Medicine and surgery require complex problem solving and tough decisions are made every single day. In Part 2 of this three-part, solo, mini series, we review pillars of self-management, choice architecture, and how to say, "No." References and reading: The First 90 Days, Nudge, Essentialism. 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. As we said in he prior episode, we're going o talk about effective decision aking this season. And what was aid, we're going to do it in hree parts and may actually ake a few more episodes than hat. So today, we're going to tart with how to make strong ecisions as an individual. And hen we think about medical ecisions, there's often a alance between the logical and he probable. And choosing isely between the two is often ey when we think about how we ake decisions and how our brain orks, causes or what we erceive as causes, often rump's statistics. Even though n medicine, we like to think of urselves occasionally as above hat, and this is really eflective of our system, one ersus system two, learning gain. And when we think about t system, one insists on causal nterpretations. Remember, this s our quick thinking mind. What e see is what there is, and hat's what we interpret uickly, or system to is hallenging and time consuming. t is what we what is required o learn and comprehend new nformation. So based on that ystem, one quick learning, we ften see stereotypes to redominate our thinking. For nstance, we all think that tall eople will have taller hildren. But in fact, if you ook at the statistics, tall eople are actually more likely o have children that are maller than themselves as kind f a population base height will egress to the mean. And we erpetuate a lot of stereotypes n medicine. There are certainly tereotypes about diabetic atients, cancer patients, atients from certain ackgrounds, patients who have ertain professions, and we efinitely as surgeons, many of s had heard have heard the tereotype of who's more likely o have complications that work n the hospital, if their hysician or their lawyer, hey're more likely to have omplications, which certainly erpetuate stereotypes and not ecessarily fact or statistic. o what we commonly perceive in edicine as causal learning, ather than statistical learning s what we all refer to as n quals one, right? We've all had his experience where we have a eally strong patient experience r the most recent recent atient experience, and that is ften what drives our next ecision. So there's a fair mount of science and studies ehind this. And if you're eally interested in this, once gain, I'm going to refer you to aniel Kahneman his book hinking Fast and Slow. But one f the studies highlighted in hat book is by Nesbitt and oard Gita, who studied sychology students and resented them with statistical acts, and the students learned ery little. However, when they resented individual cases, to ighlight a fact, generalization as often inferred. And there's great quote from that study hat says, subjects nwillingness to deduce the articular from the general was atched only by their illingness to infer the general rom the particular. And this articularly applies to edicine. We can all think back o our medical school days, our esidency training, and even now s we're fully functioning hysicians, where we often learn ore from our patients than from textbook, how many of us truggle struggled with ulmonary physiology, or renal hysiology. And we didn't nderstand the data and the acts and the statistics until e met a patient that helped us ement those concepts. And that s the tangible understanding of ystem one versus system two earning. We can only refer to he facts and the statistics so uch until it's ingrained in our rain. And in general, humans re poor and making sudden ummary judgments of complex nformation. And we often make hat summary based on the ontext that we are in rather han the fact which is just a ice way of saying that that atient that experience is what elps us remember, rather than he words on the page or the umbers. So how do we get beyond his N equals one Learning, how o we get on to better, more ffective decision making? Well, mentioned Aristotle, in season ne and the three kinds of work e put forth theoretical work here the end goal is truth ractical work with the end goal s action, and poetical truth ringing forth. And this is eally what we're striving for. e're trying to bring forth good hoices. So another great book or anybody starting a job is alled the first 90 days by ichael Watkins. And it really alks about a lot of business trategy and how to kind of mplement that. And that's not here we're going to go. He puts orth three pillars of self anagement, which is really pplicable to very broad fields, ncluding business success and eadership success. But the irst is to understand success trategies. These are principles f communication, decision aking, and pitfalls. And this s where we're going to spend ome time today. The second of he pillars is personal iscipline, being able to set oundaries, being able to say no ocusing on the end, identifying ur priorities, separating urselves from emotion, and oving forward. And then the ast part is creating support ystems, both at work at home in ersonal and private life. These re our trusted compatriots, our rusted advisors, who can help s navigate through decisions. So we're going to start with successful strategies, and how can we understand them. So briefly, the first thing we have to understand choice architecture exists. Now, this is another phenomenon from the Business Economics world. And I'll give you another piece of reading here nudge by Richard Thaler and Cass Sunstein. And the basic premise of this book and multiple books in this arena are that there's a false assumption that humans make choices with their best interests in mind all of the time, and a false assumption that it is impossible to avoid influencing those choices. And in fact, we don't, and our choices can be influenced by a number of design factors, just the way we interact with data or the way we interact with choices. And if you're skeptical of what I just said, think about the products on the end of your supermarket aisle, they're put there for a reason they draw your attention to them, they bring your attention to sales and high volume products that you are more likely to buy. Think about all the opt in versus opt out choices you have in your life, whether this is for your benefits at work for your credit card statements being electronic or mail, organ donation on your driver's license, and think about how many emails and spam emails you get on a daily basis because you didn't opt out of receiving those. And lastly, in medicine, I think we have a real opportunity to change the way we practice by shaping the way our guidelines and statements are structured. Recognizing the by the way we design, or crude or architect the statements we can influence each other's behaviors. So first, recognize that architecture exists and we can influence choices. And our choices can be influenced by the way they're structured around us. The second is to recognize that our emotional states certainly influences decision making simply said frowning, and sadness actually engages our system to it is a more thoughtful, reliant process, where smiling and happiness actually engages system one, it's a little more natural and fast thinking when we're in a happy state. And emotional arousal is controlled by the amygdala. And it's activated when our decisions match our emotional frame. So when we're in a good mood, if we're making easy choices, it becomes easier to make those choices. Whereas if we are down or in a sad mood, it is harder to make a happy choice. The anterior cingulate which controls our conflict and self control is activated when a natural choice is not taken. So if a to b should naturally lead you to see, but you're not making that choice, today, you're choosing D, the anterior cingulate will fire up making you aware of the conflict created by that decision. And lastly, the frontal brain what makes humans humans fires up when we have discordance between our emotional state and our rational thought process. And that's what helps us gain control over our emotions or helps us process the logic or helps us process the probable so what we think about how this emotional state influences our decision making. In general, decision makers will take a short choice not a gamble. When outcomes are framed as good or positive. We will tend to read Jecht a sure thing, and take a gamble when outcomes are framed as negative and moral feelings may be attached to that description, more than it's attached to reality ourself. And we give you examples to understand what I'm talking about here. So when we think about I'm a cancer surgeon, when we think about describing cancer outcomes, or choice of options to our patients, if we frame the options as good decision makers are more likely to choose the short thing. So if we say, your success rates for the surgery are 95% or higher, patients are much more likely to choose the shore thing, what we're describing. If we framed it another way, and said, you've got a 5% chance of having a major complication or not being cured by the surgery we're recommending, they are much more likely to take a gamble or choose something other than a short choice. And we also have to recognize that each one of us carries bias into these conversations. Each of our patients carries emotional bias into these conversations, where the word cancer may bring up a huge feelings for one person as opposed to another person. Complications, deaths or good outcomes may generate much more, or many may generate different feelings for us than it does for our patients. And so these are just some examples of how we can consider those successful strategies. When we're thinking about our pillars of self management. The second area of focus is on personal discipline. And this is really in defining what is our priority? What are our priorities beneath that? And how do we say no, Greg McGowan's book, essentialism really breaks us down into a very meaningful and simple task. If you break down your most inspirational and concrete goals, those are your that is your essential intent. It is inspirational, concrete, meaningful and measurable. If he says, If you could only pick one thing to be truly excellent at what would it be, and this is where you should devote most of your time and energy. So why don't we say no? Well, we're worried that we may miss out on the next great thing, we're worried about rocking the boat, pissing off our boss or colleagues, or burning bridges with others. But saying no is really a key to a process of elimination to get us to those goals. And instead of worrying that we're going to miss out on great opportunity. It helps us choose and create that great the great opportunity that we want. And there's a concept called opportunity cost, which says that something was always be sacrificed to accommodate new commitments. And that is true, but we can help define that cost and have more control of it by choosing what we say yes to and choosing what we say no to. It's really hard to say no, though, because often we are saying no to people, to our colleagues, to our bosses, to our friends to our loved ones. And we have to be able to separate that once again, recognizing the emotional decisions that we talked about in that first framework of understanding how decisions are made. And saying that when we say no, we're not saying no to the person, we're saying no to the request. And good leaders will recognize that it is not a personal affront, to say no to them. But poor leaders will make it personal can hold a grudge. And so we need to think about that as we develop into leadership positions to not hold grudges on those who say no. And in fact, we should respect them for making a wise decision. So there are lots of ways to say no, sometimes the simplest one is to just give space. Most often if we're talking if we're engaging with a boss or a colleague who wants us to do something, if we don't respond or reply immediately, we're implying that there's a decision making process going on here. We're giving feedback by not responding immediately. And sometimes it's easier to say no after a period of contemplation than it is to say it right right away. There are a variety of other ways to do it. Once again, I'd recommend Craig McKellen's book if you want to get more into how to say no, but you can. Now Ella bat, who was a Indian activist has a wonderful quote about choosing and saying no, she says out of all virtues, simplicity is my favorite virtue. So much so that I tend to believe that simplicity can solve most of the problems, personal as well as the world problems. If the life approach is simple, one not need to lie so frequently, nor quarrel nor steal, nor envy, anger, abuse or kill. Everyone will have enough and plenty so need not hoard speculate gamble hate when character is beautiful. You are beautiful. And that is the beauty of simplicity. So how do we get to simplicity? How do we get to being efficient? First, don't be afraid to cut your losses. There's a number of biases something called a sunk cost bias. Because we've made an initial investment in something, we have to carry it to furnish fruition, or because we always did it one way, we have to do it that way. Again, that's called status quo bias, it is more important to admit to making mistake and moving forward in a positive direction than continuing to move forward in a negative direction. We can edit or condense our lives, it doesn't mean that we're doing more with less, which is some times that connotation with editing. But it means we're having less waste, we're being being more efficient. And most importantly, we have to set boundaries. Many people think of boundaries as constraints that get in the way of your life, they stop you from doing what you want to do. But in fact, you need to change your frame of mind boundaries can actually protect your time, free from the burden of having to say no, if you set up with your colleagues that you're not answering emails after 6pm, then they're not going to send you emails after 6pm. And it will facilitate efficient conversation during the day. Same thing with patients. There's nothing wrong with giving a patient your email or cell phone. But if you answer it at two o'clock in the morning, for non emergent or urgent reasons, you can certainly expect more phone calls at two o'clock in the morning. You have to set boundaries, it keeps you safe protects you from the burdens of having to say no similar to boundaries are buffers. And this is basically planning for the unexpected. One of most common things we see with surgeons is the planning fallacy, right? We underestimate how much time it takes to do something. And in fact, it's often about 50% of the time and we all know colleagues and surgeons who do this. Oh, yeah, that case takes three hours. Well, about four and a half hours later, they're wrapping up, right about a 50% fallacy. Oh, no, I'll be there in 20 minutes. Guess what, half an hour later, they finally show up. It's remarkable that this 50% is pretty accurate. So in your own life, give yourself a 50% buffer on everything you think you're going to do. And guess what, if you finish early, you've now have found time to do something else, you didn't think you were going to be able to do that day, and plan for small wins rather than a huge victory. Lots of little successes will help build a culture of success in yourself in the people you work with. Whether this is in the operating room, whether this is in your academic career, whether this is in your practice with your colleagues. And remember, recognize people's achievements. The two primary motivators for achievement, are giving people goals, and then recognizing them for achieving those. So if we set small goals and recognize small wins, we are building a culture of success. And importantly, not only is this applicable to our colleagues in the people we work with, but this is applicable to ourselves. If we set small goals, we achieve small victories, we are building a sense of success in ourselves, and matched with self confidence. This is a very powerful tool. And I've talked about the beginner versus the expert mind in multiple podcasts. And this is really one of the dichotomies that we need to work through to make effective decisions. The beginner's mind is open to many possibilities, or in the experts mind, there are few, we need to use our expert minds. That's what we do, we were trained to be experts, as physicians and surgeons. However, we need to choose the times where we need to be expert. And we need to open our mind to the other possibilities. In times of uncertainty or challenge. This will help us be efficient. So to summarize here, our brain is organized to facilitate learning by experience, so take advantage of it. Whether you're thinking of your N equals one learning, how do we move beyond that, whether we're thinking of choice architecture, by the way we organize our choices, or the way choices are given to us. And lastly, that emotion certainly influenced our choices. So we need to understand that to be able to integrate when to include emotion into our choices, but also when to take emotion out of the choices, most importantly, to create discipline, and especially to say no, and create simplistic essential goals and outcomes that we want to achieve on a daily basis, a weekly basis, throughout a career or for life. So I'd like to thank you for listening. In the next podcast, we're going to try and give some more concrete examples of good decision making. Through a wonderful book called seven ways to think differently. We're going to try something new andUnknown: