even if you’re certain nothing bad could ever happen on you.32
How Not to Spot Aspirin Poisoning
It’s not just bad news that we have a tendency to unwittingly dismiss.
Take what happened to Dr Harrison J. Alter, then an emergency-room physician in Tuba City, Arizona, a small town in the Painted Desert just a sixty-mile drive from the Grand Canyon National Park.33
Alter isn’t your usual medical-school type. Born in Chicago, he attended the prestigious Francis Parker prep school before heading off to Brown to get an undergraduate degree in comparative literature and art history.34 He still lists reading among his interests, along with his children,35 but his area of professional expertise is medical, and in particular the hullabaloo of the emergency room.
Alter’s emergency room was a focal point of medical care for the Navajo Nation, and during the winter of 2003 he took a routine admission in: Blanche Begaye, a Navajo woman in her sixties. Blanche explained that she was having trouble breathing. At first she just thought she just had ‘a bad head cold’, and did what most of us would do: she drank lots of orange juice and tea, popped a few aspirin, and expected that to be the end of it. But it wasn’t. She got worse.
Dr Alter knew that Blanche worked in a grocery store on the reservation. He also knew that something was amiss within her community. Lately, his emergency room had been full of people with similar symptoms to Blanche’s. He’d diagnosed them all with viral pneumonia, a nasty lung infection that can knock you out for weeks. Alter couldn’t help noticing that Blanche had quite similar symptoms.
After Blanche was admitted, Alter went through the normal procedures. First came the observations. He noticed that her respiratory rate was almost twice normal. On top of that, she had a low-grade fever – her temperature was up, but it wasn’t through the roof. Next came the tests – in particular, the bloods. The first thing he checked was the white-blood-cell count, a typical marker of infection. It wasn’t actually raised, but her blood chemistry showed that the acid-base balance of her blood was now weighted towards acid, a red flag for a major infection.
Alter totted up the signs, and plumped for a diagnosis of ‘subclinical viral pneumonia’. Mrs Begaye’s X-ray showed that she didn’t have the classic white streaks across her lungs, but he reasoned that this was because her illness was in its early stages. From here on it was routine: admit her, work on getting that fever down, and keep an eye on her heart rate. He had her hooked up to some intravenous fluids and medicine, and put her under observation. Then he moved on to the next bed.
Case closed.
Or so he thought.
A few minutes after Alter had begun evaluating his next patient, the junior doctor to whom he had passed Mrs Begaye’s case attracted his attention. Thankfully for Mrs Begaye, this wasn’t the type of subordinate who was too scared to speak up when he disagreed with his boss. ‘That’s not a case of viral pneumonia,’ he told Alter. ‘She has aspirin toxicity.’
How could Dr Alter, who had not only studied medicine at the prestigious University of California at Berkeley, but following his residency had gone to the University of Washington in Seattle to study medical decision-making, have got his diagnosis so wrong? As the always open-to-learning doctor later reflected, ‘Aspirin poisoning, bread-and-butter toxicology … She was an absolutely classic case – the rapid breathing, the shift in her blood electrolytes … and I missed it.’
It wasn’t that he hadn’t been asking the right questions, or conducting the right tests to get to this diagnosis. He had.
Dr Alter had all the information he needed to make the correct diagnosis right in front of him. The trouble was that even though the information had been plain to see, he hadn’t taken it in. And he hadn’t taken it in because when he saw Mrs Begaye, what came to mind were all the recent cases of pneumonia he’d been seeing.
This meant that instead of treating her story as an independent one, and focusing on all the information she gave him, he had zoomed in on the symptoms that fitted the pneumonia diagnosis, and ignored or reasoned away the information that didn’t.
This is a common thinking error we are all prone to. In fact, it turns out that we actually get a dopamine rush when we find confirming data, similar to the one we get if we eat chocolate, have sex, or fall in love.36 Having jumped to a particular conclusion, we focus on information that supports it, and ignore everything that contradicts or doesn’t conform to our initial analysis. We’re especially prone to being overly swayed by what we’ve most recently seen. It’s as if once we’ve decided that the only danger we can face is tigers, even if we see a snake in the grass we don’t process that it could be a danger to us too.
That is what famously happened in 1940 when French intelligence, arguably the best service of its kind in the world at that time, made a catastrophic error. Having undertaken sophisticated analysis of German blitzkrieg tactics earlier that year, the intelligence service came to the conclusion that the brunt of the German attack would come through the plains of Belgium. Growing evidence that the Nazis were planning to invade through the Ardennes Forest instead was ignored, despite information gleaned on the pattern of German reconnaissance flights (which closely mirrored the later invasion route) and aerial photography of German pontoon-bridge construction in the area. Even ‘hard information’, it seems, will be sidelined unless it is received by open eyes and open minds.37
What should we take from all of this, from these stories and insights?
Well, if we are to make smarter decisions, we need to make sure that we are not overly swayed by what we’ve seen most recently, or by the information that’s most easily available, or by our initial assessment, or by what it is we most want to hear.
We should consciously practise being more observant. Take a raisin. Rub it between your hands. How does it feel? Look at it, examine its contours. Smell it. Lick it – how does it feel against your tongue?38 Practising mindfulness techniques like this helps us to get better at opening our eyes to what we might otherwise overlook.
We must also force ourselves to actively search for information that challenges our preconceived ideas.
We have to treat each new situation as independent, and each new piece of information as potentially game-changing.
And when making assessments, we must question not only whether things are as we think, but also what else they could possibly be.
We can do this on our own, but it’s often easier if we have someone who can help. Who could you deploy to help you interrogate your own ways of thinking, help force you to see everything in the jungle, not just what you’re most drawn to? So you don’t make the same kind of cognitive mistakes as Dr Alter, or Tali Sharot’s volunteers, or the French intelligence services. So you don’t get consumed by your confirmation dopamine buzz.
The head of one of Europe’s leading hedge funds – a fund that succeeds or fails on the basis of its analysts’ assessments of the industries and companies they decide to invest in – tells me that he sees one of his primary roles as that of ‘Challenger in Chief’, as the person who niggles his staff to focus not only on the evidence
