Give me an easier question!
I’ve been practicing a lot of Paganini. Paganini, for those of you who weren’t paying attention in music appreciation class, wrote crazy difficult violin music. Practicing, of course, is supposed to lead to improvement in performance. Practicing Paganini, however, mostly leads to improvement in my well-honed ability to tell myself I suck.
If you were to ask me on one occasion “What is the probability that you would ever perform Paganini in public?” the answer would be “zero to none”. But ask me on a different day, when I played a little better, and I might say “unlikely, but maybe someday”. Then ask me right after I’ve had a lesson in which my teacher says something encouraging and I might say “someday.” My answers go from completely hopeless to quite hopeful.
My responses can be explained by three observations made by Daniel Kahneman in Thinking, Fast and Slow. My first response – slim to none – is given when I have a negative assessment of my ability. This is an example of what Daniel Kahneman calls The Affect Heuristic. He says that “The dominance of conclusions over arguments is most pronounced where emotions are involved.” Similarly for the second answer – unlikely, but maybe some day. The third response has not only to do with the Affect Heuristic but the Mood Heuristic. Being asked a question about the probability of me playing Paganini after being encouraged by my teacher made my assessment more positive. This would be true even if my teacher had been encouraging about an completely different composition written by a completely different composer.
What I have done is substitute a hard question for an easy one. In this case the actual probability that I would ever perform Paganini is very hard to calculate. So my brain substitutes the question “how do I feel about Paganini, or about myself, right now?” which is easy to answer. Richard Feynman, the Nobel-prize winning physicist, did this all the time with math. When asked to calculate the cube root of 1729.03 in his head, Feynman substitutes the question “how long is a cubic foot?” because a cubic foot is 1728 cubic inches and thus the answer has to be around 12. I can do that in my practice room too: instead of asking “How do I play this passage of ascending thirds?” I can ask “how would I play it if I needed to play only the top note of each third?” which is easy.
Patients do the same thing in making decisions. If you ask someone if they want to get a mammogram at 40 or wait until 50 what you are really asking the person to do is calculate the probability of getting breast cancer between ages 40 and 50 and not finding it until it is too late. This is a very difficult calculation to do, even if the patient understands the statistics on breast cancer. So the patient substitutes in a series of different questions with easier answers: How scared am I of breast cancer? What is my current mood? Am I optimistic or pessimistic in general right now? How do I feel about the doctor asking me the question? Do I like him or her? If the doctor mentioned a recent case in which a 42 year old woman had been diagnosed with breast cancer and then asked the patient if she wanted to get a mammogram at 40 or 50, the answer would change in favor of starting at 40. If the doctor made reassuring remarks about how low the patients chances are, the answer might change toward 50.
The same thing happens in end-of-life discussions all the time. The question “Do you want us to do everything to keep you alive if there is little chance of a good outcome?” is difficult to answer. So the patient or family member asks an easier one: “How do I feel about my loved one right now?” “How do I feel right now?” “How much emotion comes up when I think about death?”
These responses are automatic – our brains will jump to an answer to a difficult question by substituting in an easier one because it is more comfortable with some sort of answer. The problem is that the answers to the easier questions can change over time, and are influenced by our mood and the way the questions are sequenced. The frustration, for the doctor, comes from thinking that everything is settled when it was only settled for a specific moment in time. The challenge for doctors is to remember that medicine is not an exact science because humans are involved, and humans like easy questions.