The late Hans Rosling gave an amazingly popular TED talk back in 2006 (and many other popular talks since). You may have seen it. It’s the one showing recent human progress by following counties over time as a series of bubbles. It’s not all rosy, but it shows us how counterintuitive reality can be compared with our usually grimmer assumptions. One could summarize: things can be bad but still be improving. Trajectories matter.

In his follow-up book, Factfulness, Rosling discusses the fact that almost all “news” by definition is bad news. His helpful grounding suggestion: When you hear bad news, ask yourself if similar good news would be able to reach you.

* * *

In healthcare, M&M is full of bad outcomes. Do you hear about the patients who recover uneventfully in the hospital? Not really. Do people gossip about the patients who go home after surgery with well-healed incisions? No, they do not. As a radiologist, I only hear about my misses. About once a year, someone congratulates me on a good catch, and usually, that’s coming from another radiologist who read the follow-up.

As an attending evaluating my residents’ overnight work, I have to grade every change. We have grades for verbiage changes, incidental additions, small relevant misses, and big emergent misses. There’s nothing forcing me to tell my residents that I recognize the great job they’re doing tackling a large volume of complex cases. Most of what they see is negative feedback, even though that parade of bad news doesn’t really tell them an accurate story about the work they’re doing.

When I was a resident, my program had a separate grade for doing an amazing job. You could receive a coveted “1” on the 1-4 scale for crushing a subtle case, performing at a subspecialty level, etc. 1’s were rare.

One evening as I logged in for another shift, I was reviewing my grades from the night before and I saw I’d received a 1. Exhaustion aside, I was always excited when I earned a 1. The comment said, “Everyone deserves a 1 every now and again, so here’s yours.” I didn’t know how to parse that cryptic statement, so I clicked on the link to see the case.

It was a completely normal head CT in a young patient.

I hadn’t changed a word of the template.

* * *

We learn medicine through the slow accumulation of emotional microtrauma. As an educator, it takes special effort to try to really teach through praise and positive reinforcement; usually the vague “great jobs” show up on end-of-rotation evaluations. I’ll be the first to admit I can be too far on the pedantic curmudgeon spectrum.

Yes, feedback—even negative feedback—is a critical component of the learning process. But, when you’re beating yourself up about your mistakes and questioning your skills/growth, you also need to ask yourself:

What are the odds that I’m receiving the true positive side of the same coin?

The answer is you’re probably not.

Things can be bad and still be improving. Trajectories matter.

You can have a lot to learn and a long way to go and still be doing a great job.

Highlights from Build: An Unorthodox Guide to Making Things Worth Making by Tony Fadell (who led the teams for the iPod, iPhone, and Nest Learning Thermostat):

On the need to divide decisions into two main camps, data-driven or opinion-driven:

Data-driven: You can acquire, study, and debate facts and numbers that will allow you to be fairly confident in your choice. These decisions are relatively easy to make and defend and most people on the team can agree on the answer.

Opinion-driven: You have to follow your gut and your vision for what you want to do, without the benefit of sufficient data to guide you or back you up. These decisions are always hard and always questioned-after all, everyone has an opinion.

Every decision has elements of data and opinion, but they are ultimately driven by one or the other. Sometimes you have to double down on the data; other times you have to look at all the data and then trust your gut. And trusting your gut is incredibly scary. Many people don’t have either a good gut instinct to follow or the faith in themselves to follow it. It takes time to develop that trust. So they try to turn an opinion-driven business decision into a data-driven one. But data can’t solve an opinion-based problem. So no matter how much data you get, it will always be inconclusive. This leads to analysis paralysis-death by overthinking.

“Data can’t solve an opinion-based problem” is a core problem of the universe.

And the problems are worse when you can find a way to shirk responsibility for making those decisions:

But we fell into the same trap as everyone else. We were wowed by the consultants, excited by the numbers. And we quickly became far too reliant on them: everyone wanted data so they wouldn’t have to make decisions themselves. Instead of moving forward with a design, you’d hear, “Well, let’s just test it.” Nobody wanted to take responsibility for what they were making.

So you’d run the test. And then run it again. On Monday the customer panel would pick option X. On Friday, the same group would go with option Y. Meanwhile, we were paying millions of dollars to consultants who took a month and a half to put their own slant on everything.

The data wasn’t a guide. At best, it was a crutch. At worst, cement shoes. It was analysis paralysis.

“Design by committee” is an adjunct to the crutch of data, where there is no vision for the product and no responsibility for the outcome. I see this in medical schools, residency programs, and medical centers of all varieties. So many meetings to discuss so many dashboards. The analytic tools have become robust, so we are awash in numbers and react by massaging our processes to push various metrics in the right direction, often with no regard to second-order effects.

We so often seem locked into a rearranging deck chair approach to problem-solving instead of designing from first principles to make better products and achieve better outcomes.

On being a doofus:

I remember we had a huge all-hands meeting at Apple once these meetings would only happen two, maybe three times a year. And a guy stands up during the Q&A and starts asking Steve Jobs why he didn’t get a raise or a good review. Steve looks at him in stunned disbelief and says, “I can tell you why. Because you’re asking this question in front of ten thousand people.”

On quitting:

Anyone who’s ever stuck with a job they hated knows the feeling.

Every meeting, every pointless project, every hour stretches on and on. You don’t respect your manager, you roll your eyes at the mission, you stagger out the door at the end of the day exhausted, dragging yourself home to complain to family and friends until they’re as miserable as you are. It is time and energy and health and joy that disappear from your life forever. But hey, that title, that stature, that money it’s worth it all, right?

(He’s asking a rhetorical question.)

The threat of leaving may be enough to push your company to get serious and make whatever change you’re asking for. But it might not. Quitting should never be a negotiating tactic. It should be the very last card you play.

So before you quit, you’d better have a story. A good, credible, and factual one. You’ll need to have a rationale for why you left.

And you’ll need one for why you want to join whatever company you’re heading to next. These should be two very different narratives. You’ll need them for the interview, but also for yourself to make sure you’ve really thought things through. And to make sure you’re making the right choice for the next job.

The last part I think is sometimes underappreciated. You don’t just quit from something. Until you retire, you’re also quitting to something.

I wrote a brief article last year on evaluating jobs, where I referenced a 2020 study that showed 41% of radiologists had changed jobs in the past 4 years. I bet it’s even higher now given the current market. Lots of folks are quitting. The question is, are they learning from their experiences?

On the benefits of integrating old and young people:

The best teams are multigenerational Nest employed twenty-year-olds and seventy-year-olds. Experienced people have a wealth of wisdom that they can pass on to the next generation and young people can push back against long-held assumptions. They can often see the opportunity that lies in accomplishing difficult things, while experienced people see only the difficulty.

The generational conflict is real, and it’s often amazing to see in person how easily both groups generously weigh only their own strengths.