Latest / Flourishing in Medicine: From Surviving to Thriving / Flourishing in Medicine: From Surviving to Thriving Episode 17 From Psychology to Emergency Medicine: Dr. Pat Croskerry on Cognitive Bias and Diagnostic Safety

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Flourishing in Medicine: From Surviving to Thriving Episode 17 From Psychology to Emergency Medicine: Dr. Pat Croskerry on Cognitive Bias and Diagnostic Safety · Flourishing in Medicine: From Surviving to Thriving

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So what we've been trying to do in a nutshell is trying to turn medicine back on itself
0:12
to where it was a number of centuries ago, which sounds a bit regressive, but at a time
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when people relied less on knowledge and more on the art of medicine and thinking about
0:25
your thinking and in the earlier days of medicine, you probably know philosophy and logic and
0:30
psychology were very much more a part of what a physician did because they didn't have the
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fund of knowledge that we have now.
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We now have plenty of access to lots of knowledge, but we don't have as good access to how to
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think about that knowledge that we do have.
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Welcome to flourishing in medicine from surviving to thriving.
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I'm your host, Dr. Mick Krasner, and this podcast is produced by EmPRO, a medical professional
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liability insurance carrier headquartered in the New York City area.
1:07
And they are committed through a number of peer support offerings to really supporting
1:12
the physicians that they protect.
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Today I'm excited to share with you my conversation with Dr. Pat Croskerry, an emergency medicine
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specialist and professor at Dalhousie University in Halifax, Nova Scotia, Canada.
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He trained initially as an experimental psychologist before entering medicine, and he's become
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arguably one of the world's foremost experts in safety and emergency medicine and diagnostic
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errors.
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He directs the critical thinking program within the division of medical education at Dalhousie,
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and he continues to study and write about clinical decision-making, diagnostic failure,
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and the role of cognitive and affective bias, with more recent work focusing on how to mitigate
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cognitive bias and its impact.
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During this fascinating conversation, Pat shares his unique path to medicine stemming
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from a background in psychology that instilled a focus on critical thinking and cognitive
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biases and the discipline to study medicine, which was, we found out, informed by his brief
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growing career, during which he, as a member of the Canadian national team, competed in
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the Olympic Games.
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He delves into specific biases affecting medical decision-making, such as emotional, affective,
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anchoring, and search-satisficing biases, stressing the need to mitigate these biases
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for accurate diagnosis.
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Furthermore, he explores the impact of cognitive load and decision fatigue on physician well-being,
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advocating for a reconsideration of critical thinking's role in modern medical practice
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to ensure optimal performance and professional satisfaction.
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I hope you enjoyed this conversation with Pat Croskerry. 35 00:02:59,200 --> 00:03:04,120 Welcome Dr. Croskerry to Flourishing in Medicine, From Surviving to Thriving, where
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we really are interested in exploring all the different ways in which we can, as health
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professionals, especially physicians, improve our sense of effectiveness, meaning, and well-being
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in our work.
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And what I'd like to start with is a little bit about you, your story.
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It's interesting how people come to the work that they do, especially in medicine.
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Sometimes there's common threads that have to do with early experience.
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Sometimes these are developmental experiences that happen over one's education and work
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life, et cetera.
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So for you, if you could just kind of walk us through what were some of the early influences
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and ideas that has led you to this really interesting career in both medicine and research.
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Yeah, thanks for the invite, Mike, to be here.
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My journey has been slightly different, I guess, from the average clinician doctor in
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the sense that I turned to medicine fairly late in life, that was age 16 instead of age
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14, because in England, where I grew up, you had to sort of commit yourself early, which
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meant that you had to get into a science track, do all the basic sciences, physics, chemistry,
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zoology, and yet all of my background was in languages and history and art.
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So I made this transformation, but didn't make it very well.
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So by the time the qualifying exams came from medical school, I didn't have good enough
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grades in the sciences, having been at it only a couple of years.
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And I had to spend some extra time trying to bring those grades up.
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But in the meantime, got offered a place at the university in Scotland to do psychology.
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That wasn't entirely the obvious default for medicine, but in my case, it was very fortuitous.
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So I did an undergraduate degree in psychology and thought, well, I'll be a psychologist,
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I think, for the rest of my life.
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But then my earlier leanings got back to me and I decided to go into medicine.
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So I ended up, I had finished my training as a psychologist, my undergraduate and postgraduate
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training, and so came to medicine a little bit later than the average person.
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And of course, medicine was what I always wanted to do, so I kind of put all the psychology
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behind me.
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And during undergraduate training, that was fine.
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But when I got into medical practice, I started to notice that one of the most important things
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that I seemed to do each day was make decisions and think.
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It wasn't the background of medical knowledge that I was concerned about, all of that was
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fine.
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But what I seemed to spend most of my time doing was thinking about how I was thinking.
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And I guess that is outside of the usual trajectory.
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Most people in medicine accept what they're taught and they go with it and they follow
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their careers through in their various specialty training.
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But in my case, I couldn't get away from how important it was to think about what you were
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thinking.
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And that sounds a little bit sort of basic and maybe a little even circular.
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But what I'm getting at is that we, many of us just follow the habits and the drives and
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do the obvious things for the culture that we're in.
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And here was I, trained psychologist, I'd actually gone through to complete my PhD and
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postdoctoral work in psychology.
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And I was suddenly thinking, this is not my environment.
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It's an environment I really like.
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But I think there's something missing.
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I don't think we're thinking enough about what we're doing.
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So this got me into various kinds of trouble.
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But after a while, people began to accept that there was an opening here for people
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to consider how they were thinking when they were approaching a problem.
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Now, there was no question that you absolutely needed medical knowledge.
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There's no substitute for medical knowledge.
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And at that time, there were very few shortcuts.
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There are shortcuts now.
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You can immediately go to up to date programs and all kinds of IT backup to get information
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very quickly.
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But you couldn't so much earlier on.
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So that was really it.
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I started to focus in and notice that people, not just in medicine, but in pretty well every
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walk of life, people are vulnerable to these kind of flaws in their thinking.
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We all tend to make, whether you're an engineer or a lawyer or a construction worker or a
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mechanic, we all tend to make certain assumptions about the environment.
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And most of us have a tendency to be overconfident in what we can deal with.
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Not so much what we know.
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And this trait is encouraged in medicine.
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People want you to be confident and assured and reassuring and a source of good source
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of knowledge and so on.
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So we ended up focusing a lot on the main things that distort our thinking.
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And those were cognitive biases.
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And these are pervasive everywhere you go where there is human activity.
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And that includes deep space.
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We were recently approached by NASA to offer some insights into what kinds of challenges
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in decision making might happen if you were on a mission to Mars, for example.
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And what sorts of things couldn't you take for granted?
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And I don't know if you saw the movie The Martian, but he got into some serious trouble
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and got out of it by some pretty good thinking.
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So what we've been trying to do in a nutshell is trying to turn medicine back on itself
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to where it was a number of centuries ago, which sounds a bit regressive.
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But at a time when people relied less on knowledge and more on the art of medicine and thinking
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about your thinking.
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And in the earlier days of medicine, as you probably know, philosophy and logic and psychology
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were very much more a part of what a physician did because they didn't have the fund of knowledge
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that we have now.
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We now have plenty of access to lots of knowledge, but we don't have as good access to how to
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think about that knowledge that we do have.
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That's great.
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Thank you.
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That is a really good walk through how you got to where you are.
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Although I still am curious and maybe we can step back.
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We're going to get deeper into the cognition and cognitive bias.
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It was fortuitous indeed, although you say it got you into all sorts of trouble.
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I think trouble in a good way for you and for us too as a profession.
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But you still said something about you always wanted to do medicine.
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And I want to get a little bit underneath that.
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Why?
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Because I think this is a driving force for many, many, many, probably most of our colleagues.
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And I think to combine that deep desire to really understand that also knowing that,
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well, if you really, really want to do this and there's this love that you're moving
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toward, we do have to think about how we approach it in terms of our cognition.
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So back to square one, why did you really want to do this medicine piece?
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And then maybe can you just thread in a little bit because I'll bet there's something there.
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I'm wondering if there's something there about your athletic experiences, whether that informed
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any of those desires as well.
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It didn't at that time, but later on it did.
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In the beginning, I was, I think, trying to get at this interest in medicine.
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And it really was a strong vocation with me that I wasn't able to realize at that time
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because of the lack of science background and so on.
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But I lived in a small town on the English coast near Dover.
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And a local hero in our community was the physician because shipping frequently got
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into trouble in the English Channel.
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It's one of the busiest shipping routes in the world.
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And there were lifeboats all along the English coast.
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These were extremely well equipped vessels that could survive virtually any sea conditions.
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And the doctor would be would be called out on some of these rescue missions.
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And we would all hear it in the town because the alert for shipping in distress was two
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rockets that would be fired from the town center.
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And if a third rocket was fired, it meant that they wanted the doctor to come down to
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the lifeboat as well.
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So everybody used to sort of hang on for the third rocket.
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And then we all knew that the doctor was going.
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And the doctor who did do that became very famous in England.
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He was called the sea surgeon, but he did some heroic things.
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And I think like anything else in any community, if you have somebody who's perceived as a
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local hero, then young, especially in my case, if he was a male and a hero that I could relate
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to directly, then that was a good direction to go.
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So that really was my incentive, I think, was this famous local doctor that I thought
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we all looked up to.
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And to get to the other point that you mentioned, which was sport.
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The other thing we did in that little town was we rode on the sea.
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And each town down the coast of the English Channel had these rowing clubs.
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And they weren't rowing like you think of it, you know, Harvard and Yale and Princeton
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and these beautiful eight beautifully calm lakes.
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These were rough, tough rowing boats on the English Channel.
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And the boats would frequently fill up with water and you'd sink and you'd have to swim
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to shore and bail them out.
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And you couldn't have an eight on the water because it would be too fragile.
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So when I got to university, I suddenly found that I had access to these beautiful racing
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boats that you could.
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This was real finesse compared with what we used to do on the English Channel.
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And I got more and more involved in rowing.
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And then eventually ended up on the national team in Canada and went to the Olympics.
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So I think what that did was above anything else.
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I mean, if medicine itself wasn't enough of a discipline that one had to learn to follow,
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as you know, there's no shortcuts in medicine.
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You have to put in the work, you have to put in the hours and it's a highly disciplined
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profession.
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And on top of this, I had this rigorous training in rowing on the national team that went far
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beyond anything I did when I first got into it.
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If I knew what I was going to get into, I probably wouldn't have done it.
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I rowed at that level for two or three years.
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That was as far as I wanted to go with that.
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It was cutting into my time a lot.
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So those are just putting those two things together.
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It's funny because I haven't really tried to do that before.
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This was a first.
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I think that there is what you say is that the discipline that one has to apply, perhaps
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that also influenced in some ways the discipline you applied to experimental psychology and
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then also coming back to medicine and really focusing on that.
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I want to share with you a quote I found from an interview you had a number of years ago
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and as a way of kind of getting back into this discussion about cognition.
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And it goes the following, I really wasn't aware of the issue until I became head of
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an emergency department.
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It says something about the covert nature of error in medicine that I really wasn't
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aware of what was going on in the department until suddenly everything started coming across
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my desk.
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What struck me was that I never ran into a case where a mistake was malevolent or egregious
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in any way.
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The errors always involve well-intentioned efforts by hardworking people, but these people
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were working with imperfect systems and flawed cognition.
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So just that as an entree into discussion about this growing recognition and how you
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began to think about how we think.
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Yeah, that's a really important topic.
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Part of the problem in medicine, I mean, I'm not picking holes in medicine, but medicine
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is an imperfect science in a number of ways.
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And in fact, you know, it's described by the people in it as both an art and a science.
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So that we've always kind of had a foot.
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Medicine has had a foot in one camp, the sort of artistic moiety, and yet just from our
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background, primarily medicine has a major foot in science.
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And in some ways, it's kind of struggled a bit to become a fully fledged science.
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I remember when I was a psychologist, experimental psychologist, I was working in a research
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team and people used to talk about research and they'd say, I saw this paper the other
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day that was quite interesting, but it was from medicine.
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There was a but in there.
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It was from medicine.
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And why was the but there?
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It was because people didn't accept in rigorous science, which experimental psychology is,
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and so it is in physics and chemistry and the other major sciences.
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There is a very hard objective line that you follow of evidence.
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In medicine, we don't have that luxury.
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In a way, it's a luxury.
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And at the same time, it's a hindrance.
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But it's this notion of dealing with the sort of soft underbelly of what it is that we do.
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Because of the uncertainty in medicine, the fact that you never can know everything in
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the way that a physicist can when they're studying the relationships between physical
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matter, we have this big variable in there called people.
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And people are capable of a lot of kind of noise in the system.
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In psychophysics, it would be called noise that the psychologists talk about separating
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the signal from the noise.
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And it seemed to me in emergency medicine that that's a lot of the time what we were
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doing.
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I used to tell medical students, every patient who walks in that door into the emergency
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department has got a critical signal in them.
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There's a reason that they're there.
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And our job is to separate away that signal from the noise, the contaminating noise that
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it has.
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For example, if you had a drug user who came into emergency and was complaining of a headache,
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often you would hear comments on the side from people saying that they were looking
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for drugs.
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There really wasn't anything wrong with them.
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They're here all the time.
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They're frequent flyers and so on.
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And that's all noise.
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But the critical signal that you couldn't afford to miss was that that person who was
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a victim of addiction could carry some very important signal.
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They were just as vulnerable to a whole range of diseases as the rest of the population.
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And in fact, they were more vulnerable in certain ways than others.
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The only full arrests I ever saw in young people in emergency were cocaine users.
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And you couldn't afford to be diverted by the noise.
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The signal was there and you had to make sure that you took care of the signal and you weren't
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getting distracted by noise.
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It gives a very practical example of what we're talking about.
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I'd like to share a brief story of mine and have you look at it through the lens of cognitive
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and affective bias and whatever other kind of categories of bias.
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And then if you could, it'd be interesting to hear kind of how you would analyze this.
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So this happened to my daughter.
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I have three children, but the two older ones, one was six and my daughter was four.
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The son and daughter are playing.
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I'm at work.
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She hurts herself.
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They're wrestling, wrestling on the ground.
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My wife takes them into the pediatrician.
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The pediatrician sends a medical student in, does a wonderful history, brings the doctor
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in and as this medical student is beginning to recount the history to the physician,
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the physician says, stop right there.
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You don't have to say anything.
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I know exactly what it is.
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It's a nursemaid's elbow.
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It's classic.
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And so my wife, not knowing what that meant says, well, what's that?
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And she said, well, you know, at that age of a child, if you kind of yank on their wrist
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and pull their arm, one of the bones comes out of a little fibrous annulus and it's very
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painful.
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But the really cool thing about it is it's super easy to fix and it's classic cause that's
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how she's holding her elbow.
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And all you have to do is do here.
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I'll show you.
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And she puts her through this maneuver and my daughter screams and then she gives her
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a minute or two and does it again and then she again doesn't like it and holds her arm
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just the same way.
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And she says, listen, let's get an x-ray, but I'm sure it's fine.
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It's an x-ray.
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The x-ray is normal.
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And she sends her home with my wife and says, you know, this is just, you know, it's just
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the, all the emotion of coming to the doctor and all this happening.
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She'll be fine.
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You'll see.
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You'll get home and in a few minutes, she's going to be fine when she's home in her own
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setting away from us.
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And as they're walking out, the funny, it's not so funny.
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And this is a physician I have a lot of respect for even still.
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The physician turns to the medical student and says, you know, the doctor's children,
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there's always a little bit more going on there kind of in a snarky kind of way.
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And I get home a little early and I see her, this is an hour later, she's still holding
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her arm the same.
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And I say, you know, honey, where does it hurt?
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And she points to her wrist.
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I call the radiologist up and the radiologist says the elbow x-ray is normal, which it would
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be in the nursemaid's elbow, of course.
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And I say, well, can I bring her in?
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And sure enough, she had a little buckle fracture of the rich wrist.
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No big deal, but really a source of the pain.
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So given that story, walk us through some of those cognitive and affective biases, which
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may be kind of the example being the comment the physician makes toward the student about
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us.
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And that would be really interesting for you to walk us through those multiple biases there,
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of course.
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Okay.
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So I'd say a major bias in there to start off with is an injured child, which affects
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us all, whoever we are.
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And it's a kind of widespread emotional polarization.
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You know, when you see a child in distress, your immediate reaction is to try and help
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try to solve the problem and also to be reassuring and comforting to the child.
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And I'm sure that the attending physician was as much a victim of that as the medical
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student was.
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And in the teaching context, the attending physician has a tendency sometimes, depends
23:02
how strong their ego is, I guess, but a tendency to want to appear knowledgeable.
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And I've seen all this before and sort of teachers, the medical student that, you know,
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inadvertently a bit of experience is the key factor here, and that he recognizes a common
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injury in children.
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That's all very well, but unfortunately, he is kind of reacting in a way to the noise
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that we talked about earlier.
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He's distracted by a young child in distress, and he's also got this intermediate thing
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that the medical student has examined the child and perhaps his ego is caught up in
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this a bit.
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And he wants to demonstrate that he's seen this before and he knows what to do.
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So trying to recognize sources of noise is really critical.
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And also being able to say to yourself, to detach yourself from the situation and say,
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what else could this be?
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Is there anything I could be missing?
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That should be almost a reflexive, I'll say strategy, but it almost should be a reflexive
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habit that physicians have when they think they know what's going on.
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So there's an element there, certainly of overconfidence.
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And if you are overconfident, you're dangerous, and you must be willing to get out of the
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particular bias here is an anchor.
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It's called anchoring and adjustment.
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Making anchors is okay.
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If the child comes in with a painful arm and you immediately focus on the arm, that's anchoring,
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but it's appropriate.
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You don't start checking their neck and checking their legs.
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You anchor into the appropriate area.
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But your adjustment should be to any new information that's come on.
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And there is a rule in pediatrics that for any injury, you examine the joint above and
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below.
25:00
That is almost a mantra among emergency physicians.
25:03
So the first thing that the experienced physician should be thinking is, if the complaint seems
25:10
to be the elbow, I need to examine the wrist and I need to examine the shoulder.
25:16
And unless that is done, then you get into these traps with anchoring.
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And the other bias there is search-satisficing, where when you approach the patient, as we
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said earlier, you're trying to distinguish the signal from the noise.
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And sometimes when you think you've found the signal, you satisfy yourself too quickly.
25:39
Search-satisficing is a bias that seems to be passed down genetically.
25:44
If you think of our ancient ancestors, cavemen ancestors, you know, when the light was going
25:51
down, say, on a day, there were a couple of things that they had to satisfy themselves
25:56
about.
25:57
That they would have shelter for the night and that it would be safe.
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And Herbert Simon, who won a Nobel Prize in this area, decision-making, talks about this
26:07
bias of search-satisficing, which means as soon as you think you've got a good shelter
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and as soon as you think it's safe and as soon as you've protected your wife or partner
26:18
and children, then you can satisfy yourself that you've, you know, you've accomplished
26:25
what needs to be done.
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In this case, if you translate it into medicine, what search-satisficing does sometimes is
26:32
it pushes you into an early kind of stopping point.
26:39
The psychologists talk about this a lot, that when we're going through these sort of how
26:43
do people make decisions and the decision trees that are built around decisions, each
26:50
of these little branches is a potential stopping point.
26:54
And you have to be careful that you don't settle for a stopping point too soon.
27:00
So this attending physician, in your daughter's case, settled on the elbow too quickly because
27:06
a nursemaid's elbow is a common condition in children when they're playing and wrestling
27:12
and being thrown around.
27:14
So settled on this very quickly.
27:17
So that was search-satisficing, anchoring in the first place, then search-satisficing
27:23
and then kind of protecting themselves with an x-ray of the elbow, which clearly isn't
27:28
going to show the buckle fracture of the wrist.
27:31
So that's the way we sort of go at it.
27:33
However good you think your decision-making is, you really do have to follow some general
27:39
rules.
27:40
And one of them is watch out for anchoring, watch out for search-satisficing, follow the
27:46
clinical rules of every discipline in medicine has its own little collection of rules and
27:53
sort of red flags.
27:55
And for children, the one I mentioned, the red flag here, be careful of this, examine
28:00
the joint above and below.
28:02
Make sure you've covered it at the two extremes and then you're welcome to focus in on where
28:08
you think the problem is.
28:09
But make sure you cover yourselves because you can be deceived by your own primitive
28:16
decisions from hundreds of thousands of years ago, search-satisficing and anchoring, probably
28:22
two big ones.
28:23
And then there's some more subtle biases probably in play here.
28:28
Probably attending is in a teaching role and probably is less humble than he might otherwise
28:33
be if he was practicing by himself.
28:36
And then starts to bring in some of this additional noise, like this is a physician's child and
28:42
they add in that bit of noise that they tend to be over-concerned about their children
28:49
and complain too readily.
28:51
That is putting a label on the parent, which is fairly common.
28:56
They see it a lot, but you do at the same time have to trust the parent's intuition.
29:02
Sometimes they get it completely wrong.
29:05
Not that long ago, had a young girl came in who was playing basketball and she got an
29:10
elbow alongside her head, got an elbow against her head.
29:14
And so mother brought her in to emergency and said, I'd like to get my daughter checked
29:19
out.
29:20
She suffered a head injury in basketball and I'm really concerned about her.
29:25
I examined the child.
29:26
She seemed to be perfectly well.
29:28
I couldn't find anything.
29:29
I did as much of a neurological exam as you can do on a young girl.
29:33
I thought, well, it's a contusion.
29:36
And the mother said, well, how do we know she hasn't got a brain injury?
29:41
And in the back of my mind is this other mantra about always listen to the patient.
29:47
And I said, well, I accept your concerns, but I really don't find anything to support
29:51
that.
29:52
And she said, well, why can't we get a CAT scan to prove it, to prove that she doesn't
29:56
have a brain injury?
29:58
And I said, well, we could.
29:59
There's no reason why we can't other than this is an awful lot of radiation to the brain
30:05
of a 14 year old girl.
30:08
And the mother said, but isn't a brain injury more important?
30:11
All I'm getting at here is that the parent has a justifiable concern and wants to rule
30:17
out worst case scenario.
30:20
And the physician in this case is trying to back the parent away from it and say, you
30:25
know, you have to take these other things into account.
30:28
So those are the biases.
30:30
I would say most of them.
30:32
There may be more there.
30:34
We found in our study, we looked at about 30 cases in emergency medicine in a lot of
30:39
detail.
30:40
And we found that whenever we had one of these cases that was noticeable enough that it warranted
30:47
a close examination, that these cognitive biases often occurred together in clumps.
30:53
And that typically we found about half a dozen of them in any particular case.
30:59
So in your daughter's case, I'd say if you gave me a bit of time and a bit more information,
31:04
I could probably come up with a couple more.
31:06
But I'd say the big ones are anchoring, search, satisfying, maybe some sort of hubris bias
31:13
where the clinician has to demonstrate his, you know, where he is on the authoritarian
31:20
scale, the ladder for the medical student, and so on.
31:24
Probably about four or five biases there.
31:26
Yeah.
31:27
And I think also one more I'm thinking of, as you were talking, which is confirmation
31:30
bias.
31:31
You know, of course, the elbow x-ray just confirms your suspicion that a nursemaid's
31:35
elbow is a normal elbow x-ray.
31:38
So that's confirmation bias.
31:39
So I want to ask you a little bit.
31:41
You've written about and thought about, especially in the fast world of emergency medicine, but
31:46
actually in the current environment in medicine in so many fields, there's this issue between
31:52
the way we think, this intuitive fast thinking that you've written about and spoken about
31:57
versus the slower analytical thinking.
31:59
And what I'd like to do with the time remaining in our conversation is starting there, think
32:05
about how cognition, these different ways that we think contribute to wellbeing in general,
32:12
professional wellbeing I'm talking about.
32:14
And maybe you can help create a connection or think about a connection between the wellbeing
32:19
of the professional and how we think and these cognitive biases and awareness of that in
32:26
our work.
32:27
I think that's a very interesting corollary of this whole area is that first of all, you
32:34
know, we're talking about something for physicians that is not traditional.
32:39
I mean, if you go through the medical training that I had, nobody mentioned, I don't think
32:46
anybody actually mentioned the importance of clinical decision making, that it had to
32:51
be taught as a science.
32:54
The general rule, the general approach, I think, was that people would say, what you
32:59
do is you go into the environment and you will pick this up by osmosis or something
33:06
else, but you'll pick it up in a very implicit way, not explicit.
33:11
So if we put you into a pediatrics residency programme, you start spending time with paediatricians
33:19
and you learn implicitly of ways in which you connect.
33:25
I mean, what are acceptable?
33:27
We don't just learn the content of pediatrics, but we learn how to behave, how to make decisions,
33:33
how to behave professionally, I think is extremely important.
33:37
So that's one major problem that medicine has is we haven't really focused on the decision.
33:43
I mean, there are one or two schools now in the States and in Canada that do do this.
33:48
They explicitly address clinical decision making.
33:52
Harvard does it, people in Cleveland, in Pittsburgh and a couple of other places.
33:57
So but when you think about that, that's sort of remarkable that medicine would have got
34:01
this far before actually thinking about how they make decisions.
34:06
That itself is a major issue.
34:08
But the second issue, trying to focus more onto your point about how physicians can think
34:16
about themselves and their well-being in that environment is that once you start to study
34:23
medical decision making, one of the first things you discover is that it is highly influenced
34:30
by the environment in which the decision is made.
34:33
We used to, I think medical people used to think they thought they were more robust than
34:39
they were, that you could, for example, in my environment, you could take an emergency
34:44
department and you could put 40 people in the waiting room and harassed and harried
34:51
nurses running around and the chief nurse coming up to you and saying, things are really
34:55
ugly out there.
34:57
Can we move somebody?
34:58
Can we create some space and get some flow going, stuff like that?
35:02
And so there is a relationship between the workload and also the cognitive load and how
35:10
well people perform.
35:12
And what we find is that most of these things are an inverted view function.
35:17
If you start to increase the amount of pressure people are under, they tend to perform better
35:23
and better and better and then they reach a sort of plateau.
35:27
And this is the same for cognitive load.
35:29
It's the same for stress.
35:31
It's the same for a few other variables.
35:34
They reach a plateau.
35:36
If you keep applying the pressure, then they start to decline, their performance starts
35:42
to go down.
35:43
So you have to think very much about the environment in which people are working.
35:48
And physicians themselves need to think about this.
35:51
They need to think, what is the environment doing to me right now?
35:56
There's some very interesting recent work just emerged on this called decision fatigue.
36:03
And it used to be thought, like not that long ago, maybe about 10 or 15 years ago, it was
36:09
thought that what happens with decision fatigue is that there is a gradual depletion of some
36:18
essential nutrients or like glucose or something else in that part of the brain that is responsible
36:26
for decision-making, which is mostly the prefrontal cortex.
36:31
And so these arguments were circulating that maybe people were running out of glucose at
36:37
a cellular level or they were running out of something else.
36:41
And that's why if you study a number of these scenarios of decision fatigue, you find that
36:48
at the start of the day, people perform quite well.
36:52
Probably their optimum performance is pretty good at eight or nine o'clock in the morning.
36:58
And as you approach noon, the quality of decision-making goes down.
37:03
And then if there is some sort of nutritional break at noon, it seems to be rejuvenated
37:10
and then it will decline further through the afternoon.
37:12
You can show this, a dozen studies show this for your willingness to give vaccines for
37:20
you to do breast exams, for you to decline giving drugs to opioid dependent people and
37:27
so on.
37:28
A whole range of studies show this decision fatigue.
37:31
And so people should be aware of that.
37:33
And the impact it's having on them.
37:35
And it turns out just recently, like within the last two years, a great study was published
37:41
showing that this decision fatigue doesn't seem to be the depletion of some essential
37:48
nutrient.
37:49
It seems to be instead the accumulation of some metabolite in the extracellular space
37:55
in the prefrontal cortex.
37:58
And it turns out that they were exactly on the money, some stuff called glutamate, which
38:04
you've probably heard of is one of the main major excite A3 neurotransmitters in the brain.
38:10
And they showed through some very sophisticated imaging techniques that glutamate starts to
38:16
build up in the extracellular fluid space and interferes with your ability to make a
38:22
decision.
38:23
Now, this is proof at a cellular level.
38:27
So we can tell, in fact, I'm giving a talk this week to medical students, and I'll bring
38:32
up this whole glutamate theory and say, look, you have to think about what the environment
38:39
is doing to you and the quality of decisions you can make.
38:43
And you can say similar phenomenon applies to increase the workload, increase the amount
38:50
of stress, deprive people of nutritional breaks or threats, any kind of threat to their homeostatic
38:57
state, especially loss of sleep.
39:01
All of these things add up to the environment and the well-being of the people who function
39:07
in it.
39:08
You know, the old adage was physician, take care of myself first, and it still holds,
39:15
you know, and I know that some of the work that you've been doing is more sophisticated
39:20
than that.
39:21
But the stuff that we've looked at is fairly crude and blunt, you know, too much work,
39:27
too much sleep, too much fatigue, and all of these things translate into a compromised
39:34
clinical performance.
39:35
Well, I'm really glad you mentioned the environment because that actually is very consistent with
39:44
most people's thinking about what are the drivers of physician well-being and health
39:48
professional well-being.
39:49
And it's really this culture of medicine, as you talked about, the systems within medicine,
39:55
and that there is a role for explicitly addressing this versus assuming the implicit cultures
40:02
and subcultures within medicine is going to take care of this.
40:06
I think a whole other domain, you've written about the electronic health record as a possible
40:12
using it as a way of addressing diagnostic errors, and clearly it seems really clear
40:16
to me and maybe not so clear to everyone, but if you're starting to use functions within
40:22
the AI domain and machine learning domain, this can maybe, I'm thinking in terms of what
40:27
you just shared, take away some of the drivers that are causing that buildup of the glutamate,
40:33
in some ways relieving some of the cognitive load that we have so that we can continue
40:38
to perform at the level that we like to perform.
40:42
I'm wondering if you could just comment on the culture of medicine and what medical systems,
40:46
educational and otherwise, can do to help make the discussion of errors and failures
40:51
more commonplace, more normal.
40:53
In fact, a vital part of the discourse among medical professionals, you've written and
40:56
spoken about how departments, different areas in medicine discuss morbidity and mortality
41:03
and what they focus on.
41:04
And I think these are really kind of places that we can have real practical interventions
41:10
that we don't have to wait for the glacial pace of medical culture to change, but can
41:14
happen now even within our settings to help.
41:17
Yeah, I think there's some very interesting features about the medical culture that don't
41:23
serve as well.
41:25
As I said earlier, when I was a psychologist, if you got into any kind of difficulty, often
41:33
the first thing you did was to share it with your supervisor or share it with a colleague
41:38
or disperse the sort of cognitive load in some way.
41:44
So you share it.
41:46
And when I got into medicine, I noticeably missed that.
41:50
There suddenly was this pressure on the individual to perform and perform to some extent in isolation
41:58
without sharing the cognitive load.
42:01
And I don't mean I've got a lot on my plate here.
42:04
Can you help me out?
42:05
I mean, just sharing the actual cognition.
42:09
People don't seem to be very good at that.
42:11
And that is an untapped resource, I think, in medicine.
42:15
I'm working on a book with another guy in the UK right now, Mike Clancy.
42:20
And we've been trying to identify some of these practices that could be changed in medicine
42:26
that might lead to improved well-being of the individual physician, but importantly
42:32
to improve performance.
42:35
So sharing, distributing the cognition.
42:38
The idea is already there in the literature and it can be exploited.
42:42
We need to accept that somebody else's thinking is often a good component of your thinking.
42:49
And that isn't shifting the responsibility or trying to diminish the amount of work that
42:55
you're doing, but simply bringing in the help from outside.
43:01
That was one issue.
43:02
Another one that comes to mind when you were talking about this was medicine is a hugely
43:07
balkanized business.
43:09
I mean, it's split up into all these little factions, both within disciplines and between
43:16
disciplines.
43:17
So you have intra and interdisciplinary issues.
43:22
And you have all these sort of built-in authority gradients and so on that interfere with people
43:29
being willing to express their thoughts.
43:32
And like in this case, the medical student, your case, the medical student may well have
43:37
had some ideas about what else might be going on, but was not willing to share them because
43:42
of the dominance of the authoritarian figure and so on.
43:47
So those are a couple, distributed cognition, trying to tap into the authority gradients.
43:53
I think the other thing too is although it has been admirable in some respects in medicine,
44:00
there has been a sort of, we have had a kind of heroic kind of, I don't know what you would
44:08
call it, but some sort of, I'm reminded of a physician who they were talking about their
44:13
careers and how well they'd spent their careers.
44:18
And a physician, Gravestone, they mentioned where it said he cared everything for his
44:23
patients.
44:25
And there was nothing there about, but he completely disregarded his family in the process.
44:31
But I think I see less of it now, I think, as I get older.
44:36
There was this kind of heroic component to physician performance that I must keep going,
44:42
even though I'm beginning to act a bit stupid, you know.
44:46
But when I was an intern, we did 36-hour rotation.
44:50
I mean, that is heroic, but it's stupid.
44:52
It's absolutely stupid.
44:54
And there were times, told my son, who's just gone into medicine, told him once about a
44:59
situation where I was running an arrest and I fell asleep.
45:03
I mean, I just had not had any sleep for about 36 hours.
45:07
I was going through a routine, you know, do this, then do this, then do this.
45:11
I did the critical things.
45:12
I got the patient intubated and then we got some lines started and so on.
45:16
And everybody knew what the routine was.
45:18
But I just fell asleep and fell across the patient's legs.
45:21
I mean, that is so stupid, and yet that was going on everywhere.
45:26
And I'm sure a lot of that has changed.
45:29
But that is something else about, I mean, if you add up all of these insults to physician
45:35
homeostasis that go on, not taking reasonable nutrition breaks, not taking work breaks,
45:43
not getting enough sleep, working at high pressures and so on.
45:48
If you add enough of them up and the effects that they have on the physician, then eventually
45:54
you can be looking at burnout.
45:56
And burnout is very real.
45:58
I've seen a couple of colleagues go through it and it was too close for comfort.
46:03
But these were very hardworking, sacrificial people who did everything they could for medicine
46:09
and did nothing for themselves.
46:11
And it's all very heroic.
46:13
But once it happens, you've actually lost somebody in the process.
46:17
So...
46:18
Well, I really appreciate you discussing all these parts.
46:23
This is a really a nice way to segue toward a close.
46:26
You started off telling us about the sea surgeon or the sea, whatever it was called in Kent
46:32
in the southeast of England along the coast there and how that heroism in a sense drew
46:40
you in and then realizing that it's quite a bit more complex than that.
46:44
And one can actually lose the important qualities of our life in the process of giving so much
46:52
in a sense in that way.
46:54
And I think I wanted to kind of close in two ways.
46:58
One, as I'm thinking about what we've discussed with cognition, I'm thinking about our genus
47:04
and species.
47:05
You know, we've given ourselves the name Homo sapiens sapiens.
47:09
We've given ourselves two doses of our species.
47:11
And my understanding of the roots of that has to do with awareness or thinking.
47:18
We are the species of the genus Homo that knows through our senses, through our cognition,
47:25
through our awareness.
47:26
And why do we give ourselves that second sapiens name?
47:29
Because we know that we know.
47:30
So built in, we know that we think.
47:33
We think about thinking unlike what we assume other species do or don't do.
47:39
So we can actually think about what it would be like to have a life that is of service,
47:47
but also at the same time takes care of ourselves so that we can be of service to ourselves
47:52
and to others and to our families.
47:53
So I did want you to reflect on that piece and also share with us, what do you do for
47:59
enjoyment and fun?
48:00
You shared with us before we started the podcast about being out and hiking, et cetera.
48:05
But fun is being connected in some way with actually keeping yourself and keeping us all
48:10
healthy enough to mitigate those cognitive biases, distortions and errors.
48:15
So there you go.
48:16
We'll finish with that.
48:18
It's an open field for those reflections.
48:21
Well, my wife is a little bit critical of me there and says that I still have remnants
48:28
of this, you know, I've got to work hard stuff.
48:32
And she's right.
48:33
I don't take, I'm still working on another book, which is my fifth, fourth or fifth.
48:41
And I think she's kind of gently pointing out that I'm getting a bit old for this and
48:46
maybe I ought to spend a bit more time.
48:48
So I deliberately now seek out things that fall into that sort of wellbeing domain.
48:56
What can I do to sort of make myself less of a hero and less of a slave and more of
49:04
a, I mean, I don't have any family around anymore.
49:07
They've all left except my good wife.
49:10
And but so I deliberately try to cultivate interesting things that might interest her
49:17
that we could share together and I could do for myself.
49:21
I think it requires a bit of effort after you've had, after you step out of the race
49:28
that you've been in for about 40 years and you suddenly say, now I'm on my own and what
49:34
can I do to sort of improve my reflection and my sense of perspective on what I've done?
49:44
And I think it's part of somebody should write a good book.
49:47
They probably have about how to grow old properly.
49:54
I'm sure I'm not doing it right, but there's probably somebody out there and they've probably
49:59
done that.
50:00
It's just, I haven't found the time to look through the books yet, but they're probably
50:04
out there.
50:05
I think you're absolutely right.
50:06
We do need to engage that sort of post-physician phase where we're saying, okay, now what?
50:15
I don't really want people to put on my gravestone that I really took care of my patients.
50:20
I'd prefer they mentioned my family to somewhere in there.
50:23
Lovely.
50:24
Well, thank you.
50:25
This has been just completely enjoyable.
50:28
Thank you so much for listening.
50:30
We will include a summary of today's podcast and links about Dr. Croskerry and other
50:35
references discussed in the show notes.
50:38
I'd like to conclude by sharing another practical exercise to help you flourish.
50:43
Because of the work that Dr. Croskerry does in thinking about how we think, today's home
50:49
practice relates directly to that.
50:51
I'd like you to just sit as you're listening to this, however you're sitting or standing,
50:57
and just settling into an awareness of your body.
51:00
One way to do that is to just bring awareness to the breathing, the sensations of breathing.
51:05
As you do that, perhaps becoming also aware of how you're feeling, feeling in terms of
51:13
feeling okay, or this is uncomfortable, or I like this moment, or I don't like this moment.
51:20
It doesn't really matter.
51:22
Just noticing how you are actually feeling and relating to this moment emotionally.
51:31
And then you may notice with a pause, which I'll give you a five to 10 second pause here,
51:37
that there will be some thoughts, perfectly natural.
51:42
Perhaps noticing, if you can, these thoughts as simply events, things that are happening
51:53
that your mind is doing.
51:55
You don't have to believe or agree or disagree with the thoughts, simply noticing them.
52:07
One option is to just say to yourself, oh, thinking, thinking.
52:12
I'm thinking.
52:18
And that's the practice.
52:19
That's it.
52:20
You can do this from time to time to bring awareness to the thinking mind, doing what
52:25
it always does, thinks.
52:29
No need to change it, no need to direct it, no need to feel bad about it or good about
52:34
it, just awareness to it.
52:37
Simply practice the awareness of thoughts.
52:39
And perhaps as you do this, as it becomes part of your regular activities, you may begin
52:45
to link how one thought leads to another and eventually to deconstruct how a decision is
52:51
made.
52:52
Eventually, we can trace where these cognitions help and where they may derail our decision
52:59
making process.
53:01
I hope you found this podcast and this very simple exercise useful to you and look forward
53:06
to having you join us for the next episode of flourishing in medicine from surviving
53:11
to thriving.
53:13
For more about EmPRO, please visit www.myEmpro.com or www.myEmpro.com forward slash peer dash
53:24
support or a variety of their peer support programs.
53:28
If you are in need of urgent support as a physician or medical student, please consider
53:34
calling the physician support line at 1-888-409-0141 or visiting www.physiciansupportline.com.
53:48
And for more information about me and my work, please visit www.MickKrasnermd.com or www.MindfulPracticinMedicine.com.
54:01
I hope to have you listen to our next episode.
54:05
Until then.