Elite Thinking
The first two articles in this series were built on the idea that there are two forms of thought that I have come to believe are present in nearly every area where performance and pressure intersect. For convenience I refer to them as left-brain thinking and right-brain thinking. That’s not as a strict neurological claim, but rather a practical distinction and way of thinking about it that helps explain why some individuals can perform reliably under pressure while others, despite considerable talent or preparation, struggle to do so consistently.
As you read about here, by left-brain thinking, I mean the disciplined, procedural side of performance. That’s the part of the brain concerned with preparation, mechanics, sequencing, repetition, and the reduction of avoidable interference. In surgery, this includes everything from positioning and exposure to instrument handling and operative planning. People tend to focus on the visible and specific moment in which the surgeon removes the clot, separates the vessel from the nerve, or excises the tumor. Yet those moments, dramatic as they may appear, are often the least important part of the operation. What determines the outcome is more commonly an accumulation of small decisions made correctly and in proper sequence long before the apparent “big moment” arrives. A technically demanding operation is rarely dependent on the surgeon’s brilliance in some specific moment. It succeeds because the surgeon has created conditions in which the decisive step can be performed safely and without unnecessary improvisation. My partner Seth Joseffer, MD told me about a mentor (Pat Kelly, MD) who said “You don’t want to be doing a lot of thinking in the operating room… that should have been done way before.” That's a powerful idea.
That same truth exists in athletics, military training, and leadership. Spectators usually remember the winning shot, the takedown, or the decisive command decision because those are the obvious expressions of performance. Yet the individual responsible for that performance usually remembers something other things: repetition, discipline, years spent creating and refining habits that can be relied upon to show up under pressure. This is one reason experienced performers often appear calmer than younger ones. Their confidence, when it is genuine, rests less on emotion than on familiarity with their process. They have learned that consistency rarely emerges from intensity alone. It comes from structure.
Over the years I have found it useful to think about performance through a simple formulation: performance comes from potential minus interference. Potential is a function of skill, training, and knowledge. Interfering factors subtract from that potential. Some interference is external… equipment fails, schedules change, fatigue accumulates, and external circumstances change. Some interference is internal. Doubt, distraction, overanalysis, and emotion can consume cognitive bandwidth that ought to remain directed toward the task at hand.
My earlier article about left-brain thinking discusses Ilia Malinin’s struggle during the 2026 Olympics where he described letting the Olympic platform interfere with his execution.
Yet technical preparation alone isn’t enough. Experience shows that a person can be extremely well trained and still fail to perform effectively when psychological dimensions dominate attention.
This is the time when what I call right-brain thinking becomes essential. Right-brain thinking is about orientation rather than mechanics. It addresses the internal stories we tell ourselves.
Over decades in medicine, coaching, and reflecting on performance, I have become increasingly convinced that fear is among the most corrosive forces acting on human performance, not because it reflects weakness, but because it shifts attention away from the present and toward imagined futures that do not yet exist.
Fear, as I have come to understand it, is rarely the event itself. In fact, as described in my book Cognitive Dominance: A Surgeon’s Quest to Out-Think Fear, I believe that fear lives entirely in the future. It is the anticipation of a future event combined with the belief that if that event occurs, one will experience something emotionally intolerable. How does that work in the arena?
The performer stops inhabiting the task directly and begins living future imagined consequences instead. The surgeon starts thinking about catastrophe rather than anatomy. The athlete starts thinking about losing rather than competing. The leader begins protecting against judgment rather than exercising judgment. In each case performance deteriorates.
This distinction matters because right-brain thinking attempts to restore proper orientation. The surgeon or athlete must recognize that performance and outcome don’t always correspond as we hope. In medicine this lesson arrives sooner or later for nearly everyone. Reality is that some patients recover against impossible odds, and others deteriorate despite competent and conscientious care. If a physician interprets each favorable outcome as a proof of worth and every unfavorable one as evidence of personal failure, then fear is inescapable.
Over time I have come to understand that while we are absolutely responsible for our preparation, integrity, effort, and judgment, the outcomes in complex situations are never entirely under our control. Accepting this doesn’t diminish accountability. If anything, it clarifies it by separating responsibility from self-condemnation.
What ultimately interests me about the distinction between left-brain and right-brain thinking is not that they represent opposing modes of performance, but that we need the integration of both models to perform at our highest potential. Left-brain thinking without right-brain thinking can produce technical competence that is susceptible to collapse when pressure is applied. Right-brain thinking without left-brain thinking can produce inspiration unsupported by technical competence. Reliable performance only emerges as a function of the two forms working together.
In medicine this integration becomes especially important because surgery is not merely technical work. It is technical work performed under moral conditions. A coach of mine once suggested that we need to work on patients as if they are simultaneously a fine watch and a person. The more my brain simultaneously incorporates those two concepts while operating the better I will perform. The hands must know what they are doing, but the mind must also remain sufficiently ordered to allow those hands to function well when uncertainty, fatigue, fear, or consequence inevitably appear. Wrestling taught me something similar many years earlier. A match may appear physical from the outside, but underneath it lies an ongoing negotiation between preparation, emotion, identity, and composure. Military leadership and leadership in general, I believe, operate under the same principles.
As I have grown older, I have become less interested in dramatic ideas about performance and more interested in what is reliable and repeatable. The best performers I have known are rarely theatrical. Their steadiness comes not from suppressing fear through force of will, but from orienting themselves properly towards the work in front of them. They trust in preparation because they have invested in it seriously, and they remain psychologically available to the moment because they are not consumed by the need for outcomes to validate who they are.
And that ultimately is why both forms of thought matter.
Left-brain thinking prepares the performer to execute. Right-brain thinking allows the performer to remain inwardly free enough to do so. Together they create the conditions under which clear thinking, precise action, and steadiness under pressure become possible.
