1
00:00:11,440 --> 00:00:13,640
Welcome to the Clinical
Center Grand Rounds,

2
00:00:13,640 --> 00:00:17,440
a weekly series of educational
lectures for physicians and

3
00:00:17,440 --> 00:00:20,080
health care professionals
broadcast from the Clinical

4
00:00:20,080 --> 00:00:23,040
Center at the National
Institutes of Health in

5
00:00:23,040 --> 00:00:24,840
Bethesda, MD.

6
00:00:24,840 --> 00:00:28,400
The NIH Clinical Center is the
world's largest hospital totally

7
00:00:28,400 --> 00:00:32,080
dedicated to investigational
research and leads the global

8
00:00:32,080 --> 00:00:35,040
effort in training today's
investigators and discovering

9
00:00:35,040 --> 00:00:37,200
tomorrow's cures.

10
00:00:37,200 --> 00:00:47,680
Learn more by visiting us online
at http://clinicalcenter.nih.gov

11
00:00:47,680 --> 00:00:49,320
OUR SPEAKER IS DR. GURPREET

12
00:00:49,320 --> 00:00:51,640
DHALIWAL, PROFESSOR OF MEDICINE

13
00:00:51,640 --> 00:00:53,680
AT UNIVERSITY OF CALIFORNIA, SAN

14
00:00:53,680 --> 00:00:56,760
FRANCISCO, DIRECTOR OF INTERNAL

15
00:00:56,760 --> 00:01:00,360
MEDICINE STUDENT CLERKSHIPS SAN

16
00:01:00,360 --> 00:01:02,000
FRANCISCO VETERANS AFFAIRS

17
00:01:02,000 --> 00:01:04,840
MEMORIAL CENTER, A BACHELOR'S

18
00:01:04,840 --> 00:01:07,040
DEGREE AT NORTHWESTERN AND

19
00:01:07,040 --> 00:01:10,640
MEDICAL DEGREE IN 1994,

20
00:01:10,640 --> 00:01:11,400
COMPLETED INTERNAL MEDICINE

21
00:01:11,400 --> 00:01:15,560
RESIDENCY  UNIVERSITY OF

22
00:01:15,560 --> 00:01:17,000
CALIFORNIA, SAN FRANCISCO,

23
00:01:17,000 --> 00:01:19,080
COMPLETED UCSF TEACHING SCHOLARS

24
00:01:19,080 --> 00:01:22,920
PROGRAM, FOLLOWING THIS HE

25
00:01:22,920 --> 00:01:24,840
JOINED THE UCSF FACULTY,

26
00:01:24,840 --> 00:01:28,680
FOCUSING ON HOW DOCTORS DIAGNOSE

27
00:01:28,680 --> 00:01:29,360
AND TEACH CLINICAL REASONING,

28
00:01:29,360 --> 00:01:31,200
TEACHING IN A BROAD ARRAY OF

29
00:01:31,200 --> 00:01:34,800
SETTINGS, ACADEMIC INTERESTS ARE

30
00:01:34,800 --> 00:01:35,800
COGNITIVE PROCESSES AND

31
00:01:35,800 --> 00:01:36,680
DIAGNOSTIC REASONING AND

32
00:01:36,680 --> 00:01:38,800
CLINICAL PROBLEM SOLVING, STUDY

33
00:01:38,800 --> 00:01:39,560
OF DIAGNOSTIC EXPERTISE.

34
00:01:39,560 --> 00:01:45,760
CONSIDERED ONE OF THE MOST

35
00:01:45,760 --> 00:01:53,400
SKILLFUL DIAGNOSE  DIAGNOSING, E

36
00:01:53,400 --> 00:01:54,560
MESMERIZES AUDIENCES MEANT TO

37
00:01:54,560 --> 00:01:54,840
STUFF US.

38
00:01:54,840 --> 00:01:56,280
THE "NEW YORK TIMES" SAID TO

39
00:01:56,280 --> 00:01:58,560
OBSERVE HIM AT WORK IS LIKE

40
00:01:58,560 --> 00:02:00,440
WATCHING STEVEN SPIELBERG TACKLE

41
00:02:00,440 --> 00:02:06,920
A SCRIPT OR RORY MACKELROY A

42
00:02:06,920 --> 00:02:10,360
GOLF COURSE, HE WAS PROFILED IN

43
00:02:10,360 --> 00:02:16,000
AN ARTICLE  AND WAS A WRITER FOR

44
00:02:16,000 --> 00:02:24,320
"WALL STREET JOURNAL" A  GUEST N

45
00:02:24,320 --> 00:02:26,480
HIGHLY RATED PODCASTS, UCFS

46
00:02:26,480 --> 00:02:28,480
DEPARTMENT OF MEDICINE COUNSEL

47
00:02:28,480 --> 00:02:32,840
OF MASTER CLINICIANS, HAS WON

48
00:02:32,840 --> 00:02:36,720
MUCH TEACHING AWARDS AND

49
00:02:36,720 --> 00:02:38,760
PURPOSED MORE THAN 150 JOURNAL

50
00:02:38,760 --> 00:02:39,400
ARTICLES, A VISITING PROFESSOR

51
00:02:39,400 --> 00:02:42,240
ACROSS THE U.S., CHINA, JAPAN.

52
00:02:42,240 --> 00:02:43,800
THIS IS THE POINT WHERE I PUT

53
00:02:43,800 --> 00:02:47,160
DOWN THE SCRIPT AND TELL YOU HOW

54
00:02:47,160 --> 00:02:49,240
DR. DHALIWAL CAME TO THE NIH.

55
00:02:49,240 --> 00:02:53,760
I HAD A SPECTACULAR STUDENT WHO

56
00:02:53,760 --> 00:02:55,840
BURNT OUT IN A TOP TEN MEDICAL

57
00:02:55,840 --> 00:02:56,280
RESIDENCY.

58
00:02:56,280 --> 00:02:58,680
AFTER BEING ON THE TREADMILL, SO

59
00:02:58,680 --> 00:03:00,120
MANY RESIDENTS DO.

60
00:03:00,120 --> 00:03:01,840
I COULD NOT INSPIRE THEM NO

61
00:03:01,840 --> 00:03:03,640
MATTER WHAT I TRIED.

62
00:03:03,640 --> 00:03:07,880
SUDDENLY, THEY PRESENTED WITH A

63
00:03:07,880 --> 00:03:10,600
LASER FOCUSED MONO MANIA

64
00:03:10,600 --> 00:03:12,200
RELATING TO ECSTASY OF MEDICINE.

65
00:03:12,200 --> 00:03:14,560
I HAD TO ASK THEM IF THERE WAS

66
00:03:14,560 --> 00:03:16,560
AN INFECTIOUS AGENT, THEY SAID

67
00:03:16,560 --> 00:03:19,640
FIVE WORDS.

68
00:03:19,640 --> 00:03:22,240
DR. DHALIWAL GAVE GRAND ROUNDS.

69
00:03:22,240 --> 00:03:24,040
FAST FORWARD, A DIFFERENT FORMER

70
00:03:24,040 --> 00:03:26,880
STUDENT NOW A RESIDENT AT UCSF,

71
00:03:26,880 --> 00:03:29,280
PRESENTED WITH THE SAME INDUCED

72
00:03:29,280 --> 00:03:32,040
MONO MANIA FOCUSED ON MEDICINE,

73
00:03:32,040 --> 00:03:34,120
THIS TIME I RECOGNIZED THE

74
00:03:34,120 --> 00:03:36,120
SYMPTOMS AND ASKED WHAT THE

75
00:03:36,120 --> 00:03:37,640
INFECTIOUS AGENT WAS.

76
00:03:37,640 --> 00:03:40,800
THEY SAID TWO WORDS.

77
00:03:40,800 --> 00:03:41,560
DR. DHALIWAL.

78
00:03:41,560 --> 00:03:46,400
THIS, MY CASE SERIES, IS BETTER

79
00:03:46,400 --> 00:03:48,040
THAN A RANDOMIZED CONTROLLED

80
00:03:48,040 --> 00:03:48,480
TRIAL.

81
00:03:48,480 --> 00:03:49,800
YOU'RE ABOUT TO BE REMINDED WHY

82
00:03:49,800 --> 00:03:53,640
YOU WENT TO MEDICAL SCHOOL AND

83
00:03:53,640 --> 00:03:54,680
REDISCOVER THE MEANING IN

84
00:03:54,680 --> 00:03:55,280
MEDICINE, WELCOME OUR SPEAKER,

85
00:03:55,280 --> 00:03:58,120
DR. GURPREET DHALIWAL.

86
00:03:58,120 --> 00:04:00,440
FROM SUPERFORECASTERS TO SUPER

87
00:04:00,440 --> 00:04:02,360
DIAGNOSTICICIANS.

88
00:04:02,360 --> 00:04:04,400
>>THANK YOU FOR

89
00:04:04,400 --> 00:04:05,440
THE VERY KIND INTRODUCTION, ALL

90
00:04:05,440 --> 00:04:08,000
OF IT WAS KIND.

91
00:04:08,000 --> 00:04:18,440
IF THERE'S ANY PANDEMIC OR

92
00:04:19,520 --> 00:04:20,080
MONOMANNIC ENDEMIC

93
00:04:20,080 --> 00:04:21,880
I'LL BE ATTACHED TO THAT.

94
00:04:21,880 --> 00:04:24,160
THINKING AND DIAGNOSIS AND

95
00:04:24,160 --> 00:04:25,720
JUDGMENT, COMING FROM THE

96
00:04:25,720 --> 00:04:27,560
PERSPECTIVE OF A TEACHER WHO

97
00:04:27,560 --> 00:04:29,720
CARES ABOUT DIAGNOSIS AND TO

98
00:04:29,720 --> 00:04:31,280
CONVINCE US WE SHOULD, DIAGNOSE

99
00:04:31,280 --> 00:04:32,560
IS THE MOST IMPORTANT PROCEDURE

100
00:04:32,560 --> 00:04:35,360
THAT WE DO IN MEDICINE, OUR

101
00:04:35,360 --> 00:04:37,320
ENTRYWAY TO GETTING PEOPLE

102
00:04:37,320 --> 00:04:37,560
BETTER.

103
00:04:37,560 --> 00:04:38,760
AND IT'S REMARKABLE THAT DOCTORS

104
00:04:38,760 --> 00:04:41,160
DO IT AS WELL AS WE DO BUT

105
00:04:41,160 --> 00:04:43,200
THERE'S ALWAYS OPPORTUNITY FOR

106
00:04:43,200 --> 00:04:43,520
IMPROVEMENT.

107
00:04:43,520 --> 00:04:54,040
THERE'S A SAFETY DIMENSION, WE

108
00:04:54,880 --> 00:04:59,280
HAVE TO GIVE PEOPLE THE RIGHT

109
00:04:59,280 --> 00:05:02,600
LABEL ON WHAT AILS THEM TO GET

110
00:05:02,600 --> 00:05:04,680
THEM BETTER.

111
00:05:04,680 --> 00:05:06,000
HOUSEKEEPING SLIDES, OBJECTIVES,

112
00:05:06,000 --> 00:05:06,320
DISCLOSURES.

113
00:05:06,320 --> 00:05:07,760
THE ORIENTING FRAMEWORK FOR

114
00:05:07,760 --> 00:05:09,960
TODAY'S TALK IS THIS EQUATION.

115
00:05:09,960 --> 00:05:11,440
SO DIAGNOSIS WHEN YOU LOOK AT

116
00:05:11,440 --> 00:05:14,200
HOW DOCTORS DO IT, WE DO IT

117
00:05:14,200 --> 00:05:15,960
QUITE WELL, PROBABLY GET IT

118
00:05:15,960 --> 00:05:18,080
RIGHT 85 TO 90% OF ENCOUNTERS

119
00:05:18,080 --> 00:05:23,840
BUT THAT MEANS THERE'S ROOM FOR

120
00:05:23,840 --> 00:05:27,000
IMPROVEMENT, INFLUENCED BY THIS

121
00:05:27,000 --> 00:05:28,280
EQUATION THAT GARY KLEIN SHOWED

122
00:05:28,280 --> 00:05:30,200
AT A MEETING, IF YOU'RE TRYING

123
00:05:30,200 --> 00:05:31,400
TO IMPROVE PERFORMANCE THERE'S

124
00:05:31,400 --> 00:05:32,800
TWO WAYS TO DO IT.

125
00:05:32,800 --> 00:05:35,000
ONE IS THAT YOU CAN DECREASE

126
00:05:35,000 --> 00:05:37,200
ERRORS, AND THE OTHER IS THAT

127
00:05:37,200 --> 00:05:38,400
YOU CAN INCREASE EXPERTISE.

128
00:05:38,400 --> 00:05:41,000
I WAS STRUCK BY IT BECAUSE THERE

129
00:05:41,000 --> 00:05:42,680
ARE TWO SIDES TO THE SAME COIN

130
00:05:42,680 --> 00:05:44,440
BUT THEY REQUIRE VERY DIFFERENT

131
00:05:44,440 --> 00:05:45,080
APPROACHES.

132
00:05:45,080 --> 00:05:47,800
IF YOU THINK OF MAYBE THE SPORTS

133
00:05:47,800 --> 00:05:48,480
ANALOGY, DIFFERENCE BETWEEN

134
00:05:48,480 --> 00:05:51,880
GREAT DEFENSE AND GREAT OFFENSE.

135
00:05:51,880 --> 00:05:54,440
OR BETWEEN AVOIDING UNFORCED

136
00:05:54,440 --> 00:05:56,040
ERRORS AND HITTING WINNERS.

137
00:05:56,040 --> 00:05:57,680
AND DIALING DOWN ERRORS AND

138
00:05:57,680 --> 00:05:58,640
DIALING UP EXPERTISE HAS THE

139
00:05:58,640 --> 00:05:59,760
SAME ANALOGY.

140
00:05:59,760 --> 00:06:01,720
SO IN THIS TALK, WHAT I'M GOING

141
00:06:01,720 --> 00:06:04,120
TO DO IS SHARE A MENU OF

142
00:06:04,120 --> 00:06:12,120
APPROACHES TO BECOMING A BETTER

143
00:06:12,120 --> 00:06:12,520
DIAGNOSTICICIAN.

144
00:06:12,520 --> 00:06:13,880
SOME ARE DRAWN FROM EXPERIENCE,

145
00:06:13,880 --> 00:06:17,160
I PRESENT AS A  MENU OF THINGS

146
00:06:17,160 --> 00:06:18,920
THAT ANYONE AT ANY STAGE CAN

147
00:06:18,920 --> 00:06:20,440
ADAPT IF WE'RE MOTIVATED BY THE

148
00:06:20,440 --> 00:06:24,080
POSSIBILITY OF GOING FROM BEING

149
00:06:24,080 --> 00:06:25,480
A GOOD DIAGNOSTICICIAN TO A

150
00:06:25,480 --> 00:06:28,160
GREAT ONE.

151
00:06:28,160 --> 00:06:30,680
DO THE MATH, WE'LL HIT THE

152
00:06:30,680 --> 00:06:32,640
HIGHLIGHTS OF EACH ONE.

153
00:06:32,640 --> 00:06:35,920
THE FIRST AND PERHAPS MOST

154
00:06:35,920 --> 00:06:37,920
IMPORTANT FOR THE ASPIRES

155
00:06:37,920 --> 00:06:39,000
DIAGNOSTICIAN IS TO GET YOURSELF

156
00:06:39,000 --> 00:06:40,880
IN FRONT OF AS MANY STORIES AS

157
00:06:40,880 --> 00:06:41,320
POSSIBLE.

158
00:06:41,320 --> 00:06:44,520
WE'RE  ACCUSTOMED TO LEARNING

159
00:06:44,520 --> 00:06:45,640
THROUGH STUDIES AND TEXT BUT THE

160
00:06:45,640 --> 00:06:47,560
UNIT OF LEARNING OF THE HUMAN

161
00:06:47,560 --> 00:06:48,760
MIND IS BY STORIES.

162
00:06:48,760 --> 00:06:49,960
IF YOU THINK ABOUT EVERY PATIENT

163
00:06:49,960 --> 00:06:51,720
THAT WE TALK ABOUT WITH EACH

164
00:06:51,720 --> 00:06:53,560
OTHER, IT HAS A STORY ELEMENT TO

165
00:06:53,560 --> 00:06:53,880
IT.

166
00:06:53,880 --> 00:06:57,760
EVERY PATIENT HAS A STORY.

167
00:06:57,760 --> 00:07:03,400
AND THEY FOLLOW A PYRAMID, A

168
00:07:03,400 --> 00:07:05,200
PLAYWRIGHT SAID ALL DRAMATIC

169
00:07:05,200 --> 00:07:06,680
STORIES HAVE THIS ARC.

170
00:07:06,680 --> 00:07:08,000
STORIES THEY SAY "ONCE UPON A

171
00:07:08,000 --> 00:07:10,520
TIME THE PATIENT WAS IN THEIR

172
00:07:10,520 --> 00:07:12,400
USUAL STATE OF HEALTH," AND

173
00:07:12,400 --> 00:07:15,800
SOMETHING HAPPENS, LIKE THIS MAN

174
00:07:15,800 --> 00:07:23,480
STARTED TO DEVELOP FEVER,

175
00:07:23,480 --> 00:07:25,800
LYMPHADENOPATHY, THEY DID A

176
00:07:25,800 --> 00:07:28,560
BIOPSY, NON-DIAGNOSTIC, A PET

177
00:07:28,560 --> 00:07:30,120
SCAN SHOWED REGIONAL LYMPH NODES

178
00:07:30,120 --> 00:07:31,680
IN THE NECK AND ARM, WASN'T

179
00:07:31,680 --> 00:07:34,520
CLEAR WHAT WAS GOING ON.

180
00:07:34,520 --> 00:07:36,920
EVERYONE WAS WORRIED ABOUT

181
00:07:36,920 --> 00:07:38,560
LYMPHOMA SOMEONE TOOK A REAL

182
00:07:38,560 --> 00:07:39,480
SOCIAL HISTORY AND FOUND --

183
00:07:39,480 --> 00:07:41,760
FOUND THAT HE HAD JUST ACQUIRED

184
00:07:41,760 --> 00:07:44,640
A NEW YOUNG KITTEN.

185
00:07:44,640 --> 00:07:48,600
THAT LED THEM TO GET A

186
00:07:48,600 --> 00:07:51,120
BARTONELLA SEROLOGY, POSITIVE,

187
00:07:51,120 --> 00:07:53,000
TREATED WITH DOXYCYCLINE, GOT

188
00:07:53,000 --> 00:07:56,200
BETTER, LIVED HAPPILY EVERY

189
00:07:56,200 --> 00:07:57,560
AFTER AND WATCHED CAT MEMES ON

190
00:07:57,560 --> 00:07:58,360
THE INTERNET INSTEAD.

191
00:07:58,360 --> 00:08:01,560
WHEN WE LEARN A STORY LIKE THAT,

192
00:08:01,560 --> 00:08:03,720
THE STORY OF CAT SCRATCH

193
00:08:03,720 --> 00:08:05,000
DISEASE, IT IMPRINTS IN OUR

194
00:08:05,000 --> 00:08:05,320
MIND.

195
00:08:05,320 --> 00:08:06,720
THE BRAIN IS GOOD AT LEARNING

196
00:08:06,720 --> 00:08:08,840
THROUGH STORIES, NOT SO GREAT AT

197
00:08:08,840 --> 00:08:09,720
LEARNING THROUGH STUDIES OR

198
00:08:09,720 --> 00:08:10,040
STATISTICS.

199
00:08:10,040 --> 00:08:11,600
ONE OF THE ACTION STEPS TO

200
00:08:11,600 --> 00:08:20,680
BECOMING A GREAT DIAGNOSE

201
00:08:20,680 --> 00:08:21,000
 -

202
00:08:21,000 --> 00:08:21,880
DIAGNOSTICIAN, SOMEONE FIGURED

203
00:08:21,880 --> 00:08:23,720
OUT THERE WAS A PET IN HIS LIFE,

204
00:08:23,720 --> 00:08:25,160
THE STORY WON'T BE FORGOTTEN.

205
00:08:25,160 --> 00:08:27,240
WHEN YOU LOOK AT STUDIES OF

206
00:08:27,240 --> 00:08:28,640
EXPERTS IN OTHER FIELDS YOU FIND

207
00:08:28,640 --> 00:08:29,760
THE WAY THEY REALLY TAKE

208
00:08:29,760 --> 00:08:31,840
THEMSELVES FROM GOOD TO GREAT IS

209
00:08:31,840 --> 00:08:34,600
ACCUMULATING AS MANY STORIES AS

210
00:08:34,600 --> 00:08:34,920
POSSIBLE.

211
00:08:34,920 --> 00:08:37,560
IN THE BOOK, MADE THE STICK, THE

212
00:08:37,560 --> 00:08:44,040
HEATH BROTHERS TALK ABOUT

213
00:08:44,040 --> 00:08:45,600
ACQUISITION AMONG COPY MACHINE

214
00:08:45,600 --> 00:08:46,800
REPAIR MANUALS, THEY TAKE THE

215
00:08:46,800 --> 00:08:48,640
SAME TESTS, BUT THE WAY THEY GET

216
00:08:48,640 --> 00:08:51,280
BETTER IS THEY GET TOGETHER AND

217
00:08:51,280 --> 00:08:52,040
SWAP STORIES.

218
00:08:52,040 --> 00:08:53,800
YOU SHOULD MAKE NO MISTAKE, A

219
00:08:53,800 --> 00:08:56,520
COPY MACHINE IS A WILDLY

220
00:08:56,520 --> 00:08:58,480
COMPLICATED THING, CHEMICAL

221
00:08:58,480 --> 00:08:59,400
ELEMENTS, ELECTRICAL AND

222
00:08:59,400 --> 00:09:00,120
MECHANICAL ELEMENTS.

223
00:09:00,120 --> 00:09:01,440
IN THE BOOK, WHAT THEY TALK

224
00:09:01,440 --> 00:09:02,960
ABOUT IS THEY REALLY GET BETTER

225
00:09:02,960 --> 00:09:04,520
BY SAYING HOW DID YOU APPROACH

226
00:09:04,520 --> 00:09:06,240
THIS PROBLEM?

227
00:09:06,240 --> 00:09:07,560
WHAT DID DO YOU WHEN YOU GOT

228
00:09:07,560 --> 00:09:08,320
THIS ERROR MESSAGE?

229
00:09:08,320 --> 00:09:10,000
THE WAY THEY ARE TALKING ABOUT

230
00:09:10,000 --> 00:09:10,800
SOLVING THAT MACHINE SOUNDS

231
00:09:10,800 --> 00:09:12,960
SIMILAR TO THE WAY WE GET

232
00:09:12,960 --> 00:09:14,440
TOGETHER A CASE CONFERENCE OR

233
00:09:14,440 --> 00:09:16,800
MORNING REPORT TO SOLVE THAT

234
00:09:16,800 --> 00:09:17,840
SAME STORY.

235
00:09:17,840 --> 00:09:19,840
AND THE POWER OF STORIES IS THAT

236
00:09:19,840 --> 00:09:23,280
WHEN YOU ARE HEARING A STORY, IF

237
00:09:23,280 --> 00:09:24,800
IT'S TOLD WELL, VIVIDLY ENOUGH,

238
00:09:24,800 --> 00:09:27,320
YOU CAN ENVISION YOURSELF IN THE

239
00:09:27,320 --> 00:09:28,680
SAME SITUATION, AND YOU CAN

240
00:09:28,680 --> 00:09:29,800
ALMOST MENTALLY TEST OUT HOW I

241
00:09:29,800 --> 00:09:31,120
WOULD HAVE HANDLED THAT

242
00:09:31,120 --> 00:09:31,360
SITUATION.

243
00:09:31,360 --> 00:09:33,640
AND IF IT'S DONE WELL, EITHER BY

244
00:09:33,640 --> 00:09:35,160
THE STORY TELLER OR PERSON

245
00:09:35,160 --> 00:09:36,800
ENGAGING IN IT, THE LINE BETWEEN

246
00:09:36,800 --> 00:09:40,840
BEING IN THE AUDIENCE AND BEING

247
00:09:40,840 --> 00:09:41,680
THE PROTAGONIST BLURS FOR

248
00:09:41,680 --> 00:09:42,520
LONG-TERM MEMORY WHEN YOU NEED

249
00:09:42,520 --> 00:09:44,920
TO CALL ON THAT MEMORY IN THE

250
00:09:44,920 --> 00:09:45,360
FUTURE.

251
00:09:45,360 --> 00:09:47,320
SO, FOR US IN MEDICINE, WE TAKE

252
00:09:47,320 --> 00:09:48,520
CARE OF PATIENTS, THE CORE

253
00:09:48,520 --> 00:09:49,840
FOUNDATION OF COURSE IS TO LEARN

254
00:09:49,840 --> 00:09:53,120
FROM THE CASES THAT WE TAKE CARE

255
00:09:53,120 --> 00:09:53,360
OF.

256
00:09:53,360 --> 00:09:54,440
AND ENSURING ADEQUATE VOLUME IN

257
00:09:54,440 --> 00:09:55,880
TRAINING AND CAREER IS A

258
00:09:55,880 --> 00:10:00,560
FOUNDATION OF BEING A GREAT

259
00:10:00,560 --> 00:10:00,920
DIAGNOSTICIAN.

260
00:10:00,920 --> 00:10:03,600
IF WE WANT TO GO FROM GOOD TO

261
00:10:03,600 --> 00:10:05,360
GREAT, NEXT STEP IS TO EXPAND

262
00:10:05,360 --> 00:10:05,680
CASES.

263
00:10:05,680 --> 00:10:07,440
IF I'M A TRAINEE, I TAKE CARE OF

264
00:10:07,440 --> 00:10:08,200
MY OWN CASES.

265
00:10:08,200 --> 00:10:10,520
DO I HAVE MY HEAD DOWN WHEN I'M

266
00:10:10,520 --> 00:10:12,480
IN THE TEAM ROOM OR HEAD UP AND

267
00:10:12,480 --> 00:10:14,120
LISTENING TO WHAT MY FELLOW

268
00:10:14,120 --> 00:10:15,200
STUDENTS OR FELLOW RESIDENTS ARE

269
00:10:15,200 --> 00:10:16,760
DOING AND LEARNING FROM THEIR

270
00:10:16,760 --> 00:10:18,040
CASES AS WELL?

271
00:10:18,040 --> 00:10:19,200
IF I'M NOT SATISFIED ENOUGH JUST

272
00:10:19,200 --> 00:10:21,000
FROM LEARNING ABOUT ALL THE

273
00:10:21,000 --> 00:10:23,560
CASES ON THE TEAM, CAN I FIND MY

274
00:10:23,560 --> 00:10:25,320
WAY TO CONFERENCES, LIKE MORNING

275
00:10:25,320 --> 00:10:27,400
REPORT OR M & M, OTHER CASES
ARE

276
00:10:27,400 --> 00:10:29,480
DISCUSSED AND I CAN UPLOAD MORE

277
00:10:29,480 --> 00:10:31,880
CASES TO MY LONG-TERM MEMORY OR

278
00:10:31,880 --> 00:10:33,200
DO I EVEN AVAIL MYSELF OF ALL

279
00:10:33,200 --> 00:10:35,600
THE CASES THAT EXIST NOW.

280
00:10:35,600 --> 00:10:38,480
USED TO BE IN THE PAST THEY WERE

281
00:10:38,480 --> 00:10:41,080
IN JOURNALS, NOW ON TWITTER OR

282
00:10:41,080 --> 00:10:43,360
PODCAST, AND INTERNET, AS WELL

283
00:10:43,360 --> 00:10:44,160
AS TRADITIONAL JOURNALS, CASES

284
00:10:44,160 --> 00:10:46,120
WHERE YOU CAN LEARN FROM ANOTHER

285
00:10:46,120 --> 00:10:47,640
DOCTOR'S GREAT WORK AN INSIGHT

286
00:10:47,640 --> 00:10:48,840
CRYSTALLIZED IN A SHORT WAY

287
00:10:48,840 --> 00:10:49,200
OFTENTIMES.

288
00:10:49,200 --> 00:10:51,000
IF YOU DO THIS RIGHT, ONCE YOU

289
00:10:51,000 --> 00:10:52,120
GET ADDICTED TO THE LEARNING

290
00:10:52,120 --> 00:10:53,320
THAT COMES FROM NOT ONLY YOUR

291
00:10:53,320 --> 00:10:55,080
OWN CASES BUT HEARING FROM OTHER

292
00:10:55,080 --> 00:10:56,640
CASES, YOU CAN SORT OF SLIDE TO

293
00:10:56,640 --> 00:11:00,480
WHERE YOU ALMOST GET THE SENSE

294
00:11:00,480 --> 00:11:01,880
OF FOMO, I MISSED A CONFERENCE,

295
00:11:01,880 --> 00:11:05,160
TOOK A DAY OFF AND DIDN'T HEAR

296
00:11:05,160 --> 00:11:06,280
WHAT MY CASES WERE GOING ON, I

297
00:11:06,280 --> 00:11:07,880
HAVE TO CATCH UP AND FIND OUT.

298
00:11:07,880 --> 00:11:08,760
YOU LEARN THE UNIT OF LEARNING

299
00:11:08,760 --> 00:11:10,320
IS THE MOST POWERFUL OF ALL.

300
00:11:10,320 --> 00:11:12,640
SO THE FIRST ACTION STEP FOR A

301
00:11:12,640 --> 00:11:14,720
GREAT DIAGNOSTICIAN IS PUT

302
00:11:14,720 --> 00:11:16,880
YOURSELF IN FRONT OF AS MANY

303
00:11:16,880 --> 00:11:22,040
STORIES, NOT STUDIES, THAT YOU

304
00:11:22,040 --> 00:11:23,680
CAN.

305
00:11:23,680 --> 00:11:25,440
THE SECOND ACTION STEP, GIVE

306
00:11:25,440 --> 00:11:26,240
YOURSELF STRETCH ASSIGNMENTS,

307
00:11:26,240 --> 00:11:27,240
SOMETHING THE BUSINESS WORLD

308
00:11:27,240 --> 00:11:28,200
USES FREQUENTLY.

309
00:11:28,200 --> 00:11:29,840
WHAT THEY DO IS DELIBERATELY

310
00:11:29,840 --> 00:11:32,080
PLACE A PERSON IN A CHALLENGING

311
00:11:32,080 --> 00:11:33,280
SITUATION, SO THAT THEY HAVE TO

312
00:11:33,280 --> 00:11:34,960
LEARN A LITTLE BIT MORE THAN

313
00:11:34,960 --> 00:11:37,280
THEY KNOW CURRENTLY IN ORDER TO

314
00:11:37,280 --> 00:11:38,560
FULFILL THE JOB.

315
00:11:38,560 --> 00:11:39,920
I WAS REMINDED OF IMPORTANCE OF

316
00:11:39,920 --> 00:11:42,400
THIS EARLY IN MY CAREER.

317
00:11:42,400 --> 00:11:48,160
I MOONLIT AT A HOSPITAL IN AN

318
00:11:48,160 --> 00:11:49,560
ADJACENT HOSPITAL, I LEARNED SO

319
00:11:49,560 --> 00:11:51,280
MUCH, PART WAS NUMBER OF CASES,

320
00:11:51,280 --> 00:11:54,120
PART WAS HABITS LIKE TRACKING

321
00:11:54,120 --> 00:11:55,200
PATIENT OUTCOMES, PART WAS I WAS

322
00:11:55,200 --> 00:11:56,560
PUSHED OUT OF MY COMFORT ZONE.

323
00:11:56,560 --> 00:11:58,520
I WOULD BE ASKED FOR INSTANCE TO

324
00:11:58,520 --> 00:12:01,360
ADMIT A PEDIATRIC PATIENT WHO

325
00:12:01,360 --> 00:12:03,040
WAS 16 WITH PANCREATITIS EVEN

326
00:12:03,040 --> 00:12:04,080
THOUGH I'M AN INTERNIST, OR

327
00:12:04,080 --> 00:12:08,680
ASKED TO TAKE CARE OF A WOMAN IN

328
00:12:08,680 --> 00:12:13,080
LATE PREGNANCY WITH ASTHMA

329
00:12:13,080 --> 00:12:17,600
EXACERBATION OR GI BLEEDING OR

330
00:12:17,600 --> 00:12:18,360
INTRACRANIAL BLEEDING, WAS LEFT

331
00:12:18,360 --> 00:12:20,560
FOR ME TO MANAGE ALONE.

332
00:12:20,560 --> 00:12:22,720
I WAS LEFT WITH DISCOMFORT BUT

333
00:12:22,720 --> 00:12:27,600
HAD A WHOLE LOT OF GROWTH.

334
00:12:27,600 --> 00:12:29,320
A HOSPITALIST HERE DID A STUDY

335
00:12:29,320 --> 00:12:30,800
OF COUNCIL OF MASTER CLINICIANS

336
00:12:30,800 --> 00:12:33,160
AND FOUND THE SAME STORY, MANY

337
00:12:33,160 --> 00:12:34,840
TOOK ON STRETCH ASSIGNMENTS

338
00:12:34,840 --> 00:12:36,040
EARLY IN THEIR CAREERS, WAY

339
00:12:36,040 --> 00:12:37,760
BEFORE THEY WOUND UP BECOMING

340
00:12:37,760 --> 00:12:38,640
MASTER CLINICIANS.

341
00:12:38,640 --> 00:12:41,160
HERE ARE SOME QUOTES THAT SOME

342
00:12:41,160 --> 00:12:42,280
TOLD THEM.

343
00:12:42,280 --> 00:12:44,000
STORIES ABOUT WORKING WHERE

344
00:12:44,000 --> 00:12:46,440
VOLUME WAS HIGH, AND WORKING AS

345
00:12:46,440 --> 00:12:47,720
HARD AS THEY COULD BUT LEARNING

346
00:12:47,720 --> 00:12:49,160
AS THEY WENT ALONG.

347
00:12:49,160 --> 00:12:50,120
BEING THE ONLY DOCTOR

348
00:12:50,120 --> 00:12:51,320
RESPONSIBLE FOR A CADRE OF

349
00:12:51,320 --> 00:12:52,840
PATIENTS, DIFFERENT FROM THE

350
00:12:52,840 --> 00:12:54,960
SAFETY OF EITHER MEDICAL CENTER

351
00:12:54,960 --> 00:12:57,160
OR THEIR PRIVATE PRACTICE.

352
00:12:57,160 --> 00:12:58,880
AND JUST FRAMING THE WHOLE

353
00:12:58,880 --> 00:13:00,640
EXPERIENCE AS BEING INTENSE

354
00:13:00,640 --> 00:13:02,000
LEARNING BUT EMPHASIZING THE

355
00:13:02,000 --> 00:13:03,320
LEARNING PART OF IT.

356
00:13:03,320 --> 00:13:06,000
BECAUSE I HAVE TO SAY WHEN MANY

357
00:13:06,000 --> 00:13:07,320
OF US KNOW WHAT WE'RE

358
00:13:07,320 --> 00:13:09,280
CREDENTIALS TO TAKE CARE OF, OR

359
00:13:09,280 --> 00:13:11,240
IN OUR OWN MIND UNDERSTAND

360
00:13:11,240 --> 00:13:12,880
LIMITS, IT'S EASY TO SAY THERE'S

361
00:13:12,880 --> 00:13:13,800
PATIENTS I CAN AND CAN'T TAKE

362
00:13:13,800 --> 00:13:14,560
CARE OF.

363
00:13:14,560 --> 00:13:16,720
BUT THERE'S A SUBSET OF PATIENTS

364
00:13:16,720 --> 00:13:17,920
RIGHT ON THE MARGIN.

365
00:13:17,920 --> 00:13:20,240
AND YOU MAY WORRY ABOUT, WELL,

366
00:13:20,240 --> 00:13:21,440
EITHER BY LEGALLY OR

367
00:13:21,440 --> 00:13:22,120
CREDENTIALING OR MY COMFORT

368
00:13:22,120 --> 00:13:24,160
SHOULD I TAKE CARE OF THIS

369
00:13:24,160 --> 00:13:24,400
PATIENT?

370
00:13:24,400 --> 00:13:26,240
I WANT TO ENCOURAGE YOU TO ALSO

371
00:13:26,240 --> 00:13:28,000
WORRY ABOUT THE MISLEARNING THAT

372
00:13:28,000 --> 00:13:29,560
MIGHT HAPPEN IF WE NEVER VENTURE

373
00:13:29,560 --> 00:13:31,080
OUT OF OUR COMFORT ZONE.

374
00:13:31,080 --> 00:13:32,600
IF YOU FIND YOURSELF ON THE

375
00:13:32,600 --> 00:13:34,800
MARGIN WHERE THE PATIENT

376
00:13:34,800 --> 00:13:36,000
SLIGHTLY FURTHER ON THAN YOU'VE

377
00:13:36,000 --> 00:13:37,400
TAKEN CARE OF, TRY TO THINK

378
00:13:37,400 --> 00:13:39,640
ABOUT ENGAGING THIS AND SAY, YES

379
00:13:39,640 --> 00:13:41,640
I'LL TAKE THIS PATIENT.

380
00:13:41,640 --> 00:13:42,640
SWIPE RIGHT NOT LEFT ON THE

381
00:13:42,640 --> 00:13:43,640
PATIENT WHEN THAT OPTION IS

382
00:13:43,640 --> 00:13:45,400
RIGHT THERE IN FRONT OF YOU

383
00:13:45,400 --> 00:13:47,360
BECAUSE WHEN YOU SAY YES, I CAN

384
00:13:47,360 --> 00:13:50,320
DO IT, THE ODDS ARE THAT YOU

385
00:13:50,320 --> 00:13:50,480
CAN.

386
00:13:50,480 --> 00:13:51,960
AND THAT YOU'LL LEARN AND THE

387
00:13:51,960 --> 00:13:53,080
PATIENT WILL BENEFIT FROM

388
00:13:53,080 --> 00:13:54,360
SOMEONE SO DEDICATED TO LEARNING

389
00:13:54,360 --> 00:13:56,240
AT THE SAME TIME.

390
00:13:56,240 --> 00:13:58,520
SECOND ACTION STEP FOR

391
00:13:58,520 --> 00:14:00,160
DIAGNOSTIC EXPERTISE MOVE FROM

392
00:14:00,160 --> 00:14:01,920
COMFORT ZONE TO LEARNING ZONE

393
00:14:01,920 --> 00:14:03,440
AND STAY AT THAT MARGIN.

394
00:14:03,440 --> 00:14:04,960
NOW, ONE OF THE THINGS THAT

395
00:14:04,960 --> 00:14:07,600
MOTIVATED ME TO GET IN THIS

396
00:14:07,600 --> 00:14:09,800
FIELD ALTOGETHER IS ROLE MODELS.

397
00:14:09,800 --> 00:14:12,520
EXCELLENT CLINICIANS WHO I

398
00:14:12,520 --> 00:14:14,040
WATCHED AND ADMIRED DIAGNOSTIC

399
00:14:14,040 --> 00:14:14,800
SKILL.

400
00:14:14,800 --> 00:14:17,560
SOME WERE IN MY RESIDENCY, AMONG

401
00:14:17,560 --> 00:14:19,720
MY COLLEAGUES, BUT YOU FIND

402
00:14:19,720 --> 00:14:20,880
GREAT DIAGNOSTICIANS IN ALL

403
00:14:20,880 --> 00:14:22,800
CORNERS IF YOU LOOK AROUND.

404
00:14:22,800 --> 00:14:24,880
ONE OF MY FAVORITE ARE THE TWO

405
00:14:24,880 --> 00:14:25,240
HERE.

406
00:14:25,240 --> 00:14:28,560
YOU MAY OR MAY NOT RECOGNIZE

407
00:14:28,560 --> 00:14:29,880
THESE TWO DIAGNOSTICIANS, THEY

408
00:14:29,880 --> 00:14:31,480
ARE GENERALISTS, IF THEY HAVE

409
00:14:31,480 --> 00:14:33,160
BEEN IN PRACTICE FOR 40 YEARS,

410
00:14:33,160 --> 00:14:35,160
THEY CAN SOLVE MULTIPLE CASES

411
00:14:35,160 --> 00:14:36,600
PER HOUR, BUT IF YOU TAKE A LOOK

412
00:14:36,600 --> 00:14:38,040
AT THEIR OFFICE YOU MAY GET A

413
00:14:38,040 --> 00:14:45,360
SENSE OF WHO I'M TALKING ABOUT. 

414
00:14:45,360 --> 00:14:48,240
THIS IS THE TAPPER BROTHERS, ON

415
00:14:48,240 --> 00:14:50,320
NATIONAL PUBLIC RADIO TOOK CARE

416
00:14:50,320 --> 00:14:52,280
OF VIRTUALLY EVERY CAR MALADY

417
00:14:52,280 --> 00:14:53,840
YOU CAN IMAGINE THAT CAME

418
00:14:53,840 --> 00:14:54,720
THROUGH THE DOOR.

419
00:14:54,720 --> 00:14:56,680
THEY WORK IN TEAMS.

420
00:14:56,680 --> 00:14:58,200
THEY LOVE THEIR JOBS.

421
00:14:58,200 --> 00:14:59,200
WHEN YOU LISTEN CAREFULLY YOU

422
00:14:59,200 --> 00:15:00,880
SEE THAT THEY CARE MORE ABOUT

423
00:15:00,880 --> 00:15:02,920
THE PERSON THAN THEY DO ABOUT

424
00:15:02,920 --> 00:15:03,720
THE CAR.

425
00:15:03,720 --> 00:15:06,560
BUT ONE OF THE THINGS FROM AN

426
00:15:06,560 --> 00:15:07,560
EXPERT DIAGNOSTICIAN STANDPOINT

427
00:15:07,560 --> 00:15:09,760
THEY DID SO WELL IS THEY WENT

428
00:15:09,760 --> 00:15:12,600
BACK AND CHECKED THEIR WORK.

429
00:15:12,600 --> 00:15:17,080
SO JUST LIKE DIAGNOSTICIANS,

430
00:15:17,080 --> 00:15:20,600
THEY READ DIAGNOSES BUT HAD A

431
00:15:20,600 --> 00:15:21,680
FEATURE, STUMP THE CHUMP, ASKED

432
00:15:21,680 --> 00:15:24,360
PREVIOUS ASKED HOW WAS OUR

433
00:15:24,360 --> 00:15:25,000
ADVICE?

434
00:15:25,000 --> 00:15:26,240
WE BASICALLY MAKING

435
00:15:26,240 --> 00:15:26,960
PROGNOSTICATIONS AND GUESSES,

436
00:15:26,960 --> 00:15:28,680
AND WE HAVE TO FIND OUT HOW THE

437
00:15:28,680 --> 00:15:29,360
STORY ENDS.

438
00:15:29,360 --> 00:15:32,880
THAT'S EXACTLY WHAT THEY DID.

439
00:15:32,880 --> 00:15:33,840
THEY WOULD GIVE SIMPLE ADVICE,

440
00:15:33,840 --> 00:15:35,280
DID YOU REPLACE THE BRAKES LIKE

441
00:15:35,280 --> 00:15:35,920
WE ASKED?

442
00:15:35,920 --> 00:15:37,240
DID THE MOTOR START RUNNING

443
00:15:37,240 --> 00:15:39,320
BETTER WHEN YOU SWAPPED OUT THE

444
00:15:39,320 --> 00:15:39,600
SPARK PLUGS?

445
00:15:39,600 --> 00:15:42,280
EVEN IF THEY GAVE LIFE ADVICE,

446
00:15:42,280 --> 00:15:44,440
DID YOU DUMP THAT USELESS

447
00:15:44,440 --> 00:15:45,760
BOYFRIEND LIKE WE TOLD YOU TO?

448
00:15:45,760 --> 00:15:47,200
THEY WANTED TO KNOW HOW THE

449
00:15:47,200 --> 00:15:49,400
ADVICE WENT AND PUT THEIR ADVICE

450
00:15:49,400 --> 00:15:51,240
THERE AND SCORE FOR EVERYONE TO

451
00:15:51,240 --> 00:15:51,440
SEE.

452
00:15:51,440 --> 00:15:53,120
IT WASN'T PERFECT BUT IT'S AN

453
00:15:53,120 --> 00:15:55,040
AWESOME DISPLAY OF A COMMITMENT

454
00:15:55,040 --> 00:15:57,600
TO LEARNING BY TRACKING YOUR OWN

455
00:15:57,600 --> 00:15:58,360
WORK.

456
00:15:58,360 --> 00:16:00,440
IF YOU GO BACK TO THE STUDY OF

457
00:16:00,440 --> 00:16:02,280
MASTER CLINICIANS THAT I

458
00:16:02,280 --> 00:16:03,280
MENTIONED, BY DR. MURTHY, THAT'S

459
00:16:03,280 --> 00:16:05,480
WHAT HE FOUND IN HIS STUDY AS

460
00:16:05,480 --> 00:16:05,680
WELL.

461
00:16:05,680 --> 00:16:08,640
HERE IS A CASE OF SOMEONE WHO

462
00:16:08,640 --> 00:16:10,600
DESCRIBES SEEING A PATIENT WHERE

463
00:16:10,600 --> 00:16:12,560
WAS THOUGHT TO HAVE A BONE

464
00:16:12,560 --> 00:16:14,680
MARROW DISORDER AND DIED.

465
00:16:14,680 --> 00:16:16,400
AND ON AUTOPSY, THEY HAD AN

466
00:16:16,400 --> 00:16:18,920
AUTOPSY, WHICH WAS A GIFT OF THE

467
00:16:18,920 --> 00:16:19,760
FAMILY, TO THE DOCTORS AT THE

468
00:16:19,760 --> 00:16:22,560
TIME, BUT THERE WAS NO EVIDENCE

469
00:16:22,560 --> 00:16:24,200
OF THE MALIGNANCY THEY FOUND.

470
00:16:24,200 --> 00:16:27,000
INSTEAD, WHAT THEY FOUND, THERE

471
00:16:27,000 --> 00:16:35,360
WAS AS PERGILLUS, A PERVASIVE

472
00:16:35,360 --> 00:16:35,800
FUNGUS.

473
00:16:35,800 --> 00:16:37,440
IT'S NOT JUST THE MEDICAL

474
00:16:37,440 --> 00:16:39,600
LEARNING THAT IT CAN MIMIC

475
00:16:39,600 --> 00:16:40,520
HEMATOLOGIC MALIGNANCY, THAT'S

476
00:16:40,520 --> 00:16:42,800
IMPORTANT, BUT THE THING I WANT

477
00:16:42,800 --> 00:16:44,080
TO EMPHASIZE IS INSIGHT OF THE

478
00:16:44,080 --> 00:16:46,160
PERSON TELLING THE STORY WHO

479
00:16:46,160 --> 00:16:48,280
CONCLUDED THIS BY SAYING WE CAME

480
00:16:48,280 --> 00:16:50,560
PRETTY CLOSE TO NOT LEARNING

481
00:16:50,560 --> 00:16:51,920
FROM THAT CASE.

482
00:16:51,920 --> 00:16:54,000
I WANT TO EMPHASIZE AGAIN WE

483
00:16:54,000 --> 00:16:55,280
CAME PRETTY CLOSE TO NOT

484
00:16:55,280 --> 00:16:56,920
LEARNING FROM THAT CASE, WHICH

485
00:16:56,920 --> 00:16:58,000
UNDERSCORES THERE'S SO MANY

486
00:16:58,000 --> 00:16:59,120
TIMES WE'RE ADJACENT TO LEARNING

487
00:16:59,120 --> 00:17:01,960
BUT IF WE COULD MAKE ONE EXTRA

488
00:17:01,960 --> 00:17:03,640
STEP WE COULD UPDATE OUR

489
00:17:03,640 --> 00:17:04,240
KNOWLEDGE AND INSIGHTS THAT

490
00:17:04,240 --> 00:17:05,560
WE'RE SO CLOSE TO GETTING BUT

491
00:17:05,560 --> 00:17:08,440
TAKES A LITTLE BIT OF EFFORT.

492
00:17:08,440 --> 00:17:10,040
IF YOU STUDY OUR PRACTICE OF

493
00:17:10,040 --> 00:17:11,880
MEDICINE, IT'S HIGH IN

494
00:17:11,880 --> 00:17:12,320
DECISIONS.

495
00:17:12,320 --> 00:17:14,640
HAS A HIGH DECISION DENSITY,

496
00:17:14,640 --> 00:17:17,160
DECISIONS MADE PER UNIT TIME.

497
00:17:17,160 --> 00:17:18,920
BUT QUITE OFTEN, WE OPERATE IN

498
00:17:18,920 --> 00:17:21,600
AN OPEN LOOP SYSTEM.

499
00:17:21,600 --> 00:17:22,960
SO WE GIVE INPUT, DECISION IS

500
00:17:22,960 --> 00:17:25,080
MADE, THERE'S AN OUTCOME.

501
00:17:25,080 --> 00:17:27,240
BUT THE OUTCOME MIGHT NOT BE

502
00:17:27,240 --> 00:17:28,600
KNOWN TO US.

503
00:17:28,600 --> 00:17:30,760
I MAY GIVE A PATIENT ON THE

504
00:17:30,760 --> 00:17:33,720
PHONE OR THEY ARE TAKEN CARE OF

505
00:17:33,720 --> 00:17:43,000
BY ANOTHER PERSON, OR I'M IN THE

506
00:17:43,000 --> 00:17:44,440
ICU AND THE PATIENT IS SENT BACK

507
00:17:44,440 --> 00:17:47,080
TO THE WORD.

508
00:17:47,080 --> 00:17:52,400
NO BIOLOGICAL OR INDUSTRIAL OR

509
00:17:52,400 --> 00:17:53,520
COGNITIVE SYSTEM THAT DOESN'T

510
00:17:53,520 --> 00:17:54,320
IMPROVE BY FEEDBACK.

511
00:17:54,320 --> 00:18:01,520
WE OPERATE IN AN OPEN LOOP

512
00:18:01,520 --> 00:18:01,760
SYSTEM.

513
00:18:01,760 --> 00:18:03,360
WITH A TRACKING SYSTEM YOU FIND

514
00:18:03,360 --> 00:18:05,560
OUT HOW THE STORY ENDED WITH MY

515
00:18:05,560 --> 00:18:05,800
PATIENT.

516
00:18:05,800 --> 00:18:07,440
IF WE DON'T DO THIS, THIS IS THE

517
00:18:07,440 --> 00:18:08,840
CHALLENGE, THAT I CAN GO ON NOT

518
00:18:08,840 --> 00:18:11,120
FINDING OUT THE STORY OF MY

519
00:18:11,120 --> 00:18:12,520
PATIENTS.

520
00:18:12,520 --> 00:18:13,840
I CAN GIVE PROGNOSTICATIONS,

521
00:18:13,840 --> 00:18:14,760
JUDGMENTS, MOVE THEM ALONG IN

522
00:18:14,760 --> 00:18:15,840
THE HEALTH CARE SYSTEM.

523
00:18:15,840 --> 00:18:17,360
BUT IF I LOSE TRACK, WHAT

524
00:18:17,360 --> 00:18:19,080
HAPPENS IS I'M BUILDING MY

525
00:18:19,080 --> 00:18:21,960
CONFIDENCE IN MYSELF BUT I'M NOT

526
00:18:21,960 --> 00:18:23,120
NECESSARILY BUILDING MY

527
00:18:23,120 --> 00:18:23,720
COMPETENCE.

528
00:18:23,720 --> 00:18:26,560
SO WORKING WITHOUT FEEDBACK

529
00:18:26,560 --> 00:18:29,320
BUILDS YOUR CONFIDENCE BUT

530
00:18:29,320 --> 00:18:30,160
DOESN'T BUILD YOUR COMPETENCE.

531
00:18:30,160 --> 00:18:33,120
YOU HAVE TO BUILD A TRACKING

532
00:18:33,120 --> 00:18:36,080
SYSTEM, LOW TECH BY PAPER AND

533
00:18:36,080 --> 00:18:41,440
POST--IT  NOTES OR HIGH TECH.

534
00:18:41,440 --> 00:18:42,280
IMPROVE THE JUDGMENT AND

535
00:18:42,280 --> 00:18:43,280
CALIBRATION OF THE MIND.

536
00:18:43,280 --> 00:18:47,360
IT HAS TO KNOW HOW THE STORY

537
00:18:47,360 --> 00:18:48,480
ENDS.

538
00:18:48,480 --> 00:18:50,400
OSLER, REFLECTING ON THIS TRAIT

539
00:18:50,400 --> 00:18:52,400
OVER A CENTURY AGO SAID, HAVE

540
00:18:52,400 --> 00:18:54,920
MERCY AND CONSIDERATION FOR THE

541
00:18:54,920 --> 00:18:56,880
OTHER PERSON, BUT NONE FOR

542
00:18:56,880 --> 00:18:57,760
YOURSELF AS A CLINICIAN, OVER

543
00:18:57,760 --> 00:18:59,840
WHOM YOU MUST KEEP AN INCESSANT

544
00:18:59,840 --> 00:19:00,160
WATCH.

545
00:19:00,160 --> 00:19:02,760
I WANT TO EMPHASIZE THAT POINT

546
00:19:02,760 --> 00:19:05,200
ABOUT INCESSANT WATCH, IT IS A

547
00:19:05,200 --> 00:19:05,960
HUMBLING BUT REALLY PRODUCTIVE

548
00:19:05,960 --> 00:19:08,000
WAY TO GIVE YOU THE BEST FORM OF

549
00:19:08,000 --> 00:19:09,680
CME AROUND IF YOU CAN TRACK YOUR

550
00:19:09,680 --> 00:19:11,120
PATIENTS AND FIND OUT HOW THE

551
00:19:11,120 --> 00:19:12,560
STORY ENDS BECAUSE IT UPDATES

552
00:19:12,560 --> 00:19:13,960
YOUR MENTAL MODEL FOR THE NEXT

553
00:19:13,960 --> 00:19:22,400
TIME IT SEES THAT SAME PATIENT. 

554
00:19:22,400 --> 00:19:28,080
DOCTORS WHO FOUND ASPERGILUS

555
00:19:28,080 --> 00:19:29,080
UPDATED THEIR MODEL, AND WE

556
00:19:29,080 --> 00:19:30,560
SHOULD ALL HOPE FOR THAT BECAUSE

557
00:19:30,560 --> 00:19:32,520
ALL OF OUR PATIENTS DESERVE US

558
00:19:32,520 --> 00:19:36,280
TO LEARN FROM THEIR PAST

559
00:19:36,280 --> 00:19:36,600
EXPERIENCES.

560
00:19:36,600 --> 00:19:41,320
NOW, THE FOUNDATION OF

561
00:19:41,320 --> 00:19:42,600
REASONING, MUCH INK HAS BEEN

562
00:19:42,600 --> 00:19:44,800
SKILLED HOW TO BE A BETTER

563
00:19:44,800 --> 00:19:45,680
SPEAKER OTHER REASONER BUT YOU

564
00:19:45,680 --> 00:19:48,080
HAVE TO HAVE A MASSIVE AMOUNT OF

565
00:19:48,080 --> 00:19:48,640
KNOWLEDGE.

566
00:19:48,640 --> 00:19:50,400
SOMETIMES THERE'S A MISTAKE

567
00:19:50,400 --> 00:19:51,720
THAT'S MADE BY SAYING IN AGE OF

568
00:19:51,720 --> 00:19:53,480
INTERNET YOU DON'T HAVE TO

569
00:19:53,480 --> 00:19:55,000
MEMORIZE THINGS BECAUSE

570
00:19:55,000 --> 00:19:55,880
EVERYTHING IS ACCESSIBLE.

571
00:19:55,880 --> 00:19:57,400
BUT THAT'S NOT TRUE AT ALL.

572
00:19:57,400 --> 00:20:00,360
JUST BECAUSE I HAVE ACCESS TO A

573
00:20:00,360 --> 00:20:01,680
GERMAN DICTIONARY DOESN'T MEAN

574
00:20:01,680 --> 00:20:02,800
I'M FLUENT IN GERMANY.

575
00:20:02,800 --> 00:20:03,760
HAVING ACCESS TO KNOWLEDGE IS

576
00:20:03,760 --> 00:20:07,480
NOT THE SAME AS KNOWING HOW TO

577
00:20:07,480 --> 00:20:08,920
ACTIVATE, DEPLOY, APPLY IT.

578
00:20:08,920 --> 00:20:10,200
SO WE SPEND MUCH OF OUR CAREERS,

579
00:20:10,200 --> 00:20:12,160
IN FACT YOU CAN DESCRIBE THE

580
00:20:12,160 --> 00:20:13,720
ENTIRE ARC OF OUR CAREER,

581
00:20:13,720 --> 00:20:14,720
BUILDING MORE AND MORE

582
00:20:14,720 --> 00:20:15,000
KNOWLEDGE.

583
00:20:15,000 --> 00:20:16,000
YOU NEED IT.

584
00:20:16,000 --> 00:20:18,920
CAN YOU NOT REASON YOUR WAY INTO

585
00:20:18,920 --> 00:20:20,040
A DIAGNOSIS LIKE MYASTHENIA

586
00:20:20,040 --> 00:20:21,240
GRAVIS UNLESS YOU HEARD ABOUT IT

587
00:20:21,240 --> 00:20:23,120
AND KNOW IT AND UNDERSTAND ABOUT

588
00:20:23,120 --> 00:20:23,640
IT.

589
00:20:23,640 --> 00:20:24,640
BUT THERE'S AN INTERESTING

590
00:20:24,640 --> 00:20:25,480
PHENOMENON THAT CAN HAPPEN WHICH

591
00:20:25,480 --> 00:20:27,760
YOU CAN GET TO THE POINT OF

592
00:20:27,760 --> 00:20:28,600
DIMINISHING RETURNS.

593
00:20:28,600 --> 00:20:30,320
WE CONTINUE TO PACK MORE AND

594
00:20:30,320 --> 00:20:31,960
MORE KNOWLEDGE INTO OUR BRAINS,

595
00:20:31,960 --> 00:20:33,920
TO THE BEST OF OUR KNOWLEDGE

596
00:20:33,920 --> 00:20:35,480
LONG-TERM MEMORY DOESN'T HAVE A

597
00:20:35,480 --> 00:20:35,800
STORAGE LIMIT.

598
00:20:35,800 --> 00:20:37,320
BUT THERE IS A PROBLEM WHEN WE

599
00:20:37,320 --> 00:20:38,920
SPEND ALL OUR TIME LEARNING

600
00:20:38,920 --> 00:20:40,640
STUFF AND FORGET TO PRUNE THE

601
00:20:40,640 --> 00:20:42,920
INFORMATION WE HAVE AND FAIL TO

602
00:20:42,920 --> 00:20:44,440
ACT IN UNLEARNING.

603
00:20:44,440 --> 00:20:46,080
SO REMEMBER THAT THE DIAGNOSTIC

604
00:20:46,080 --> 00:20:47,960
PROCESS IS A JUDGMENT.

605
00:20:47,960 --> 00:20:49,600
THAT JUDGMENT IS INFORMED BY THE

606
00:20:49,600 --> 00:20:50,680
KNOWLEDGE THAT WE POSSESS OR

607
00:20:50,680 --> 00:20:53,080
READ ABOUT OR LOOK UP.

608
00:20:53,080 --> 00:20:55,440
BUT MANY THINGS GET PERPETUATED

609
00:20:55,440 --> 00:20:57,040
YEAR AFTER YEAR, GENERATION

610
00:20:57,040 --> 00:20:59,440
AFTER GENERATION, AND THEY CAN

611
00:20:59,440 --> 00:21:01,200
CONTAMINATE OUR THINKING BECAUSE

612
00:21:01,200 --> 00:21:02,200
THEY ARE FAKE NEWS, FALSE

613
00:21:02,200 --> 00:21:03,280
KNOWLEDGE, THINGS THAT GET

614
00:21:03,280 --> 00:21:03,960
PASSED ON AS MYTHS.

615
00:21:03,960 --> 00:21:05,040
THERE ARE MANY.

616
00:21:05,040 --> 00:21:06,840
SOME ARE CONTROVERSIAL.

617
00:21:06,840 --> 00:21:08,120
SOME ARE HELD BY ONE GROUP OR

618
00:21:08,120 --> 00:21:08,480
THE OTHER.

619
00:21:08,480 --> 00:21:10,400
BUT WE HAVE TO BE AWARE OF

620
00:21:10,400 --> 00:21:12,040
SOMETIMES WHEN WE'RE CARRYING

621
00:21:12,040 --> 00:21:13,440
THINGS FORWARD THAT ACTUALLY ARE

622
00:21:13,440 --> 00:21:14,920
HARMING OUR PATIENTS RATHER THAN

623
00:21:14,920 --> 00:21:16,000
HELPING THEM.

624
00:21:16,000 --> 00:21:18,400
YOU KNOW, THERE'S DEBATES ABOUT

625
00:21:18,400 --> 00:21:20,400
WHETHER IV CONTRAST CAUSES RENAL

626
00:21:20,400 --> 00:21:22,840
INJURY WHICH WE'VE HELD AS AN

627
00:21:22,840 --> 00:21:23,800
AXIOM BUT SO MUCH SHOWS THAT'S

628
00:21:23,800 --> 00:21:24,640
NOT THE CASE.

629
00:21:24,640 --> 00:21:33,320
OR YOU LEARN SOMETHING LIKE IF

630
00:21:33,320 --> 00:21:36,920
YOU MIX ALCOHOL AND FLAGELA, YOU

631
00:21:36,920 --> 00:21:38,760
GET A SULPHUR REACTION, THEY ARE

632
00:21:38,760 --> 00:21:41,320
A DISSERVICE IF WE CARRY THEM

633
00:21:41,320 --> 00:21:42,640
FORWARD.

634
00:21:42,640 --> 00:21:43,840
IT'S SUPER HARD TO UNLEARN WHAT

635
00:21:43,840 --> 00:21:44,720
YOU HAVE LEARNED.

636
00:21:44,720 --> 00:21:46,080
IT'S NOT NATURAL.

637
00:21:46,080 --> 00:21:47,760
ONCE THE NEURONS WIRE TOGETHER

638
00:21:47,760 --> 00:21:50,480
THEY FIRE TOGETHER, AND IT'S

639
00:21:50,480 --> 00:21:52,080
VERY HARD TO DISENTANGLE THEM.

640
00:21:52,080 --> 00:21:53,680
SO I THINK IN A GENTLE WAY I'M

641
00:21:53,680 --> 00:21:54,960
TRYING TO SAY THIS IS SOMETHING

642
00:21:54,960 --> 00:21:57,600
YOU HAVE TO TRY REALLY HARD TO

643
00:21:57,600 --> 00:21:58,880
DO, NOT JUST LEARNING BUT

644
00:21:58,880 --> 00:22:00,080
UNLEARNING SOME OF THE THINGS

645
00:22:00,080 --> 00:22:01,280
WE'VE BRING TO THE DIAGNOSTIC

646
00:22:01,280 --> 00:22:04,040
PROCESS THAT ARE FAKE NEWS OR

647
00:22:04,040 --> 00:22:04,600
OUTDATED INFORMATION.

648
00:22:04,600 --> 00:22:06,440
BUT AS MUCH AS I MIGHT TRY IT IN

649
00:22:06,440 --> 00:22:08,200
A GENTLE WAY, SOMETIMES WE HAVE

650
00:22:08,200 --> 00:22:11,520
TO HAVE A MORE FORCEFUL TEACHER

651
00:22:11,520 --> 00:22:13,200
TO TELL US THIS IS WAIT TO

652
00:22:13,200 --> 00:22:15,320
IMPROVE DIAGNOSTIC THINKING.

653
00:22:15,320 --> 00:22:18,600
WHILE I MAY HAVE SOME HEFT AT MY

654
00:22:18,600 --> 00:22:20,120
AGE, THE HELP OF A 900-YEAR-OLD

655
00:22:20,120 --> 00:22:23,640
TEACHER MAY DRIVE THIS POINT

656
00:22:23,640 --> 00:22:27,880
HOME. 

657
00:22:27,880 --> 00:22:30,640
>>WE'LL NEVER GET IT OUT
NOW.

658
00:22:30,640 --> 00:22:33,680
>>SO CERTAIN ARE YOU.

659
00:22:33,680 --> 00:22:39,600
 

660
00:22:39,600 --> 00:22:41,040
ALWAYS WHAT YOU WOULD CONNECT BE

661
00:22:41,040 --> 00:22:41,480
DIFFERENT.

662
00:22:41,480 --> 00:22:43,960
HEAR YOU NOTHING THAT I SAY?

663
00:22:43,960 --> 00:22:45,640
>>MASTER MOVING STONES IS
ONE

664
00:22:45,640 --> 00:22:49,120
THING, THIS IS TOTALLY

665
00:22:49,120 --> 00:22:49,440
DIFFERENT.

666
00:22:49,440 --> 00:22:50,520
>>NO, NO DIFFERENT.

667
00:22:50,520 --> 00:22:52,120
ONLY DIFFERENT IN YOUR MIND.

668
00:22:52,120 --> 00:22:54,480
YOU MUST UNLEARN WHAT YOU HAVE

669
00:22:54,480 --> 00:22:54,760
LEARNED.

670
00:22:54,760 --> 00:22:55,160
>>ALL RIGHT.

671
00:22:55,160 --> 00:22:57,440
I'LL GIVE IT A TRY.

672
00:22:57,440 --> 00:22:57,720
>>NO.

673
00:22:57,720 --> 00:23:00,400
TRY NOT.

674
00:23:00,400 --> 00:23:01,520
DO.

675
00:23:01,520 --> 00:23:03,400
OR DO NOT.

676
00:23:03,400 --> 00:23:06,640
THERE IS NO "TRY." 

677
00:23:06,640 --> 00:23:08,960
>>YODA IS STERN BUT HE'S
GOT A

678
00:23:08,960 --> 00:23:10,480
POINT WHICH IS THAT IT'S SO HARD

679
00:23:10,480 --> 00:23:12,360
THAT YOU HAVE TO MAKE A

680
00:23:12,360 --> 00:23:14,280
COMMITMENT TO DOING IT.

681
00:23:14,280 --> 00:23:16,680
SO THE ACTION STEP FOR US AS WE

682
00:23:16,680 --> 00:23:17,720
MOVE FORWARD TO CONTINUE TO

683
00:23:17,720 --> 00:23:19,320
LEARN, PAY ATTENTION TO THE

684
00:23:19,320 --> 00:23:21,520
LATEST AND GREATEST, BUT WE ALSO

685
00:23:21,520 --> 00:23:22,840
HAVE TO PAY ATTENTION TO THE

686
00:23:22,840 --> 00:23:24,280
AUTHORS AND SCIENTISTS WHO GO

687
00:23:24,280 --> 00:23:28,720
BACK AND REEXAMINE WHAT WE ONCE

688
00:23:28,720 --> 00:23:29,960
BELIEVED.

689
00:23:29,960 --> 00:23:31,160
PAY ATTENTION TO THE MYTH

690
00:23:31,160 --> 00:23:33,360
BUSTERS THAT YOU HEAR ABOUT.

691
00:23:33,360 --> 00:23:35,880
WHETHER YOU CALL IT UNLEARN OR

692
00:23:35,880 --> 00:23:40,440
TAKE THE MORE GENTLE "LET IT GO"

693
00:23:40,440 --> 00:23:46,240
RECOGNIZE THAT SKILL IS AS

694
00:23:46,240 --> 00:23:47,280
IMPORTANT AS ACRETING MORE

695
00:23:47,280 --> 00:23:47,600
KNOWLEDGE.

696
00:23:47,600 --> 00:23:52,280
WE HAVE TO BING  BRING THE BESTT

697
00:23:52,280 --> 00:23:53,080
OUTDATED KNOWLEDGE.

698
00:23:53,080 --> 00:23:55,560
ONE THING I LOVE ABOUT WORKING

699
00:23:55,560 --> 00:23:58,120
AT THE V.A. HOSPITAL, I HEAR

700
00:23:58,120 --> 00:24:00,960
PATIENTS FROM STORIES, RICH

701
00:24:00,960 --> 00:24:05,200
LIVES THEY CARE, BUT THE STORY

702
00:24:05,200 --> 00:24:06,640
IS OFTEN THE CLUE.

703
00:24:06,640 --> 00:24:09,040
I FOR TOO LONG OVERLOOKED THAT.

704
00:24:09,040 --> 00:24:09,720
SOMETIMES THE ANSWER IS IN THE

705
00:24:09,720 --> 00:24:11,480
STORIES THE PATIENT HAS TO TELL,

706
00:24:11,480 --> 00:24:13,000
IN THE SIMPLEST WAY.

707
00:24:13,000 --> 00:24:14,760
I WAS REMINDED OF THIS A WHILE

708
00:24:14,760 --> 00:24:15,600
BACK WHEN TAKING CARE OF A

709
00:24:15,600 --> 00:24:18,320
PATIENT IN THE EMERGENCY ROOM, I

710
00:24:18,320 --> 00:24:22,400
WORKED IN THE EMERGENCY ROOM AND

711
00:24:22,400 --> 00:24:24,800
URGENT CARE, IN THE HOSPITAL AND

712
00:24:24,800 --> 00:24:26,760
GENERAL MEDICAL CLINIC, ALL THE

713
00:24:26,760 --> 00:24:27,880
SETTINGS, I LOVE THAT

714
00:24:27,880 --> 00:24:30,720
OPPORTUNITY AS A GENERALIST.

715
00:24:30,720 --> 00:24:32,440
IN URGENT CARE THE PATIENT'S

716
00:24:32,440 --> 00:24:34,640
LEFT ARM WAS HURTING AND HE HAD

717
00:24:34,640 --> 00:24:35,760
A RASH ON HIS LEGS.

718
00:24:35,760 --> 00:24:38,480
IF YOU SPEND ENOUGH TIME IN

719
00:24:38,480 --> 00:24:40,000
URGENT CARE YOU KNOW

720
00:24:40,000 --> 00:24:41,560
MUSCULOSKELETAL COMPLAINTS AND

721
00:24:41,560 --> 00:24:42,760
SKIN CONDITIONS ARE DESTINED

722
00:24:42,760 --> 00:24:44,000
OFTEN TO GET A NON-SPECIFIC

723
00:24:44,000 --> 00:24:45,240
LABEL FROM US.

724
00:24:45,240 --> 00:24:46,480
I ANTICIPATED THAT'S WHERE I

725
00:24:46,480 --> 00:24:47,040
MIGHT GO.

726
00:24:47,040 --> 00:24:48,160
BUT I ASKED HOW THINGS WERE

727
00:24:48,160 --> 00:24:49,040
GOING IN LIFE.

728
00:24:49,040 --> 00:24:50,440
WHAT ELSE HE WAS DOING.

729
00:24:50,440 --> 00:24:52,640
HE HAD THE NON-SPECIFIC ACHE

730
00:24:52,640 --> 00:24:53,440
THAT I COULDN'T LOCALIZE.

731
00:24:53,440 --> 00:24:57,240
I GOT TO TALKING ABOUT HIS LIFE.

732
00:24:57,240 --> 00:25:00,520
HE'S A MOUNTAIN MAN, NORTHERN

733
00:25:00,520 --> 00:25:01,080
CALIFORNIA, ISOLATED AREA,

734
00:25:01,080 --> 00:25:02,280
BUILDING A SHED IN THE SNOW

735
00:25:02,280 --> 00:25:03,640
ESSENTIALLY AT THIS TIME OF

736
00:25:03,640 --> 00:25:03,840
YEAR.

737
00:25:03,840 --> 00:25:05,880
HE WAS PUTTING UP CAULKING, PUT

738
00:25:05,880 --> 00:25:07,520
THE WALKING TRAY ON HIS ARM, HE

739
00:25:07,520 --> 00:25:09,240
HAD BEEN HOLDING IT FOR HOURS ON

740
00:25:09,240 --> 00:25:09,480
END.

741
00:25:09,480 --> 00:25:11,200
BY HIM TELLING ME THAT, I SAID,

742
00:25:11,200 --> 00:25:13,520
I THINK I KNOW WHY YOUR FOREARM

743
00:25:13,520 --> 00:25:14,600
IS HURTING.

744
00:25:14,600 --> 00:25:16,360
I WAS PUTTING MASSIVE WEIGHT ON

745
00:25:16,360 --> 00:25:17,800
IT, THAT WAS EASY.

746
00:25:17,800 --> 00:25:19,120
WE TURNED TO THE RASH.

747
00:25:19,120 --> 00:25:20,440
RASHES OFTENTIMES ARE THE TYPE

748
00:25:20,440 --> 00:25:22,160
OF THING DOCTORS ARE LIKE, BOY,

749
00:25:22,160 --> 00:25:24,480
IF I CAN'T GIVE AN

750
00:25:24,480 --> 00:25:25,760
ANTI-INFECTIVE AGENT OR STEROID

751
00:25:25,760 --> 00:25:27,240
AGENT I DON'T KNOW IF I'M GOING

752
00:25:27,240 --> 00:25:28,200
TO MAKE PROGRESS AND THIS IS

753
00:25:28,200 --> 00:25:30,400
WHAT I FELT LIKE WHEN HE ROLLED

754
00:25:30,400 --> 00:25:33,120
UP HIS PANTS AND SHOWED ME

755
00:25:33,120 --> 00:25:35,120
RASHES ON BOTH LEGS, SHINS TO

756
00:25:35,120 --> 00:25:36,720
THE ANKLES, A LITTLE ON THE

757
00:25:36,720 --> 00:25:37,200
FEET.

758
00:25:37,200 --> 00:25:37,920
LIKE SMALL DOTS.

759
00:25:37,920 --> 00:25:40,720
I LOOKED AND SAID HE DOESN'T

760
00:25:40,720 --> 00:25:43,840
LOOK SICK, LIKE VASCULITIS.

761
00:25:43,840 --> 00:25:46,160
DIDN'T LOOK LIKE CELLULITIS,

762
00:25:46,160 --> 00:25:47,920
WASN'T A FUNGAL INFECTION.

763
00:25:47,920 --> 00:25:49,320
I'M IN A BIND HERE, I DON'T KNOW

764
00:25:49,320 --> 00:25:50,760
WHAT I'M GOING TO DO.

765
00:25:50,760 --> 00:25:52,840
WITH A LITTLE BIT OF TIME I SAID

766
00:25:52,840 --> 00:25:54,400
TELL ME MORE ABOUT WHAT'S BEEN

767
00:25:54,400 --> 00:25:55,920
GOING ON WITH THAT WOOD SHED

768
00:25:55,920 --> 00:25:57,040
YOU'VE BEEN BUILDING OUT BACK IN

769
00:25:57,040 --> 00:25:58,080
THE SNOW.

770
00:25:58,080 --> 00:25:59,480
OH, WELL, IT'S GREAT, I LOVE IT.

771
00:25:59,480 --> 00:26:06,440
I TOLD YOU ABOUT THE CAULKING

772
00:26:06,440 --> 00:26:07,200
BUT IT'S FREEZING COLD, BUT THE

773
00:26:07,200 --> 00:26:09,160
GOOD NEWS IS I WENT TO COSTCO

774
00:26:09,160 --> 00:26:11,480
AND GOT THESE SOCKS, WINTER

775
00:26:11,480 --> 00:26:12,720
SOCKS, THEY ARE TERRIFIC!

776
00:26:12,720 --> 00:26:13,560
WINTER SOCKS?

777
00:26:13,560 --> 00:26:15,080
TELL ME ABOUT THOSE SOCKS.

778
00:26:15,080 --> 00:26:17,280
AS HE TOLD ME MORE ABOUT THE

779
00:26:17,280 --> 00:26:18,720
SOCKS, NOT GREAT DETAIL, BUT HE

780
00:26:18,720 --> 00:26:20,240
BOUGHT THEM ABOUT TWO WEEKS AGO.

781
00:26:20,240 --> 00:26:23,840
WHEN DID YOUR RASH START?

782
00:26:23,840 --> 00:26:24,600
TWO WEEKS AGO.

783
00:26:24,600 --> 00:26:27,320
EXACTLY MATCHED OF THE NYLON

784
00:26:27,320 --> 00:26:30,440
LINING OF WHERE HIS RASH WAS.

785
00:26:30,440 --> 00:26:32,240
THE NYLON THREADS AT THE TOP

786
00:26:32,240 --> 00:26:34,000
WERE AN EXACT MATCH.

787
00:26:34,000 --> 00:26:36,960
I RECOGNIZED NOT FROM YEARS OF

788
00:26:36,960 --> 00:26:38,080
MEDICAL TRAINING BUT JUST COMMON

789
00:26:38,080 --> 00:26:41,040
SENSE, HEARING THE STORY, HE HAD

790
00:26:41,040 --> 00:26:42,520
A CONTACT DERMATITIS.

791
00:26:42,520 --> 00:26:44,160
I GAVE HIM STEROIDS, WHICH I

792
00:26:44,160 --> 00:26:46,280
WOULD HAVE DONE ANYWAY, BUT I

793
00:26:46,280 --> 00:26:47,560
KNEW THE DIAGNOSIS IN THIS CASE.

794
00:26:47,560 --> 00:26:49,880
THIS AND MANY OTHER STORIES AND

795
00:26:49,880 --> 00:26:51,200
EXPERIENCES REMINDED ME THAT

796
00:26:51,200 --> 00:26:52,720
SOMETIMES WE THINK ASKING PEOPLE

797
00:26:52,720 --> 00:26:56,120
ABOUT THEIR LIFE IS LIKE SMALL

798
00:26:56,120 --> 00:26:58,320
TALK, OR JUST RAPPORT BUILDING,

799
00:26:58,320 --> 00:27:00,000
AND IT IS, HUMANIZING THE

800
00:27:00,000 --> 00:27:01,840
RELATIONSHIP, I'LL ALLUDE IN A

801
00:27:01,840 --> 00:27:04,680
MINUTE, BUT IT'S OFTENTIMES AN

802
00:27:04,680 --> 00:27:05,600
ENTRY WAY TO RICH DIAGNOSTIC

803
00:27:05,600 --> 00:27:06,560
INFORMATION.

804
00:27:06,560 --> 00:27:09,640
ONE OF THE WAYS TO HABITUATE IS

805
00:27:09,640 --> 00:27:11,680
UNLEARN SOMETHING MANY OF US GET

806
00:27:11,680 --> 00:27:14,680
TAUGHT, THAT A SOCIAL HISTORY IS

807
00:27:14,680 --> 00:27:16,440
WHAT DO YOU WHEN YOU SMOKE,

808
00:27:16,440 --> 00:27:17,320
DRINK, USE DRUGS.

809
00:27:17,320 --> 00:27:19,000
ALMOST EVERYONE IN THE ROOM HAS

810
00:27:19,000 --> 00:27:21,040
GONE THROUGH TRAINING, THIS IS A

811
00:27:21,040 --> 00:27:23,480
SOCIAL HISTORY, BUT NOT ONLY IS

812
00:27:23,480 --> 00:27:24,760
IT IMPOVERISHED, THERE'S TONS OF

813
00:27:24,760 --> 00:27:26,120
CASES WHERE THIS DOESN'T MATTER,

814
00:27:26,120 --> 00:27:28,840
IT'S NOT A GREAT USE OF THE WORD

815
00:27:28,840 --> 00:27:30,680
"SOCIAL," WHEN WE TALK ABOUT

816
00:27:30,680 --> 00:27:32,240
SOCIAL JUSTICE, SOCIAL

817
00:27:32,240 --> 00:27:33,200
DETERMINANTS OF HEALTH, ME MEAN

818
00:27:33,200 --> 00:27:36,640
IT TO REFER TO THE WORLD AROUND

819
00:27:36,640 --> 00:27:37,720
US.

820
00:27:37,720 --> 00:27:38,920
THIS SORT OF PHYSICIAN-CENTERED

821
00:27:38,920 --> 00:27:40,880
SOCIAL HISTORY JUST GETS AT

822
00:27:40,880 --> 00:27:42,200
THREE BEHAVIORS THAT MAY SOLVE

823
00:27:42,200 --> 00:27:44,320
SOME CASES AND ARE IMPORTANT IN

824
00:27:44,320 --> 00:27:46,120
OTHERS BUT HARDLY PORTRAY THE

825
00:27:46,120 --> 00:27:48,120
SOCIAL WORLD OF THE PATIENT.

826
00:27:48,120 --> 00:27:50,320
THE ACTION STEP TO GET BETTER,

827
00:27:50,320 --> 00:27:52,040
NOT JUST FOR RAPPORT BUILDING

828
00:27:52,040 --> 00:27:54,000
BUT ALSO FOR TRUST BUILDING AND

829
00:27:54,000 --> 00:27:55,000
DIAGNOSTIC INFORMATION BECAUSE

830
00:27:55,000 --> 00:27:57,280
IT'S OFTEN THERE, GETTING A TRUE

831
00:27:57,280 --> 00:27:57,640
SOCIAL HISTORY.

832
00:27:57,640 --> 00:27:59,280
HOW DO YOU START YOUR TYPICAL

833
00:27:59,280 --> 00:28:01,160
DAY, WHO IS IN YOUR WORLD, TELL

834
00:28:01,160 --> 00:28:01,800
ME MORE.

835
00:28:01,800 --> 00:28:03,880
AT THE V.A. HOSPITAL THAT

836
00:28:03,880 --> 00:28:05,120
INVOLVES TAKING A MILITARY

837
00:28:05,120 --> 00:28:06,280
HISTORY, WHAT BRANCH YOU WERE

838
00:28:06,280 --> 00:28:08,120
IN, WHAT DID YOU DO.

839
00:28:08,120 --> 00:28:10,760
AND IT IS MORE THAN JUST

840
00:28:10,760 --> 00:28:11,800
BUILDING RAPPORT, I WANT TO SAY

841
00:28:11,800 --> 00:28:13,920
THAT'S MAYBE ONE OF THE BEST

842
00:28:13,920 --> 00:28:14,680
EFFECTS, OFTENTIMES THE MOST

843
00:28:14,680 --> 00:28:16,320
IMPORTANT INFORMATION IS THERE.

844
00:28:16,320 --> 00:28:18,080
NOW, WE ARE BUSY IN PRACTICE,

845
00:28:18,080 --> 00:28:18,960
IT'S HARD TO REMEMBER TO DO

846
00:28:18,960 --> 00:28:19,280
THIS.

847
00:28:19,280 --> 00:28:21,840
ONE OF THE THINGS WE'VE DONE IN

848
00:28:21,840 --> 00:28:23,320
OUR TEACHING CONFERENCES, HARD

849
00:28:23,320 --> 00:28:24,640
WIRE THIS ACTIVITY, TO CARVE OUT

850
00:28:24,640 --> 00:28:27,040
THE SOCIAL HISTORY AND USE IT AS

851
00:28:27,040 --> 00:28:28,240
A PATIENT-CENTERED BOX RATHER

852
00:28:28,240 --> 00:28:29,640
THAN DOCTOR-CENTERED BOX.

853
00:28:29,640 --> 00:28:31,480
WHEN WE PRESENT DATASETS LIKE IN

854
00:28:31,480 --> 00:28:32,920
MORNING REPORT CONFERENCE WE DO

855
00:28:32,920 --> 00:28:34,280
HAVE ALL THE HEALTH-RELATED

856
00:28:34,280 --> 00:28:35,840
BEHAVIORS BUT EXTEND THEM BEYOND

857
00:28:35,840 --> 00:28:38,520
THE THREE, NOT JUST SMOKING,

858
00:28:38,520 --> 00:28:40,000
DRINKING, DRUGS.

859
00:28:40,000 --> 00:28:40,720
NUTRITION, EXERCISE, SEXUAL

860
00:28:40,720 --> 00:28:42,800
ACTIVITY, ALL OF THOSE HAVE

861
00:28:42,800 --> 00:28:45,120
IMPLICATIONS FOR HEALTH, A GOOD

862
00:28:45,120 --> 00:28:46,520
INVENTORY ASKS ABOUT IT.

863
00:28:46,520 --> 00:28:48,080
WHAT WE HAVE AS A SEPARATE BOX

864
00:28:48,080 --> 00:28:50,480
FOR SOCIAL HISTORY, AND IF I'M

865
00:28:50,480 --> 00:28:51,800
PRESENTING A PATIENT OR WRITING

866
00:28:51,800 --> 00:28:53,200
A NOTE, REALIZE I DON'T HAVE

867
00:28:53,200 --> 00:28:55,400
ANYTHING TO PUT IN THERE, THEN I

868
00:28:55,400 --> 00:28:57,000
REALIZE I REALLY DON'T KNOW THE

869
00:28:57,000 --> 00:28:58,080
PATIENT AT ALL.

870
00:28:58,080 --> 00:28:59,960
I'VE TREATED HIM AS A BIOMEDICAL

871
00:28:59,960 --> 00:29:00,960
ENTITY AND DATASET.

872
00:29:00,960 --> 00:29:02,760
AND THE REAL HUMAN CONNECTION OR

873
00:29:02,760 --> 00:29:05,040
OPPORTUNITY TO KNOW THEM AS A

874
00:29:05,040 --> 00:29:07,000
PERSON AND PERHAPS GET

875
00:29:07,000 --> 00:29:08,080
DIAGNOSTICALLY RICH INFORMATION

876
00:29:08,080 --> 00:29:10,520
WAS MISSED BY ME.

877
00:29:10,520 --> 00:29:11,960
SO THIS HELPS REMIND US THE

878
00:29:11,960 --> 00:29:14,120
ACTION STEP TO GET BETTER AT

879
00:29:14,120 --> 00:29:16,880
DIAGNOSIS IS TO DISCARD THE OLD

880
00:29:16,880 --> 00:29:18,640
NOTION OF A SOCIAL HISTORY AND

881
00:29:18,640 --> 00:29:20,160
ASK PEOPLE ABOUT A TRUE SOCIAL

882
00:29:20,160 --> 00:29:20,400
HISTORY.

883
00:29:20,400 --> 00:29:23,040
ONE THAT SHOWS US THE WORLD THEY

884
00:29:23,040 --> 00:29:26,200
INHABIT, THE WORLD THAT MATTERS

885
00:29:26,200 --> 00:29:28,960
TO THEM AND MAY HAVE THE ANSWER

886
00:29:28,960 --> 00:29:31,920
TO THEIR DIAGNOSTIC QUANDARY.

887
00:29:31,920 --> 00:29:38,160
 

888
00:29:38,160 --> 00:29:41,200
 

889
00:29:41,200 --> 00:29:43,200
ONE CONCEPTUALIZATION, IT'S A

890
00:29:43,200 --> 00:29:45,000
COGNITIVE ACTIVITY, THE BRAIN

891
00:29:45,000 --> 00:29:45,680
AND COMPUTATIONAL MODES.

892
00:29:45,680 --> 00:29:47,440
WE THINK ABOUT THE PROCESS,

893
00:29:47,440 --> 00:29:48,960
WELL, IT'S MY BRAIN, THE

894
00:29:48,960 --> 00:29:51,160
PATIENT'S BRAIN, MAYBE NOW THE

895
00:29:51,160 --> 00:29:52,320
COMPUTER, AND TOGETHER THE THREE

896
00:29:52,320 --> 00:29:55,440
OF US ARE GOING TO SOLVE THIS

897
00:29:55,440 --> 00:29:55,880
CASE.

898
00:29:55,880 --> 00:29:58,000
WHAT I'VE LEARNED FROM MANY

899
00:29:58,000 --> 00:29:58,960
COLLEAGUES AND SOME EXPERIENCES,

900
00:29:58,960 --> 00:30:00,560
THAT WE'RE NOT ALONE IN THE

901
00:30:00,560 --> 00:30:01,000
ROOM.

902
00:30:01,000 --> 00:30:03,760
THE IDEA THAT MY BRAIN AS AN

903
00:30:03,760 --> 00:30:04,840
INSTRUMENT, THE PATIENT'S BRAIN

904
00:30:04,840 --> 00:30:07,520
AS A PURVEYOR OF INFORMATION,

905
00:30:07,520 --> 00:30:11,320
AND EXPERTISE IN THE BODY, THE

906
00:30:11,320 --> 00:30:13,080
COMPUTER TO BUTTRESS THE PROCESS

907
00:30:13,080 --> 00:30:14,400
IS NOT ENOUGH, NOT EVEN THE

908
00:30:14,400 --> 00:30:15,920
WHOLE INFLUENCE IN THE

909
00:30:15,920 --> 00:30:16,600
DIAGNOSTIC PROCESS, THAT THERE'S

910
00:30:16,600 --> 00:30:18,840
A LOT OF BIAS THAT IS INJECTED

911
00:30:18,840 --> 00:30:20,720
INTO THIS PROCESS AND IT'S IN

912
00:30:20,720 --> 00:30:22,240
MORE WAYS THAN WE KNOW.

913
00:30:22,240 --> 00:30:23,640
I THINK ONE OF THE THINGS THAT

914
00:30:23,640 --> 00:30:25,200
HAS COME ABOUT IN THE LAST TWO

915
00:30:25,200 --> 00:30:26,840
TO THREE YEARS WHICH HAS BEEN

916
00:30:26,840 --> 00:30:28,600
UNKNOWN TO US BUT NOW WELCOME

917
00:30:28,600 --> 00:30:30,040
INSIGHT, THAT MANY OF THE TOOLS

918
00:30:30,040 --> 00:30:33,440
WE USE IN DIAGNOSIS ARE BIASED.

919
00:30:33,440 --> 00:30:36,360
BE THEY AROUND RACE, ETHNICITY,

920
00:30:36,360 --> 00:30:46,560
OR GENDER, BUT WE'RE LEARNING

921
00:30:46,560 --> 00:30:50,200
LIKE THE PULSE OXIMETER, PEOPLE

922
00:30:50,200 --> 00:30:51,520
WITH DARKER SKIN, SICKER THAN WE

923
00:30:51,520 --> 00:30:54,920
MIGHT BE AWARE OF BUT IN SOME

924
00:30:54,920 --> 00:30:58,240
WAYS WE INSIGHTS WHETHER

925
00:30:58,240 --> 00:30:59,840
PULMONARY FUNCTION, PULSE OX,

926
00:30:59,840 --> 00:31:03,600
EGFR, HAD HE -- THEY FEEL LIKE A

927
00:31:03,600 --> 00:31:05,040
TECHNICAL FOIBLE OF THE PAST,

928
00:31:05,040 --> 00:31:06,680
PERHAPS WE CAN START OVER AND DO

929
00:31:06,680 --> 00:31:09,720
A BETTER JOB WITH BUT THE THING

930
00:31:09,720 --> 00:31:13,200
I'M TALKING ABOUT ISN'T

931
00:31:13,200 --> 00:31:15,080
DIAGNOSTIC TOOLS LIKE THIS BUT

932
00:31:15,080 --> 00:31:18,080
OUR MINDS, THE MOST IMPORTANT

933
00:31:18,080 --> 00:31:19,760
INSTRUMENT.

934
00:31:19,760 --> 00:31:21,520
MY COLLEAGUE DENISE CONOR HERE

935
00:31:21,520 --> 00:31:22,520
AND OTHER COLLEAGUES TAUGHT ME

936
00:31:22,520 --> 00:31:23,800
TO OPEN MY EYES TO THE IDEA WHEN

937
00:31:23,800 --> 00:31:26,440
WE'RE IN THE ROOM IT'S NOT TWO

938
00:31:26,440 --> 00:31:27,520
BRAINS AND THE COMPUTER, WE'RE

939
00:31:27,520 --> 00:31:31,840
OPERATING IN A SOCIAL AND

940
00:31:31,840 --> 00:31:32,600
HISTORICAL CONFECTION

941
00:31:32,600 --> 00:31:33,240
INFLUENCING A LOT.

942
00:31:33,240 --> 00:31:39,640
WAIT PEOPLE HAVE BEEN TREATED BY

943
00:31:39,640 --> 00:31:41,480
THE HEALTH SYSTEM, AND HOW MUCH

944
00:31:41,480 --> 00:31:42,560
AGENCY THEY FEEL WHEN THEY ARE

945
00:31:42,560 --> 00:31:46,080
TRYING TO GET HELP AND GIVE

946
00:31:46,080 --> 00:31:48,280
INFORMATION, AND COLORS THE WAY

947
00:31:48,280 --> 00:31:49,160
MY BRAIN PROCESSES INFORMATION,

948
00:31:49,160 --> 00:31:51,440
WHETHER I LIKE TO ADMIT IT OR

949
00:31:51,440 --> 00:31:51,760
NOT.

950
00:31:51,760 --> 00:31:53,400
DOCTORS ARE A SOCIAL PRODUCT

951
00:31:53,400 --> 00:31:54,520
INFLUENCED BY SOCIETY WE'RE IN.

952
00:31:54,520 --> 00:31:55,800
NEITHER ONE OF THOSE TWO BRAINS

953
00:31:55,800 --> 00:31:59,000
IS OPERATING IN A PURE COGNITIVE

954
00:31:59,000 --> 00:32:00,400
MODE, HEAVILY INFLUENCED BY THE

955
00:32:00,400 --> 00:32:02,080
SOCIETY IN WHICH WE LIVE, AND

956
00:32:02,080 --> 00:32:07,240
EVEN THE HEALTH SYSTEM WHICH HAS

957
00:32:07,240 --> 00:32:09,080
INNATE BIAS AND INEQUITIES BUT

958
00:32:09,080 --> 00:32:11,960
APPRECIATE HOW MUCH IT AFFECTS

959
00:32:11,960 --> 00:32:13,400
THE JUDGMENT INSTRUMENT.

960
00:32:13,400 --> 00:32:18,880
THERE'S MANY WAYS THIS HAPPENS.

961
00:32:18,880 --> 00:32:20,080
OFTENTIMES WHEN WE'RE TREATING

962
00:32:20,080 --> 00:32:23,160
PEOPLE OR SEEKING CARE THE BRAIN

963
00:32:23,160 --> 00:32:25,120
NATURALLY CATEGORIZES PEOPLE

964
00:32:25,120 --> 00:32:27,840
INTO IN GROUPS AND OUT GROUPS IN

965
00:32:27,840 --> 00:32:30,240
AN AUTOMATED WAY, IT'S NOT

966
00:32:30,240 --> 00:32:32,440
AWARE, DOESN'T HAVE ANY INTENT

967
00:32:32,440 --> 00:32:33,480
BUT WE NATURALLY CATEGORIZE

968
00:32:33,480 --> 00:32:35,440
PEOPLE AS BEING MORE LIKE US OR

969
00:32:35,440 --> 00:32:37,840
BEING LESS LIKE US.

970
00:32:37,840 --> 00:32:39,680
THIS HAS REALLY IMPORTANT

971
00:32:39,680 --> 00:32:40,040
IMPLICATIONS.

972
00:32:40,040 --> 00:32:45,360
PEOPLE ARE IN OUR IN GROUP, MY

973
00:32:45,360 --> 00:32:47,000
GENDER, RACE, GEOGRAPHIC,

974
00:32:47,000 --> 00:32:47,560
SOCIOECONOMIC STATUS, MY

975
00:32:47,560 --> 00:32:49,120
PROFESSION, WHATEVER IT IS, YOU

976
00:32:49,120 --> 00:32:51,160
TEND TO BE MORE CHARITABLE TO

977
00:32:51,160 --> 00:32:53,880
THEM, MORE INTERESTED, TEND TO

978
00:32:53,880 --> 00:32:55,360
REMEMBER MORE, TEND TO EXTEND

979
00:32:55,360 --> 00:32:56,640
PEOPLE MORE GRACE AND TEND TO GO

980
00:32:56,640 --> 00:32:57,960
THE EXTRA MILE.

981
00:32:57,960 --> 00:32:59,480
THE MORE PEOPLE ARE OUTSIDE OF

982
00:32:59,480 --> 00:33:03,440
THE GROUP THAT OUR BRAIN

983
00:33:03,440 --> 00:33:06,280
SUBCONSCIOUSLY MAKES AN

984
00:33:06,280 --> 00:33:10,760
ASSIGNMENT TOO, THE LESS LIKELY

985
00:33:10,760 --> 00:33:16,040
WE ARE TO GO THE EXTRA MILE,

986
00:33:16,040 --> 00:33:17,760
WITH IMPLICATIONS, COGNITIVE AND

987
00:33:17,760 --> 00:33:18,040
PHYSICAL.

988
00:33:18,040 --> 00:33:20,600
IT'S SUBTLE, WE WOULD NEVER BE

989
00:33:20,600 --> 00:33:22,800
AWARE OR ADMIT IT BUT THIS IS

990
00:33:22,800 --> 00:33:25,200
WHAT HAPPENS EXPERIMENT AFTER

991
00:33:25,200 --> 00:33:25,520
EXPERIMENT.

992
00:33:25,520 --> 00:33:26,760
MANY PEOPLE HAVE SAID THIS IS

993
00:33:26,760 --> 00:33:28,400
ONE OF MANY PROBLEMS, BUT I WANT

994
00:33:28,400 --> 00:33:31,040
TO NOT TALK ABOUT SORT OF LIKE

995
00:33:31,040 --> 00:33:31,760
THE SOCIETAL AND PROFESSIONAL

996
00:33:31,760 --> 00:33:35,040
THINGS WE HAVE TO DO TO ADDRESS

997
00:33:35,040 --> 00:33:36,040
THOSE INEQUITIES, WORTHY OF ITS

998
00:33:36,040 --> 00:33:37,240
OWN TALK.

999
00:33:37,240 --> 00:33:37,920
BUT JUST THINKING OF

1000
00:33:37,920 --> 00:33:38,680
DIAGNOSTICIAN IN THE ROOM,

1001
00:33:38,680 --> 00:33:41,240
WHAT'S ONE THING I COULD DO IN

1002
00:33:41,240 --> 00:33:42,760
THE ROOM TO TRY TO NEUTRALIZE

1003
00:33:42,760 --> 00:33:49,680
THIS THING MY BRAIN DOES

1004
00:33:49,680 --> 00:33:50,520
AUTOMATICALLY?

1005
00:33:50,520 --> 00:33:51,960
MY COLLEAGUE KIMBERLY MANNING,

1006
00:33:51,960 --> 00:33:54,280
DR. CAPERS, THE IDEA OF

1007
00:33:54,280 --> 00:33:54,760
INDIVIDUALIZATION.

1008
00:33:54,760 --> 00:33:56,920
WHICH IS THAT EVEN IF IT'S

1009
00:33:56,920 --> 00:33:59,840
OBJECTS TO US THAT WE'RE IN

1010
00:33:59,840 --> 00:34:00,560
DIFFERENT DEMOGRAPHIC GROUPS

1011
00:34:00,560 --> 00:34:03,560
THERE'S SOMETHING WE HAVE IN

1012
00:34:03,560 --> 00:34:05,320
COMMON, AND THE SKILLED

1013
00:34:05,320 --> 00:34:05,960
CLINICIAN, CARING PERSON, WILL

1014
00:34:05,960 --> 00:34:06,520
FIND THAT.

1015
00:34:06,520 --> 00:34:07,800
SO THAT YOU WILL FIND SOMETHING

1016
00:34:07,800 --> 00:34:09,600
IN THE COURSE OF THAT SOCIAL

1017
00:34:09,600 --> 00:34:10,880
HISTORY THAT I MENTIONED THAT

1018
00:34:10,880 --> 00:34:11,560
CONNECTS US.

1019
00:34:11,560 --> 00:34:13,520
MAYBE WE GREW UP IN THE SAME

1020
00:34:13,520 --> 00:34:16,040
PLACE, MAYBE WE BOTH HAVE

1021
00:34:16,040 --> 00:34:17,840
TEENAGE SONS, MAYBE WE BOTH HATE

1022
00:34:17,840 --> 00:34:19,800
HAVING TO WAIT FOR PARKING AT

1023
00:34:19,800 --> 00:34:20,760
THE HEALTH CENTER, WHATEVER IT

1024
00:34:20,760 --> 00:34:22,640
IS, FIND SOMETHING YOU HAVE IN

1025
00:34:22,640 --> 00:34:22,960
COMMON.

1026
00:34:22,960 --> 00:34:25,000
WHAT WE FIND IS THAT WHEN YOU

1027
00:34:25,000 --> 00:34:26,880
FIND JUST ONE COMMON GROUND WITH

1028
00:34:26,880 --> 00:34:29,440
THE PERSON, TRUST IS ENHANCED,

1029
00:34:29,440 --> 00:34:30,600
INFORMATION EXCHANGE IS

1030
00:34:30,600 --> 00:34:31,720
ENHANCED, AND THE COGNITIVE

1031
00:34:31,720 --> 00:34:33,480
EFFORT AND PHYSICAL EFFORT THAT

1032
00:34:33,480 --> 00:34:36,360
WE EXHIBIT FOR THE PATIENT GOES

1033
00:34:36,360 --> 00:34:36,680
UP.

1034
00:34:36,680 --> 00:34:37,920
IT'S A SMALL STEP.

1035
00:34:37,920 --> 00:34:39,320
WE HAVE BIGGER ISSUES TO DEAL

1036
00:34:39,320 --> 00:34:41,160
WITH THAN JUST INTERACTION IN

1037
00:34:41,160 --> 00:34:44,320
THE ROOM AT SOCIETAL AND

1038
00:34:44,320 --> 00:34:46,800
PROFESSIONAL LEVEL BUT FINDING

1039
00:34:46,800 --> 00:34:47,720
COMMON GROUND,

1040
00:34:47,720 --> 00:34:49,240
INDIVIDUALIZATION, IS ONE WAY TO

1041
00:34:49,240 --> 00:34:50,480
MITIGATE BIAS FROM THE

1042
00:34:50,480 --> 00:34:52,040
INFORMATION PROCESS WHEN

1043
00:34:52,040 --> 00:34:54,640
TREATING ACROSS DIFFERENCES.

1044
00:34:54,640 --> 00:34:59,160
NOW, THIS IDEA OF IMPLICIT BIAS

1045
00:34:59,160 --> 00:35:00,360
IN INTERACTION IS RELATIVELY

1046
00:35:00,360 --> 00:35:02,120
NEW, NOT IN SOCIAL SCIENCE

1047
00:35:02,120 --> 00:35:05,160
DISCUSSED FOR DECADES BUT IN

1048
00:35:05,160 --> 00:35:05,920
MEDICAL SCIENCE WITH A

1049
00:35:05,920 --> 00:35:07,320
RENAISSANCE IN THE LAST COUPLE

1050
00:35:07,320 --> 00:35:07,560
YEARS.

1051
00:35:07,560 --> 00:35:09,880
ONE THING IN THE MEDICAL

1052
00:35:09,880 --> 00:35:11,880
LITERATURE LONGER THAN IMPLICIT

1053
00:35:11,880 --> 00:35:15,880
BIAS IS COGNITIVE BIAS.

1054
00:35:15,880 --> 00:35:17,000
COGNITIVE BIAS IS POPULARIZED

1055
00:35:17,000 --> 00:35:18,640
BECAUSE IT'S IN POPULAR LOOKS.

1056
00:35:18,640 --> 00:35:25,440
SO IF YOU TAKE AN AUTHOR LIKE

1057
00:35:25,440 --> 00:35:30,800
MALCOLM GLADWELL, YOU WILL TALK

1058
00:35:30,800 --> 00:35:32,960
ABOUT THE BRAIN, DANIEL CONEMAN

1059
00:35:32,960 --> 00:35:34,720
WILL TALK ABOUT THE FOIBLES OF

1060
00:35:34,720 --> 00:35:37,200
THE BRAIN.

1061
00:35:37,200 --> 00:35:38,160
BOTH ARE RIGHT, ACCURATE

1062
00:35:38,160 --> 00:35:39,520
CHARACTERIZATION OF THE BRAIN.

1063
00:35:39,520 --> 00:35:41,840
A BIAS IS A PREDICTABLE

1064
00:35:41,840 --> 00:35:43,640
DEVIATION, BUT ONE OF THE THINGS

1065
00:35:43,640 --> 00:35:46,360
TO EMPHASIZE IS A BIAS IS A LOT

1066
00:35:46,360 --> 00:35:47,360
LIKE A MIRAGE.

1067
00:35:47,360 --> 00:35:48,960
JUST BECAUSE YOU SEE IT DOESN'T

1068
00:35:48,960 --> 00:35:50,480
MEAN YOU CAN TRICK YOUR BRAIN

1069
00:35:50,480 --> 00:35:52,000
INTO BELIEVING IT DOESN'T EXIST

1070
00:35:52,000 --> 00:35:53,400
AND DOESN'T NECESSARILY IMPLY WE

1071
00:35:53,400 --> 00:35:56,840
SHOULD TRY TO AVOID THEM.

1072
00:35:56,840 --> 00:35:59,120
LET ME DELVE AND GIVE A PRIMER

1073
00:35:59,120 --> 00:36:03,520
OF JUST A COUPLE BIASES.

1074
00:36:03,520 --> 00:36:04,600
ANCHORING BIAS, THE IDEA ONCE

1075
00:36:04,600 --> 00:36:06,880
THE BRAIN FORMS AN IDEA WE LOCK

1076
00:36:06,880 --> 00:36:07,440
IN.

1077
00:36:07,440 --> 00:36:10,840
LIKE, YOU KNOW, I THINK OF THIS

1078
00:36:10,840 --> 00:36:12,880
PATIENT HAVING A MIGRAINE

1079
00:36:12,880 --> 00:36:14,880
HEADACHE AND DON'T ADJUST, EVEN

1080
00:36:14,880 --> 00:36:16,960
IF THE NEURO EXAM HAS A SLIGHT

1081
00:36:16,960 --> 00:36:18,120
ABNORMALITY OR FEVER, I'LL STICK

1082
00:36:18,120 --> 00:36:19,720
TO MY GUNS AND CALL THIS

1083
00:36:19,720 --> 00:36:22,000
MIGRAINE HEADACHE EVEN THOUGH

1084
00:36:22,000 --> 00:36:25,200
THERE'S A CONTRADICTING

1085
00:36:25,200 --> 00:36:25,600
INFORMATION.

1086
00:36:25,600 --> 00:36:26,600
THERE'S THE AVAILABILITY

1087
00:36:26,600 --> 00:36:28,000
HUERISTIC, THAT THE BRAIN IS NOT

1088
00:36:28,000 --> 00:36:30,760
GOOD AT JUDGING THE PROBABILITY

1089
00:36:30,760 --> 00:36:31,960
OF THINGS ALONE, HEAVILY

1090
00:36:31,960 --> 00:36:33,840
INFLUENCED BY WHAT'S RECENT OR

1091
00:36:33,840 --> 00:36:36,760
SALIENT SO IF A PATIENCE COMES

1092
00:36:36,760 --> 00:36:38,920
WITH A HEADACHE, THE GOOD CHANCE

1093
00:36:38,920 --> 00:36:41,200
IT'S A MIGRAINE, BUT IF LAST

1094
00:36:41,200 --> 00:36:43,920
WEEK I MADE A MISTAKE AND MISSED

1095
00:36:43,920 --> 00:36:47,560
A PATIENT WITH A SUBARACHNOID

1096
00:36:47,560 --> 00:36:51,240
HEMORRHAGE, I'M GOING TO FOR

1097
00:36:51,240 --> 00:36:53,960
THIS PATIENT WILDLY OVERESTIMATE

1098
00:36:53,960 --> 00:36:56,400
THE POSSIBILITY OF A

1099
00:36:56,400 --> 00:36:57,400
SUBARACHNOID HEMORRHAGE.

1100
00:36:57,400 --> 00:36:59,920
OUR BRAIN IS HEAVILY INFLUENCED

1101
00:36:59,920 --> 00:37:02,000
BY WHAT HAS EMOTIONAL VALENCE,

1102
00:37:02,000 --> 00:37:03,480
NOT GOOD AT RATIONALLY

1103
00:37:03,480 --> 00:37:04,840
CALCULATING BASE RATE.

1104
00:37:04,840 --> 00:37:06,240
THERE'S THE ISSUE OF

1105
00:37:06,240 --> 00:37:07,800
CONFIRMATION BIAS WHICH DOESN'T

1106
00:37:07,800 --> 00:37:10,200
COME UP IN MEDICINE AS IN THE

1107
00:37:10,200 --> 00:37:13,040
NEWS, WHICH IS WE SEEK

1108
00:37:13,040 --> 00:37:14,320
INFORMATION THAT CONFIRMS OUR

1109
00:37:14,320 --> 00:37:15,440
INITIAL IMPRESSIONS.

1110
00:37:15,440 --> 00:37:16,680
SO IF I THINK HAVE YOU THIS

1111
00:37:16,680 --> 00:37:19,720
DISEASE, I MIGHT CONTINUE TO

1112
00:37:19,720 --> 00:37:22,760
SEND TESTS AND LABS FOR THAT

1113
00:37:22,760 --> 00:37:25,400
DISEASE, NOT NECESSARILY SEEKING

1114
00:37:25,400 --> 00:37:29,120
ALTERNATIVE INFORMATION.

1115
00:37:29,120 --> 00:37:32,400
A COUSIN OF THE ANCHORING BIAS.

1116
00:37:32,400 --> 00:37:34,160
THERE'S EXAMPLES AND STUDIES IN

1117
00:37:34,160 --> 00:37:35,160
MEDICINE, POPULAR IN POPULAR

1118
00:37:35,160 --> 00:37:36,800
PRESS, AND BECAUSE OF THAT THE

1119
00:37:36,800 --> 00:37:38,760
HOPE IF WE COULD IDENTIFY THEM

1120
00:37:38,760 --> 00:37:41,080
AND EXTINGUISH THEM WE MAY

1121
00:37:41,080 --> 00:37:42,280
IMPROVE DIAGNOSTIC REASONING.

1122
00:37:42,280 --> 00:37:44,320
BUT THAT'S PROVED HARDER THAN WE

1123
00:37:44,320 --> 00:37:44,520
THINK.

1124
00:37:44,520 --> 00:37:46,960
ONE OF THE PROBLEMS IS THAT WE

1125
00:37:46,960 --> 00:37:49,280
ONLY USE THIS LANGUAGE OF

1126
00:37:49,280 --> 00:37:51,680
HUERISTICS AND BIASES WHEN CASES

1127
00:37:51,680 --> 00:37:52,960
HAVE BAD OUTCOMES.

1128
00:37:52,960 --> 00:37:54,160
THAT MAKES US FORGET THAT

1129
00:37:54,160 --> 00:37:56,360
ACTUALLY MOST OF THE TIME THAT

1130
00:37:56,360 --> 00:37:59,880
SAME MENTAL MACHINERY WORKS

1131
00:37:59,880 --> 00:38:01,400
REALLY WELL.

1132
00:38:01,400 --> 00:38:03,480
I'LL GIVE AN EXAMPLE FROM THE

1133
00:38:03,480 --> 00:38:04,680
WORLD OF SPORTS.

1134
00:38:04,680 --> 00:38:08,240
IMAGINE THAT IT'S THE END OF THE

1135
00:38:08,240 --> 00:38:09,200
GAME, HIGH RISK/HIGH RETURN

1136
00:38:09,200 --> 00:38:11,480
MOMENT, THE COACH HAS TO MAKE A

1137
00:38:11,480 --> 00:38:13,240
CALL WHETHER THE TEAM GOES FOR A

1138
00:38:13,240 --> 00:38:13,560
PLAY.

1139
00:38:13,560 --> 00:38:14,840
HIGH RISK BUT HIGH RETURN IF

1140
00:38:14,840 --> 00:38:15,520
THEY WIN.

1141
00:38:15,520 --> 00:38:18,280
IF THE TEAM GOES FOR THE PLAY ON

1142
00:38:18,280 --> 00:38:20,680
THE COACH'S CALL, GONE THROUGH

1143
00:38:20,680 --> 00:38:21,720
THE DECISION-MAKING PROCESS AND

1144
00:38:21,720 --> 00:38:23,440
SHE MAKES THE CALL, AND THE TEAM

1145
00:38:23,440 --> 00:38:26,040
SCORES, AND THEY WIN THE GAME,

1146
00:38:26,040 --> 00:38:27,840
THE ADJECTIVES THAT WOULD BE

1147
00:38:27,840 --> 00:38:31,360
APPLIED WOULD BE GUTSY,

1148
00:38:31,360 --> 00:38:32,960
VISIONARY, BRILLIANT.

1149
00:38:32,960 --> 00:38:35,200
IF THAT COACH GOES TO THE EXACT

1150
00:38:35,200 --> 00:38:37,160
SAME DECISION-MAKING PROCESS,

1151
00:38:37,160 --> 00:38:38,360
WEIGHS THE FACTORS, MAKES THE

1152
00:38:38,360 --> 00:38:40,000
DECISION TO GO FOR THE PLAY BUT

1153
00:38:40,000 --> 00:38:41,480
THE TEAM DOESN'T GET IT, DON'T

1154
00:38:41,480 --> 00:38:43,480
GET THE SCORE, THEREFORE THEY

1155
00:38:43,480 --> 00:38:48,520
LOSE THE GAME, THE COACH WILL BE

1156
00:38:48,520 --> 00:38:50,000
CALLED SHORT-SIGHTED, FOOLISH,

1157
00:38:50,000 --> 00:38:50,640
INEXPERIENCED, OTHER ADJECTIVES

1158
00:38:50,640 --> 00:38:52,680
WILL BE PULLED OUT EVEN THOUGH

1159
00:38:52,680 --> 00:38:53,600
THE DECISION-MAKING PROCESS IS

1160
00:38:53,600 --> 00:38:54,680
THE SAME.

1161
00:38:54,680 --> 00:38:56,200
THAT'S BECAUSE THE HUMAN BRAIN

1162
00:38:56,200 --> 00:39:02,440
IS NO GOOD AT JUDGING

1163
00:39:02,440 --> 00:39:03,160
DECISION-MAKING PROCESS, ONLY

1164
00:39:03,160 --> 00:39:04,720
OUTCOMES, SHOWN IN STUDIES OF

1165
00:39:04,720 --> 00:39:05,600
DOCTORS AND LAWYERS.

1166
00:39:05,600 --> 00:39:07,560
WHEN YOU GIVE DOCTORS A BAD

1167
00:39:07,560 --> 00:39:09,320
OUTCOME THEY ASSIGN A LOT OF

1168
00:39:09,320 --> 00:39:11,080
HUERISTIC AND BIAS LABELS TO A

1169
00:39:11,080 --> 00:39:12,600
CASE, THREE IN ONE STUDY, IF THE

1170
00:39:12,600 --> 00:39:15,040
PATIENT HAS A GOOD OUTCOME WITH

1171
00:39:15,040 --> 00:39:16,240
THE EXACT SAME DECISION-MAKING

1172
00:39:16,240 --> 00:39:17,880
PROCESS TO THE VERY LAST MINUTE,

1173
00:39:17,880 --> 00:39:19,840
DOCTORS CAN ONLY FIND ONE

1174
00:39:19,840 --> 00:39:21,360
HUERISTIC AND BIAS.

1175
00:39:21,360 --> 00:39:23,080
SO, AS AN EXAMPLE IF I'M WORKING

1176
00:39:23,080 --> 00:39:25,080
IN THE EMERGENCY ROOM AND

1177
00:39:25,080 --> 00:39:31,960
PATIENT HAS ACUTE ONSET OF FLANK

1178
00:39:31,960 --> 00:39:33,160
PAIN, HEMATURIA, SOUNDS LIKE A

1179
00:39:33,160 --> 00:39:34,360
KIDNEY STONE.

1180
00:39:34,360 --> 00:39:36,360
BUT THE CAT SCAN IS NEGATIVE.

1181
00:39:36,360 --> 00:39:38,960
A GOOD TEST FOR KIDNEY STONE.

1182
00:39:38,960 --> 00:39:43,040
IF I CONTINUE TO HOLD ONTO MY

1183
00:39:43,040 --> 00:39:43,920
HYPOTHESIS FOR KIDNEY STONE,

1184
00:39:43,920 --> 00:39:46,320
SOMEONE MAY BE LIKE, THAT GUY IS

1185
00:39:46,320 --> 00:39:47,840
ANCHORING, TOTALLY STUCK ON THAT

1186
00:39:47,840 --> 00:39:49,040
DIAGNOSIS, WILL NOT BUDGE EVEN

1187
00:39:49,040 --> 00:39:51,360
IN THE FACE OF CONTRADICTING

1188
00:39:51,360 --> 00:39:51,640
INFORMATION.

1189
00:39:51,640 --> 00:39:53,840
AND THAT WILL BE CALLED

1190
00:39:53,840 --> 00:39:54,520
ANCHORING BIAS.

1191
00:39:54,520 --> 00:39:55,960
BUT IF THE PATIENT COMES IN THE

1192
00:39:55,960 --> 00:39:58,040
NEXT DAY WITH THE KIDNEY STONE

1193
00:39:58,040 --> 00:40:00,080
THAT THEY STRAINED OUT, HERE,

1194
00:40:00,080 --> 00:40:01,320
DOC, HERE IS THE STONE, THEN

1195
00:40:01,320 --> 00:40:04,160
I'LL BE CALLED A BRILLIANT

1196
00:40:04,160 --> 00:40:04,600
DIAGNOSTICIAN.

1197
00:40:04,600 --> 00:40:07,760
THAT'S THE WAY THE BRAIN WORKS.

1198
00:40:07,760 --> 00:40:09,960
CANNOT JUDGE DECISION-MAKING

1199
00:40:09,960 --> 00:40:11,160
PROCESSES WELL, ONLY OUTCOMES.

1200
00:40:11,160 --> 00:40:14,800
AND WE USE THE VOCABULARY IN

1201
00:40:14,800 --> 00:40:15,080
RETROSPECT.

1202
00:40:15,080 --> 00:40:17,760
THE IMPLICATIONS FOR DECISION

1203
00:40:17,760 --> 00:40:18,960
MAKING HERE HUERISTIC AND BIASES

1204
00:40:18,960 --> 00:40:20,760
ARE NOT A BUG IN OUR PROGRAM,

1205
00:40:20,760 --> 00:40:22,560
THEY WORK SO MANY TIMES, THEY

1206
00:40:22,560 --> 00:40:24,320
ARE AN ESSENTIAL FEATURE OF THE

1207
00:40:24,320 --> 00:40:26,160
PROBLEM SOLVING HARDWARE.

1208
00:40:26,160 --> 00:40:28,800
IF IT DIDN'T WORK, WE

1209
00:40:28,800 --> 00:40:29,880
WOULDN'T -- IF WE DIDN'T USE IS

1210
00:40:29,880 --> 00:40:31,520
WE WOULDN'T BE ABLE TO GET

1211
00:40:31,520 --> 00:40:32,840
THROUGH OUR DAY.

1212
00:40:32,840 --> 00:40:34,720
THAT MAKES THEM FALL SHORT AS

1213
00:40:34,720 --> 00:40:37,520
EFFORT FOR QUALITY AND SAFETY

1214
00:40:37,520 --> 00:40:38,520
EFFORTS, EFFORTS TO EXTINGUISH

1215
00:40:38,520 --> 00:40:40,600
BIASES WOULD COME AT THE COST OF

1216
00:40:40,600 --> 00:40:42,600
ALSO EXTINGUISHING TIMES THAT

1217
00:40:42,600 --> 00:40:43,280
EXACT SAME THOUGHT PROCESS,

1218
00:40:43,280 --> 00:40:45,560
COGNITIVE BIAS I SHOULD SAY, LED

1219
00:40:45,560 --> 00:40:52,480
TO THE CORRECT DIAGNOSIS, LESS

1220
00:40:52,480 --> 00:40:53,240
SOMETHING TO EXTINGUISH, MORE

1221
00:40:53,240 --> 00:40:56,600
SOMETHING TO BE AWARE OF.

1222
00:40:56,600 --> 00:40:58,200
EVEN DANIEL CONEMAN, WHO I

1223
00:40:58,200 --> 00:41:00,800
MENTIONED BEFORE, GODFATHER OF

1224
00:41:00,800 --> 00:41:07,400
THE FIELD OF HUERISTICS SAID AT

1225
00:41:07,400 --> 00:41:09,960
THE END OF "THINKING FAST AND

1226
00:41:09,960 --> 00:41:12,640
SLOW," AT THE END HE SAYS I'VE

1227
00:41:12,640 --> 00:41:13,960
STUDIED, HAVE WRITTEN, GOT THE

1228
00:41:13,960 --> 00:41:17,160
NOBEL PRIZE FOR IT.

1229
00:41:17,160 --> 00:41:18,880
EVEN STILL I MIGHT RECOGNIZE A

1230
00:41:18,880 --> 00:41:22,920
FEW SITUATIONS WHERE I'M AT RISK

1231
00:41:22,920 --> 00:41:24,800
BUT FOR THE MOST PART STILL

1232
00:41:24,800 --> 00:41:25,800
BETTER AT SEEING OTHER PEOPLE

1233
00:41:25,800 --> 00:41:27,200
THAN I AM MYSELF.

1234
00:41:27,200 --> 00:41:28,520
THAT'S ONE TRUISM OF BIAS.

1235
00:41:28,520 --> 00:41:30,400
WE CAN EASILY SEE THEM IN OTHER

1236
00:41:30,400 --> 00:41:33,240
PEOPLE BUT DON'T HAVE AN EARLY

1237
00:41:33,240 --> 00:41:43,640
ERROR DETECTION SYSTEM TO CATCH

1238
00:41:43,640 --> 00:41:44,720
THEM IN OURSELVES.

1239
00:41:44,720 --> 00:41:46,600
THE NEXT ACTION STEP IS THE HALL

1240
00:41:46,600 --> 00:41:48,360
OF JUSTICE, I'LL GET TO THAT IN

1241
00:41:48,360 --> 00:41:49,880
A SECOND.

1242
00:41:49,880 --> 00:41:51,960
IT STARTED WITH A STORY ABOUT A

1243
00:41:51,960 --> 00:41:54,480
PATIENT WAS BROUGHT BY

1244
00:41:54,480 --> 00:41:55,680
AMBULANCE, SOCIALLY ISOLATED, A

1245
00:41:55,680 --> 00:41:58,200
MAN, NOT MUCH CONTACT FOR MANY

1246
00:41:58,200 --> 00:42:00,600
YEARS, LIVED IN AN APARTMENT,

1247
00:42:00,600 --> 00:42:02,760
LANDLORD WAS WORRIED.

1248
00:42:02,760 --> 00:42:06,960
HE WAS CONFUSED, LOSING WEIGHT,

1249
00:42:06,960 --> 00:42:09,720
KIND OF INCOHERENT, A LOT OF

1250
00:42:09,720 --> 00:42:10,000
BRUISING.

1251
00:42:10,000 --> 00:42:11,520
THIS LED TO A MAJOR WORKUP

1252
00:42:11,520 --> 00:42:13,720
TRYING TO FIGURE OUT THE CAUSE

1253
00:42:13,720 --> 00:42:17,000
OF THE SYSTEMIC DISEASE, IN

1254
00:42:17,000 --> 00:42:18,520
CONFUSION, BREEZING, WEIGHT

1255
00:42:18,520 --> 00:42:21,160
LOSS, A SEARCH FOR ENDOCARDITIS

1256
00:42:21,160 --> 00:42:25,760
WAS FRUITLESS, SOCIAL PHENOMENON

1257
00:42:25,760 --> 00:42:31,040
LIKE ELDER ABUSE, BUT THAT

1258
00:42:31,040 --> 00:42:33,440
WASN'T VERIFIED.

1259
00:42:33,440 --> 00:42:35,320
INTENSE BIOMEDICAL WORKUP WITH

1260
00:42:35,320 --> 00:42:36,440
ENDOSCOPY, LOOKING FOR CANCER,

1261
00:42:36,440 --> 00:42:37,640
SCANNED, SCOPED.

1262
00:42:37,640 --> 00:42:39,160
ALL OF THAT CAME UP NEGATIVE.

1263
00:42:39,160 --> 00:42:41,320
HE CONTINUED TO HAVE BLEEDING.

1264
00:42:41,320 --> 00:42:43,960
ONE DAY HAD A SPONTANEOUS BLEED

1265
00:42:43,960 --> 00:42:49,240
IN THE HIGH CONVEYED BY CT SCAN,

1266
00:42:49,240 --> 00:42:50,520
AND DESPITE GENERALIST,

1267
00:42:50,520 --> 00:42:51,120
RHEUMATOLOGIST, HEMATOLOGIST,

1268
00:42:51,120 --> 00:42:52,120
LAB MEDICINE THINKING ABOUT THIS

1269
00:42:52,120 --> 00:42:55,880
CASE WE DIDN'T COME UP MUCH,

1270
00:42:55,880 --> 00:42:57,200
LIKE $100,000 IN THE HOLE BUT

1271
00:42:57,200 --> 00:42:58,640
NONE THE WISER ABOUT WHAT WAS

1272
00:42:58,640 --> 00:43:02,120
GOING ON WITH HIM.

1273
00:43:02,120 --> 00:43:03,520
ONE DAY A TEAM MEMBER, THE

1274
00:43:03,520 --> 00:43:05,200
DIETICIAN, CAME OUT OF THE ROOM

1275
00:43:05,200 --> 00:43:06,760
AS DOCTORS WERE ROUNDING AND

1276
00:43:06,760 --> 00:43:09,120
SAYS, YOU KNOW, I'VE BEEN

1277
00:43:09,120 --> 00:43:12,960
OBSERVING HIS TRAY, AND HE ONLY

1278
00:43:12,960 --> 00:43:14,400
EATS CERTAIN FOODS.

1279
00:43:14,400 --> 00:43:15,160
THAT'S INTERESTING, NOT REALLY

1280
00:43:15,160 --> 00:43:16,560
BELIEVING IT WOULD BE

1281
00:43:16,560 --> 00:43:17,480
INTERESTING, WONDERING WHERE

1282
00:43:17,480 --> 00:43:19,720
THIS WAS GOING.

1283
00:43:19,720 --> 00:43:21,960
SHE SAID, YOU KNOW, HE EATS HIS

1284
00:43:21,960 --> 00:43:25,680
MAIN MEAL BUT NEVER TOUCHES THE

1285
00:43:25,680 --> 00:43:26,960
VEGETABLES OR THE FRUIT.

1286
00:43:26,960 --> 00:43:28,320
SHE SAID, DID YOU KNOW IT

1287
00:43:28,320 --> 00:43:29,360
BOTHERS HIS STOMACH?

1288
00:43:29,360 --> 00:43:32,000
OH, YEAH, WE KNOW HE HAS A

1289
00:43:32,000 --> 00:43:33,440
SENSITIVE STOMACH, PUT HIM ON A

1290
00:43:33,440 --> 00:43:36,280
PPI TO TAKE CARE OF THAT.

1291
00:43:36,280 --> 00:43:38,160
CURIOUS, HE NEVER HAS FRUIT.

1292
00:43:38,160 --> 00:43:38,360
EVER.

1293
00:43:38,360 --> 00:43:40,440
HE NEVER EATS HIS VEGETABLE.

1294
00:43:40,440 --> 00:43:41,960
WHAT SHE WAS TRYING TO SAY IN A

1295
00:43:41,960 --> 00:43:43,840
GENTLE WAY WAS THAT WHAT HE DID

1296
00:43:43,840 --> 00:43:46,160
NOT NEED WAS ANOTHER SCAN OR

1297
00:43:46,160 --> 00:43:48,440
DOCTOR OR ANOTHER TEST.

1298
00:43:48,440 --> 00:43:49,880
MORE THAT WE PROBABLY NEEDED A

1299
00:43:49,880 --> 00:43:50,240
HISTORY LESSON.

1300
00:43:50,240 --> 00:43:51,720
WHAT HAD HE WAS A DISEASE THAT

1301
00:43:51,720 --> 00:43:54,880
GOES BACK TO THE AGE OF SAIL, A

1302
00:43:54,880 --> 00:43:58,160
TIME WHEN SHIP TECHNOLOGY

1303
00:43:58,160 --> 00:44:01,240
EXPANDED, SO THAT SHIPS COULD GO

1304
00:44:01,240 --> 00:44:03,320
ON LONG DISTANCES FOR COMMERCE

1305
00:44:03,320 --> 00:44:05,320
OR EXPLORATION BUT THE PRICE

1306
00:44:05,320 --> 00:44:10,000
PAID BY SAILORS ON LONG TRIPS

1307
00:44:10,000 --> 00:44:11,400
THEY COULDN'T CARRY FRESH

1308
00:44:11,400 --> 00:44:14,480
PRODUCE, THEY HAD TO CARRY

1309
00:44:14,480 --> 00:44:16,440
THINGS WITH PRESERVED LIVES,

1310
00:44:16,440 --> 00:44:17,440
THEY DID THEIR CONQUEST, BUT

1311
00:44:17,440 --> 00:44:20,040
MANY DIED ALONG THE WAY, MANY

1312
00:44:20,040 --> 00:44:23,880
WHO CAME BACK CAME BACK LOOKING

1313
00:44:23,880 --> 00:44:27,680
LIKE THIS BECAUSE THEY HAD A

1314
00:44:27,680 --> 00:44:28,760
COMPLETE ABSENCE OF VITAMIN C,

1315
00:44:28,760 --> 00:44:30,120
UNBEKNOWNST TO THEM AT THE TIME.

1316
00:44:30,120 --> 00:44:33,080
THEY WOULD ONLY HAVE KNOWN THIS

1317
00:44:33,080 --> 00:44:34,800
AS SCURVY.

1318
00:44:34,800 --> 00:44:35,920
TURNS OUT THIS MALADY,

1319
00:44:35,920 --> 00:44:37,680
CHARACTERIZED BY FRAGILITY OF

1320
00:44:37,680 --> 00:44:38,640
BLOOD VESSELS AND CONNECTIVE

1321
00:44:38,640 --> 00:44:41,920
TISSUES BECAUSE OF THE ROLE OF

1322
00:44:41,920 --> 00:44:43,240
COLLAGEN INTEGRITY WAS THE SAME

1323
00:44:43,240 --> 00:44:44,600
THING CAUSING THE BRUISING AND

1324
00:44:44,600 --> 00:44:49,640
WEIGHT LOSS IN OUR PATIENT,

1325
00:44:49,640 --> 00:44:52,800
SEVERELY MALNOURISHED, NEVER

1326
00:44:52,800 --> 00:44:57,120
TOUCHED FRUITS AND VEGETABLES.

1327
00:44:57,120 --> 00:44:58,600
DESPITE ALL THE TECHNOLOGY AND

1328
00:44:58,600 --> 00:45:00,840
DOLLARS AND CONSULTANTS IT WAS A

1329
00:45:00,840 --> 00:45:02,600
REMINDER TO MOVE AWAY FROM THE

1330
00:45:02,600 --> 00:45:08,600
IDEA OF DOCTOR AS

1331
00:45:08,600 --> 00:45:09,720
SUPERDIAGNOSTICIAN TO SOLVE THE

1332
00:45:09,720 --> 00:45:13,840
CASE AND MOVE INSTEAD TO MORE OF

1333
00:45:13,840 --> 00:45:14,920
A HALL OF JUSTICE APPROACH

1334
00:45:14,920 --> 00:45:17,600
LEANING ON ALL MEMBERS OF THE

1335
00:45:17,600 --> 00:45:18,600
TEAM, EVEN CONCEPTUALIZED AS

1336
00:45:18,600 --> 00:45:22,240
BEING ABLE TO SOLVE THE CASE.

1337
00:45:22,240 --> 00:45:23,640
MANY TIMES I HAVE MANY

1338
00:45:23,640 --> 00:45:25,480
RECOLLECTIONS ONCE I STARTED TO

1339
00:45:25,480 --> 00:45:27,560
GET BETTER, I DON'T WANT TO SAY

1340
00:45:27,560 --> 00:45:30,320
I'M GOOD BUT BETTER, THE

1341
00:45:30,320 --> 00:45:31,240
PHYSICAL THERAPIST PICKED UP

1342
00:45:31,240 --> 00:45:32,240
PARKINSON'S DISEASE I MISSED,

1343
00:45:32,240 --> 00:45:36,800
THE NURSE HAS PICKED UP WHAT

1344
00:45:36,800 --> 00:45:40,960
ANTIGEN IS CAUSING 

1345
00:45:40,960 --> 00:45:41,960
HYPERSENSITIVITY, THE PHARMACIST

1346
00:45:41,960 --> 00:45:47,880
RECOGNIZED A DRUG CAUSING A DRUG

1347
00:45:47,880 --> 00:45:48,160
REACTION.

1348
00:45:48,160 --> 00:45:49,960
I'M HAPPY TO SAY THINGS LIKE,

1349
00:45:49,960 --> 00:45:52,680
OH, I LOVE IT WHEN THE

1350
00:45:52,680 --> 00:45:54,000
PHARMACIST CATCHES MY MISTAKE OR

1351
00:45:54,000 --> 00:45:55,640
LISTEN TO YOUR NURSES, THEY KNOW

1352
00:45:55,640 --> 00:45:57,720
WHAT'S GOING ON, THEY GET

1353
00:45:57,720 --> 00:45:59,160
PARROTED IN HALLWAYS AND SOCIAL

1354
00:45:59,160 --> 00:46:00,360
MEDIA, THEY ARE SAGE ADVICE.

1355
00:46:00,360 --> 00:46:02,480
WHAT I'M TALKING ABOUT IS

1356
00:46:02,480 --> 00:46:03,680
SOMETHING MORE ACTIVE.

1357
00:46:03,680 --> 00:46:05,760
THIS WAS IN PRACTICE, NOT

1358
00:46:05,760 --> 00:46:07,600
WELCOMING WHEN THEY SAY IT ABOUT

1359
00:46:07,600 --> 00:46:09,280
YOU REACHING OUT TO OTHER

1360
00:46:09,280 --> 00:46:10,680
MEMBERS AND ASKING WHAT DO YOU

1361
00:46:10,680 --> 00:46:12,720
THINK MIGHT BE GOING ON?

1362
00:46:12,720 --> 00:46:16,040
THAT EXTENDS TO THE PATIENT AND

1363
00:46:16,040 --> 00:46:16,360
FAMILY.

1364
00:46:16,360 --> 00:46:18,360
BUT OFTENTIMES WE FAIL TO

1365
00:46:18,360 --> 00:46:19,240
CAPITALIZE ON POTENTIAL

1366
00:46:19,240 --> 00:46:20,840
KNOWLEDGE IN DIAGNOSTIC TEAM.

1367
00:46:20,840 --> 00:46:23,280
ACTION STEP IS TO MOVE AWAY FROM

1368
00:46:23,280 --> 00:46:26,400
SUPER HERO MODEL AND GO TOWARDS

1369
00:46:26,400 --> 00:46:28,280
THE HALL OF JUSTICE MODE

1370
00:46:28,280 --> 00:46:30,160
PARTICULARLY FOR COMPLEX CASES

1371
00:46:30,160 --> 00:46:30,800
WE HAVE.

1372
00:46:30,800 --> 00:46:32,640
ONE OF THE KEY ELEMENTS OF

1373
00:46:32,640 --> 00:46:34,040
PROBLEM SOLVING IS TO GET THE

1374
00:46:34,040 --> 00:46:35,480
RIGHT ANSWER, ONE OF THE BEST

1375
00:46:35,480 --> 00:46:37,600
WAYS TO ASSESS FOR REASONING,

1376
00:46:37,600 --> 00:46:38,480
CORRECTNESS OF ANSWER.

1377
00:46:38,480 --> 00:46:41,720
YET MANY OF US ARE SCARED BY

1378
00:46:41,720 --> 00:46:42,600
OCCASIONS IN THE SCHOOL YEARS

1379
00:46:42,600 --> 00:46:44,360
WHEN WE TURNED IN A PROBLEM SET

1380
00:46:44,360 --> 00:46:46,680
MAYBE FOR MATH CLASS OR SCIENCE

1381
00:46:46,680 --> 00:46:47,960
CLASS WHERE WE TURNED IN THE

1382
00:46:47,960 --> 00:46:50,080
SET, GOT ALL THE ANSWERS RIGHT

1383
00:46:50,080 --> 00:46:52,240
AND THE TEACHER PUT A RED MARK

1384
00:46:52,240 --> 00:46:55,560
ON EVERY ONE AND GAVE US 50%.

1385
00:46:55,560 --> 00:46:57,400
I'LL ASK YOU TO THINK, WHY IS

1386
00:46:57,400 --> 00:46:57,720
THAT?

1387
00:46:57,720 --> 00:46:59,680
WHY IS IT THAT YOU GOT ALL THE

1388
00:46:59,680 --> 00:47:02,880
ANSWERS RIGHT BUT ONLY GOT 50%

1389
00:47:02,880 --> 00:47:05,600
CREDIT INSTEAD OF 100%?

1390
00:47:05,600 --> 00:47:12,880
 

1391
00:47:12,880 --> 00:47:14,280
WHAT MIGHT BE ECHOING AROUND,

1392
00:47:14,280 --> 00:47:16,640
YOU DIDN'T SHOW YOUR WORK.

1393
00:47:16,640 --> 00:47:18,000
QUITE OFTEN WE GIVE PEOPLE A

1394
00:47:18,000 --> 00:47:19,600
PASS FOR SHOWING THEIR WORK

1395
00:47:19,600 --> 00:47:25,200
BECAUSE IT'S BOTH EFFICIENT AND

1396
00:47:25,200 --> 00:47:26,160
INTELLECTUALLY SATISFYING TO

1397
00:47:26,160 --> 00:47:27,520
KNOW WE GOT THE RIGHT ANSWER

1398
00:47:27,520 --> 00:47:29,400
HOWEVER VERIFIED BUT THE ACTION

1399
00:47:29,400 --> 00:47:31,800
STEP TO BECOMING A BETTER

1400
00:47:31,800 --> 00:47:32,480
DIAGNOSTICIAN AND TEACHER IS

1401
00:47:32,480 --> 00:47:34,000
MOVE AWAY FROM THE RIGHT ANSWER

1402
00:47:34,000 --> 00:47:35,280
AND TOWARDS A RIGHT ARGUMENT.

1403
00:47:35,280 --> 00:47:37,800
THE ARGUMENT IS THE UNIT OF

1404
00:47:37,800 --> 00:47:38,240
REASONING.

1405
00:47:38,240 --> 00:47:39,720
THINK OF YOURSELF WHEN WE SAY I

1406
00:47:39,720 --> 00:47:40,840
THINK THIS IS WHAT'S GOING ON

1407
00:47:40,840 --> 00:47:42,720
WITH THE PATIENT, MOVING AWAY

1408
00:47:42,720 --> 00:47:44,040
FROM THE IDEA THAT THIS IS WHAT

1409
00:47:44,040 --> 00:47:45,680
I THINK THEY HAVE, LIKE THE WAY

1410
00:47:45,680 --> 00:47:46,880
A DOCTOR MIGHT SPEAK, TO

1411
00:47:46,880 --> 00:47:48,600
THINKING LIKE AN ATTORNEY,

1412
00:47:48,600 --> 00:47:50,560
MAKING CLOSING ARGUMENTS IN A

1413
00:47:50,560 --> 00:47:51,920
COURT OF LAW.

1414
00:47:51,920 --> 00:47:53,520
WE REALLY SHARE THE RANGE OF

1415
00:47:53,520 --> 00:47:55,080
POSSIBILITY WE THOUGHT ABOUT AND

1416
00:47:55,080 --> 00:47:55,840
EVIDENCE GOING FORWARD AND

1417
00:47:55,840 --> 00:47:56,520
AGAINST IT.

1418
00:47:56,520 --> 00:47:59,560
BEFORE YOU'RE GOING TO IMPLICATE

1419
00:47:59,560 --> 00:48:02,200
DIAGNOSIS BEING GUILTY, YOU HAVE

1420
00:48:02,200 --> 00:48:05,880
TO SHARE THE EVIDENCE FOR, AND

1421
00:48:05,880 --> 00:48:06,640
INTELLECTUAL HONESTLY EVIDENCE

1422
00:48:06,640 --> 00:48:07,760
AGAINST, BEING THE PROSECUTION

1423
00:48:07,760 --> 00:48:08,440
AND DEFENSE.

1424
00:48:08,440 --> 00:48:10,400
WHAT DOES THIS LOOK LIKE?

1425
00:48:10,400 --> 00:48:12,680
IN THE CLINICAL ENVIRONMENT YOU

1426
00:48:12,680 --> 00:48:13,560
CAN CREATE A STRUCTURE, I WANT

1427
00:48:13,560 --> 00:48:17,160
YOU TO PRESENT IN A WAY YOU CAN

1428
00:48:17,160 --> 00:48:18,800
LABEL THE PROBLEM, LABEL THE

1429
00:48:18,800 --> 00:48:20,480
SCHEMA, THE MAP OF HOW THE BRAIN

1430
00:48:20,480 --> 00:48:22,120
ORGANIZES THE PROBLEM BUT WHEN

1431
00:48:22,120 --> 00:48:23,520
WE GET DOWN TO POSSIBILITIES

1432
00:48:23,520 --> 00:48:29,760
SPEAK IN TERMS OF PROBABILITY,

1433
00:48:29,760 --> 00:48:31,560
NOT DEFINITIVENESS AND SHOW ME

1434
00:48:31,560 --> 00:48:32,520
ARGUMENT FOR OR AGAINST.

1435
00:48:32,520 --> 00:48:34,560
WHEN YOU START DOING IT, BETWEEN

1436
00:48:34,560 --> 00:48:36,680
BOTH TEACHER AND TEAM IT WINDS

1437
00:48:36,680 --> 00:48:37,400
UP BEING A REASONING

1438
00:48:37,400 --> 00:48:38,520
CONVERSATION AND CLEAR TO THE

1439
00:48:38,520 --> 00:48:39,720
TEACHER WHERE THEY DON'T NEED TO

1440
00:48:39,720 --> 00:48:40,720
COVER BECAUSE THE REASONING IS

1441
00:48:40,720 --> 00:48:43,120
SOUND AND WHERE THEY DO NEED TO

1442
00:48:43,120 --> 00:48:44,640
INTERVENE, WHETHER IT'S THE

1443
00:48:44,640 --> 00:48:45,640
PROBABILITY ASSESSMENT OR DATA

1444
00:48:45,640 --> 00:48:48,280
USED FOR AND AGAINST IT.

1445
00:48:48,280 --> 00:48:50,040
IF I WAS TO SUMMARIZE THIS, IT

1446
00:48:50,040 --> 00:48:52,200
MEANS TO ACT IN THIS WAY,

1447
00:48:52,200 --> 00:48:54,400
ACTUALLY TO RELINQUISH A PHRASE

1448
00:48:54,400 --> 00:48:57,240
YOU SOMETIMES SAY, JUST PUT YOUR

1449
00:48:57,240 --> 00:48:59,960
NICKEL DOWN.

1450
00:48:59,960 --> 00:49:01,480
MODE OF DEFLATION, IT'S GETTING

1451
00:49:01,480 --> 00:49:03,160
BETTER AT ASKING FOR A PENNY FOR

1452
00:49:03,160 --> 00:49:04,240
YOUR THOUGHTS, NOT PUTTING THE

1453
00:49:04,240 --> 00:49:04,960
NICKEL DOWN.

1454
00:49:04,960 --> 00:49:07,760
BUT THAT PENNY HAS TO COME WITH

1455
00:49:07,760 --> 00:49:09,400
REASONING AND KNOWLEDGE, THE

1456
00:49:09,400 --> 00:49:11,800
VIRTUE OF UNDERSTANDING GREAT

1457
00:49:11,800 --> 00:49:14,000
REASONING PROCESSES, FOR

1458
00:49:14,000 --> 00:49:16,920
DIAGNOSIS AND FOR MANAGEMENT.

1459
00:49:16,920 --> 00:49:17,800
CONCLUDING TIP RELATES TO BOOKS.

1460
00:49:17,800 --> 00:49:19,840
MUCH OF WHAT WE DO IN TERMS OF

1461
00:49:19,840 --> 00:49:21,240
REASONING TO GET BETTER IS

1462
00:49:21,240 --> 00:49:23,600
SPENDING OUR TIME IN THE MEDICAL

1463
00:49:23,600 --> 00:49:24,480
LITERATURE.

1464
00:49:24,480 --> 00:49:25,880
BOOKS, JOURNALS, SOCIAL MEDIA,

1465
00:49:25,880 --> 00:49:26,800
WEBSITES, WHEREVER THAT

1466
00:49:26,800 --> 00:49:28,560
KNOWLEDGE IS, BUT THERE'S WISDOM

1467
00:49:28,560 --> 00:49:30,320
TO BE GAINED OUTSIDE OF

1468
00:49:30,320 --> 00:49:32,040
MEDICINE, ONCE YOU RECOGNIZE

1469
00:49:32,040 --> 00:49:33,360
THAT THE MOST IMPORTANT

1470
00:49:33,360 --> 00:49:39,520
DIAGNOSTIC TOOL IS NOT THE CHEM

1471
00:49:39,520 --> 00:49:42,440
7, CT SCAN, IT'S YOUR OWN MIND.

1472
00:49:42,440 --> 00:49:48,480
I'LL RECOMMEND THREE BOOKS, ONE

1473
00:49:48,480 --> 00:49:51,560
IS "NOISE," THE FOLLOW-UP TO

1474
00:49:51,560 --> 00:49:53,640
"THINKING FAST AND SLOW,"

1475
00:49:53,640 --> 00:49:53,880
MARVELOUS.

1476
00:49:53,880 --> 00:49:56,520
POINTS OUT THAT WE COULD BE

1477
00:49:56,520 --> 00:49:59,760
BIAS, THE FIRST BOOK IS ABOUT BY

1478
00:49:59,760 --> 00:50:01,560
AS, BEING WRONG IN ONE DIRECTION

1479
00:50:01,560 --> 00:50:03,040
BUT THE SECOND BOOK POINTS OUT

1480
00:50:03,040 --> 00:50:04,800
ANOTHER PROBLEM THAT WE HAVE,

1481
00:50:04,800 --> 00:50:06,960
THAT WE CAN BE INCONSISTENT WITH

1482
00:50:06,960 --> 00:50:08,840
THE SAME JUDGMENT.

1483
00:50:08,840 --> 00:50:11,440
THIS CAN BE WHETHER IT'S JUDGES

1484
00:50:11,440 --> 00:50:12,680
GIVING PAROLE SENTENCES, WHETHER

1485
00:50:12,680 --> 00:50:13,760
IT'S A BANK LOAN OFFICER

1486
00:50:13,760 --> 00:50:15,280
DECIDING WHO DOES OR DOESN'T GET

1487
00:50:15,280 --> 00:50:17,280
A LOAN OR DOCTOR LOOKING AT

1488
00:50:17,280 --> 00:50:18,880
X-RAY AND SEEING FOR ONE PATIENT

1489
00:50:18,880 --> 00:50:20,680
MAKING ONE CALL AND LOOKING AT

1490
00:50:20,680 --> 00:50:22,240
THE SAME X-RAY AND HOUR LATER

1491
00:50:22,240 --> 00:50:23,240
MAKING THE OTHER CALL.

1492
00:50:23,240 --> 00:50:25,840
THAT THERE'S A LOT OF NOISE OR

1493
00:50:25,840 --> 00:50:27,600
VARIABILITY IN OUR JUDGMENT,

1494
00:50:27,600 --> 00:50:28,400
UNWANTED VARIATION.

1495
00:50:28,400 --> 00:50:30,240
NOISE TALKS ABOUT WAYS TO

1496
00:50:30,240 --> 00:50:36,440
RECOGNIZE IT AND MITIGATE IT. 

1497
00:50:36,440 --> 00:50:37,520
THE SECOND IS "PEAK."

1498
00:50:37,520 --> 00:50:38,880
THE UNDERLYING FRAMEWORK FOR THE

1499
00:50:38,880 --> 00:50:40,600
WORK I'M OUTLINING HERE IS

1500
00:50:40,600 --> 00:50:41,600
CALLED THE EXPERTISE SCIENCE

1501
00:50:41,600 --> 00:50:42,960
APPROACH, IF YOU'RE TRYING TO

1502
00:50:42,960 --> 00:50:44,000
GET GOOD AT SOMETHING, YOU'RE

1503
00:50:44,000 --> 00:50:45,320
NOT TRYING TO GET EXPERIENCE,

1504
00:50:45,320 --> 00:50:46,520
YOU'RE TRYING TO GET EXPERT.

1505
00:50:46,520 --> 00:50:49,680
THERE'S AN EXTRA FORM OF HARD

1506
00:50:49,680 --> 00:50:50,520
WORK THAT'S REQUIRED.

1507
00:50:50,520 --> 00:50:52,200
ERICKSON WAS ONE OF THE PIONEERS

1508
00:50:52,200 --> 00:50:54,400
OF THE CONCEPT OF DELIBERATE

1509
00:50:54,400 --> 00:50:57,160
PRACTICE AS A WAY TO DOING THAT,

1510
00:50:57,160 --> 00:50:58,320
AN ACCESSIBLE WAY TO

1511
00:50:58,320 --> 00:51:00,120
UNDERSTANDING, HE DOESN'T HIDE

1512
00:51:00,120 --> 00:51:00,960
IT'S HARD WORK,TELLS YOU WHAT

1513
00:51:00,960 --> 00:51:02,400
THE HARD WORK IS LOOK LIKE IF

1514
00:51:02,400 --> 00:51:05,480
YOU'RE TRYING TO GET PHYSICAL,

1515
00:51:05,480 --> 00:51:06,320
PSYCHOMOTOR, COGNITIVE

1516
00:51:06,320 --> 00:51:06,760
EXPERTISE.

1517
00:51:06,760 --> 00:51:08,920
MY FAVORITE BOOK OF ALL IN THE

1518
00:51:08,920 --> 00:51:12,920
TRIO, I LOVE ALL THREE, "SUPER

1519
00:51:12,920 --> 00:51:13,240
FORECASTING."

1520
00:51:13,240 --> 00:51:15,640
IT'S THE STORY OF PEOPLE WHO

1521
00:51:15,640 --> 00:51:17,080
HAVE OUTSTANDING JUDGMENT.

1522
00:51:17,080 --> 00:51:19,480
HIS LARGELY CENTERS ON THE GOOD

1523
00:51:19,480 --> 00:51:20,720
JUDGMENT PROJECT, CROWDSOURCING

1524
00:51:20,720 --> 00:51:23,200
PEOPLE FROM ACROSS THE WORLD,

1525
00:51:23,200 --> 00:51:25,160
ACROSS THE COUNTRY MAKING

1526
00:51:25,160 --> 00:51:25,680
POLITICAL JUDGMENTS.

1527
00:51:25,680 --> 00:51:30,320
WILL NORTH KOREA DO THIS?

1528
00:51:30,320 --> 00:51:35,880
WILL GREEN LAND DO THAT, WILL

1529
00:51:35,880 --> 00:51:37,440
RUSSIA INVADE UKRAINE?

1530
00:51:37,440 --> 00:51:38,720
HE HAS PEOPLE MAKE PREDICTIONS

1531
00:51:38,720 --> 00:51:40,480
AND CHECKS THE WORK.

1532
00:51:40,480 --> 00:51:42,280
A SMALL SUBSET ARE SUPER

1533
00:51:42,280 --> 00:51:43,040
FORECASTERS, NOT GOVERNMENT

1534
00:51:43,040 --> 00:51:45,200
AGENTS, DON'T HAVE ACCESS TO

1535
00:51:45,200 --> 00:51:47,160
CLASSIFIED INFORMATION.

1536
00:51:47,160 --> 00:51:48,800
INSTEAD, THEY HAVE VERY UNIQUE

1537
00:51:48,800 --> 00:51:49,680
HABITS OF MIND.

1538
00:51:49,680 --> 00:51:51,360
AND THIS IS WHAT I WANT TO

1539
00:51:51,360 --> 00:51:53,560
CONCLUDE ON, HABITS OF MIND OF

1540
00:51:53,560 --> 00:51:54,760
SUPERFORECASTERS, AFTER ALL

1541
00:51:54,760 --> 00:51:56,480
THAT'S WHAT DIAGNOSIS IS,

1542
00:51:56,480 --> 00:52:00,640
DIAGNOSIS IS MAKING A FORECAST.

1543
00:52:00,640 --> 00:52:03,600
IT'S A PROBABLISTING JUDGMENT.

1544
00:52:03,600 --> 00:52:04,920
WE GET CONFIRMATORY TESTING BUT

1545
00:52:04,920 --> 00:52:08,920
A HUGE NUMBER IS PROVISIONAL

1546
00:52:08,920 --> 00:52:09,240
HYPOTHESIS.

1547
00:52:09,240 --> 00:52:10,280
AND THE SUPERFORECASTERS WHO

1548
00:52:10,280 --> 00:52:12,680
MAKE THESE JUDGMENTS BETTER THAN

1549
00:52:12,680 --> 00:52:18,400
EVERYONE ELSE HAD THIS MINDSET,

1550
00:52:18,400 --> 00:52:19,360
HYPOTHESES THAT GREENLAND WILL

1551
00:52:19,360 --> 00:52:22,880
DO THIS OR NATURAL GAS PIPELINE

1552
00:52:22,880 --> 00:52:24,880
WILL BE CUT OFF, HYPOTHESES TO

1553
00:52:24,880 --> 00:52:27,720
BE TESTED, NOT TREASURED,

1554
00:52:27,720 --> 00:52:29,240
CONSTANTLY ADJUSTING THINKING.

1555
00:52:29,240 --> 00:52:32,400
THEY HAVE A CONSTANT

1556
00:52:32,400 --> 00:52:33,640
POINT-COUNTERPOINT TO THE POINT

1557
00:52:33,640 --> 00:52:34,800
THEY ARE SUPERSKILLED AT

1558
00:52:34,800 --> 00:52:36,840
UPDATING FORECASTS BUT DO IT IN

1559
00:52:36,840 --> 00:52:38,880
A SLIGHTEST OF WAYS.

1560
00:52:38,880 --> 00:52:40,520
THEY DON'T SWING FROM ONE

1561
00:52:40,520 --> 00:52:41,320
OPINION TO ANOTHER.

1562
00:52:41,320 --> 00:52:44,080
THEY DON'T SAY THIS IS CHF, OH,

1563
00:52:44,080 --> 00:52:45,600
THIS TEST CAME BACK?

1564
00:52:45,600 --> 00:52:49,200
I'M SWITCHED TO PNEUMONIA.

1565
00:52:49,200 --> 00:52:51,920
THIS LOW LEVEL MAKES IT LESS

1566
00:52:51,920 --> 00:52:54,960
LIKELY IT'S CHF, SLIGHTLY

1567
00:52:54,960 --> 00:52:56,760
INCREASES PROBABILITY MIGHT BE

1568
00:52:56,760 --> 00:52:58,360
PNEUMONIA, SPEAKING IN A NUANCED

1569
00:52:58,360 --> 00:52:58,920
WAY.

1570
00:52:58,920 --> 00:53:03,080
MIGHT CHANGE THEIR MIND BUT MAKE

1571
00:53:03,080 --> 00:53:04,040
MINOR ADJUSTMENTS.

1572
00:53:04,040 --> 00:53:08,000
THE DRAGONFLY BEAUTIFUL AT

1573
00:53:08,000 --> 00:53:10,880
DISTANCE, HAS COMPLEX EYES, OVER

1574
00:53:10,880 --> 00:53:12,640
3,000 -- 30,000 LENSES, ALLOWS

1575
00:53:12,640 --> 00:53:15,600
IT TO LOOK ALL AROUND, LIKE A

1576
00:53:15,600 --> 00:53:15,880
360 VIEW.

1577
00:53:15,880 --> 00:53:18,080
EVERY ONE OF THE LENSES TAKES IN

1578
00:53:18,080 --> 00:53:19,640
A LITTLE BIT OF INFORMATION BUT

1579
00:53:19,640 --> 00:53:21,280
IT'S THE MAGIC THAT HAPPENS IN

1580
00:53:21,280 --> 00:53:22,600
THE BRAIN, SYNTHESIZING LOTS OF

1581
00:53:22,600 --> 00:53:24,440
PIECES OF INFORMATION AND

1582
00:53:24,440 --> 00:53:25,440
SLIGHTLY ADJUSTS ACCORDINGLY.

1583
00:53:25,440 --> 00:53:27,400
PEOPLE WHO HAVE THAT HABIT OF

1584
00:53:27,400 --> 00:53:28,800
MIND BUT MOST IMPORTANTLY TREAT

1585
00:53:28,800 --> 00:53:31,400
THEIR HYPOTHESES AS SOMETHING TO

1586
00:53:31,400 --> 00:53:34,960
BE TESTED NOT TREASURED WIND UP

1587
00:53:34,960 --> 00:53:36,200
MAKING THE BEST JUDGMENTS.

1588
00:53:36,200 --> 00:53:39,640
SO WHAT IT IS ON THE STORY OF

1589
00:53:39,640 --> 00:53:41,760
BECOMING A SUPERFORECAST OTHER

1590
00:53:41,760 --> 00:53:43,160
SUPERDIAGNOSTICIAN I OFFERED

1591
00:53:43,160 --> 00:53:45,800
THIS MENU OF THINGS, SOME FROM

1592
00:53:45,800 --> 00:53:48,080
LITERATURE, SOME FROM

1593
00:53:48,080 --> 00:53:49,760
EXPERIENCE, AND OFTEN

1594
00:53:49,760 --> 00:53:50,080
AMALGAMATION.

1595
00:53:50,080 --> 00:53:52,880
THE POINT IS THAT WE'RE ALL

1596
00:53:52,880 --> 00:53:54,600
DEVOTED TO A CAREER IN CLINICAL

1597
00:53:54,600 --> 00:53:56,880
MEDICINE, TO HELP PEOPLE.

1598
00:53:56,880 --> 00:53:57,520
IT'S SO INTELLECTUALLY

1599
00:53:57,520 --> 00:53:59,520
SATISFYING, SO IMPORTANT TO OUR

1600
00:53:59,520 --> 00:54:01,800
SOCIETY, AND SUCH A GREAT PUBLIC

1601
00:54:01,800 --> 00:54:03,560
GOOD THAT WE PROVIDE.

1602
00:54:03,560 --> 00:54:05,920
BUT IF WE REALLY ENGAGE IN THAT,

1603
00:54:05,920 --> 00:54:07,160
MORAL OBLIGATION SHOULD BE AS

1604
00:54:07,160 --> 00:54:08,720
GOOD AS WE CAN BE.

1605
00:54:08,720 --> 00:54:10,560
IT'S VERY EASY TO BECOME AN

1606
00:54:10,560 --> 00:54:12,840
EXPERIENCED DOCTOR BUT IT'S VERY

1607
00:54:12,840 --> 00:54:16,240
HARD TO BECOME AN EXPERT DOCTOR.

1608
00:54:16,240 --> 00:54:17,640
WHAT I OFFERED HERE IS A MENU OF

1609
00:54:17,640 --> 00:54:19,320
THINGS, NOT THINGS YOU DO EVERY

1610
00:54:19,320 --> 00:54:20,480
DAY, YOU MAY DO THEM IN

1611
00:54:20,480 --> 00:54:21,680
DIFFERENT TIMES OF THE WEEK,

1612
00:54:21,680 --> 00:54:23,360
DIFFERENT TIMES OF THE DAY,

1613
00:54:23,360 --> 00:54:25,080
DIFFERENT PHASES OF YOUR CAREER.

1614
00:54:25,080 --> 00:54:27,960
THIS IS A NON-HIERARCHICAL MENU.

1615
00:54:27,960 --> 00:54:30,480
BUT THEY ARE ALL WAYS TO IMPROVE

1616
00:54:30,480 --> 00:54:32,520
THE INSTRUMENT THAT MATTERS MOST

1617
00:54:32,520 --> 00:54:33,520
IN THE DIAGNOSTIC PROCESS, THE

1618
00:54:33,520 --> 00:54:36,360
RAIN THAT WE HAVE TO CALL UPON

1619
00:54:36,360 --> 00:54:37,560
AND CONTINUALLY CALIBRATE.

1620
00:54:37,560 --> 00:54:39,880
I HOPE WHEN YOU LOOK AT THIS

1621
00:54:39,880 --> 00:54:41,480
LIST YOU'LL RECOGNIZE WHAT YOU

1622
00:54:41,480 --> 00:54:43,720
SAID SOUNDS LIKE A LITTLE EXTRA

1623
00:54:43,720 --> 00:54:45,160
WORK AND THAT'S EXACTLY TRUE.

1624
00:54:45,160 --> 00:54:46,960
THERE'S NEVER BEEN A FIELD WHERE

1625
00:54:46,960 --> 00:54:49,440
PEOPLE DON'T ACHIEVE THEIR

1626
00:54:49,440 --> 00:54:51,160
MAXIMAL POTENTIAL WITHOUT EXTRA

1627
00:54:51,160 --> 00:54:51,920
WORK.

1628
00:54:51,920 --> 00:54:54,200
SO MY GOAL HERE ISN'T TO HIDE

1629
00:54:54,200 --> 00:54:55,320
THAT THIS IS EXTRA WORK.

1630
00:54:55,320 --> 00:54:56,280
IT IS EXTRA WORK.

1631
00:54:56,280 --> 00:54:57,840
MY GOAL IS JUST TO CONVINCE YOU

1632
00:54:57,840 --> 00:55:01,200
THAT FOR THE JOB THAT WE HAVE,

1633
00:55:01,200 --> 00:55:02,120
IT'S DEFINITELY WORTH IT.

1634
00:55:02,120 --> 00:55:03,760
THANK YOU SO MUCH FOR YOUR TIME

1635
00:55:03,760 --> 00:55:04,520
AND ATTENTION.

1636
00:55:04,520 --> 00:55:05,720
I HOPE YOU FOUND SOMETHING

1637
00:55:05,720 --> 00:55:07,160
USEFUL IN THIS TALK TODAY.

1638
00:55:07,160 --> 00:55:09,680
THANK YOU.

1639
00:55:09,680 --> 00:55:15,720
 

1640
00:55:15,720 --> 00:55:19,200
 

1641
00:55:19,200 --> 00:55:20,920
>>DR. DHALIWAL, THANK YOU
FOR

1642
00:55:20,920 --> 00:55:22,280
THAT OUTSTANDING TALK.

1643
00:55:22,280 --> 00:55:23,640
AS I HOPE EXPECTATIONS WEREN'T

1644
00:55:23,640 --> 00:55:25,600
MADE TOO HIGH BUT WHATEVER THEY

1645
00:55:25,600 --> 00:55:28,520
WERE, YOU CERTAINLY EXCEEDED

1646
00:55:28,520 --> 00:55:29,920
THEM.

1647
00:55:29,920 --> 00:55:31,680
>>I HOPE -- THOSE TWO
STUDENTS

1648
00:55:31,680 --> 00:55:33,040
WHO MENTIONED ME, I HOPE THEY

1649
00:55:33,040 --> 00:55:35,200
ARE SATISFIED AS WELL, I LIVED

1650
00:55:35,200 --> 00:55:38,040
UP TO THEIR EXPECTATIONS.

1651
00:55:38,040 --> 00:55:40,520
>>I SENT BOTH THE LINK
TODAY

1652
00:55:40,520 --> 00:55:45,800
AND TOLD BOTH THEY INSPIRED

1653
00:55:45,800 --> 00:55:46,240
THIS.

1654
00:55:46,240 --> 00:55:47,040
>>MARVELOUS.

1655
00:55:47,040 --> 00:55:47,880
>>A NUMBER OF QUESTIONS,
A

1656
00:55:47,880 --> 00:55:49,520
NUMBER OF THINGS ALREADY.

1657
00:55:49,520 --> 00:55:50,840
SO I'M GOING TO START WITH A

1658
00:55:50,840 --> 00:55:51,080
COMMENT.

1659
00:55:51,080 --> 00:55:52,720
THIS IS NOT JUST THE BEST

1660
00:55:52,720 --> 00:55:53,680
CLINICAL CENTER GRAND ROUNDS

1661
00:55:53,680 --> 00:55:55,560
I'VE EVER HEARD, IT'S THE BEST

1662
00:55:55,560 --> 00:55:58,840
MEDICAL EDUCATION I'VE EVER

1663
00:55:58,840 --> 00:56:00,680
ATTENDED.

1664
00:56:00,680 --> 00:56:01,440
>>THANK YOU.

1665
00:56:01,440 --> 00:56:03,440
>>THE SECOND IS A
QUESTION.

1666
00:56:03,440 --> 00:56:05,480
DO YOU HAVE ANY ADVICE FOR

1667
00:56:05,480 --> 00:56:08,200
PRE-MEDS HOW TO JUMP START THE

1668
00:56:08,200 --> 00:56:11,920
PROCESS OF BECOMING A GREAT

1669
00:56:11,920 --> 00:56:12,720
DIAGNOSTICIAN?

1670
00:56:12,720 --> 00:56:13,880
>>PRE-MED IS AN
INTERESTING

1671
00:56:13,880 --> 00:56:16,080
TIME YOU'RE NOT YET FULLY

1672
00:56:16,080 --> 00:56:17,840
OVERLOADED WITH MEDICAL FACTS.

1673
00:56:17,840 --> 00:56:19,120
SOME BOOKS I SUGGESTED, I MIGHT

1674
00:56:19,120 --> 00:56:22,360
MAKE THEM YOUR PRE-MED BOOKS.

1675
00:56:22,360 --> 00:56:23,680
WE MIGHT NORMALLY THINK I SHOULD

1676
00:56:23,680 --> 00:56:25,240
BEEF UP ON SCIENCE AND MEDICINE

1677
00:56:25,240 --> 00:56:27,280
BUT I MIGHT SAY TAKE A PAUSE AND

1678
00:56:27,280 --> 00:56:28,600
FOCUS ON YOUR JUDGMENT AND

1679
00:56:28,600 --> 00:56:30,440
REASONING PROCESS WITH SOME

1680
00:56:30,440 --> 00:56:32,080
OTHER BOOKS AND THEN GET THOSE

1681
00:56:32,080 --> 00:56:34,040
HABITS IN PLACE SO WHEN DO YOU

1682
00:56:34,040 --> 00:56:36,120
START CONSUMING ALL THE

1683
00:56:36,120 --> 00:56:36,680
BIOMEDICAL AND BIOSOCIAL

1684
00:56:36,680 --> 00:56:38,520
INFORMATION IN MED SCHOOL YOU'LL

1685
00:56:38,520 --> 00:56:41,160
HAVE A GREAT FRAMEWORK HOW TO

1686
00:56:41,160 --> 00:56:42,040
DEPLOY IT.

1687
00:56:42,040 --> 00:56:43,680
>>THE NEXT QUESTION WE
HAVE,

1688
00:56:43,680 --> 00:56:46,520
HOW DO YOU RENEW, HOW DO YOU

1689
00:56:46,520 --> 00:56:47,720
STAY FRESH?

1690
00:56:47,720 --> 00:56:49,280
>>AH, YEAH, I LOVE MY
JOB.

1691
00:56:49,280 --> 00:56:50,920
I THINK THAT'S PROBABLY A HUGE

1692
00:56:50,920 --> 00:56:51,760
PART OF IT.

1693
00:56:51,760 --> 00:56:53,760
I THINK IF I HAD TO GIVE ANY

1694
00:56:53,760 --> 00:56:55,960
CREDIT, IT WOULD BE TO TEACHING,

1695
00:56:55,960 --> 00:56:56,840
RIGHT?

1696
00:56:56,840 --> 00:56:58,280
IT'S VERY EASY TO BECOME SORT OF

1697
00:56:58,280 --> 00:57:00,000
COMPLACENT AND HOW MUCH I KNOW

1698
00:57:00,000 --> 00:57:01,480
OR SAY I'M GOOD ENOUGH OR KNOW

1699
00:57:01,480 --> 00:57:03,920
ENOUGH BUT IF YOU ARE IN THE

1700
00:57:03,920 --> 00:57:05,560
BUSINESS OF TEACHING, THE MINUTE

1701
00:57:05,560 --> 00:57:07,040
YOU HEAR YOURSELF TALKING,

1702
00:57:07,040 --> 00:57:07,640
IMMEDIATELY BECOMES APPARENT

1703
00:57:07,640 --> 00:57:08,760
THERE'S SOMETHING I DON'T KNOW,

1704
00:57:08,760 --> 00:57:10,280
THERE'S A HOLE IN MY KNOWLEDGE,

1705
00:57:10,280 --> 00:57:11,880
THERE'S A DEFICIT IN MY

1706
00:57:11,880 --> 00:57:13,240
UNDERSTANDING, AND IF YOU ARE

1707
00:57:13,240 --> 00:57:14,480
REALLY OBLIGATED TO MAKE IT

1708
00:57:14,480 --> 00:57:15,520
CLEAR FOR SOMEONE ELSE, YOU WIND

1709
00:57:15,520 --> 00:57:17,640
UP GOING BACK TO LEARN MORE.

1710
00:57:17,640 --> 00:57:19,680
SO I THINK PROBABLY IT'S

1711
00:57:19,680 --> 00:57:20,480
MULTI-FACTORIAL BUT TEACHING IS

1712
00:57:20,480 --> 00:57:23,760
AT THE HEART OF IT.

1713
00:57:23,760 --> 00:57:26,800
>>SO CAN I ADD SOMETHING?

1714
00:57:26,800 --> 00:57:29,240
MY OWN PERSONAL ADDENDUM TO THE

1715
00:57:29,240 --> 00:57:31,200
QUESTION, HOW DO YOU DECOMPRESS,

1716
00:57:31,200 --> 00:57:32,600
WHAT DO YOU DO?

1717
00:57:32,600 --> 00:57:34,400
>>IT'S INTERESTING, I
WOULD SAY

1718
00:57:34,400 --> 00:57:35,800
I'M MORE -- PERSONAL, I'M MORE

1719
00:57:35,800 --> 00:57:37,680
LIKE A BATTERY.

1720
00:57:37,680 --> 00:57:39,200
I GET UP EARLY IN THE MORNING,

1721
00:57:39,200 --> 00:57:39,680
VERY CHARGED.

1722
00:57:39,680 --> 00:57:41,400
I GET TIRED BY THE END OF THE

1723
00:57:41,400 --> 00:57:41,760
DAY.

1724
00:57:41,760 --> 00:57:42,880
USUALLY A GOOD NIGHT'S REST IS

1725
00:57:42,880 --> 00:57:44,280
WHAT I NEED TO GET READY THE

1726
00:57:44,280 --> 00:57:44,960
NEXT DAY.

1727
00:57:44,960 --> 00:57:47,280
I'M GRATEFUL FOR A JOB THAT HAS

1728
00:57:47,280 --> 00:57:48,920
VARIETY, LIKE I HAVE A LOT OF

1729
00:57:48,920 --> 00:57:51,480
CLINICAL WORK, BUT I ALSO WORK

1730
00:57:51,480 --> 00:57:52,720
WITH TRAINEES, DIFFERENT SET

1731
00:57:52,720 --> 00:57:55,080
THINGS, AND THE V.A. IS A GREAT

1732
00:57:55,080 --> 00:57:56,280
HEALTH SYSTEM.

1733
00:57:56,280 --> 00:57:58,760
SOME SYSTEMS MAKE LIFE HARDER,

1734
00:57:58,760 --> 00:58:00,400
AND THE V.A. I THINK MAKES LIFE

1735
00:58:00,400 --> 00:58:01,640
EASIER, GREAT TO WORK IN A

1736
00:58:01,640 --> 00:58:03,760
SYSTEM CAN YOU PROVIDE TO YOUR

1737
00:58:03,760 --> 00:58:04,920
PATIENTS, THAT'S SUPER CHARGING

1738
00:58:04,920 --> 00:58:07,160
IN A WAY THAT IF YOU WORK IN A

1739
00:58:07,160 --> 00:58:13,280
SYSTEM  WHERE YOU CAN'T PROVIDE

1740
00:58:13,280 --> 00:58:15,480
FOR YOUR PATIENTS THAT COULD SAP

1741
00:58:15,480 --> 00:58:15,720
ENERGY.

1742
00:58:15,720 --> 00:58:18,280
>>WHY DO YOU THINK
THERE'S BEEN

1743
00:58:18,280 --> 00:58:19,520
THIS EPIDEMIC OF BURNOUT?

1744
00:58:19,520 --> 00:58:21,680
WHY DO YOU THINK PEOPLE LOST

1745
00:58:21,680 --> 00:58:23,480
SIGHT OF THE MEANING IN

1746
00:58:23,480 --> 00:58:24,160
MEDICINE?

1747
00:58:24,160 --> 00:58:26,520
>>YEAH, WORTHY OF ITS OWN
TALK.

1748
00:58:26,520 --> 00:58:27,640
THE CONCEPT I'VE LEARNED, WHICH

1749
00:58:27,640 --> 00:58:30,040
TO ME IS MAYBE A BETTER

1750
00:58:30,040 --> 00:58:32,200
EXPLANATION, CONCEPT OF MORAL

1751
00:58:32,200 --> 00:58:32,560
INJURY.

1752
00:58:32,560 --> 00:58:34,760
I WANT TO EXPAND.

1753
00:58:34,760 --> 00:58:37,480
MEDICINE HAS ALWAYS BEEN A

1754
00:58:37,480 --> 00:58:38,160
DEMANDING PROFESSION, MANY

1755
00:58:38,160 --> 00:58:39,640
PEOPLE WHO GO IN ARE WILLING TO

1756
00:58:39,640 --> 00:58:41,200
GIVE WHAT IS REQUIRED BUT WHAT'S

1757
00:58:41,200 --> 00:58:43,280
BECOME MORE APPARENT IS MORAL

1758
00:58:43,280 --> 00:58:44,360
INJURY, A VETERAN CONCEPT, WHEN

1759
00:58:44,360 --> 00:58:46,040
PEOPLE GO TO A THEATER OF WAR

1760
00:58:46,040 --> 00:58:49,400
AND THEY HAVE TO DO THINGS THAT

1761
00:58:49,400 --> 00:58:50,440
VIOLATE THEIR MORALS, BECAUSE OF

1762
00:58:50,440 --> 00:58:51,920
THE RULES, BECAUSE OF THE

1763
00:58:51,920 --> 00:58:53,240
COMMANDERS, BECAUSE OF THE WAY

1764
00:58:53,240 --> 00:58:54,000
THE WORLD WORKS.

1765
00:58:54,000 --> 00:58:55,720
WHEN YOU LOOK AT MEDICINE, IT

1766
00:58:55,720 --> 00:58:57,280
ALSO HAS A LOT OF MORAL INJURY

1767
00:58:57,280 --> 00:58:58,360
TO IT.

1768
00:58:58,360 --> 00:58:59,480
AND YOU CAN IDENTIFY MORAL

1769
00:58:59,480 --> 00:59:01,880
INJURY EVERY TIME YOU SAY TO A

1770
00:59:01,880 --> 00:59:03,400
PATIENT, I'M SORRY.

1771
00:59:03,400 --> 00:59:07,560
LIKE I'M REALLY SORRY YOUR

1772
00:59:07,560 --> 00:59:08,440
INSURANCE ISN'T COVERING THIS,

1773
00:59:08,440 --> 00:59:10,120
WE DON'T HAVE AN APPOINTMENT FOR

1774
00:59:10,120 --> 00:59:11,560
SIX MONTHS, I'M REALLY SORRY WE

1775
00:59:11,560 --> 00:59:12,760
DON'T HAVE HOUSING FOR YOU.

1776
00:59:12,760 --> 00:59:15,080
EVERY ONE OF THOSE APOLOGIES

1777
00:59:15,080 --> 00:59:17,760
MAPS ONTO LIKE A SHORTCOMING IN

1778
00:59:17,760 --> 00:59:20,520
THE SYSTEM THAT, YOU KNOW, WE'RE

1779
00:59:20,520 --> 00:59:21,280
WORKING IN, VIOLATES YOUR

1780
00:59:21,280 --> 00:59:24,480
INTENT, WHAT YOU THOUGHT TO BE A

1781
00:59:24,480 --> 00:59:24,680
DOCTOR.

1782
00:59:24,680 --> 00:59:26,680
BURNOUT IS A SEPARATE CONCEPT,

1783
00:59:26,680 --> 00:59:28,400
NOT SEPARATE, SORRY, ADJACENT

1784
00:59:28,400 --> 00:59:29,280
CONCEPT, BUT UNDERSTANDING THAT

1785
00:59:29,280 --> 00:59:30,920
IF YOU DO HAVE THE ENGAGEMENT,

1786
00:59:30,920 --> 00:59:32,480
YOU CAN STILL HAVE THIS MORAL

1787
00:59:32,480 --> 00:59:34,000
INJURY, I WISH THE SYSTEM WASN'T

1788
00:59:34,000 --> 00:59:35,720
SO DIFFICULT TO HELP THE

1789
00:59:35,720 --> 00:59:37,080
PATIENTS WHICH IS DIFFERENT THAN

1790
00:59:37,080 --> 00:59:39,160
IT'S DIFFICULT FOR ME TO DO MY

1791
00:59:39,160 --> 00:59:39,560
WORK IN.

1792
00:59:39,560 --> 00:59:43,000
BUT THEY ARE CLOSE, FOR SURE.

1793
00:59:43,000 --> 00:59:44,920
 

1794
00:59:44,920 --> 00:59:48,560
>>WE'RE EXACTLY AT THE
HOUR.

1795
00:59:48,560 --> 00:59:50,760
I CAN -- ACTUALLY MAYBE I'LL

1796
00:59:50,760 --> 00:59:52,280
TEXT YOU OR E-MAIL SOME OF THE

1797
00:59:52,280 --> 00:59:52,840
OTHER QUESTIONS.

1798
00:59:52,840 --> 00:59:57,320
>>I'D BE HAPPY TO ANSWER
THEM.

1799
00:59:57,320 --> 00:59:58,520
I'D BE HAPPY TO ADDRESS THEM.

1800
00:59:58,520 --> 01:00:00,280
>>THANK YOU SO MUCH.

1801
01:00:00,280 --> 01:00:08,240
THE HONOR HAS BEEN  OURS.

1802
01:00:08,240 --> 01:00:10,760
THERE WILL BE A LOT OF TALK AND

1803
01:00:10,760 --> 01:00:11,760
I'M GRATEFUL YOU CAME TO SPEAK.

1804
01:00:11,760 --> 01:00:12,760
THANK YOU SO MUCH.

1805
01:00:12,760 --> 01:00:13,560
>>IT'S MY HONOR.

1806
01:00:13,560 --> 01:00:14,760
I WISH I COULD BE THERE TO HEAR

1807
01:00:14,760 --> 01:00:15,120
THE CHATTER.

1808
01:00:15,120 --> 01:00:16,360
THANK YOU, AND ANYONE IS WELCOME

1809
01:00:16,360 --> 01:00:17,000
TO REACH OUT TO ME.

1810
01:00:17,000 --> 00:00:00,000
EVERYONE, HAVE A WONDERFUL DAY.