As the world becomes more connected, there are increasing opportunities for collections of disparate forces to come together in unexpected ways. This unpredictable uncertainty is exactly what anesthesiologists deal with every day.

In his new book, Vigilance: An Anesthesiologist’s Notes on Thriving in Uncertainty, Dr. Nabil Othman explains the skill set of his job and how they can be applied to larger societal issues and concerns.

On Author Hour today, he shares how cognitive psychology saves lives during surgery, how he uses economic theory on the job, and why anesthesiologists are facing extinction.

Jane Stogdill: Hi, Author Hour listeners. I’m here today with Dr. Nabil Othman, author of Vigilance: An Anesthesiologist’s Notes on Thriving in Uncertainty. Nabil, thank you so much for being with us today.

Dr. Nabil Othman: Thank you for having me.

Jane Stogdill: I have so many questions. First, tell me if I’ve got this right. You’re an anesthesiologist, who over the years has been thinking about how much the skill set of anesthesiology applies outside of medicine.

Dr. Nabil Othman: Correct.

Solving Situations without All the Facts

Jane Stogdill: Tell us more about how that is. What does that mean?

Dr. Nabil Othman: It all started when I was in my first year of residency and I had to explain to my parents what anesthesiologists actually do because it’s the only medical specialty where patients don’t participate in their care. I show up in the morning, say we’re going to go to the operating room, but you just sleep, then you wake up unharmed.

Patients don’t really know what happens then. In the operating room, there’s a blue drape between us and the surgeon. No one really knows, except for us. Much to my surprise, it was a scary thing, because a lot of bad things happened. Anesthesia mortality is actually very good. By good, I mean low. In the 1940s, the anesthesia mortality was about 600 deaths per million cases. For perspective, that means if I did 100 cases a month, someone would die from anesthesia about every one and a half years.

In 2015, it’s about between six and 10 cases per million anesthetics. That means that I would have to do 100 cases a month for about 190 years, in order for someone to die of an anesthesia complication.

What I realized is, anesthesiologists are very good at what they do. It’s crazy how good we’ve gotten over the last 80 years or so. The book is about that–how anesthesiologists got so good at what they do. A lot of the things we face in the operating room that no one else sees are large, unforeseen complications. For example, a patient suddenly starts bleeding, a patient’s airway collapses, the patient’s heart rate suddenly drops to zero. We have to figure out how to solve these situations without really knowing all the facts. Now during the COVID times in the 21st century, some of our methodologies can be transferred outside of the operating room as well.

Jane Stogdill: Interesting. The ability to improvise when faced with stakes, using your knowledge to adjust to a situation. Is that right?

Dr. Nabil Othman: Yeah. The question that the book answers is, with incomplete knowledge, going into an unknown situation, how do you deal with that? Because that’s what the century has been for a lot of people, including myself–we have no idea what’s going to happen tomorrow. I was just reading on Instagram earlier this morning that the crypto market has fallen 45% in value in a day. It’s just interesting because I think what we’re seeing is as our world has become more connected, what we see is larger fluctuations.

Recognizing Uncertainty

Jane Stogdill: Let’s back up then and let’s talk about what anesthesiologists do. The book is full of really interesting information about the field and the professionals in it. For example, you write about anesthesiologists’ ability to recognize uncertainty and how cognitive psychology plays into that to help save lives. Can you tell us about that?

Dr. Nabil Othman: Yeah. Psychologically, humans crave a black and white, straightforward narrative of the world. If we don’t have it, we like to create it. The most famous psychologist that I came across, was a guy named Daniel Kahneman, who won a Nobel Prize in Economics. It’s technically a Nobel Prize, but it’s the equivalent of the Nobel Prize in Economics for his work on decision-making under uncertain circumstances. What he found were all these very interesting patterns that anesthesiologists deal with.

One of the first is a premature closure. Whenever people face an uncertain, or an uncomfortable situation, oftentimes our first instinct is to jump to one conclusion, then hold on to it, even though we might be wrong. A lot of anesthesia is being able to be okay not knowing everything, being able to keep calm, and to sort through data as it comes through, even though your patient might be dying in front of you.

Jane Stogdill: Wow. Okay. Did you study psychology in your schooling to be trained?

Dr. Nabil Othman: No. This is, I think, why the book is valuable. It’s because doctors, for better or for worse, we’re very much focused on the science of medicine, which is not all the time, that.

I found as I went through medical school residency, there were all kinds of cool stuff that I think doctors intuitively understand, but that nobody has written down yet. I think having a basic understanding of psychology and a basic understanding of economics helped me immensely in my training. I’m also very lucky that I live in a time when you can literally just go to Amazon and buy all these books.

I think over the last eight years of my medical training, I read probably close to between 50 and 80 books. It was really cool. You can literally read the life’s work of a guy who won the Nobel Prize in Economics for 15 bucks. It’s very remarkable. Another example of this is Al Roth, who also won the Nobel Prize in Economics, he was the one who designed the kidney transplant matching system, that we use today.

Because people can’t buy organs, at least not in the United States, somebody has to either die or donate their organ. Al Roth designed the matching algorithm that matches kidneys to recipients. What I learned is there were all these crazy examples of psychology and economics and I started to read about them.

Black Swans

Jane Stogdill: And determined that the work you’re doing is an applicable soft skill. I don’t know that soft skill is the right word. I think we’re going to need to define a couple of terms for listeners, as we are making the jump from an anesthesiologist’s skillsets to wider societal applications. Tell us what you mean when you write about synergy and black swans.

Dr. Nabil Othman: I think that was what put everything together for me. I eventually stumbled upon a guy named Nassim Taleb, who is an investor, a mathematical–they call him a quant. What these people are is essentially, math geeks who use models to invest money in the stock market. So, he wrote a series of books about how a lot of the mathematical models of investing were actually incorrect. What I saw in his books was the same thing that I saw in the operating room–that people want to believe that the world works on a normal curve, that there’s cause and effect, that things are distributed symmetrically.

What Taleb wrote and what I saw in the operating room were actually the opposite. Which is that, how reality really works is that you have periods of nothing happening, followed by extreme fluctuations, a collapse, and then rebuilding.

What thought was in the operating room, is that you have the patient’s medical illnesses, the anesthetic medications, and what the surgeons do to them in terms of the operation. Those things combined in unforeseeable ways. What I call that is synergy, that you have, instead of this one plus one equals two model of reality, what I found that it’s actually, one plus one equals three. Is that things can combine in unforeseen combinations and cause unforeseen, huge fluctuations.

Nassim Taleb calls those things Black Swans. In the operating room, we would call them complications. These are weird things that happen that nobody can predict, that can cause a lot of damage. I saw those two things were the same.

Jane Stogdill: The idea is that each force, combines together in ways that can’t be predicted by the individual forces that comprise them.

Dr. Nabil Othman: Exactly. That begs the question, what do you do about these things? If it’s something that you can’t predict, you don’t know what it is. You don’t know when it’s going to happen. You know it can cause extreme damage or death. What do you do about these things?

Jane Stogdill: You learn to manage uncertainty.

Dr. Nabil Othman: Exactly. Yeah. That’s what the book is about, that as our world becomes more connected, synergy is going to increase. Because now we have people interacting all over the world in real-time.

I think it’s a very interesting time to be alive. Innovation is happening everywhere, from social media, business, medicine. Everything is changing so fast. While that’s great, a side effect of that is these black swan events, right? Crypto drops 45% in a day. These are crazy fluctuations. Or Elon Musk tweets about those Dogecoin and suddenly, it’s worth billions of dollars. Everything is, now, combining and these unforeseen, weird events. No one really knows what’s going to happen, and it can’t be predicted.

Jane Stogdill: Okay. I feel like, an instinct people would have is to say, “Well, we have to figure out how the synergy is happening that’s leading to these events.” Certainly, that’s advisable. Your point, it sounds like is, we may not know that for quite some time. What we can deal with right now is the uncertainty and learn how to manage it.

Dr. Nabil Othman: Yeah. That’s the thing, is sometimes with these with Black Swan events, and you will never know why they happened. Whereas there are several instances in my book where I write about some of the bad things that have happened to me as a doctor. Patients have come within seconds of dying. I watched people almost died literally in front of me, and I dealt with a situation. The reality is, I can’t go back and figure out why. You can’t. That’s not how life works.

That’s the reality, these bad things are going to happen, which is okay. Sometimes you just don’t know. You just can’t know. Then the question is when this thing is happening, what do you do about it? That’s what the book is about. How do you deal with something that you can’t predict, you can’t understand, and you don’t know when it’s going to happen?

Tools in the Toolbox

Jane Stogdill: Let’s get into that then. What are some of the tools in an anesthesiologist’s toolbox to approach this situation?

Dr. Nabil Othman: What I would say to that is, the first thing you should do is identify how much uncertainty is present in the situation. Because if you already know the cause, you’d have to act quickly. Part of the battle is just knowing what is going wrong, and then it just being fast.

The second thing is when you don’t know what something is, the second best thing is to eliminate things that it’s not. There’s this example in my book, where this patient who we intubated, flipped and prone, which is face down, we couldn’t ventilate him. His lips turned blue, sat, went to zero. How can you not then ventilate someone with a breathing tube in them? It’s crazy. It’s like, well what happened? This guy almost died when we flipped him over to do surgery on his back.

We were sitting there with the surgeon in the operating room. None of us had seen this before. We had a guy who couldn’t be ventilated when he was turned upside down. I’ve never even heard of that. None of us had. What we did was we eliminated all possible causes that we could think of. What we eventually thought was that he had an undiagnosed heart failure exacerbation. His lungs were very wet, so they couldn’t expand properly. He had symptoms of it.

It turned out we were actually correct. We sent him to the ICU for a couple of days, gave him a medication to pee off all this extra fluid in his lungs, to come back to the operating room, and he did fine. I think, what we did by eliminating everything else, brought us closer to what the problem was.

Then the third thing is what I call saving the valuable parts. Whenever a system crashes, the first thing you should do is to save the essential parts. One of the parallels that I don’t forget is in medicine, we talk about chest compressions and CPR. There are also parallels to that in economics and business. Whenever an industry crashes, like a bank when you bail out the executives, what you’re doing is just allowing that system to continue and make mistakes.

If I was in charge of it, what I would do as an anesthesiologist is take all of the workers and give them a year’s salary, and then fire all the administrators, and then let new entrepreneurs enter the market. That what you want to save. You want to save the machinery of the system. There are different ways that doctors deal with life-threatening situations, that I think are applicable outside of medicine.

Jane Stogdill: Thank you for those examples. You write that anesthesiologists are going extinct.

Dr. Nabil Othman: Yeah. It’s a complicated issue, but we just haven’t trained enough of us for the future. There are two main reasons for it. One, doctors themselves did not advocate for more residency spots. What a lot of people don’t know about anesthesiologists and doctors as well, is that it takes a very long time to train us. You have to do four years of an undergraduate degree to get into a medical school, then four years of medical school. Then three to seven years of residency. Residency is called residency because doctors used to live in the hospital.

Now, our hours in residency are limited to only 80 per week, which sounds crazy, but it was a huge win. I wouldn’t say, “Oh, I don’t have to work 100 hours a week anymore. This is great.” Doing it, supporting trainees through that process is expensive. I think the previous generation of doctors did not advocate for expanding residency programs to keep up with healthcare demands, or with the increasing population. That was really what started the issue, is doctors didn’t advocate for the next generation of doctors.

What’s happening is that now that we have so much healthcare demand and all this infrastructure and people, training doctors takes about a decade, at a minimum. You can’t just snap your fingers and make more of us.

However, what we are seeing happening now is that non-physician providers are increasingly being utilized. These are nurse practitioners, physician assistants, nurse anesthetists, nurse midwives. They’re now being given the responsibilities of doctors. These groups are now lobbying state governments for independent practice rights, even though they only had 1/10th to 1/20th of the training physicians do. Doctors have dug their own grave in a way, right? We didn’t train enough of us and now, there really is no easy solution.

Because these non-physician providers are so easy to train, that they’re just multiplying uncontrollably. How do you train more doctors if we’re being crowded out? It’s tough because doctors created this problem. Now it’s up to our new generation of doctors to fix it.

Jane Stogdill: Sounds like some uncertainty about the anesthesiologist’s skill set.

Dr. Nabil Othman: Yeah. Yeah. It’s not all bad. For us, especially nurse anesthetists are not inherently bad. The problem is when they think that they can be independent when they lack the expertise to do so.

Jane Stogdill: Which only comes from extensive training.

Dr. Nabil Othman: Exactly. Yeah, exactly. Trust me, I didn’t burn my entire 20s for fun. It’s like, doctors don’t do this stuff for fun, or to show off. Trust me. It is necessary. I think, looking back at my training, I think it was a perfect amount of time and I don’t think it could have been done safely with less time. I think that more time would have been a waste. The plus four was the perfect amount of time.

Jane Stogdill: There’s a lot to think about here. It’s been such an interesting conversation. I really appreciate it. Congratulations again on the book. Again, listeners, the book is Vigilance: An Anesthesiologist’s Notes on Thriving in Uncertainty. Nabil, in addition to reading the book, where can people go to learn more about you and your work?

Dr. Nabil Othman: I made a website called One word, spelled how it sounds. It’s based on this joke of how the ABCs of anesthesia are airway, breathing, circulation. That’s how we deal with emergencies–secure the airway, make sure blood is moving throughout the body. There are all these inside jokes among anesthesiologists about what they actually mean. They’d be like, put the tube in and go get a bagel and coffee, come downstairs and come back. That’s it. That’s where it’s from.

Jane Stogdill: Great. Thanks so much.

Dr. Nabil Othman: Thank you.