A few years ago,
I broke into my own house.
00:13
I had just driven home,
00:16
it was around midnight
in the dead of Montreal winter,
00:18
I had been visiting my friend,
Jeff, across town,
00:20
and the thermometer on the front porch
read minus 40 degrees --
00:23
and don't bother asking
if that's Celsius or Fahrenheit,
00:27
minus 40 is where the two scales meet --
00:30
And as I stood on the front porch
fumbling in my pockets,
00:34
I found I didn't have my keys.
00:37
In fact, I could see them
through the window,
00:40
lying on the dining room table
where I had left them.
00:42
So I quickly ran around
and tried all the other doors and windows,
00:45
and they were locked tight.
00:48
I thought about calling a locksmith --
at least I had my cellphone,
00:50
but at midnight, it could take a while
for a locksmith to show up,
00:53
I couldn't go back to my friend
Jeff's house for the night
01:00
because I had an early flight
to Europe the next morning,
01:03
and I needed to get
my passport and my suitcase.
01:05
So, desperate and freezing cold,
01:08
I found a large rock and I broke
through the basement window,
01:10
cleared out the shards of glass,
01:14
I found a piece of cardboard
and taped it up over the opening,
01:17
figuring that in the morning,
on the way to the airport,
01:21
I could call my contractor
and ask him to fix it.
01:24
This was going to be expensive,
01:26
but probably no more expensive
than a middle-of-the-night locksmith,
01:28
so I figured, under the circumstances,
I was coming out even.
01:31
Now, I'm a neuroscientist by training
01:36
and I know a little bit
about how the brain performs under stress.
01:39
It releases cortisol
that raises your heart rate,
01:43
it modulates adrenaline levels
01:46
and it clouds your thinking.
01:49
So the next morning,
01:51
when I woke up on too little sleep,
01:53
worrying about the hole in the window,
01:55
and a mental note
that I had to call my contractor,
01:58
and the freezing temperatures,
02:01
and the meetings I had upcoming in Europe,
02:02
and, you know, with all
the cortisol in my brain,
02:05
my thinking was cloudy,
02:08
but I didn't know it was cloudy
because my thinking was cloudy.
02:10
And it wasn't until I got
to the airport check-in counter,
02:15
that I realized I didn't have my passport.
02:18
So I raced home in the snow
and ice, 40 minutes,
02:22
got my passport,
raced back to the airport,
02:26
I made it just in time,
02:28
but they had given away
my seat to someone else,
02:30
so I got stuck in the back of the plane,
next to the bathrooms,
02:32
in a seat that wouldn't recline,
on an eight-hour flight.
02:35
Well, I had a lot of time to think
during those eight hours and no sleep.
02:39
And I started wondering,
are there things that I can do,
02:44
systems that I can put into place,
02:47
that will prevent bad things
from happening?
02:49
Or at least if bad things happen,
02:51
will minimize the likelihood
of it being a total catastrophe.
02:53
So I started thinking about that,
02:59
but my thoughts didn't crystallize
until about a month later.
03:00
I was having dinner with my colleague,
Danny Kahneman, the Nobel Prize winner,
03:03
and I somewhat embarrassedly told him
about having broken my window,
03:07
and, you know, forgotten my passport,
03:10
and Danny shared with me
03:13
that he'd been practicing
something called prospective hindsight.
03:14
It's something that he had gotten
from the psychologist Gary Klein,
03:20
who had written about it
a few years before,
03:24
also called the pre-mortem.
03:26
Now, you all know what the postmortem is.
03:28
Whenever there's a disaster,
03:30
a team of experts come in and they try
to figure out what went wrong, right?
03:31
Well, in the pre-mortem, Danny explained,
03:36
you look ahead and you try to figure out
all the things that could go wrong,
03:38
and then you try to figure out
what you can do
03:42
to prevent those things from happening,
or to minimize the damage.
03:45
So what I want to talk to you about today
03:48
are some of the things we can do
in the form of a pre-mortem.
03:51
Some of them are obvious,
some of them are not so obvious.
03:55
I'll start with the obvious ones.
03:58
Around the home, designate a place
for things that are easily lost.
03:59
Now, this sounds
like common sense, and it is,
04:05
but there's a lot of science
to back this up,
04:09
based on the way our spatial memory works.
04:12
There's a structure in the brain
called the hippocampus,
04:15
that evolved over tens
of thousands of years,
04:18
to keep track of the locations
of important things --
04:21
where the well is,
where fish can be found,
04:25
that stand of fruit trees,
04:27
where the friendly and enemy tribes live.
04:30
The hippocampus is the part of the brain
04:32
that in London taxicab drivers
becomes enlarged.
04:34
It's the part of the brain
that allows squirrels to find their nuts.
04:38
And if you're wondering,
somebody actually did the experiment
04:41
where they cut off
the olfactory sense of the squirrels,
04:44
and they could still find their nuts.
04:47
They weren't using smell,
they were using the hippocampus,
04:49
this exquisitely evolved mechanism
in the brain for finding things.
04:52
But it's really good for things
that don't move around much,
04:57
not so good for things that move around.
05:01
So this is why we lose car keys
and reading glasses and passports.
05:03
So in the home,
designate a spot for your keys --
05:07
a hook by the door,
maybe a decorative bowl.
05:10
For your passport, a particular drawer.
05:13
For your reading glasses,
a particular table.
05:15
If you designate a spot
and you're scrupulous about it,
05:18
your things will always be there
when you look for them.
05:21
Take a cell phone picture
of your credit cards,
05:25
your driver's license, your passport,
05:28
mail it to yourself so it's in the cloud.
05:30
If these things are lost or stolen,
you can facilitate replacement.
05:32
Now these are some rather obvious things.
05:37
Remember, when you're under stress,
the brain releases cortisol.
05:39
Cortisol is toxic,
and it causes cloudy thinking.
05:43
So part of the practice of the pre-mortem
05:46
is to recognize that under stress
you're not going to be at your best,
05:49
and you should put systems in place.
05:53
And there's perhaps
no more stressful a situation
05:55
than when you're confronted
with a medical decision to make.
05:58
And at some point, all of us
are going to be in that position,
06:02
where we have to make
a very important decision
06:05
about the future of our medical care
or that of a loved one,
06:07
to help them with a decision.
06:11
And so I want to talk about that.
06:12
And I'm going to talk about
a very particular medical condition.
06:14
But this stands as a proxy for all kinds
of medical decision-making,
06:17
and indeed for financial decision-making,
and social decision-making --
06:21
any kind of decision you have to make
06:25
that would benefit from a rational
assessment of the facts.
06:27
So suppose you go to your doctor
and the doctor says,
06:31
"I just got your lab work back,
your cholesterol's a little high."
06:34
Now, you all know that high cholesterol
06:39
is associated with an increased risk
of cardiovascular disease,
06:42
heart attack, stroke.
06:46
And so you're thinking
06:47
having high cholesterol
isn't the best thing,
06:49
and so the doctor says,
"You know, I'd like to give you a drug
06:51
that will help you
lower your cholesterol, a statin."
06:54
And you've probably heard of statins,
06:57
you know that they're among
the most widely prescribed drugs
06:59
in the world today,
07:01
you probably even know
people who take them.
07:03
And so you're thinking,
"Yeah! Give me the statin."
07:05
But there's a question
you should ask at this point,
07:07
a statistic you should ask for
07:10
that most doctors
don't like talking about,
07:11
and pharmaceutical companies
like talking about even less.
07:14
It's for the number needed to treat.
07:18
Now, what is this, the NNT?
07:21
It's the number of people
that need to take a drug
07:23
or undergo a surgery
or any medical procedure
07:26
before one person is helped.
07:29
And you're thinking,
what kind of crazy statistic is that?
07:31
The number should be one.
07:34
My doctor wouldn't prescribe
something to me
07:35
if it's not going to help.
07:37
But actually, medical practice
doesn't work that way.
07:39
And it's not the doctor's fault,
07:41
if it's anybody's fault,
it's the fault of scientists like me.
07:43
We haven't figured out
the underlying mechanisms well enough.
07:46
But GlaxoSmithKline estimates
07:48
that 90 percent of the drugs work
in only 30 to 50 percent of the people.
07:51
So the number needed to treat
for the most widely prescribed statin,
07:56
what do you suppose it is?
08:00
How many people have to take it
before one person is helped?
08:02
This is according to research
08:07
by research practitioners
Jerome Groopman and Pamela Hartzband,
08:08
independently confirmed by Bloomberg.com.
08:12
I ran through the numbers myself.
08:14
300 people have to
take the drug for a year
08:17
before one heart attack, stroke
or other adverse event is prevented.
08:20
Now you're probably thinking,
08:24
"Well, OK, one in 300 chance
of lowering my cholesterol.
08:25
Why not, doc? Give me
the prescription anyway."
08:28
But you should ask at this point
for another statistic,
08:30
and that is, "Tell me
about the side effects." Right?
08:33
So for this particular drug,
08:36
the side effects occur
in five percent of the patients.
08:37
And they include terrible things --
08:41
debilitating muscle and joint pain,
gastrointestinal distress --
08:43
but now you're thinking, "Five percent,
08:47
not very likely
it's going to happen to me,
08:49
I'll still take the drug."
08:51
Remember under stress
you're not thinking clearly.
08:54
So think about how you're going
to work through this ahead of time,
08:56
so you don't have to manufacture
the chain of reasoning on the spot.
08:59
300 people take the drug, right?
One person's helped,
09:02
five percent of those 300
have side effects,
09:05
You're 15 times more likely
to be harmed by the drug
09:09
than you are to be helped by the drug.
09:13
Now, I'm not saying whether you
should take the statin or not.
09:16
I'm just saying you should have
this conversation with your doctor.
09:19
Medical ethics requires it,
09:22
it's part of the principle
of informed consent.
09:24
You have the right to have access
to this kind of information
09:26
to begin the conversation about whether
you want to take the risks or not.
09:29
Now you might be thinking
09:33
I've pulled this number
out of the air for shock value,
09:34
but in fact it's rather typical,
this number needed to treat.
09:37
For the most widely performed surgery
on men over the age of 50,
09:40
removal of the prostate for cancer,
09:45
the number needed to treat is 49.
09:47
That's right, 49 surgeries are done
for every one person who's helped.
09:50
And the side effects in that case
occur in 50 percent of the patients.
09:54
They include impotence,
erectile dysfunction,
09:59
urinary incontinence, rectal tearing,
10:01
fecal incontinence.
10:04
And if you're lucky, and you're one
of the 50 percent who has these,
10:06
they'll only last for a year or two.
10:09
So the idea of the pre-mortem
is to think ahead of time
10:12
to the questions
that you might be able to ask
10:16
that will push the conversation forward.
10:19
You don't want to have to manufacture
all of this on the spot.
10:21
And you also want to think
about things like quality of life.
10:24
Because you have a choice oftentimes,
10:27
do you I want a shorter life
that's pain-free,
10:29
or a longer life that might have
a great deal of pain towards the end?
10:31
These are things to talk about
and think about now,
10:35
with your family and your loved ones.
10:37
You might change your mind
in the heat of the moment,
10:39
but at least you're practiced
with this kind of thinking.
10:42
Remember, our brain under stress
releases cortisol,
10:45
and one of the things
that happens at that moment
10:49
is a whole bunch on systems shut down.
10:52
There's an evolutionary reason for this.
10:54
Face-to-face with a predator,
you don't need your digestive system,
10:56
or your libido, or your immune system,
10:59
because if you're body is expending
metabolism on those things
11:02
and you don't react quickly,
11:05
you might become the lion's lunch,
and then none of those things matter.
11:07
one of the things that goes out the window
during those times of stress
11:12
is rational, logical thinking,
11:16
as Danny Kahneman
and his colleagues have shown.
11:18
So we need to train ourselves
to think ahead
11:22
to these kinds of situations.
11:25
I think the important point here
is recognizing that all of us are flawed.
11:27
We all are going to fail now and then.
11:33
The idea is to think ahead
to what those failures might be,
11:36
to put systems in place
that will help minimize the damage,
11:40
or to prevent the bad things
from happening in the first place.
11:44
Getting back to that
snowy night in Montreal,
11:48
when I got back from my trip,
11:50
I had my contractor install
a combination lock next to the door,
11:52
with a key to the front door in it,
an easy to remember combination.
11:56
And I have to admit,
12:00
I still have piles of mail
that haven't been sorted,
12:01
and piles of emails
that I haven't gone through.
12:04
So I'm not completely organized,
12:07
but I see organization
as a gradual process,
12:09
and I'm getting there.
12:12
Thank you very much.
12:13