How to stay calm when you know you'll be stressed

My own house was broken into a few years ago. I had just returned from visiting my friend Jeff across town at midnight in the dead of Montreal winter. The thermometer on the front porch read minus 40 degrees, and no, that's not Celsius or Fahrenheit; that's where the two scales meet. It was freezing. And I realized I was missing my keys as I stood on the front porch, reaching into my pockets for them. In fact, I could see them through the window, lying on the dining room table where I had left them.

I hurried around and attempted all the other windows and doors, but they were securely locked. I considered calling a locksmith because, well, I had my phone, but it was cold and it could take some time for a locksmith to arrive at midnight. I had an early flight to Europe the following morning and had to get my passport and suitcase, so I was unable to spend the night at my friend Jeff's place. In desperation and extreme cold, I used a big rock to smash through the basement window.

I found a piece of cardboard and taped it over the opening after clearing out the glass shards. I did this because I thought that when I got to the airport in the morning, I could call my contractor and ask him to fix the opening. This would undoubtedly cost more than calling a locksmith in the middle of the night, but considering the situation, I believed I would come out ahead. I have a background in neuroscience, so I have some knowledge of how the brain functions under pressure. It causes the release of cortisol, which quickens heart rate.

It distorts your thoughts and modifies your adrenaline levels. So the following morning, after getting too little sleep, I was worried about the hole in the window, and I made a mental note to call my contractor. I was also worried about the freezing temperatures, and I had meetings in Europe. Plus, my brain was cloudy from all the cortisol I was taking, so I wasn't even aware that my thinking was cloudy. (Laughter) And I didn't realize I didn't have my passport until I got to the airport check-in counter.

(Laughter) So I hurried home in the snow and ice for forty minutes, got my passport, and hurried back to the airport. I arrived just in time, but my seat had been given away to someone else, so I was forced to spend the entire eight-hour flight in the back of the aircraft, in a seat that wouldn't recline. Well, I had a lot of time to think during those eight hours and no sleep. (Laughter) At that point, I began to wonder: Are there any actions or procedures I can implement to stop negative things from happening?

If bad things do happen, they will be less likely to be a complete disaster, at the very least. I began to consider that, but it took me until about a month for my ideas to really come together. During a dinner with my colleague, Nobel Prize winner Danny Kahneman, I confided in him about breaking my window and forgetting my passport. To my surprise, Danny informed me that he had been practicing a technique known as prospective hindsight. (Laughter) It's something he learned from Gary Klein, the psychologist.

who had written about it a few years before, also called the pre-mortem. By now, everyone is aware of what a postmortem is. Whenever there's a disaster, a team of experts come in and they try to figure out what went wrong, right? According to Danny, a pre-mortem entails planning ahead and identifying all potential problems before attempting to determine the best course of action to either minimize the harm or stop it from occurring. Thus, I would like to discuss with you today a few of the pre-mortem actions that we can take.

While some of them are readily apparent, others are not as much. I'll address the most evident ones first. Around the home, designate a place for things that are easily lost. This may seem like common sense, and it is, but there is a wealth of scientific evidence supporting it, based on the functioning of our spatial memory. The hippocampus is a structure in the brain that has developed over tens of thousands of years to remember the locations of significant objects, such as fruit trees, wells, and fish.

where the neighboring and hostile tribes reside. The area of the brain that enlarges in London taxicab drivers is the hippocampus. It's the area of the brain responsible for helping squirrels locate their nuts. And in case you were wondering, the experiment in which the squirrels' ability to smell was taken away was actually carried out, and the squirrels were still able to locate their nuts. Instead of utilizing scent, they were making use of the highly developed hippocampus, a part of the brain used for object recognition. However, it works really well for stationary objects,

unsuitable for objects that move. This explains why we misplace our passports, reading glasses, and car keys. Decide where you want your keys to be kept in your house; a decorative bowl or a hook by the door would work well. For your passport, a particular drawer. A specific table for your reading glasses. Your belongings will always be there when you look for them if you set aside a space and are meticulous about it. How about travel? Snap a photo of your passport, driver's license, credit cards, and other documents with your phone.

To ensure it is in the cloud, mail it to yourself. You can arrange for a replacement in the event that these items are lost or stolen. These are a few things that are pretty obvious now. Recall that the brain releases cortisol when you are under stress. Because cortisol is toxic, it impairs reasoning. Therefore, acknowledging that you won't function at your best under pressure and putting procedures in place are important parts of the pre-mortem process. Making a medical decision can be one of the most stressful situations one can find themselves in.

And eventually, we will all find ourselves in that situation where we must make a crucial choice regarding the course of our medical treatment.or that of a close relative, to assist them in making a choice. I would like to discuss that. And I'll be discussing a very specific medical issue. However, this serves as a stand-in for all forms of medical decision-making, as well as financial and social decisions, and any other kind of decision that would benefit from a logical analysis of the available information.

Let's say your doctor tells you, upon reviewing your lab results, that your cholesterol is a little elevated. As everyone is aware, having high cholesterol raises the risk of heart disease, stroke, and cardiovascular disease. Because of your growing belief that having high cholesterol is not a good thing, the doctor suggests that you take a statin, a medication that lowers cholesterol. Furthermore, it's likely that you are aware of statins, having been prescribed as one of the most common medications.

You most likely even know people who take them in today's world. You're probably thinking, "Yeah! Please give me the statin. However, at this point, there's a statistic you should ask for and a question you should ask that most doctors find uncomfortable discussing, and pharmaceutical companies find even less comfortable discussing. It is for the quantity that must be treated. What is this, the NNT, now? It's the quantity of patients who must take medication, have surgery, or receive any other medical treatment before even one is assisted. You may be wondering what kind of absurd statistic that is.

One should be the number. If it wouldn't help, my doctor wouldn't prescribe it to me. However, that is not how medical practice actually operates. Furthermore, if anyone is to blame, it's scientists like me; the doctor is not it. The underlying mechanisms remain poorly understood. However, 90 percent of medications, according to GlaxoSmithKline, only work in 30 to 50 percent of patients. What do you think the number required to treat for the most commonly prescribed statin is then?

How many people have to take it before one person is helped? 300. This is according to research by research practitioners Jerome Groopman and Pamela Hartzband, independently confirmed by Bloomberg.com. I ran through the numbers myself. 300 people have to take the drug for a year before one heart attack, stroke or other adverse event is prevented. 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." Right? So for this particular drug, the side effects occur in five percent of the patients. And they include terrible things -- debilitating muscle and joint pain, gastrointestinal distress -- but now you're thinking, "Five percent, not very likely it's going to happen to me, I'll still take the drug." But wait a minute. Remember under stress you're not thinking clearly. So 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.

Surely, 300 people use the drug? One person's helped, five percent of those 300 have side effects, that's 15 people. The likelihood that the drug will hurt you more than help you is fifteen times higher. I'm not advising you to take a statin at this point. All I'm saying is that you and your physician ought to discuss this. It is a requirement of medical ethics and is a component of the informed consent principle. It is your right to talk to someone about whether or not you want to take the risks by having access to this kind of information.

Now you might be thinking I've pulled this number out of the air for shock value, but in fact it's rather typical, this number needed to treat. 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. That's right, 49 surgeries are done for every one person who's helped. And the side effects in that case occur in 50 percent 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 percent 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. You don't want to have to manufacture all of this on the spot. And you also want to think about things like quality of life. Because you have a choice oftentimes, do you I want a shorter life that's pain-free, or a longer life that might have a great deal of pain towards the end?

These are things to talk about and think about now, with your family and your loved ones. You might change your mind in the heat of the moment, but at least you're practiced with this kind of thinking. Remember, our brain under stress releases cortisol, and one of the things that happens at that moment is a whole bunch on systems shut down. 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 you're 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 Danny 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 implement measures that will lessen the harm or stop the negative events from occurring in the first place.

Rewinding to that snowy night in Montreal, I had my contractor install a combination lock next to the door, which had an easy-to-remember combination and a key to the front door inside. Furthermore, I have to admit that I still have mountains of unsorted mail and unread emails. I therefore consider organization to be a process rather than a final state,

and I'm making progress. Many thanks for that. (Claps)