One of the only times I have a chance to think without distraction is while riding a motorcycle. What does a guy like me think about when I’m tooling around on curvy roads? Well, stuff like this. Here are some things I’ve learned about motorcycles and how they apply to medicine.
Often repeated aphorisms are rarely true (or based on good evidence at least).
Every culture has its axioms, dogmas, and aphorisms: little nuggets of wisdom passed on from rider to rider – or doctor to doctor. Most of them are bogus. They are presented as self-evident truths and packaged as neat little earworms, but the thing about self-evident truths is that they are self-evident. In other words, if someone has to share the saying with you, it’s probably flawed in the first place.
In the motorcycle world, “Loud pipes save lives” is one such example. It’s not true. The thought is that we can make ourselves more noticeable to car drivers by generating more noise pollution. But this argument is not scientific, evidence-based, or even logical if it is properly analyzed.
In medicine, clever sayings such as “dilution is the solution to pollution” (advocating for routine irrigation during surgeries ) are often patently false. Neat pearls of wisdom like vitamins are good for you or stress causes heart disease or thousands of other examples are usually wrong. These ideas are often promoted because they support some preexisting beliefs or practices.
The lesson is not to fall prey to narrative fallacies and motivated reasoning but rather to make decisions based upon empiric evidence, not theory (skeptical empiricism vs theorism).
Always ride with a clear head.
The quickest way to get killed on a motorcycle is not to be mentally present while riding. Riding requires all of your attention and even a few seconds of distraction can lead to a serious accident. Riding a bike is far less forgiving than driving a car. You should be constantly scanning for danger and trying to anticipate the moves of other drivers before they make them. You must focus.
If you are upset emotionally or tired mentally or physically or if your reflexes and thought processes are dulled by alcohol or drugs, a bike ride might easily lead straight to the morgue. Nearly half of all motorcycle fatalities involve alcohol. The lesson is to ride with a clear and sober head.
In medicine, we talk about cognitive dispositions to respond (CDRs) and how those dispositions affect our thinking and mistakes we might make. These CDRS include things like cognitive biases and logical fallacies that pervert our thoughts but also our emotional state. A physician who is under great personal stress (problems with family life or finances) or a physician who has a physical or psychological impairment (substance abuse, health problems, etc.) may also respond differently given a challenging clinical scenario. Distraction, burn-out, cynicism, substance abuse, fatigue, an abusive work environment, depression, anxiety, stress, too heavy a workload, interpersonal conflict, and a variety of other issues can all affect a physician’s cognitive function in a very negative way, leading to sometimes profound mistakes. We need to come to work with a clear head, too.
Old things can still be fun.
There’s nothing wrong with an old, vintage bike. If it still runs, the sounds and smells and feelings of riding it are irreplaceable. If it doesn’t run, the joy of resurrecting its soul is its own beautiful experience. Classics are classics for a reason. New bikes definitely have their place and every motorcycle gearhead loves the latest suspensions and tires and engines and technology. But the old stuff definitely has a home.
In medicine, we are too often drawn to flashy new things, whether it’s new drugs, surgical devices, or even “evidence.” We scorn and discount virtually everything old and have a preference (a bias) for new things. This is part of what is called the optimism bias or perhaps the newness fallacy. It’s why gynecologists perform robotic or endoscopic hysterectomies when they should be doing vaginal hysterectomies or why doctors prescribe too many branded drugs when a generic might work just as well. New isn’t always better.
The bike keeps itself upright, not you.
A lot of riders believe that they have good balance because they can ride a motorcycle or that they have to constantly adjust the handlebars to keep the bike upright. Nope. The bike balances itself and if you put a rubber band and a popsicle stick on the throttle the bike will continue to drive by itself until it hits something. In fact, not realizing this can get you hurt. If you ride over large gravel, for example, and the bike mushes around you might actually cause an accident by trying to provide stability with the handlebars. Just relax. As long as it’s moving forward fast enough it will self-correct due to gyroscopic forces. This is an example of an illusion of control.
In medicine, illusions of control are everywhere. When an Ob/Gyn uses a tocolytic drug to treat preterm labor, she is trying to exercise control over something she cannot control. Worse, like riding on gravel, she might even be causing harm due to side-effects of the medications. This is a common problem. The solution is to understand the evidence and the magnitude of effect for things you do so that you can guard against an illusion of control.
The faster you go, the more stable you are.
It might seem scary, but the faster you ride, the more stability the bike has due to the huge gyroscopes under your butt. At speed, it’s almost impossible to fall over whereas at slower speeds dropping the bike is a real possibility. Even in the corners, higher speeds make more downforce and therefore more contact between the rubber and the concrete, providing more friction. Of course, there is a limit to everything and you obviously can go too fast.
Still, the faster you go, the more significant the crash. There are all sorts of tradeoffs like this on a motorcycle. When you do crash going fast, it easily could be fatal whereas slower crashes almost never are. It’s a tradeoff. You need to go fast to be stable but you have to accept some risk to be stable. Less likely to crash, more likely to die going fast. More likely to crash, less likely to die going slow. Somewhere there is a perfect balance of risk and benefit.
All of medical science centers around balancing risk and benefit. We put people to sleep and cut their bodies open or prescribe chemotherapy (riding fast) because we believe the risk is worth the benefit. Finding that sweet spot is everything. We illustrate this using receiver operator curves formally but we do it every day when we prescribe treatments. Everything has risk and sometimes taking one risk reduces another more important risk. Too little and too much of anything can kill you. Learn to find the sweet spot. Fear of risk and unnecessary risk aversion are often our biggest enemies on a motorcycle and in medicine. Fear, by the way, causes anxiety, and too much anxiety can cause your performance to suffer negatively.
Stay in your lane.
It should go without saying but staying in your line is important. Taking the corner too fast and drifting into oncoming traffic or off the road is a quick way to die.
Staying in your lane in medicine is just as important. Too many doctors dabble in things beyond their expertise. Patients are harmed as a consequence. It’s okay to do lots of things but be positive that you are competent and adequately trained.
Passion is a great thing.
Most motorcyclists are passionate people. They ride every chance they get. They practice and challenge themselves to be better. The find new places to ride and new adventures. They love the smells and sounds and vibrations on the bike. They read and watch videos and go to rallies. They throw a wave to fellow riders whenever they see one.
Medicine should be that way, too. Passion leads to joy. Passion leads to competence. Passion leads to excellence. Passion is everything.
Looks at what’s coming, not what’s here or behind you.
On a motorcycle, the thing most likely to kill you is the curve or car or obstacle down the road. You need to plan for what’s coming now. Slow down for the curve, swerve for the obstacle, or get out of the way of that car. Yes, you need situational awareness and you definitely need to know what’s going on around you but down the road is where you should focus most of your attention. You better spend most of your time on what’s coming up, not on what’s behind you.
It’s true of life, too. Your past and present definitely are formative for your future. Be thankful for previous good decisions and forget the bad ones. Accept where you are right now and don’t bemoan it. But look to the future. Make progress right now towards where you want/need to be and you’ll get there alive (even if the progress is small). Aim the bike in the right direction and you will get there eventually, even if you’re not going very fast. Aim in the wrong direction and you’re just getting further away from your goals. Keep your eyes down the road in the right direction.
Same thing in medicine. Learn from your mistakes and capitalize on your successes but dwell on neither. What you are doing right now should be informed by where you want to go. It’s never too late to do the right thing. It’s never too late to learn.
Guys with bright lights are jerks.
It’s always like this: some guy in a lifted pickup truck with Xeon headlamps stuck on bright driving toward you on a super dark, curvy road. Your visibility is instantly gone and you either pray that you can remember how the road goes and that nothing jumps out in front of you or you slow down or even stop until he passes. He never even puts the lights on dim. He cares only about his ability to see and be seen (from a mile away). He aftermarket modified his truck just so his weak eyes could be better served. He is a jerk.
Medicine has it’s share of jerks, too. Believe me. There are lots of greedy, narcissistic, self-centered people who call themselves doctors. Most of them are incompetent. They don’t play by the same rules that you do. They don’t care about you (let alone their patients). They will run over whoever they need to in order to get where they want to go. All you can do is recognize that they are there and take evasive action when you see them. Unfortunately, you don’t always realize how big of jerks they are until things are dark. When you need them to be helpful the most is when they are the least helpful. Don’t be surprised by it when it happens and protect yourself.
It’s nice to ride with friends.
One of the true joys of riding is sharing the experience with someone else. Many friendships have been made on two wheels. What’s more, if the worst should happen (like an accident or a flat or a breakdown), your buddy will prove invaluable (might even save your life).
Same for medicine. A good partner is the best feeling in the world. Helpful consultants whom you can trust are irreplaceable. Your patients will benefit and so will you. When you feel burnt out or oppressed, a physician friend can actually save your life (yeah, I’m talking about suicide).
Don’t let some car (or another rider) push you to go faster on a dangerous road.
It’s not a competition. The goal is to get home alive. Sometimes a car behind you is impatient and you feel pressured to ride faster than you are comfortable riding. Don’t. Or you’re riding with a buddy who has a faster bike and she has more experience. Let her go. You’ll catch up. You do you. Know your limitations and ride within them.
In medicine, too, you aren’t competing with anyone but yourself. Your patients’ health and safety are what’s important. Know your limitations. Ask for help when you need it. Work at a speed that allows you to perform safely. Getting home alive is the goal.
Things don’t always work the way you think they do.
Pop quiz: Look at the handlebars above. If you want to go to the left with the bike, what do you do? Do you turn the handlebars to the left (that is, pull on the left handle and push on the right handle) or do you turn the handlebars to the right (push on the left handle and pull on the right handle)? Turn them to the left, you say? Wrong. If you want to go left you must turn the handlebars to the right. Yes, your instincts are completely wrong. Doesn’t make sense? Don’t worry. Most riders don’t even understand this though if you film them with high-speed photography, they all do it. Every single person who rides a motorcycle or bicycle at any speed more than a few miles per hour turns handlebars the opposite direction they want the bike to go without even realizing it in many cases. The concept is called countersteering and it is definitely counter-intuitive. Bar fights have ensued over a poor understanding of this concept. I’ll let you Google or YouTube it if you want to understand countersteering better.
The point is that a lot of things don’t work as you assume. Sometimes, you don’t even realize what it is that you are doing that is working. You may be doing the exact opposite of what you think you are doing.
In medicine, this is even more true. People do things every day that do work but they have no concept about why they work. Worse, they make up a reason that is often incorrect or even completely opposite of the truth. Don’t make assumptions. Use a scientific approach to understand what we do and don’t rely on your instinct. Take nothing for granted. Assume that even the most basic and obvious assumptions you make could be exactly wrong.
Weaknesses are magnified when the stakes are high.
An “average” rider never really knows quite how average he is until he is in circumstances that really test his mettle. Weekend warriors who think they are the bee’s knees on a bike are unaware of just how bad they are at a lot of motorcycle skills. But go on to track day or tackle a windy road a little too fast or drive when you’re tired or your reflexes are impaired (yes I’m talking about weed and alcohol) and you’ll soon find out that you’re not as good as you thought.
In medicine, poor skills are common: poor diagnostic skills, poor physical exam skills, poor surgical skills, poor cognitive skills. Yet, most patients do okay and have reasonable outcomes because most patients and most patient problems are easy. But the patients who get hurt by some doctor’s averageness are the ones who are difficult: complex or rare diagnoses, complex or difficult anatomy, etc. Your goal as a physician should not be to be good enough for most people, it should be to be the best for everyone.
Advanced techniques may be dangerous for beginners.
One thing you’ll learn in your motorcycle safety course is to never apply the brake while in a corner; it could kill you as you lose traction when the physics are most against you. Good advice; take it. In fact, if the instructors see you apply the brake light during your practical exam, they will probably fail you. Later, though, you might watch a MotoGP race and note that nine-time World Champion Valentino Rossi’s brake light is on throughout virtually every corner. What gives? In this case, he is trail braking, an advanced technique that allows him to brake in the corner safely. Most advanced riders do this. But just because Rossi does it doesn’t mean you should, at least not until you’ve mastered the basics (if you want to stay alive).
Same in surgery. I’m quite good at vaginal hysterectomy. I use some of the most advanced techniques in the world to perform nearly 100% of all hysterectomies vaginally. But you need to work up to what I do. The same techniques just aren’t right for beginners. Take your time. Learn. Pay your dues. No one learns how to master anything overnight and the basics definitely come first.
A certain level of competency is essential.
Have I tempted you into taking the two-wheeled plunge? Be warned: a certain level of competency is essential before you get on the steel horse. You need to master several fundamental driving and safety skills before you ever think about getting on a real road. Take a safety course. Remember, you can’t safely ride if you can’t change gears, brake, turn, use the clutch, etc. All of these skills and more are essential. If any basic competency is missing, you might find yourself dead. Medicine is no different. There are no shortcuts to becoming a competent physician, though a lot of people try to make some. You have to put in the work, read the books, practice, study, etc. An online review course and passing a multiple-choice exam does not equal competency. Make sure you know what physician competency means (you can start by reading this) and then work on it as if your life depended on it. Your patient’s life does.
On dirt, keep it in gear even when it’s easy.
If you’re going downhill on a dirt bike, you might be tempted to pop it in neutral and coast; don’t. You never know when you might need to grab some gear to correct a slide.
Same in medicine. Yes, a lot of what we do and a lot of our days are easy and mundane. But don’t be fooled. That’s when we get blindsided by mistakes. Don’t be lulled into overconfidence. Are you certain of the diagnosis? Ask what else it might be. Know the best way to treat some diseases? Look it up every few months anyway. Can you do that surgery in your sleep? Read the latest evidence anyway and find ways to improve. Keep it in gear.
The rut is usually best (especially in the beginning).
This is another lesson from dirt bikes. If you are starting a new course or mountain path, it’s a good idea to go in the ruts that are already there, at least until you know what you’re doing and know the path well. Even then, those ruts are usually best but sometimes you’ll improve the course by making new ruts in better places.
Medicine is no different. If you are learning a new surgery, best do it the way the book says. You might develop a new and better technique later, but master what has been done already before you venture off if you want to stay out of serious trouble.
Don’t change gears while popping a wheely.
Popping a wheely is one thing. It’s hard enough on its own but adding more unnecessary complexity can make it far more difficult. If your shift isn’t very smooth, the bottom of the bike might lurch forward and you’ll find your knees banged up and your bike upside down. Be happy just popping wheelies.
In medicine, we do many complex tasks, especially in surgery. The goal of any procedure or task should be to reduce complexity. Albert Einstein said,
Everything should be made as simple as possible, but no simpler.
Reduction of cost and error and in procedures and surgeries comes from a clear understanding of what is necessary (and always doing those things after deliberate practice) and eliminating what is not necessary. We should strive to reduce complexity wherever we can. It is the fundamental philosophy behind Lean, Six Sigma, and other process improvement strategies. If you must change gears while popping wheelies, become an expert at each individually before integrating them together.
You have to take some chances to have some fun.
Of course, you might get killed taking chances. Try not to take them unnecessarily. But even choosing to ride a motorcycle at all involves some risk. The average rider has around a 1 in 50 chance or so that she will die on a motorcycle in her lifetime. I can make my risk lower just by not drinking, so maybe a 1% risk. By comparison, I have a 1 in 300 chance of dying in a car accident in my lifetime. But death is inevitable. Many physicians would criticize me for doing something as “stupid” as riding a motorcycle, especially since its something I “choose” rather than something I “must” do. But in the weeks of the COVID-19 pandemic, I will just point this out: I chose to become a doctor to help people and I will continue to practice medicine during the pandemic. I am diabetic and hypertensive; according to data current as of this writing, I have about a 1 in 12 chance of dying in the next three months because I “choose” to practice medicine. Yet, here I am. Everything in life is a risk.
Now I am a very safe motorcyclist. Of course, that’s what we all say or think. But just now as I was driving my car, a dude on a Kawasaki came flying past me on the interstate. He must’ve been doing at least 110 because I was doing 80. He was only wearing shorts and a T-shirt but he was at least wearing a full-face helmet.
But I couldn’t help but cheer him on. I know at that moment on that motorcycle he truly felt alive. Much more alive than me in my Volkswagen station wagon wearing my seatbelt. A few minutes earlier I heard the Passenger song Let Her Go on the radio. He sings,
Well you only need the light when it’s burning low
Only miss the sun when it starts to snow
Only know you love her when you let her go
Only know you’ve been high when you’re feeling low
Only hate the road when you’re missing home
Only know you love her when you let her go
And you let her go
Staring at the bottom of your glass
Hoping one day you’ll make a dream last
But dreams come slow and they go so fast
You see her when you close your eyes
Maybe one day you’ll understand why
Everything you touch surely dies
Truer lyrics have never been written. Crazy motorcycle dude was risking his life. But it’s his life. We are all going to die. All of our patients are going to die, eventually. Everything we touch surely dies, as Passenger sings. What does this have to do with medicine? Nothing really. But maybe understand from that motorcycle dude, who was careless and stupid, that you should have a little fun every now and again and not worry so much about everything. Life is short. We have a common fate. Your work isn’t everything and no one can live forever. Yes, work hard. But don’t be so hard on yourself.
Relax. Roll that throttle back. Twist your wrist and let it go every now and again.