A few years ago, I broke into my own house. I had just driven home, it was around midnight in the dead of Montreal winter, I had been visiting my friend, Jeff, across town, and the thermometer on the front porch read minus 40 degrees -- and don't bother asking if that's Celsius or Fahrenheit, minus 40 is where the two scales meet -- it was very cold. And as I stood on the front porch fumbling in my pockets, I found I didn't have my keys. In fact, I could see them through the window, lying on the dining room table where I had left them. So I quickly ran around and tried all the other doors and windows, and they were locked tight. I thought about calling a locksmith -- at least I had my cellphone, but at midnight, it could take a while for a locksmith to show up, and it was cold. I couldn't go back to my friend Jeff's house for the night because I had an early flight to Europe the next morning, and I needed to get my passport and my suitcase.
Hai uns anos, quedei fóra da casa sen chaves. Acababa de chegar á casa era sobre media noite, en pleno inverno en Montreal. Fora visitar un amigo ó outro lado da cidade e o termómetro do soportal sinalaba 40 graos baixo cero. E non preguntedes se eran graos Celsius ou Fahrenheit porque a esa temperatura coinciden as dúas escalas. Ía moito frío. E eu estaba no soportal, buscando nos petos e deime conta de que non tiña as chaves. De feito, podía velas pola fiestra enriba da mesa do comedor, onde as deixara. Corrín arredor da casa, comprobando tódalas portas e fiestras pero estaban todas pechadas. Pensei en chamar un cerralleiro, xa que tiña o móbil comigo pero coa hora que era, podía tardar moito en chegar e ía moito frío. Non podía pasa-la noite na casa do meu amigo porque pola mañá cedo tiña un voo a Europa e necesitaba coller o pasaporte e a maleta.
So, desperate and freezing cold, I found a large rock and I broke through the basement window, cleared out the shards of glass, I crawled through, I found a piece of cardboard and taped it up over the opening, figuring that in the morning, on the way to the airport, I could call my contractor and ask him to fix it. This was going to be expensive, but probably no more expensive than a middle-of-the-night locksmith, so I figured, under the circumstances, I was coming out even.
Así que, desesperado e morrendo de frío collín unha pedra e rompín a fiestra do soto limpei ben os cristais e entrei por ela. Collín un cacho de cartón e pegueino na fiestra para cubrila. Díxenme que pola mañá, de camiño ó aeroporto podía chama-lo contratista e pedirlle que o arranxase. Íame custar moitos cartos pero tampouco máis que un cerralleiro no medio da noite. Dadas as circunstancias, pareceume que tanto tiña.
Now, I'm a neuroscientist by training and I know a little bit about how the brain performs under stress. It releases cortisol that raises your heart rate, it modulates adrenaline levels and it clouds your thinking. So the next morning, when I woke up on too little sleep, worrying about the hole in the window, and a mental note that I had to call my contractor, and the freezing temperatures, and the meetings I had upcoming in Europe, and, you know, with all the cortisol in my brain, my thinking was cloudy, but I didn't know it was cloudy because my thinking was cloudy.
Ben, dedícome á neurociencia e sei bastante sobre como o cerebro se comporta baixo estrés. Emite cortisol, que eleva o ritmo cardíaco modula os niveis de adrenalina e nubra a mente. Así que, á mañá seguinte cando me levantei despois de durmir pouco, preocupado pola fiestra rota e por lembrarme de chama-lo contratista e polo frío que ía e polas reunións que ía ter en Europa e, vaia, con todo o cortisol que tiña no cerebro tiña a mente nubrada pero non sabía que tiña a mente nubrada porque tiña a mente nubrada.
(Laughter)
(Risas)
And it wasn't until I got to the airport check-in counter, that I realized I didn't have my passport.
E ata chegar ó mostrador do aeroporto non me dei conta de que esquecera o pasaporte.
(Laughter)
(Risas)
So I raced home in the snow and ice, 40 minutes, got my passport, raced back to the airport, I made it just in time, but they had given away my seat to someone else, so I got stuck in the back of the plane, next to the bathrooms, in a seat that wouldn't recline, on an eight-hour flight. Well, I had a lot of time to think during those eight hours and no sleep.
Así que volvín rapidamente á casa, con neve e xeo, en 40 minutos collín o pasaporte, volvín ó aeroporto e cheguei xusto a tempo, pero déranlle o meu asento a outra persoa así que tiven que sentarme ó fondo, ó lado dos aseos nun asento que non se podía reclinar nun voo de 8 horas. E tiven bastante tempo para pensar sen durmir durante esas 8 horas.
(Laughter)
(Risas)
And I started wondering, are there things that I can do, systems that I can put into place, that will prevent bad things from happening? Or at least if bad things happen, will minimize the likelihood of it being a total catastrophe. So I started thinking about that, but my thoughts didn't crystallize until about a month later. I was having dinner with my colleague, Danny Kahneman, the Nobel Prize winner, and I somewhat embarrassedly told him about having broken my window, and, you know, forgotten my passport, and Danny shared with me that he'd been practicing something called prospective hindsight.
E empecei a pensar se sería posible facer algo establecer sistemas para evitar que pasasen cousas malas. Ou, no caso de que pasasen cousas malas, para minimizar a probabilidade de que fosen unha catástrofe. Pero non cheguei a ningures ata un mes despois. Estaba ceando cun colega, o premio Nobel Danny Kahneman, e conteille, avergoñado, o que me pasara coa fiestra e co pasaporte e Danny contoume que estivera practicando o que chamaba pensamento a posteriori anticipado.
(Laughter)
(Risas)
It's something that he had gotten from the psychologist Gary Klein, who had written about it a few years before, also called the pre-mortem. Now, you all know what the postmortem is. Whenever there's a disaster, a team of experts come in and they try to figure out what went wrong, right? Well, in the pre-mortem, Danny explained, you look ahead and you try to figure out all the things that could go wrong, and then you try to figure out what you can do to prevent those things from happening, or to minimize the damage.
Foi algo que sacara do psicólogo Gary Klein que escribira sobre isto había uns anos e que tamén se chama pre mortem. Todos sabedes qué é o post mortem. Cando ocorre un desastre chega un equipo de expertos que intenta determinar qué pasou, non? Pois no pre mortem, como explicou Danny, miras cara ó futuro e intentas determinar qué pode saír mal e logo intentas determinar qué podes facer para evitar que pasen esas cousas, ou para minimizar os seus efectos.
So what I want to talk to you about today are some of the things we can do in the form of a pre-mortem. Some of them are obvious, some of them are not so obvious. I'll start with the obvious ones.
Do que vos quero falar hoxe é do que podemos facer no referido ó pre mortem. Algunhas cousas son evidentes, outras non o son tanto. Vou empezar polas evidentes.
Around the home, designate a place for things that are easily lost. Now, this sounds like common sense, and it is, but there's a lot of science to back this up, based on the way our spatial memory works. There's a structure in the brain called the hippocampus, that evolved over tens of thousands of years, to keep track of the locations of important things -- where the well is, where fish can be found, that stand of fruit trees, where the friendly and enemy tribes live. The hippocampus is the part of the brain that in London taxicab drivers becomes enlarged. It's the part of the brain that allows squirrels to find their nuts. And if you're wondering, somebody actually did the experiment where they cut off the olfactory sense of the squirrels, and they could still find their nuts. They weren't using smell, they were using the hippocampus, this exquisitely evolved mechanism in the brain for finding things. But it's really good for things that don't move around much, not so good for things that move around. So this is why we lose car keys and reading glasses and passports. So in the home, designate a spot for your keys -- a hook by the door, maybe a decorative bowl. For your passport, a particular drawer. For your reading glasses, a particular table. If you designate a spot and you're scrupulous about it, your things will always be there when you look for them.
Designar lugares por toda a casa para as cousas que se perden facilmente. Ben, isto parece de sentido común, e é así pero a ciencia apoia isto baseándose en como funciona a memoria espacial. Hai unha estrutura do cerebro, chamada hipocampo que evolucionou durante centos de miles de anos para lembrar a localización de cousas importantes. Onde está o pozo, onde se pode pescar, onde están as árbores froiteiras onde viven as tribos aliadas e inimigas. O hipocampo é a parte do cerebro que se atopa aumentada nos condutores de taxis de Londres. É a parte do cerebro que lles permite ós esquíos atopar as súas noces. De feito, houbo alguén que fixo o experimento de corta-lo sentido do olfacto dos esquíos e seguían atopando as noces. Non usaban o olfacto, senón o hipocampo, un mecanismo do cerebro exquisitamente evolucionado para atopar cousas. Pero funciona ben con cousas que non se moven demasiado e non con cousas que se moven. Por iso perdémo-las chaves do coche, as gafas de ler ou o pasaporte. Por iso hai que designar algún sitio para as chaves. Un gancho ó lado da porta ou un prato decorativo. Para o pasaporte, un caixón específico. As gafas de ler, nunha mesa específica. Se se designa un lugar e se é escrupuloso as cousas van estar no seu sitio cando as busquemos.
What about travel? Take a cell phone picture of your credit cards, your driver's license, your passport, mail it to yourself so it's in the cloud. If these things are lost or stolen, you can facilitate replacement.
E cando viaxemos? Saca unha foto co móbil das tarxetas de crédito, do carné de conducir e do pasaporte. Mándate un correo coa foto para subila á nube. Se perdes ou che rouban estas cousas, pódelas substituír máis facilmente.
Now these are some rather obvious things. Remember, when you're under stress, the brain releases cortisol. Cortisol is toxic, and it causes cloudy thinking. So part of the practice of the pre-mortem is to recognize that under stress you're not going to be at your best, and you should put systems in place.
Estas parecen cousas evidentes. Recordade que cando estamos baixo estrés, o cerebro emite cortisol. O cortisol é tóxico e nubra a mente. Parte da práctica do pre mortem consiste en recoñecer que baixo estrés non vas poder dar o mellor de ti mesmo e que deberías establecer algún sistema.
And there's perhaps no more stressful a situation than when you're confronted with a medical decision to make. And at some point, all of us are going to be in that position, where we have to make a very important decision about the future of our medical care or that of a loved one, to help them with a decision.
E quizais non haxa una situación de máis estrés que cando te enfrontas a unha decisión médica. Todos estaremos nalgún momento nunha situación na que teñamos que tomar unha decisión importante sobre a nosa saúde ou a dun ser querido ou axudalos a tomar unha decisión.
And so I want to talk about that. And I'm going to talk about a very particular medical condition. But this stands as a proxy for all kinds of medical decision-making, and indeed for financial decision-making, and social decision-making -- any kind of decision you have to make that would benefit from a rational assessment of the facts.
E sobre iso quero falar. E vou falar dun problema médico moi particular, pero isto pode aplicarse a calquera tipo de decisión médica e incluso a decisións financeiras ou sociais ou calquera decisión que teñamos que facer na que sexa beneficioso realizar unha análise racional de datos.
So suppose you go to your doctor and the doctor says, "I just got your lab work back, your cholesterol's a little high." Now, you all know that high cholesterol is associated with an increased risk of cardiovascular disease, heart attack, stroke. And so you're thinking having high cholesterol isn't the best thing, and so the doctor says, "You know, I'd like to give you a drug that will help you lower your cholesterol, a statin." And you've probably heard of statins, you know that they're among the most widely prescribed drugs in the world today, you probably even know people who take them. And so you're thinking, "Yeah! Give me the statin."
Supoñamos que ides ó médico e este di "Teño os resultados das probas e ten o colesterol un pouco alto". Sabedes que o colesterol alto está asociado a unha elevación do risco de enfermidades cardiovasculares, ataque ó corazón ou apoplexía. E dades en pensar que ter o colesterol alto non é moi bo. E o doutor di: "Quero receitarlle un medicamento que lle vai axudar a baixa-lo colesterol: unha estatina". É probable que coñezáde-las estatinas e saibades que son un dos medicamentos máis receitados hoxe en día. Quizas ata coñecedes a alguén que as toma. E dicides "Si, déame a estatina!" Pero deberiades preguntar algo neste momento.
But there's a question you should ask at this point, a statistic you should ask for that most doctors don't like talking about, and pharmaceutical companies like talking about even less. It's for the number needed to treat. Now, what is this, the NNT? It's the number of people that need to take a drug or undergo a surgery or any medical procedure before one person is helped. And you're thinking, what kind of crazy statistic is that? The number should be one. My doctor wouldn't prescribe something to me if it's not going to help. But actually, medical practice doesn't work that way. And it's not the doctor's fault, if it's anybody's fault, it's the fault of scientists like me. We haven't figured out the underlying mechanisms well enough. But GlaxoSmithKline estimates that 90 percent of the drugs work in only 30 to 50 percent of the people. So the number needed to treat for the most widely prescribed statin, what do you suppose it is? How many people have to take it before one person is helped? 300. This is according to research by research practitioners Jerome Groopman and Pamela Hartzband, independently confirmed by Bloomberg.com. I ran through the numbers myself. 300 people have to take the drug for a year before one heart attack, stroke or other adverse event is prevented.
Deberiades pedir unha estatística da que moitos doutores non queren falar e as compañías farmacéuticas aínda menos. É o número necesario a tratar (NNT). E que é o NNT? É o número de persoas que teñen que toma-lo medicamento ou recibir calquera outro tratamento ou procedemento antes de que axude unha persoa. E pensaredes "que demo de estatística é esa? O número debería ser un. O meu médico non me receitaría algo que non axuda". Pero a medicina non funciona así. E non é culpa do doutor. Se alguén é culpable sómo-los científicos coma min. Aínda non coñecemos ben os mecanismos subxacentes. GlaxoSmithKline estima que o 90 % dos medicamentos funcionan entre un 30 % e un 50 % dos casos. Polo que o NNT no caso da estatina máis receitada cal pensades que é? Cantas persoas teñen que tomala antes de que axude a alguén? 300. Isto segundo os resultados dos investigadores Jerome Groopman e Pamela Hartzband confirmados de forma independente por Bloomberg.com. Eu mesmo comprobei os datos. 300 persoas deben toma-la estatina durante un ano antes de que evite un ataque ó corazón, unha apoplexía ou outro caso adverso.
Now you're probably thinking, "Well, OK, one in 300 chance of lowering my cholesterol. Why not, doc? Give me the prescription anyway." But you should ask at this point for another statistic, and that is, "Tell me about the side effects." Right? So for this particular drug, the side effects occur in five percent of the patients. And they include terrible things -- debilitating muscle and joint pain, gastrointestinal distress -- but now you're thinking, "Five percent, not very likely it's going to happen to me, I'll still take the drug." But wait a minute. Remember under stress you're not thinking clearly. So think about how you're going to work through this ahead of time, so you don't have to manufacture the chain of reasoning on the spot. 300 people take the drug, right? One person's helped, five percent of those 300 have side effects, that's 15 people. You're 15 times more likely to be harmed by the drug than you are to be helped by the drug.
E pensaredes "Teño unha posibilidade entre 300 de baixa-lo colesterol. Por que non? Déame o medicamento, doutor". Pero neste momento deberiades pedir outra estatística que é: "Fáleme dos efectos secundarios", non? No caso deste medicamento os efectos secundarios danse no 5 % dos pacientes. E inclúen cousas terribles. Dor aguda en músculos e articulacións, malestar gastrointestinal... Pero pensaredes, "Un 5 %. Non creo que me pase a min. Sigo querendo tomalo". Pero esperade un momento. Recordade: baixo estrés non pensades claramente. Pensade en como ides procesar isto antes de tempo para non ter que crea-lo razoamento no momento. Ben, 300 persoas toman o medicamento. Unha cura, e o 5 % desas 300 sofre efectos secundarios é dicir, 15 persoas. Tes 15 veces máis posibilidades de que o medicamento te dane que de que te axude.
Now, I'm not saying whether you should take the statin or not. I'm just saying you should have this conversation with your doctor. Medical ethics requires it, it's part of the principle of informed consent. You have the right to have access to this kind of information to begin the conversation about whether you want to take the risks or not.
Non estou dicindo se debedes toma-la estatina ou non só que deberiades ter esta conversación co voso médico. Por ética médica, é parte do principio de consentimento informado. Tedes dereito a ter acceso a esta información para poder falar sobre se aceptade-los riscos. Quizais pensedes
Now you might be thinking I've pulled this number out of the air for shock value, but in fact it's rather typical, this number needed to treat. For the most widely performed surgery on men over the age of 50, removal of the prostate for cancer, the number needed to treat is 49. That's right, 49 surgeries are done for every one person who's helped. And the side effects in that case occur in 50 percent of the patients. They include impotence, erectile dysfunction, urinary incontinence, rectal tearing, fecal incontinence. And if you're lucky, and you're one of the 50 percent who has these, they'll only last for a year or two.
que falo deste número para sorprender pero en realidade o NNT é bastante habitual. No caso da cirurxía máis estendida entre os homes de máis de 50 anos, a extracción da próstata por cancro, o NNT é 49. Si: hai que realizar 49 cirurxías por cada persoa que se axuda. E os efectos secundarios neste caso danse no 50 % dos pacientes. Inclúen impotencia, disfunción eréctil, incontinencia urinaria, fisuras anais, incontinencia fecal. Se tes sorte, se pertences a este 50 % que sofre isto só durará un ou dous anos.
So the idea of the pre-mortem is to think ahead of time to the questions that you might be able to ask that will push the conversation forward. You don't want to have to manufacture all of this on the spot. And you also want to think about things like quality of life. Because you have a choice oftentimes, do you I want a shorter life that's pain-free, or a longer life that might have a great deal of pain towards the end? These are things to talk about and think about now, with your family and your loved ones. You might change your mind in the heat of the moment, but at least you're practiced with this kind of thinking.
Entón, a idea do pre mortem é pensar antes do momento nas preguntas que podes facer para que a conversación avance. O ideal é non ter que crear todo isto no momento. Tamén hai que pensar en temas como a calidade de vida. Porque a miúdo temos opcións. Quero vivir unha vida máis corta pero sen dor ou unha vida máis longa quizais con moita dor cara ó final? Son cousas nas que debemos pensar agora e falalas coa familia e seres queridos. Pode que cambiemos de idea coa presión do momento pero é bo practicar este tipo de razoamento.
Remember, our brain under stress releases cortisol, and one of the things that happens at that moment is a whole bunch on systems shut down. There's an evolutionary reason for this. Face-to-face with a predator, you don't need your digestive system, or your libido, or your immune system, because if you're body is expending metabolism on those things and you don't react quickly, you might become the lion's lunch, and then none of those things matter. Unfortunately, one of the things that goes out the window during those times of stress is rational, logical thinking, as Danny Kahneman and his colleagues have shown. So we need to train ourselves to think ahead to these kinds of situations.
Recordade: baixo estrés o cerebro emite cortisol e unha das cousas que pasa nese momento é que se apagan un montón de sistemas. A evolución dáno-la explicación. Cando nos enfrontamos a un predador, non precisamos do sistema dixestivo ou da libido ou do sistema inmunolóxico porque se o corpo inviste metabolismo nestas cousas e non reaccionamos rapidamente podemos se-la comida do león, e todas esas cousas deixan de importar. Desafortunadamente, unha das cousas que se apaga neses momentos de estrés é o pensamento lóxico e racional, como demostraron Danny Kahneman e os seus colegas. Por iso necesitamos adestrarnos para pensar anticipadamente neste tipo de situacións.
I think the important point here is recognizing that all of us are flawed. We all are going to fail now and then. The idea is to think ahead to what those failures might be, to put systems in place that will help minimize the damage, or to prevent the bad things from happening in the first place.
Creo que o máis importante é recoñecer que todos temos defectos. Nalgún momento imos equivocarnos. A idea é pensar anticipadamente no que poden ser estas equivocacións, establecer sistemas que poidan minimizar os danos ou simplemente evitar que estas cousas malas pasen.
Getting back to that snowy night in Montreal, when I got back from my trip, I had my contractor install a combination lock next to the door, with a key to the front door in it, an easy to remember combination. And I have to admit, I still have piles of mail that haven't been sorted, and piles of emails that I haven't gone through. So I'm not completely organized, but I see organization as a gradual process, and I'm getting there.
Volvendo a aquela noite con neve en Montreal. Cando volvín da viaxe o meu contratista instaloume unha pechadura con código ó lado da porta coa chave da porta da casa dentro e un código fácil de recordar. E recoñezo que teño montóns de correo que aínda teño que ordenar e montóns de correos electrónicos que teño que ler. Non son totalmente organizado pero creo que a organización é un proceso gradual e estou traballando niso.
Thank you very much.
Moitas grazas.
(Applause)