The decision was fast, the thinking wasn't finished.
At three in the morning, part of me had already left the phone call.
I was listening. I was asking questions. But some part of me was doing the arithmetic on how much of the night was left, and whether I’d get back to sleep before the next call came in.
A woman in her late seventies. Breathless, a heaviness in her chest, an ECG that wasn’t quite textbook. The registrar needed a plan, a bed where to place her, and beds were the thing everyone was actually solving for.
Admit under general medicine. Cardiology can see her in the morning.
The decision took about ninety seconds. It seemed reasonable at the time. I wish I could remember more about what I was thinking. Mostly, I remember how ordinary it felt.
Cardiology didn’t see her for three days. By then a fair amount of damage had already happened.
I’ve gone over that call since. There are things I can explain: the hour, the presentation, the pressure on beds. There are also things I can’t know. Whether another question would have changed my mind. Whether a longer look would have made the difference.
What I keep landing on is this. The decision was fast. My thinking wasn’t finished. Those two things happened in the same ninety seconds, and nobody on that call, least of all me, noticed the gap between them. But I don’t think she had my full attention.
That’s an uncomfortable thing to write. I was doing my job. I cared what happened to her. And still, some part of me was trying to get through the on-call.
I suspect those things coexist more often than we like to admit.
We talk a lot about attention as if it’s a matter of discipline. Put the phone away. Concentrate. Try harder.
At three in the morning, after nineteen hours awake, that advice doesn’t get you very far. You can’t ask for a rested brain because someone needs one. You can, sometimes, notice that you’re struggling. Or someone else can notice, if you’ve made it possible for them to say so.
Before we perform a procedure or operate, we stop. We say the patient’s name, the procedure, the site, out loud, even when three people in the room already know all three. It can feel like theatre. We do it anyway, because the pause is the point, not the words.
I’ve started wondering about the decisions that happen earlier than that. The phone call. The referral. The moment someone says “sounds like general medicine” and the whole ward starts moving in that direction before anyone has actually decided anything.
There’s no scheduled pause for that moment. You have to make one, mid-shift, while another phone is ringing and somebody is waiting for you to finish this sentence so they can start theirs.
There isn’t always an obvious place to stop. You have to make one, while the phone is ringing elsewhere and somebody is waiting for you to finish.
I have three questions I keep returning to, and Red Team Thinking® (RTT) gave me the shape of the first two. Cognitive Oxygen® (COx), the framework I’ve spent the last few years building, gave me the third.
What am I taking for granted? On a busy take, that can simply be saying out loud: we’re treating this as routine, what’s making us comfortable with that. Then actually listening to the answer, including the version that makes the plan less convenient. In RTT, that’s an Assumptions Challenge™: name what everyone is silently agreeing to, before it becomes the decision nobody remembers making.
Have I really looked, or does this just sound familiar? Experience is what lets us recognise a pattern in three seconds instead of three minutes. It’s also what lets us stop listening once we think we’ve heard the shape of the thing. I know that feeling well: the case is still being described to me, and some part of my mind has already filed it and moved on to the next problem.
And then the one I find hardest. Am I able to give this my attention right now? Am I able to give this my attention right now?
Sometimes the honest answer is: not very well.
That’s where Cognitive Oxygen® (COx) starts to mean something practical to me. Being able to admit that there isn’t much left of you, while there is still work to do. Perhaps you need another pair of eyes. Perhaps you need the registrar to start again because you realise you weren’t properly listening the first time.
That can be embarrassing. Especially when you’re supposed to be the person with the answer.
I once heard a junior doctor say, midway through a decision, “I think I’m calling this routine because I’m tired. Let me actually check.”
A second look at the ECG. A call to cardiology. The patient went to the right ward.
I still think about that moment. It takes something to say that out loud on a busy take. I’d like it to be easier.
The woman from the night I started with recovered, mostly. When I see her, she still asks why nobody caught it sooner. I don’t have an answer that feels adequate.
Five months later, the stairs were still harder than they had been. She was living with the consequences of something that, for us, had occupied a few minutes of a shift.
I can’t say a pause would have changed everything. I wish I could.
But she deserved those minutes with me fully there.
That’s what I want to practise this week.
Catching myself when I’ve started to move on before the person in front of me has finished. Asking them to go back a bit. Making room to hear what I might have missed.