how to cope with a stressed husband
a few years ago,i broke into my own house. i had just driven home, it was around midnightin the dead of montreal winter, i had been visiting my friend,jeff, across town, and the thermometer on the front porchread minus 40 degrees -- and don't bother askingif that's celsius or fahrenheit, minus 40 is where the two scales meet -- it was very cold. and as i stood on the front porchfumbling in my pockets,
i found i didn't have my keys. in fact, i could see themthrough the window, lying on the dining room tablewhere i had left them. so i quickly ran aroundand tried all the other doors and windows, and they were locked tight. i thought about calling a locksmith --at least i had my cellphone, but at midnight, it could take a whilefor a locksmith to show up, and it was cold. i couldn't go back to my friendjeff's house for the night
because i had an early flightto europe the next morning, and i needed to getmy passport and my suitcase. so, desperate and freezing cold, i found a large rock and i brokethrough the basement window, cleared out the shards of glass, i crawled through, i found a piece of cardboardand taped it up over the opening, figuring that in the morning,on the way to the airport, i could call my contractorand ask him to fix it.
this was going to be expensive, but probably no more expensivethan a middle-of-the-night locksmith, so i figured, under the circumstances,i was coming out even. now, i'm a neuroscientist by training and i know a little bitabout how the brain performs under stress. it releases cortisolthat raises your heart rate, it modulates adrenaline levels and it clouds your thinking. so the next morning,
when i woke up on too little sleep, worrying about the hole in the window, and a mental notethat i had to call my contractor, and the freezing temperatures, and the meetings i had upcoming in europe, and, you know, with allthe cortisol in my brain, my thinking was cloudy, but i didn't know it was cloudybecause my thinking was cloudy. (laughter)
and it wasn't until i gotto the airport check-in counter, that i realized i didn't have my passport. so i raced home in the snowand ice, 40 minutes, got my passport,raced back to the airport, i made it just in time, but they had given awaymy seat to someone else, so i got stuck in the back of the plane,next to the bathrooms, in a seat that wouldn't recline,on an eight-hour flight. well, i had a lot of time to thinkduring those eight hours and no sleep.
and i started wondering,are there things that i can do, systems that i can put into place, that will prevent bad thingsfrom happening? or at least if bad things happen, will minimize the likelihoodof it being a total catastrophe. so i started thinking about that, but my thoughts didn't crystallizeuntil about a month later. i was having dinner with my colleague,danny kahneman, the nobel prize winner, and i somewhat embarrassedly told himabout having broken my window,
and, you know, forgotten my passport, and danny shared with me that he'd been practicingsomething called prospective hindsight. it's something that he had gottenfrom the psychologist gary klein, who had written about ita few years before, also called the pre-mortem. now, you all know what the postmortem is. whenever there's a disaster, a team of experts come in and they tryto figure out what went wrong, right?
well, in the pre-mortem, danny explained, you look ahead and you try to figure outall the things that could go wrong, and then you try to figure outwhat you can do to prevent those things from happening,or to minimize the damage. so what i want to talk to you about today are some of the things we can doin the form of a pre-mortem. some of them are obvious,some of them are not so obvious. i'll start with the obvious ones. around the home, designate a placefor things that are easily lost.
now, this soundslike common sense, and it is, but there's a lot of scienceto back this up, based on the way our spatial memory works. there's a structure in the braincalled the hippocampus, that evolved over tensof thousands of years, to keep track of the locationsof important things -- where the well is,where fish can be found, that stand of fruit trees, where the friendly and enemy tribes live.
the hippocampus is the part of the brain that in london taxicab driversbecomes enlarged. it's the part of the brainthat allows squirrels to find their nuts. and if you're wondering,somebody actually did the experiment where they cut offthe olfactory sense of the squirrels, and they could still find their nuts. they weren't using smell,they were using the hippocampus, this exquisitely evolved mechanismin the brain for finding things. but it's really good for thingsthat don't move around much,
not so good for things that move around. so this is why we lose car keysand reading glasses and passports. so in the home,designate a spot for your keys -- a hook by the door,maybe a decorative bowl. for your passport, a particular drawer. for your reading glasses,a particular table. if you designate a spotand you're scrupulous about it, your things will always be therewhen you look for them. what about travel?
take a cell phone pictureof your credit cards, your driver's license, your passport, mail it to yourself so it's in the cloud. if these things are lost or stolen,you can facilitate replacement. now these are some rather obvious things. remember, when you're under stress,the brain releases cortisol. cortisol is toxic,and it causes cloudy thinking. so part of the practice of the pre-mortem is to recognize that under stressyou're not going to be at your best,
and you should put systems in place. and there's perhapsno more stressful a situation than when you're confrontedwith a medical decision to make. and at some point, all of usare going to be in that position, where we have to makea very important decision about the future of our medical careor that of a loved one, to help them with a decision. and so i want to talk about that. and i'm going to talk abouta very particular medical condition.
but this stands as a proxy for all kindsof medical decision-making, and indeed for financial decision-making,and social decision-making -- any kind of decision you have to make that would benefit from a rationalassessment of the facts. so suppose you go to your doctorand the doctor says, "i just got your lab work back,your cholesterol's a little high." now, you all know that high cholesterol is associated with an increased riskof cardiovascular disease, heart attack, stroke.
and so you're thinking having high cholesterolisn't the best thing, and so the doctor says,"you know, i'd like to give you a drug that will help youlower your cholesterol, a statin." and you've probably heard of statins, you know that they're amongthe most widely prescribed drugs in the world today, you probably even knowpeople who take them. and so you're thinking,"yeah! give me the statin."
but there's a questionyou should ask at this point, a statistic you should ask for that most doctorsdon't like talking about, and pharmaceutical companieslike talking about even less. it's for the number needed to treat. now, what is this, the nnt? it's the number of peoplethat need to take a drug or undergo a surgeryor any medical procedure before one person is helped.
and you're thinking,what kind of crazy statistic is that? the number should be one. my doctor wouldn't prescribesomething to me if it's not going to help. but actually, medical practicedoesn't work that way. and it's not the doctor's fault, if it's anybody's fault,it's the fault of scientists like me. we haven't figured outthe underlying mechanisms well enough. but glaxosmithkline estimates
that 90 percent of the drugs workin only 30 to 50 percent of the people. so the number needed to treatfor the most widely prescribed statin, what do you suppose it is? how many people have to take itbefore one person is helped? 300. this is according to research by research practitionersjerome groopman and pamela hartzband, independently confirmed by bloomberg.com. i ran through the numbers myself.
300 people have totake the drug for a year before one heart attack, strokeor other adverse event is prevented. now you're probably thinking, "well, ok, one in 300 chanceof lowering my cholesterol. why not, doc? give methe prescription anyway." but you should ask at this pointfor another statistic, and that is, "tell meabout the side effects." right? so for this particular drug, the side effects occurin five percent of the patients.
and they include terrible things -- debilitating muscle and joint pain,gastrointestinal distress -- but now you're thinking, "five percent, not very likelyit's going to happen to me, i'll still take the drug." but wait a minute. remember under stressyou're not thinking clearly. so think about how you're goingto work through this ahead of time, so you don't have to manufacturethe chain of reasoning on the spot.
300 people take the drug, right?one person's helped, five percent of those 300have side effects, that's 15 people. you're 15 times more likelyto be harmed by the drug than you are to be helped by the drug. now, i'm not saying whether youshould take the statin or not. i'm just saying you should havethis conversation with your doctor. medical ethics requires it, it's part of the principleof informed consent.
you have the right to have accessto this kind of information to begin the conversation about whetheryou want to take the risks or not. now you might be thinking i've pulled this numberout of the air for shock value, but in fact it's rather typical,this number needed to treat. for the most widely performed surgeryon men over the age of 50, removal of the prostate for cancer, the number needed to treat is 49. that's right, 49 surgeries are donefor every one person who's helped.
and the side effects in that caseoccur in 50 percent of the patients. they include impotence,erectile dysfunction, urinary incontinence, rectal tearing, fecal incontinence. and if you're lucky, and you're oneof the 50 percent who has these, they'll only last for a year or two. so the idea of the pre-mortemis to think ahead of time to the questionsthat you might be able to ask that will push the conversation forward.
you don't want to have to manufactureall of this on the spot. and you also want to thinkabout things like quality of life. because you have a choice oftentimes, do you i want a shorter lifethat's pain-free, or a longer life that might havea great deal of pain towards the end? these are things to talk aboutand think about now, with your family and your loved ones. you might change your mindin the heat of the moment, but at least you're practicedwith this kind of thinking.
remember, our brain under stressreleases cortisol, and one of the thingsthat happens at that moment is a whole bunch on systems shut down. there's an evolutionary reason for this. face-to-face with a predator,you don't need your digestive system, or your libido, or your immune system, because if you're body is expendingmetabolism on those things and you don't react quickly, you might become the lion's lunch,and then none of those things matter.
unfortunately, one of the things that goes out the windowduring those times of stress is rational, logical thinking, as danny kahnemanand his colleagues have shown. so we need to train ourselvesto think ahead to these kinds of situations. i think the important point hereis recognizing that all of us are flawed. we all are going to fail now and then. the idea is to think aheadto what those failures might be,
to put systems in placethat will help minimize the damage, or to prevent the bad thingsfrom happening in the first place. getting back to thatsnowy night in montreal, when i got back from my trip, i had my contractor installa combination lock next to the door, with a key to the front door in it,an easy to remember combination. and i have to admit, i still have piles of mailthat haven't been sorted, and piles of emailsthat i haven't gone through.
so i'm not completely organized, but i see organizationas a gradual process, and i'm getting there. thank you very much. (applause)
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