Our daily lives as dermatologists involve interactions with people who may not be aligned with our thinking or ideas, and may have unreasonable expectations or opinions before, during, and after encounters. Using psychological “hacks” to improve experiences is just one method of improving the patient’s perception of their encounter. Sometimes, these concepts can even inform our daily lives to improve our “reality.”

Daniel Kahneman won the Nobel Prize in 2002 for his work on behavioral economics, but his main work on the Peak-End Rule is more applicable to our daily work. Wikipedia describes the Peak-End Rule as “a psychological heuristic in which people judge an experience largely based on how they felt at its peak and at its end, rather than based on the total sum or average of every moment of the experience. The effect occurs regardless of whether the experience is pleasant or unpleasant.”

Although I only recently learned about the Peak-End Rule, it is already familiar to me, as I utilize it every day when I perform fillers: I always concentrate on the more painful areas (lips and areas with multiple insertion points) early in the experience and end with neurotoxins, which are less painful. While this theory had been around for quite some time, I came to it on my own without the benefit of the Nobel Prize committee influencing me; still, it is reassuring to some extent that I chose correctly.

Among many other insightful contributions to the field along with his collaborator, Amos Tversky, Kahneman also introduced the fast thinking/slow thinking (System 1/System 2) in the book, Thinking, Fast and Slow. Fast (instinctive) thinking is used when we immediately recognize disease states we are trained to recall (“sick” vs. “not sick,” or “inflammatory” vs. “infectious” vs. “neoplastic”), while slow (deliberate) thinking is more in line with the thought process that pieces together a difficult case that nags on your mind until you decipher it. Accompanying this major body of research is their work to expand the field of heuristics (derived from the Greek word “heuriskein,” which means “to discover”). It is astonishing how much of what we take for granted in our daily decisions was thoroughly analyzed and explained by these two geniuses.

One other aspect of Kahneman himself was that he was described by his friend Richard Thaler as an “avid pessimist.” This translated to expecting the worst so as not to be unhappy when the worst happened. On the other hand, his partner, Tversky, was a self-described optimist, stating, “When you are a pessimist and the bad thing happens, you live it twice: once when you worry about it, and the second time when it happens.” 

Although I would describe myself as a perpetual optimist, there are many aspects of my life wherein I follow the “avid pessimist” rule. For example, when I take a flight, I always assume that it will be late and therefore I will misconnect or, alternatively, that the flight will be canceled, and I will have to take the next flight. Since I live in Omaha, a city where many travel routes require a connecting stop, these variables are nearly always in play. This means that, in general, I take flights that depart earlier and offer connections later in their connecting cities. It also means that I will avoid any connecting city that only has one main airline, if possible, in order to have more options if the inevitable does happen. 

What this does is to create joy for me each time the flights go right and there are no delays. In many ways, this is the setting that we offer to our patients when we give informed consent or explain realistic outcomes for surgeries or medical conditions. I am not sure if this is the way that my patients think, but I would like to hope that our explanations (under-promise, over-deliver) help them to consider the pros and cons, and ultimately understand and appreciate the positive outcomes more, knowing that there is always a negative outcome option.

I tend to think of this attitude as a “Planning for a Plan B” option. This is helpful in any practice situation, ranging from hiring a new employee (what happens if they don’t work out) to performing a new kind of procedure (what if this flap doesn’t give me the tissue mobility I need) to entering into a contract with a company (how do I get out of this if it goes south, or they don’t perform). 

I didn’t always have this approach, but time and experience have proven this to be helpful. Additionally, the benefit of happiness when things actually do go right is a remarkable and recurrent spot of brightness. I would therefore call this a “cautious optimist” approach rather than “avid pessimist.” 

Whatever approach you take, I hope things turn out well, but if they don’t, consider the option of a “permanent backup plan” approach. I think you will find it helpful and instructive.