5 Books Every Resident Must Read

Hans House, MD, MACM, FACEP Vice Chair for Education Department of Emergency Medicine University of Iowa

Objectives Achieving mastery Honing intuition Think differently Understand sources of error Apply the art of medicine

The “5” Books

Malcolm Gladwell’s trilogy Tipping Point, Blink, and Outliers Freakonomics by Dubner and Levit How Doctors Think by Groopman Complications by Gawande The House of God by Shem

Malcolm Gladwell

The Tipping Point

2000 Inspired by the drop of crime in NYC – real change possible Analyzes “epidemics” Mavens, connectors, salesmen 80 / 20 rule Limited application to medicine except public health

Blink

2005 Experts make snap judgments without realizing how they do it Enormous power of intuition Sick v not sick Thin slicing Prone to biases (curtained auditions blind tasting, IAT ) To do it correctly, it requires mastery of the subject . . .

Outliers

2008 10,000 hours, K Anders Ericsson ACGME latched on Deliberate practice (more on this later) Success is a group practice- not innate talent Environment of success (Bill Gates, The Beatles, Julia Child) Achievement gap

Outliers

Plane crashes Sequence of errors 1990 Avianca 052 crash Mitigated Speech 2013 Asiana 214 crash 1. Command (Do this now) 2. Obligation statement (We need to do this) 3. Suggestion (Lets do this) 4. Query (Should I do this now?) 5. Preference (it might be a good idea to do this) 6. Hint (How about them Bears?)

Outliers

Pure IQ does equate with success Threshold IQ needed Compared case studies, identified that success requires “Practical Intelligence Emotional Intelligence (EI) BBC firing example IQ vs EI

Freakonomics

Stephen J Dubner and Steven D Levit

Freakonomics

Originally published 2005 People respond to incentives, sometimes in unpredictable ways Unafraid to challenge conventional wisdom Relies on data, thinks differently Alternative explanation to the crime rate drop in NYC Physicians need to have alternate explanations for observations

Super Freakonomics

2009 Deliberate practice Setting goals Obtaining feedback Concentrating on technique Describes the development of the EHR Crash testing booster and seat restrained Prostitute chapter

AEM 2013; 20:880

How Doctors Think

2007 Something for every specialty Systematic review of medical error types using patient anecdotes Example of “anchoring” Art of medicine

How Doctors Think

“…few if any physicians work with this mathematical paradigm. The physical examination begins with the first visual impression” “A phenomenon called the “eyeball test,” pivotal moment when a doctor identifies “something intangible yet unsettling in the patient’s presentation.” “That freedom of patient speech is necessary if the doctor is to get clues about the medical enigma before him [sic]. . . On average, physicians interrupt patients within eighteen seconds of when they begin telling their story”

How Doctors Think

Yerkes-Dodson law of task performance

The Art of Medicine

Negative feeling cloud judgment Taking the time to sit and listen Newman: applying the art as Hippocrates would have done Plan for backup during a procedure = do the same with a complicated patient Example: Spanish speaking patient with headache with 4 visits

Complications

Atul Gawande, MD, MPH

Affordable Healthcare Act

Complications

Wrote as a surgical resident, published 2002 Discusses his own medical errors Echoes of Blink, Outliers, and House of God

Complications

“The most important talent may be the talent for practice itself” Atul Gawande “It is only human nature to want to practice what you can already do well, since its hell of lot less work and a hell of a lot more fun” Sam Snead, golfer

Lifelong Quest for Perfection

Complications

“See one do one teach one” Learning central line placement “It is all I can do not to take over. But she cannot learn without doing, I tell myself. I decide to let her have one more try.”

Complications

Impaired physicians

Blink -> Complications

Complications

“Medicine’s ground state is uncertainty. And wisdom- for both patients and doctors- is defined by how one copes with it” Its OK to say “I don’t know”

The House of God

1978 Shocking, hypersexual, coarse, and unprofessional Embarrassingly real, burnout risk Collects traditions and mottos of hospital medicine Intro from How Doctors Think echoes some of these themes

Hoof beats and zebras LOL in NAD Buffing the chart Turfing the patient Being a sieve or a wall If what you’re doing is working, keep doing it

Traditions

O sign and Q sign Chance to Cut is Chance to Cure Nothing Cures like Cold Hard Steel Gomer If what you’re doing is not working, stop

Rules of the House of God

GOMERS DON’T DIE GOMERS GO TO GROUND AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE THE PATIENT IS THE ONE WITH THE DISEASE.

PLACEMENT COMES FIRST.

THERE IS NO BODY CAVITY THAT CANNOT BE REACHED WITH A #14G NEEDLE AND A GOOD STRONG ARM.

AGE + BUN = LASIX DOSE

Rules of the House of God

THEY CAN ALWAYS HURT YOU MORE.

THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.

IF YOU DON'T TAKE A TEMPERATURE, YOU CAN'T FIND A FEVER.

SHOW ME A BMS WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.

IF THE RADIOLOGY RESIDENT AND THE MEDICAL STUDENT BOTH SEE A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.

THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

“In the [ED], as well, the jolt of feeling human refused to fade. I felt good, proud of my skills, excited. . . Sitting in the [ED] was like sitting on a bench in the Louvre; a human tapestry, ever unraveling under my eyes. Like Paris, the [ED] was a place unlimited in time: I’d leave it and it would go on with me until I returned. An immense, humbling eternity of disease.” - Samuel Shem, The House of God

“Addicts trying to dupe you for dope, drunks, the poor, the clap, the lonelies- I hate ‘em all. I don’t trust anyone. It comes from being vomited on and spit at and yelled at and conned. Everyone’s out to get me to do something for their fake disease. The first thing I look for now is how they’re trying to take me for a ride.” - Samuel Shem, The House of God

Conclusions

Wow, the New Yorker has some awesome writers Challenge conventional thinking with data (EBM) Deliberate practice is hard, but works Disasters develop from a sequence of errors Use heuristics, but be aware of sources of error Avoid burnout