Adi Kumar Profile picture
Aug 3, 2022 15 tweets 6 min read Read on X
Surgical Decision Making Heuristics 🧵

I estimate a #neurosurgery on call doubles the usual 3000 decisions we make each day.

A "razor" cuts away what is unnecessary and simplifies decision making.

Here are 10 surgical razors to sharpen your decisions: Image
Occam’s Razor: (The OG Razor)

"Plurality must never be posited without necessity." If the patient with the enlarging CSDH has worsening falls, its likely the CSDH and not the new medicine they’ve started. Image
Hickam’s Dictum:

"A man can have as many diseases as he damn well pleases.” The patient with the enlarging CSDH may also have had a stroke causing their falls.

Occam's > Hickam's in my experience. Image
Barack Razor:

If you are 51% sure something is correct then make the decision. I’d rather make 100 decisions at 51% and get the 100 pieces of feedback vs 1 decision at 100% and 1 piece of feedback. Image
Reversibility Razor:

51% Razor is blunted by Reversibility. Some decisions can’t be reversed (opening a head). Irreversible decisions need a different % success rate, scenario specific. Image
Regression Razor:

The quality of your decisions will regress to your mean. You will be wrong. You will be right. Ignore the nadir/zenith of the sine curve. Focus on the midpoint instead. Image
Skin Razor:

When seeking opinion of others, give more weight to those with skin in the game over arm chair enthusiasts. Image
Feynman Razor:

If you can’t explain the reason for your decision to a child, you don’t understand it yourself. Image
The Silent Razor:

Reality is bent by silent evidence. You don’t see all the people who didn’t have a stroke from anticoagulants, but you curse them for causing ICH. What you see is not all that there is. Image
Urgent/Important Razor:

To decide if you need to decide, use urgent/important matrix. Urgent jobs demand your time and attention and are usually aligned with other’s goals. Important jobs are aligned with your own goals.

My YT video: Image
AI Razor:

Where possible use computer algorithms to confirm your decision making. If conflict in a naive AI go with human. If conflict in established AI go with computer. e.g. CRASH/IMPACT calculators for #TBI outcomes. Image
Bonus:

There is no failure only feedback. Reflect on the outcomes of your decisions and refine with time. Build algorithms where possible.
Bonus bonus:

There is a difference between being decisive and a good decision maker. Decisive people make decisions quickly. Good decisions lead to good outcomes.

Do not conflate the two, but aim for their unity.
TL/DR: Decision Making Razors

1-Occam's
2-Hickam's
3-Barack's
4-Reversibility
5-Regression
6-Skin in the Game
7-Feynman's
8-Silent
9-Urgent
10-AI
If you learnt anything from this please RT and decide 😛 to follow me for more @adi_kumar1

Check out my #youtube channel youtube.com/channel/UCA_AD… for similar.

Now go make better decisions.

#decisionmaking #AI #Algorithms #thinking

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More from @adi_kumar1

May 25
I have delivered over 10,000 hours of emergency neurosurgery care.

Here's advice to myself back in 2014. Image
1 - Don't Multitask

"Multi-tasking" is a word created by IBM in 1965. It was used to describe a computer, not a human.

Focus 100% on the task at hand then move on to the next.

Most of my mistakes have come when multi-tasking.
2 - Call for Help

If you think you need help, you need help. The small voice in your head means you should pick up the phone.

No one will say, "Why did you call me?!"

They will say, "Why didn't you call me?!"
Read 14 tweets
Feb 23
I have delivered over 10,000 hours of emergency neurosurgery care.

Advice to myself back in 2014 🧵 Image
1/ Call for Help

If you think you need help, you need help.

The small voice in your head means you should pick up the phone.

No one will say, "Why did you call me?!"

They will say, "Why didn't you call me?!"
2/ Urgent does not Equal Important

What is urgent for someone else, is not always important for you.

Urgent = time critical, for you or others.

Important = in keeping with your job of providing emergency care.

Focus on the urgent and important.

Use the matrix below. Image
Read 16 tweets
Feb 20
The over-confident surgeon causes harm by doing too much.

The under-confident surgeon causes harm by doing too little.

5 steps to building surgical confidence 🧵 Image
The old model of confidence said, "fake it 'til you make it".

To act confident and have absolute belief in your skills.

But the person who proclaims their confidence is anything but confident.
My weekly newsletter contains reflections on life as a neurosurgeon.

It'll teach you how to own your work and your life.

If you're interested, you can sign up here:

adi-kumar.ghost.io
Read 12 tweets
Feb 9
Why being a surgeon is a Loser's Game 🧵 Image
In the 1999 book, Extraordinary Tennis for the Ordinary Tennis Player, Simon Ramo explained the difference between amateur and professional tennis players.

It goes like this...
Amateur tennis is a Loser's Game. 80% of points are lost on unforced errors.

You win by avoiding errors and waiting for your opponent to make errors.

Professional tennis is a Winner's Game.

80% of points are won on incredible shots. You win by hitting incredible shots.
Read 13 tweets
Feb 6
The operating room is a hostile environment for surgeons.

38% of surgeons are in pain.

87% if using an endoscope.

A primer on surgical ergonomics to save you suffering 🧵 Image
Ergonomics is dedicated to understanding the interactions between humans and systems.

It focuses on making sure the environment fits the worker.

Physical, cognitive and organisational ergonomics create safe and efficient work environments.
There are 4 parts to physical ergonomics in the OR - personal equipment, theatre setup, posture and stretching.

Let's take a look at each.
Read 14 tweets
Dec 18, 2023
As a neurosurgeon I've taught about the Dunning-Kruger effect.

But it isn't real.

If you think it is, this will be an eye-opener.

If you haven't heard about it before, you will still learn how false ideas can be useful and true ideas can be harmful. 🧵 Image
Towards the end of surgical training, you are particularly dangerous.

If you've passed your final exams then you are doubly dangerous.

Your governing body has agreed that you have the knowledge to operate independently.
But that knowledge does not mean you have the experience of how best to use it.

One of the most difficult skills to learn is when not to operate, even if you think you can.
Read 21 tweets

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