Hey everyone, I'm Brandon Odo.
And I'm Brian Bulling.
And this is Critical Care Scenarios, the podcast where we use clinical cases, narrative storytelling,
and expert guests to unpack how critical care is practiced in the real world.
Hey everyone, it's Brandon back with another Turbo.
I want to chat today about a somewhat philosophical concept, but I think one that has a great
deal of application to us in medicine.
And you know, I think probably there are some lessons for life itself here too.
The question here is how much value is to be found and whether you might actually be
overestimating the value of experience.
You talk a lot about experience in medicine, experiences the idea that as you do this work
for longer, you accumulate experiences with patients and situations that can inform your
practice and make you better.
Make you a better clinician because you've been around for a while, you've done it a
lot, and you've essentially practiced the practice of medicine for more time.
And this is the difference between a fresh graduate and the 20 year clinician.
Obviously on some level, this is all true.
The more you've done things, the more practiced you become at them.
But I think there are nuances here and really pitfalls if you overestimate the value of experience
that might not be obvious.
And let me tell you what I mean.
The whole idea that experience would be valuable, would have utility is only born out if the
future resembles the past.
In other words, if the next patient you see with, let's say, a certain disease resembles
the patients that you've seen before with that disease.
If that were true, then the fact that you'd seen those previous patients would be useful
because you know something about the disease that you wouldn't have known had you not
seen those patients.
All those little subtleties and learned skills and observations and tacit learning that you
don't necessarily learn from a textbook, more practical things, you have those in your
armamentarium, in your history, in your learned knowledge because you saw those patients.
However, patients are not all the same, situations are not all the same, and it's probably just
as possible here that the new scenario you encounter differs in important ways.
Maybe even in ways that exceed and outweigh the ways in which it resembles the patients
you've seen.
This patient may be more different than he is similar to the ones you've treated in
the past.
And of course, everyone would acknowledge that, but what I'm saying is because you've
seen this before, you may overestimate your ability to predict what's going to happen.
You may overestimate how similar this patient is going to be.
Now it is useful additional knowledge.
It is one more stick to throw on the fire of your reasoning.
The problem is that compared to the other pieces of knowledge you bring to the table,
you are likely to over weigh this knowledge because it's yours.
You're biased to believe your hard one experiential knowledge above something you read in a book
or in an article, or you skimmed off up to date, or even that somebody else told you
that was part of their knowledge because it's yours.
You saw it with your own eyes.
It happened to you.
You earned this knowledge with your blood sweat and tears.
All the more so if you came by it in some unlikely scenario, something full of drama
and emotion, maybe a surprise like a diagnosis or a complication that you didn't see coming,
those are maybe one in a lifetime experiences that maybe absolute flukes and yet are likely
to change your practice forever.
You'll hear people say things like, now I always check for a cuff leak because this
one time, I didn't and then the airway closed up and the patient coded or whatever.
This is like the most anecdote of anecdotes, the least evidence based in robust piece of
knowledge you can have, but because it came to you in a certain way which you find privileged,
it got right to your heart, like the conduit and the death star.
It just went straight to the center of your reasoning and you're probably never going
to not believe in this thing.
Sometimes it also happens in a shorter term and less dramatic way.
Maybe for a particular patient, maybe you're trying to pull something off, something you're
going to try to achieve something and maybe you tried it once and you failed.
Very routinely, this will be things like, we tried to wean off the sedation and you tried
that yesterday and the patient got real agitated and then you had to turn it back up.
So then today you said, maybe we can wean off the sedation and maybe part of you or one
of your staff or someone says, yeah, we tried that and it didn't work.
Well, all right.
What does that mean?
Does that mean that it cannot work?
That it will never work?
That if we try again, we will fail again.
Perhaps it is useful knowledge, but this is one of those situations where it's very
liable to be more misleading than helpful because if you believe in the lesson of this
experience, what you're going to do is just never try again and that doesn't make sense.
When failure occurs in a clinical context, there may be some lesson to learn there, but
the lesson is not usually to never try again and yet we don't like failure.
We don't like wasting effort.
So that easily can be the lesson you learn.
And in fact, if you had to weigh between over learning the wrong lessons and learning no
lesson, sometimes I think the better answer would be to learn no lesson.
You're almost better off not having the lesson of experience in cases like this.
They're just too misleading.
Or if you take the longer view, look at those senior clinicians with decades of experience,
you'd think that the more time you spend doing this, the better you get at it and you
can and certainly in some ways you probably do.
But don't you also see some people who are clinging to practices or concepts or teachings
that are probably outdated.
And by outdated I mean there are new ways which are probably better.
There are ways of doing things that are no longer really appropriate.
Times have changed and things have moved on.
And yet they spent the blood, sweat and tears to learn how to do things their way.
So of course they're going to be biased to preserving them.
Those lessons of experience are such a part of them that their strong inclination is to
find a way to preserve them and to continue to learn from them and make use of them.
Even if probably the best solution would be to discard them completely.
You know I don't want to make it sound like experience is kind of a universal bad thing.
I mean absolutely it's of critical importance.
I guess I just want us to pump the brakes a little and understand that it is not always
of value and our bias when we weigh its contribution to our decision making is generally going
to be to overvalue it.
Ed Lasso the TV show had a saying that you should really try and be a goldfish.
Goldfish you know creature with a memory span of like a few seconds at most.
Really sometimes the best lesson to learn from experience is not at all.
It's just to forget about it.
Whatever you take to your core from remembering something happened it may just be of no use.
It may be best if you just forget about it.
Just have amnesia and just move on and then address a new situation as if it's for the
first time.
You know when we consider other data that goes into decision making such as medical research
we understand that you need volume of data to really build a robust understanding of
something.
If you showed me a study with 10 or 20 patients I'd say I don't know what to make of this.
It's just not enough patients.
It's not enough data and yet you have an experience one time or a couple times and you say I
know how this goes.
You know I know what's going to happen here because it happened to me once.
One time.
Even if it was such a strong imprint upon your memory one time how can you say you think
you know how it's going to go in the future.
Now if you've encountered something 400 times now you're talking.
Now that's usable volume and you should still not extend that beyond its parameters.
You can counter something that's different.
It's probably going to be different but perhaps within the bounds of what you've seen that's
pretty useful data.
And again the bias in your memory is always going to be to overweight this stuff.
There's the old joke that when you hear somebody say you know in my experience it means they've
seen that thing once.
And if they say in my repeated experience it means they've seen it twice.
If they say you know time after time after time that means they've seen it three times.
In other words people want to value what's happened to them and kind of play it up and
weigh it to the maximal possible extent you know without actually lying.
So just understand this bias you have.
You know imagine if somebody else was telling you about the experience that you've had in
the past how much would you value that and realize how much less it would be because
it was somebody else's experience.
And even that you're probably still overvalued because we do value experience in stories
more than data even when it's essentially just a single datum.
In other words an anecdote.
The final thought I'll leave you with is that everything I've said about medicine probably
applies about life too.
Wow there's much to be learned from experience.
I think there's also much that can mislead you and there are probably a lot of times if
you're looking back on your memories and lessons learned and the twists and turns of
your past and you probably be better off if you could just forget about it.
Yeah it's part of who you are.
I'm not saying that that's a problem.
What I'm saying is that to the extent that you're using it to inform your future decisions
you should probably weigh more strongly the most important factor which is often just
chance.
Chance and luck plays a bigger part in most of what goes on than we realize and what that
means is if you flip a coin twice you're just as likely to get a different result.
So there's a bit of food for thought for you.
Try to go forth and be that goldfish and you know tackle each situation as if it were
fresh while giving appropriate due to your experiences but recognizing them for what
they are which is essentially anecdotes and just as likely to have no bearing on what's
in front of you as it is to inform you.
Talk to you next time.
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