are worse, because by the time they surface, nobody can remember what you were thinking, so nobody can stop it happening a second time.

So this week, at the end of one decision that genuinely matters, spend the sixty seconds. “What were we thinking, and could we explain it to whoever inherits it?”, not just “what did we decide.”

The room was sure within ninety seconds.

Chest pain, clammy, an ECG that looked the part. Someone said heart attack before the trace had finished printing, and the whole team leaned the same way at once. Aspirin. Get him to the lab. The choreography was beautiful, the way a good team moves when it already knows the answer. Everyone was certain, and the certainty felt like competence, because most of the time that is exactly what it is.

One registrar stood slightly outside the huddle and said the pain did not fit. It was tearing, not crushing. It ran into his back. Something was off.

For a moment the room almost ran her over. Certainty does that. It has a momentum, and a person raising her hand against it feels like friction in a machine that is finally working. But someone paused. We looked again. It was a dissection, not an infarct. The drug the room had been seconds from giving would have been precisely the wrong one. The certainty that felt like competence was, for about ninety seconds, the most dangerous thing in the building.

Here is what we get wrong about being sure. We treat it as the finished form of good judgement. The decisive leader knows. The strong clinician commits. Doubt reads as weakness, as dithering, as the thing you grow out of when you get good. So under pressure we reach for certainty like a handrail, and we mistake the grip for the ground.

Certainty and clarity are different things, and pressure hides the difference.

Clarity is the capacity to see a situation for what it is and act wisely inside it while some of it stays unknown. Certainty is the feeling that the unknown has been closed. One is a skill you can build. The other is a sensation, and sensations lie. You can feel completely certain and be completely wrong, and the feeling gives you no warning, because the whole point of certainty is that it removes the discomfort that would have warned you.

That discomfort was information. The registrar’s unease was not noise in the system. It was the system working. The tightness of not-quite-fitting is often the only signal you get that the obvious answer is the wrong one, and certainty is the thing that switches that signal off. It does not resolve the doubt. It anaesthetises it.

That is the trap, and it tightens exactly when the stakes rise. When a decision is heavy and the room is watching and the clock is loud, the pull toward certainty is strongest, because uncertainty is uncomfortable and the discomfort feels unaffordable. So the more it matters, the more we grab the handrail, and the more it matters is precisely when the handrail is most likely to be bolted to nothing.

Some rooms reward certainty honestly. A problem with a known answer, where experience gives you the right move and hesitation only wastes time, deserves a decisive hand. But most of the decisions that define a senior life do not live in that room. They live in the other one, where the parts interact in ways you cannot fully see, where the same move gives different results on different days, where the answer only becomes knowable after you have acted and watched. In that room, certainty is a category error, not strength. You are using the confidence that fits a solvable problem on a problem that was never solvable in advance, and the mismatch is invisible from the inside, because certainty feels identical whether it is earned or borrowed.

This is where the margin I keep writing about does its quietest work. Cognitive Oxygen® (COx) is the steadiness and bandwidth that thinking runs on, and one of the things it buys you is the capacity to sit inside not-knowing without panicking your way out of it. When that margin thins, uncertainty becomes unbearable, and an unbearable feeling gets resolved the fastest way available, which is to decide and stop feeling it. The depleted leader is not reckless. He is reaching for relief. Certainty is a painkiller, and like every painkiller it works by removing the sensation, not the cause. The exhausted brain will take the dose every time.

So the discipline is not to think harder toward the right answer. It is to keep the door open a few seconds longer than the pressure wants you to, and to put something in the gap that reintroduces the doubt on purpose. This is the work Red Team Thinking® exists to do: to take a decision the room feels sure about and ask, out loud, before anyone commits, what would have to be true for us to be wrong. To make the certainty earn its place, not to slow the team down. The question the registrar asked without knowing she was asking it. What are we assuming, and what does not fit?

A single, deliberate pause between feeling sure and being sure, long enough for the thing that does not fit to speak before the momentum drowns it. Ten seconds. One honest question. A door held open against the pull to close it.

The leaders who frighten me are not the ones who admit they are unsure. They are the ones who are never unsure. Who move through complex, shifting, half-visible problems with the same clean confidence they would bring to a solved one, and read their own lack of doubt as a sign they are right, when it is often only a sign they have stopped looking. Their certainty is not a summit they climbed to. It is a light that went out.

The room was sure within ninety seconds. It was also, for those ninety seconds, wrong. The gap between the two was one person willing to feel the discomfort a moment longer than everyone else, and a system with just enough oxygen left to hear her.

Being sure is the easiest feeling in the world to trust. It is also the one that asks you the fewest questions on the way down.

This week, catch yourself at the moment you feel certain about something that matters, and hold the door one question longer. Not what do I know. What would have to be true for me to be wrong.

Monday, three meetings before ten. Tuesday, the audit, the rota, the complaint that would not die. Wednesday, back to back until seven, no lunch, a sandwich eaten standing up between a bed meeting and a phone call he took in the corridor. He said it with a kind of grim pride, the tone people use for something they have rehearsed, because somewhere underneath he suspected he might one day be asked to account for it.

So I asked. Not what did you do. What did you decide?

He stopped. Then he laughed, a little too quickly, and changed the subject.

I have watched that exact pause in more capable people than I can count. The week is full. The days are accounted for down to the quarter hour. And when you ask what actually got thought through, what got weighed, what got decided and why, there is nothing there. Because they have been running on the one thing that always looks like work and often is something else, not because they are lazy.

Here is what we get wrong about busy. We treat it as evidence. Evidence of effort, of commitment, of coping, of worth. A full calendar is the socially safe answer to almost any question about how you are doing. Nobody has ever been criticised in a corridor for looking too busy. So we perform it, and after a while we stop performing it and simply become it, and by then we cannot tell the difference between a day that moved us forward and a day that merely moved.

Busy is the opposite of thinking. It was never the opposite of idle.

The two run on different fuel, and only one of them shows. Activity is visible. It fills inboxes, closes tickets, populates the calendar, leaves a trail anyone can point to. Thinking leaves no trail. It happens in the quiet, in the pause before the decision, in the second opinion you hold in your own head before you commit. And when you are under pressure, when the margin that good thinking runs on has already thinned, you spend down the currency you can see and let the one you cannot see run dry. You do the visible thing, because the visible thing is the one that pays off in the moment and the one that reads as coping to everyone watching.

That margin has a name. I call it Cognitive Oxygen® (COx), the steadiness and attention and bandwidth that thinking depends on, and the first thing that goes when a role asks more than a person can supply. When it thins, people do not stop. They triage. They go into a permanent, low-grade sorting of what is loudest, and the sorting produces motion, and the motion looks exactly like competence. The inbox at eleven at night is not evidence that the work is getting done. It is evidence that the thinking got postponed until there was no oxygen left to do it with.

This is the trap, and it is a clever one, because it rewards you the whole way down. Every task you clear gives a small hit of having achieved something. Every meeting attended feels like a box ticked. The busier you get, the more proof you accumulate that you are indispensable, and the less time you have to notice that you have not had a single thought all the way to the end in days. Busy is the most flattering way there is to avoid the harder work, and the hardest work in any senior role was never the doing. It was the deciding. And I see that more and more since the pandemic.

There is a second cost, and it is the one that eventually finds you. When you never stop long enough to think, you also never stop long enough to check. Every plan you shipped at speed, every assumption you leaned on because there was no time to test it, every call you made on a hunch and hoped would hold, all of it stays open behind you, unexamined. This is the tax that Red Team Thinking® exists to collect deliberately, in daylight, by design. You take a real decision and you ask, out loud, before you commit: what are we assuming here, and what would have to be true for us to be wrong? That is the thing the busyness is quietly stealing, not a luxury for the day you are less busy. Because the assumption you never had time to challenge does not go away. It waits. And it tends to present itself at the worst possible moment, wearing the face of a problem you could have seen coming if you had given yourself ten minutes and a decent question.

The cruel symmetry is that the fuller the week, the more of these you accumulate, and the less oxygen you have to catch any of them. Busy does not just crowd out thinking. It manufactures the very risks that thinking was there to catch, and then hides them behind the motion. And somewhere deep inside you know that. And because there is not much of you left, you fill the evening with binge-watching, or some other bad choice.

So look at your own week, honestly. Not the version you would recite if someone asked. The real one. How much of it was you moving things, and how much of it was you thinking about whether they were the right things to move? If the honest answer makes you uncomfortable, that discomfort is a reading, not a verdict on you. It is telling you the design of your days has left no room for the one activity the days actually exist to serve.

The fix is not to do less for the sake of doing less. Empty calendars are not the goal, and nobody is asking you to go slow in a job that will not slow down. The fix is to stop treating motion as proof and start protecting the room where deciding happens. Ten minutes, guarded, where a real question gets asked and a real answer gets thought through, is worth more than three hours of the kind of busy you could do in your sleep. In fact you probably already are doing it in your sleep, which is rather the problem.

My consultant did not need a fuller week. He had run out of week to fill years ago. He needed one hour in it that he was willing to defend, an hour where he was not producing motion but producing a decision, made on purpose, with the assumptions dragged into the light before they could ambush him later.

Busy is the easiest thing in the world to prove. It is also the easiest place in the world to hide.

This week, when someone asks how you are and you hear yourself say busy, stop and ask what you actually decided. If nothing comes, that is the reading. Not a failing. A place to protect.

She said it almost as a confession, the way people do when they suspect the fault is theirs. She had done everything the wellbeing emails told her to do. Off the caffeine by two. Phone out of the bedroom. Eight hours ringed on the tracker like a target hit. And still she surfaced each morning already behind, already braced, as though the night had happened to someone else and left her the bill.

She wanted to know what was wrong with her sleep.

Nothing was wrong with her sleep. She was asking the wrong organ.

Here is the thing we get backwards. We treat tiredness as one substance, a single tank that empties through the day and refills overnight. Work drains it, rest restores it, and if rest stops restoring it, the rest must be broken. Fix the sleep, fix the tiredness. It is a clean model. It is also, past a certain point, wrong.

There are two kinds of tired, and they run on different circuits.

The first kind is the honest one. You worked hard, your body spent itself, and sleep pays it straight back. A long shift, a bad night on call, a week that asked too much. This is recoverable fatigue, and a full night genuinely mends it. You wake up and the tank is full again. Most people, most of the time, are living inside this kind. It behaves exactly as the model predicts.

The second kind does not behave. It is not about how hard your body worked. It is about how long your mind has been running without margin. And it does not drain the way muscles drain. It accumulates the way a debt does, quietly, with interest, in a currency that sleep cannot pay.

I have come to call the thing being spent Cognitive Oxygen® (COx). It is the margin that good thinking runs on: the steadiness, the attention, the few seconds between a stimulus and your response, the bandwidth to hold more than one thing in mind without dropping the lot. When that margin stays below what the role demands for long enough, you cross into something with its own physiology. Cognitive hypoxia. The state where the supply has fallen under the threshold the job requires, and stayed there.

And here the two kinds separate cleanly. The first is a shortfall in the tank: your body spent itself, and sleep refills it. The second is a mismatch in the wiring. The deciding parts of the brain, the frontal networks that weigh and plan and hold a second opinion, are the most fuel-hungry tissue you own and the first to feel a shortage. Ask them to run at full demand, day after day, with no slack, and they fall behind their own supply. That is not a tank you can top up. It is a load you have to redesign.

And cognitive hypoxia does not clock off at night.

Think about what your registrar was actually carrying to bed. Not tired legs. A nervous system that never got the signal to stand down. The decision she was second-guessing from the ward round. The conversation she rehearsed and never had. The forty small judgements she made at speed, under pressure, without a moment to set any of them down and look at them properly. All of it still running, low and constant, like a fan that will not switch off. She slept. Her body rested. But the part of her that decides, that weighs, that stays open to being wrong, never left the building.

That is why the morning felt borrowed. Sleep restored the muscle. It could not restore the margin, because the margin was never the sort of thing a night could refill. You cannot rest your way out of a debt you keep taking on before breakfast.

Notice what this does to the usual advice. Sleep hygiene, the ten-minute wind-down, the meditation app with the whale noises: all of it is aimed at the first kind of tired. It works, for that kind. But offer it to someone in cognitive hypoxia and you have handed a splint to a person who is short of breath. You have treated the wrong system, confidently, and when it fails to work they draw the obvious conclusion. The problem must be them. They are not resilient enough. They cannot even sleep properly.

They can sleep perfectly well. They are drowning in a different pool.

There is a reason this second tiredness bites hardest in people who decide for a living. Every unexamined call you carry, every assumption you never got to test out loud, every plan you shipped at speed and quietly hope holds, stays open in the background. This is the tax that Red Team Thinking® was built to collect deliberately, in daylight, on purpose, rather than letting it collect itself at three in the morning. Thinking that never gets externalised does not disappear. It goes underground and keeps charging you rent. The most stretched leaders I meet are not tired because they thought too hard. They are tired because they were never given the room to finish a thought, so none of it ever closed.

So the question to ask, when good sleep stops working, is not what is wrong with the night. It is:

What did I bring to bed that was never mine to hold alone?

And here is the part I find genuinely hopeful. You do not have to guess which tired you are in, and you do not have to wait for the car park at the end of the day to tell you. Both kinds leave a reading, and a reading can be watched. Set how you wake after a real night’s rest beside how loaded the day before actually was, week on week, two needles on one dashboard. When a good night moves the first needle back to where it should sit, that was recoverable fatigue behaving exactly as it should. When the needle stays flat after eight honest hours, that is the second kind speaking, and it is not asking you to sleep more. It is telling you the design of your days has outrun the margin your mind was built with.

The gap between the two readings is the diagnosis.

And a bad design, unlike a bad night, is something you are allowed to change.

Look at the capable person near you who is doing everything right and getting nowhere. Off their phone. On their tracker. Still grey by Thursday. Before you send them another link about sleep, sit with the possibility that their sleep is fine. The thing they cannot refill is not rest. It is margin. And margin does not come from a better bedtime routine. It comes from a system that stops taking the oxygen before the person has to go looking for it at midnight.

The registrar did not need a wind-down ritual. She needed ten minutes in the day where the decisions could be set down and examined, out loud, with someone, before they followed her home.

You do not sleep your way back from cognitive hypoxia. You think your way back, in the light, where the thoughts can be seen.

This week, when you wake up already tired, ask which tank is empty before you blame the night.

She was not. She ran a busy unit. She hit her numbers. Her patients did well and her juniors trusted her. From the outside, nothing was wrong. But every evening she sat in her car in the hospital car park for ten minutes before she could face the drive home. She had started snapping at people she loved. She read the same paragraph four times and took none of it in. She told me she had lost her edge, her patience, the version of herself she used to like.

She had not lost any of those things. She had run out of something. And because she could not name it, she blamed the only thing in the room she could see clearly. Herself.

We are good, in medicine, at naming what we can see. A rhythm on a monitor. A shadow on a film. A number that has drifted out of range. We are far less good at naming the thing that has no waveform, no image, no reference interval. So when a capable leader starts to struggle, we reach for the labels we already own.

We call it a leadership problem. We send them on a course about influence and difficult conversations.

We call it a communication breakdown. We commission a workshop, write a new policy, add a step to the handover.

We call it burnout, or a resilience gap, and we offer mindfulness at lunchtime and a wellbeing webinar nobody has time to watch.

None of it holds. The course is forgotten by the following Tuesday. The policy becomes another thing to comply with. The webinar is one more demand on a person who already has too many. We keep prescribing, and the patient keeps not getting better, and slowly we conclude that the patient is the problem.

Here is the reframe I want to leave you with this week.

Healthcare does not have a leadership crisis. It has an oxygen crisis.

I mean that almost literally. In medicine, oxygen is not one factor among many. It is the enabling condition. Get the oxygen wrong and it does not matter how strong the heart is or how clever the drug regime is. Everything downstream degrades. And the brain, the most oxygen-hungry organ we have, is the first to feel it. Starve it for seconds and higher function starts to fail before the person even knows anything is happening.

Leadership under modern pressure follows the same physiology. There is a kind of margin that good thinking runs on. Call it attention, emotional steadiness, the few seconds between a stimulus and your response, the bandwidth to hold more than one thing in mind without dropping the lot. When that margin is adequate, people are curious, steady, willing to be challenged, able to see the whole board. When it falls below what the role demands, the higher functions go first. Strategic thinking narrows to firefighting. Empathy shrinks. Curiosity collapses into certainty. The person becomes sharper, colder, quicker to close a conversation down.

This is the thing my colleague had run out of. I have come to call it Cognitive Oxygen® (COx), and I have spent years watching it deplete in people far too able to be failing.

The cruel part is how well the depletion hides. A starving heart does not stop. It compensates. It works harder, recruits reserve, holds the line, and from the outside it looks like it is coping right up until the moment it is not. Depleted leaders do the same. They go into a kind of permanent triage, and triage produces visible activity. Inboxes get cleared. Meetings get attended. The motion looks like competence. So the very thing that should alarm us reassures us instead. Everyone is busy, therefore everyone must be fine.

And there is the matter of shame, which keeps the whole thing in the dark. Naming your own depletion feels like confessing weakness, so people do not say it. They sit in the car park instead. They assume they are the only one. They are almost never the only one.

I want to be careful here, because this is where the usual story goes wrong. The usual story says: you are depleted, so you must look after yourself better. Sleep more. Be more resilient. The implication is that the problem lives inside you, and so does the fix.

That is the part I do not accept. The leaders I have watched struggle most were not the least intelligent, the least trained, or the least committed. They were the most stretched. Their environments had quietly removed the conditions that good thinking requires, and then asked them to think well anyway, and then, when the thinking suffered, offered them a webinar about themselves. The depletion was real. The diagnosis was aimed at the wrong target.

So the question is not “how do I cope better.” Coping better is what she had been doing for two years in that car park, and it was eating her alive. The question is the one we ask about any patient who is not improving on the treatment we chose. Did we get the diagnosis right?

Look again at the next capable person you see starting to fray. The one who has gone quiet, or short-tempered, or strangely certain about everything. Before you reach for the word leadership, or communication, or resilience, try a different question.

What in this system keeps taking the oxygen out of the room?

Ask that, and a great deal changes. The problem stops being a person and starts being a set of conditions. Conditions can be redesigned. And an oxygen crisis, once you actually name it as one, turns out to be the most treatable crisis there is.

That is where we are going, week by week. Not to make you cope. To help you see.

Next week: why a full night’s sleep stopped fixing it.

Not because I had stopped loving cardiology. I loved it still. I resigned because I could no longer think properly inside it, and a cardiologist who cannot think clearly is a hazard wearing a lanyard.

Nobody collapses in a heap. That is the part people misunderstand. You do not run out of intelligence. You run out of something quieter. Room. The half-second before you speak. The willingness to ask the awkward question on the ward round. The capacity to hold two possibilities open when everyone in the room wants you to close them down and move on.

I started calling that quiet thing oxygen, because it behaves like oxygen. You only notice it when it runs low, and by then your judgement is already slurring.

This publication is about Cognitive Oxygen® (COx): the conditions that wise action depends on, and what it takes to protect them when the pressure will not stop.

Here is what I have learned, first as a clinician and then as a coach. Three things go before anyone sees them go.

Judgement goes first. Tired leaders do not make obviously stupid decisions. They make subtly worse ones, faster, with more confidence. The confidence is the tell. Pressure pushes people towards certainty exactly when the situation is calling for clarity, and certainty under complexity is not strength. It is a smaller version of the truth, wearing a louder voice.

Humanity goes second. The person who used to listen starts interrupting. The leader who used to ask starts telling. Not because they became unkind, but because kindness is metabolically expensive and they have run out of margin to pay for it. I have watched good doctors become difficult to work with inside a single bad winter, and I have been one of them.

The truth goes last, and it goes silently. This is the dangerous one. When a leader runs low, the people around them quietly decide it is no longer safe to bring bad news. The corrections stop. The early warnings stop. The leader experiences this as calm and reads it as competence. It is neither. It is the sound of a team that has stopped telling you what you most need to hear.

None of this is a character flaw. That is the whole point. It is a predictable response to depleted conditions, and conditions can be protected. We protect oxygen for patients without a second thought. We have never thought to protect it for the people making the decisions.

So that is the work. Three commitments, said plainly. Protect judgement, so decisions stay sound when the stakes are high. Preserve humanity, so the team stays whole and stays honest. Generate usable clarity, so people can orient and act inside the fog rather than pretending the fog has lifted.

I will not pretend this is gentle. Some of what I write will sit uncomfortably with how leadership is rewarded in healthcare, where stamina is mistaken for strength and the leader who admits they are running low is read as the weak one. I think we have that exactly backwards. The leader who can see their own oxygen falling, and say so, is the safest person in the building.

I called the principle margin is medicine before I fully believed it. I believe it now. The margin you keep, the half-second you protect, the awkward truth you make it safe to say, these are not the soft edges of the job. They are the clinical core of it.

You did not run out of talent. You ran out of air.

Let me show you how to get it back.

It is Saturday on-call. By lunchtime, you have seen twelve admissions. The pace is steady, the pressure is familiar, and you handle it with the practiced ease of a consultant who has seen it all before. You move through the wards, making decisions, steadying the team, and managing the quiet chaos that defines a weekend in a busy hospital.

By the time you finally climb into bed at half past two in the morning, you have made dozens of decisions. Three of those decisions were not small. They were the kind of calls that change lives, the kind that require you to weigh complex variables in seconds. You have worked a twenty-hour day on a handful of snatched calories and a great deal of adrenaline.

You get four hours of sleep.

On Monday morning, you are in clinic. The first patient sitting in front of you is a woman with a complex history and a list of questions she has waited six months to ask. She deserves a fresh mind. She deserves a clinician who can hear the thing she is not quite saying.

She does not get one. Instead, she gets the residue of your weekend.

You are calm. You are fluent. You are entirely competent. To the patient, to your colleagues, and even to yourself, you look like a model of resilience. You are still standing. You are still working. But something is missing. There is a thinning of the air.

This is the part of resilience that nobody photographs.

The Margin for Thought

We are often told that we need more resilience. The word is thrown around as a solution to every systemic failure and every personal struggle. If you are tired, you need to be more resilient. If the system is breaking, the people within it must be more resilient.

I believe this is a fundamental misunderstanding of the problem.

Most healthcare leaders are not short of resilience. They are some of the most resilient people on the planet. They have survived decades of high-stakes environments, navigated constant change, and held onto their humanity in the face of immense suffering. They are not running out of the will to continue.

They are running out of Cognitive Oxygen® (COx).

Cognitive Oxygen® (COx) is the margin a leader needs to pause. It is the mental space required to notice what is happening, to question assumptions, to hold complexity, and to choose the next right move rather than simply reacting to the loudest noise.

When we talk about oxygen in a clinical sense, we understand that it is finite. We know that without it, cells begin to struggle and eventually die. We do not ask a patient with low oxygen levels to simply be more resilient. We recognise that they are in a state of physiological crisis.

The mind works in much the same way. Attention is not infinite. Judgement has a metabolic cost. Compassion has a bandwidth. Every decision you make, every conflict you navigate, and every hour of sleep you lose thins that margin.

The Silence of Cognitive Hypoxia

When physical oxygen levels drop, the body has ways of sounding the alarm. In the world of leadership, the signs of a thinning margin are much more subtle. I call this state cognitive hypoxia.

The danger of cognitive hypoxia is that it does not cause people to fail loudly. Instead, they deteriorate quietly. Because you are a high-performing professional, you have spent years learning how to mask fatigue and stress. You know how to sound certain even when you are unsure. You know how to maintain the appearance of authority while your internal capacity is depleted.

This deterioration shows up across four linked domains:

Cognitive clarity. Your ability to process information slows. You find it harder to separate the signal from the noise. You start to rely more on shortcuts and heuristics, which are useful until they lead you into an unforced error.

Emotional steadiness. Your fuse becomes shorter. You might find yourself becoming more defensive or less empathetic. The emotional labour of leadership, which usually feels manageable, starts to feel like an impossible weight.

Behavioural discipline. You stop doing the things you know are right. You skip the team debrief. You avoid the difficult conversation. You stop questioning the status quo because you simply do not have the energy to deal with the answer.

Physical recovery. Your body stops bouncing back. The four hours of sleep no longer feel like enough to get you through the day. The fatigue becomes a baseline rather than a temporary state.

Because you stay calm enough and fluent enough, nobody sees this deterioration. The system continues to demand more, and because you are resilient, you continue to give it. But the quality of your thinking and the depth of your leadership are being slowly starved of the margin they need to thrive.

The Three Layers of Capacity

Restoring Cognitive Oxygen® (COx) is not as simple as taking a holiday or attending a wellness seminar. It requires a fundamental shift in how we view our capacity and our responsibility to the teams we lead. We have to look at the three layers where this margin is created or destroyed.

First, there is the inner layer. This is your own capacity to notice and regulate your internal state. It is the ability to recognise when your margin is thinning and to have the tools to pause and reset. It is about understanding that your brain is a biological organ with physical limits.

Second, there is the social layer. This is the team’s ability to speak, listen, repair, and trust. A team that lacks psychological safety is a team that consumes vast amounts of cognitive oxygen just to navigate internal politics and fear. A healthy social layer acts as a shared lung, allowing the team to think more clearly together than any individual could alone.

Third, there is the structural layer. This is the design of the system itself. It includes the governance, the meeting schedules, the time for recovery, and the windows of quiet that are built into the work. If the structure is designed to consume every second of your time, no amount of personal resilience will save you from cognitive hypoxia.

Why This Matters Now

I am starting this Substack because I believe the current pace of healthcare leadership is unsustainable. We are losing too many good people not because they aren’t strong enough, but because they are being asked to lead in an environment that is cognitively suffocating.

My goal is to explore how we can reclaim that margin. We will look at how clinicians actually think and decide, and how we can use tools like Red Team Thinking® to challenge our assumptions and reduce unforced errors. We will talk about the human cost of the relentless pace and how we can build systems that respect our carrying capacity.

This is a space for leaders navigating the reality of clinical work, not a home for generic corporate advice. It is a space for leaders who want to lead with calm authority and compassion, even when the stakes are high and the certainty is low.

Oxygen First

I have spent almost 25 years in high-stakes clinical leadership across seven countries. I have been the consultant on that Saturday on-call and have felt the air thinning in my own leadership. As a cardiologist and executive coach, I founded the School of Cognitive Oxygen® to help leaders create the cognitive margin needed to think clearly, decide wisely, and remain deeply human under pressure. Together with my co-author, , we explore what it takes to protect that margin—not only for leaders, but for the teams and systems they serve.

I invite you to subscribe and join this conversation. We will look at the tools of metacognition, the practices of emotional intelligence, and the structural changes that can restore the oxygen to our systems.

We cannot change the pressure of the work, but we can change how we respond to it. We can choose to stop relying solely on resilience and start protecting our capacity to think.

Dr Toomas Särev FRCP

Consultant Cardiologist & Executive Coach

Creator of the Cognitive Oxygen® (COx) framework