You win the game by assembling the right team. In medicine, the right team thinks.
Before my sleep apnea surgery, I interviewed surgeons the way you interview contractors. Notebook in my pocket, questions prepared, specific concerns about specific structures, specific tradeoffs, and speculation about areas outside of the medical literature.
After ten years of complaining about sleep to at least a half-dozen doctors, I finally met a surgeon who lit up when I pulled out the notebook. We were in a teaching hospital; his students were in the room. He went question-by-question with me. He enjoyed the questions the way an expert juggler enjoys a bowling ball being thrown at his head. I pushed him hard. He juggled the chainsaws. We became friends.
The second surgeon, at a different and widely respected teaching hospital, wore a very nice lab coat and said things like “the standard practice in this scenario is…” She said it several times. When I pressed on specifics, she returned to standard practice. She was pleasant. She was credentialed. She was a pattern-matcher. She wanted me to use a CPAP for the rest of my life.
Doctors are often pattern-matchers. You go in with symptoms, they recognize the pattern, they prescribe the standard response. Most of the time this works, because most symptoms are common. The pattern holds.
The problem is that pattern-matching is indistinguishable from competence until you’re the edge case. And then it’s catastrophically different.
A real scientist notices when the pattern doesn’t fit. A pattern-matcher doesn’t notice, because noticing would require understanding the mechanics rather than seeing the pattern. The failure is perceptual, not moral. The pattern-matcher isn’t lying and usually isn’t careless — they don’t understand the mechanics of the machine, so they follow the owner’s manual.
This is why “they didn’t intend to be malicious” is such a weak defense of anyone in a professional role. Nobody intends malice. Bullies don’t intend malice — they perceive attacks where there aren’t any. Cruel people don’t intend cruelty — they mis-observe what cruelty is (often by thinking they’re acting righteously). The failure of perception is the failure.
Optimism is a specific, dangerous version of this. The optimist sees only what’s going right. If their own work is the problem, they can’t see it — and they can’t hear it when other people raise it, because the pattern in their head is: my work is fine.
I don’t want a doctor. I want a scientist who practices medicine. Even better: a philosopher who uses science to practice medicine.
A test: can you break your surgeon in conversation? If they can be broken – if your uneducated mind can throw questions that cause them to buckle – are you really going to trust them cutting into your unconscious body? If a surgeon can’t handle intensity well, do you really trust them with your surgery?
After my first six doctors mis-diagnosed or mis-treated my sleep issue, I now attack the ideas of every doctor who consults on my case. If they can’t hack it, I want a different doctor. I didn’t even go to medical school, and you can’t handle me?
I may irk some competent doctors who are unwilling to tolerate my approach. I accept this rate of false negatives, since I am happy to travel the country to find a doctor. If I had limited options, I would behave differently.
It’s lonely to keep searching for a new doctor over and over again. For one recent medical topic, I’m on six consults and counting.
When it’s not a big deal, I don’t fight this hard. But when it is, I’ll keep attacking your ideas, methodology, and approach until I dismiss you or I trust you.
Most people fall into the first category. The second category is how I befriended my surgeon.
Game on.
Julian Wise 