WEBVTT

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A few years ago,
I broke into my own house.

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I had just driven home,

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it was around midnight
in the dead of Montreal winter,

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I had been visiting my friend,
Jeff, across town,

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and the thermometer on the front porch
read minus 40 degrees --

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and don't bother asking
if that's Celsius or Fahrenheit,

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minus 40 is where the two scales meet --

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it was very cold.

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And as I stood on the front porch
fumbling in my pockets,

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I found I didn't have my keys.

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In fact, I could see them
through the window,

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lying on the dining room table
where I had left them.

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So I quickly ran around
and tried all the other doors and windows,

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and they were locked tight.

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I thought about calling a locksmith --
at least I had my cellphone,

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but at midnight, it could take a while
for a locksmith to show up,

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and it was cold.

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I couldn't go back to my friend
Jeff's house for the night

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because I had an early flight
to Europe the next morning,

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and I needed to get
my passport and my suitcase.

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So, desperate and freezing cold,

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I found a large rock and I broke
through the basement window,

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cleared out the shards of glass,

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I crawled through,

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I found a piece of cardboard
and taped it up over the opening,

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figuring that in the morning,
on the way to the airport,

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I could call my contractor
and ask him to fix it.

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This was going to be expensive,

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but probably no more expensive
than a middle-of-the-night locksmith,

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so I figured, under the circumstances,
I was coming out even.

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Now, I'm a neuroscientist by training

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and I know a little bit
about how the brain performs under stress.

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It releases cortisol
that raises your heart rate,

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it modulates adrenaline levels

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and it clouds your thinking.

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So the next morning,

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when I woke up on too little sleep,

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worrying about the hole in the window,

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and a mental note
that I had to call my contractor,

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and the freezing temperatures,

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and the meetings I had upcoming in Europe,

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and, you know, with all
the cortisol in my brain,

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my thinking was cloudy,

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but I didn't know it was cloudy
because my thinking was cloudy.

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(Laughter)

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And it wasn't until I got
to the airport check-in counter,

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that I realized I didn't have my passport.

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(Laughter)

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So I raced home in the snow
and ice, 40 minutes,

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got my passport,
raced back to the airport,

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I made it just in time,

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but they had given away
my seat to someone else,

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so I got stuck in the back of the plane,
next to the bathrooms,

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in a seat that wouldn't recline,
on an eight-hour flight.

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Well, I had a lot of time to think
during those eight hours and no sleep.

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(Laughter)

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And I started wondering,
are there things that I can do,

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systems that I can put into place,

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that will prevent bad things
from happening?

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Or at least if bad things happen,

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will minimize the likelihood
of it being a total catastrophe.

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So I started thinking about that,

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but my thoughts didn't crystallize
until about a month later.

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I was having dinner with my colleague,
Danny Kahneman, the Nobel Prize winner,

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and I somewhat embarrassedly told him
about having broken my window,

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and, you know, forgotten my passport,

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and Danny shared with me

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that he'd been practicing
something called prospective hindsight.

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(Laughter)

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It's something that he had gotten
from the psychologist Gary Klein,

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who had written about it
a few years before,

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also called the pre-mortem.

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Now, you all know what the postmortem is.

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Whenever there's a disaster,

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a team of experts come in and they try
to figure out what went wrong, right?

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Well, in the pre-mortem, Danny explained,

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you look ahead and you try to figure out
all the things that could go wrong,

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and then you try to figure out
what you can do

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to prevent those things from happening,
or to minimize the damage.

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So what I want to talk to you about today

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are some of the things we can do
in the form of a pre-mortem.

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Some of them are obvious,
some of them are not so obvious.

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I'll start with the obvious ones.

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Around the home, designate a place
for things that are easily lost.

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Now, this sounds
like common sense, and it is,

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but there's a lot of science
to back this up,

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based on the way our spatial memory works.

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There's a structure in the brain
called the hippocampus,

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that evolved over tens
of thousands of years,

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to keep track of the locations
of important things --

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where the well is,
where fish can be found,

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that stand of fruit trees,

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where the friendly and enemy tribes live.

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The hippocampus is the part of the brain

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that in London taxicab drivers
becomes enlarged.

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It's the part of the brain
that allows squirrels to find their nuts.

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And if you're wondering,
somebody actually did the experiment

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where they cut off
the olfactory sense of the squirrels,

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and they could still find their nuts.

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They weren't using smell,
they were using the hippocampus,

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this exquisitely evolved mechanism
in the brain for finding things.

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But it's really good for things
that don't move around much,

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not so good for things that move around.

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So this is why we lose car keys
and reading glasses and passports.

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So in the home,
designate a spot for your keys --

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a hook by the door,
maybe a decorative bowl.

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For your passport, a particular drawer.

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For your reading glasses,
a particular table.

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If you designate a spot
and you're scrupulous about it,

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your things will always be there
when you look for them.

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What about travel?

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Take a cell phone picture
of your credit cards,

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your driver's license, your passport,

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mail it to yourself so it's in the cloud.

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If these things are lost or stolen,
you can facilitate replacement.

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Now these are some rather obvious things.

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Remember, when you're under stress,
the brain releases cortisol.

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Cortisol is toxic,
and it causes cloudy thinking.

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So part of the practice of the pre-mortem

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is to recognize that under stress
you're not going to be at your best,

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and you should put systems in place.

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And there's perhaps
no more stressful a situation

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than when you're confronted
with a medical decision to make.

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And at some point, all of us
are going to be in that position,

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where we have to make
a very important decision

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about the future of our medical care
or that of a loved one,

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to help them with a decision.

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And so I want to talk about that.

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And I'm going to talk about
a very particular medical condition.

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But this stands as a proxy for all kinds
of medical decision-making,

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and indeed for financial decision-making,
and social decision-making --

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any kind of decision you have to make

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that would benefit from a rational
assessment of the facts.

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So suppose you go to your doctor
and the doctor says,

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"I just got your lab work back,
your cholesterol's a little high."

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Now, you all know that high cholesterol

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is associated with an increased risk
of cardiovascular disease,

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heart attack, stroke.

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And so you're thinking

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having high cholesterol
isn't the best thing,

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and so the doctor says,
"You know, I'd like to give you a drug

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that will help you
lower your cholesterol, a statin."

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And you've probably heard of statins,

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you know that they're among
the most widely prescribed drugs

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in the world today,

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you probably even know
people who take them.

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And so you're thinking,
"Yeah! Give me the statin."

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But there's a question
you should ask at this point,

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a statistic you should ask for

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that most doctors
don't like talking about,

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and pharmaceutical companies
like talking about even less.

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It's for the number needed to treat.

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Now, what is this, the NNT?

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It's the number of people
that need to take a drug

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or undergo a surgery
or any medical procedure

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before one person is helped.

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And you're thinking,
what kind of crazy statistic is that?

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The number should be one.

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My doctor wouldn't prescribe
something to me

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if it's not going to help.

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But actually, medical practice
doesn't work that way.

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And it's not the doctor's fault,

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if it's anybody's fault,
it's the fault of scientists like me.

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We haven't figured out
the underlying mechanisms well enough.

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But GlaxoSmithKline estimates

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that 90 percent of the drugs work
in only 30 to 50 percent of the people.

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So the number needed to treat
for the most widely prescribed statin,

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what do you suppose it is?

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How many people have to take it
before one person is helped?

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300.

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This is according to research

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by research practitioners
Jerome Groopman and Pamela Hartzband,

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independently confirmed by Bloomberg.com.

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I ran through the numbers myself.

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300 people have to
take the drug for a year

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before one heart attack, stroke
or other adverse event is prevented.

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Now you're probably thinking,

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"Well, OK, one in 300 chance
of lowering my cholesterol.

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Why not, doc? Give me
the prescription anyway."

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But you should ask at this point
for another statistic,

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and that is, "Tell me
about the side effects." Right?

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So for this particular drug,

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the side effects occur
in five percent of the patients.

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And they include terrible things --

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debilitating muscle and joint pain,
gastrointestinal distress --

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but now you're thinking, "Five percent,

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not very likely
it's going to happen to me,

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I'll still take the drug."

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But wait a minute.

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Remember under stress
you're not thinking clearly.

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So think about how you're going
to work through this ahead of time,

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so you don't have to manufacture
the chain of reasoning on the spot.

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300 people take the drug, right?
One person's helped,

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five percent of those 300
have side effects,

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that's 15 people.

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You're 15 times more likely
to be harmed by the drug

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than you are to be helped by the drug.

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Now, I'm not saying whether you
should take the statin or not.

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I'm just saying you should have
this conversation with your doctor.

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Medical ethics requires it,

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it's part of the principle
of informed consent.

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You have the right to have access
to this kind of information

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to begin the conversation about whether
you want to take the risks or not.

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Now you might be thinking

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I've pulled this number
out of the air for shock value,

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but in fact it's rather typical,
this number needed to treat.

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For the most widely performed surgery
on men over the age of 50,

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removal of the prostate for cancer,

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the number needed to treat is 49.

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That's right, 49 surgeries are done
for every one person who's helped.

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And the side effects in that case
occur in 50 percent of the patients.

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They include impotence,
erectile dysfunction,

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urinary incontinence, rectal tearing,

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fecal incontinence.

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And if you're lucky, and you're one
of the 50 percent who has these,

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they'll only last for a year or two.

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So the idea of the pre-mortem
is to think ahead of time

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to the questions
that you might be able to ask

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that will push the conversation forward.

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You don't want to have to manufacture
all of this on the spot.

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And you also want to think
about things like quality of life.

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Because you have a choice oftentimes,

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do you I want a shorter life
that's pain-free,

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or a longer life that might have
a great deal of pain towards the end?

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These are things to talk about
and think about now,

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with your family and your loved ones.

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You might change your mind
in the heat of the moment,

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but at least you're practiced
with this kind of thinking.

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Remember, our brain under stress
releases cortisol,

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and one of the things
that happens at that moment

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is a whole bunch on systems shut down.

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There's an evolutionary reason for this.

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Face-to-face with a predator,
you don't need your digestive system,

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or your libido, or your immune system,

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because if you're body is expending
metabolism on those things

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and you don't react quickly,

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you might become the lion's lunch,
and then none of those things matter.

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Unfortunately,

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one of the things that goes out the window
during those times of stress

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is rational, logical thinking,

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as Danny Kahneman
and his colleagues have shown.

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So we need to train ourselves
to think ahead

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to these kinds of situations.

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I think the important point here
is recognizing that all of us are flawed.

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We all are going to fail now and then.

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The idea is to think ahead
to what those failures might be,

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to put systems in place
that will help minimize the damage,

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or to prevent the bad things
from happening in the first place.

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Getting back to that
snowy night in Montreal,

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when I got back from my trip,

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I had my contractor install
a combination lock next to the door,

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with a key to the front door in it,
an easy to remember combination.

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And I have to admit,

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I still have piles of mail
that haven't been sorted,

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and piles of emails
that I haven't gone through.

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So I'm not completely organized,

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but I see organization
as a gradual process,

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and I'm getting there.

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Thank you very much.

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(Applause)