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By Folasade Akinola Published 21 days ago • 9 min read
Photo by Nik Shuliahin 💛💙 on Unsplash

Several years ago, I moved into my own home. It was around midnight in the dead of Montreal winter, and I had just driven home from visiting my friend, Jeff, across town.

The thermometer on the front porch read minus 40 degrees, and don't bother asking if that's Celsius or Fahrenheit; minus 40 is where the two scales meet. It was very cold. And as I stood on the front porch, rummaging in my pockets, I realized I didn't have my keys. In fact, I could see them through the window, still on the dining room table where I had left them. So I dashed around and tested all the other doors and windows, all of which were securely locked. I considered calling a locksmith because I had my cell phone, but at midnight, it could take a long time for a locksmith to arrive, and it was freezing.

I couldn't return to my friend Jeff's place for the night because I had an early departure to Europe the next morning and wanted to retrieve my passport and suitcase. So, desperate and cold, I found a large rock and broke through the basement window, clearing out the shards of glass, crawling through, finding a piece of cardboard and taping it over the opening, figuring that in the morning, on the way to the airport, I could call my contractor and ask him to fix it. This was going to be pricey, but probably not any more expensive than a middle-of-the-night locksmith, so I figured I'd come out even. I'm a neuroscientist by training, so I know a little about how the brain works under stress.

It produces cortisol, which boosts your heart rate, regulates adrenaline levels, and impairs your memory. So the next morning, when I awoke from too little sleep, I worried about the hole in the window and a mental note that I needed to call my contractor, the freezing temperatures, and the meetings I had planned in Europe, and, you know, with all the cortisol in my brain, my thinking was cloudy, but I didn't realize it was cloudy because my thinking was cloudy. It wasn't until I arrived at the airport check-in counter that I realized I wasn't carrying my passport. So I rushed home in the snow and ice for 40 minutes, got my passport, and raced back to the airport. I arrived just in time, but they had given away my seat to someone else, so I was trapped in the back of the plane, near the bathrooms, in a seat that wouldn't recline, on an eight-hour flight.

I had a lot of time to contemplate during those eight hours of no sleep. And I began to wonder whether there were things I could do or procedures I could implement to prevent awful things from happening. At the very least, if horrible things happen, the risk of a total disaster will be reduced. So I started thinking about it, but my ideas didn't come together until about a month later. I was having dinner with my colleague, and I somewhat embarrassedly told him about breaking my window and, you know, forgetting my passport, and he informed me that he'd been practicing something called prospective hindsight.

It was something he had learned from a psychologist, who had written about it a few years ago, and it was also known as the premortem.

You all know what a postmortem is. Whenever there is a calamity, a team of experts arrives to investigate what went wrong, correct?

He mentioned that during the pre-mortem, you look ahead and try to figure out all of the things that could go wrong, and then you try to find out what you can do to prevent or limit the damage. So, now I'd like to discuss some of the things we can do as part of a pre-mortem. Some are evident, while others are not as obvious.

I will begin with the obvious ones.

Make a designated area in your home for easily misplaced items.

This may appear to be basic sense, and it is, but there is plenty of science to back it up, based on how our spatial memory works. The hippocampus is a structure in the brain that evolved over tens of thousands of years to keep track of the locations of vital things such as wells, fish, fruit trees, and friendly and enemy tribes.

The hippocampus is a brain region that expands in London taxicab drivers. It's the area of the brain that helps squirrels find their nuts.

In case you're wondering, someone ran an experiment where they shut off the squirrels' smell sense and still found their nuts. They weren't using smell; instead, they were using the hippocampus, the brain's wonderfully designed system for finding objects. However, it works well for items that don't move much, and poorly for things that do. This is why we misplace our vehicle keys, reading glasses, and passports.

So, in your home, designate a space for your keys, such as a hook near the door or a lovely dish. One drawer is designated for your passport. A specific table to store your reading glasses. If you choose a location carefully, your belongings will always be there when you look.

How about travel?

Take a cell phone photo of your credit cards, driver's license, and passport and email it to yourself so it is saved in the cloud. If these items are lost or stolen, you can arrange for a replacement.

Now there are some really apparent points. Remember that when you're stressed, the brain releases cortisol. Cortisol is harmful and creates hazy thinking.

Therefore, part of the pre-mortem technique is to recognize that stress will lower your performance and implement procedures. And arguably, no situation is more stressful than having to make a medical decision. And, at some point, all of us will be in a position where we must make a critical decision regarding the future of our medical care or that of a loved one in order to assist them in making that decision. And so I'd like to discuss that. And I'm going to discuss a really specific medical condition.

However, this serves as a proxy for all types of medical decision-making, as well as financial and social decision-making—any type of decision that would benefit from a logical appraisal of the facts.

So, if you go to your doctor and he says,

"I just got your lab work back, your cholesterol's a little high."

You're all aware that excessive cholesterol increases the risk of cardiovascular disease, heart attack, and stroke.

So you're thinking that having high cholesterol isn't a good thing, and the doctor says,

"You know, I'd like to give you a statin that will help you lower your cholesterol."

And you've probably heard of statins; you know they're one of the most often prescribed drugs in the world today, and you probably know someone who uses them.

So you're thinking,


Give me the statins."

But there's one thing you should ask at this point:

a statistic that most doctors and pharmaceutical corporations dislike discussing. It is for the number of patients to be treated.

So, what is this, the NNT?

It refers to the number of people who must take a medicine, have surgery, or go through any other medical process before one person is helped. And you're wondering what kind of insane statistic that is. The number must be one. If something was ineffective, my doctor would not recommend it to me.

However, this is not how medical practice works. And it's not the doctor's fault; if anyone is to blame, it's scientists like me. Scientists don't understand the fundamental mechanics well enough.

However, GlaxoSmithKline estimates that 90 percent of the medications are effective in approximately 30 to 50 percent of patients.

So, what do you think the number of patients required to be treated with the most commonly prescribed statin is?

How many people must take it before one person gets help?


This is according to research conducted by Jerome Groopman and Pamela Hartzband, which has independently corroborated. I ran the calculations myself.

300 patients must take the medication for a year before one heart attack, stroke, or other adverse event is averted.

You're probably thinking,

"Okay, one in 300 chances of lowering my cholesterol.

Why not, Doctor?"

Give me the prescription anyway." But at this time, you should ask for another statistic:

"Tell me about the side effects."


So, for this specific medicine, adverse effects occur in 5% of people. And they include dreadful consequences—excruciating muscle and joint pain, gastrointestinal trouble—but you're thinking, "Five percent, not very likely; I'll still take the drug."

But wait a minute.

Remember that when you're stressed, you don't think clearly.

So, plan out how you're going to work through this ahead of time so you don't have to create the chain of reasoning on the fly.

Is it correct that 300 people use the medicine?

One person has benefited, while 5% of those 300 have adverse effects, which equals 15 people.

You are 15 times more likely to be harmed than helped by the medicine. Now, I'm not saying you should take statins or not. I'm just saying you should discuss this with your doctor.

It is required by medical ethics and is a component of the informed consent concept. You have the right to obtain this type of information in order to begin a conversation about whether or not you want to take the risk. You might assume I made up this figure for shock value, but it's actually rather common, and it needed to be treated. The most commonly performed procedure on males over the age of 50, prostate cancer removal, requires 49 treatments.

That's right,

49 procedures are performed for every person who has benefited.

In this case, half of the patients experience adverse effects.

They include


erectile dysfunction,

urine incontinence,

rectal tearing,

and fecal incontinence.

And if you're lucky enough to be one of the 50 percent who have these, they'll only last a year or two.

So the idea behind the pre-mortem is to consider ahead of time what questions you might be able to ask to move the conversation forward.

You don't want to have to generate all of this on the spot.

You should also consider factors such as quality of life.

Because you often have a choice, do you want a shorter, pain-free life or a longer one with a lot of agony at the end?

These are things you should discuss and consider right now with your family and loved ones.

You may change your mind in the heat of the moment, but at least you've practiced this type of thinking.

Remember that when our brain is stressed, it releases cortisol, which causes a number of processes to shut down. There is an evolutionary explanation for this.

When confronted with a predator, you don't need your digestive system, libido, or immune system because if your body expends metabolism on those things and you don't react quickly, you could become the lion's food, and none of those things will matter. Unfortunately, one of the things that goes out the window during those times of stress is reasonable, logical thinking, as Danny Kahneman and his colleagues have demonstrated. So we need to teach ourselves to anticipate these kinds of scenarios. Recognizing our flaws is the most important message. We're all going to fail now and again.

The goal is to anticipate potential failures and put mechanisms in place to help mitigate the damage or prevent bad things from happening in the first place. Returning to that frigid night in Montreal, when I returned from my trip, I had my contractor install a combination lock next to the entrance, which contained a key to the front door and an easy-to-remember combination. And I have to admit, I still have piles of mail that haven't been sorted and piles of emails that I haven't gone through. So I'm not entirely organized, but I see organization as a long process, and I'm getting there. Thank you very much.


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Folasade Akinola

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    Folasade Akinola Written by Folasade Akinola

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