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.

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.

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.

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.

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.

To conclude our evaluation of Macolm Gladwell’s book Outliers, we evaluate the effects of what he calls “The Culture of Honor.” He discusses why the famous American feuds like Howard-Turner and Hatfield-McCoy standoffs were steeped in a culture that traced back several centuries on a different soil. Gladwell argues that these intense clan battles that centered around familial honor originated in the idea of the herdsman living on the hinterland. The farmer, by contrast, who must work in a team to cultivate arable land, would not risk alienating those around him. The herdsman, on the other hand, living on the rocky highlands must defend his sheep and cattle from the encroachment of strangers and thereby defines a certain code of honor that makes his battles per force openly querulous and staunchly virile. Gladwell discovered that these individuals acted in such a fashion from a legacy that predated their arrival in the heartland of America. Coming from the lawless borderlands of the United Kingdom, these “Scotch-Irish” engaged in feuds and fights because they were classic herdsmen as found in the Basque region of Spain, Sicily, and parts of Greece. Their behavior had been imprinted through generations of predecessors before them.

In a famous psychological experiment in Michigan, Nisbett and Cohen measured the testosterone and cortisol levels before and after an insult was levied. A student would be asked to complete a questionnaire and then walk down a long, narrow hallway where a proctor would accept their folded submission and then utter the word “asshole” under his breath. This provocative utterance was used as the catalyst for measuring any heightened responses. What was extremely interesting was that there was no difference between jocks and nerds nor wealthy and poor but there was a remarkable difference between those students who hailed from the South and those who resided already in the North. The gentlemen who came from the South, irrespective of background, were almost uniformly enraged by the comment as measured by the aforementioned physiologic markers; whereas the Northerners actually lowered their levels almost in a way to suggest that they were trying to counter any trace of their ire. The thought in short was that the legacy of the “Culture of Honor” was passed down through generations of Southerners irrespective of almost any other environmental or genetic factor.

When I look at some of my accomplishments, I can’t just measure my own successes from within but respect where I came from. Although my parents did not express the opprobrious and overt pressure that most Asian parents do on their children, they exerted a level of covert pressure to succeed that definitely affected my behavior. I remember when I was very young sitting around all afternoon watching television when my mother came in and with rancorous disdain told me to get up and do something constructive with my time. I was so upset at her behavior (or perhaps mine) that I got up and “ran away from home” shoeless for at least several hours to upset them. Of course, my parents were very upset at me for my needlessly stupid behavior. I would love to believe that my desire for success has been all internally derived but there is an honesty about the lingering effects of the cultural legacy that Asian parents and in this case mine imposed on me during my formative years. I remember my father beating me silly when I did not respect my elders at parties. These strict tones must have influenced me more than subtly. Now all that being said, my parents were and are the gentlest spirits that I know, especially compared to many of the fascist behavior of other observed Asian parents. But the cultural legacy that it has imparted for me is unmistakable and undeniable. Why else would I remember these isolated incidences? In many positive ways, I owe who I am to where I am from.

I was greatly looking forward to Malcolm Gladwell’s new book, Outliers, having read his two other brilliant treatises, Blink and The Tipping Point. I so thoroughly enjoyed Outliers that it has inspired several blog ideas. I would go so far as to say that Outliers is the best book that I have read in the past decade or, at very least, in the pantheon of one of the very best.

The thesis for Outliers is that the classic “rags to riches” story of the self-made man is bunk. He focuses on from whence do these so-called successful outliers truly come. In his estimation, they are a product of their environment among other factors. However much I would like to attribute my own successes to my DNA, I have to humbly admit that I am a product of circumstances, legacy, and luck. That is not humility but the very core of truth. My blogs will feature a story from Mr. Gladwell’s book that I find fascinating and then relate how I see myself within the context of that story. Of course, in deference to Gladwell’s genius (or should I say environmental good fortune), I will only reveal a select handful of stories to encourage you to read the entire book, which is a worthy read.

Let’s begin with a boy genius, Bill Gates…or is that the case? Everyone is familiar with his story, nerdy braniac drops out of Harvard to start a fledgling business called Microsoft that turns into a global multi-billion dollar empire. Did Bill Gates rise from nowhere? Not really. He was a product of a very special time and place that fostered his success in an unequivocally tangible way.

Gates grew up in Seattle to well-to-do parents and was enrolled in an elite, private high school, Lakeside. Lakeside just happened to have a Mother’s Club that raised $3000 dollars to start a computer club in 1968, which didn’t even exist at major universities at that time. Most computer programming used an unfathomably laborious technique known as a computer-card system. Gates’ high school relied instead on an advanced time-sharing system that greatly facilitated his ability to program efficiently and effortlessly. When the money ran out for his computer club, a mother of one of the Lakeside boys just happened to need a programmer at a computer company called C-Cubed, which turned into another opportunity to work at ISI then TRW. He happened to be within walking distance of the University of Washington, which allowed him to work on computers between 3 and 6 am. Now none of all that would be that remarkable today. But that was 1968 when computers really did not exist and computer programming opportunities were nil. Gladwell argues that the software billionaires of today all came of age at a very narrow window in time with a narrow timeframe of 1953-55 birthdates: Bill Gates 1955, Paul Allen 1953, Steve Ballmer 1956, Steve Jobs 1955, Eric Schmidt 1955, Bill Joy 1954 (btw a great story of Bill Joy, the founder of the Internet and UNIX code in the book), etc.

I look back at my circumstances that has catapulted me to write 5 books in 5 years, have published hundreds of scientific papers and book chapters, to write a blog every day without too much difficulty, to respond to thousands of forum posts within minutes, to speak on live TV in front of millions of people without a blink, to lecture without notes, to create a video log almost every day with no prepared or studied notes, and to love every minute of it.

It began I believe in high school when I was an over-achieving Asian kid who did not fit in entirely. I was particularly sensitive about my ethnicity and for me without natural athletic abilities I strived to differentiate myself from being a stereotypical Asian kid good at math and science. I became the editor-in-chief of the yearbook and the editor-in-chief of the literary magazine Reflections, etc. To be honest, I was a terrible writer who struggled with putting down a sentence let alone a paragraph. I think I had some animadversion to science in college partly to fight the stereotype of the Asian math whiz. However, I was drawn incredibly to the study of history. My years at Princeton and the need to write a several hundred page thesis before graduating forced me to write, write, and write. It put me in an environment to write and to cultivate my craft. History is perhaps the most recognized major at Princeton due to the quality of the professors and that pulled me to major in a field that was my worse subject and most hated in high school. Also, the small preceptorial system compelled me to begin to be comfortable with spoken argument and presenting my ideas out loud. However, I was still dreadfully afraid of public speaking.

I remember that I have always been enamored by my uncle, Sir David Lam (yes, he has been knighted by the Queen of England), who was the Lieutenant Governor (that would be Governor here Stateside since the Governor of Canada is the Queen of England) and who had the uncanny ability to speak extemporaneously without notes at public gatherings. He was always an idol to me and continues to be now in his mid 80s. I remember being so frightened of public speaking that the idea of it made me physically ill. I gave my speeches always with prepared notes that I had to read because a small blink would make me forget what I was saying or at least that is what I thought. I remember it was not until my fellowship with Ed Williams that I was called by Susan, his administrator, “Sam, Dr. Williams is sick tonight. You will have to give his seminar for him.” I was at the gym at the time, got off the treadmill, and basically panicked. I had no time to prepare and even if I did, it would not be my lecture but someone else’s. I gave the speech that night with tremendous trepidation without notes and resorted to my usual humorous asides when nervous. I had an overwhelming reception and it paved my way to be a much more comfortable public speaker.

Without these life circumstances and a catalog that would take a thousand blogs to fill, I would not be where I am today. I will discuss more in-depth other forces that have clearly shaped me external to any magical DNA that I may possess.

Blink by Malcolm Gladwell

I was attending a lecture by my colleague in St. Louis 2 weeks ago and I really liked how he envisioned the facial aging process. He likened it to the book, Blink, by Malcolm Gladwell. For those who have not read Blink or Gladwell’s other phenomenal book, The Tipping Point, I would highly recommend both reads.

Gladwell’s thesis is that we judge another individual or almost anything in a visceral blink of an eye. It does not take 5 minutes to figure out something but we can tell almost immediately about something and we are typically correct in our initial assumptions, which are also very hard to shake if we are wrong.

That is how we view each other when it comes to aging. We can almost instantaneously tell if the other person is older, younger, attractive, or unattractive. We can tell in a blink of an eye from 10 feet away. However, when people come in to fix something, usually they are focused on the minutiae that no other human being can even see. In particular, because women put makeup on, the tiny lines around the mouth (that no one can see. believe me.), the crepiness of the upper eyelid, the dot on the right cheek, the tiny asymmetry of the upper lip, etc. are on the top of the wish list for correction even though after paying all the money to do those things nothing really looks any better.

Instead, I truly believe that overall facial shape (geometry) and proportion is how we make a judgment about another person in a blink of the eye. So, when people come to see me, I would rather help them create a favorable blink impression on all those around them than try to fix the minor flaws that only they can see. If you want to understand how we view aging geometrically, you can watch the first part of my video lecture I gave 2 weeks ago in St. Louis that discusses in my opinion an original thesis on how we see aging. Here is the link to the video.

Btw, a patient of mine told me that Gladwell’s new book is coming out in a few weeks so I checked it out on Google, and it’s called Outliers, about how successful people are successful not just because of who they are but where they are from (at least that is what Amazon says).