Hindsight in the Valley of the Normal

From Nobel-laureate Daniel Kahneman’s Noise: A Flaw in Human Judgement:

More broadly, our sense of understanding the world depends on our extraordinary ability to construct narratives that explain the events we observe. The search for causes is almost always successful because causes can be drawn from an unlimited reservoir of facts and beliefs about the world.

[…]

This continuous causal interpretation of reality is how we “understand” the world. Our sense of understanding life as it unfolds consists of the steady flow of hindsight in the valley of the normal. This sense is fundamentally causal: new events, once known, eliminate alternatives, and the narrative leaves little room for uncertainty. As we know from classic research on hindsight, even when subjective uncertainty does exist for a while, memories of it are largely erased when the uncertainty is resolved.

Noise is a good book. It’s not an exciting book–though neither is Thinking, Fast and Slow for that matter–but it’s an important book. Bias is important, but human noisiness and our imperfect and very noisy systems are also important: Judgments (predictions, decisions) are hard to get right, and so much of the world’s punditry is just storytelling.

Doctors make dozens if not hundreds of little and big decisions every day. And I know that not only I am noisy, but I’m noisy in a variety of ways. A big part of my deliberate practice as it pertains to radiology is to try to limit how much noise distorts my decision-making and the quality of my reports.

We want to be not just good but consistently so.

 

It’s Always Your Fault

I came across this brief article (“It’s Always Your Fault“) from 2016 by DHH, who–among other things–was the creator of the web application framework Ruby on Rails and co-founder of Basecamp/37Signals:

There’s a system in place that caused this to happen, and you’re part of that system. Shit never happens in a vacuum. The vast majority of it is a predictable consequence of the way things are. Even if it was “just somebody’s fault”, others put or kept that person there.

The goal is to change the system, and to change the system, you have to change its parts. Have the courage to start with yourself. Absorb as much blame and responsibility you can for what happened, and hopefully some of that introspection will rub off on the other parts of the system. But even if it doesn’t, you’ve still done your bit to improve matters.

In Medicine, we seem to oscillate between blame-game individual-at-fault finger-pointing and Just Culture the-system-is-the-problem.

It’s true we shouldn’t go around punishing people who are trying to learn and doing their best, and equally true that we need to always be looking to address system flaws. It’s also critical to keep in mind how many people working in healthcare are second victims of those mistakes, which prevents healthy introspection in favor of guilty misery.

But I also found his point just a little refreshing. As usual, it’s not either/or, it’s both.

 

Coffee at Work

The coffee at work has been—for most locations of my training and attending career—terrible. From the burnt “Parks and Coffee” drip sitting for hours on the hot plate during residency to the cheapest K-cups at the imaging center. It doesn’t matter what sweetener or creamer you might add, it was rare to finish the cup once it was cold enough to taste. I’m not a coffee snob. I’m really more of a pragmatist. I don’t have the time or inclination for a long ritual even when working from home let alone the desire to do anything elaborate at work. Walking to the hospital Starbucks is slow and expensive. It’s a treat on the way for an early call shift morning but not something I enjoy doing routinely.

One of my residents shared Cometeer with me. It’s a variation on a coffee subscription (which is itself a variation on the incredible number of subscriptions available these days). I generally don’t like these sorts of things (who wants to remember to pause or cancel?), but I enjoyed the one I tried at work so I gave it a try.

The twist is that it’s a small recyclable cup of liquid-nitrogen flash-frozen coffee concentrate. Add your liquid of choice, hot to the frozen puck or cold after thawing, and you have instant coffee that isn’t, well, instant coffee. I predominantly use it as an espresso shot equivalent for making ice lattes, and for this purpose, it is effective and efficient. And it’s easy to slip in my bag and use on-site. On the enjoyment scale, I put it way above Starbucks’ regular iced coffee and just underneath their shaken iced espresso.

 

 

I honestly don’t know if I will continue to subscribe in the future, because it’s not the cheapest. You can cancel at any time and thankfully it’s also easy to spread out deliveries and pause them for months, because there’s no way I would want tons of coffee piling up in my freezer at any given time. I just don’t drink that much. With a $25 new member coupon, the per cup cost is $1.20 per pod (just a bit more than Nespresso pods) and cheaper than what I get at the coffee shop (but also more expensive than nothing, free tea, or the burnt brown caffeinated sludge otherwise available).

So, if you happen to be in the market for a new caffeine source and are interested in trying something new, you can try Cometeer and get $25 off (and subsidize my coffee consumption by the same amount!). Note that this is not a sponsored post; I just wouldn’t mind having cheaper coffee in the future. Also, note that I have literally never done a post like this in this site’s 13-year history. And finally, note that I can only use one referral bonus per order, so alas no matter how many of you choose to buy some I won’t be getting any coffee for free.

Always Something to Learn

From the very pleasant small corner (seriously, just check out the comments!) of the internet that is author George Saunders’ substack, Story Club, answering a question about finding a mentor:

One of the things I’ve come to love about this Story Club community is its generosity. From where I sit, it feels like people show up here with the right attitude for any artistic endeavor, which is, “I bet there’s something for me to learn here.” This doesn’t mean that the person doesn’t already know quite a lot. But she has reverence for the importance and difficulty of the task and knows at some level that showing up in a curious, humble, friendly spirit, she’s more likely to return home with something of value.

If that’s not wisdom for approaching just about anything, I don’t know what is.

A lopsided fig

Jason Kottke, a true OG blogger, on taking a sabbatical:

Does what I do here make a difference in other people’s lives? In my life? Is this still scratching the creative itch that it used to? And if not, what needs to change? Where does kottke.org end and Jason begin? Who am I without my work? Is the validation I get from the site healthy? Is having to be active on social media healthy? Is having to read the horrible news every day healthy? What else could I be doing here? What could I be doing somewhere else? What good is a blog without a thriving community of other blogs? I’ve tried thinking about these and many other questions while continuing my work here, but I haven’t made much progress; I need time away to gain perspective.

I love good curation. With my two young kids, personal wants and need, and professional demands, I don’t personally have the bandwidth to really produce a filter+share site myself, but I really appreciate when someone can steadily put a high-quality narrative or personal spin on *waves hands vaguely in the air* all of this.

Kottke is an excellent blogger, and he’s been doing it since 1998.