Silence, Pride, & Behavioral Engineering

“We cannot change the human condition — but we can change the conditions in which humans work.”  — James Reason

This guy literally wrote the book on Human Error.

Good thing we came up with a new hashtag today.


If you can’t prevent them, trap them.

John Nance told us to never expect perfection. As soon as we demand that of ourselves, we become the enemy. We become unable to acknowledge failure… to ask for help… to ask for feedback… to ask for clarification.

And that last one is huge. Even on my best day, I will misunderstand 13.8% of what my colleagues are saying. (They call it the 12.5% rule, but it’s a rounded number just to keep it pretty.)

And that’s a lot. Because physicians talk a lot.

The average doctor only waits 15 seconds to interrupt a patient’s narrative.

The average professor only pauses for 3 seconds after asking: “so, any questions?”

If Yoda were here, he would say something like:

Pride is the path to the Dark Side. Pride leads to Arrogance, Arrogance leads to over-Speaking, over-Speaking leads to not-Listening, not-Listening leads to medical Mistakes, medical Mistakes lead to… Suffering. 

(Told ya)

I like my mom’s version even better. Shortly after I graduated college, she gave me the BEST career advice:

“Speak only when your words are more beautiful than the silence.”

In other words: when it’s useful.

To the patient. To my colleagues.

The rest of the time: shut up.

After all, the same 6 letters make up LISTEN & SILENT.

That’s why God gave us twice as many ears as mouths…

So where does Pride come in?

On the negative side, it’s when Cincinnati Children’s Hospital makes baseless claims about being the best Cystic Fibrosis treatment facility for decades. Or when an over-confident surgeon ignores the precautionary checklist and shuts down team communication. Or any time the patient becomes an Object, not the Subject.

On a more positive note, Pride also helps us celebrate 100 days in a row at Stanford Children’s Hospital without a serious adverse event. Or when the CANDOR program simultaneously reduces harmful events 60% and adds $60M to the annual operating budget. Or any time a patient life is saved through professional humility and double-checking.

One of my favorite authors calls this trait Epistemological Modesty.

Most of the great observers of humanity had it. Michael Oakeshott, Isaiah Berlin, Reinhold Niebuhr, Friedrich Hayek, George Orwell. That line of thinking is frequently referred to as the “crooked-timber school of public philosophy”. And it’s based on Immanuel Kant’s observation that “Out of the crooked timber of humanity no straight thing was ever made.”

The Wikipedia page for Cognitive Bias lists hundreds, and they’re all relevant to healthcare.

One of my favorites is another manifestation of pride: the Dunning-Kruger Effect.

AKA “illusory superiority”.

Humans mistakenly (and routinely) assume their skills to be greater than they are.

  • 86% of Americans think they are above-average drivers.
  • The bottom 10% of students who take the LSAT think they’re in the top two-thirds.
  • Congress has a <20% approval rating, while each individual Congressman is <80%.

We tend to drastically overestimate our own abilities, and place blame far away from ourselves.

Then what are prideful, mortal, carbon-based life-forms to do?

Engineer human factors.

There are entire hospital departments experimenting with behavioral biology (like at MedStar).

In the clinic, operating room, and ICU floor, our “illusory superiority” can be deadly.

Which is why premature closure happens so often.

And why hospitals suck at Root-Cause Analysis.

Organizational process is not easy. Daily safety huddles with HRO review, Good-Catch Mondays, 60 Seconds for Safety, 5:1 feedback, the SAFE toolbox — none of these are easy. And they usually go against the grain of human nature. They fly in the face of our pride and usually require us to be quiet.

Better get started.

It takes a lot of practice.

P.S. Save this video to watch later: the most famous Buddhist monk talking about happiness. It’s a habit. A muscle that must be exercised. Kinda like safety. It’s a habit, a muscle. Use it or lose it.