The Black Death of Childbirth: What can it tell us about dysphagia?

In the 1800s, something terrible happened during childbirth. Women were dying in extraordinary numbers. It became so bad that the people experiencing it gave it a name that's hard to forget: The Black Death of Childbirth. Ugh, even the name sounds scary. Of course, this happened when medicine began to pride itself on evidence-based practice. So, were these doctors going to stand around and let this horror continue to happen? No, they were going to fix it, darn it!

What happened next is a lesson in decision-making. The doctors began to study the cadavers to see if they could stop the deaths from happening in the future. It was a worthy cause, of course, but they realized that the number of deaths wasn't slowing down as they researched. It was speeding up. More and more women were dying at even higher numbers. The research wasn't helping. Somehow, it was hurting.

Finally, a doctor named Oliver Wendell Holmes arrived at the scene to try to sort everything out. He had an inkling that it was something the doctors were doing (or not doing) that was making the problem worse. It turns out the doctors examining the cadavers were neglecting to do one very crucial thing after touching the cadavers and before going into the delivery room to deliver the babies. Can you guess what it was that they weren't doing? Yup, they weren't washing their hands.

Cognitive Biases and Heuristics

Medicine has come a long way since the 1800s, but the problems we get ourselves into can look very similar. This is because of a little thing called confirmation bias. See, when looking for something, we tend to ignore everything else around it. We have tunnel vision. When you're a hammer, everything's a nail. And when you're a med SLP, everything is dysphagia. We look for and eventually find dysphagia, whether it's there or not.

Confirmation bias is just one example of many cognitive biases and heuristics—the mental shortcuts that have become an enormous problem in healthcare. A review of 20 studies with almost 7,000 physicians found that cognitive biases caused errors up to 77% of the time. Whoa. That means that most of the decisions we make in healthcare could be plagued by these harmful patterns. How in the world could we have let this happen? And how do we stop cognitive biases and heuristics from ever happening again?

The truth is, you can't. Cognitive biases are a part of us. The world has experienced incredible change over the past few hundred years. Think about how we were living just 200 years ago. We were commuting by walking, not driving, out to our farm that we probably lived on, only to settle down at night after the sunset because there were no lights, television, or, God forbid, smartphones. Today, we order food with a click of a button while listening to our favorite songs and watching our favorite show, all while we cruise across the Atlantic at 600 MPH to enjoy a spritz on the streets of Rome.

Our brains haven't evolved much since we lived on the Serengeti 300,000 years ago. But the world has. The decisions we made on the Serengeti were instinctual and automatic. If you wanted to weigh the pros and cons to decipher whether that rustling in the bushes was a lion or a chipmunk, you'd get eaten before you decided. Thinking fast allowed us to survive, and that type of thinking has served us well, which is why we still use it today. But in a complex world, thinking fast is no longer as helpful.

So what's the solution? Thinking slowly, of course.

The late Daniel Kahneman uses this terminology in his seminal book on cognitive biases and heuristics called Thinking Fast and Slow. We still use fast thinking today; for example, when a deer jumps in front of your car, you hit the brakes before seeing it coming. It still serves us well, so we don't want to rid ourselves of it completely. But in healthcare, especially when there's medical complexity to manage, multiple variables to sort out, and several simultaneous risk factors to address, we can't always get away with these knee-jerk reactions.

Thinking slowly means taking time and sorting out what we are looking at. A few approaches can help us think slowly.

Use a decision-making process: A systematic process with checklists uses cognitive forcing. It protects you from yourself by forcing you to look at the most critical variables and assess the most relevant features using the most effective approaches.

No, what we do isn't rocket science, but that doesn't mean we can't create the same processes, redundancies, and checklists that rocket scientists use to check and double-check their work. See below for a method that has helped me avoid moving too fast and missing critical information that might help me evaluate and treat my patients effectively.

Work with a group: Remember that we use a brain that hasn't evolved much for 300,000 years. Do you know what our species has been doing for at least that long? That's right! Working in groups (You read the title of this paragraph, didn't you?). We are social creatures, so a good team is often worth more than the sum of its parts. A good colleague provides additional knowledge and experience you couldn't get anywhere else. A good team also double-checks each others' decisions by poking holes in our reasoning and filling those holes up with the information we need. And it's not just one colleague we should utilize when making tough decisions, but the entire interdisciplinary team. In Who Wants to be a Millionaire, you're about 60% accurate when you phone a friend. That accuracy increases to 90% when you ask the audience. This is because of a concept called the wisdom of the crowd. The more people we get involved in the decision, as long as they are familiar with the case and can contribute relevant expertise, the better.

Use a decision journal: We can't always rely on making slow decisions, can we? Unfortunately, we don't always have the time to go through our entire systematic process, check everything off the list, and talk to every team member. So when can we rely on faster, more automatic decisions? When we have experience making similar decisions in a similar environment with similar patients. And, most importantly, when we receive timely and accurate feedback on those decisions. The best way to do this is to keep a decision journal. Make a decision now, document the decision with all of the variables you considered when making that decision, and come back to it after a couple of weeks when the outcome is apparent. This helps us avoid hindsight bias or the "I knew that was going to happen all along" bias. A decision journal forces you to confront your errors and blind spots: "How could I have missed that?" Don't take it personally; it happens to everyone (77% of the time, remember?), but don't let it happen again next time. Improve your process by making sure you are forced to check what you missed the first time.

But I don't have enough time to do all of this!

And to that, I say, you don't have enough time not to. It may take some time upfront to incorporate some of these new habits into your daily practice, but once they're there, it's only a few extra minutes per patient. Those few minutes of using a systematic process could mean the difference between making a recommendation that helps your patient achieve their goal of eating their favorite food versus a patient who is left eating food that looks like it's been through a systematic process.

Conclusion

Let's go back to the Black Death of Childbirth. How long do you think it took those doctors to start washing their hands after they learned the cause of the problem? Days? Weeks? Months??? No, no, and no. It took years, many years. It took decades for hand washing to be widely used in healthcare. This is because they had tunnel vision. They couldn't admit that they were a part of the problem. They needed something else to blame. They were looking for something that wasn't there and ignoring what was. Occam's razor tells us the simplest explanation is often the right one. But nobody said the simplest answer is the easiest to find. Using a process, incorporating a team, and using a journal are three ways to find that answer and, ultimately, effectively care for the patients we serve.

*New course offered for ethics credit: Let Us Eat: The ethics of swallowing in older adults at high risk