Tips for premeds on shadowing doctors

One of my interns asked me about shadowing doctors. Shadowing any professional is a great way to learn more about a field. In their new book, Decisive, Chip and Dan Heath point out how we often make career choices with very little knowledge of the professional reality in that field.

For assistance on this question, I emailed our network of 60+ intern alumni, who are mostly in or just emerging from medical school, and asked for their advice.

Here's what they said would be considerations in shadowing doctors...

Location

• Emergency departments
• Specialty clinics
• Community health centers
• Private practices

The type of work that you want to see

• Interventional
• Surgical
• People/talking
• Family-heavy
• Research
• Administration

What do you want to learn/establish from the experience?

• Get the gist of what a clinic feels like
• Mentorship relationship with one of the doctors
  • If they are an alumnus of a certain school that you are applying for, this could be very helpful in the application process
• Research positions
• Guidance on the application process  
  • The practice of medicine is so varied and individual, so you should take this time to explore in a broad and open way
• You do not need to choose a specialty at this point in time; it is more important to determine what type of activity drives you
  • Eventually, you will find “your people” with whom you’ll enjoy spending 80 hours a week during residency and for the rest of your career
• Because medicine is such a long road, you should love it to get through it
  • The only way you can know is if you experience a doctor’s life
  • After the experience, do a self-reflection and be honest with yourself about whether medicine is the right thing for you

How to contact doctors 

• Email request or in-person
• 1 paragraph statement of interest/your background
• Mention if you have already worked with patients

Serving your audience #Huddle12

My professional mission is to help people grow in their capacity for leadership, teamwork, and decision-making. I'm proud to be affiliated with the organization CAMPUSPEAK as one of the speakers on their roster. CAMPUSPEAK connects individuals and organizations on campuses nationwide with experts who contribute to student growth and development. The speakers, facilitators, and consultants at CAMPUSPEAK address  issues such as leadership, diversity, career planning, character development, student physical and mental health, hazing, drug and alcohol abuse, and many others.

In addition to serving students, CAMPUSPEAK invests in the roster's professional development through a biannual Huddle, where we learn from external experts and from each other. I want to briefly share some of the lessons I took away from Huddle12.

This summary itself is an effort to enact one of the themes of  Huddle12. We generally don't make enough time for reflection. Neen James and Justin Jones-Fosu reminded us to schedule appointments with ourselves, for example when returning from conferences, in order to protect time for reflection. So here I am, reflecting...

Another theme was the importance of non-verbal communication. Michael Grinder taught us some very concrete principles and techniques on the effective use of pauses, gestures, objects, and space. For example, when arriving at an agreement with someone, you don't really want the agreement to be between you and your counterpart. You want your counterpart to make the agreement with himself or herself. So you externalize the agreement in a document, and when referring to it, invoke the document object, located in a space, with a gesture. You can do this in presentations, and appeal to people's imagination. Michael presented many other ways to make pauses, gestures, objects, and space the focus of our communication. If you are looking to learn pragmatic techniques for enhancing the power of your non-verbal communication, Michael is the best I've learned from so far. Michael mentioned being inspired by, among other sources, Michael Caine's book on acting, which I am going to check out.

Neen James reminded us to think in terms of serving our audience when we are communicating. I found this to be a powerful frame, compared to informing, educating, persuading, motivating or even inspiring. Along these lines, David Mathison taught us powerful ways to play the game of social media, but reminded us that our deepest relationships and interactions are to be found with a small number of friends, family, and colleagues. We learned all about measuring and increasing our Klout scores (a quantitative measure of online influence), but also how to understand the limitations of Klout, both literally and figuratively.

The thing I like most about CAMPUSPEAK is that the organization and its representatives are all mission-driven. When you are mission-driven, you measure yourself against that mission, which is often hard to quantify. Maybe I'm rationalizing, because my Klout score is rather low, but the lesson I really took away is to develop our own scorecards (which may be qualitative as well as quantitative), and then use David's techniques to harness social media and networks for the mission. As an example, you can raise your Klout score by tweeting questions that many people will comment on (e.g. boxers versus briefs?), but have you advanced your mission? If you're looking to learn about social media and networking, while keeping it all in perspective, David is the best I've learned from to date.

I got to spend some time with Mike Dilbeck. I am such a fan of his Everyday|Hero campaign and the Response Ability project. Mike has taken academic work on bystander behavior and made it his mission to spread the lessons of that research. We've all heard about dramatic situations where bystanders could have intervened, but instead ignored calls for help and a victim died in a crowd. The same principles that apply to dramatic situations also apply to more everyday situations, where you might see someone getting drunk, or saying something discriminatory. How do we teach people to intervene rather than stand around? The earlier you intervene, the easier it is. And the more you intervene early, the more you develop that muscle, so it's there when you need it in more difficult situations. Mike also taught us about social media and networking based on his recent successes. He has combined offline and online activities. For example, he's been traveling to conferences teaching workshops and certifying trainers to carry his message forward. Good old fashioned one-to-many-to-many kind of social networking. But he's also using a ton of video and is moving towards having students self-administer the training they need online. He mentioned a bunch of sources of inspiration that I am going to check out, including Scott Stratten of Unmarketing ("stop marketing, start engaging"), and Brendan Burchard of Experts Academy. Some of his favorite tools include Mailchimp, Infusionsoft, joinspeaker, Kajabi, Audio Acrobat, and the Yeti microphone. It's great to get both strategic and tactical tips from someone who has been there and done that.

Somewhat similar to the issue of overcoming bystander inertia, we learned to form accountability partnerships to make changes stick in our own lives. For example, I am now scheduled for an accountability checkup with my partner, Hudson Taylor. (Hudson is an amazing guy who is on an a personal mission to get rid of homophobia and other forms of discrimination in the college athletic scene.) We'll be calling each other to check in on our resolutions. Having a buddy is such a simple but powerful step. Again, I heard this idea from Neen James (in her workshop), Justin Jones-Fosu (in his book), and Tom Healy. I'm grateful for the repetition - that's another principle of making change.

Speaking of needing a reminder, Rick Barnes reinforced the importance of value-focused thinking - putting the why before the how or the what. Among many other things, Rick teaches campus organizations how to recruit members through better articulation of values and mission. It's so interesting to me that many leading organizations do spend significant time on strategic planning, but so few of us do that for our individual lives. It goes back to making time for reflection, which is what you hear from personal productivity specialists ranging from Stephen Covey to David Allen. So important, and so rare.

We concluded the biannual Huddle with a rapid-fire session, in which we all shared a most valuable tip or tool. Some that stood out to me included Triberr (gather your tribe and communicate with them efficiently); unfollowme (for when you hit your Twitter limit); pdanet (I use this too, it's awesome); the health and professionalism reasons to always use a microphone; scottevest; the dreamzone sleep mask; saying "I get to" instead of "I've got to" (like I choose to instead of I have to); Using your "panda paws" (palms) to give a massage instead of "monkey fingers"; using your passport as well as driver's license even when traveling domestically; exercising with bodyrock.tv; improv tips; the power of benchmarking or modeling role models; and some other more intimate tips that will just have to stay in Vegas, where we were huddling.

Erica Upshaw and Cara Jenkins used their rapid-fire time to remind us of the importance and healing powers of altruism. (Among other things, Erica is preparing a new campaign around preventing substance abuse by setting positive conditions in middle school.) We prepared a message for one of our colleagues who is being treated for cancer, and made donations to preferred causes. 

The Huddle12 theme was "the intelligence to inspire" and indeed we ended on an inspirational note. I can't wait for Huddle14.

Continuous improvement through critical reflection

One of the mantras I have adopted in my life is: "there is no such thing as failure, only feedback."

Corollary: Back in my days at a high tech startup, my colleagues and I would regularly try to raise money from venture capitalists. We would come back to the office after making our pitch and employees would ask, "Well, did you get the money?" Our CEO would say, "No, but we learned a lot." So the expression was born in our office: "Learning is what you get what you don't get a check."

I do like to extract maximum learning from failure or feedback or not getting a check or whatever you want to call it. I have evolved a short template for reflecting critically on my performance. After any experience (e.g. giving a talk, putting on a training workshop, writing a grant, etc), I write down my answers to the following questions:

1. Current goals? What was I trying to accomplish? (These are usually carried over from a previous attempt, see last item below.)

2. Achievements? It's important to note and celebrate the ways in which I did accomplish or contribute to my goals. As my daughter's first-grade teacher says: give yourself a pat on the back.

3. Failures? What did not go well or according to plans, hopes, desires?

4. Success factors? What did I or other people say or do, or what was happening in the environment, that contributed to the achievements above?

5. Barriers? What did I or other people say or do, or what was happening in the environment, that contributed to the failures (or inhibited the achievements) listed above?

6. Next goals? What am I going to work on next time? I carry those over to the next performance.

Just as an example, here is my reflection after conducting a workshop that I give periodically on decision making:

Goals? – experiential; shorter (6 hours); same content. Focused only on skills.

Achievements? Individual, realistic practice (e.g. with computers), focused (not distracted by sharing  a computer). Finished on-time. Students were all engaged, even at the end of a long week. Students did arrive at skills they will need (confident).

Failures? Half-trained (not a lot of process training); Not ready to initiate a phone call; Did not present the service delivery lifecycle very well; (in SF Margot took us through the clinic before, recording of Margot initiating a phone call). The context. This was presented week before.

Success Factors? Computers available: kept away until they needed them (no checking emails). Experiential worked (practice, role playing). Undergrads had very fresh perspectives. No model clash.

Barriers? Limited time availability (of medical students – almost sporadic availability).

Goals for next time? Integrate the skills and process training? Immediate follow up and practice? Pipeline of patients waiting to be served? Process training would include scripts, practice calling, etc. Add time and split between two days? Video clip of process (project for student). Course for undergrads (intense), weave in medical students. 

In addition to using this framework to reflect episodically, I use it every week with my team. Each of us responds to those six questions with reference to the week we just completed.

Here are some excerpts of my reflections from last week (redacted for privacy):

LAST TIME GOALS  -  Finalize performance reviews; Film SCOPED promo; Fix budget for Mendocino in CMS Innovation; SSU affiliate agreement; BCT paper – check calculations; SV/O2O/MAP manuscripts; Reimbursements.

ACHIEVEMENTS - Performance reviews; SCOPED promo v1; CMS Innovation grant submitted; BCT paper moving along; PANCAN; Shanti; QL WCRC; IHPS adv bd meetings - leadership summit idea; CERC idea well received. Some progress on SSU.

FAILURES - Did not get to O2O/MAP manuscripts; reimbursements; CS video and marketing materials; 

BARRIERS - Grant collaborator canceled meeting, did not complete draft on time.

SUCCESS FACTORS - Grant collaborator put more resources on project and team rallied to submit a promising proposal.

UPCOMING GOALS - Mtg with John and Jill; SV/O2O/MAP manuscripts; SSU; CHQI Feb privacy mtg; reimbursements; Feedback; BMB syllabus; Promo video to Trina

Each week I share my reflections with my team, and they share theirs with me, and we discuss all the elements. It's a powerful way of going beyond setting/reporting on goals... to reflecting on the dynamics surrounding our productivity.

Occupy Your Mind

My wireless carrier recently sent me a text message:

You used 19767713 KB of 12634112 3G/4G data. Overage is 0.05/MB. Usage resets 12/08/2011.

That week, I spoke to a student who was applying to nursing school and was offered a package of loans. She was clearly informed of the total loan amounts and the interest rates, but not what the total monthly payments would be.

Simultaneously, I was reading an article in Rolling Stone about the Occupy movement, and this really resonated with me:

"There's no better symbol of the gloom and psychological repression of modern America than the banking system, a huge heartless machine that attaches itself to you at an early age, and from which there is no escape. You fail to receive a few past-due notices about a $19 payment you missed on that TV you bought at Circuit City, and next thing you know a collector has filed a judgment against you for $3,000 in fees and interest. "

Finally, I was reading Walter Isaacson's biography of Steve Jobs. Regardless of whether you agreed with him or not, Steve Jobs was passionate about Apple's products and committed to continuously improving them. He cared about how people used them.

What do these threads have in common?

Well, I appreciated that my wireless carrier was proactively notifying me of my data usage. But they did not really put much effort into actually communicating what I need to know. Even in 160 characters, they could have done much better than:

You used 19767713 KB of 12634112 3G/4G data.

First, I could not tell whether the first number was larger or smaller than the second. Can you?

That's because they used KB and no commas to parse the numbers into millions or billions or whatever.

They could have saved characters and increased the clarity of the message if they had converted to GB, and mentioned that the second number was my monthly cap:

You used 19.77 GB of your 12.63 GB cap on 3G/4G data.

Now I can see the first number is bigger than the second. 

Then they told me the penalty was 0.05/MB. Notice how they use the unit MB, when in fact they quoted usage in KB, and I really want to know in GB. I would suggest "Overage is $50/GB"

Now this all begs the question: why are they waiting until AFTER I exceed the cap to notify me?

If they cared about their product and service, they would know that I would appreciate a warning, say, at the 10 GB mark (out of 12) because at that time I could adjust my data usage and avoid fees.

Instead, I got on the phone with them to try to get them to reverse a $300+ overage fee. (All this data use related to the fact that I had accidentally backed up a movie file over my mobile hotspot connection.) They "adjusted" my bill based on the fact that I have been a mobile subscriber with this carrier since 1997. I wonder if others would have parsed the text message the way I did, noticed an overage, and called promptly. Calling promptly to contest it was big, because the company had not actually generated my bill yet, and so could still "adjust" things on the data level without having to make adjustments to the actual bill. A less informed consumer might have been stuck with the $300+ tab, and fees, penalties, and ultimately a collection agency.

The relevance to student debt is that apparently we are entering a student debt bubble similar to the mortgage bubble. A common cause of all these problems is that companies are not communicating numbers clearly to a public that is not terribly numerate (literate in the use of numbers.) My student had not yet translated the loans and interest rates into monthly payments over a defined term - which is how you really can make sense of payments.

Based on my coaching, she inquired and calculated and I heard back from her:

"The Stafford loan I received for 5,500 per semester is a little confusing for me. The rate is 3.4% for loans between 2011-2012, and 6.8% for loans between 2012-2013, and the term is 10 years. In either case, an origination fee of .5% is deducted from each disbursement- I've looked this up and it seems it's an extra fee added on for each monthly payment. I can defer this payment up to 6 months after graduation. I used an online financial aid calculator for the loan. I calculated each at their separate rates- so that'd be $5,500 at 3.4% for ten years (plus the fee), plus $16,500 at 6.8% for ten years, and that came to a total of $245.24."

She did the same for other loans, all with different rates and terms (Perkins, Unsubsidized) and came up with

"In total, my monthly payments would be around $328.41 per month."

That's now comprehensible because you can relate it to a monthly take-home on your paycheck, and to expenses such as a car payment or rent. Notice how we went from how the loan is quoted per semester at variable interest rates (because her school term spanned two rate periods), to one monthly payment for ten years.

My student had not really paid a lot of attention to the amount of debt her parents were going to take on. So I pointed out that she should really be helping her parents make sure the debt was affordable for them. They might lose their jobs or pension and she might end up having to carry their portion of the loan or otherwise supporting them in their old age!

"I calculated my parents loan payment- it would be about $965.56 per month, the rate is 7.9% over ten years with a 2.5% origination fee."

These are large monthly payments for a middle class family. The investment in a nursing career might well be worthwhile, but regardless, it's important to translate the blizzard of numbers from the university, into a set of total monthly payments. 

Most human beings are blessed with huge, flexible brains capable of learning the basics of discounted cash flow calculations, including compounding interest. I'd like to see companies and universities putting their collective minds to work on simplifying debt communication; and of course students and families should take on the task of educating themselves to the monthly payment and other implications of the bargains they are striking. I try to approach such tasks as puzzles. It can be fun and confidence building for anyone to brush off our math skills and figure out the details. For anyone who knows what I do in my day job (medical decision making), it should be obvious that all of this applies equally to interpreting the statistics we may hear about risks and benefits of treatments. We are blessed to live in an age where some internet research, or consulting a librarian or consumer/health advocate can usually generate better understanding at low cost.

Occupy your mind, and your wallet (and body) will thank you.

Cancer Screening Controversies

UPDATE - just got off the air and will add a postcript below.

I have just been invited to speak on KQED Forum, a San Francisco-based radio talk show, regarding cancer screening controversies.

The show will air Wed Oct 19, 2011, at 9 am PST and can be heard at 88.5 FM in San Francisco, or online at http://www.kqed.org/radio/listen/, or by podcast a day later at http://www.kqed.org/a/forum/R201110190900

I'm going to assemble a few resources that I can point listeners to and update this post. Email me if you have anything you want me to share with the public.

My key message about cancer screening or indeed any health-related action, is that all medical interventions have potential risks as well as benefits. It makes sense for individuals to learn what these are. In addition to consulting physicians, there are now educational resources called decision aids that take on specific topics. These decision aids can be print, audio-visual, or web-based materials. What distinguishes a decision aid from other health education materials is that they are organized entirely around a frequently encountered dilemma. Producers of good decision aids are not trying to persuade anyone to do anything in particular; rather they try to present a fair and balanced view of the pros and cons, including both quantitative evidence as well as qualitative stories or testimonials from patients who have experienced treatments and outcomes.

Producers of decision aids include a non-profit, the Foundation for Informed Medical Decision Making, which produces web, audio-visual and print decision aids with its commercial partner, a company called Health Dialog. Disclosure: I am the recipient of both research and implementation grants from the Foundation for Informed Medical Decision Making. Another producer is the non-profit organization Healthwise, which supplies many websites and medical centers with web or print patient education materials. Other sources of good information on medical decisions include the National Cancer Institute and the Mayo Clinic. There's a comprehensive index of decision aids at http://decisionaid.ohri.ca/AZlist.html. 

Decision aid producers recognize that cancer screening programs create harms as well as benefits. Therefore, these producers have created decision aids targeted at some of the most frequent decisions: breast, prostate, colon cancer. I'll provide some links below. 

So why is there controversy? What could possibly be wrong with people weighing the risks and benefits of screening and making an informed decision with their doctor? I'm the wrong person to ask: I'm personally and professionally committed to informed and involved decisions. I am comfortable, overall, with the ethic of individual patient autonomy and self-determination. Occasionally ethical conflicts arise pitting the welfare of many against the freedom of the few, but these are rare and I don't see them in screening. The controversy may arise because we are still transitioning from paternalism to participation in health care decisions. As William Gibson said, "The future is already here, it's just unevenly distributed." 

Part of this transition is that there are many entrenched viewpoints and interests at stake. Outside of the health effects of screening on individuals and populations, there are people whose wealth or power or status grow with the use of screening technologies and processes. Conversely, some will benefit if screening technologies and processes decline in popularity. This is true in all industries, and health care is no exception. Some people are trying to drive revenue (for example, producers of drugs, devices, procedures and fees), while others are trying to contain costs (employers, insurance companies, government payers.) The patient is a passenger in a car with two drivers, one with a foot on the accelerator, the other with a foot on the brake. This is a dangerous ride. In that situation, the patient's best hope is to find a good doctor and take control of the car together.

OK on to some links:

1. Gary Schwitzer is a journalist who critiques media coverage of controversies, including screening. He has a great blog post at http://engagingthepatient.com/2011/10/17/how-the-news-media-may-hurt-not-help-health-literacy-efforts/. Scroll down to read his third point about cancer screening. A screening program is different from testing someone who is high risk or has symptoms. Testing can have very high benefits with very low risks or harms. Screening is when you go fishing in the general population in the hopes of preventing deaths at relatively low cost in financial or human terms. In actual fact, most screening programs prevent very few deaths at high human and financial cost.

2. Prostate cancer. A company called Health Dialog (see above) normally reaches patients through contracts with insurers, who pay to offer decision aids as a benefit to their members. However, the general public can access Health Dialog's decision aid on prostate cancer screening at https://www.healthcrossroads.com/example/crossroad.aspx?contentGUID=fc326615-5b29-47f1-87c3-9a3e2d946919. Again, Health Dialog works with the non-profit Foundation for Informed Medical Decision Making to assure that the content is fair and balanced. Only medical editors with no financial or other conflicts of interest are allowed to shape the content.

3. Breast cancer - age 40. Regarding screening for breast cancer at age 40, my colleagues at the University of Sydney have produced a decision aid for that dilemma: http://www.mammogram.med.usyd.edu.au/. 

4. Breast cancer - age 50. A prominent health services researcher, Gil Welch of Dartmouth, has drafted a simple balance sheet that summarizes the benefits and risks of breast cancer screening for women in their 50s, I'm reproducing it here from his article in the British Medical Journal at http://www.bmj.com/content/339/bmj.b1425/T1.expansion.html:

For every 1000 women undergoing annual mammography for 10 years in their 50s:

Credits	Debits
1 woman will avoid dying from breast cancer	2-10 women will be overdiagnosed and treated needlessly
	10-15 women will be told they have breast cancer earlier than they would otherwise have been told, but this will not affect their prognosis
	100-500 women will have at least one “false alarm” (about half of these women will undergo a biopsy)

5. Breast cancer - all ages. There is a more detailed presentation, broken down by age groups, in a Canadian decision aid for breast cancer screning: http://www.phac-aspc.gc.ca/cd-mc/mammography-mammographie-eng.php. 

6. Colon cancer. This screening is considered highly effective. I was a little shocked to review some numbers recently and learn how small the absolute benefit is, or to put it another way, how many people must be screened to detect one colon cancer (thousands!). The National Cancer Institute has helpful resources on screening. They are not exactly decision aids, because they are not structured in such a way as to synthesize the absolute data. But they provide good summaries. The one on colon cancer screening is at http://www.cancer.gov/cancertopics/pdq/screening/colorectal/HealthProfessional/page3

Other than websites, I encourage people to review some informative books on the topics of cancer screening and risk reduction:

Gil Welch - Should I Be Tested for Cancer? Maybe Not and Here's Why. http://www.amazon.com/Should-Be-Tested-Cancer-Maybe/dp/0520248368 

Gerd Gigerenzer - Calculated Risks. How to Know When Numbers Deceive You. http://www.amazon.com/Calculated-Risks-Know-Numbers-Deceive/dp/0743205561 

POSTSCRIPT

We had a few callers on the show that with cancers diagnosed through screening. Their understandable reaction is that screening saved their lives. The hard truth is that we don't know what would have happened, whether symptoms would have developed, whether treatments at that point would have been effective. What we do know is that out of 100,000 people screened, we would expect a few lives saved. People have an understandable reaction that "if ANYONE is saved, it's worth it." If you feel that way, I understand, but then all of us should be parking a mile away from our office each day and walking that extra distance to work, because we would save about an equivalent number of lives, at no real harm (look both ways when you cross the street), and with the added benefit of feeling good from exercise. These are not mutually exclusive of course, you can do both. But the point is that we do make decisions that cost people lives - such as commuting to work from further away, in order to save on housing expenses. Lengthening your commute kills people. So if you feel your life was saved by screening, please evangelize people driving less as much as you evangelize screening.

I come away feeling that, in urging caution about screening, I am cast in the role of someone who wants to deny people access to potentially life-saving therapy. Not at all. My professional mission is for people to make informed decisions. If the benefits of screening sound like they are worth the harms, you should advocate for your access to the programs. The key point is self-determination. And the screening slogan should be, not so much, "Screening saves lives" but more accurately, "Screening saves a few lives per 1,000 people screened, and can lead to varying degrees of harm for dozens or hundreds of others. Whether it makes sense for you will depend on your priorities and perspectives. Review a decision aid and talk to your physician about it."

My wish is that people advocate harder for their access to decision aids. The public has long been too satisfied with the news media digesting and (mis)interpreting scientific studies. Ask your hospital or clinic or insurer to obtain decision aids for you if they don't already. Then make a list of questions and consult one or more doctors and record their answers so you don't forget them. These strategies are proven to improve patient understanding, question-asking, and information recall.

POST-POSTSCRIPT

I have now heard from some colleagues who wish to convey their messages on this topic.

Hope Rugo, Director of the Breast Oncology Clinical Trials Program at the UCSF Breast Care Center, writes, "I think it is important for women to know that the reason for the controversy is that rapidly growing tumors that have the highest risk are least likely to be found on screening exams.  So in my mind, what we should learn from that is that: 1.  Screening mammograms are still useful, it is just not clear that you need to get them yearly when you are under the age of 50 as the breasts are very dense and lesions are less visible, as the benefit is low.  2.  Abnormal exam findings should always be thoroughly evaluated.  3.  The less frequent screening may not be the right advice for those with a family history or personal high risk (prior DCIS, calcs, etc)."

On the topic of bi-annual versus annual screening, Laura Esserman, Director of the UCSF Breast Care Center, writes: "Data is pretty clear. There is no demonstrated data that screening every year is better than every 2 years. There is an increased risk of being called back and having an unnecessary biopsy (Annals of internal medicine last week)- by almost 50% if you screen every year. The risk of missing advanced cancers is not statistically significant, and the magnitude of any difference negligible (2-3%). Same benefits, less risks. Screen every 2 years. And it fits biology that fast growing tumors present between screenings- even when annual." I will add from years of working with Laura, her highest priority is always that patients arrive at an informed decision with their doctors based on their personal priorities and unique biology.

From the Palo Alto Medical Foundation, Dr. Edmund Tai writes: "Family history is often overlooked and is tedious to do. We need to enlist patient to help with their own care by providing a more detailed history. THere is a free website run by the NCI called "My Family Health Portrait" that has a nifty software to allow a patient to enter their FH.  It can be tedious if there is a large family but it is a free tool developed by the surgeon general and is actually a good idea.  As I am involved in clinical cancer genetics FH is fundamental in identifying patients who are at the highest risk.  It is estimated that >30% of all cancer patients have some family hisotory of cancer and 2-5% (depends on cancer type) have very high risk hereditary transmission.  We have only developed an indepth understanding of breast, ovary, and colorectal cancer but more are forthcoming.  The reason is that there are only a few genes that have high penetrance and high specificity.  The majority probably are affected by multiple genes with low specificity and we hope newer technology would allow us to pick those up."

If you have to ebb, make sure you flow

A recent article in the NY Times magazine about decision fatigue got me thinking. Thinking leads to fatigue, and fatigue prevents thinking. So thinking leads inexorably to impulsiveness. Seems like a paradox. I will be brief lest I deplete my thoughts.

Decision scientists know that impulsiveness is not always bad, as Malcolm Gladwell summarizes in Blink. Sometimes we make wiser choices by acting on our unconscious instincts or impulses. My critique of Blink is that the unconscious is most effective when we act based on deep pattern recognition borne of expertise borne of repetition. For example, after years of experience with rock climbing, you might approach a pitch and find yourself troubled about the rope setup without being able to articulate exactly why. As described in The Gift of Fear (de Becker), it can be very important to listen to your unconscious even if it is not articulate.

In the modern world, however, we often encounter brand new situations, some of which involve very high stakes (medical, housing, career, relationship decisions). In these situations, under-thinking and impulsiveness may not channel the informed unconscious, but simply our ignorance. Then we may overlook missing but knowable information, or act out rashly on ill-considered preferences (e.g. fight/flight defensive reactions). This is really stark in medical and financial decision making. We may react impulsively to a perceived threat (pre-cancer diagnosis, stock market churn) and embark on irreversible decisions (surgery, divestments) based on fears that may be, on further reflection, overblown. On the financial topic, Warren Buffett supposedly says, "Be greedy when others are fearful."

I am drawing several connections to this work on decision fatigue. First, fatigue is the result of consequentialism - the commitment to evaluating the pros and cons of different alternatives. Besides impulsiveness, there is another alternative to consequentialism, namely formalism. This is when you resolve to follow a rule rather than constantly evaluate the consequences of your actions.

My favorite example is that I find it very depleting to constantly re-evaluate whether to keep scheduled commitments. I often schedule commitments 3 months in advance, and then find that when the time approaches, there are suddenly three competing claims on that time. I used to re-evaluate: should I reschedule with A so I can do this new activity with B? I now have a rule that I keep commitments in the order I made them. I don't think about it. It's a no-decision. Technically, I might have better optimized my time by rescheduling dynamically. But I have preserved daily capacity for decision making through rule-following.

In my experience, though, there is an even better way to preserve decision capacity than to follow rules. Find Flow. Flow is the state of being perfectly challenged: enough so as not to be bored; not so much as to become frustrated. You know you are in Flow when you lose track of time. It's a form of self-hypnosis. It is inherently energizing. I can spend six hours at a stretch making complex decisions that flow like water in a stream. I might be designing a training exercise, writing a song, or writing a research report. In those cases, I can emerge with full decision capacity. Conversely, if I spend six hours processing my expense reimbursement requests, I achieve a state of anti-Flow and feel totally depleted. Productivity gurus have therefore pointed out we should manage our energy, not our time (see The Power of Full Engagement by Loehr and Schwartz).

When you are conscious of the possibility of decision fatigue, you can anticipate it, and prevent it.

If you have to ebb, make sure you flow.

Unanswered questions, never asked

I got in the elevator this morning at the hospital where I work, and the man who boarded next to me said, in a friendly tone, "So did you get in to see the doctor?"

I was taken by surprise.

This was a presumptive question, in the sense that it presumed I was waiting to see a doctor.

Answering the question truthfully with a "No" might still leave the wrong impression.

That's the problem with a presumptive question.

"I work here. I'm a researcher," I responded. I had put my badge in my bag as I departed my meeting. Next time I'll keep it on.

My first thought was that he mistook me for someone he saw in the waiting room. People have been known to wait for a while to get in to their appontments in our hospital...

I was wrong.

"Oh, I thought you were a sales guy from a drug company, those guys are always trying to get in to see the doctors."

Our brief ride came to an end, leaving me with unanswered questions, mostly because I did not think fast enough to ask them before my outgoing companion disappeared into the day.

My main question was: What did I say or do that led this gentleman to believe I was a drug rep?

There was a cascade of unspoken questions behind that: did he see being a drup rep as a good thing or a bad thing? Was it my appearance? My demeanor? My clothes? Should I be flattered or insulted? Was this the first time in history a systems engineer had been confused with a drug rep? Has anyone ever approached a drug rep and confused them with a systems engineer?

The presence of drug reps is controversial in clinical settings. Basically, where they once roamed the land with relative impunity, they are now banned or on their way to being banned. Many feel that their sales mentality embodies the potential for corruption in our fee for service health care system, where health care providers and producers make more money by pushing more treatment. With this background knowledge, I felt somewhat threatened by my elevator companion's casual branding of me as a pariah. My self-image is much more the knight in shining armor - the patient advocate who helps people work with their doctors against the conflicting forces of insurance companies cutting costs and pharmaceutical companies driving revenue. 

I did see the whole interaction was a gift. I try to be pleasant on elevators, but I'm guarded. This gentleman, who if I may counter with my own attributions, was dressed like a recreational golfer (bright blue collared polo and long green shorts), was not guarded. He gave me the Robert Burns gift: "to see ourselves as others see us."

"Jeff," he was saying, "You may think you are Mr. Patient Advocate, but under some conditions you can come across as Mr. Corporate Rep."

I really wish I had been quicker to ask my follow up questions. This led me to ponder how much we miss because we are too slow to inquire. We often respond to any interaction defensively rather than with curiosity.

For example, I noticed a few years ago that when someone gave me a compliment, I tended to deflect it. Now if someone says, "I really enjoyed your talk/paper/program," I immediately respond, "Thank you. What did you like about it?" I have gained so much valuable, actionable feedback that I would have missed if I had just stammered some awkward thanks and turned the conversation to another topic.

In general, when I hear someone evaluate anything, I now try to get them to say more about what is driving their impression. You can't always trust the specifics you get. Sometimes a holistic impression is driven by unconscious reactions that are not easily surfaced. But often people are aware of their preferences and inferences.

I enjoyed the conversational gambit that my elevator friend employed, opening with a presumptive question. It gave me a lot of food for thought.  It's entertaining in a social setting as an icebreaker.

I don't recommend it professionally though. Your patient or colleague may become as distracted as I was by the implications of your presumption.

But I do recommend developing the conditioned reflex to ask productive questions. Whereas a presumptive question stimulates distraction, a productive question stimulates more concrete and specific examples or gets people to illustrate their reasoning.

Imagine the mysteries we could solve if we surfaced responses to those unanswered questions that we never asked.

Life and death in other professions

Last week I hosted a meeting in which premedical interns working in my program at UCSF got to ask questions of two of our most experienced clinicians at the UCSF Breast Care Center - an advanced practice nurse and a medical oncologist. 

One of the interns asked about how, as medical professionals, they cope with the life and death responsibility that can accompany their work (e.g. how the right move can save someone but an error can kill them). Both clinicians pointed out how even routine daily activities like driving a car can be come a matter of life or death, and certainly many other professions are responsible for public safety. 

The following day, another colleague drove this point home with the story of her mystery illness. She was pregnant and started experiencing fainting spells, headaches, dizziness, and a cognitive fog (not able to think straight or concentrate). Her physicians ran all kinds of tests, ended up attributing it to pregnancy, and put her on bed rest. She got worse in a matter of days. Through sheer coincidence a Pacific Gas and Electric inspector came out to her house at this time, and it turned out that my colleague was suffering from carbon monoxide poisoning. The landlord had upgraded a water heater before my colleague moved in, and did not realize that pipes that should have been slanted were horizontal, creating a backup and leak of gases including carbon monoxide. The building inspector signed off on it without realizing the hazard. Both of these people, in somewhat more everyday professions than our nurses and oncologists, ended up poisoning her through their errors. The building inspector said to her, “I’ve been doing this for decades and sometimes I wonder if what I do really matters. This is such a wake up call that it is critical.”

The happy ending to the story is that my colleague was fine (it was low level carbon monoxide poisoning at that point) and her body apparently filtered out the poison so the fetus was fine, and is now a very healthy toddler. So it was more of a close call or potential harm than actual. But it could have been a lot worse.

One of my take-aways from this anecdote is that western medicine still doesn't pay enough attention to the environment and system in which patient complaints arise. My colleague had dozens of sophisticated tests, but no one really probed the angle of where she was living and what might be going on in that environment.

I have been known to complain about our smoke detectors and carbon monoxide monitor at home waking me up in the middle of the night with that intermittent beep they make when their batteries are low. Which one is it? So annoying!

I think I'm going to reinterpret that intermittent beep as reassuring. And just change the batteries on all of them.

Decisions and reversals of fortune

I feel fortunate that my schooling led me to discover my professional calling. Based on undergraduate and graduate work in statistics and engineering, I now help people improve their leadership, teamwork, and decision-making skills. The most challenging decisions I have encountered are those involving a family health crisis.

One of the key concepts I learned early from my teachers (especially Professor Ron Howard) was the difference between a good decision and a good outcome.

In theoretical terms, you can look at decision-making in terms of coherence or correspondence. The coherence approach says, "How coherent is this decision at the time you make it?" In other words, you judge the quality of a decision at the time you make it, along a continuous spectrum. The correspondence approach says, you can't tell how good a decision was until you see the outcome.

The implications are significant for medical decision making. But before I get into that, let me illustrate them using an example from everyday life.

In early February, 2011, we had a busy father/son day in my family. The Giants were celebrating FanFest and we were given passes to get in early. My son was also looking forward to his playoff game in a local basketball league. Then we were celebrating Chinese New Year with my in-laws. (None of us is Chinese, but we live in San Francisco where this feels like a national holiday for all to enjoy.) To conclude this busy day, we had an invitation to go to a Cal basketball game as guests of my in-laws, or stick with our plans to watch USF play Santa Clara.

As the day progressed, we faced a series of decisions. It started early in the morning. I was intent on getting my son out the door so we could catch the bus (my wife and our daughter had the car). We needed to look ahead at all the gear we would need that day. I printed out a color map of the FanFest events. My son was sure that with our early passes we would have unlimited access to autographs etc. I figured out the bus schedule online and off we went. I was feeling pretty good. Ten minutes into the bus ride, my son asked me if I had the FanFest tickets. No! We jumped off the bus and headed back home.

Now we were going to be running late for the 9:30 gates at FanFest. As we rode another bus home to get the tickets, I formulated some scenarios. First I called my wife to see where she was with the car. No answer. I didn't leave a message, figuring I shouldn't bother her. We can work this out on our own, right son?

Next I told my son we could call a cab. But cabs are notoriously unwilling to come out to our house on the outskirts of San Francisco. They almost always pick up rides off the street even after accepting the dispatch to our house. Another alternative was to call Uber. This is a unique company that dispatches airport limos that have downtime, and redeploys them as city taxis during each hiatus between booked rides. You can order them using your smartphone and see their progress on a map as they come and pick you up. But it's two or three times as expensive as a cab.

My son thought we should just call a cab. I did, and got an estimate of 5-20 minutes. Twenty minutes later, no cab. Now we were really stuck because going with Uber would cost a lot and still not get us there on time.

How am I doing, son, with my decision-making?

Just at that moment, we got bailed out. My wife came home with the car. I called and canceled the cab (still no sign of it). We all dashed down to FanFest. We got there in time for the opening of the gates at 9:30 am.

Now here's where things get interesting from a decision making point of view. The gates did not open at 9:30 as scheduled for us special pass holders. And when we got there at 9:30, as opposed to waltzing in with no line (as in previous years), we had to find the back of the line... which was a 20 minute walk down the Embarcardero, practically at the Ferry Plaza. Apparently winning the World Series changes the dynamics at the Giants FanFest.

I despaired of ever getting into FanFest. I asked the kids, "Should we bail on the line and go get an ice cream sundae at the Ferry Plaza?" I don't EVER offer food bribes as distractors, so this captured their interest. But they were more intent on FanFest.

The line started moving at 10:10 and we got in at around 10:30. It was jammed. No hope of getting autographs by noon (our departure time for my son's basketball game). My son lamented the timing of his game - without it, he would have gotten in line for the autographs and grab bags, and maybe even viewed the World Series trophy (longest line for that one). But one of my management principles, for family and work alike, is that we keep our commitments in the order we make them. We attended some Q&A, watched some video highlights of backstage at the World Series, and wandered around. Then left for my son's game. As we left the attendant reminded us, no coming back in.

As soon as we got to a quiet place, my wife checked her voicemail and indeed there was a message. Our son's game was canceled - rescheduled to Monday. Aargh! Had we known this 10 minutes earlier, we would have stayed at FanFest for another couple hours before meeting my in-laws for lunch. There was much wailing and gnashing of the teeth and bemoaning of our fate, particularly by a certain 10 year old for whom this was a big big deal.

For the second time that day (an all-time record), I offered a junk food bribe as a distractor, this time successfully, and we all went to Jamba Juice.

Of course, when we got to lunch at Shanghai Dumpling, the line was long and we then faced the decision of, should we stay or should we go? We stayed. Service was slow. The food, when it arrived, was divine.

Finally, we went to the USF game. This was a make-up game because I had been too sick to take my son to the USF-Gonzaga game earlier in the month. Which turned out to be a cliffhanger pulled out by the home team, USF. This one, against Santa Clara, was OK. Meanwhile, the game we didn't go to turned out to be a triple-overtime thriller at Cal.

So how did we do in terms of decision-making?

Let's recap. First, except to my son, there was nothing terribly high stakes on this afternoon. I would say I made a low-quality decision when I spent a lot of time printing out a color map of the Fanfest events and lost sight of what should have been a higher priority, locating and bringing the tickets. This was a low-quality decision regardless of the outcome: I would recognize that as an error even if it never cost me anything.

I also made a foreseeable error when it came to ordering a cab. At that point, my son and I believed that arriving by 9:30 would be critical to our enjoyment of an event we had been looking forward to for weeks. Given what I value in clear-headed moments, this was not the right time to save a few dollars, particularly given my long and negative experiences getting cabs out to our neighborhood in a timely fashion. The Uber airport limo service, in contrast, is a lock. I should have splurged. Note that I feel that way even though we had a happy outcome, in that my wife and daughter showed up with the car.

With the benefit of hindsight, some would say, "Fanfest was over-run. You would have wasted money on a car service, and the delay associated with returning to get your tickets turned out to be immaterial." True, but given what I believed and what I valued at the time I made those decisions, they were lower quality decisions than I could and should have made. Regardless of the outcome.

Leaving FanFest was, in contrast, a good decision even though the outcome was unhappy. We experienced much regret over leaving when we learned we did not have to be at my son's playoff game. But again, given what we believed and valued, it was the right thing to do and I would do it again under the same circumstances. Perhaps my wife could have checked her voicemail before leaving the park, but it was too noisy, and anyway we share a family value of not being obsessive about checking our voicemails and emails when we are together.

At the restaurant, we chose to wait because my mother-in-law assured us the food would be worth it, based on her prior experience. We loved it. It would have been a good decision, based on what we believed and valued at the time, even if the food had turned out badly.

We attended a decent USF game and missed a splendid Cal effort in their triple-overtime loss to Arizona. My son doesn't quite subscribe to the coherence theory of decision quality (yet!), so his consolation was that Cal lost, and in retrospect, three overtimes preceding a loss would have simply prolonged his suffering. Better for him to have enjoyed the USF win. This logic is impeccable among sports fans, and matches the correspondence theory of decision quality. As a management scientist, I feel this is indeed incoherent. Attending the USF game over the Cal game was a good decision before the games took place, based on what we believed and valued that afternoon. How could the outcome of the night-time games change the quality of our decision?

Coming back almost full circle to the Chinese New Year, I just read my daughter a Buddhist fable that illustrates the different reactions we all may have to reversals of fortune. The gist of the fable is that a villager's most prized possession, his horse, disappears one night. Others come to express their condolences, or perhaps revel in his misfortune. "What bad luck," they say. "Good luck, bad luck, we'll see." shrugs the villager. Next, the horse returns with a dozen wild horses. "Congratulations on your good luck," sings the chorus. "We'll see" says the villager. Then the villager's son breaks his leg while taming the wild horses. "Such bad luck" say the neighbors. Again, from the villager: "We'll see." As the son is limping around, the Emperor's army sweeps through the village and drafts all able-bodied men. The son escapes this fate. "So lucky," say the other parents. "We'll see" says the son, who has internalized his father's attitude.

This fable illustrates that even the quality of outcomes cannot be judged in the short term! So even if you subscribe to the correspondence theory of decision quality, you are stuck waiting an arbitrarily long time before you can judge a decision. The correspondence view of decision quality is indeed incoherent.

The coherence theory of decision quality - judging a decision based on what is known and valued at the time it is made - allows us to surf on the sea of uncertainty without drowning in regrets at every reversal. This philosophy of decision making is perfectly captured in the Serenity Prayer - "Give me the courage to change the things I can change, the serenity to accept the things I cannot, and the wisdom to know the difference."

Conversely, many in our culture tend to judge outcomes. If things turn out well, conventional wisdom supposes the happy events must have been preceded by good decisions. If things turn out badly, it was because of bad decisions. 

Over the years I have directly worked with hundreds upon hundreds of patients making life and death decisions. I have reviewed hundreds more such cases through my work with organizations implementing decision support programs. Bringing the coherence theory of decision quality to the patient bedside or examining room has been rewarding because people recognize and embrace it as the most productive way to take positive action while recognizing the limits of our control. Decision support programs encourage patients to review information, ask questions of their doctors, and reflect critically on the responses they get. In practice, this usually means slowing down, challenging authority, and getting second opinions, among the seven steps I have described previously. And, having followed this process of critical reflection, we can move forward with confidence and recognize any reversals of fortune as simply bad outcomes that sometimes follow even good bets.

Recently one of my colleagues saw a patient who had experienced a recurrence of breast cancer five years after her initial treatment. In addition to suffering from the recurrence, this patient was experiencing significant distress over her recollection that she had declined the most aggressive possible treatment the first time around, opting instead for a slightly less aggressive strategy with significantly fewer side effects and a slightly higher rate of recurrence. My colleague showed this patient the list of questions  and consultation records generated five years ago as part of our decision support program at UCSF. The patient was relieved to be reminded of the coherence of her original decision, based on what she and her doctors knew and valued five years earlier. Although no one likes to think of medicine as a gamble, she recognized that she had made a bet that was right for her at the time. With a reminder, our patient was able to separate her decision from a subsequent reversal of fortune. Indeed, she might have recurred even with the more aggressive and invasive treatment. Who knows? We will support her in moving forward with courage, serenity, and wisdom.

My personal and professional experiences leave me more resolved than ever to promote the coherence view of decision quality. Others have used fighting words such as logical or rational to describe this view of decision making. Fighting words because people can have different standards for logic or rationality, and will resist the imposition of someone else's definition. But decision quality is not binary like logical/illogical or rational/irrational. It is a spectrum. Please join me in asking this question, especially in high stakes situations: to what extent do our decisions reflect what we know and value at the time we take action?

Structure empowers and constrains

Oulipo is an artistic movement committed to creating works of art based on constraints. The most famous constraint-based art forms are probably the haiku and sonnet.

I've been reflecting on the Oulipo recently because patients and colleagues have commented on my SCOPED model for structuring notes about decisions. I teach people to use the SCOPED model for writing lists of questions (e.g. for their doctors); for taking notes at a consultation; and for arriving at a decision. (See www.scoped.org.) It's not limited to medical decisions, but those are particularly well-suited to this kind of analysis.

SCOPED stands for Situation, Choices, Objectives, People, Evaluation, and Decisions.

Some people love the structure. One patient recently wrote:

"I loved the way my summaries were organized, i.e. "Situation"; "Choices/Questions" etc. It is an excellent way to make this confusing process more clear. I don't know if this is standard. If it is not standard, it should be. This program should be shared with all major medical centers. It is an amazing method of actually educating patients and involving them in their own healthcare decisions, rather than just being passive patients who "receive" treatment."

A physician once told me that SCOPED was the next-generation standard for documenting informed consent.

I coined SCOPED as an homage to the SOAP note in medicine. SOAP stands for Subjective, Objective, Assessment, Plan. It is the rubric that doctors and nurses use to guide their patient interviews and notes today. Notice, however, it does not actually mention decision making. So SCOPED is intended as the SOAP note for shared/informed medical decision making.

One reason to have a mnemonic is that it helps with thinking. People can hold 7 or so thoughts in their short term memory. But if you form a hierarchy out of your thoughts, you can retain 7 items within each of 7 categories. So the six elements of SCOPED can be a scaffolding to hold 7 items per category. The people I train to process decisions using SCOPED go from being able to think and talk about 7 items at once, to balancing 42 decision issues in their heads. 

Another reason for structure of this type is simply analytic. We can communicate more clearly when we focus our communication on one subject at a time. We can cluster topics under a rubric and then deal very efficiently with related topics together. So, for example, I recommend that doctors and patients discuss the key facts driving a Situation (e.g. the key prognostic indicators) before going on to discussing what treatment Choices are available. Otherwise, decision conversations become a spaghetti jumble of past, present, and future issues.

Communication can also become much more efficient if people adopt a common scaffold or structure. If people adopted SCOPED (or another worthy framework) as a common structure for thinking, talking, and writing about decisions, they could focus in very quickly on the sparse or underdeveloped dimensions. It's great to be very clear on the Situation (physicians spend a long time taking a history), but not so good if that only allows 3 minutes for Evaluation of how each Choice affects each Objective. A structure like SCOPED allows you to see where the gaps are in your current thinking.

Admittedly, this is a very propositionally oriented view of communication. Much communication is non-verbal and that is very important. But in discussions where some factual learning is going on, such as patient-physician conversations, we want to make sure the verbal communication is as good as it can be. I have found that, somewhat paradoxically, being more business-like about communication (e.g. following an agenda) provides structure that is very conducive to intimacy and relationship-building. In my view, a structure like SCOPED can enhance the therapeutic alliance. 

But some people think SCOPED is too complex. A very popular author told me, "For every letter you drop, you'll see an exponential increase in adoption." A very experienced medical school professor told me, "students can't handle something so conceptual. Maybe four letters." Another colleague asks, "Is there a SCOPED light version?"

Maybe we'll get there. But I am not giving up on the idea that people can quickly learn and hold a 6-item scaffold in their mind. I also like the fact that SCOPED is a theory-based framework. Decision and organizational theory suggest that these dimensions are necessary and sufficient to critically analyze any decision. In other words, if you leave one of the SCOPED elements out (the People section is often under-developed), you are at risk for making a poor decision, one that may not be fully endorsed and implemented by other participants and stakeholders. Conversely, the theoretical claim is that there is nothing you can think, say, or write about a decision that does not fit into one of these categories. You need all six, but you don't need any others.