I sometimes think about the day to day life my parents experienced in the 1950’s through 1970’s when they were raising children and compare them to my own experience. A cost of living that I saw them experience would include plumbing repairs or for example, the installation of a dishwasher—they hired plumbers for this work. My experience has been different. The presence of the web has allowed me to consider home repairs that would have confounded my parents. Watching a Youtube video on how to install a dishwasher makes it quite doable and in our case, when taking the old one out, we sorted that the original installation (by our contractor) was not done correctly. Victory, knowledge, and money in the bank!
There is a cost. I have installed three ceiling fans; I swear each time, I will not do another. Likewise under the sink plumbing repairs, and even the simplest carpentry. But the default remains, “Should I try to do this on my own?”
And then there are gutter cleanings and repairs………on ladders........
Watching a process done on video is useful, but can set you up for failure; you don’t know what you don’t know. An example: looking at the internet documents brought in by patients who have no background in science regarding a condition they may or may not have is a daunting experience, especially if in finding the documents, they have a Eureka moment. That explains everything. Or not. The patient now has sunk cost into his/her research and the trained doctor has their work cut out for them, both coming to an accurate diagnosis and then, selling it to someone with an anchored position.
Creatively thinking problems through helps prevent failures. It is easier said than done, especially if your problem solving skills are not tested very often.
Use it or lose it—-problem solving, that is. How many of us have a quick answer to a problem identified in the news but never think it through in detail or consider the many likely reactions to that first, “solution?”
As a seventh grader, I was great at memorizing things and with this, mostly did well on tests. Math was an exception that with time helped me adapt and develop some problem solving. Chess presents an altogether different set of problems for which experience, being organized, as well as creative is essential for success. It was in middle school I first encountered the puzzle of nine dots set in a three by three symmetrical orientation with the task to connect all the dots without lifting the pencil in no more than four strokes. I worked on this for some time but did solve it by thinking, literally, “out of the box.” It was a revelatory moment for me; I was elated at solving this. I actually solved something that did not just come to me and it opened up a world of possible solutions going forward.
In tenth grade English, my teacher sought out a designated projectionist for the year, and I, being very self-conscious about being a nerd, cut up in class as she tried to find a candidate. She found one and then designated me, as a form of punishment, to being the manager of the quarterly purchase of books that would be offered to the class. There was no work for this up front and I took my punishment in stride. The Scholastic Book Club offerings were presented in the Fall. I took on the role of accountant and manager of orders. The books were affordable and were relevant to our literature class. If one bought 5 books, a free one was then made available. Very few people ordered five books. I realized as I started organizing the order, that the company would give a free book for every five in the total order that was made up of thirty students. I suddenly had an epiphany. I could get the books I wanted for free. I could take the money from all the students, order some of those ordered books for free, and pocket money. I could help students with a small orders for lack of money with an option to get a book on the house. As the year went on, I used all of these options. My friend Bruce, when he understood that my punishment for acting up in class had led to a larger personal library, some extra spending money, and some charitable activity gave me credit for having used my brain. Like the nine dot puzzle, I felt creative and that I had achieved something practical though in this case, the moral implications of my choices weighed on me a bit; what was the best ethical option and did I ever come to terms with that?
No, I did not.
My college and post graduate careers would only rarely challenge me to be truly creative. Often this would fall outside of the realm of formal studies. Could I get the MG started? How could I most affordably make furniture that could be easily broken down and stored? Where would I get the best post doctoral training? I went nuts trying to critique the flaws in published science experiments and was terrible at it.
Trial and error is a fine method for personal learning, clunky as it is. As I progressed with my career, I often worked on teams and so had the advantage of an exchange of ideas quite different from any personal attempts at creativity. For example, when on call and needing advice, I would call the resident the year above me (and who was commonly sound asleep). I would present the case and we would come to a conclusion about what was wrong and next steps managing that, together. One morning as I reviewed a case with my fellow residents, the advice giver denied giving me the advice I had used. Lesson learned—with him, I would not start a medical discussion when on call until he was awake enough to solve a simple math problem, like making change for a 63 cent charge paid with a five dollar bill. More commonly we doctors would share experience, usually at lunch, and there was an opportunity to both learn and shine. I found that having a patient dilemma outlined to me by the attending doctor found me much more creative in my consideration for possible solutions and next steps than when it was my patient and I was the one presenting. My cases biased me and rendered me in a sense, blind.
While working as a medical director, one task I had was sorting out system failures. One interesting case involved the critical thinking of other doctors. For example, there was a woman in rural Washington who had a leaking brain aneurism which once diagnosed, required urgent transportation to a neurosurgeon in Seattle. She was hospitalized and underwent a major brain surgery. Her post operative course was stormy and six weeks after surgery, when she was coughing more than expected, a chest x-ray was ordered. She had metastatic lung cancer. The neurosurgeon was incensed; this X-ray should have been done and part of the contextual information used when evaluating the patient for surgery which in this case, might not have been performed if she had been known to have an incurable cancer that was advanced. He apparently did not think this pre-operative assessment was his responsibility. The family and urgent care doctors were clear that in the setting of this woman’s emergency, it seemed like delaying her for a pre operative chest x ray was not a primary focus of their care. As an administrator of systems with doctors, it was common for my peers to speak of, “herding cats.” Getting agreement from doctors who saw things with a unique point of view and sense of responsibility was no small thing. I find the value of teamwork is dependent on motivation, skill, and orientation to an agreement of what the problem to be solved actually is. No one ever gets it right every time. Teams that do this well are the envy of the rest of us.
My personal victory in this light: I had an affable late-middle aged man who was working less and less because of a problem with mobility. I had initiated a series of tests that had me thinking he had a neurological problem. He subsequently saw a neurologist and neurosurgeon all of whom expressed his problem as being similar to one degenerative disease or another. After vigorous testing with images and nerve conduction testing, no one had a definitive answer, a treatment, or a next step. He came back to me after many months with disability papers in hand. I do not like filling out disability papers; in Washington State, they are legal documents that try to make black and white what is in reality an infinity of grey. Step one: what is the diagnosis? I did not have a diagnosis. I needed time after work to sort his form. He had had too many delays and insisted we do them then and there. I sought advice from my team: the neurologist was not working that day and the neurosurgeon was in surgery. I reviewed the chart notes. I watched him walk down the hall. It occurred to me that no one had ever gotten X-rays of his hips. I did that then and there; he had advanced arthritis in both hips; the X-rays looked like his hip joints were fused. Subsequently, I got pats on the back by the orthopedist (he had never seen such X-rays or a gait quite like his) and the neurosurgeon ("Great pick up! As I think about his gait, it does remind me of adults born with hip dislocations that never got treated!”). I never heard back from the neurologist. Motivation, skill, and orientation. ….I had counted too much on a team that had more expertise than I had. I had a practical problem solving his question of disability and it took an administrative task (shame on me!) on my part to rethink the actual problem to be solved.
I felt like a winner of the lottery, especially when three months later he reported being thrilled with his mobility and the ability to get back to work.
Medical systems across the board are broken and I come back to among other things, motivation, skill, and agreement on what the problem to be solved actually is. If you have examples of a system failure, let me know!
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