The Stress Heuristic

Cal Newport, author of the beloved Deep Work (among others), writing in The New Yorker.

…most workers who are fortunate enough to exert some control over their efforts—such as knowledge workers and small-business entrepreneurs—tend to avoid working way too much, but also tend to avoid working a reasonable amount. They instead exist in a liminal zone: a place where they toil, say, for the sake of fixing a specific number, twenty percent more than they really have time for. This extra twenty percent provides just enough overload to generate persistent stress—there’s always something that’s late, always a message that can’t wait until the next morning, always a nagging sense of irresponsibility during any moment of downtime. Yet the work remains below a level of unsustainable pain that would force a change.

If you’re a professor, or a mid-level executive, or a freelance consultant, you don’t have a supervisor handing you a detailed work order for the day. Instead, you’re likely bombarded with requests and questions and opportunities and invites that you try your best to triage. How do you decide when to say no? In the modern office context, stress has become a default heuristic. If you turn down a Zoom-meeting invitation, there’s a social-capital cost, as you’re causing some mild harm to a colleague and potentially signaling yourself to be uncoöperative or a loafer. But, if you feel sufficiently stressed about your workload, this cost might become acceptable: you feel confident that you are “busy,” and this provides psychological cover to skip the Zoom. The problem with the stress heuristic is that it doesn’t start reducing your workload until you already have too much to do. Like Parkinson’s naval bureaucracy, which expanded at a regular rate regardless of the size of the Navy, this stress-based self-regulation scheme ensures that you remain moderately overloaded regardless of how much work is actually pressing.

“The Stress Heuristic” is a great term for people’s default strategy for avoiding more work: being literally too busy for more work.

But while saying ‘no’ is easiest when saying ‘yes’ is impossible, it forces you to live without margin. And margin–space in your life for yourself, serendipity, and the chance to chase down things of interest–is where the magic happens.

Even for academics, consider the words of psychologist Amos Tversky (whose work with Daniel Kahneman yielded the Nobel-prize-winning Prospect Theory and the crazy popular book Thinking, Fast and Slow): “The secret to doing good research is always to be a little underemployed. You waste years by not being able to waste hours.”

Writing Makes It “True”

From “How to Leverage Language to Cultivate Your Creative Process” by Nicole He in Killscreen.

I had a concept in my mind—maybe I felt it emotionally, I had a feeling about what this thing is supposed to represent. Now what I’m saying makes it real. After that, I started responding to journalists the next morning. What blew my mind was this: the thing I wrote about my project became true about the project. Many of the things I would say, the lazier journalists would just copy and paste. Weirdly, seeing my own ideas in the media suddenly made them even more true—things about a project being about intimacy, about computers knowing more than we know about ourselves. All of this became true, because someone else was saying things about my project, but based on what I had said about my project.

There’s a lot to be said for putting in the effort of distilling a vague idea into a clear concept and writing it down (and, yes, maybe even sharing it). Not just for a specific project, but for you and your whole career.

There is power in storytelling, both internally and externally.

And, perhaps weirdest of all is that–on the whole–you get to define your own narrative.

The Availability Heuristic in Practice

We all use mental models (heuristics, rules of thumb) across a host of simple and complex problems. They often work; they sometimes don’t. You shouldn’t (and can’t) avoid having and using them, but you should be aware of them (and their limitations).

The Influence of the Availability Heuristic on Physicians in the Emergency Department” is a cute little paper demonstrating recency bias in real-life practice:

Heuristics, or rules of thumb, are hypothesized to influence the care physicians deliver. One such heuristic is the availability heuristic, under which assessments of an event’s likelihood are affected by how easily the event comes to mind. We examined whether the availability heuristic influences physician testing in a common, high-risk clinical scenario: assessing patients with shortness of breath for the risk of pulmonary embolism.

The sample included 7,370 emergency physicians who had 416,720 patient visits for shortness of breath. The mean rate of pulmonary embolism testing was 9.0%. For physicians who had a recent patient visit with a pulmonary embolism diagnosis, their rate of pulmonary embolism testing for subsequent patients increased by 1.4 percentage points (95% confidence interval 0.42 to 2.34) in the 10 days after, which is approximately 15% relative to the mean rate of pulmonary embolism testing. We failed to find statistically significant changes in rates of pulmonary embolism testing in the subsequent 50 days following these first 10 days.

Of course, one of the biggest components of the availability heuristic in real life isn’t just how recent the event is (though that’s what’s measurable in this sort of dataset). It’s anything that makes certain events easier to recall. This is, for example, why some of our mistakes or surprise diagnoses can have an outside impact on our practice. We remember that unexpected PE we didn’t see coming more than the many more common examples of the negative CTA.

(Further reading availability bias: Farnam Street.)

The Jargon of the Business Dark Arts

From Brian Alexander’s The Hospital: Life, Death, and Dollars in a Small American Town:

(Phil Ennen, one of the main characters, is the CEO of a struggling small-town community hospital in Bryan, Ohio.)

That was the world where Ennen and the vice presidents now found themselves as they listened to consultants they were auditioning to help create a strategic plan. “Transformational changes dictate that leaders within the physician enterprise focus on enterprise sustainability.” So they drove. They drove at “solutions.” The consultants offered entire suites of solutions. The solutions could be “leveraged” toward “accelerating the journey to risk capability.” There’d be “applied analytics” in “the Achieve solution set,” which was “purposely designed to assist physician enterprise leaders to align compensation models and strategic priorities, maximize productivity.” “The Achieve solution set not only drives current performance improvement but also establishes the forward-looking strategic, financial and operational structures to provide for the future risk capable physician enterprise.” Change was driven. Results were driven. Everything was “forward-looking” and “dynamic.” Zoom!

It wasn’t just about style. Ennen thought the world—and especially the world of medical care—was complicated enough without further obscuring meaning and understanding by spouting terms of the business dark arts. Such terms were deliberate obfuscations, thrown up as fortress walls to keep the uninitiated outside and throwing cash over the walls to the mysterious magicians inside so they’d shout down their wisdom. Now, though, like it or not (and he didn’t), Ennen and the others were knocking on the gates of the consultants.

What a great line by Alexander: “Such terms were deliberate obfuscations, thrown up as fortress walls to keep the uninitiated outside and throwing cash over the walls to the mysterious magicians inside so they’d shout down their wisdom.”

The book came out in March of this year and is a meticulous deep dive and narrative take of modern American healthcare through the lens of small-town America as a community hospital struggles to stay independent and survive.

Equity, Organized Medicine, and the Radiology Value Chain

It’s often said that large organizations are difficult to steer and slow to change course, but that’s only part of why they sometimes act in seemingly inexplicable ways. There’s another more insidious reason, and that is conflicts of interest, not just within leadership but also in the changing demographics of the membership.

A passage from “Value Chain: Where Radiologists Should Put Their Focus in Threats Against Income” by Seth Hardy MD MBA in Applied Radiology:

So, while private/public equity firms can use leverage to amplify profits to the upside, leverage has an opposite effect when gross income is in decline. Any cuts to reimbursement would be truly devastating to these firms’ employees; since the debt holders get paid before the radiologists, the impact on employed radiologists’ salaries may be significant. As equity-employed radiologists make up a greater share of dues-paying members within organized medical societies, it is easy to understand why the proposed CMS cuts were characterized as draconian by those societies. But a clear understanding of value chain by physicians is increasingly critical to evaluate the rhetoric of our medical society leadership.

I am now a partner in a physician-owned independent radiology practice. A CMS paycut would mean that we earn commensurately less money–not that we will become insolvent.

That should count for something when choosing where to work.