After having driven home around midnight in winter, Levitin found that he didn’t have his keys.
“In fact, I could see them through the window, lying on the dining room table where I had left them,” he said. “I ran around and tried all the other doors and windows, but they were locked tight. I couldn’t go back to my friend’s house for the night because I had an early flight to Europe the next morning, and I needed to get my passport and my suitcase.
“I found a large rock and broke through the basement window. I figured that in the morning, on the way to the airport, I could call my contractor and ask him to fix it. Now, I know a little bit about how the brain performs under stress. It releases cortisol that raises your heart rate, it modulates adrenaline levels and it clouds your thinking. So the next morning, when I woke up on too little sleep, worrying about the hole in the window, a mental note that I had to call my contractor, the freezing temperatures, and the meetings I had upcoming in Europe, my thinking was cloudy.”
Needless to say it wasn’t until he got to the airport that he realised he didn’t have his passport. So he raced home in the snow, got his passport, raced back to the airport, and made it just in time – due to his late arrival however, his pre-booked seat had already been given away to someone else.
“Well, I had a lot of time to think during those eight hours and no sleep,” he said. “And I started wondering whether there were things I could do that would prevent bad things from happening. Or at least if bad things happen, will minimise the likelihood of it being a total catastrophe. But my thoughts didn’t crystallise until about a month later. I was having dinner with my colleague, Nobel Prize winner Danny Kahneman, and I told him about having broken my window. Kahneman shared with me that he’d been practicing something called prospective hindsight.
“It’s something that he had gotten from the psychologist Gary Klein, who had written about it a few years before, called the pre-mortem. Now, you all know what the postmortem is. Whenever there’s a disaster, a team of experts come in and they try to figure out what went wrong. Well, in the pre-mortem, Kahneman claimed you look ahead and you try to figure out all the things that could go wrong, and then you try to figure out what you can do to minimise the damage.
“There are some things we can do in the form of a pre-mortem. Some of them are obvious, so i’ll talk about the not so obvious ones. Remember, when you’re under stress, the brain releases cortisol. Cortisol is toxic, and it causes cloudy thinking. Part of the practice of the pre-mortem is to recognise that under stress you’re not going to be at your best, and you should put systems in place.
“And there’s perhaps no more stressful a situation than when you’re confronted with a medical decision to make. As such, I’m going to talk about a very particular medical condition. But this stands as a proxy for all kinds of medical decision-making, and indeed for financial decision-making, and social decision-making.
“Suppose you go to your doctor and the doctor says, ‘I just got your lab work back, your cholesterol’s a little high.’ You know that high cholesterol is associated with an increased risk of cardiovascular disease, heart attack and stroke. Now picture the doctor saying, ‘I’d like to give you a drug that will help you lower your cholesterol, a statin.’ You’ve probably heard of statins, you know that they’re among the most widely prescribed drugs in the world today, so you’re thinking, ‘Yeah! Give me the statin.’
“But there’s a question you should ask at this point. It’s for the number needed to treat. Now, what is this, the NNT? It’s the number of people that need to take a drug or undergo a medical procedure before one person is helped. And you’re thinking, what kind of crazy statistic is that? The number should be one. My doctor wouldn’t prescribe something to me if it’s not going to help. But actually, medical practice doesn’t work that way. And it’s not the doctor’s fault, if it’s anybody’s fault, it’s the fault of scientists like me.
“We haven’t figured out the underlying mechanisms well enough. But GlaxoSmithKline estimates that 90 per cent of the drugs work in only 30 to 50 per cent of people. So the number needed to treat for the most widely prescribed statin, what do you suppose it is? How many people have to take it before one person is helped? 300. Now you’re probably thinking, ‘Well, OK, one in 300 chance of lowering my cholesterol. Why not, doc? Give me the prescription anyway.’ But you should ask at this point for another statistic, and that is, ‘Tell me about the side effects.’
“For this particular drug, the side effects occur in five per cent of the patients. And they include terrible things – debilitating muscle and joint pain, gastrointestinal distress – but now you’re thinking, ‘Five per cent, it’s not very likely it’ll happen to me, I’ll still take the drug.’ But think about how you’re going to work through this ahead of time, so you don’t have to manufacture the chain of reasoning on the spot. Some 300 people take the drug, right? One person’s helped, five per cent of those 300 have side effects, that’s 15 people. You’re 15 times more likely to be harmed by the drug than you are to be helped by the drug.
“For the most widely performed surgery on men over the age of 50, removal of the prostate for cancer, the number needed to treat is 49. And the side effects in that case occur in 50 per cent of the patients. They include impotence, erectile dysfunction, urinary incontinence, rectal tearing, fecal incontinence. And if you’re lucky, and you’re one of the 50 per cent who has these, they’ll only last for a year or two.”
So the idea of the pre-mortem is to think ahead of time to the questions that you might be able to ask that will push the conversation forward.
“Our brain under stress releases cortisol, and one of the things that happens at that moment is a whole bunch of systems shut down,” he said. “There’s an evolutionary reason for this. Face-to-face with a predator, you don’t need your digestive system, or your libido, or your immune system, because if your body is expending metabolism on those things and you don’t react quickly, you might become the lion’s lunch, and then none of those things matter. Unfortunately, one of the things that goes out the window during those times of stress is rational, logical thinking, as Kahneman and his colleagues have shown. So we need to train ourselves to think ahead to these kinds of situations.
“I think the important point here is recognizing that all of us are flawed. We all are going to fail now and then. The idea is to think ahead to what those failures might be, to put systems in place that will help minimise the damage, or to prevent the bad things from happening in the first place.”