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