Category Archives: Figure Stuff Out

“Science has eliminated distance,” Melquíades proclaimed.  “In a short time, man will be able to see what is happening in any place in the world without leaving his own house.”

 

– Gabriel García Márquez, One Hundred Years of Solitude (1967).

As a college student I thought medicine is just a vast combination of facts, then medical school taught me that it was more complicated.

In medical school I thought that radiology is just about pattern recognition, then residency taught me that it was more complicated.

In residency I thought that the health care crisis is just a problem of not enough money, then business school taught me that it was more complicated.

In business school I thought that informatics is just about customizing to user needs, then working on a project taught me that it was more complicated.

But after being wrong so many times, I find myself continue to simplify complex concepts in my head. Maybe we’re built to do that. If I knew how complex medicine is, I may have gone into another field.  If I knew how difficult radiology is, I may have applied into another specialty.  If I knew the full complexity of healthcare informatics, I may have waited years before launching into a project.

Maybe it’s how society moves forward – by foolhardy people acting on oversimplified versions of the world.  Although the person who jumped in without understanding the complexity of the world might frequently fail, the person who held back would always fail no matter how much complexity he appreciates.

On the sitcom Friends, first-time pregnant Rachel sees an obstetrician for ultrasound, nods her head and smiles as the monitor shows her future child.  Then, she returns home and exclaims, “I don’t see it!”

Radiology trainees struggle with the fear of “not seeing it” as well.  As a radiograph, MRI or ultrasound displays on screen, at first we just see nothing.  Then, there is the proverbial sinking feeling in the chest as we slowly come to the realization that something is amiss.  Something doesn’t look quite right – except we don’t see it.  It can be intensely frustrating, resolved only by a supervising radiologist pointing with a finger, and we think, “ah, I knew I saw something.”

There is something about that initial sinking feeling when we see something is wrong without consciously knowing why.  It shows that we are now aware of our ignorance (as opposed to unaware – which is infinitely worse).  It’s the strange category of unknown knowns, where we don’t yet consciously know something that we can already pick out.

It is a sign of learning.

Gently lit by low wall lights and candles on the table, slow pentatonic music in the background, my girlfriend and I brushed off the speckled snow on our coats and sat down for our highly anticipated dinner at a local sushi restaurant one evening.

What caught our eyes on the menu were rolls topped with House Special Sauce.

There is something about a restaurants’ “secret sauce,” the exclusive special dish that makes them particularly appealing, that is counter-intuitive.  After all, commercial sauce-makers are known for – well, sauce.  Mayo mayonnaise, sriracha chili sauce, and Heinz ketchup are all popular because they are backed by large R&D funding, tasting tests, and marketing.

So why would anyone not choose a time-tested favorite and go for the house special sauce?  An independent restaurant has but a single percentage of the resources of a large conglomerate.  They are outmatched in almost every way.

It’s David versus Goliath.

But sometimes we favor the underdog, the adventure of the limited, the David who did defeat Goliath. We believe something may be better because it is limited in quantity or limited availability.  It is a secret, and secrets are good.

We convince ourselves that independent “specials” can sometimes end in a pleasant surprise.  We try the homemade potato chips over Lay’s, or the hole-in-the-wall eatery out in the suburbs over Applebee’s, or house special sauces over Kikkoman’s sushi sauce.

Every time we make such a decision, we implicitly take the risk that things can work out the other way – that the homemade chips can end up soggy and soaked in grease, or the hole-in-the-wall may serve thawed frozen fish fillets.

Or the house special sauce may end up being a concoction whose off-center flavor profile fully explains its limited availability.

Substantial research has shown that we substitute a difficult decision with an easier one without realizing it.  When applying for colleges, graduate schools, or a job position, we cognitively understand the importance of finding the best fit – the culture, the environment, the location, the available resources.  This is an extraordinarily difficult question partly because we do not understand what constitutes “good fit.”  It is, however, much easier to look at metrics like USNews rankings, funding, or teacher-to-student ratios.  Advisors frequently recommend that applicants “go with the gut feeling,” not the numbers.

The same is true for those on the other side of the interview table.  It is difficult to prove whether a candidate is an excellent fit to the organization; it is much easier to evaluate their test scores, grades, recommendation letters.  Selection committee members are frequently cautioned against judging solely at the scintillating “objective data” on an application.

Medical school 101 teaches aspiring physicians to treat the patient, not their x-ray or labs.  Each individual piece of objective data contributes but does not replace good – albeit imperfect and subjective – clinical judgement.

The reason why this lesson is frequently repeated in almost every cognitive discipline is simple: it is very easy to forget that we are constantly making judgments using imperfect information.  Deciding whether you are qualified for a position is a metrics game – formal education, prestigious pedigree, ample experience.  But maybe we’ve had it wrong all along – maybe qualification is a threshold and not gradient.

Determining “fit” is a more process for which qualification is but one element – will you be happy being part of this organization?  Do you see yourself performing maximally in this setting? Because we place more emphysis on those we can measure, clinicians sometimes focus on small aberrations in laboratory values while forgetting the patient, and radiologists sometimes mull over the small findings regardless of their clinical significance, just as investors are frequently faulted for focusing on the day-to-day fluctuations of the market rather than on the overarching economic trend.

For the rest of us, we sometimes put unwarranted amount of emphasis on metrics-driven qualification and forget the fit because numbers are easier to interpret than people.