5 books every resident must read

5 Books Every Resident Must ReadHans House, MD, MACM, FACEPVice Chair for EducationDepartment of Emergency MedicineUniversity of Iowa

ObjectivesAchieving masteryHoning intuitionThink differentlyUnderstand sources of errorApply the art of medicine

The “5” BooksMalcolm Gladwell’s trilogy

Tipping Point, Blink, and Outliers

Freakonomics by Dubner and LevitHow Doctors Think by GroopmanComplications by GawandeThe House of God by Shem

Malcolm Gladwell

The Tipping Point2000Inspired by the drop of crime in NYC – real change possibleAnalyzes “epidemics”Mavens, connectors, salesmen80 / 20 ruleLimited application to medicine except public health

Blink2005Experts 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 . . .

Outliers200810,000 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 gap

OutliersPlane crashesSequence of errors1990 Avianca 052 crashMitigated Speech2013 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?)

OutliersPure IQ does equate with successThreshold IQ neededCompared case studies, identified that success requires “Practical IntelligenceEmotional Intelligence (EI)

BBC firing exampleIQ vs EI

Freakonomics

Stephen J Dubner and Steven D Levit

FreakonomicsOriginally 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 observations

Super Freakonomics2009Deliberate practice

Setting goalsObtaining feedbackConcentrating on technique

Describes the development of the EHRCrash testing booster and seat restrainedProstitute chapter

AEM 2013; 20:880

How Doctors Think2007Something for every specialtySystematic review of medical error types using patient anecdotesExample 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 MedicineNegative 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 visits

Complications

Atul Gawande, MD, MPH

Affordable Healthcare Act

ComplicationsWrote as a surgical resident, published 2002Discusses his own medical errorsEchoes 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.”

ComplicationsImpaired 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 God1978Shocking, hypersexual, coarse, and unprofessionalEmbarrassingly real, burnout riskCollects traditions and mottos of hospital medicineIntro from How Doctors Think echoes some of these themes

TraditionsHoof beats and zebrasLOL in NADBuffing the chartTurfing the patientBeing a sieve or a wallIf what you’re doing is working, keep doing it

O sign and Q signChance to Cut is Chance to CureNothing Cures like Cold Hard SteelGomerIf what you’re doing is not working, stop

Rules of the House of God

GOMERS DON’T 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 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

ConclusionsWow, the New Yorker has some awesome writersChallenge conventional thinking with data (EBM)Deliberate practice is hard, but worksDisasters develop from a sequence of errorsUse heuristics, but be aware of sources of errorAvoid burnout