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.

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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 on availability bias: Farnam Street.)

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.

In 2003, Charlie Munger gave a lecture titled ‘Academic Economics: Strengths and Weaknesses, after Considering Interdisciplinary Needs,’ at the University of California at Santa Barbara.

It’s a pretty good read.

He mostly discusses problems with economics as a soft science that desperately wants to be a hard science.

Medicine is also surprisingly soft. I’ve replaced some words with medicine in several paragraphs to illustrate how cross-domain the problems with medical practice can be:

The Man with a Hammer Syndrome

Yet medicine, like much else in academia, is too insular.

The nature of this failure is that it creates what I always call, “man with a hammer syndrome.” And that’s taken from the folk saying: To the man with only a hammer, every problem looks pretty much like a nail. And that works marvelously to gum up all professions, and all departments of academia, and indeed most practical life. The only antidote for being an absolute klutz due to the presence of a man with a hammer syndrome is to have a full kit of tools. You don’t have just a hammer. You’ve got all the tools. And you’ve got to have one more trick.

This is an argument for a broad foundation in medicine before specialization. The more siloed we are, the less we can draw on different toolsets to help patients.

This is also an argument against fee-for-service. If doctors and hospitals can generate the most money with a certain hammer, that hammer is likely to be used disproportionately.

Overweighing what can be counted

A special version of this “man with a hammer syndrome” is terrible, not only in economics but practically everywhere else, including medicine. It’s really terrible in medicine. You’ve got a complex system and it spews out a lot of wonderful numbers that enable you to measure some factors. But there are other factors that are terribly important, [yet] there’s no precise numbering you can put to these factors. You know they’re important, but you don’t have the numbers. Well practically everybody (1) overweighs the stuff that can be numbered, because it yields to the statistical techniques they’re taught in academia, and (2) doesn’t mix in the hard-to-measure stuff that may be more important. That is a mistake I’ve tried all my life to avoid, and I have no regrets for having done that.

This gives rise to the classic Goodhart’s Law: when a measure becomes a target, it ceases to be a good measure.

We shouldn’t confuse measurability with importance. In many cases, the measure is a poor surrogate for what we really care about or can be gameable to ultimately negative downstream effects. An example? Patient satisfaction.

The first-order short-term focus

Too little attention in medicine to second-order and even higher-order effects. This defect is quite understandable, because the consequences have consequences, and the consequences of the consequences have consequences, and so on. It gets very complicated. When I was a meteorologist I found this stuff very irritating. And medicine makes meteorology look like a tea party.

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Extreme economic ignorance was displayed when various experts, including Ph D. economists, forecast the cost of the original Medicare law. They did simple extrapolations of past costs. Well the cost forecast was off by a factor of more than 1000%. The cost they projected was less than 10% of the cost that happened. Once they put in place all these new incentives, the behavior changed in response to the incentives, and the numbers became quite different from their projection. And medicine invented new and expensive remedies, as it was sure to do. How could a great group of experts make such a silly forecast? Answer: They over simplified to get easy figures, like the rube rounding Pi to 3.2! They chose not to consider effects of effects on effects, and so on.

Short-term thinking is bad at both micro and macro levels.

On the micro level, the patient’s care doesn’t end when they leave the clinic or hospital. It keeps going throughout their life. And each episode of care from each different provider doesn’t exist in a vacuum. It interfaces with every other bit of care they get. The combination of direct patient care, socioeconomic factors, and education is a complicated mess at baseline.

But decisions lead to decisions, and outcomes further affect outcomes. We treat at the n of 1 and often at the timepoint of right this second. Missing the forest for the trees is easy to do when your patient is usually coming to you for a tree and you are also paid to look at the tree.

On the macro level, Munger’s Medicare example above. Or, the more recent news, approving a multibillion-dollar a-year Alzheimer’s drug with no evidence that it works: It won’t just cost billions of upfront, it will result in other companies diverting resources in a rush for me-too drugs that also may not work to get a slice of a massive market and likely cost still billions more while potentially resulting in less novel drug development. We think in linear terms but systems often work exponentially.

A century-old tidbit of wisdom from the Book on the Physician Himself by DW Cathell MD (published way back in 1902, so ignore the pronouns):

EVERY Medical Man discovers sooner or later that The Practice of Medicine has two sides: A Greater Scientific Side, and a Lesser, but important, Personal Side, and that to fight the battles of life successfully it is as necessary for even the most scientific physician to possess a certain amount of professional tact and business sagacity as it is for a ship to have a rudder.

Only one of these sides is meaningfully taught or modeled in school, and I think we’ve all met physicians who do not seem to possess “professional tact” or “business sagacity” and been worse for it. Cathell was writing during a time when most physicians literally were one-man shops, but if anything the “lesser” side of the Practice of Medicine is more important than ever.

Discussing the ancient pro/cons of specialization that led to ever-increasing specialization over the next 120 years:

You may also ask the question: Shall I adopt a specialty? Would it pay me to do so? The adoption of a specialty, to the exclusion of other varieties of practice, is successful with but a few of those who attempt it. It should never be undertaken without first studying the whole profession and attaining a few years’ experience among the people as a general practitioner.

A successful specialist has many advantages over the hurly-burly life of the general practitioner: He is independent of general practice. He has short hours and is seldom or never called out at night. He can escape the expenses of horses, carriages, stables, and drivers. His Sundays are his own if he chooses. His fees are always good, sometimes fat. He can tell his terms and arrange about the payment of his fees at the beginning of each case, and usually gets them cash, and after a much easier life he generally dies a great deal better off pecuniarily than the general practitioner.

On the other hand, the specialist must be better equipped in instruments, etc., and more dextrous and masterful in their use and also more concise in the details of treatment; should possess a faultless manner and must foster his practice more carefully; in other words, if you put all your eggs in one special basket you must watch that basket much more closely.

So much energy has been spent fighting in the turf wars of watching and growing those special baskets that doctors dropped the ball on the broader healthcare basket entirely.

Dying rich after an easy life sounds nice, but he did miss the part where the physician became an employee and stopped being able to choose those short hours and Sundays “as his own.”

(Hat tip @archives_Rx.)

After reading stories of match success and failure on social media this spring, I’m already thinking about another set of virtual interviews this fall and contemplating how applicants can shine.

Here are some takeaways from Backable: The Surprising Truth Behind What Makes People Take a Chance on You. While this book and its many examples mostly center on entrepreneurship and how startups can get money from investors, there are some nuggets that cross domains nicely. The interview is in some ways a pitch meeting where you’re selling yourself.

The power of unique perspectives and experience

[Investor Ben] Horowitz responded that great ideas typically stem from an “earned secret”—discovered by going out into the world and “learning something that not a lot of other people know.”

Everyone says the same things in personal statements, is drawn to their chosen fields for the same reasons, and has largely similar clinical experiences. When you have rare real-world experience—frankly in any context or domain—that makes you different.

Share how those insights have changed you and inform your approach to medicine.

Earned insights are rare

What’s the single best piece of advice that would help them succeed?” [Oscar-winning producer Brian] Grazer paused for a moment, then said, “Give me something that isn’t google-able. I want an idea that is based on a surprise insight. Not something I could find through a Google search.”

An idea that stems from hands-on experience is way more backable than the same exact idea if it simply originated sitting behind a desk. But the catch is, without being boastful, you have to make that effort shine through your pitch. It can’t be hidden.

Here’s an open secret: a few months of clinical experience don’t make you an expert in your chosen field just as even less time in other specialties doesn’t make you an expert in those either. Bringing fourth-year swagger to interviews often isn’t a great idea.

That said, real insights—whether about your specialty, health care, or even just being a human being and having a good attitude about showing up to work every day for your patients—are a breath of fresh air. I love when I can tell an applicant has an active mind and thoughtful approach, when I can really see their gears turning.

Why should someone be scared to miss out on you?

As creators, our job isn’t to use FOMO to manipulate backers, but rather to neutralize their fear of taking a bad bet. Though it may sound strange, FOMO can make a risky bet feel safe because it shields us from the risk of being left behind. This feeling of inevitability rarely comes from the argument that we should change the world, but rather from the argument that the world is already changing—with or without us.

If there’s a knock on your record and you’re scared people are going to pass you over, own it. The typical advice is to talk about what you learned after your failure, how you’ve changed, and other such bland platitudes, but the fact is that I expect anyone who has messed up to tell me they’ve grown.

That’s all fine. Go ahead and do that.

But…don’t just approach your candidacy from a position of weakness. What about you is unique or special? Why should a program director be scared to lose you? Why are you backable despite (or because of) that setback?

Connections are powerful

Salman Rushdie once wrote, “Most of what matters in our lives takes place in our absence.” While we’re present for the pitch, we’re most likely absent for the hallway huddles, backroom meetings, and email threads that decide the fate of our ideas. Backers become fierce advocates when they are on the inside of an idea. They crack their own egg and add it to the mix.

Stronger-than-average connections with your interviewer will cause people to go to bat for you in the post-interview huddle. So many interviews are bland Q&A. True connections are rare. If you can get an organic discussion going and the time flies, everybody wins.

Each interaction is an independent variable

We don’t typically win people over in one conversation, but through a series of interactions that builds trust and confidence. Even if the last conversation went poorly, you can use the next one to show them how they influenced your work. This type of follow-up is so powerful that it can often change a backer’s response from no to yes.

You can’t really do this with your interviewer (post-interview correspondence doesn’t carry that kind of power), but you can take each interview as a fresh start.  Don’t let one sour interaction spoil the day.

Interviewing is a skill that requires practice

We’ll spend hours researching, outlining, pulling together slides—but very little time practicing what we’re going to share. The feeling seems to be that if we have the right content and we know it well enough, then there’s no need for practice. But I’ve found that backable people tend to practice their pitch extensively before walking into the room. They practice with friends, family, and colleagues. They’re rehearsing on jogs with running partners, in the break room, and during happy hour. They prepare themselves for high-stakes pitches through lots of low-stakes practice sessions—what I now call exhibition matches.

You need to practice. The common approach is to do practice interviews, often with residents and faculty at your home institution (and potentially online organized on social media). You should do those things.

But I’d take it a step further.

You should talk to strangers. Practice having genuine interactions and conversations with people who don’t know you.  Practice really listening to your patients. Get to know them as the three-dimensional human beings they are.

The easy flow of conversation is a delight to interviewers.

You are a process, not an outcome

The other techniques in this book got me comfortable with content, but I still had to learn to get truly comfortable with myself. I had to learn to let go of my ego—to express, rather than impress.

So much of your identity feels tied to your success in school, the match, and your developing career as a physician. But internal validation is always superior to external validation. You don’t and can’t control outcomes. You—at best—control yourself and your approach.

You will enjoy and likely be more successful in the match process if you are content with yourself, happy to do your best, and try to find a good fit. We call it “practicing” medicine, but living life is also the practice of showing up each day working on being the version of ourselves that we strive to be.

When you receive an interview, your goal is not to impress your interviewers. It should be to express yourself and be open to others so that you can find the best place to live and grow in your practice.