Better Habits for Better Medicine

Doing a Good Thing Over and Over

Notes from a Family Meeting is a newsletter where I hope to join the curious conversations that hang about the intersections of health and the human condition. Poems and medical journals alike will join us in our explorations. If you want to come along with me, subscribe and every new edition of the newsletter goes directly to your inbox.

For those of you just joining, consider starting here to trace how I’ve been thinking about medicine and technology, a conversation I’ve been returning to time and again.

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What about the Tylenol?

I had previously shared that I didn’t think the forming of habits in the latter part of my training allowed some latent compassion to rise within me. I still think habits are important.

Before I get into that, let’s consider the Tylenol. In the early days of my internship in the hospital, I had choices to make: patients needed potassium supplemented, they needed home medications re-ordered, and some needed Tylenol for an ache. In one sense, I was just a lowly intern and someone was always looking over my shoulder. In another sense, I had the prescribing power now and I needed to make sure I got this right. So I reviewed patients’ medical histories, current medications, recent blood work. I was meticulous lest I fling someone into liver failure with a dose of Tylenol (the likes of which I myself would take without thinking).

This level of deliberation, as you might imagine, was taxing. Compound it across many decisions for many patients throughout the long hours of the day, and it’s exhausting. But this is what doctors do. I wanted to be a doctor so I white-knuckled my way through it. Eventually more urgent matters forced me to turn my attention from these mundane issues. The second year of residency allows for much more of that, as the intern is ordering all the Tylenol while the junior assistant resident (JAR) gets to scratch their chin at what medical scholarship says about their patient’s most pressing problems. But sometimes the JAR would need to order Tylenol too, and you know what? By the time I was a JAR, it wasn’t that bad. I ordered the medication and moved on without a second thought.

If we consciously considered every detail of every decision we had to make throughout the day, we’d be toast before lunch. Decision fatigue is no joke. This is an unpleasant feeling so most of us develop ways of avoiding that problem: we rely on biases, habits, and avoidance to ration our resolve. Success depends on your definition: it’s one thing to just survive the day without burning out, it’s another to reserve your strongest deliberative powers for the decisions that truly require them. The latter strategy requires a clear-eyed sense of the purpose not only of your work, but of your life, for you’ll often need to deliberate (at least I do) between competing priorities like work and family.

Tired with Deciding

The problem with ordering Tylenol during my intern year was that each time I did it, the decision taxed my capacity to make subsequent decisions well (or at all). This may be part of why I hate shopping: I want to stick to my budget and so I deliberate about the pros and cons of every possible purchase, making the whole endeavor a drag.

I don’t think I’m the only one who’s experienced decision fatigue in medicine. A few studies have looked into it. For example, antibiotic prescribing increases as the day wears on and more patients are added to the list of those who need to be seen. It’s not that those patients are sicker, but clinical decision-making slips down the easiest route (just give them the antibiotics). So, too, surgeons are less likely to recommend surgery for the patients seen later in the day.

This is a big problem. We want the care we offer to our patients to be equitable: if someone really needs antibiotics, they should get them, but if they don’t, they shouldn’t. The same for surgery. But here we see situations in which what patients get is dependent on factors totally irrelevant to their health needs. What’s to be done about it?

Well, one response to decision fatigue would be to eliminate the fatiguable elements. We could prop up or remove human decision-making. We could do this through triggers or hard stops in the electronic medical record (EMR): you must prescribe antibiotics to this person, or you must not. It’s unlikely an EMR would constrain clinician choice that boldly. Instead, it could nudge clinicians toward a preferred choice via defaults and algorithms. It might also require some justification for a clinician’s choice to make them think twice before ordering something or bypassing an alert.

In the future, we might envision a world in which autonomous algorithms provide something resembling health care. The machine would dispense medication to the patient for self-administration, or apply the treatment itself. No risk for decision fatigue there (at least not for the robot). The human clinician might just be there as a responsible party (i.e., someone to blame when something goes awry), or to gather information to feed the machine.

In our world, though, right now, medical evidence rapidly changes and education (particularly after training) is spotty, so nudges, algorithms, and order justifications in the EMR might be one of the better means of directing clinician attention and activity toward an evidenced-based decision. Whether it’s the right decision is another matter, for that requires taking the evidence and applying it to the unique person in front of you. Machines won’t help you do that.

If we’ll have human clinicians for the foreseeable future, we might want to figure out human ways of managing our capacity to make good decisions while preserving our energy for other important activities. That’s why we have habits.

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Gustave Caillebotte. “The Parquet Planers.” 1876.

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Habits for Life

Early in my training, I would write down a template of the interview on a blank sheet of paper before psychiatric interviews. I must have done this dozens, maybe hundreds, of times. The template included spaces for the general story, the past history of mental illness, family relations, substance use, various categories of psychiatric symptoms, and so on. Eventually I was able to stop pre-writing the template. It was burned into my brain. As I spoke with a patient, and they offered some bit of information I would have normally asked about later in the interview, I’d jump to that part of the blank sheet of paper to write it down. This helped the interview to feel more conversational as I wasn’t rigidly adhering to the template structure to set the pace or order of the encounter. I still practice this way, even though the content of my interview is different as a palliative care physician. I just carry with me a blank sheet of paper, but anyone watching would see I write all over it, seemingly out of order. I’m following the template in my brain.

What I just described is a habit. These are helpful for learning, for focusing attention, and for doing the right thing.

For learning, Doug Lemov explains that “making common, everyday activities familiar enough that we can do them without having to think about them makes it easier for us to do them - and therefore more likely that we will - and means we can free our minds up to think more deeply while doing them.” My psychiatric interview template was valuable during training as I attempted to juggle a lot of new information and learn how to apply it in real time. I had to cover several domains with or without a template, so I was happy to avoid dedicating precious resources to remembering those domains in every single encounter. Instead I could try to remember what my psychotherapy supervisor told me about how to consider some particular dilemma.

That template also allowed me to focus my attention where I needed it. There’s so much information within the clinical encounter. Sorting out what’s relevant in the moment requires mental fortitude the likes of which I can only sustain for brief periods of time. The template provides a guide for those things that I suspect will need to be addressed every time I meet someone (and modified for when I see them again). This also flags for me those things off-template that require my careful deliberation, the stuff of actual clinical decision-making.

Doing the right thing isn’t always the result of deliberation; it can be built into habit too. I could look at my sheet of paper and see a hole where, in the course of our conversation, we neglected to talk about family structure. The template kept me from forgetting. It also allowed me to think about a differential diagnosis and treatment on the fly without stressing about how to collect important information. With that extra mind-margin, I could stop and empathize with a patient’s emotions without losing track of what else I needed to do in the encounter (the anxiety about which might inhibit genuine empathy).

From this we see that habits are:¹

1. …context-sensitive. I’m not following a template when I’m out to dinner with friends (but other habits are probably in play there).

2. …(nearly) effortless. Grabbing a piece of paper before each encounter isn’t at all difficult.

3. …effective. If they didn’t work, they wouldn’t become a habit.

Many habits aren’t chosen. Sometimes you wake up to discover your morning routine chose you instead. For anyone who’s tried to form a habit, you probably noticed it’s a bit of a challenge. If it’s a new habit, you’re stumbling through unknown, awkward territory. If you’re trying to replace an old habit, you’re up against something that’s hard to change by its very nature. You might be able to do this using sheer grit, but I can think of two ways to make it easier to do and sustain.

Think about a kid learning how to play basketball. If they want to play the game well, they’re going to shoot a lot of baskets. They don’t start out, if they’re smart, to make a habit of “playing basketball well” (too complex, too big). They start small. But starting small carries with it the challenge of drudgery. What keeps this poor kid going, shooting basket after basket? If it’s just them, a ball, and a hoop in the middle of nowhere, probably not much. They’ll find something else to do. But many kids have a community around them watching and playing the sport. They have professional players to admire. They learn the history of the game. In short, they inherit and participate in a tradition that helps them develop the habits of a basketball player.

This tradition, as well as the game itself, helps them develop motivation in addition to skill. It’s not just about shooting baskets, after all; each basket scores a point to win a game. Winning is a powerful motivator, but humans appreciate winning in different ways. Animals can be conditioned, machines can be programmed, but humans have a choice about how they’ll direct their desires. Surely there’s a difference between an athlete who plays just to win and an athlete who plays, in the words of Eric Liddell, to feel the pleasure of God. This internal motivation is critical to moral development, as I’ll get to in a moment.

First, though, a bad habit.

In addition to my handy template, I developed some habits that were less-than-helpful. Under the formative pressure of American billing rules, I was trained to perform more of a physical exam than was necessary. Someone comes in for a stuffy nose? They’ll get an abdominal exam anyway. Certain portions of the exam became rote. Practicing this way grated on me because it wasn’t for the patient’s good; it was meant to check some administrative box. So rather than cultivate an inner disposition oriented toward the “right thing” in the clinical encounter, this was a bureaucratic blow against my integrity as a clinician. It dis-integrated my capacity to act with a singular purpose toward my patients’ good.

But that bad habit revealed something. Remember I said that habits are effective. You might say that bad habits aren’t effective - they’re bad! But don’t let that judgment fool you. They are effective, or else they wouldn’t have become habits. Bad habits show what we really value and how we’re in some way self-deceived. I wanted to style myself as a patient-centered physician but in reality, I lacked the wherewithal, resolve, and courage to resist a system that demanded I behave in ways that weren’t helpful for my patients. I conceded because at least this wasn’t harmful. I examined far more abdomens and listened to far more hearts than necessary.

We wind up with bad habits because, over a period of time, doing this thing helped in some way. Someone might have a habit of avoiding looking at their bank account balance to reduce anxiety, or insulting their family to make themselves feel more important, or smoking to connect with others during their break. Habits work, even if they harm in other ways, or else they wouldn’t become and stay habits.² But that brings us to the importance of seeing habits in a broader habitat of life, not merely in a narrow behavioristic way.

Thankfully my habit of doing a full physical exam on every patient changed - not because I stood up for myself and my patients against the bureaucracy that demanded such silliness, but because the powers that be finally updated the billing rules. I’m just as much a subject of medical traditions as that aspiring basketball player is to their game. Now I can do the exam I think is most appropriate for a given complaint.

Two things about habits then:

1. Traditions, embodied in community, help to form and sustain habits. Habits then contribute to sustaining those traditions.

2. Habits form and shape internal dispositions as those internal dispositions form and shape habits.

Habits in the Bigger Picture

Let’s consider how my habit of using a template during clinical encounters fits into a broader understanding of moral formation (Shannon Vallor’s framework):

1. Moral habituation³

   1. I use the template over and over, nearly every time I meet with a patient.

2. Relational understanding

   1. I care about my patient.

   2. I owe my patient my best effort.

   3. I have time constraints and commitments to other patients so I can’t spend hours with one patient.

   4. The template gives me a structure to teach learners.

3. Reflective self-examination

   1. I know I work better when I off-load common tasks to a habit like this template.

   2. I know I think better if I have a structure through which to think.

4. Intentional self-direction of moral development

   1. By developing a template, I acknowledge certain things are worth templating and others are not.

   2. The template gives me a structure to refine my practice outside the clinical encounter.

5. Perceptual attention to moral salience

   1. I attend better to important facets of the clinical encounter when my mind isn’t tied up in figuring out where in the interview I should go.

   2. The template sears into my memory those things that I consider very important to assess.

   3. I’m free to attend to nuances of moral or emotional importance because my attention isn’t tied up in tracking the structure of the interview.

6. Prudential judgment

   1. I preserve my capacity to make important decisions by making a large portion of the interview (namely, its structure and content) effortless by way of a template.

7. Appropriate extension of moral concern

   1. Not everything important is on the template, but a lot of it is.

   2. Even if something isn’t on the template, having a template helps me stay oriented about how those other things will fit within the clinical encounter and serve the patient’s good.

Make no mistake, I didn’t think through this framework and then develop the habit of a templated clinical interview. What this does, though, is show how habits are intimately connected to the rest of one’s moral formation, and the rest of one’s moral formation shapes one’s habits. Maybe you, like me, will find it interesting to write in some part of your life using Vallor’s framework, starting anywhere on the wheel and continuing all the way ‘round. Thinking of it this way also helps teachers to consider the reasons why they want learners to learn certain habits. Is it to serve a bureaucratic need, or is it for the actual good of the learner (and thus, in medicine, the patient)?

This also highlights how a habit, divorced from the rest of one’s life, might not be a good habit. I could become so dependent on a template, so rigidly adherent to its application, that it detracts from other areas of my life and practice. Lonely habits are easily corrupted.

Decision fatigue is signals human frailty. We’re not perfect. One response to those imperfections is to make clinicians more like machines. But we can’t expunge our own humanity. When we try, we degrade the moral integrity of clinicians. When clinicians are dehumanized, medicine becomes dehumanizing for patients too. Habits also mitigate decision fatigue. That alone is not the definition of a good habit though. To suggest as much would be to treat clinicians like the machines they’re already expected to be. Cultivating efficient habits would be like oil to keep the machine running efficiently and quietly. Just like oil in a car, though, it wouldn’t have any say on where the car actually goes. This is not the hallmark of a good habit. Good habits are oriented toward a particular good purpose. Habits are shaped by and shape good work and a good life. When we see them that way, we situate the work of clinicians in human-sized context that honors every person’s need for meaning and community.

1. I found this summary of a habit in Kent Dunnington’s fantastic book, Addiction and Virtue.

2. The disease model of addiction, as discussed by Dunnington in his book, might have us believe that people are captured by their neurochemistry and that their bad habits serve no greater function. Not so, argues Dunnington: “Addiction provides a response to the underwhelming life of boredom that plagues the bourgeois in its leisure time by making one thing matter. And addiction provides a response to the overwhelming life of boredom that plagues the working class with fragmented and compartmentalized striving by making one thing matter. For those who are bored with nothing to do, addiction stimulates by entangling and consuming; for those who are bored with too much to do, addiction disburdens by simplifying and clarifying.”

3. Vallor explains that a habit is a “moral habit” if it’s marked by three criteria: “the habituated action is done for motivating reasons … the action is normatively valued as positive, such that there is a (defeasible) expectation that I should perform it in the relevant situation(s) … the action pattern shapes, and continues to shape, my cognitive and emotional states in a manner conducive to the broader practice of moral self-cultivation.” I think using my template for each clinical encounter can be called a moral habit.