10 minute read.
Based on research done by a man named Daniel J. Levitin, I have a story to tell that was similar to a story he told in a Ted Talk.
About 30 years ago, when I was an unattached young man, I broke into my own apartment. I had just gotten a ride home after a night of being out with my buddy.
It was around midnight in the dead of winter in Wisconsin. I had been visiting with my friend Steve who lived across town, and the thermometer on the front porch read minus 20 degrees.
It was cold. Colder than a well digger’s hiney. As I stood on the front porch fumbling in my pockets, I found that I didn’t have my keys with me. I could see them through the window.
They were lying on the kitchen counter where I had left them last before I locked the door. So I quickly ran around the building and tried all the other doors and windows. They were locked tight. Wonderful! Just great!
I thought about calling a locksmith but I didn’t have a phone. It was 1988. No cell phones yet. But even if I had access to a phone, at midnight, it would take a while for a locksmith to show up, and it was colder than a brass toilet seat.
I couldn’t go back to my friend’s house for the night, because my car keys were also locked inside my apartment. I had an early work shift the next morning, and I needed to get some sleep.
So, desperate and frozen to the bone, I found a large rock and I broke through the front window. I crawled through and found a piece of cardboard and taped it up over the opening, then stuffed a thick pillow next to the window, and taped that as well.
I figured that in the morning before work, I could call my friend to have him come over and fix it. He was a handy guy and would know what to do. This was going to be a pain in the rump, but probably no more inconvenient than a middle-of-the-night locksmith.
So I figured, under the circumstances, I was coming out even. Now, I think like a psychologist by nature. That’s what I majored in college. And I know a little bit about how the brain operates under stress. It releases cortisol that raises your heart rate. It also modulates adrenaline levels and clouds your thinking.
So the next morning, when I woke up on too little sleep, worrying about the hole in my window, and a mental note that I had to call my friend, and the freezing temperatures that were colder than a banker’s heart on foreclosure day, and the shift I had to work that morning, and with all the cortisol in my brain, my thinking was cloudy, but I didn’t know it was cloudy because my thinking was cloudy.
And it wasn’t until I got to work, that I realized I didn’t have my wallet. So I raced home in the snow and ice, and in 20 minutes, got my wallet, raced back to work, and made it just in time to clock in.
But then at lunch time, I realized I didn’t have enough money for a meal, so I settled for a piece of fruit and went hungry for the rest of the day until my shift ended. Face palm! I had a lot of time to think about how hungry I was during those eight hours and no sleep on my shift.
And I started wondering, are there things that I can do, or systems that I can put into place that will prevent bad things from happening? Or at least if bad things happen, can I do something to minimize the likelihood of it being a total catastrophe.
So I started thinking about that, but my thoughts didn’t crystallize about it until I was much older.
I was having a beer with my friend Steve later that week, and I told him about having broken my window, and forgetting my wallet. After having a good laugh at my expense, Steve asked me what I had learned from the experience. I didn’t know how to answer the question at that time, but I can answer it today.
That’s when I remembered reading about Prospective hindsight from Dr. Levitin. Always being interested in reading about the human brain, there was something that he learned from a psychologist named Gary Klein, who had also written about it. He called it pre-mortem.
Now, you know what postmortem is, right? Whenever there’s a disaster, a team of experts come in and they try to figure out what went wrong. Well, in the pre-mortem, you look ahead and you try to figure out all the things that could go wrong, and then you try to figure out what you can do to prevent those things from happening, or minimize the damage.
So what I want to talk to you about today are some of the things we can do in the form of a pre-mortem. According to Dr. Levitin, some of them are obvious, and some of them are not so obvious.
I’ll start with the obvious ones.
Around the home, designate a place for things that are easily lost. Now, this sounds like common sense, but there’s a lot of science to back this up, based on the way our spatial memory works. There’s a structure in the brain called the hippocampus that evolved over tens of thousands of years, to keep track of the locations of important things.
It told early humans where the water was, where fish could be found, where to find the fruit trees, and where the friendly and enemy tribes lived.
The hippocampus is the part of the brain that in New York taxicab drivers becomes enlarged. It’s the part of the brain that allows squirrels to find their nuts. And if you’re wondering, somebody actually did the experiment where they cut off the sense of smell for the squirrels, and they could still find their nuts.
They weren’t using smell, they were using the hippocampus. This is a perfectly evolved mechanism in the brain for finding things. But it’s really good for things that don’t move around much, not so good for things that move around.
So this is why we lose car keys, reading glasses, and wallets. In your home, designate a spot for your keys, like a hook by the door, or maybe a decorative bowl. For your wallet, keep it in a particular drawer. For reading glasses, keep them on a particular table or desk. If you designate a spot and you’re consistent with it, your things will always be there when you look for them.
What about travel? Take a smartphone picture of your credit cards, your driver’s license, and your passport, and then email them to yourself so it’s in the cloud. If these things are lost or stolen, you can easily replace them. These are some rather obvious things. But remember, when you’re under stress, the brain releases cortisol. Cortisol is toxic, and it causes cloudy thinking.
So part of the practice of the pre-mortem is to recognize that under stress, you’re not going to be at your best, and you should put systems in place.
Now think about really stressful situations. There is no more stressful a situation than when you’re confronted with a medical decision to make. At some point, all of us are going to be in that position, where we have to make a very important decision about the future of our medical care or that of a loved one, to help them made a sound decision.
Dr. Levitin talks about a very particular medical condition. But this stands as an example for all kinds of medical decision-making, and also for financial decision-making, and social decision-making. It helps with any kind of decision you have to make that would benefit from a rational assessment of the facts.
Suppose you go to your doctor and the doctor says, “I just got your lab work back, your cholesterol’s a little high.” You know that high cholesterol is associated with an increased risk of cardiovascular disease, heart attack, and stroke. So you are probably thinking that having high cholesterol isn’t the best thing in the world.
Then your doctor says, “I’d like to give you a drug that will help you lower your cholesterol.” Drugs like this are called a statin. They stabilize you and they’re among the most widely prescribed drugs in the world today. You probably even know people who take them. So you’re thinking, “Sure, I’ll take it because it helps my condition.”
But there’s a question you should ask at this point. Dr. Levitin says you should ask about a statistic that most doctors don’t like talking about, and pharmaceutical companies like talking about even less. It’s for the number needed to treat. It’s called the NNT. It’s the number of people that need to take a drug or undergo a surgery or any medical procedure before one person is helped.
You may be thinking, what kind of crazy statistic is that? The number should be one. My doctor wouldn’t prescribe something to me if it’s not going to help. But actually, medical practice doesn’t work that way, and it’s not the doctor’s fault. If it’s anybody’s fault, it’s the fault of scientists. They haven’t figured out the underlying mechanisms well enough yet.
According to Dr. Levitin, GlaxoSmithKline, a global healthcare company, estimates that 90 percent of the drugs work in only 30 to 50 percent of the people. So what do you suppose the number needed to treat for the most widely prescribed statin is? How many people have to take it before one person is helped? The answer is 300.
This is according to research by practitioners Jerome Groopman and Pamela Hartzband, and independently confirmed by Bloomberg.com. 300 people have to take the drug for a year before one heart attack, stroke or other adverse event is prevented.
Now you’re probably thinking, “One in 300 chance of lowering my cholesterol? Why not? Give me the prescription anyway.” But then you should ask for another statistic at this point “What are the side effects?”
For this particular drug, the side effects occur in five percent of the patients, and they include terrible things, debilitating muscle and joint pain, gastrointestinal distress. But now you’re thinking, “Five percent means that it’s not very likely to happen to me. I’ll still take the drug.”
But wait a minute.
Remember under stress you’re not thinking clearly. So think about how you’re going to work through this ahead of time. You don’t have to manufacture the chain of reasoning on the spot. 300 people take the drug, right? One person was helped, and five percent of those 300 have side effects. That’s 15 people.
That means you’re 15 times more likely to be harmed by the drug than you are to be helped by the drug. I’m not saying whether you should take the statin or not. I’m just saying you should have this conversation with your doctor. Medical ethics requires it, and it’s part of the principle of informed consent.
You have the right to have access to this kind of information to begin the conversation about whether you want to take the risks or not.
Now you might be thinking, Dr. Levitin pulled this number out of the air for shock value. But in fact this number needed to treat is rather typical. For the most widely performed surgery on men over the age of 50, removal of the prostate for cancer, the number needed to treat is 49.
That’s right. 49 surgeries are done for every one person who’s helped. And the side effects in that case occur in 50 percent of the patients. They include impotence, erectile dysfunction, urinary incontinence, rectal tearing, and fecal incontinence (uncontrolled pooping).
And if you’re lucky, and you’re one of the 50 percent who has these, they’ll only last for a year or two. So the idea of the pre-mortem is to think ahead of time to the questions that you might be able to ask that will push the conversation forward.
You don’t want to have to manufacture all of this on the spot. And you also want to think about things like quality of life. Often times, you have a choice. Do you I want a shorter life that’s pain-free, or a longer life that might have a great deal of pain towards the end?
These are things to talk about and think about now with your family and your loved ones. You might change your mind in the heat of the moment, but at least you’re practiced with this kind of thinking.
Remember, our brain under stress releases cortisol, and one of the things that happens at that moment is a whole bunch on systems shut down. There’s an evolutionary reason for this. Face-to-face with a predator, you don’t need your digestive system, or your libido, or your immune system.
If you’re body is giving energy to those things and you don’t react quickly, you might become the lion’s dinner, and then none of those things matter anymore.
Unfortunately, one of the things that goes out the window during those times of stress
is rational and logical thinking. So we need to train ourselves to think ahead to these kinds of situations.
I think the important point here is recognizing that all of us are flawed. We all are going to fail now and then. The idea is to think ahead to what those failures might be, and to put systems in place that will help minimize the damage, or to prevent the bad things from happening in the first place.
Back to my freezing cold night in Wisconsin. When I got back home from my shift that day, I had my friend fix the window. Then I hid a key under a mat outside near my front door. I have to admit, I’m not completely organized in many aspects of my life, but I see an opportunities now and I can learn things through a gradual process.
I’m getting there. I’ll always keep working to make my life more manageable. Will you?
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Always keep leaping forward my friend!