Surgeons Should Not Look Like Surgeons
medium.com
medium.com
That guy who looks and sounds like a doctor may have paid his own way through college. Maybe he went to speech therapy to overcome a stutter. Maybe he works out regularly and follows a good diet because he truly believes in the advantages of a healthy lifestyle and he knows how hard it is for his patients to do the same.
The point is, the vast majority of the time we don't have any way of judging how much a person has had to overcome just by looking at their appearance. It's not that we're drawing the wrong conclusion from the metric, it's the metric itself that's broken.
That's the point. When a metric is broken, you can exploit its defects.
Let's say you have two surgeons applying for a job. One has the image down, one does not. Both have a 90% success rate in their surgery. The one with the better image will get hired more often. The one with the bad image will have to be better at his job (95% success rate) to get hired as often.
When you have a highly overvalued attribute, that attribute becomes an indicator of overvaluation. Meaning, it's a negative indicator of true value. The article applies this rule to "image".
If I told you that startups with a name that started with an "S" got 10x the early valuation compared to other companies, would you ever invest in a company that started with an "S"? Hopefully not. The startup may be good, but the odds are lower it would ever live up to its hype.
In real life, I have no way of knowing which doctor is better at his job. The only metric I have to go off of is the degree and board certifications, and yet this article discounts those entirely in favor of the other guy. To use bedside manner as a metric instead of appearance, most of the brusque, rude doctors I know are just jerks, not real-life versions of Dr. House.
Adjusting for the relaxed standards of computer programming, proportionally I know just as many mediocre unconventional ones as I do mediocre conventional ones. The comments in this very thread suggest that the one with the worse image will get closer attention by many (though obviously not all) hiring managers just because of his/her appearance. So why should I believe the unkempt programmer was hired because he was more talented, and not because some other person just assumed he was?
It seems similar, but it's really not the same. There's a comment in this thread suggesting if a surgeon spends more time fitting in, that means they have less time and energy to spend on being a surgeon. I totally disagree with this.
I don't believe there's some finite amount of energy (that you could call willpower or character points) that's somewhat consistent across people and you only get to spend in certain ways.
To keep overusing the surgeon analogy: let's pretend New York surgeons suck compared to Boston surgeons. For every measurable metric, Boston surgeons are better on average. Everyone knows this. Accent becomes a reasonable indicator of skill.
You go to a top-tier hospital in a different state. Everyone there is great at their job. You meet two doctors. One has a Boston accent (indicator of skill) and one has a New York accent (indicator of lower skill).
The suggestion of this article is to look at the New York doctor and think "What's so great about this guy that even while walking around with something that every single person is going to judge him for, he still made it all the way to a top-tier hospital? He must be damn good at his job to make it this far."
An attribute can be an indicator of value. But, if it is overvalued, it becomes an indicator of overvaluation.
When people are discriminated against but still successful, the discrimination criteria becomes an indicator of skill.
Shit, call it the Jackie Robinson Effect. When no one wants you around, when you don't look the part, you have to be damn good at your job to keep it.
I'm guessing here, but I'd bet money that in the first few years of desegregating baseball, the average black player in the MLB was way better than the average white player. They had to be amazing to get a spot. Being black in the MLB was an indicator of value. Now that those pressures aren't the same, I'd bet they're equivalent and being black in the MLB isn't an indicator of skill.
But you would have counted on this, so I cannot choose the wine in front of you.
Appearance and social ability in surgical teams are important because surgeons are also leaders and caregivers. These attributes will matter to the members of their team and their patients. Team members who believe in their leadership tend to be more effective. Patients who believe in their care have better recovery rates.
If you did find such an example, it would be worth finding out what they are doing in other areas to compensate for the lack of this attribute.
There may be other factors regarding recovery rates perhaps counter-intuitive with respect to the presence of leadership (or appearance of leadership). Somewhat related:
https://hms.harvard.edu/news/startling-benefit-cardiology-me...
"High-risk patients with certain acute heart conditions are more likely to survive than other similar patients if they are admitted to the hospital during national cardiology meetings, when many cardiologists are away from their regular practices."
"The researchers found that certain intensive procedures were performed less often on the high-risk patients in the study during meeting dates than outside meeting dates.
One explanation for these findings, the researchers said, is that physicians who don’t attend the conferences take a more conservative approach for high-risk patients; another is that the physicians who stayed behind were reluctant to perform intensive procedures on another physician’s patients while that doctor was out of town. Survival rates might be higher because, for high-risk patients with cardiovascular disease, the harms of intensive procedures may unexpectedly outweigh the benefits."
This sounds a little like the programming conference effect. Where someone comes home excited about a new way of doing things, and applies it without first proving it out in isolation. Except people die.
There seems to be a similar trend in mortality with respect to getting treated in a teaching hospital vs nonteaching hospital:
http://health.usnews.com/health-news/patient-advice/articles...
At teaching hospitals treatments, may be very conservative as well (perhaps even more so than at non-teaching hospitals) with residents whose teaching is freshly learned.
A VC may very well believe that you are brilliant, and doing great work, and can make all the right decisions.
But it matters to his investment that he believes that others will buy into your agenda.
Investors are incentivized to prefer a 'fast talker' over someone who is not, if only because they believe that the 'fast talk' will benefit their future investment.
Or he could fast talk his way into preference, or get a drinking buddy to hire him, or countless other ways that don't involve being better at his job.
That is a hell of a leap. It is actually a strict logical fallacy, called affirming the consequent. https://en.wikipedia.org/wiki/Affirming_the_consequent
In other words this is a huge gap in your reasoning, it is claim - not a conclusion - that you are making and it is one that requires evidence. To put it another way: your argument is wholly conclusory and the only way to settle this argument is with evidence. It cannot be derived from first principle. There may be some instances where surface-level indicia (I can tell about the quality of a fabric pretty quickly, and it is typically indicative of good tailoring) are strongly correlated with quality and others where there is a low (a fresh paint job on a house) or even a potenitally inverse correlation (REALLY NICE ads for attorneys - located on bus stops).
But your blanket statement is just unsupported. I am not saying it is false - I am saying it is unsupported and you are jumping to a huge conclusion that does not follow logically, nor can it be proved to follow on the basis of logic alone.
Assume attribute X is overvalued.
Object A has attribute X.
Object A is indicated to be overvalued.
I'm not making a statement here about exactly what attributes are overvalued (fabric, paint jobs, bus stops or otherwise).
An argument of the article is that "image" is overvalued. I don't think the author did the best job supporting this argument.
If X, then Y
!X
Therefore, !Y
Attribute X is overvalued
Object B does NOT have attribute X.
Therefore Object B is NOT overvalued.
> When you have a highly overvalued attribute, that attribute becomes an indicator of overvaluation.
but the implication of the inverse: when you DON'T have a highly overvalued attribute, lack of that attribute becomes an indicator of a lack of overvaluation. is not.
A signal of quality is likely to be reliable if it's inherently expensive to produce and is correlated to the desired metric. A big peacock tail is a reliable indicator of the peacock's health, because to falsely grow a bigger tail than it should support would end up being detrimental for the peacock. Same with lion manes, college degrees, etc.
The author points out that there are metrics and signals that can be overvalued, and that's true, but the hospital example is a terrible one because fellow physicians have access to the true quality of a doctor. A surgeon with a good degree, expensive watch, and nice clothing will not fool his or her fellow doctors because they actually see how they operate in the theatre. If a doctor X tells me that surgeon Y is good (and I trust doctor X), then that's sufficient evidence because doctor X almost certainly knows better than me, and I can entirely skip the process of evaluating surgeon Y's sartorial choices myself.
Where the author's point makes more sense is addressing pop-culture indications of quality, which are more likely to be incorrect because the general public (or the media industry specifically) is not an expert in any given field.
You probably shouldn't hire an engineer simply based on ideas of what hackers look and talk like gleaned from Mr. Robot, but I think most people already knew that?
And signaling.
That's all.
EDIT: I almost didn't read the article because of your comment. That would have been a mistake.
First of all - forget about the tech industry, surgeons are overwhelmingly male. It's obviously a tough path to get there, and takes a huge toll on you when you get there (eg., their divorce rate is pretty high). This made me realize simply the scenario of Gray's Anatomy - some hospital with like eight female surgeons - is ridiculous.
Now, all doctors have a God complex, but the surgeons take the cake. They deal with tons of death and save countless lives. My gf fiercely defended this - her point was you want a surgeon who doesn't think twice about huge terrible bloody trauma, people freaking out and intense pressure. You want a surgeon who will be bold, roll the dice and do what needs to be done. I've helped build pretty important systems that affect many lives, but certainly nothing close to that kind of immediacy.
Finally, and this is going totally off topic now, but I also saw how terribly confusing the state of American health costs are. We lived in a big city, and doctors did rotations among the hospitals in the area. The same doctors would be doing the same procedures and patients in different hospitals would be billed hugely different amounts. Of course that has many secondary impacts; maybe you get a nicer facility, a room to yourself, certainly (and maybe as importantly) the demeanor of the nurses attending you would be much nicer.
Essentially, a sociopath. I think this sheds some light on the paradox of Ben Carson.
I want a surgeon who is well-trained, well-rested, aware of and working within her circle of competence, working with a communicative support team, and using a clear defense-in-depth strategy against error. In such an environment, doing what needs to be done is more certain.
Being able to bring oneself do X is not the same as knowing X needs to be done.
In that case, a quality like 'boldness' might help the surgeon execute successfully, rather than shrink away instinctively, if you define 'boldness' as being willing to make on-the-fly, risky, life-changing decisions when the need calls for it and then follow through. Most people are either not able to do this well, or deliberately choose not to work in an environment where it is called for.
This same sort of calculus weighs in any profession that is in same way already inherently unpleasant, such as being a soldier, a fireman, or a spy.
Surely 'first year anatomy' is not the same thing as a bloody mess on the table, alarms going off, a frantic staff, and someone about to die in front of you unless you do something that happens to be fairly close to the right thing.
I didn't study medicine, but I was in the Army, and I confess that a degree of slightly irrational hubris is necessary in some situations.
Surely, we would all prefer our surgeons to be calm, team-oriented and thoughtful in front of us, but I think the situational dynamics just don't apply well to that. Also, people can be all of those things and 'bold'.
Admittedly, 'bold' may not be the right word.
If there is a word for someone who can be called upon to think clearly and 'do what is necessary' in a complex, high-stress scenario ... well than that.
I don't want an overly confident surgeon. I want a surgeon who has my health in the best interests. If that means refusing a surgery they deem too risky then so be it.
"There are only two barbers in town. One is neatly trimmed, smooth shaven, professional, and is sweeping up after his last customer. The other has a wild appearance, terribly-cut hair, his shop is messy and has no customers. Which do you go to?"
I wasn't quite sure how it would work with surgeons, though... "One has perfectly-sutured incisions all over his body, the other has organs flopping out..."
Actually, I kind of feel like the reasoning in this article can be profitably applied to Taleb's own image management.
That said, maybe people can reconsider buying that next pair of hipster glasses[1].
1. https://www.google.com/search?q=hipster+glasses&espv=2&biw=1...
This is the one hiring maxim which has never steered me wrong, and also provided a very diverse (and really fun!) development team. :)
A programmer myself, I couldn't help but thinking about mammoth frameworks and architecture fads as I read the article
I generally dress well. Like a business guy. To overcome prejudice, I would wear sandals to my interviews.
I wouldn't care to get a job in software today, but being a little older, and dressing the way I do, I doubt anyone would overlook their conventions and hire me!
But I'm grateful you're doing it.
Maybe you have some devs that look like bankers on your team?
Either way it's completely anecdotal. I would venture to say there's no correlation between how someone looks and how someone performs.
I could save time in the bathroom by not washing my hands, but I'd rather not.
14 years of schooling vs 30 min on the internet?
I'd say the effort trade off is statistically insignificant.
I would argue that if someone looks the part, then they can be successful with a lower level of skill, and so they have less incentive to really be as good. My impression is that people generally, and doctors in particular, are quite lazy and generally aim to only be as good at a thing as they need to to get what they want, so the guy who looks the part is likely to be less competent.
There will be exceptions obviously, but I know that if I meet someone who puts a lot of effort into appearances, my presumption is not that he does this because he is incredibly hard working and just puts more energy into everything. In my experience that's not usually the explanation.
I would guess that's the most common reason for people to look the part. I can't really tell if you're agreeing or disagreeing with what I said!
The KEY information here is that they're at the same rank. That means the slob has had to overcome people using the heuristic you've just described in order to reach the same rank, probably through being an objectively better surgeon.
I read this as Paul Graham's point that startups should not "play house". They're both saying that creating a company isn't about getting funding, hiring people, having a website and a logo, etc. It's about making something that people want, which can start in any number of ways that might not look like a company.
Maybe he kept with appearances until he got tenure and now he's slacking because no one can fire him.
Maybe the hospital was short on staff and took anyone willing to apply at the time.
Or a hundred other reasons why, if you can choose a doctor, do research on them, if you dont have time, pick one by virtue of conversation, if you can't do either, you are just trying to make a pattern out of randomness.
"The idea is Lindy compatible."
"In any activity, hidden details are only revealed via Lindy-style experience."
Having read the whole piece and done some web searches I still have no idea what this could possibly mean.
The fact that he continues to be a surgeon provides you with information about his fitness as a surgeon. In the face of poor appearance, his existence as a surgeon provides you information about his quality.
The Lindy effect describes cases in which real-life outcomes get better as one progresses down the "bad odds axis". For example, a 95-year-old selected at random from the general population might have a higher likelihood of being alive one year from now than an 80-year-old selected at random -- e.g., due to fact that living 95-year-olds tend to be people with good genetics who make healthy life decisions [0].
Taleb is somewhat sloppily trying to tie this phenomenon to the broad assertion that the relative aptitude of two given individuals at any given pursuit is often counterintuitive to first impressions. This ties into Taleb's favorite argument, which he predictably makes in a slightly different way with each new book or essay: what is often rewarded by society / companies / etc is the appearance of being good at something, rather than actually being good at it, and the pursuit of being perceived as good at something is not only not helpful to being better at it, but often actively counterproductive to said task....but if you ignore people's perceptions about what it means to be excellent, and "put skin in the game" by focusing on being excellent rather than cultivating that perception, you will be less susceptible to unforeseen bad events ("black swans").
[0] This very well may not be statistically true, just trying to put forth an illustrative example.
For green lumber the hidden details that determine price (as exploited by the successful trader) are only apparent after some time (that exists after the knowledgeable guy exited the market via bankruptcy). The argument that is that these hidden details are fundamental to determining price so likely indicate a power-law distribution of remaining utility (basically if you've been successful for 50 years you will continue to be successful for another 50).
So oddly he says that past performance determines future success (until it doesn't).
You see this develop posthumously (Elvis) and also during their life time (the Bill Murray effect). He's been in so many comedies and successful movies and now a meme that basically his estate may always be (unless it's not and then his influence will be at his half life and decays exponentially).
You still need regeneration but the brands can endure Mickey Mouse, Winnie the Poo.
But in support of the thesis, this hospital is not located where one might expect one of the top three heart hospitals to be located.
Only some surgeons can be full time lifesavers, some hairdressers however can be full time media production savers.
Either way, for someone in the top performance bracket who is truly saving the day with each head they work on, more energy professionally devoted to clients which would otherwise be expended on their own superficial appearance and gratuitious recognition-seeking can only be a good thing for the clients themselves.
The best could possibly be expected to not appear very much like the well-known Hollywood stereotypes or not be fashionable themselves at all very often.
I would say that if you have no other information, pick the female (and preferably minority) surgeon. I know a lot of excellent white male surgeons, but within my circle of acquaintances, a randomly selected woman is unquestionably a better option than a randomly selected man.
I don't mean to be flip. This is an article about assumptions and yet it makes one it shouldn't.