5 Books Every Resident
Must Read
Hans House, MD, MACM, FACEP
Vice Chair for Education
Department of Emergency Medicine
University of Iowa
Objectives
Achieving mastery
Honing intuition
Think differently
Understand sources of error
Apply the art of medicine
The “5” Books
Malcolm Gladwell’s trilogy
Tipping Point, Blink, and Outliers
Freakonomics by Dubner and Levit
How Doctors Think by Groopman
Complications by Gawande
The House of God by Shem
Malcolm Gladwell
The Tipping Point
2000
Inspired by the drop of crime in
NYC – real change possible
Analyzes “epidemics”
Mavens, connectors, salesmen
80 / 20 rule
Limited application to
medicine except public health
Blink
2005
Experts make snap judgments
without realizing how they do it
Enormous power of intuition
Sick v not sick
Thin slicing
Prone to biases (curtained
auditions blind tasting, IAT)
To do it correctly, it requires
mastery of the subject . . .
Outliers
2008
10,000 hours, K Anders Ericsson
ACGME latched on
Deliberate practice (more on this
later)
Success is a group practice- not
innate talent
Environment of success (Bill Gates,
The Beatles, Julia Child)
Achievement gap
Outliers
Plane crashes
Sequence of errors
1990 Avianca 052 crash
Mitigated Speech
2013 Asiana 214 crash
1.
2.
3.
4.
5.
6.
Command (Do this now)
Obligation statement (We need to do this)
Suggestion (Lets do this)
Query (Should I do this now?)
Preference (it might be a good idea to do this)
Hint (How about them Bears?)
Outliers
Pure IQ does equate with success
Threshold IQ needed
Compared case studies, identified
that success requires “Practical
Intelligence
Emotional Intelligence (EI)
BBC firing example
IQ vs EI
Freakonomics
Stephen J Dubner
and
Steven D Levit
Freakonomics
Originally published 2005
People respond to incentives,
sometimes in unpredictable ways
Unafraid to challenge conventional
wisdom
Relies on data, thinks differently
Alternative explanation to the crime
rate drop in NYC
Physicians need to have alternate
explanations for observations
Super Freakonomics
2009
Deliberate practice
Setting goals
Obtaining feedback
Concentrating on technique
Describes the development of the EHR
Crash testing booster and seat restrained
Prostitute chapter
AEM 2013; 20:880
How Doctors Think
2007
Something for every
specialty
Systematic review of
medical error types using
patient anecdotes
Example 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 Medicine
Negative feeling cloud judgment
Taking the time to sit and listen
Newman: applying the art as
Hippocrates would have done
Plan for backup during a
procedure = do the same with a
complicated patient
Example: Spanish speaking
patient with headache with 4 visits
Complications
Atul Gawande, MD, MPH
Affordable Healthcare Act
Complications
Wrote as a surgical resident,
published 2002
Discusses his own medical
errors
Echoes 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.”
Complications
Impaired 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 God
1978
Shocking, hypersexual, coarse, and
unprofessional
Embarrassingly real, burnout risk
Collects traditions and mottos of
hospital medicine
Intro from How Doctors Think
echoes some of these themes
Traditions
Hoof beats and zebras
O sign and Q sign
LOL in NAD
Chance to Cut is Chance
to Cure
Buffing the chart
Turfing the patient
Nothing Cures like Cold
Hard Steel
Being a sieve or a wall
Gomer
If what you’re doing is
working, keep doing it
If what you’re doing is not
working, stop
Rules of the House of God
GOMERS DON’T DIE
GOMERS GO TO GROUND
AT A CARDIAC ARREST, THE FIRST PROCEDURE IS
TO TAKE YOUR OWN PULSE
THE 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
Conclusions
Wow, the New Yorker has some awesome writers
Challenge conventional thinking with data (EBM)
Deliberate practice is hard, but works
Disasters develop from a sequence of errors
Use heuristics, but be aware of sources of error
Avoid burnout