I listened to an episode of Malcolm Gladwell’s Revisionist History called The Trust Diagnosis and haven’t stopped thinking about it since.
The story is about a bloke facing a serious cancer diagnosis who got wildly different advice from every doctor he spoke to. Fifteen said don’t operate. Two said operate. He went with the two. It worked.
But the medical stuff isn’t the interesting part. What stuck with me was how he made the decision, because the same process applies to picking a builder, changing jobs, choosing a school or handing money to a financial adviser. Here’s what I took from it.
First facts are always wrong
This was his big one, learned over 40 years of crisis work. When a situation is new, the information arriving is incomplete, rushed, and filtered through whoever gathered it. Some of it will turn out to be wrong. Not because anyone is lying or incompetent, but because that’s how early information behaves.
The trap is that credible people deliver it. A specialist, a lawyer, a lab result. So you believe it, and then you make decisions on top of it. His first doctor told him to get an MRI sometime in the next few months. That advice nearly cost him his life.
Assume your first version of the story is partly wrong and hold your decisions loosely until you’ve tested it.
Listen to what people are actually optimising for
His doctors kept telling him “we can keep you alive.” They thought that was reassuring. He wasn’t scared of dying, he was worried about the quality of the years he had left. They were answering a question he hadn’t asked.
This happens constantly. The accountant optimises for tax. The lawyer optimises for not getting sued. The builder optimises for not having to come back. All reasonable, and none of them are optimising for what you actually want unless you tell them what that is.
Be suspicious of anyone who says they can solve your problem
His line on this was blunt: people who tell you they can solve your problem, be extremely suspicious. Real problems have layers and history and moving parts.
The surgeon he picked was the one who said “I’m confident I can do the procedure. I can’t give you false confidence about the outcome.” He split it into two questions instead of one. Can I do this, and will it work? Those are different questions, and most people blur them together to sound reassuring.
Confidence about process is a good sign. Confidence about outcomes usually isn’t.
Reps beat credentials
He didn’t choose a prostate specialist. He chose a surgeon at Duke who handled complicated cancer cases of every kind, someone used to looking at things that seemed impossible.
Someone who has seen your kind of mess a hundred times will read it better than someone with a fancier title who has seen it twice. Worth remembering next time you’re weighing up a CV.
A majority isn’t proof
Fifteen of eighteen doctors said no. He went with the two. Not because he thought he knew more than them, but because he’d worked out where their information came from and why it might be flawed.
To be honest this is the part I’d find hardest. Going against a clear majority of qualified people takes something most of us don’t have. But a consensus built on the same shaky data isn’t fifteen independent opinions. It’s one opinion, repeated.
The peace comes from the process, not the result
The bit that got me was that after he decided, he slept fine. Gladwell was the one lying awake at 3am. He wasn’t confident it would work. He was confident he’d done the work properly, gathered what he could, thought about it the way he’d think about it for a client, and picked the best available option. After that, what happens happens.
That’s a good way to hold most decisions. You can’t control outcomes. You can control whether you did the thinking honestly. If you did, you get to stop chewing on it.
Trust is something you arrive at
The whole episode makes the case that trust isn’t a feeling you have at the start. That thing at the start is hope, or fear, or the fact that someone you know vouched for them. Real trust comes at the end, after you’ve done the reading, asked the questions and watched how someone handles being honest with you about what they don’t know.
Most of us do it backwards. We extend trust early because someone has the right credentials or a good manner, then find out later whether it was warranted. It’s worth listening to the full episode, it’s about 40 minutes and it’s the best thing I’ve heard this year.
