By Rob Cooney (@EMEducation)
The Unthinkable: Who Survives When Disaster Strikes – and Why
by: Amanda Ripley
I recently picked up a copy of The Unthinkable in preparation for an upcoming book club sponsored by the Wilderness Medical Society. As medical professionals interested in providing care in austere and unpredictable environments, the content of the book makes immediate sense. But after reading it, and seeing parallels to similar cognitive patterns in clinical learning environments, I suspect medical educators may find its exploration of human behavior under stress even more compelling. Beneath its disaster narratives, Amanda Ripley offers a fascinating examination of cognitive psychology, decision-making, and the ways people respond when the unexpected suddenly disrupts routine.
At the center of this book is the idea that we humans are surprisingly poor at recognizing and responding to rapidly unfolding or novel stress. When facing uncertainty, we often default to denial, delay, or rigid adherence to familiar routines. Chapters in the book describe these patterns through the lens of major disasters. In the chapter about 9/11 and escaping the World Trade Cener, victims spent valuable time trying to normalize or rationalize what was happening rather than accepting and adapting to reality and evacuating the towers.
In medical education, similar “micro-freezes” occur every day: the learner who notices a patient deteriorating but hesitates to speak up, the intern who fails when managing the airway and can’t recover to move to plan B, or the resident who becomes cognitively overloaded during a chaotic clinical encounter. While these moments may occur on a smaller scale than the disasters described in the book, the underlying psychology is remarkably similar.
Equally compelling is Ripley’s discussion about preparation and rehearsal. She tells stories about individuals who mentally rehearse stressful scenarios or repeatedly train in realistic environments. These people are far more likely to respond effectively under pressure. How many of you count the rows between your seat and the exit when boarding a plane? How about reviewing the safety card? It might save your life, as it has for others based on interviews with those who successfully survived crashes.
The parallels to simulation-based medical education are obvious. By inducing stress and uncertainty in a controlled environment and allowing repetitive practice, our leaners are building cognitive frameworks that remain accessible when stress, fatigue, and uncertainty threaten performance. Ripley’s work reinforces the importance of deliberate practice, graduated autonomy, and psychologically realistic simulation experiences that prepare our learners for the cognitive and emotional realities of clinical care.
A later section of the book focuses on the importance of leadership and communication during crisis situations. In moments of uncertainty, people instinctively look for calm voices, clear direction, and simple next steps. These voices can help reorient survivors and spur them to action (breaking through the denial and rationalization phases). This isn’t a surprise to anyone who studies the clinical learning environment. Learners often take emotional cues from supervising physicians during difficult patient encounters, emergencies, or high-pressure conversations. Faculty who model composure, structured thinking (maybe even think out loud?), and psychological safety can significantly improve both learning and team performance. Conversely, as we know, environments that punish mistakes or create fear unintentionally reinforce unwanted behaviors and silence future concerns.
In the final chapter and appendix Ripley challenges readers to rethink preparedness itself. True readiness is less about memorizing protocols and more about learning how to notice, interpret, and act under stress. Teaching learners how to recover from uncertainty, communicate despite discomfort, and continue functioning during cognitive overload in today’s chaordic learning environments is becoming just as important as teaching foundational medical knowledge.
In The Unthinkable, Ripley delivers well-crafted narratives to illustrate the study of human behavior under pressure and the cognitive realities that shape performance in moments of stress. For medical educators, her message serves as an important reminder that the behavior we witness and consider problematic may just be a predictable human response. Our responsibility, then, is not simply to transfer knowledge, but to create learning environments that prepare future clinicians to adapt, respond, and continue moving forward when the unexpected inevitably occurs.
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