Medicine and surgery require complex problem solving and tough decisions are made every single day. A mindful or thoughtful approach to decision making is one framework by which we can simply our day and decision-making process. In Part 1 of this three part, solo, mini-series, concepts of decision fatigue, what makes a great surgeon, and kindness are discussed. References and reading: Peak Performance, Attending: Medicine, Mindfulness, and Humanity. Music Credit: Sunshine, Simon Jomphe Lepine.
My name is Phil Pierorazio and I'm a urologic oncologist, a surgeon. Like many of you, I absolutely love what I do, and I would not choose another profession. But I've struggled professional identity practice efficiency and wellness over the years. operate with Zen is a podcast designed to explore a mindful approach to surgery and to being a surgeon. By discussing these struggles and mindful solutions, I hope together we can create a community of strong and healthy surgeons enjoy. Welcome back to Season Two of operate with ZEN. First, I'd like to thank everyone who listened and tuned in for making season one a tremendous success. Secondly, your feedback is greatly appreciated. We're going to aim for less monologues this season shorter monologues, we're going to focus on interviews, discussions and personal stories with our guests. That being said, we will have some focused discussions this season, we're going to focus on effective decision making or medical decision making. We're going to do that in three parts. And the first part will be on a mindful approach to decision making. So to set the stage we all know that medicine pulls us in many directions, particularly cognitively. We diffuse brain power, we have to make a lot of decisions throughout a day. Some of those decisions and some of that use of brain power is desirable and some was not. And we introduced concepts of decision fatigue in season one, where we know the more choices that we're forced to make, the more the quality of our decision deteriorates. We give examples of judges who grant parole more commonly at the beginning of the day at the end, we talked about prescribing errors that happen more commonly at the end of the day. And there's even an orthopedic study that showed that surgeons in Sweden were less likely to offer elective surgeries as the day in clinic progressed. Interestingly, right after lunch when surgeons were well rested and well fed, the there was a slight uptick in the proportion of surgeries offered to patients. But there still was a well documented decision fatigue as the day went on. Now, Thomas Merton, who was an American monk and theologian, wrote that we find ourselves doing many things that we do not really want to do saying things we don't really mean needing things we do not really need, exhausting ourselves for what we secretly realized to be worthless and without meaning in our lives when we spread ourselves too thin. And so the focus really needs to be back on what does give our life meaning what gives our practice meaning what gives our patients meaning. So how do we focus on that? So in a similar concept to decision fatigue, Roy Baumeister, who is a psychologist put forth a concept of ego depletion, where we basically have a shared pool of mental energy from which all of our cognitive, emotional and physical voluntary efforts can come from. And his group did a number of studies that documented how much blood glucose our brains use when making tough decisions, but also how our serum blood glucose levels drop during difficult cognitive situations. Which brings us back to our study of Swedish orthopedic surgeons were right after lunch, where they were well fed, and had more sugar flowing through their veins, their decision making seemed to be a little better than it was without that. And the underlying mechanisms here are we can attribute to system one and system two thinking which we once again discussed in season one member system. One is our automatic, quick thinking, it's instinct and intuition, or system two is our more thoughtful and analytical, effortful mental activities. And when we think about how we can effectively or do not effectively make decisions in that framework, we all recognize that we can do several things at once, so long as they are easy and not particularly demanding. We also know as highly intelligent individuals are most of us are that we don't always need a ton of effort to solve problems. And part of that is the natural function of system one and system two, when combined, they optimize our cognitive performance. But it's important to remember that system one has biases and systematic errors that are innate to kind of that intuitive quick thinking. But system two can modulate our system when thinking by programming are normally automatic functions to behave in the way we want them to. But importantly, Daniel Kahneman who's really the kind of founder of the system one system two thinking says that in this system or in this framework, there's a law of least effort that basically says when several options exist, people will gravitate to the least demanding course of action. So for system one, the automatic system, the law of least effort says that it's going to be biased to believe what we see, or it's going to move quickly on to the next situation, it's going to be gullible. And the easiest, one of the easiest examples of this is something called the halo effect, where a single trait can cause us to completely like or dislike someone or something, right, we've all seen someone walking down the street or into our clinic that's wearing something that we don't approve of. And it can, it can shadow your entire perspective about that person, which is a function of system one. System two, however, because it is cognitive, because it requires effort is by nature, lazy. And we do not always want to employ our systems to system to when we don't have to. And so being intentional, being mindful, being thoughtful, forces us to engage system too. So how do we avoid mental overload? Simple things we can do, we can do to avoid decision fatigue or ego depletion. One, we divide tasks into easy steps, right? We do this all the time in the operating room, we break down procedures for our trainees. And for our residents, we all did that when we were learning, we can avoid overload by committing results either to long term memory or to paper so they don't have to stay in our active memory. And there's a couple of really interesting mindful ways we can do that we can work towards getting into a flow state, which we're going to talk more about, or using our intuition and how we can cultivate intuition. So how do we avoid fatigue? How do we avoid ego depletion? How do we prevent falling victim to our system one, I'll give you a couple of pointers, the first thing we can do is slow down. And there's a great paper written in 2007 by Carol and Moulton who studied surgeons, and studied what makes a great surgeon. And what she found was that those who slowed down when they should, when encountering what she called speed bumps, were perceived as the true masters were those who went full speed or accelerated in the operating room when things weren't going well, we're less than masters, those were the ones who made errors. And we've all seen this and experienced this, in ourselves and in our colleagues. We've all had moments where things weren't going well, and we sped up and things get worse. We also have the moments where things aren't going well. And we slow down, and we take them in, and we work our way through to a proper solution. We've also seen colleagues who are not particularly adept at high acuity or tougher cases, because they have a tendency to accelerate or speed up when things aren't going well, when the first thing you want to do is slow down. And that's why one of the first things I teach our trainees, when you're a consultant or when you're walking into an operating room where things are challenging, adjust your retractors ask for different antibiotics for we always make that joke that you expand the antibiotic coverage, but what you're doing is you're buying time you're taking in the moment you're being present, you're allowing yourself to engage your system to and really make fundamentally good decisions in the moment. So the first thing we want to do as surgeons as physicians is slow down. And what that does is it facilitates system two thinking it prevents the issues of system one, and it can help facilitate a flow state and it allows integration to take a prominent role. So what is a flow state Mahali check semi is a psychologist who wrote the book, aptly named flow, really nice read if you want to get into kind of cognitive processes, but we know flow more colloquially as being in the zone we often talk about it in sports or athletes will talk about being in the zone. But this is really the psychology of the optimal experience. And he describes it as a state of effortless concentration so deep that they lose their sense of time of themselves and of their problems. And the three requisite pieces to being in a flow state are the merging of action and awareness, in full concentration of the task at hand, focusing attention on that on that task without any concern for the outcome, task focused, not outcome focused, and then self forgetfulness or losing oneself in the awareness of the activity, forgetting what else is going on. And interestingly, the research and the data shows that being in a state of flow over time will actually sharpen our perceptual apparatus. It will increase our capacity to focus attention to concentrate deeply To now distractions, potentially making us better performers, and for surgeons and physicians, make us better in the operating room make us better with patients. So we would be should be working towards flow states. The other part of this is intuition. While there's a misconception, that intuition is innate, but we certainly can develop intuition. And Herbert Simon, who was once again, a cognitive researcher says nothing, intuition is nothing more and nothing less than recognition. Gary Klein, another researcher developed what was called the recognition primed decision model or the RPD model. And he did this by studying firefighters, and firefighter commanders. And the poignant observation he made was that commanders usually only generated a single option for their teams, and that was all they needed. And when he investigated that further, he found that this tentative plan was actually created by system one, our quick thinking intuitive self. It was simulated and tested by system two, before it was verbalized, and enacted by the team. And so that model is broken down. And intuition is built through actually a conglomerate of mini skills. And there are two examples of this. The first is something called chunking, which the best example of is in chess. So chess masters, instead of memorizing every piece on the board in every configuration, and all the possible outcomes, study, and remember, patterns. So when the Knight and the rooks and the bishop line up in a certain quadrant, you have certain moves or plays out of that, rather than trying to remember what every piece does. I think particularly effective surgeons do a good job of this, of recognizing patterns that allow you to accelerate in an operating room, and recognizing patterns that may tell you to slow down that something isn't normal here. And we've all worked with senior surgeons who've done the peak and shriek for lack of a better term, they've made an incision, they've put their hands over. And they said, We're not proceeding with this operation, because it's not safe. And we didn't always understand at the time, the reasons why. But what they were doing was chunking, or basically putting together prior experiences, they had developed their intuition, and they know when to stop an operation and when to proceed. Another good example, of mini skills is something like basketball. In basketball, you dribble pass and shoot are the three basic skills. And we may have professional expertise that requires multiple skills, recognizing that we may be really good at one skill, but not another allows us to work on the area that we need to maintain our expertise in the areas we're good at, but develop the areas where we're not as good. And the best way to develop intuition is, first of all, to practice, practice, practice, put yourself in situations where you need to practice. Or you need to see you need to see these chunks you need to work on your skills. But it's also seeking out good quality and timely feedback, so that you can register the awareness of what you just went through with the notion that you need to improve, or that you're doing well. What second concept of mindfulness in medical decision making is to be open minded. And there's a great concept of beginners versus expert mind. And this is really hard for physicians. Because we're trained to be experts, we're explain, we're trained to have the answer, to provide that answer to our colleagues to our patients. But we need to expand and express a beginner's mind, seek out answers, particularly with patients, and also with ourselves. So with patients, we want to understand their perspective, not just gathered data to give them a diagnosis. We know that patients who feel unheard are less likely to disclose important information in a consultation. And we also know on the flip side, when we give informed consent, it's not only providing information, but it's facing uncertainty together with with a patient. And Eric Castle, who was a primary care doc wrote in a great New England journal article in 1982, said that doctors often missed the point they missed the patient's suffering. And there are domains of suffering that are more devastating to that patient than just the physical symptoms. And these can include psychological existential, spiritual financial, social toxicities, that are more than the physical symptoms that they're actually coming to see you about. And doctors often few patients as a sum of their problems that could be recognized diagnosed and fixed, rather than as a whole person. And the more we can address the entire person, the the more of a therapeutic effect and relationship we're going to develop with them. There's also a concept of using presence as a connectional dimension of care. And by using quality listening without interrupting, interpreting, judging or minimizing what our patients have to say Say, we offer great dignity and respect we validate who they are and what they're saying. And we we build a relationship. And so it's not just the data or treatment, but it's also how that data is shared and how that treatment is delivered. And there's a concept of elapsed versus perceived time. And there's a great study Sweden at all 2012 interviewed patients after they had an interview or meeting with a physician, when physicians sat down, when they talked about life, not just medicine, when they allowed for silences, to listen, and didn't rush their patients. And when they sat on the bed, the perception of time with the patient was dramatically longer than the actual time spent in the room. And the last part of this is being open minded using both curiosity and uncertainty, recognizing that we don't know everything, and we don't have to judge with negative emotions when we don't know something. But in fact, we can ask patients about it, we can sit in that uncertainty together. And we observe this in our own research in our small renal mass surveillance population, that our anxiety scores improved over time. Even though we were just as uncertain with the patients as what their tumor was going to do. My interpretation is that it was the relationship and the under shared experience that improved their disease, uncertainty and their anxiety over time. So there's also a concept of embodied immersion. And this was put forth by a researcher named Giuseppe Riva, where the sense of self dissolves and this is most often noted in musicians, teachers and doctors who are at the top of the game, top of their game, and where the boundaries between people get blurred, right, there's a shared experience shared mindfulness. And the science supporting this is something called mirror neurons. These are parts of the anterior cingulate actually, that allow us to form meaningful interactions with other humans, particularly notable in children and babies. And the areas in which these mirror neurons live have been shown to grow and develop as we build relationships with others. And actually, as we practice mindfulness meditation practices, we can also express a beginner's mind with ourselves, and be present and aware of our own internal processes. In Buddhism, there's a concept that emptiness is fundamental. And for physicians, it means we can be self assured and confident. While at the same time understanding we can make mistakes, we don't know everything. So just because you don't know everything doesn't mean you need to suffer from imposter syndrome, you can still be self assured and confident in what you do know. And the master clinician is attentive not only to the patient and the person in front of them, but also aware of how they're interpreting data, how are they emotionally responding to the patient? Or to the diagnosis, or to the potential outcomes? What are they analyzing? What's their intuition, saying? What do they think's going on with the patient. And the last way to include mindfulness into medical decision making is to include compassion, and the ingredients of compassion or noticing another one suffering resonating with that suffering, and then acting on behalf of that person. And we can improve our compassion we can improve our emotional intelligence, with specifically compassion trading or meditation. This has been shown by Tanya singer and the Max Planck Institute for Functional MRI studies, basically showing the reward circuits in our dorsolateral prefrontal cortex or nucleus accumbens, the inferior parietal cortex, are linked to our abilities to resonate feelings of others, and can be enhanced through mindfulness practices. So putting this all together. In the face of complexity, we strive for efficiency, which often reflects our system one, but we can engage our system to we can slow down strive for flow, develop intuition, and use a beginner's mind with patients and ourselves. Be mindful means that we can use our protocols and our guidelines, but we're not constrained by them. We can speak with intelligence in confidence, but at the same time, recognize when we are uncertain or unsure and share that with our patients. Aristotle called this for nesis, or practical wisdom, and that is basically what serves the patient best now. And lastly, when we think about medicine and meditation, they actually have the same etymology, the same word route, which is to consider advise, reflect or take appropriate measures. And it's important to recognize that meditation is not about bliss. It's about presence. Balance and connection, which is really what we're trying to achieve as physicians. And it's been shown over and over again that attention and compassion training can increase awareness of biases, reduce those influences over decision making, make clinicians more empathetic to their patients aware of their own self distress, but keep focused on the patient and cultivate intuition. If you want to read more about mindfulness in medicine, Ronald Epstein has a great book called attending medicine, mindfulness in humanity. And in that book, he puts forward a model of mindful practice. mindful practice improves quality of care, which is tied to clinician well being, as well as the quality of caring that we give to our patients. And it brings me to the quote from the classic quote for Francis Peabody for the secret of the care of the patient is in caring for the patient. So in summary, effective decision making avoids fatigue. A mindful approach to decision making can facilitate an efficient approach. So slow down, be open minded, use your beginner's mind, be self aware of your internal processes include compassion, and focus on the patient and be focused on the quality of the care. Thank you for listening, and I look forward to talking to you again