What the Dog Saw Part 4 of 4: Late Bloomers
February 18, 2010 by dr. lam · 7 Comments
The story of Ben Fountain, the celebrated author, is fascinating. He quit his day job as an attorney in Dallas at Akin, Gump, Strauss, Hauer & Feld, to write full time, leaving his wife to go on to become partner in the same firm. Fountain became famous for his collection of short stories entitled, Brief Encounters with Che Guevara, which the Time Book Review called “heartbreaking”. He was listed on almost every major bestseller list and won the Hemingway Foundation/PEN award. All of this sounds like the typical story of a struggling writer whose precocity is recognized and takes the literary world by storm.
Not exactly. Fountain quit his day job in 1988. It was not until 2006, 18 years later that he got his breakthrough with Brief Encounters. A novel that he wrote and put into a drawer took him 4 years to write. Our idea of genius is inextricably linked to precocity. Someone who at a tender age creates his masterpiece like Orson Welle’s Citizen Kane at 25 years of age or Herman Melville’s Moby-Dick at 32 years of age. However, is this always the case?
The best example of understanding how this may not always be the case is looking at Picasso and Cézanne. Picasso was celebrated from the get go. He was given a generous stipend when arriving to Paris and won acclaim at the age of twenty and continued to marvel the world as he matured. Cézanne on the other hand tore up pieces on and off again until his maturity. His aborted painting of his dealer, Ambrose Vollard, is a typical example. He had the dealer show up at 8 in the morning and worked feverishly until 11:30, with 150 sittings during that time before abandoning the project. Picasso, on the other hand, said “I can hardly understand the importance given to the word research.” Picasso knew what he wanted and painted it. In fact, paintings from Picasso in his midtwenties are valued at four times what his later work sells for; whereas for Cézanne the opposite is true: paintings in his sixties are valued at 15 times what his paintings from his early years are worth. He was a late bloomer.
David Galenson, an economist at the University of Chicago, wrote in his study “Old Masters and Young Geniuses: The Two Life Cycles of Artistic Creativity” believes that younger artists who achieve fame start at a “conceptual” level. They have a concept and they execute on it. Other artists that slog toward a result are “experimental”: they constantly revise a work until they get it right. That might take years to achieve. They are the Cézannes and Fountains of this world.
In contrast to Ben Fountain, the writer Jonathan Safran Foer wrote his masterpiece, Everything is Illuminated in 2002 while he was an undergraduate student at Princeton. He took a class by famed author Joyce Carol Oates and tried his hand at creative writing, being encouraged for a second semester by Oates’ comment that she was a fan of his writing, which of course shocked him. She said he had the most essential element of a good writer, energy. He then took a summer retreat to Europe after his sophomore year to visit where his grandfather came from in Ukraine. He wrote 300 pages in 10 weeks of a book he was not even planning to write and it became his famous first outing, Everything is Illuminated.
Gladwell then recounts how Fountain was able to survive all of those years in obscurity without a real job so to speak. It was his wife Sharie who worked and continued to believe in his artistry. She was his muse and patron. Similarly Cézanne was encouraged by Emile Zola, taught by Camille Pisarro, and supported by Ambrose Vollard and his own disbelieving but wealthy banker father, Louis-Auguste. Without patrons, “experimental” artists may never see the light of day.
This chapter for me was fascinating since I love art, artists, and artistry. It is amazing to see this dichotomy between two types of artists and it makes sense. I fashion myself more of a conceptual artist, as I tend to have a strong vision that starts my quest toward a goal. I then execute on it. In fact, one of my favorite artists Sol Lewitt is the father of conceptual art, as the concept is king. I love to see how Gladwell wove this amazing story from start to finish. It reveals a lot about the rich tapestry of humanity and complexity that lies within each of us.
What the Dog Saw Part 3 of 4: Blowup
February 17, 2010 by dr. lam · 2 Comments
When the space shuttle Challenger blew up in the sky over southern Florida 45 minutes into its voyage on the fateful day of January 28, 1986, a search for blame began. The slipshod policies of NASA and its prime contractor, Morton Thiokol, were clearly to blame. Thirty-two months later, the shuttle Discovery was redesigned and launched as a testament to that correction. However, the sociologist Diane Vaughan, in her book, The Challenger Launch Decision, argued “No fundamental decision was made at NASA to do evil.” She further states, “Rather, a series of seemingly harmless decisions were made that incrementally moved the space agency toward a catastrophic outcome.” What? No one was to blame? Perhaps. Even if Vaughan’s arguments are only partly correct, it raises a fundamental concern of how we as humans need to wrap up our understanding of failure by laying blame.
In the near disaster of Three Mile Island (TMI) nuclear-power plant in March of 1979, the president’s commission concluded that the result was of human error, particularly on the part of the plant’s operators. However, perhaps the story is not that simple. It all began with a blockage in the plant’s polisher, a giant water filter of sorts. Polisher problems are a relatively common occurrence and one that typically does not lead to any major problems. However, in this case, the blockage caused moisture to leak into the plant’s air system, which then tripped two valves that in turn shut down the flow of cold water into the plant’s steam generator. Typically, the backup cooling system handles such a problem. However, for a reason that is unclear, the valves for the backup system were closed. In addition, a repair tag hanging on a switch above the indicator just so happened to block the visibility of the off setting in the control room. That left the relief system to handle the problem. However, it just so happened that the relief system was not working that day. In addition, it just so happened the gauge to tell the operators in the control room that the relief system was not working was also not working. By the time that the operators figured out the 5 things that all went wrong at the same time, TMI was near hitting a melt down.
Charles Perrow of Yale University is a sociologist who has investigated these matters and has classified the accumulation of minor events that lead to catastrophe as a “normal accident.” In his classic 1984 treatise on accidents, Perrow uses examples of well-known plane crashes, oil spills, chemical-plant explosions, etc., to show that many of them can best be understood as “normal”. The most famous example of a normal and not a “real” accident is Apollo 13, as brilliantly depicted in the movie of the same name. The Apollo flight was hit with a combination of the failure of the spacecraft’s oxygen and hydrogen tanks and the failure of the astronauts to recognize the problem due to an indicator light that diverted their attention.
Was the Challenger accident then a normal accident? Not exactly. The Challenger failed because of one catastrophic problem, the O-ring. However, Vaughan looked at the culture of NASA that over decades had accepted what was deemed normal risk or deviance. This creep of behavior over time allowed the brass to accept the O-ring problem as within tolerable limits of normal. So it was not amoral or immoral individuals that ignored dangers, it was the longstanding culture of NASA to factor in this risk as part of conformed policy.
In fact, how we handle risk is something fascinating. When we become accustomed to risk, we start to behave a bit like NASA. Since the O-rings never caused problems in the past, then we can lower our standards a bit. This is known as risk homeostasis. The introduction of ABS brakes actually led to a higher incidence of accidents because people began to act erratically on the roads and took greater risks. The adoption of seat belts however was such a powerful factor toward safety that it overcame the limited increase in risk homeostasis. An example in Sweden is fascinating. In the late 1960s, Sweden switched from driving on the left hand side of the road to the right side. Instead of an increase of accidents, there was a decrease of 17% during the next year, followed by a steady return to previous accident levels. People were simply driving much more safely to avoid a possible accident.
What this chapter brought to my attention were several important ideas. First, we humans tend to ascribe blame to an accident because we want a reason for something and a story to tell it. However, sometimes accidents just occur no matter what we do to try to avoid them. Second, if we look less proximally at the accident but at the larger culture we may be able to create an environment that is less prone to having an accident. Finally, if we take even a deeper look at our own irrationality, we can see that our accustomed insouciance toward risk can be the ultimate cause for increasing our own risk, the so-called concept of risk homeostasis.
What the Dog Saw Part 2 of 4: JFK, Jr. and The Art of Failure
February 16, 2010 by dr. lam · 6 Comments
Gladwell investigates the difference between choking and panicking. In the 1993 Wimbledon finals, Jana Novotna led Steffi Graff by 4-1 and serving 40-30, was poised to win the tournament. But then the tide turned, and Novotna after a double fault began to lose control ultimately to her own demise and Graff’s victory. Did she choke or did she panic?
Gladwell says that choking occurs when we resort to our “explicit learning” system, the time when we were younger and just starting out to learn something and when our conscious minds dominated our every thought. Remembering Maxwell Maltz’s four stages of mastery, we go from unconscious incompetence (we don’t know we are doing it wrong), conscious incompetence (we know we are doing it wrong but don’t know how to fix it), conscious competence (we are doing it right but with a lot of conscious effort), to unconscious competence (it is effortless).
In a stage of choking, we return to conscious competence or worse a lower stage. We tend to become extremely deliberate with every movement because we are trying very very hard not to screw up. The effortlessness that we have acquired with experience is thrown out the window and we become in short, a junior player, once again. That is the essence of choking.
Panicking is altogether different. An example is of a diving accident in Monterey Bay, California. At nineteen years of age just two weeks into dive training, a young man recounts that during an exercise he had to remove his regulator and replace it with his secondary one after clearing the line of water. When doing so, his mouth was engulfed with salt water. Panicking, he couldn’t think and reached out to grab the regulator from the mouth of his buddy. Doing so could have imperiled both of them. Instead of reaching for his primary regulator or for his partner’s secondary regulator, panic set in. Perceptual narrowing caused him to forget all logic and move to instinct, “I need air now” causing him to react in the manner he did. With added experience, an individual has less chance of panicking because he can draw from his accumulated experience.
As evident, panic is the opposite of choking. Choking involves a return to a logical, explicit system of behavior. Panicking involves a return to a base instinctual response. Why does this matter? It doesn’t so much if you lost a tennis match due to a choke or panic. However, it can bring about an understanding in certain cases of failure. Take for example the aerial death of JFK, Jr.
On a Friday evening in July of 1999, John F. Kennedy, Jr., his wife and his sister-in-law took off for Martha’s Vineyard, a course that he was quite familiar with. However, that night the air was particularly hazy and visibility was poor. Kennedy accustomed to looking for Martha’s Vineyard’s lights at night looked out into a bleak oblivion, as there were no visual guides whatsoever. He started to frenetically bank his plane. However, a slight embankment can lead to a greater embankment, as the plane enters what is known as a “graveyard spiral”. The pilot may not even feel the G force since the spiral in a pressurized cabin feels like he is moving level with the absent horizon. The time between initial radio contact and the crash into the ocean was less than sixty seconds.
JFK, Jr. panicked. He was very used to using the lights of Martha’s Vineyard to guide him. Without them, he was lost. Rather than returning to his explicit learning of using his instruments, he continued to literally spiral into his instinctual flying habits but without a noticeable G force of the downward spiral and no lights to guide him, he most likely remained frozen and lost concentration. That loss of concentration for less than one minute cost 3 lives that night.
There are two important things to learn from this situation. First, experience counts for a lot. The more that we perform in our specialty, focus on it, and spend time with it, we can create alternative strategies in times of apparent failure. Second, we should possibly go back to our explicit learning system rather than our intuitive one when we reach a point when our intuition fails us. Profound.
What the Dog Saw Part 1 of 4: Breast Cancer
February 12, 2010 by dr. lam · 3 Comments
Malcolm Gladwell and my niece Baby Bailey
As many of you know, I love Malcolm Gladwell’s writing, as I have reviewed all of his previously published books in this blog. His latest book, What the Dog Saw is a collection of articles published in The New Yorker and represents so many unique ways for you to change your perception of an issue that has left me simply amazed…once again. This book is extremely dense with profound information, all told with interesting stories, anecdotes and allusions. I have selected only a few tales to tell here and encourage all my readers to get this book because this blog series will only scratch the surface of Gladwell’s writing.
One of the most earth-shattering revelations in this book concerns how we prognosticate, perceive, and treat breast cancer. He starts the chapter discussing Memorial-Sloan Kettering’s head of breast imaging, David Dershaw, who recounts his method for detecting breast cancer on radiography. After a protracted, convoluted paragraph on the subject, the reader is left bewildered at the vagaries of detecting cancer consistently. There are few examples of clearly benign disease and a few examples that would highly suggest cancer, but then there is a tremendous stream of gray in the middle.
A study involved 10 board-certified radiologists reviewing 150 mammograms with 27 having actual breast cancer and 123 without the disease. This cadre of experienced medical experts chimed in with a whole range of responses that were highly inconsistent and betrayed the lack of science to the reading of a mammogram.
Gilbert Welch, a medical-outcomes specialist at Dartmouth Medical School, pointed out that currently nine out of every thousand sixty-year-old women will die of breast cancer in the next 10 years. With frequent mammography, that number will decline by 3. The question is that with 3 three lives saved by mammogram in this subgroup, what is the rate of unnecessary biopsies and other invasive procedures related to a false positive or as we will see in a moment an actual positive?
Take the case of Ductal Carcinoma in Situ (DCIS), a type of early cancer that has only been detected since the early 1980s with advancing radiographic technologies. With the ever increasing detection of DCIS, which when found is promptly removed, what has this meant on cancer survivals? About 50,000 cases of DCIS are found and treated each year. However, the incidence of late-stage cancers has steadily continued to rise during this period of early detection of DCIS. How can this be?
In 1987 Danish pathologists performed a series of autopsies in women in their 40s who died of unrelated causes like automobile accidents. They found that the incidence of DCIS was about 40% of the 275 sampled breast tissues. Since breast cancer only accounts for 4% of female deaths, how do we account for this discrepancy? The answer may be that many of these cancers are corrected by the body through a continual process of repair. We in fact as men and women may have many cancers that we fix without our conscious mind ever knowing about it.
In the book, Gladwell also proves that the size of the tumor has a very negligible role in determining the predilection for the tumor to continue to become larger in size or metastasize. In fact, the genetic coding within the tumor may contain more information about the tumor’s likelihood to progress than anything else. At this time, investigators are continuing to determine what these factors are for progression versus possible regression of the tumor.
A Canadian study in the 1980s has shown that careful finger evaluation of one’s breast under skilled hands had no difference in breast cancer death rates with a second group that underwent combined breast examination and mammography. The conclusion can be drawn that tactile evaluation can be as sensitive as an image but we tend to trust our eyes more than our fingers.
Do mammograms do anything beneficial? Well, yes. For a woman in her 50s, the chance for reducing the risk of dying from cancer is about 10%, which divided over millions of women accounts for thousands of lives saved. Of course, the cost of doing so, false positives and even true positives that might not need treating, should also be accounted for.
Obviously, this blog is not meant to endorse a change in medical policy or behavior. This blog is meant to summarize some spectacular thinking that may spur you forward to think and investigate on your own or with your physician a well healthier dialogue about your health.
For me, it points out a few things. First, cancer is not some kind of ineluctable devil but a part of life that we often and unknowingly correct on our own. That is why good diet, exercise, and a stress-free life can be so important to permit your body a chance to destroy any cancers that may arise. Second, is that science as we know it may not always be a good thing, at least without proper judgment and thinking. Gladwell offers an amazing way to see differently.
The Trouble of Mitigated Speech & Hofstede’s Power Distance Index
December 30, 2008 by dr. lam · Leave a Comment
I can’t help but draw from Gladwell’s Outliers again as source material since it is so rich with ideas that have profoundly shaped my thinking. He talked about why Korean Airlines had one of the worst crash records from the late 80s to the late 90s. Interestingly, what he also found is that when the most experienced pilot flew, there was the highest chance for a crash, whereas when the least experienced pilot flew, it tended to be the safest flight.
What was observed at KAL was that the subordinate or lesser pilot would pay deference to the senior captain so he could almost never overtly challenge the senior captain’s stewardship of the plane. He would then speak in what is termed “mitigated speech”, i.e., very elliptically made speech that never directly attacked the captain. For example, if the plane had too much ice to make flying the plane a safe venture, the co-pilot would say something like, “Boy, it’s cold out there.” Of course, the pilot would have no idea what he was talking about. He could up the ante a bit and say, “Boy, the wings look a bit icy tonight, what do you think?” He might even go so far as to say, “Maybe we should take another look to see if there is too much ice on the wings to fly?” In almost every case, the Korean pilot would be too oblique in his commentary and deferential to change the captain’s mind about something that should have been very obvious.
The Korean language carries many honorifics and many layers of deferential speak that separate societal ranks. Customs further reinforce this behavior. For example, no one can start eating at the table until the most senior person starts. However, the most senior person can start eating way before anyone else is sitting at the table. Gladwell looked at Hofstede’s power distance index of various countries (click here to see Hofstede’s global PDI map). He found that Americans have a very low PDI, i.e., subordinates are very comfortable telling off a senior member whom they found to be wrong. However, even in the U.S., lower-ranked pilots would still at times have trouble telling the captain that there was a problem so that new training required that a lower-ranked U.S. pilot would try 3 times to convince a senior pilot that what he was doing was dangerous and if he could not that he would simply take over the cockpit.
Korean Airlines has become one of the safest airlines today because of a radical overhaul to the culture. All KAL pilots must be fluent in English, which helps them communicate better with international air-traffic control and also minimize the PDI issues. They also trained with U.S. pilots to start breaking down long-held PDI structures.
I have told this story to all of my staff so that they do not engage in a PDI issue with me. I need to know honestly what I am doing right and what I am doing wrong. I have asked them to run my ship with frank candor. I do not hire “Yes Men” and I do not want a “Yes Men” mentality to hold sway over my ship. I have asked the same candor from my patients. Open dialogue is the key to any relationship by breaking down the PDI at a fundamental level.