People may understand statistics, but they believe stories. Imagine you are supervising a junior resident during an eye procedure and the patient exhibits a significant oculocardiac reflex with a heart rate of 17 bpm that is unresponsive to atropine. It is your practice to have a syringe of epinephrine 10 mcg/cc available on your cart, and the patient responds to a 2-cc bolus. The next day in a vascular bypass operation, you are supervising another junior resident, and give epinephrine 20 mcg to good result for a near “flat line” of the electrocardiogram and arterial line tracings after reperfusion of the lower extremities. The resident (who heard stories about the previous case) asks whether you always have low-dose epinephrine available and, if so, why. You reply that when you were in training, one of your favorite faculty members said to you, “Always be able to get your hands on 20 mcg of epinephrine within 2 seconds. You may only need it twice in 5 years, but when you need it, you need that and only that, and you need it fast.”

The stories that we tell, or folklore, can be an indispensable part of our clinical practice. Cultural scientists and sociologists actually recognize several types of folklore; the subset most relevant to the field of anesthesia is known by the scientific term of “institutional memory.” Institutional memory is defined as a collective of facts, concepts, experiences, and plain old-fashioned know-how held by a group of people. It is transmitted (often orally) by senior members of the group to junior members, but just as often it is transmitted through the stories shared among veteran care providers around the water cooler or in the anesthesia break room. Institutional memory can be facilitative to a group’s “way of work,” preserve a desired ideology, or be maladaptive—if too heavily established, it can make change difficult in the face of new information and input to the system.

The value of institutional memory and the importance of lore in maintaining patient safety have been established in anesthetic practice on many levels. Although morbidity and mortality seminars are one type of story, they often leave out an essential narrative that carries value: the personal experience. Pearls of wisdom that have been developed through folk tales and anesthesia “mythology” can be a source of useful information. In this raw
form of folklore, the information distilled through the experience of others is concentrated and often powerful. Telling co-workers a personal story of a specific patient “going south” in a narrative can provide the valuable context that will help that person recognize the diagnosis when they encounter it themselves.

Stories can have an effect beyond conveying the clinical facts. Stories of an attending thanking the nurse that stopped a procedure when the nurse noticed the attending’s breach of sterile practice send a powerful message that patient safety is more important than the caregiver’s ego. Stories of the nurse being recognized for excellence by the institution create a folklore about the values of the institution, promulgating the values of the workplace.

Although institutional memory and folklore are frequently based on factual information, almost by definition they are anecdotally based and not outcomes based or verified by rigorous trials. The advantages of this are that the information is often vividly presented and therefore quite memorable—the human mind is wired to remember stories, not facts. Judgment is often biased by the “salience” heuristic, in which conspicuous or dramatic events are easily recalled. Use the bias to your advantage: By telling a compelling story, it becomes more likely that the story will be recalled when a person needs to retrieve relevant information. The disadvantages are that anesthesia providers must maintain an open but discerning mind and a healthy skepticism.