5 Books Every Resident Must Read
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5 Books Every Resident Must Read
5 Books Every Resident Must ReadHans House, MD, MACM, FACEPVice Chair for EducationDepartment of Emergency MedicineUniversity of Iowa1ObjectivesAchieving masteryHoning intuitionThink differentlyUnderstand sources of errorApply the art of medicineThe 5 BooksMalcolm Gladwells trilogyTipping Point, Blink, and OutliersFreakonomics by Dubner and LevitHow Doctors Think by GroopmanComplications by GawandeThe House of God by ShemMalcolm Gladwell
The Tipping Point
2000Inspired by the drop of crime in NYC real change possibleAnalyzes epidemicsMavens, connectors, salesmen80 / 20 ruleLimited application to medicine except public healthBlink
2005Experts make snap judgments without realizing how they do itEnormous power of intuitionSick v not sickThin slicingProne to biases (curtained auditions blind tasting, IAT)To do it correctly, it requires mastery of the subject . . . Outliers
200810,000 hours, K Anders EricssonACGME latched onDeliberate practice (more on this later)Success is a group practice- not innate talentEnvironment of success (Bill Gates, The Beatles, Julia Child)Achievement gapOutliersPlane crashesSequence of errors1990 Avianca 052 crashMitigated Speech2013 Asiana 214 crash
Command (Do this now)Obligation statement (We need to do this)Suggestion (Lets do this)Query (Should I do this now?)Preference (it might be a good idea to do this)Hint (How about them Bears?)Capt: tell them we are in emergencyFirst: thats right to 180 Im heading and ah we will try once again. Were running out of fuelCapt: what did he say?First: I already advised him that we are going to attempt again because we now we cantCapt: advised him we are in emergencyCapt: Did you tell him?First: yes sir I already advise himFirst: 150 maintaining 2000 Avianca 052 heavyCapt: Advise him WE DONT HAVE FUELFirst: climb and maintain 3000 and ah running out of fuel sirCapt: did you advise that we dont have fuel?First: yes sir I already advise himCapt: BeunoTraffic Control: And Avianca 052 Im going to bring you about 15 miles north east then turn it back onto the approach is that okay with you and your fuel?First: I guess so, thank you very much8OutliersPure IQ does equate with successThreshold IQ neededCompared case studies, identified that success requires Practical IntelligenceEmotional Intelligence (EI)BBC firing exampleIQ vs EI
SAN FRANCISCO It was pilot Lee Hang-kook's first time landing a Boeing 777 at San Francisco International Airport, and with a key part of the airport's automated landing system not working, he was forced to visually guide the massive jetliner onto the runway.
As Asiana Airlines Flight 214 approached the airport 400 feet above San Francisco Bay, it was flying too low and too slow. That should have been a warning to the pilot to abort the landing and make another attempt, aviation experts said.
But Lee didn't abort. What was even more baffling: He and the more experienced co-pilot next to him didn't discuss their predicament. Cockpit voice recordings show the two didn't communicate until less than two seconds before the plane struck a sea wall and then slammed into Runway 28L.
Investigators and aviation safety experts focused Monday on why the crew did not recognize the danger they faced and take action. "There was no discussion of any problems clearly at a time when one was developing. Both pilots should have seen that something was going wrong," said Barry Schiff, a TWA pilot for 34 years and now an aviation safety expert. "Why didn't one of them say or do something?9Freakonomics
Stephen J Dubner and Steven D LevitFreakonomics
Originally published 2005People respond to incentives, sometimes in unpredictable waysUnafraid to challenge conventional wisdomRelies on data, thinks differentlyAlternative explanation to the crime rate drop in NYCPhysicians need to have alternate explanations for observationsSuper Freakonomics
2009Deliberate practiceSetting goalsObtaining feedbackConcentrating on techniqueDescribes the development of the EHRCrash testing booster and seat restrainedProstitute chapter
AEM 2013; 20:880How Doctors Think
2007Something for every specialtySystematic review of medical error types using patient anecdotesExample of anchoringArt of medicineHow Doctors Thinkfew if any physicians work with this mathematical paradigm. The physical examination begins with the first visual impressionA phenomenon called the eyeball test, pivotal moment when a doctor identifies something intangible yet unsettling in the patients 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 storyHow Doctors Think
Yerkes-Dodson law of task performanceThe Art of Medicine
Negative feeling cloud judgmentTaking the time to sit and listenNewman: applying the art as Hippocrates would have donePlan for backup during a procedure = do the same with a complicated patientExample: Spanish speaking patient with headache with 4 visitsComplications
Atul Gawande, MD, MPHAffordable Healthcare Act
Wrote as a surgical resident, published 2002Discusses his own medical errorsEchoes of Blink, Outliers, and House of God
It is still not apparent to me what clues there were that I was registering when I first saw Eleanor's leg. . . Yet as arbitrary as our intuitions seem, there must have been some underlying sense to them. What there is no sense to is how anyone could have known that, how anyone can reliably tell when a doctors intuitions are heading down the right track or spinning wildly off20Complications The most important talent may be the talent for practice itselfAtul GawandeIt 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 funSam Snead, golfer
Deliberate practice. Recall Freakonomics IQ threshold- just have to be good enough then practice
surgeons as a group adhere to a curious egalitarianism. They believe in practice, not talent. people often assume that you have to have great hands to become a surgeon but its not true. When I interviewed to get into surgery programs no one made me sew or take it dexterity test or checked if my hands are steady.
Two kinds of learning: improving the skills you already have and extending the reach and range of your skills.K Anders Ericcson
Takes enormous concentration, limiting the time you can spend on them
21Lifelong Quest for Perfection
ComplicationsSee one do one teach oneLearning central line placementIt 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.
with his skill and his experience, Goodman new better then most what needed to be done for Mrs. D, for the man with the shattered hip, and for many other patients but he did not do it. What happened? All he could tell me was that everything seemed wrong those last two years. He used to enjoy being in the operating room fixing people. After a while though it seemed that the only thing he thought about was getting through all the patients as quickly as possible
Example of an Orthopedic surgeon, very aggressive, doing many procedures and working long hours
Began to have unacceptable rates of complications, M and M cases, malpractice suits
Allowed to practice for years before intervened
Example of our Chief Resident
24Blink -> Complications
Example of a fire crew leaving a house before it collapsed- the commander didnt know what made him make that decision
It is still not apparent to me what the clues were that was registering when I first saw Eleanor's leg Yet as arbitrary as our intuitions seem, there must have been some underlying sense to them. What there is no sense to is how anyone could have known that, how anyone can reliably tell when a doctors intuitions are heading down the right track or spinning wildly off
25ComplicationsMedicines ground state is uncertainty. And wisdom- for both patients and doctors- is defined by how one copes with itIts OK to say I dont know
The House of God
1978Shocking, hypersexual, coarse, and unprofessionalEmbarrassingly real, burnout riskCollects traditions and mottos of hospital medicineIntro from How Doctors Think echoes some of these themesTraditionsHoof beats and zebrasLOL in NADBuffing the chartTurfing the patientBeing a sieve or a wallIf what youre doing is working, keep doing itO sign and Q signChance to Cut is Chance to CureNothing Cures like Cold Hard SteelGomerIf what youre doing is not working, stopRules of the House of GodGOMERS DONT DIEGOMERS GO TO GROUNDAT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSETHE 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 DOSERules of the House of GodTHEY 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: Id leave it and it would go on with me