Key Concepts
- Prospective Hindsight/Pre-mortem: A strategy to anticipate potential failures and mitigate their impact.
- Hippocampus: Brain structure responsible for spatial memory and remembering locations of things.
- Cortisol: Stress hormone that impairs cognitive function and rational thinking.
- Number Needed to Treat (NNT): The number of patients who need to undergo a treatment for one patient to benefit.
- Informed Consent: The ethical principle requiring patients to be fully informed about the risks and benefits of medical procedures.
Obvious Pre-Mortem Steps: Preventing Everyday Failures
The speaker begins by recounting a personal anecdote about breaking into his own house after locking himself out, highlighting the impact of stress on cognitive function. This leads to the introduction of the "pre-mortem" concept, learned from Danny Kahneman, as a method to anticipate and prevent failures.
The first set of pre-mortem steps focuses on preventing everyday failures, particularly losing important items. The speaker emphasizes the importance of designating specific locations for frequently misplaced items like keys, passports, and reading glasses. This strategy leverages the brain's spatial memory, which is primarily managed by the hippocampus. The hippocampus is highly effective at remembering the locations of stationary objects. He mentions research on London taxi drivers and squirrels to illustrate the hippocampus's role in spatial memory. For travel, he suggests taking cell phone pictures of important documents like credit cards, driver's licenses, and passports and emailing them for cloud storage, facilitating replacement if lost or stolen.
The core idea is that under stress, the brain releases cortisol, impairing cognitive function. Therefore, establishing systems and habits beforehand can compensate for reduced cognitive abilities during stressful situations.
Medical Decisions: Applying the Pre-Mortem Framework
The speaker then transitions to applying the pre-mortem framework to medical decision-making, using the example of a doctor prescribing a statin for high cholesterol. He emphasizes the importance of asking for the "number needed to treat" (NNT), which is the number of people who need to take a drug or undergo a procedure for one person to benefit. He cites research indicating that the NNT for the most widely prescribed statin is 300, meaning 300 people must take the drug for a year to prevent one adverse event (heart attack, stroke, etc.). He references research by Jerome Groopman and Pamela Hartzband, and Bloomberg.com, to support this claim.
He further advises inquiring about potential side effects. For the statin example, he states that side effects occur in 5% of patients. He then presents a calculation: if 300 people take the drug, one person benefits, but 15 people (5% of 300) experience side effects. This makes an individual 15 times more likely to be harmed than helped by the drug.
The speaker clarifies that he is not advocating against statins but rather emphasizing the importance of informed consent and having a rational conversation with a doctor about the risks and benefits. He extends this concept to other medical procedures, citing the example of prostate removal for cancer, where the NNT is 49, and side effects occur in 50% of patients, including impotence and incontinence.
The key takeaway is to proactively gather information and consider potential outcomes before making medical decisions, rather than relying solely on a doctor's recommendation in a stressful situation. He also suggests discussing quality-of-life preferences with family and loved ones in advance.
Conclusion
The speaker concludes by reiterating that everyone is prone to failure and that the pre-mortem is a valuable tool for minimizing damage and preventing negative outcomes. He shares that after his travel mishap, he installed a combination lockbox with a spare key. He acknowledges that he is not perfectly organized but views organization as a gradual process. The core message is to acknowledge human fallibility and proactively implement systems to mitigate potential failures.
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