How to stay calm when you know you'll be stressed | Daniel Levitin | TED

0:13 A few years ago, I broke into my own house.

0:16 I had just driven home, it was around midnight in the dead of Montreal winter,

0:20 I had been visiting my friend, Jeff, across town,

0:23 and the thermometer on the front porch read minus 40

0:26 degrees— and don't bother asking if that's Celsius or Fahrenheit,

0:30 minus 40 is where the two scales meet— it was very cold.

0:34 And as I stood on the front porch fumbling in my pockets,

0:37 I found I didn't have my keys.

0:40 In fact, I could see them through the window,

0:42 lying on the dining room table where I had left them.

0:45 So I quickly ran around and tried all the other doors and windows,

0:48 and they were locked tight.

0:50 I thought about calling a locksmith— at least

0:52 I had my cellphone, but at midnight,

0:54 it could take a while for a locksmith to show up, and it was cold.

1:00 I couldn't go back to my friend Jeff's house for the night

1:03 because I had an early flight to Europe the next morning,

1:05 and I needed to get my passport and my suitcase.

1:08 So, desperate and freezing cold,

1:10 I found a large rock and I broke through the basement window,

1:14 cleared out the shards of glass, I crawled through,

1:17 I found a piece of cardboard and taped it up over the opening,

1:21 figuring that in the morning,

1:22 on the way to the airport, I could call my contractor and ask him to fix it.

1:26 This was going to be expensive,

1:28 but probably no more expensive than a middle-of-the-night locksmith,

1:31 so I figured, under the circumstances, I was coming out even.

1:36 Now, I'm a neuroscientist by training and I know

1:40 a little bit about how the brain performs under stress.

1:43 It releases cortisol that raises your heart rate,

1:46 it modulates adrenaline levels and it clouds your thinking.

1:51 So the next morning, when I woke up on too little sleep,

1:55 worrying about the hole in the window,

1:58 and a mental note that I had to call my contractor,

2:01 and the freezing temperatures, and the meetings I had upcoming in Europe,

2:05 and, you know, with all the cortisol in my brain, my thinking was cloudy,

2:10 but I didn't know it was cloudy because my thinking was cloudy.

2:13 (Laughter) And it wasn't until I got to the airport check-in counter,

2:18 that I realized I didn't have my passport.

2:20 (Laughter) So I raced home in the snow and ice, 40 minutes,

2:26 got my passport, raced back to the airport, I made it just in time,

2:30 but they had given away my seat to someone else,

2:32 so I got stuck in the back of the plane,

2:35 next to the bathrooms, in a seat that wouldn't recline, on an eight-hour flight.

2:39 Well, I had a lot of time to think during those eight hours and no sleep.

2:43 (Laughter) And I started wondering, are there things that I can do,

2:47 systems that I can put into place, that will prevent bad things from happening?

2:51 Or at least if bad things happen,

2:53 will minimize the likelihood of it being a total catastrophe.

2:59 So I started thinking about that, but my thoughts

3:01 didn't crystallize until about a month later.

3:03 I was having dinner with my colleague, Danny Kahneman, the Nobel Prize winner,

3:07 and I somewhat embarrassedly told him about having broken my window,

3:10 and, you know, forgotten my passport, and Danny shared with me that he'd

3:15 been practicing something called prospective hindsight.

3:19 (Laughter) It's something that he had gotten from the psychologist Gary Klein,

3:24 who had written about it a few years before, also called the pre-mortem.

3:28 Now, you all know what the postmortem is.

3:30 Whenever there's a disaster,

3:31 a team of experts come in and they try to figure out what went wrong, right?

3:36 Well, in the pre-mortem, Danny explained,

3:38 you look ahead and you try to figure out all the things that could go wrong,

3:42 and then you try to figure out what

3:44 you can do to prevent those things from happening, or to minimize the damage.

3:48 So what I want to talk to you about today are some

3:52 of the things we can do in the form of a pre-mortem.

3:55 Some of them are obvious, some of them are not so obvious.

3:58 I'll start with the obvious ones.

3:59 Around the home, designate a place for things that are easily lost.

4:05 Now, this sounds like common sense, and it is,

4:09 but there's a lot of science to back this up,

4:12 based on the way our spatial memory works.

4:15 There's a structure in the brain called the hippocampus,

4:18 that evolved over tens of thousands of years,

4:21 to keep track of the locations of important things— where the well is,

4:26 where fish can be found, that stand of fruit trees,

4:30 where the friendly and enemy tribes live.

4:32 The hippocampus is the part of the brain

4:34 that in London taxicab drivers becomes enlarged.

4:38 It's the part of the brain that allows squirrels to find their nuts.

4:41 And if you're wondering, somebody actually did the experiment where they

4:45 cut off the olfactory sense of the squirrels,

4:47 and they could still find their nuts.

4:49 They weren't using smell, they were using the hippocampus,

4:52 this exquisitely evolved mechanism in the brain for finding things.

4:57 But it's really good for things that don't move around much,

5:01 not so good for things that move around.

5:03 So this is why we lose car keys and reading glasses and passports.

5:07 So in the home, designate a spot for your keys— a hook by the door,

5:11 maybe a decorative bowl.

5:13 For your passport, a particular drawer.

5:15 For your reading glasses, a particular table.

5:18 If you designate a spot and you're scrupulous about it,

5:21 your things will always be there when you look for them.

5:24 What about travel?

5:25 Take a cell phone picture of your credit cards, your driver's license,

5:29 your passport, mail it to yourself so it's in the cloud.

5:32 If these things are lost or stolen, you can facilitate replacement.

5:37 Now these are some rather obvious things.

5:39 Remember, when you're under stress, the brain releases cortisol.

5:43 Cortisol is toxic, and it causes cloudy thinking.

5:46 So part of the practice of the pre-mortem is to recognize

5:49 that under stress you're not going to be at your best,

5:53 and you should put systems in place.

5:55 And there's perhaps no more stressful a situation than

5:58 when you're confronted with a medical decision to make.

6:02 And at some point, all of us are going to be in that position,

6:05 where we have to make a very important decision about

6:08 the future of our medical care or that of a loved one,

6:11 to help them with a decision.

6:12 And so I want to talk about that.

6:14 And I'm going to talk about a very particular medical condition.

6:17 But this stands as a proxy for all kinds of medical decision-making,

6:21 and indeed for financial decision-making,

6:23 and social decision-making— any kind of decision you have to make

6:27 that would benefit from a rational assessment of the facts.

6:31 So suppose you go to your doctor and the doctor says,

6:34 "I just got your lab work back, your cholesterol's a little high." Now,

6:39 you all know that high cholesterol is

6:42 associated with an increased risk of cardiovascular disease,

6:46 heart attack, stroke.

6:47 And so you're thinking having high cholesterol isn't the best thing,

6:51 and so the doctor says, "You know, I'd like to give you

6:53 a drug that will help you lower your cholesterol,

6:56 a statin." And you've probably heard of statins,

6:59 you know that they're among the most widely prescribed drugs in the world today,

7:03 you probably even know people who take them.

7:05 And so you're thinking, "Yeah!

7:06 Give me the statin." But there's a question you should ask at this point,

7:10 a statistic you should ask for that most doctors don't like talking about,

7:14 and pharmaceutical companies like talking about even less.

7:18 It's for the number needed to treat.

7:21 Now, what is this, the NNT?

7:23 It's the number of people that need to take a drug

7:26 or undergo a surgery or any medical procedure before one person is helped.

7:31 And you're thinking, what kind of crazy statistic is that?

7:34 The number should be one.

7:35 My doctor wouldn't prescribe something to me if it's not going to help.

7:39 But actually, medical practice doesn't work that way.

7:41 And it's not the doctor's fault, if it's anybody's fault,

7:44 it's the fault of scientists like me.

7:46 We haven't figured out the underlying mechanisms well enough.

7:48 But GlaxoSmithKline estimates that 90 percent of the drugs

7:53 work in only 30 to 50 percent of the people.

7:56 So the number needed to treat for the most widely prescribed statin,

8:00 what do you suppose it is?

8:02 How many people have to take it before one person is helped?

8:05 300.

8:07 This is according to research by research

8:09 practitioners Jerome Groopman and Pamela Hartzband,

8:12 independently confirmed by Bloomberg.com.

8:14 I ran through the numbers myself.

8:17 300 people have to take the drug for a year before one heart attack,

8:21 stroke or other adverse event is prevented.

8:24 Now you're probably thinking, "Well, OK,

8:26 one in 300 chance of lowering my cholesterol.

8:28 Why not, doc?

8:29 Give me the prescription anyway." But you

8:31 should ask at this point for another statistic,

8:33 and that is, "Tell me about the side effects." Right?

8:36 So for this particular drug,

8:37 the side effects occur in five percent of the patients.

8:41 And they include terrible things— debilitating muscle and joint pain,

8:46 gastrointestinal distress— but now you're thinking, "Five percent,

8:49 not very likely it's going to happen to me,

8:51 I'll still take the drug." But wait a minute.

8:54 Remember under stress you're not thinking clearly.

8:56 So think about how you're going to work through this ahead of time,

8:59 so you don't have to manufacture the chain of reasoning on the spot.

9:02 300 people take the drug, right?

9:04 One person's helped,

9:05 five percent of those 300 have side effects, that's 15 people.

9:09 You're 15 times more likely to be harmed by the drug

9:13 than you are to be helped by the drug.

9:16 Now, I'm not saying whether you should take the statin or not.

9:19 I'm just saying you should have this conversation with your doctor.

9:22 Medical ethics requires it, it's part of the principle of informed consent.

9:26 You have the right to have access to this kind of information

9:29 to begin the conversation about whether you want to take the risks or not.

9:33 Now you might be thinking I've pulled

9:35 this number out of the air for shock value,

9:37 but in fact it's rather typical, this number needed to treat.

9:40 For the most widely performed surgery on men over the age of 50,

9:45 removal of the prostate for cancer, the number needed to treat is 49.

9:50 That's right, 49 surgeries are done for every one person who's helped.

9:54 And the side effects in that case occur in 50 percent of the patients.

9:59 They include impotence, erectile dysfunction,

10:01 urinary incontinence, rectal tearing, fecal incontinence.

10:06 And if you're lucky, and you're one of the 50 percent who has

10:09 these, they'll only last for a year or two.

10:12 So the idea of the pre-mortem is to think ahead of time to the questions

10:17 that you might be able to ask that will push the conversation forward.

10:21 You don't want to have to manufacture all of this on the spot.

10:24 And you also want to think about things like quality of life.

10:27 Because you have a choice oftentimes,

10:29 do you I want a shorter life that's pain-free,

10:31 or a longer life that might have a great deal of pain towards the end?

10:35 These are things to talk about and think about now,

10:37 with your family and your loved ones.

10:39 You might change your mind in the heat of the moment,

10:42 but at least you're practiced with this kind of thinking.

10:45 Remember, our brain under stress releases cortisol,

10:49 and one of the things that happens at that moment

10:52 is a whole bunch on systems shut down.

10:54 There's an evolutionary reason for this.

10:56 Face-to-face with a predator, you don't need your digestive system,

10:59 or your libido, or your immune system,

11:02 because if you're body is expending metabolism

11:04 on those things and you don't react quickly,

11:07 you might become the lion's lunch, and then none of those things matter.

11:11 Unfortunately, one of the things that goes out

11:14 the window during those times of stress is rational,

11:17 logical thinking, as Danny Kahneman and his colleagues have shown.

11:22 So we need to train ourselves to think ahead to these kinds of situations.

11:27 I think the important point here is recognizing that all of us are flawed.

11:33 We all are going to fail now and then.

11:36 The idea is to think ahead to what those failures might be,

11:40 to put systems in place that will help minimize the damage,

11:44 or to prevent the bad things from happening in the first place.

11:48 Getting back to that snowy night in Montreal, when I got back from my trip,

11:52 I had my contractor install a combination lock next to the door,

11:56 with a key to the front door in it, an easy to remember combination.

12:00 And I have to admit, I still have piles of mail that haven't been sorted,

12:04 and piles of emails that I haven't gone through.

12:07 So I'm not completely organized,

12:09 but I see organization as a gradual process, and I'm getting there.

12:13 Thank you very much.

12:14 (Applause)