tl;dr There's some disagreement over whether setting goals is a good idea. Anecdotally, enjoyment in setting goals and success at accomplishing them varies between people, for various possible reasons. Publicly setting goals may reduce motivation by providing a status gain before the goal is actually accomplished. Creative work may be better accomplished without setting goals about it. 'Process goals', 'systems' or 'habits' are probably better for motivation than 'outcome' goals. Specific goals are probably easier on motivation than unspecified goals. Having explicit set goals can cause problems in organizations, and maybe for individuals. 

 

Introduction 

I experimented by letting go of goals for a while and just going with the flow, but that produced even worse results. I know some people are fans of that style, but it hasn’t worked well for me. I make much better progress — and I’m generally happier and more fulfilled — when I wield greater conscious control over the direction of my life.

Steve Pavlina 

The inherent problem with goal setting is related to how the brain works. Recent neuroscience research shows the brain works in a protective way, resistant to change. Therefore, any goals that require substantial behavioural change or thinking-pattern change will automatically be resisted. The brain is wired to seek rewards and avoid pain or discomfort, including fear. When fear of failure creeps into the mind of the goal setter it commences a de-motivator with a desire to return to known, comfortable behaviour and thought patterns.

Ray Williams 

I can’t read these two quotes side by side and not be confused.

There’s been quite a bit of discussion within Less Wrong and CFAR about goals and goal setting. On the whole, CFAR seems to go with it being a good idea. There are some posts that recognize the possible dangers: see patrissimo’s post on the problems with receiving status by publicly committing to goals. Basically, if you can achieve the status boost of actually accomplishing a goal by just talking about it in public, why do the hard work? This discussion came up fairly recently with the Ottawa Less Wrong group; specifically, whether introducing group goal setting was a good idea.

I’ve always set goals–by ‘always’ I mean ‘as far back as I can identify myself as some vaguely continuous version of my current self.’ At age twelve, some of my goals were concrete and immediate–“get a time under 1 minute 12 seconds for a hundred freestyle and make the regional swim meet cut.” Some were ambitious and unlikely–“go to the Olympics for swimming,” and “be the youngest person to swim across Lake Ontario.” Some were vague, like “be beautiful” or “be a famous novelist.” Some were chosen for bad reasons, like “lose 10 pounds.” My 12-year-old self wanted plenty of things that were unrealistic, or unhealthy, or incoherent, but I wanted them, and it seemed to make perfect sense to do something about getting them. I took the bus to swim practice at six am. I skipped breakfast and threw out the lunch my mom packed. Et cetera. I didn't write these goals down in a list format, but I certainly kept track of them, in diary entries among other things. I sympathize with the first quote, and the second quote confuses and kind of irritates me–seriously, Ray Williams, you have that little faith in people's abilities to change?

For me personally, I'm not sure what the alternative to having goals would be. Do things at random? Do whatever you have an immediate urge to do? Actually, I do know people like this. I know people whose stated desires aren’t a good predictor of their actions at all, and I’ve had a friend say to me “wow, you really do plan everything. I just realized I don’t plan anything at all.” Some of these people get a lot of interesting stuff done. So this may just be an individual variation thing; my comfort with goal setting, and discomfort with making life up as I go, might be a result of my slightly-Aspergers need for control. It certainly comes at a cost–the cost of basing self-worth on an external criterion, and the resulting anxiety and feelings of inadequacy. I have an enormous amount of difficulty with the Buddhist virtue of ‘non-striving.’

Why the individual variation?

The concepts of the motivation equation and success spirals give another hint at why goal-driven behaviour might vary between people. Nick Winter talks about this in his book The Motivation Hacker; he shows the difference between his past self, who had very low expectancy of success and set few goals, and his present self, with high expectancy of success and with goal-directed behaviour filling most of his time.

I actually remember a shift like this in my own life, although it was back in seventh grade and I’ve probably editorialized the memories to make a good narrative. My sixth grade self didn’t really have a concept of wanting something and thus doing something about it. At some point, over a period of a year or two, I experienced some minor successes. I was swimming faster, and for the first time ever, a coach made comments about my ‘natural talent.’ My friends wanted to get on the honour roll with an 80% average, and in first semester, both of them did and I didn’t; I was upset and decided to work harder, a concept I’d never applied to school, and saw results the next semester when my average was on par with theirs. It only took a few events like that, inconsequential in themselves, before my self-image was of someone who could reliably accomplish things through hard work. My parents helpfully reinforced this self-stereotype by making proud comments about my willpower and determination.

In hindsight I'm not sure whether this was a defining year; whether it actually made the difference, in the long run, or whether it was inevitable that some cluster of minor successes would have set off the same cascade later. It may be that some innate personality trait distinguishes the people who take those types of experiences and interpret them as success spirals from those who remained disengaged.

 

The More Important Question

Apart from the question of personal individual variation, though, there’s a more relevant question. Given that you’re already at a particular place on the continuum from planning-everything to doing-everything-as-you-feel-like-it, how much should you want to set goals, versus following urges? More importantly, what actions are helped versus harmed by explicit goal-setting.

Creative Goals

As Paul Graham points out, a lot of the cool things that have been accomplished in the past weren’t done through self-discipline:

One of the most dangerous illusions you get from school is the idea that doing great things requires a lot of discipline. Most subjects are taught in such a boring way that it's only by discipline that you can flog yourself through them. So I was surprised when, early in college, I read a quote by Wittgenstein saying that he had no self-discipline and had never been able to deny himself anything, not even a cup of coffee.

Now I know a number of people who do great work, and it's the same with all of them. They have little discipline. They're all terrible procrastinators and find it almost impossible to make themselves do anything they're not interested in. One still hasn't sent out his half of the thank-you notes from his wedding, four years ago. Another has 26,000 emails in her inbox.

I'm not saying you can get away with zero self-discipline. You probably need about the amount you need to go running. I'm often reluctant to go running, but once I do, I enjoy it. And if I don't run for several days, I feel ill. It's the same with people who do great things. They know they'll feel bad if they don't work, and they have enough discipline to get themselves to their desks to start working. But once they get started, interest takes over, and discipline is no longer necessary.

Do you think Shakespeare was gritting his teeth and diligently trying to write Great Literature? Of course not. He was having fun. That's why he's so good.

This seems to imply that creative goals aren’t a good place to apply goal setting. But I’m not sure how much this is a fundamental truth. I recently made a Beeminder goal for writing fiction, and I’ve written fifty pages since then. I actually don’t have the writer’s virtue of just sitting down and writing; in the past, I’ve written most of my fiction by staying up late in a flow state. I can’t turn this on and off, though, and more importantly, I have a life to schedule my writing around, and if the only way I can get a novel done is to stay up all night before a 12-hour shift at the hospital, I probably won’t write that novel. I rarely want to do the hard work of writing; it’s a lot easier to lie in bed thinking about that one awesome scene five chapters down the road and lamenting that I don’t have time to write tonight because work in the morning.

Even if Shakespeare didn’t write using discipline, I bet that he used habits. That he sat down every day with a pen and parchment and fully expected himself to write. That he had some kind of sacred writing time, not to be interrupted by urgent-but-unimportant demands. That he’d built up some kind of success spiral around his ability to write plays that people would enjoy. 

Outcome versus process goals

Goal setting sets up an either-or polarity of success. The only true measure can either be 100% attainment or perfection, or 99% and less, which is failure. We can then excessively focus on the missing or incomplete part of our efforts, ignoring the successful parts. Fourthly, goal setting doesn't take into account random forces of chance. You can't control all the environmental variables to guarantee 100% success.

Ray Williams

This quote talks about a type of goal that I don't actually set very often. Most of the ‘bad’ goals that I had as a 12-year-old were unrealistic outcome goals, and I failed to accomplish plenty of them; I didn’t go to the Olympics, I didn’t swim across Lake Ontario, and I never got down to 110 pounds. But I still have the self-concept of someone who’s good at accomplishing goals, and this is because I accomplished almost all of my more implicit ‘process’ goals. I made it to swim practice seven times a week, waking up at four-thirty am year after year. This didn’t automatically lead to Olympic success, obviously, but it was hard, and it impressed people. And yeah, I missed a few mornings, but in my mind 99% success or even 90% success at a goal is still pretty awesome.

In fact, I can’t think of any examples of outcome goals that I’ve set recently. Even “become a really awesome nurse” feels like more of a process goal, because it's something I'll keep doing on a day-to-day basis, requiring a constant input of effort. 

Scott Adams, of Dilbert fame, refers to this dichotomy as ‘systems’ versus ‘goals’:

Just after college, I took my first airplane trip, destination California, in search of a job. I was seated next to a businessman who was probably in his early 60s. I suppose I looked like an odd duck with my serious demeanor, bad haircut and cheap suit, clearly out of my element. I asked what he did for a living, and he told me he was the CEO of a company that made screws. He offered me some career advice. He said that every time he got a new job, he immediately started looking for a better one. For him, job seeking was not something one did when necessary. It was a continuing process... This was my first exposure to the idea that one should have a system instead of a goal. The system was to continually look for better options.

Throughout my career I've had my antennae up, looking for examples of people who use systems as opposed to goals. In most cases, as far as I can tell, the people who use systems do better. The systems-driven people have found a way to look at the familiar in new and more useful ways.

...To put it bluntly, goals are for losers. That's literally true most of the time. For example, if your goal is to lose 10 pounds, you will spend every moment until you reach the goal—if you reach it at all—feeling as if you were short of your goal. In other words, goal-oriented people exist in a state of nearly continuous failure that they hope will be temporary.

If you achieve your goal, you celebrate and feel terrific, but only until you realize that you just lost the thing that gave you purpose and direction. Your options are to feel empty and useless, perhaps enjoying the spoils of your success until they bore you, or to set new goals and re-enter the cycle of permanent presuccess failure.

I guess I agree with him–if you feel miserable when you've lost 9 pounds because you haven't accomplished your goal yet, and empty after you've lost 10 pounds because you no longer have a goal, then whatever you're calling 'goal setting' is a terrible idea. But that's not what 'goal setting' feels like to me. I feel increasingly awesome as I get closer towards a goal, and once it's done, I keep feeling awesome when I think about how I did it. Not awesome enough to never set another goal again, but awesome enough that I want to set lots more goals to get that feeling again.  

SMART goals

When I work with people as their coach and mentor, they often tell me they've set goals such as "I want to be wealthy," or "I want to be more beautiful/popular," "I want a better relationship/ideal partner." They don't realize they've just described the symptoms or outcomes of the problems in their life. The cause of the problem, that many resist facing, is themselves. They don't realize that for a change to occur, if one is desirable, they must change themselves. Once they make the personal changes, everything around them can alter, which may make the goal irrelevant.

Ray Williams

And? Someone has to change themselves to fix the underlying problem? Are they going to do that more successfully by going with the flow? 

I think the more important dichotomy here is between vague goals and specific goals. I was exposed to the concept of SMART goals (specific, measurable, attainable, relevant, time-bound), at an early age, and though the concept has a lot of problems, the ability to Be Specific seems quite important. You can break down “I want to be beautiful” into subgoals like “I’ll learn to apply makeup properly”, “I’ll eat healthy and exercise”, “I’ll go clothing shopping with a friend who knows about fashion,” etc. All of these feel more attainable than the original goal, and it’s clear when they’re accomplished.

That being said, I have a hard time setting any goal that isn’t specific, attainable, and small. I’ve become more ambitious since meeting lots of LW and CFAR people, but I still don’t like large, long-term goals unless I can easily break them down into intermediate parts. This makes the idea of working on an unsolved problem, or in a startup where the events of the next year aren’t clear, deeply frightening. And these are obviously important problems that someone needs to motivate themselves to work on.

Problematic Goal-Driven Behaviour

We argue that the beneficial effects of goal setting have been overstated and that systematic harm caused by goal setting has been largely ignored. We identify specific side effects associated with goal setting, including a narrow focus that neglects non-goal areas, a rise in unethical behaviour, distorted risk preferences, corrosion of organizational culture, and reduced intrinsic motivation. Rather than dispensing goal setting as a benign, over-the-counter treatment for motivation, managers and scholars need to conceptualize goal setting as a prescription-strength medication that requires careful dosing, consideration of harmful side effects, and close supervision.

Goals Gone Wild 

This is a fairly compelling argument against goal-setting; that by setting an explicit goal and then optimizing towards that goal, you may be losing out on elements that were being accomplished better before, and maybe even rewarding actual negative behaviour. Members of an organization presumably already have assigned tasks and responsibilities, and aren’t just doing whatever they feel like doing, but they might have done better with more freedom to prioritize their own work–the best environment is one with some structure and goals, but not too many. The phenomenon of “teaching to the test” for standardized testing is another example.

Given that humans aren’t best described as unitary selves, this metaphor extends to individuals. If one aspect of myself sets a personal goal to write two pages per day, another aspect of myself might respond by writing two pages on the easiest project I can think of, like a journal entry that no one will ever see. This violates the spirit of the goal it technically accomplishes.

A more problematic consideration is the relationship between intrinsic and extrinsic motivation. Studies show that rewarding or punishing children for tasks results in less intrinsic motivation, as measured by stated interest or by freely choosing to engage in the task. I’ve noticed this tendency in myself; faced with a nursing instructor who was constantly quizzing me on the pathophysiology of my patients’ conditions, I responded by refusing to be curious about any of it or look up the answers to questions in any more detail than what she demanded, even though my previous self loved to spend hours on Google making sense of confusing diseases. If this is a problem that affects individuals setting goals for themselves–i.e. if setting a daily writing goal makes writing less fun–then I can easily see how goal-setting could be damaging.

I also notice that I’m confused about the relationship between Beeminder’s extrinsic motivation, in the form of punishment for derailing, and its effects on intrinsic motivation. Maybe the power of success spirals to increase intrinsic motivation offsets the negative effect of outside reward/punishment; or maybe the fact that users deliberately choose to use Beeminder means that it doesn’t count as “extrinsic.” I’m not sure.

 

Conclusion

There seems to be variation between individuals, in terms of both generally purposeful behaviour, and comfort level with calling it ‘setting goals’. This might be related to success spirals in the past, or it might be a factor of personality and general comfort with order versus chaos. I’m not sure if it’s been studied.

In the past, a lot of creative behaviour wasn’t the result of deliberate goals. This may be a fundamental fact about creativity, or it may be a result of people’s beliefs about creativity (à la ego depletion only happens if you belief in ego depletion) or it may be a historical coincidence that isn’t fundamental at all. In any case, if you aren’t currently getting creative work done, and want to do more, I’m not sure what the alternative is to purposefully trying to do more. Manipulating the environment to make flow easier to attain, maybe. (For example, if I quit my day job and moved to a writers' commune, I might write more without needing to try on a day-to-day basis). 

Process goals, or systems, are probably better than outcome goals. Specific and realistic goals are probably better than vague and ambitious ones. A lot of this may be because it’s easier to form habits and/or success spirals around well-specified behaviours that you can just do every day.

Setting goals within an organization has a lot of potential problems, because workers can game the system and accomplish the letter of the goal in the easiest possible way. This likely happens within individuals too. Research shows that extrinsic motivation reduces intrinsic motivation, which is important to consider, but I'm not sure how it relates to individuals setting goals, as opposed to organizations.

Discussion article for the meetup : Applied Rationality Talks: Thinking in Bayes

Discussion article for the meetup : Applied Rationality Talks: Thinking in Bayes

Introduction

Less Wrong currently represents a tiny, tiny, tiny segment of the population. In its current form, it might only appeal to a tiny, tiny segment of the population. Basically, the people who have a strong need for cognition, who are INTx on the Myers-Briggs (65% of us as per 2012 survey data), etc.

Raising the sanity waterline seems like a generally good idea. Smart people who believe stupid things, and go on to invest resources in stupid ways because of it, are frustrating. Trying to learn rationality skills in my 20s, when a bunch of thought patterns are already overlearned, is even more frustrating.

I have an intuition that a better future would be one where the concept of rationality (maybe called something different, but the same idea) is normal. Where it's as obvious as the idea that you shouldn't spend more money than you earn, or that you should live a healthy lifestyle, etc. The point isn't that everyone currently lives debt-free, eats decently well and exercises; that isn't the case; but they are normal things to do if you're a minimally proactive person who cares a bit about your future. No one has ever told me that doing taekwondo to stay fit is weird and culty, or that keeping a budget will make me unhappy because I'm overthinking thing.

I think the questions of "whether we should try to do this" and "if so, how do we do it in practice?" are both valuable to discuss, and interesting.

 

Is making rationality general-interest a good goal?

My intuitions are far from 100% reliable. I can think of a few reasons why this might be a bad idea:

1. A little bit of rationality can be damaging; it might push people in the direction of too much contrarianism, or something else I haven't thought of. Since introspection is imperfect, knowing a bit about cognitive biases and the mistakes that other people make might make people actually less likely to change their mind–they see other people making those well-known mistakes, but not themselves. Likewise, rationality taught only as a tool or skill, without any kind of underlying philosophy of why you should want to believe true things, might cause problems of a similar nature to martial art skills taught without the traditional, often non-violent philosophies–it could result in people abusing the skill to win fights/debates, making the larger community worse off overall. (Credit to Yan Zhang for martial arts metaphor). 

2. Making the concepts general-interest, or just growing too fast, might involve watering them down or changing them in some way that the value of the LW microcommunity is lost. This could be worse for the people who currently enjoy LW even if it isn't worse overall. I don't know how easy it would be to avoid, or whether

3. It turns out that rationalists don't actually win, and x-rationality, as Yvain terms it, just isn't that amazing over-and-above already being proactive and doing stuff like keeping a budget. Yeah, you can say stuff like "the definition of rationality is that it helps you win", but if in real life, all the people who deliberately try to increase their rationality do worse off overall, by their own standards (or even equally well, but with less time left over for other fun pursuits) than the people who aim for their life goals directly, I want to know that. 

4. Making rationality general-interest is a good idea, but not the best thing to be spending time and energy on right now because of Mysterious Reasons X, Y, Z. Maybe I only think it is because of my personal bias towards liking community stuff (and wishing all of my friends were also friends with each other and liked the same activities, which would simplify my social life, but probably shouldn't happen for good reasons). 

Obviously, if any of these are the case, I want to know about it. I also want to know about it if there are other reasons, off my radar, why this is a terrible idea.

 

What has to change for this to happen?

I don't really know, or I would be doing those things already (maybe, akrasia allowing). I have some ideas, though.

1. The jargon thing. I'm currently trying to compile a list of LW/CFAR jargon as a project for CFAR, and there are lots of terms I don't know. There are terms that I've realized in retrospect that I was using incorrectly all along. This presents both a large initial effort for someone interested in learning about rationality via the LW route, and also might contribute to the looking-like-a-cult thing.

2. The gender ratio thing. This has been discussed before, and it's a controversial thing to discuss, and I don't know how much arguing about it in comments will present any solutions. It seems pretty clear that if you want to appeal to the whole population, and a group that represents 50% of the general population only represents 10% of your participants (also as per 2012 survey data, see link above), there's going to be a problem somewhere down the road.

My data point: as a female on LW, I haven't experienced any discrimination, and I'm a bit baffled as to why the gender ratio is so skewed in the first place. Then again, I've already been through the filter of not caring if I'm the only girl at a meetup group. And I do hang out in female-dominated groups (i.e. the entire field of nursing), and fit in okay, but I'm probably not all that good as a typical example to generalize from. 

3. LW currently appeals to intelligent people, or at least people who self-identify as intelligent; according to the 2012 survey data, the self-reported IQ median is 138. This wouldn't be surprising, and isn't a problem until you want to appeal to more than 1% of the population. But intelligence and rationality are, in theory, orthogonal, or at least not the same thing. If I suffered a brain injury that reduced my IQ significantly but didn't otherwise affects my likes and dislikes, I expect I would still be interested in improving my rationality and think it was important, perhaps even more so, but I also think I would find it frustrating. And I might feel horribly out of place.

4. Rationality in general has a bad rap; specifically, the Spock thing. And this isn't just affecting whether or not people thing Less Wrong the site is weird; it's affecting whether they want to think about their own decision-making.

This is only what I can think of in 5 minutes...

 

What's already happening?

Meetup groups are happening. CFAR is happening. And there are groups out there practicing skills similar or related to rationality, whether or not they call it the same thing.

 

Conclusion

Rationality, Less Wrong and CFAR have, gradually over the last 2-3 years, become a big part of my life. It's been fun, and I think it's made me stronger, and I would prefer a world where as many other people as possible have that. I'd like to know if people think that's a) a good idea, b) feasible, and c) how to do it practically.

Related to: Is Rationality Teachable

“Critical care nursing isn’t about having critically ill patients,” my preceptor likes to say, “it’s about critical thinking.”

I doubt she's talking about the same kind of critical thinking that philosophers are, and I find that definition abstract anyway. There’s been a lot of talk about critical thinking during our four years of nursing school, but our profs seem to have a hard time defining it. So I’ll go with a definition from Google.

Critical thinking can be seen as having two components: 1) a set of information and belief generating and processing skills, and 2) the habit, based on intellectual commitment, of using those skills to guide behaviour. It is thus to be contrasted with: 1) the mere acquisition and retention of information alone, because it involves a particular way in which information is sought and treated; 2) the mere possession of a set of skills, because it involves the continual use of them; and 3) the mere use of those skills ("as an exercise") without acceptance of their results.¹

That’s basically rationality–epistemic, i.e. generating true beliefs, and instrumental, i.e. knowing how to use them to achieve what you want. Maybe part of me expected, implicitly, to have an easier time learning this skill because of my Less Wrong knowledge. And maybe I am more consciously aware of my mistakes, and the cognitive factors that caused them, than most of my classmates. When it’s forty-five minutes past the end of my shift and I’m still charting, I’m also calling myself out on succumbing to the planning fallacy. I once went through the first half hour of a shift during my pediatrics rotation thinking that one of my patients had cerebral palsy, when he actually had cystic fibrosis–all because I misread my prof’s handwriting as ‘CP’ when she’d written ‘CF’. I was totally confused by all the enzyme supplements on his list of meds, but it still took me a while to figure it out–a combination of priming and confirmation bias, taken to the next level. 

But, overall, even if I know what I'm doing wrong, it hasn’t been easier to do things right. I have a hard time with the hospital environment, possibly because I’m the kind of person who ended up reading and posting on Less Wrong. My cognitive style leans towards Type 2 reasoning, in Keith Stanovich’s taxonomy–thorough, but slow. I like to understand things, on a deep level. I like knowing why I’m doing something, and I don’t trust my intuitions, the fast-and-dirty product of Type 1 reasoning. But Type 2 reasoning requires a lot of working memory, and humans aren’t known for that, which is the source of most of my frustration and nearly all of my errors–when working memory overload forces me to be a cognitive miser.

Still, for all the frustration, I’m pretty sure I’ve ended up in the perfect environment to learn this skill called ‘critical thinking.’ I’m way out of my depth–which I expected. No fourth year student is ready to work independently in a trauma ICU, but I decided to finish my schooling here in the name of tsuyoku naritai, and for all the days when I’ve gone home crying, it’s still worth it. I’m learning.

 

The skills

 1.     A set of information and belief generating and processing skills.

Medicine, and nursing, are a bit like physics, in that you need to generate true beliefs about systems that exist outside of you, and predict how they’re going to behave. This involves knowing a lot of abstract theory, which I’m good at, and a lot of heuristics and pattern-matching for applying the right bits of theory to particular patients, which I’m less good at. That’s partly an experience thing; my brain needs patterns to match to. But in general, I have decent mental models of my patients. I’m curious and I like to understand things. If I don’t know what part of the theories applies, I ask.

2.     The habit, based on intellectual commitment, of using those skills to guide behaviour.

So you’ve got your mental model of your patient, your best understand of what’s actually going on, on a physiological and biochemical level, down under the skin where you can’t see it. You know what “normal” is for a variety of measures: vital signs, lung sounds, lab values, etc. Given that your patient is in the ICU, you know something’s abnormal, or they wouldn’t be there. Their diagnosis tells you what to expect, and you look at the results of your assessments and ask a couple of questions. One: is this what I expect, for this patient? Two: what do I need to do about it?

I’m not going to be surprised if a post-op patient has low hemoglobin. It’s information of a kind, telling the doctor whether or not the patient needs a transfusion, and how many units, but it’s not really new information, and a moderately abnormal value wouldn’t worry me or anyone else. If their hemoglobin keeps dropping; okay, they’re actively bleeding somewhere, that’s irritating, and possibly dangerous, and needs dealing with, but it’s not surprising.

But if a patient here for an abdominal surgery suddenly has decreased level of consciousness and their pupils aren’t reacting normally to light, I’m worried. There’s nothing in my mental model that says I should expect it. I notice I’m confused, and that confusion guides my behaviour; I call the doctor right away, because we need more information to update our collective mental model, information you can’t get just from observation, like a CT scan of the head. (Even this is optimistic–plenty of patients are admitted to the ICU because we have no idea what’s wrong with them, and are hoping to keep them alive long enough to find out.)

The basics of ICU nursing come down to treating numbers. Heart rate, blood pressure, oxygen saturations, urine output, etc; know the acceptable range, notice if they change, and use Treatment X to get them back where they’re supposed to be. Which doesn’t sound that hard. But implicit in ‘notice if they change’ is ‘figure out why they changed’, because that affects how you treat them, and implicit in that is a lot of background knowledge, which has to be put in context.

I’m, honestly, fairly terrible at this. It’s a compartmentalization thing. I don’t like using my knowledge as input arguments to generate new conclusions and then relying on those conclusions to treat human beings. It feels like guessing. Even though, back in high school, I never really needed to study for physics tests–if I understood what we’d learned, I could re-derive forgotten details from first principles. But hospital patients ended up in a non-overlapping magisterium in my head. In order for me to trust my knowledge, it has to have come directly from the lips of a teacher or experienced nurse.

My preceptor, who  hates this.  “She needs to continue to work on her critical thinking when it comes to caring for critically ill patients,” she wrote on my evaluation. “She knows the theory, and is now working to apply it to ICU nursing.” Shorthand for, she knows the theory, but getting her to apply it to ICU nursing is like pulling teeth. A number of our conversations have gone like this:

Me: “Our patient’s blood pressure dropped a bit.”

Her: “Yeah, it did. What do you want to do about it?”

Me: “I, uh, I don’t know... Should I increase the vasopressors?”

Her: “I don’t know, should you?”

Me: “Uh, maybe I should increase the phenylephrine to 40 mcg/min and see what happens. How long should I wait to see?”

Her: “You tell me.”

Me: “Well, let’s say it’ll take a few minutes for what’s in the tubing now to get pushed through, and it should take effect pretty quickly because it’s IV, like a minute... So if his blood pressure’s not up enough in five minutes, I’ll increase the phenyl to 60. Does that sound okay?”

Her: “It’s your decision to make." 

Needless to say, I find this teaching method extremely stressful and scary, and I’m learning about ten times more than I would if she answered the questions I asked. Because “the mere acquisition and retention of information alone” isn’t my problem. I have a brain like an encyclopaedia. My problem, in the critical care nursing context, is the “particular way in which information is sought and treated.” I need to know the right time to notice something is wrong, the right place to look in my encyclopaedia, and the right way to take the information I just looked up and figure out what to do with it.

 

The mistakes

Some of my errors, unsurprisingly, boil down to a failure to override inappropriate Type 1 responses with Type 2 responses–in other words, not thinking about what I’m doing. But most of them are more of a mindware gap–I don’t yet have the “domain-specific knowledge sets” that the nurses around me have. Not just theory knowledge; I do have most of that; but the procedural habits of how to stay organized and prioritize and dump the contents of my working memory onto paper in a way that I can read them back later. Usually, when I make a mistake, I knew better, but the part of my brain that knew better was doing something else at the time, that small note of confusion getting lost in the general chaos. 

Pretty much all nurses keep a “feuille de route”–I have yet to find a satisfactory English word for this, but it’s a personal sheet of paper, not legal charting, usually kept in a pocket, and used as an extended working memory. In med/surg, when I had four patients, I made a chart with four columns; name and personal information, medications, treatments/general plan for the day, and medical history; and as many rows as I had patients. If something was important, I circled it in red ink. This system doesn’t work in the ICU, so my current feuille de route has several aspects. I fold a piece of blank paper into four, and take notes from the previous shift report on one quarter of one side, or two quarters if it’s a long report. Across from that, I draw a vertical column of times, from 8:00 am to 6:00 pm (or 8:00 pm to 6:00 am). 7:00 pm and 7:00 am are shift change, so nothing else really gets done for that hour. I use this to scribble down what I need to get down during my twelve hours, and approximately when I want to do it, and I prioritize, i.e. from 1 to 5 most to least important. Once it’s done, I cross it off–then I can forget about it. On the other side of the paper, I make a cheat sheet for giving report to the next nurse, or presenting my patient to the doctors at rounds.  

This might be low-tech and simple, but it takes a huge load off my working memory, and reduces my most frequent error, which is to get so overwhelmed and frazzled that my brain goes on strike. In other words, the failure to override Type 1 responses due to the lack of cognitive capacity to run a Type 2 process. It’s drastically cut down on the frequency of this mental conversation:

Me: “I turned off the sedation, and my patient isn’t waking up as fast as I expected. I notice I’m confused–”

My brain: “You’re always confused! Everything around here is intensely confusing! How am I supposed to use that as information?” 

Odd as it might sound, I often don’t notice when my brain starts edging towards a meltdown. The feeling itself is quite recognizable, but the circumstances that lead to it, i.e. overloaded working memory, mean that I’m not usually paying attention to my own feelings.

“You need to stop and take a breath,” my preceptor says about fifty times a day. Easier said than done–but it’s more efficient, overall, to have a tiny part of my mind permanently on standby, keeping an eye on my emotions, noticing when the gears start to overheat. Then stop, take a breath, and let go of everything except the task at hand, trusting myself to have created enough cues in my environment to retrieve the other tasks, once I’m done. Humans don’t multitask well. Doing one thing while trying to remember a list of five others is intense multitasking, and it’s no wonder it’s exhausting.

 

The implications

“You can’t teach critical thinking,” my preceptor says, but I’m pretty sure that’s exactly what she’s doing right now. A great deal of what I already know is domain-specific to nursing, but most of what I’m learning right now is generally applicable. I’m learning the procedural skills to work through difficult problems, under what Keith Stanovich would call average rather than optimal conditions. Sitting in my own little bubble in front of a multiple choice exam–that’s optimal conditions. Trying to figure out if I should be surprised or worried about my patient’s increased heart rate, while simultaneously deciding whether or not I can ignore the ventilator alarm and whether I can finish giving my twelve o’clock antibiotic before I need to do twelve o’clock vitals–that’s not just average conditions, it’s under-duress conditions.

I’m hoping that after a few more weeks, or maybe a few more years, I’ll be able to perform comfortably in this intensely terrifying environment. And I’m hoping that some of the skills I learn will be general-purpose, for me at least. It’d be nice if they were teachable to others, too, but I think my preceptor might be right about one thing–you can’t teach this kind of critical thinking in the classroom. It's about moulding my brain into the right shape, and everyone's brain starts out in a different shape, so the mould has to be personalized. 

But the habits are general ones. Notice when you're faced with a difficult problem, or making an important decision. Notice that you're doing this while distracted. Stop and take a breath. Get out a piece of paper. Figure out how the problem is formatted in your mind, and format it that way on the paper. (This is probably the hardest part). Dump your working memory and give yourself space to think. Prioritize from 1 to n. Keep an eye on the evolving situation, sure, but find that moment of concentration in the midst of chaos, and solve the problem. 

Of course, it's far from guaranteed that this will work. I'm making an empirical prediction; that the skills I'm currently learning will be transferable to non-nursing areas, and that they'll make a difference in my life outside of work. I'll be on the lookout for examples, either of success or failure.

 

References

Scriven, Michael; Paul, Richard. Defining critical thinking. (2011). The critical thinking community. http://www.criticalthinking.org/pages/defining-critical-thinking/410

 

I am currently running a study on depression, in collaboration with Shannon Friedman (http://lesswrong.com/user/ShannonFriedman/overview/). If you are interested in participating, the study involves filling out a survey and will take a few minutes of your time (half an hour would be very generous), most likely once a week for four weeks. Send me an email at mdixo100@uottawa.ca, and I can give you more details. 

 

Thank you!

This is a post about something I noticed myself doing this year, although I expect I’ve been doing it all along. It’s unlikely to be something that everyone does, so don’t be surprised if you don’t find this applies to you. It's also an exercise in introspection, i.e. likely to be inaccurate. 

Intro

If I add up all the years that I’ve been in school, it amounts to about 75% of my life so far–and at any one time, school has probably been the single activity that I spend the most hours on. I would still guess that 50% or less of my general academic knowledge was actually acquired in a school setting, but school has tests, and grades at the end of the year, and so has provided most of the positive/negative reinforcement related to learning. The ‘attitudes to learning’ that I’m talking about apply in a school setting, not when I’m learning stuff for fun.

Role #1: Overachiever

Up until seventh grade, I didn’t really socialize at school–but once I started talking to people, it felt like I needed a persona, so that I could just act ‘in character’ instead of having to think of things to say from scratch. Being a stereotypical overachiever provided me with easy material for small talk–I could talk about schoolwork to other people who were also overachievers.

Years later, after acquiring actual social skills in the less stereotyped environments of part-time work and university, I play the overachiever more as a way of reducing my anxiety in class. (School was easy for me up until my second year of nursing school, when we started having to do scary things like clinical placements and practical exams, instead of nice safe things like written exams.) If I can talk myself into always being curious and finding everything exciting and interesting and cool I want to do that!!!, I can’t find everything scary–or, at the very least, to other people it looks like I’m not scared.

 

Role #2: Too Cool for School

This isn’t one I’ve played too much, aside from my tendency to put studying for exams as maybe my fourth priority–after work, exercise, and sleep–and still having an A average. (I will still skip class to work a shift at the ER any day, but that doesn’t count–working there is almost more educational than class, in my mind.) As one of my LW Ottawa friends pointed out, there’s a sort of counter-signalling involved in being a ‘lazy’ student–if you can still pull off good grades without doing any work, you must be smart, so people notice this and respect it.

My brother is the prime example of this. He spent grades 9 through 11 alternately sleeping and playing on his iPhone in class, and maintained an average well over 80%. In grade 12 he started paying attention in class and occasionally doing homework, and graduated with, I believe, an average over 95%. He had a reputation throughout the whole school–as someone who was very smart, but also cool.

 
Role #3: Just Don’t Fail Me!

Weirdly enough, it wasn’t at school that I originally learned this role. As a teenager, I did competitive swimming. The combination of not having outstanding talent for athletics, plus the anxiety that came from my own performance depending on how fast the other swimmers were, made this about 100 times more terrifying than school. At some point I developed a weird sort of underconfidence, the opposite of using ‘Overachiever’ to deal with anxiety. My mind has now created, and made automatic, the following subroutine: “when an adult takes you aside to talk to you about anything related to ‘living up to your potential’, start crying.” I’m not sure what the original logic behind this was: get the adult to stop and pay attention to me? Get them to take me more seriously? Get them to take me less seriously? Or just the fact that I couldn’t stomach the fact of being ordinarily below average at something–I had to be in some way differently below average. Who knows if there was much logic behind it at all?  

Having this learned role comes back to bite me now, sometimes–the subroutine gets triggered in any situation that feels too much like my swim coach’s one-on-one pre-competition pep talks. Taekwondo triggers it once in a while. Weirdly enough, being evaluated in clinicals triggers it too–this didn’t originally make much sense, since it’s not competitive in the sense of ‘she wins, I lose.’ I think the associative chain there is through lifeguarding courses–the hands-on evaluation aspect used to be fairly terrifying for my younger self, and my monkey brain puts clinicals and lab evaluations into that category, as opposed to the nice safe category of written exams, where I can safely be Too Cool for School and still get good grades.  

The inconvenience of thinking about school this way really jumped out at me this fall. I started my semester of clinicals with a prof who was a) spectacularly non-intimidating compared to some others I’ve had, and b) who liked me from the very start, basically because I raised my hand a lot and answered questions intelligently during our more classroom-y initial orientation. I was all set up for a semester of playing ‘Overachiever’, until, quite near the beginning of the semester, I was suddenly expected to do something that I found scary, and I was tired and scared of looking confident but being wrong, and I fell back on ‘Just Don’t Fail Me!’ My prof was, understandably, shocked and confused as to why I was suddenly reacting to her as ‘the scary adult who has the power to pass or fail me and will definitely fail me unless I’m absolutely perfect, so I had better grovel.’ I think she actually felt guilty about whatever she had done to intimidate me–which was nothing.

Since then I’ve been doing fine, progressing at the same rate as all the other students (maybe it says something about me that this isn’t very satisfying, and even kind of feels like failure in itself...I would like to be progressing faster). That is, until I’m alone with my prof and she tries to give me a pep talk about how I’m obviously very smart and doing fine, so I just need to improve my confidence. Then I start crying. At this point, I’m pretty sure she thinks I should be on anti-depressants–which is problematic in itself, but could be more problematic if she was the kind of prof who might fail me in my clinical for a lack of confidence. There’s no objective reason why I can’t hop back into Overachiever mode, since I managed both my clinicals last spring entirely in that mode. But part of my brain protests: ‘she’s seen you being insecure! She wouldn’t believe you as an overachiever, it would be too out of character!’ It starts to make sense once I stop seeing this behaviour as 'my learning style' and recognize it as a social role that I, at some point, probably subconsciously, decided I ought to play.

 

Conclusion

The main problem seems to be that my original mental models for social interaction–with adults, mostly–are overly simplistic and don’t cut reality at the joints. That’s not a huge problem in itself–I have better models now and most people I meet now say I have good communication skills, although I sometimes still come across as ‘odd’. The problem is that every once in a while, a situation happens, pattern recognition jumps into play, and whoa, I’m playing ‘Just Don’t Fail Me’. (It’s happened with the other two roles too, but they’re is less problematic.) Then I can’t get out of that role easily, because my social monkey brain is telling me it would be out of character and the other person would think it was weird. This is despite the fact that I no longer consciously care if I come across as weird, as long as people think I’m competent and trustworthy and nice, etc.

Just noticing this has helped a little–I catch my monkey brain and remind it ‘hey, this situation looks similar to Situation X that you created a stereotyped response for, but it’s not Situation X, so how about we just behave like a human being as usual’. Reminding myself that the world doesn’t break down into ‘adults’ and ‘children’–or, if it did once, I’m now on the other side of the divide–also helps. Failing that, I can consciously try to make sure I get into the 'right’ role–Overachiever or Too Cool For School, depending on the situation–and make that my default. 

Has anyone else noticed themselves doing something similar? I’m wondering if there are other roles that I play, maybe more subtly, at work or with friends. 

 

I'm currently writing an essay for one of my classes, 'Theoretical Foundations of Nursing.' I'm about the most 'gong-si' class I've ever taken. (That is a Chinese term for 'shit talking,' which is my boyfriend's favourite term for any field that gets into arguments over definitions, has concepts that don't correspond to any empirical phenomena, is based on ideology, etc.)

The essay involves analyzing a clinical situation (in this case a 55-year-old recently divorced, recently unemployed man, admitted to the psychiatric ward with major depression and suicidal ideation) using a theory (in this case, Roy's Adaptation Model). Done. The next step involves finding criticisms with the model...and despite the fact that I've been complaining about this class and its non-empirical nature all semester, I seem unable to come up with specific criticisms of what this nursing theory is missing. 

Which is what I need your help for, because LessWrong is the best community ever when it comes to specific criticisms. 

Here is a very brief overview of Roy's Adaptation Theory:

• Defines 'health' as 'state or process of becoming integrated with the environment, in the domains of survival, growth, reproduction, mastery, and personal/environmental transformation.' 
• Defines a 'person' as an 'adaptive system with coping processes.' Goes on to subdivide this a bit: there are 'regulator mechanisms' (i.e. innate, not consciously controlled) and 'cognitive mechanisms' of adaptation within four different modes: physiological, role function, interdependence, and self-concept. 
• Defines environment as 'all conditions, circumstances, and influences that affect the development and behavior of individuals and groups.' Further subdivides environmental stimuli into focal (which demand the person to immediately adapt), contextual (which affect how they adapt), and residual (i.e. attitudes, beliefs). 
• The nurse's goal is to manipulate stimuli to improve the person's level of adaptation, as well as teaching more effective coping methods. 
• The steps in the process of creating a care plan are: assessment of behavior, assessment of stimuli, choosing a nursing diagnosis from this huge lookup table, setting a goal, choosing an intervention, and evaluation the results. 

Now my question is, what is a specific criticism I can make of this particular theory in general...not "your definitions aren't specific enough" or "the whole field of nursing theory isn't reductionist enough", but something that this kind of theory should have but doesn't. Any ideas?