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- Anthony N. DeMaria, MD, Editor-in-Chief, Journal of the American College of Cardiology* ()
- ↵*Address correspondence to:
Dr. Anthony N. DeMaria, Editor-in-Chief, Journal of the American College of Cardiology, 3655 Nobel Drive, Suite 630, San Diego, California 92112
Physicians have always been proud of their achievements, justifiably so I think. We have successfully competed for positions in the best colleges, admission to medical school, and appointments to the finest training programs. We have worked long hours, mastered a large body of knowledge, and we provide an enormously valuable service to society. Our accomplishments are acknowledged by virtue of the respect accorded to us, by our social status, and by the financial compensation we receive. In general, just becoming a physician is thought of as an exceptional achievement.
In view of the above, physicians might be thought of as a type of outlier. In his recent book, Malcolm Gladwell, of whom I have written before, defines outliers as men and women who do things that are out of the ordinary (1). Of course, we tend to think of outliers as individuals of such extraordinary achievement that they receive fame and fortune, such as Albert Einstein or Bill Gates. Nevertheless, as a group, physicians are certainly above the norm in terms of accomplishment.
The ability of outliers to perform lofty feats is usually attributed to a combination of personal attributes, including talent and effort. We like to think that we have gotten where we are by virtue of intelligence and hard work. Therefore, I was deflated when I read that Gladwell attributed great personal success largely to chance occurrences. He argues that we owe something to both parentage and patronage and that great achievers “are invariably the beneficiaries of hidden advantages and extraordinary opportunities and cultural legacies” (1).
Gladwell begins his discourse with an example of interest to cardiologists. He describes Roseto, Pennsylvania, a small town uniquely settled by immigrants from a single region in Italy, and one in which heart disease virtually never occurs below the age of 65 years. The explanations usually posited for such findings, genes and environment (e.g., family history and diet/exercise), were eliminated in the case of Roseto. In fact, the protection from heart disease and other maladies, such as ulcers, seemed to be related to the nature of the close and mutually supportive community that the people had established. Thus, the outlier, that is, the absence of a prevalent form of disease, was not due to personal attributes of the residents, but rather to the nature of the society they had created.
We physicians attribute great importance to intellectual prowess. We believe it is likely that high intelligence is largely responsible for our own achievements, and feel certain that the same is true for outliers. Gladwell concedes that some minimal level of intelligence is necessary for great success; you need to be “smart enough.” However, he argues that even those with high intelligence often require other advantages to achieve greatness. As an example, he offers the fact that Nobel laureates come from both prestigious institutions like Harvard and from schools of more modest reputation like Holy Cross (my own alma mater). In fact, since Harvard has its choice of the best and brightest, the number of Nobel laureates it has produced is not as high as expected. Neither do all, or even the majority, of individuals with a very high intelligence quota attain greatness. Gladwell distinguishes between analytic and practical intelligence; the latter is the ability to effectively navigate the world and interact with society. He argues that practical intelligence is neither inborn nor related to individual effort, but rather is bestowed upon people by their family and the culture of the community in which they live. Practical intelligence can enable some individuals to realize extraordinary goals that equally gifted persons without this characteristic cannot. In this construct, a minimal level of intelligence is requisite to be an outlier, but is insufficient without other advantages.
We are also inclined to believe that great feats can be accomplished by ordinary individuals with colossal effort. Anything is possible if you just work hard enough. In fact, Gladwell provides some interesting data to suggest that a minimum of 10,000 hours of “practice” is necessary to achieve outlier status. He presents evidence supporting this from such disparate sources as Mozart and the Beatles, both of whom produced their most important works only after long hours of practice and experience over many years. However, he maintains that “grinding effort” alone is inadequate for prodigious accomplishment. Moreover, he argues that only extraordinary opportunities for such long and arduous practice will enable one to become renowned, and that such opportunities are often the result of chance.
If intelligence and hard work are not sufficient to produce an outlier, to what can we attribute such accomplishment? Gladwell asserts that hidden advantages are responsible in most, if not all, cases. The advantage may be as simple as a birthday. The book details that a disproportionate number of birthdays of elite Canadian hockey players occur in the first 3 months of the calendar year. It is explained that such birthdays provide an advantage in maturity to these athletes during childhood, when teams are defined by age as of January 1. This advantage is said to result in more attentive coaching and more opportunity for practice for those born just after January 1. Similarly, it is amazing that 14 of the 75 wealthiest people in the history of the entire world are Americans born within 9 years of each other in the 19th century. They reached adulthood during a time when the economy of the U.S. underwent a Herculean transformation involving business and manufacturing. Conversely, reaching adulthood during cataclysmic events, such as the Great Depression or a World War, is a hindrance to success.
Extraordinary opportunities represent another hidden advantage. Bill Gates was unusually fortunate in attending a private school that was one of the first to provide access to a mainframe computer. He was subsequently lucky enough to have abundant access to other computers for many years. Without this access, he might not have been an outlier. The Beatles had the hidden advantage of finding employment that enabled them to perform and practice for many hours while they honed their talents. Other extraordinary assets can be related to family, cultural background, or geography. Gladwell's contention is that if you looked hard enough, you would nearly always find some fortuitous circumstance over and above talent and effort that enabled outliers to achieve this distinction.
I must admit, I find it somewhat deflating to think that the people we most admire for extraordinary achievements, the outliers, owe their successes in large measure to chance (hidden advantages) rather than to personal attributes. In fact, I think Gladwell exaggerates. While it is always good to be lucky, I believe that remarkable accomplishments require exceptional talent and effort. Nevertheless, the role of chance does put outstanding success in perspective. In terms of those of us in medicine, it is my impression that we think of ourselves as the ultimate meritocracy. Individuals become physicians by virtue of intelligence and hard work, chance plays little if any role, and it is possible for anyone with these characteristics to achieve this distinction. However, if we look hard enough, I suspect certain advantages, hidden or otherwise, contributed to our success. It probably does us good to acknowledge this, and it certainly helps to keep us humble. We should be proud of what we have achieved, the personal attributes that made it possible, and the fact that the possibility was open to anyone. At the same time we should be thankful for whatever lucky breaks we got along the way.
- American College of Cardiology Foundation
- Gladwell M.