Richard E. Haas, PhD, CRNA, PHRN

Aesop’s fables are not as well-known as they once were, so some of you may not have heard this story before.  A cat and a fox were chatting in the forest. The fox was boasting of all the clever ways he learned to evade pursuing dogs, while the cat sighed that he had but one defense.  Suddenly the hunting dogs appeared; the cat jumped up the tree, but while the fox was trying to figure out which of his many ways to escape the dogs, the dogs caught him and…no more fox.

It turns out that Aesop instinctively knew that people do not think clearly when placed under stressful situations.  He did not know that physiology has a role to play in this degradation of thinking. This concept is particularly germane when it comes to teaching anesthesia students. Things that the seasoned practitioner takes for granted seem unrecognizable and unknowable to the novice student.  This is an amazing phenomenon, and one which we, as teachers of students, sometimes fail to take into account.  Indeed, as practitioners we may experience the same failing when speaking to our patients, particularly those explaining how they were traumatized in some accident or incident.  When we ask them why they did not get out of the way of the car, they say, “I just couldn’t move; I was paralyzed by fear.”  Let’s look at an interesting example from the professional literature (Nater, et al., 2005)that has nothing to do with so high-stakes an endeavor as anesthesia just to show how much stress can occur in every day decisions.

In this study, healthy young adults were asked to prepare a brief speech, engage in a simulated job interview, and solve a mathematics problem in front of a small audience.  That’s it: no life-saving decisions, no high-stakes questions.  What happened? Their salivary alpha amylase levels, a marker of physiological stress responses, DOUBLED in 10 minutes.  So did their salivary cortisol levels. Their heart rates went from the high 80s to the 120s.  They had profound physiologic stress responses.

What do these stress responses do to one’s ability to think through a problem? According to Schmader and colleagues (Schmader, Johns, & Forbes, 2008) one’s ability to think (frequently called “executive function”) degrades both rapidly and profoundly.  The release of physiologic neurotransmitters can activate glucocorticoid receptors in the brain. Activation of these receptors degrades working memory and executive function (Luethi, Meier, & Sandi, 2009).  So, what happens to our students and our patients? Interestingly, the same neurotransmitters which degrade executive function (resulting in “Now what do I do?”) enhance long-term memory formation (resulting in “I am never gonna do that again” two days later.  I like to call this the “Costanza Effect”, named after George Costanza in the 90’s sitcom “Seinfeld”. In the episode “The Jerk Store” George manages to come up with a snappy response to a co-worker’s insult, but only in the car on the way home when it is too late to use it!

How does this affect us? We bring a student to the operating room, they are unfamiliar with the case, or the surgeon, or the staff, or the facility, or, in the case of the new student, everything!  The student thinks every eye is upon them (and sometimes they are) and then, in the midst of everything we ask them a seemingly simple question (“How many lungs are there?”) and we are astonished by their answer (“6!?”).  This is stress speaking.  As students become more used to the stressors in the environment, as we educate them and train them to screen out distracting stimuli, their answers get better.  Not because they are smarter (though we hope they are), but because they are getting stress under control.

If, therefore, we really want to assess the strengths and weaknesses of our students, we need to take their surrounding stressors into account and measure their achievement against the cacophony of stressors surrounding them at any point in time.  We also can apply this theory to how our patients sometimes respond to us during times of intense psychological or physiological stress. Their answers to our questions and understanding of their situation is viewed through their “stress filter”.  This may help us understand why we need to go a bit slower, ask questions that are more direct, and help allay confusion when we are preparing patients for surgery.  Stress is more than just changes in bodily functions, it degrades our ability to think clearly.  Confronting and mastering stress, our own and that of our colleagues, makes us better practitioners.

Have a stress-free day!




Luethi, M., Meier, B., & Sandi, C. (2009). Stress effects on working memory, explicit memory, and implicit memory for neutral and emotional stimuli inhealthy men. Frontiers in Behavioral Neuroscience, 1-9.

Nater, U., Rohleder, N., Gaab, J., Berger, S., Jud, A., Kirschbaum, C., & Ehlert, U. (2005). Human salivary alpha-amylase reactivity in a psychosocial stress paradigm. International Journal of Psychophysiology, 333-342.

Schmader, T., Johns, M., & Forbes, C. (2008). An Integrated Process Model of Stereotype Threat Effects on Performance. Psychological Review, 336-356.