Never Waste Suffering

We're packaging her up to send her off to the intensive care unit and we get about 2 feet until all of her vitals start crashing. Every day people walk into the hospital that shouldn't die that do. Every day people walk into the hospital that should die and don't. And it isn't always the medical performance that determines that. The single biggest lesson that I've learned is this idea of their suffering is something you can use to give a gift back to society. Welcome to Lessons Learned. My guest today is Dr. Dan Dwarcis. Dan is an MD PhD, an emergency room physician, an adjunct professor at the USC Kek School of Medicine, an author, a podcast host, and the medical director for the Mission Critical Teams Institute. Dan has spent the last 20 years studying the way human beings make decision under pressure and how we work in small teams. I'm excited to have him on the show because his work is really focused on how pressure affects our decision-making, our ability to harvest information, and how small teams work together in high pressure situations. Dan, thanks for being here with me. Thanks so much. Appreciate you having me. So, why don't we start with just kind of a brief overview? You're involved in a lot of decision- making, a lot of kind of missionritical thinking. Give me just a brief overview of kind of what your current work is. Absolutely. the the theme that really ties all this together, whether you're talking about working in the emergency department or working with teams, specifically under mission critical, is the idea of applying knowledge under pressure, right? There's this idea that we have these thoughts, these theories about how things should work and then the real question is how do you take that knowledge and cross that last gap to get it to where and when it needs to be. So for us in the ER, that's really of all these ideas about how medicine should work. How do you pass it across that last mile which is a small group team working under pressure to get it to the patient where and when they need it? Similar problems in fire or military or aerospace, right? All the time you have these ideas and you got to get them into reality. But I think that's true of of anything, whether it's true of business, it's true of anyone that has to make decisions, the ability to apply what you understand at the critical moment, I think, is the challenge. Absolutely. So, one of the things that I've heard you talk about and I want to kind of dig into today is is this idea of never wasting suffering. What do you mean by that? We're going to start with like the really big deep life stuff first, right? We're going to we're going to jump right into it. Absolutely. We're going right into it. So, never waste suffering. So, I I think out of all of my time of treating patients and and being an ER doctor and working with these teams, which is a story about having a lot of brushes with life and death, right? out of all of my time of this, the single biggest lesson that I've learned is this idea of never waste suffering. It's the idea that suffering is a precious resource, right? So, you have these people in front of you, these patients, and they are suffering. They're bleeding. They may be dying. You don't always have the ability to save them. So, you have to ask yourself, what is it that you can promise them? Right? I can't promise I'm going to save this person. Unfortunately, I can't even promise I'm going to take all their pain away. I'm going to do my best, but I can't promise that. But what I can promise them is that I will learn and get better from seeing them. That I will not let their suffering go to waste. That myself and my team will get better and will be better at treating their kids and their grandkids than we are at them. And it's that ethos, that idea that whatever happens, you're going to use it to improve yourself. Well, and I think that that's true beyond the emergency department, right? That's that's true in everything. every every bit of suffering whether it's it's physical suffering in the gym or or emotional suffering from from difficult times um I think that we we have to learn from it but I think it's also very easy for us not to sure yeah I I think one of the things that we we kind of all struggle with as leaders is we get through something difficult and look back and go man that was hard and then we move on um it seems to me you're advocating exactly the opposite response yes and no right so it's appropriate to give yourself and your team some space to decompress a little bit. Right? If you have a really hard case and you move immediately into a super deep debrief of it, you're probably not actually going to be there mentally and emotionally to get it done. Right? So, as an example, I was running a cardiac arrest case and I went to decompress the person's chest with a 14 gauge needle uh missed and put it through my finger. Right? So, at the end of that case, when we wanted to step back and be like, "All right, what happened to this patient? I'm still bleeding pretty profusely out of my hand, right? Like that's not quite the right time to do a root cause analysis of what happened. Like you got to go bandage your hand first, you know? And I remember sitting there trying to talk to the team about it and the nurse is being like, "Dan, what are you doing? You're just like pouring blood out of your finger right now." Okay, okay, fine, fine. So, you take a step back and you bandage yourself up and then you go in and do it. And and that's kind of ridiculous and thankfully that's not how it normally goes. But there is that that drive to just move to the next project, move to the next problem, move to the next thing. And so I think you either hit one of those two ideas. You either want to run away from it or be like, "Wow, we made it. I don't ever want to talk about that again." Or you want to drive directly into trying to figure out how to get better. And I think what you really need is this slightly different rhythm than that. Right? You need to take a step back and say, "Hey, this just happened. This is real. Are we okay? Is anybody bleeding that we need to take care of? Did we learn anything critical that we have to fix immediately to regenerate our ability to respond again? And if that's true, if that's safe, like are you safe? Once you're safe, go to the bathroom and have a drink of water. Like go outside and, you know, look at a horizon, look at the sky for a minute, call your loved ones, whatever it is. Then when you've had that pause, then you go back in and really dig into it. It you can fail in either direction, too fast or too slow here. But I think the the critical component of that is this willingness to go back and engage in in you know the results of whatever it is whatever decision you make going back and actually looking at the decisions you've made and what the effect of those are and and you know and central to that would be debriefing it and having conversations. How do you manage that? How do I manage a debrief in general? So I I think about it like a layer cake almost, right? which is a bit of a weird metaphor to be using in this sort of circumstance. The first part that everything gets is what we just did that are you okay check-in super rapid is anybody hurt and can we respond again right now and until you can respond again basically nothing else matters right all of the learning and everything like your real job is to be able to respond to that next case when it comes in right you know I think about the uh one day in particular really stands out for that for me right you know we have a young kid who had suffered a cardiac arrest and unfortunately we weren't able to bring that kid back so we can talk in a second sort of our closing ritual for when we don't save somebody. Uh but as we were getting ready to close that case, my senior nurse comes behind me, puts puts their hand on my shoulder and says, "Dan, there's another kid coming in who just got shot. You need to split your team and scramble a second team right now." Right? So, you don't have time to do your whole debrief right there. You just have to move and respond to the next event. Right? So, can you regenerate the ability to respond? Then once you have that ability to respond, then you're starting to dig into the sense making part, the what happened, right? So there's a lot of ways to do that. We usually use like something like a plus delta model where essentially you're saying, "All right, what went well?" Plus, and what are we going to do better next time, the delta? And what we have in here is is an ability to make sense of the whole room. So you see one version of it, I see one version of it. We all live in our own heads. Can't really get out of that for sure. But what we really need is to put all those senses together to harness the wisdom of the room and get everybody to understand what happened. So that initial debrief is really a lot more about just do we even understand what happened? Not really going for deep lessons. We're not using reusable. We're not trying to find reusable skill sets. We're really just trying to figure out what happened. Then the third layer would be that much deeper dive. Okay. So if this is what happened, what do we do about it? What matters? what can last for the next thing for us and what are we going to do differently tomorrow than than we did today. And that's where you get to that ethos of never wasting suffering. Whatever came in the door, whatever your team scrambled to to to work on, whatever problem set you're working on, you're going to have some way to build out of that lessons that will help you get better. Well, and I think no matter what your your role from from an emergency department to a business boardroom, you make decisions. The decisions have consequences. And if you don't if you don't harvest the consequences. Yeah. Right. If you don't if you don't take value from the both the good and the bad. But I mean specifically we learn through failure. Right. That's as human beings we're hardwired to learn through failure. Um and and we're also hardwired to want want to run away from that. Um but I think if if you don't take the time to harvest like you said the entire room, everybody's perspective. I think as leaders we're very prone to just looking at a situation and making our own assessment and moving on and frequently we don't have all of the information right never like we're never as smart as the whole room and I think that's really hard to understand especially as a junior leader right like you think you have the perspective of everything and you live the reality but actually the room is always smarter than you and to have the humility to say all right I don't actually understand everything that happened even though I understand my own version of it what I really need to do is make sure that I understand the flow from everybody's point of view. What's the actual sense making of what went on? Well, and I think it's interesting because one of the things I talk about when I teach leadership is as a leader, you don't have to be the guy with the right answer. You have to be the guy that finds the right answer. And frequently, most often, that comes from somebody else in the room. It comes from harvesting the whole room. Um, but I think it's it's difficult when you're a young leader to to have that humility and realize I don't have to be the guy that understands everything. Yeah. Yeah. And you know, you're talking about learning from your mistakes. And to me that links back to this idea of suffering, right? And the idea that suffering is a precious resource, which is kind of a ridiculous thing to say, right? Because we're talking about like people's lives and death. We're talking about pain. We're talking about really bad stuff. And to say that that's a precious resource is a pretty ridiculous thing to say, right? Except that I'm going to double down and say that I completely believe that that suffering is a precious resource. That you and your team need to use that and convert that into fuel for whatever the thing is you're going to do next. That's that ethos of never wasting the suffering. Well, one of the things that that you and I have talked about is this idea. I mean, the the ritual that you run when you lose a patient, I think is is probably the most I don't know, kinesthetic example I've seen of that of just leaning into like we we didn't do enough. Would you mind talking about that a little bit? Yeah. Yeah. That's um there's nothing easy about that, right? I mean, I think we operate in a world in emergency medicine where we are imperfect and we are practicing an imperfect science, right? medicine is not medicine doesn't have all the answers. We do the best that we can, but you know, you think you realize um when you're a doctor that you're the current version of a lineage of a lot of other human beings that have been working really hard to keep human beings alive, right? Back from all the way to the ancient days of people trying to save each other. And you're doing the best that you can with what you have, but you are so aware of your own imperfection, your own faults, your own failures, both you and your team. And when you do have a moment where you lose a patient, and that does happen no matter how good you are as a physician, right, you have to do something to really mark that moment and to come to grips with the reality of that. So, what I was taught and what I've adopted as my own um is to have a moment to call the room together to put your hand on on that person's body and to say some version of thank you sir or thank you ma'am for teaching us I'm sorry all we could do today for you is to learn such a profound statement and I I mean I Yeah, I I feel that even even as I'm saying that now sitting here with you, right? Because that that commitment to learning from them and the gift that they've given the future generations by us getting better from what happened with them, I think is a really powerful connection human to human. And it's easy to lose sight of that in the franticness and the pace that we all work at, right? But if you really believe that the folks you were lucky enough to serve, whatever version of that that is, whether that's business or medicine or military or whatever, that their suffering is something you can use to give a gift back to society. Like if you really believe that, that conquers a lot of that fear of failure and that conquers a lot of that not wanting to deal with the sticky, dirty pieces of it because you realize you have a commitment to them not to waste the suffering they just went through. Well, it's also harvesting your own suffering. Sure. Right. In in a way that like one of the things that struck me that there's a number number of things about that statement that I think are very interesting. Um, one of them is the amazing amount of humility it displays and this moment of kind of leaning into the fact that I didn't have enough today. I didn't I didn't have enough. And I think that that kind of opens the door to learning. And that was one of the things that always struck me the first time we talked about that that because it it it lands with an emotional thud. Um, it's not, you know, that's not a statement that and and you know, you see the way you express it and it's clear that it lands with with gravitas for you. But um what I like about it is this not wasting their suffering but also not wasting your own and you know accepting the fact that you didn't get the outcome that you wanted and this didn't work the way that you wanted it to and and learning from that rather than having to re-engage it again. And it's worth saying that that you didn't get the outcome you wanted there is like probably the right way to put that. And that could be because you didn't personally have what you wanted to bring to that day. Could be that your team didn't have what you wanted to bring that day. Or it could be that you all actually did the best you possibly could. And the reality of life is the outcome is still bad, right? And all of those are important. We talked earlier about junior leaders struggling to have the humility to to see what's happening around them. I think another thing junior leaders really struggle with is not catastrophizing. I don't know if that's the right way to say that word or not, but I think you get what I'm saying. So, the idea that they think because there's a bad outcome, it must mean that they fail personally, that their performance was the reason for that. They have this very um inflated sense of ego like they're the important things in the world. So, if a bad thing happens, it must be because they failed at what they were doing. And as senior leaders, one of the things you have to do is help them break that pattern because you need them to understand the outcome is bad and that matters and you have to learn and you have to get better. But you can't let them draw the conclusion that means that every time because they failed. Interesting. Yeah. Because I guess that there is a difference between the way you perform and the result you get. And and I I think as a senior leader, one of the things that you have to teach is that you're really only going to control what you do, right? And and it strikes me that in your world, that is exceptionally true. Yeah. We don't get the final vote. I think from medicine or military, that's both true, right? Law enforcement, fire, any of these things really, you only get part of the vote, right? You get to control what you and your team does specifically before the impact, right? That's when you really have the most control is how are you training? How are you getting set up? Um we use this prepare, perform, recover, evolve loop to think about this because in the moment of performance, you have limited control, right? You have control over your team, but you also don't get to control what comes in the door or what happens to that patient or what their physiology is, but you do get to control how you set up and prepare for it, how you practice, how you get ready to do it, the drills that you run, and then you definitely get to control on the other end of it how you evolve from it. That's really what we're talking about about this not wasting suffering. That's a choice you get to make every time. And to me, part of the reason I came up with that again, talking about what I can promise my patient and what I can't, right? What can I promise that person? We go home at night after these shifts and be like, okay, what happened? What can I promise my patient tomorrow? And that idea that I will promise them I will learn. That is entirely under my control. It's one of the few things that's entirely under my control and my team's control. That ethos of learning of not wasting their suffering and the fearless dedication to do that over and over again to just smash into that problem. Well, and also to accept the fact that even if you perform well, there are circumstances you will not be able to control. Like it strikes me that every day people walk into the hospital that shouldn't die that do. And every day people walk into the hospital that should die and don't. And it isn't always the medical performance that determines that. That that sometimes it's your day and it doesn't matter what the doctors are going to do to save you. But that the opposite is also true. Sometimes they're going to get lucky. Yeah. You know, sometimes I think about like my own death, right? And I think about what I want that to look like. And hopefully, you know, I die when I'm very old, very peacefully surrounded by friends and family and this loving thing. But my second choice is actually that I die in like a ridiculously spectacular way that people can get a lot of use out of in terms of not wasting suffering, right? Because you're right, sometimes it's just your day and it's just your day. And if that's the way I'm going to do it, man, I hope it's something just totally crazy that the doctors that are there be like, "Man, we learned a lot from that." Like, you know, thanks, Dan. Like, which is kind of a ridiculous thing to say, but but truly like like that ethos, like you're right. It's not just your patient suffering, it's your suffering as a team. I don't want them to waste their suffering when they treat me either. I want them to learn from it. I want them to reflect on it. I want them to go back and think about their own mortality and what that means for them and their family and to do the hard work that it takes to turn that suffering into into fuel. So that that brings up kind of a different concept which is it also doesn't make sense to suffer needlessly, right? That's the flip side to that is is don't suffer more than you have to and don't suffer needlessly. Talk to me a little bit about that. Yeah, you know, we're sort of glorifying suffering here a little bit, which is is a danger. You're right, because suffering for its own sake is is worthless, right? You don't win rewards for suffering for no reason. Now, you have to have suffering and friction, especially when you're training at the beginning because you need that to help shape you, right? There's that great Senica quote, I think. um uh gems are polished by friction and humans are polished by their trials, right? The idea that it's the actually the friction and the suffering around you that helps shape you into the person that you're going to become and that you can be. So that's super important, right? Can't have too little, but you can't have a bunch of suffering for no reason either, right? So to us uh in medicine that often comes up as basically don't fail in unnecessary ways or eliminate unnecessary failure is probably the better way to say that right like you said there's all these things you can't control. You don't control what comes in the door. You don't control if it's that person's day to die or not. But are you controlling all the things you can? Are you eliminating all of the ways to fail unnecessarily? Yeah. Don't don't put yourself in a position where it's worse than it has to be because you are unprepared. Exactly. Or, you know, or or you you you screw up the simple stuff. Yeah. So, so let me tell a story about that. Right. So, we had this case that really stuck with me that um was this incredibly complicated uh airway case. Really hard. This woman came in and she had a bunch of lung problems and was super sick and it was up to us to do something about it, right? And it was really complicated. Getting a breathing tube in and getting her on the ventilator was super complicated. She was it was just a mess. And we finally got it. And we were so happy and proud as a team. We're packaging her up to send her off to the intensive care unit. And we get about 2 feet until all of her vitals start crashing. And I'm going to skip the middle part where we didn't know what was happening and just cut to the end and say the problem was nobody had checked the oxygen tank under the bed. O. So, we've done all of this really high powered science and medicine and everything and we're failing because nobody had double-cheed the backup oxygen system. And we brought her back to the ER and thankfully nothing bad happened and we've got her back together and got her oxygen got off. But I walked away that day being like that is so unnecessary. It's so unnecessary for that failure to happen. That's suffering that we can't afford to have. That's completely needless. is completely wasted. So, how do you go about deriving a culture where that will never happen, right? So, how do you do it? Well, you talk to the team around you and you tell the story. So, I think storytelling is actually super powerful for this kind of thing. You tell them a story and you get them thinking to yourself, all right, well, where else might we fail? What else have we not looked at? And it's nobody's specific job to check the oxygen tank, which I think is interesting, right? It doesn't fall into anybody's direct thing, but it becomes part of the stuff that all of us think through. Well, should I check it? How do I know that we're not going to fail? And what I want to see happen is six people check it, right? I want to see my junior doctor check it. I want to see the med student check it. I want to see everybody check it. Is that inefficient? Yeah, sure. That's a little inefficient. And there are other things that we, you know, don't do that with. But I want them to hear that story and have the ethos in there of how do I eliminate unnecessary suffering? How do I eliminate unnecessary ways to fail? But it's interesting because, you know, you talk about specific assignment. So, when my wife and I first had our kids, it was right when the kid drowned in Tommy Lee's pool and we have a swimming pool. We've always had swimming pools and we had a conversation about how do we prevent kid from drowning in our pool like how does because that happens because nobody's nobody's watching. And so we made a decision that anytime we were outside, the kids were never we were never both watching the kids. You had the baby or I had the baby. And we made a conscious handoff. So it's like, I'm handing you Jonathan. You have him. I have Jonathan. And it was this affirmative conversation every time. There was never a time that we were both watching him. because both watching him meant neither of us watching him, right? Like one of my favorite seal sayings is that, you know, people do what's inspected, not what's expected. And it strikes me as leaders that we have to prepare for those contingencies. We have to think about ways that we can make ourselves suffer needlessly uh and and and pre-plan, right? Murder our own operations, think about how do we get ahead of our own, you know, ourselves in time. And that that strikes me that that's kind of part of your ethos. Yeah, absolutely. So, anytime you find one of those spots of unnecessary failure, right? Like your debrief in that case should include, well, what else might be right lateral to that? What's just like that that we didn't catch? Where are we going to fail tomorrow on this? And that gives you all this great way to figure out, okay, well, what should we be building? And eventually, you build a system where it is somebody's job to check the oxygen tank. And then you have eliminated that way of failing. But you don't think that means you fixed everything, right? That's really important. Just because you have a plan doesn't mean that's enough, right? You have to have a plan and then a plan B. And your plan B has to be part of that plan. And you have to understand that it's not enough to do one thing. You actually need the culture that insists that people check around what's going to fail. Well, and at its root, it is culture, right? At its root, it is it is a a mindset that is common among the team and it's a set of rules that everybody is subscribing to. It's interesting because I think we've we've kind of come to a point that we fetishize suffering, right? We look at you look at a lot of the books that have come out and you look at a lot and it's, you know, get up at 3:00 in the morning and eat a handful of rocks and um and and we've kind of created this mindset that there is value in suffering that that there's nobility in suffering and it almost feels like your argument is counter to that that there isn't nobility and needless suffering. I'm a two handfuls of rocks person personally in the morning. But no, um I think that friction and discomfort and suffering is important in some ways, specifically when you're learning, right? You have to understand the discipline that it takes to do your job well, whatever that job is. But to create suffering for its own sake, seems kind of pointless to me. Especially when you're building more suffering than you can actually process and learn, right? The idea is never waste suffering. It's transform that suffering into growth, into forward progress, into stories for the next generation, into the ability to do your job better, right? And also transform it into meaning, but to have extra suffering for no purpose, right? Are you carrying extra weight because you're building your muscles or you carrying extra weight cuz you believe you're a bad person and maybe you should suffer? Like I I don't know, right? There's probably some other stuff going on in there that you need to poke at. That's very interesting. So, it also strikes me though that that part of this whole thing is you you kind of have to always have contingency plan, right? There's always got to be a plan B. Yeah, certainly in the ER. And I think one of the ways that's the most obvious for us is when we think about approaching an airway, right? So, we're putting a breathing tube in, we're taking over breathing, we're putting somebody on a ventilator. That's a a relatively high risk procedure, right? we're taking over that person's ability to breathe. So from the time that we paralyze them to the time that we are successfully breathing for them, they're hanging in space and there's a limited amount of time for that to happen. So as you're doing it, you're always thinking to yourself, okay, my initial approach is X, my backup approach is Y. And usually my third backup and fourth backup are or whatever. And you'll see in a lot of ERs, there's stuff up on the wall that's like, you know, your first plan, your second plan, your third plan, and you understand how to move uh seamlessly between them, right? Um a doctor I was working with uh said it in a way that really stuck with me, which is that plan B is just part of the plan, right? If you move from A to B, that's not failing. That's just succeeding with plan B. That is a really smart way to look at that. Yeah. you you're simply transitioning to the next phase of your plan. Uh that's a that's a really good way to put it, which like it's worth saying like it's not really plan B if you can't do it. That's the flip side of that, right? So if you have a plan B, but you don't know how to do it, you don't know how to use the equipment, you're not rehearsed on it, your team doesn't know how to pivot from A to B, you don't really have a backup plan. You have a plan A and a hope. And that's not enough, right? So, you have your plan A, you have your plan B, and you've rehearsed how to get from A to B, what's over at B, what the equipment looks like, and how you're going to use it. I I think a lot of us, you know, it's funny because there's that saying that it ultimately trace back to Yogi Bearer that hope is not a course of action. Um, but I think for a lot of people it is. And I think that they kind of regard, well, if worse comes to worse, I'm going to do this. Um, but in your world, that's not really an option. There there is no there's no hope as a course of action. You have to have a plan. Yeah. And then at the end, you still MacGyver whatever you need to MacGyver to make something happen. Interesting. Uh so, you know, what I've learned from you today is that we can't waste suffering. We need to learn from it. We need to debrief. We need to dig into it. We need to, you know, take advantage of of the suffering that we endure endure. But at the same time, don't suffer needlessly, right? prepare contingencies, you know, don't put ourselves in situations where we're we're going to suffer for no reason. Suffer for a purpose. I think it's a really interesting approach. Dan, how can people find your work? Uh, the easiest way to find me is either through the emergencymind project or through the mission critical team institute or emergencymind.com or missioncti.com. And we'll link to all that in our show notes. Dan, thanks so much for spending this time with me, man. My pleasure. Thanks so much.