Better Living Through Thin-Slicing

"What does it take to be good at something in which failure is so easy, so effortless?"
The man asking the question is Atul Gawande, a surgeon at the Brigham and Women's Hospital in Boston who also happens to be a bestselling author.
The question comes from Better: A Surgeon's Notes on Performance, Gawande's 2007 rumination about what constitutes success in healthcare, especially in the face of what he describes as "daunting expectations."
Although Gawande is a surgeon, I think his book offers profound insights for anyone in healthcare in general, and EMS in particular.
According to Gawande, the hurdles between doing a job and doing it well begin with the simplest of premises.
"For one, lives are on the line. Our decisions and omissions are therefore moral in nature...In medicine, our task is to cope with illness and to enable every human being to lead a life as long and free of frailty as science will allow. These steps are often uncertain. The knowledge to be mastered is both vast and incomplete. Yet we are expected to act with swiftness and consistency...It's not only the stakes but also the complexity of performance in medicine that makes it so interesting and, at the same time, so unsettling."
I thought of Gawande's book over the weekend while I watched a trauma team work on a severely injured patient brought in by one of our other ambulances.
The patient had taken a huge fall and was in cardiac arrest when found by the ambulance crew.
As most people know, there are few events so certain to result in death as a heart stopped by some kind of blunt force trauma, like, for example, the sudden stop awaiting you at the end of a long drop.
The number of people who survive this kind of event is minuscule, yet my co-workers delivered this patient to the trauma team with a pulse and blood pressure, not to mention some grievous musculoskeletal injuries.
The trauma team did a similarly professional job, and the patient made it alive to an operating room that he never should have seen, if one were only to consider actuarial tables.
I thought of the innumerable opportunities for failure with this patient, beginning with the bystanders who heard his last moans and called 911, extending to the first responders who did their jobs with aplomb, and then, of course, my co-workers who got the patient's heart pumping again despite the odds and effects of gravity.
Gawande whittles down the challenge of medical success and performance to three core requirements -- diligence, doing right and ingenuity.
Diligence, he writes, "is the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles."
On the surface of things, this should be "an easy and minor virtue," Gawande writes. "You just pay attention, right? But it is neither. Diligence is both central to performance and fiendishly hard."
I think I know what Gawande is driving at here.
In Sunday School we called these things "sins of omission," those things that we do wrong by not doing.
But Gawande doesn't judge.
"Medicine is a fundamentally human profession. It is therefore forever troubled by human failings, failings like avarice, arrogance, insecurity, misunderstanding."
Perhaps the Gawande tenet most applicable to those of us who wander the streets daily in ambulances is ingenuity.
He considers it not a matter of intelligence, but of character.
"It demands more than anything a willingness to recognize failure, to not paper over the cracks, and to change," Gawande writes. "It arises from deliberate, even obsessive, reflection on failure and a constant searching for new solutions."
Gawande admits these are difficult traits to engender, and who in EMS wouldn't agree?
We are a self-reporting profession, which means not only that the inmates occasionally run the asylum, but that only the machinations of the asylum that we allow to be seen or accidentally reveal come to light.
My favorite partners are those folks who ask themselves daily how they could do the job better.
What would EMS look like if that was a question the entire profession asked itself in earnest every day?
But then I think of the work of Malcolm Gladwell, a staff writer for The New Yorker and another bestselling author, and I think maybe it's a question we're answering all the time, even when we don't realize it.
If taken to its logical conclusion, Gladwell's book Blink:The Power of Thinking Without Thinking suggests that those of us in EMS and healthcare are constantly adding to an internal data bank of experience that we draw upon every shift.
Most busy urban systems share one common trait -- a particular pride in being able to walk into a room and know without even speaking with a patient whether they're "sick or not sick."
In observing various partners over the years in these busy systems, I'm amazed at the accuracy of their split-second assessments.
Gladwell wouldn't be.
A relatively new field of study in psychology, Gladwell says it's the brain's "adaptive unconscious" that allows for these uncannily accurate predictions based on the slimmest of evidence.
Ever wondered how that medic you work with was able to take a look at a patient and know it's a head bleed or CHF or STEMI before you've even put the first-in bag on the kitchen table?
Gladwell calls it "thin-slicing," which is "the ability of our unconscious to find patterns in situations and behavior based on very narrow slices of experience."
People who work for long periods of time in high-pressure, time-sensitive professions hone their thin-slicing skills to a razor's edge.
According to Gladwell, they have to in order to succeed.
"Thin-slicing is part of what makes the unconscious so dazzling," he writes. "But it's also what we find most problematic about rapid cognition. How is it possible to gather the necessary information for a sophisticated judgment in such a short time?"
Gladwell opines that an "automated, accelerated unconscious" processing takes over, and more often than not -- and more often, at times, than people who hashed out the same decision with lots more time and lots more data -- leads us to the right conclusion.