1. I love your reference to “antifragile simulation”. Not only is that what the service I work for has been trying to achieve for the last few years, but it’s one of the key messages in a talk I’m giving at an education conference on Monday. I note your observation that “we need to recognize that we cannot all be antifragile” – perhaps antifragility should be a trait selected for when recruiting to critical care specialties?

    Regarding simulation, and the Tyson factor – this is a line from my talk: “As educators we need to face these realities if our teaching is to be effective. It can be a challenging balance to strike – we don’t want to break the learner, but it’s disingenuous to go out of your way to remove all discomfort from a learning experience that is supposed to prepare them to deal with a very uncomfortable situation!”

    Thanks for a thought provoking post. I’ll have to read the book. I loved Taleb’s Back Swan book, which I read a few weeks before the GFC!


  2. I’m glad to see this discussion of Antifragile here. I enjoyed the book and thought that most of it did apply to emergency medicine and critical care, in one way or another.

    Taleb’s discussion of medical iatrogenics seems to me most directly applicable. My short version is: if the patient is not sick, be very reluctant to take risks (give meds, do procedures, etc.) If the patient is sick, be aggressive! In the sick patient, the risk of iatrogenic injury is small relative to the risk of decompensation and death if you do nothing.

    As I read this section of the book I kept thinking about Scott’s discussion of errors of commission vs omission. In the not-sick patient, I prefer that my errors (if any) are omissions. In sick patients if I’m going to err I prefer that they be errors of commission.

    We already vaguely know this, but Taleb’s discussion of the concepts helped me to see them in a much clearer way.

    To get a sense of Taleb’s approach in Antifragile, skip the intro math and read the excerpt on the last half of the last page: http://www.fooledbyrandomness.com/medconvex

  3. As much as I love reading about/listening to all the latest stuff in EM and critical care (despite that I won’t be able to use it in 5+ years!) – these posts on mindset, decision making, stress conditioning etc are really inspiring.

    Reading posts like this brings me back to our first simulation experiences, when we were really new at the clinical stuff. Taking on the role as team leader because everything was just chaos, directing people and keeping track of everything. Realizing that “hey, maybe I’m good at this”, despite my initial thoughts about myself when I started med school.

    In Sweden emergency medicine isn’t even a core specialty (it will hopefully be next year), so most supervisors at the ED I’ve had at our hospital aren’t the least interested in EM – it’s just a minor part of their position in internal medicine, surgery or orthopedics. Needless to say it’s really hard to find role models. That’s why I love these posts and all the comments, it’s like having virtual role models and food for thought for a starving student.

    Though with my attention span, I’ll hope for a Swedish translation of the book… 🙂

  4. Great post! I agree that in simulation we have that permission to fail and the consequence is not real. Where I work we simulate in front of our peers and record the simulation so that we can review and learn and that part is beneficial. For most, simulation is stressful but quite different than what is required for context as mentioned above. The challenge, as an educator and preceptor, is to recreate that stressful environment that further promotes failure and that ability to learn from that failure.

  5. Very nice blog entry. I look forward to meeting you at SMACC (George, Cliff, and the rest of you!!).

    Teaching Antifragility will require some experimentation on our part–that is the great news of the FOAM community.

    I have a couple thoughts about this, let me just share one, and utilize it or run with it if you find it useful, let it pass if it does not fit the bill.

    Let me suggest that antifragility can be encouraged through teaching honesty to our trainees and ancillary staff.

    Honesty takes courage. Honesty can give the caregiver the courage to take up the knife without hesitation in a surgically inevitable airway, because that caregiver knows it is the right thing to do, even if everyone else around them wallows in denial. Honesty gives the caregiver the platform with which to properly inform, instruct and guide the patient, even when it is something the patient does not want to hear, or admit.

    Maybe this is too vague or sounds too simplistic, but from my own personal experience, honesty (with the patient) has been a principal element that has kept my rump out of the fire in 19 years of practice. If you hurt someone, you go to them respectfully and explain what happened. You explain how and why it caused the complication, and that you took it seriously and did everything you could to minimize its impact on them. And that you are sorry, you only want the best for them. That’s about it–it doesn’t take you off the hook—it opens the space for the patient to forgive you. Forgiveness takes you off the hook–both theirs, and yours.

    Just something to consider. Happy New Year everyone!!! Joy to the FOAM world!

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