Hidden Brain - Ep. 71: The Fox and the Hedgehog

Episode Date: May 16, 2017

The Greek poet Archilochus is known for the phrase, "The fox knows many things; the hedgehog one big thing." This week, we'll use this metaphor as a way to understand two different cognitive styles. The first is that of a tactician who is comfortable with nuance and contradiction (the fox), the second is that of a big thinker, motivated by one organizing idea (the hedgehog). We'll explore this idea through the story of a pioneering surgeon whose hedgehog tendencies led him to great triumphs, and a heartbreaking tragedy.

This is Hidden Brain, I'm Shankar Vitaantham. We like stories about leaders who have big ideas, who define the odds and pursue their goals with messianic purpose. Think of Winston Churchill in World War II, or Abraham Lincoln during the Civil War. But what happens when a leader's vision is the wrong one? How do we think about people who dream big, only to invite disaster?

At such times, we might prefer a more cautious style, someone who plays the odds. Those leaders might not score historic triumphs, but they rarely cause catastrophes. Thousands of years ago, the Greek poet Archylicus summed up this idea. He said, the fox knows many things, but the hedgehog knows one big thing. That has been, that parable has been the subject of much debate over the last 2,500 years. What exactly are killika's meant? This is a psychologist Phil Tetlock.

Various people have offered various interpretations. Some people coming out on the side of the hedgehog, saying the hedgehog will trump the fox, and other people saying no, it really means the fox is going to do better. There are different ways to think about the metaphor, but here's how I see it. If a fox wants dinner, it has many options. It can chase down a hedgehog, it can find something else to eat. It can even go without food for a day. But if you're a hedgehog being chased by a fox, you don't have multiple goals. You have

one overarching idea. Don't get eaten. Tatlok thinks this metaphor also describes two cognitive styles in people. Foxes have different strategies for different problems. They are comfortable with nuance. They can live with contradictions. Hejog's focus on the big picture. They see every problem through the lens of a single organizing principle. The Hejogs are more parsimonious, more decisive. In most MBA programs,, they probably viewed as better leadership material. This week on Hidden Brain, we have the story of a hedgehog, a surgeon who changed the

world in daring ways. His bold style made him a pioneer in what is today become the transgender movement. It also propelled him to create one of the world's first international medical missions. Like other hedgehogs, this surgeon experienced outside success until one day he didn't. It's just that God damn disaster, an awful thing. Greatness and tragedy, this week on Hidden Brain. This week on Hidden Brain. Sandy Stone was born in 1936 in the midst of the Great Depression. Her parents gave her a Hebrew name. It was there like Ben Nautan.

Zellig Ben Nautan, a boy's name. That's because her parents thought she was a boy. But from a very early age, she knew she was a girl. This was a long time ago, decades before the modern trans movement. When Sandy was a child, there were no words, no language, to describe what she knew about herself. It was lonely, it was disorienting, it was puzzling, confusing, scary, it was all of those things. It stayed like that for Sandy all the way into adulthood. She went to school, became a recording engineer, moved to the Bay Area.

All the while, everyone thought she was a man. She kept searching for help. In the San Francisco phone book she found a promising lead. It was a group for gay men. When she called, they asked if she was gay. She said she wasn't. So they sent her away and told her to try another group. The outfit they recommended surprised Sandy. It was the San Francisco Police Department. It turned out that the police department was running a counseling unit of sorts, which they did for the population of transgender people that lived in the San Francisco tenderloin, which was sort of the

down and outskid row section of town that tended to collect people who couldn't afford to live anywhere else or who had run out of options. Trans people who ended up in the tenderloin were at high risk for drug addiction and prostitution. They were social outcasts. When Sandy got in touch with the police to ask for help, the first thing they did was to dissuade her from acting on her feelings.

And they actually tried to discourage me by taking on a tour that reminded me of Dante being led down into the lower circles of hell. They really showed me the worst of everything and then said, are you sure you still want to go ahead with what you were thinking of? And to be perfectly honest, I wasn't quite sure what you were thinking of. And to be perfectly honest, I was not quite sure what I was thinking of. I was just trying to collect information.

And I think it would be safe to say that that's what we were all doing at that time. Still, the referral to the police turned out to be a stroke of luck. The cops told her that a center at Stanford University had recently started performing what were then called sex change operations. They didn't refer me to Stanford as much as talk about it, as the great unethaneable

goal, the great beautiful shining star in the sky. After years of suffering and loneliness and confusion, the Stanford program felt like a beacon. Sandy felt she might finally have a chance to live a more honest, satisfying life. But first, she had to convince the gatekeeper, who stood between her and the person she wanted to become. He ran what was then called the Gender Disphoria Program at Stanford. His name was Don Lob.

The gatekeeper of Stanford's Gender Disphoria Program was a hedgehog. From a very early age, he had a big picture right there. He wanted to help people. He wanted to help a lot of people. As a small child, when kids in his school were asked to donate money to a charity, his classmates contributed a dime. Don worked in a vegetable garden an entire summer to raise a whopping $10. Now, I got a letter, a preserved letter from it that my mother wrote to some of her friends saying, Don, he's done something and nobody has ever done.

Don's father feared his little boy was consumed with being a do-gooder, that he would turn out to be a failure at business. His father was right. Don Lob became a doctor. When he came to Stanford in the 1960s, he was a young, ambitious plastic surgeon, very much in awe of his prize winning colleagues. Coming to Stanford, I was overshadowed by the hugeness of what people were doing, the importance of it.

So I knew that I had to do something, right? Maybe, you know, I gotta do this, somewhere along the line because everybody else here is doing it. Don was looking for a place to make his mark. One day, a colleague walked out of an examination room and came up to him. When I said, Don, I'm watching you to see a patient.

It's a good case. You might not like it. It's a sex change. Remember, this was 1968. I said, Dave, send that patient away. I'm a Catholic boy from the Midwest and I'm at Stanford. We don't do those things. But Dan's colleague insisted he meet the patient. To be clear, this patient was not Sandy Stone. He said, do me a favor and go in that room. I went in the room and talked to the patient and I said,

now why do you want to section? She said, well, I was born and this is what I should be. I said, well, when did you decide that she said, I didn't decide it? This is what I was born with from day one. This patient was a pioneer. No one on the west coast had received what's come to be done today as gender reassignment surgery or gender confirmation surgery.

In fact, the surgery had been rarely performed across the whole world. Don was an unlikely choice of doctor. He was, by his own account, a prim man from the Midwest. But although Dawn initially blanched the idea of gender reassignment surgery, he felt a shiver of excitement. He didn't send the patient away. Instead, he went looking for information. He consulted with psychiatrists and a few surgeons around the world who had already performed

this kind of surgery. What prompted you, this sort of, you know, Catholic doctor from the Midwest, to basically take this on? It seems like an unlikely fit. It was a wonderful opportunity to do a big thing, and to help a lot of people. Altruism and ambition were always tightly woven in Don's identity. He wasn't interested in superficial cosmetic work, he wanted to change the world. He decided to take the leap.

In November 1968, Don Law performed California's first gender reassignment surgery. We were more than prepared for all the things that might happen. And a surgery went fine. It took about three and a half hours. We did it with the skin graft method, and no problem. Don soon became one of the world's leading experts on gender reassignment surgery. He started a program.

His reputation grew. A reputation for being a good surgeon and a tough gatekeeper. He turned away many people because he felt they weren't good candidates for surgery. Sandy still and vividly remembers her first appointment with him in the mid-70s. I go in and sit down and Don is behind his desk and he's wearing his white coat. And he's very distinguished looking and calm and very friendly and open. And he says, well, what can I do for you? And I say the first thing that comes into my head, which is, I think I'm a woman. Now, the scene we have is Don behind his desk and me. I have a long black beard and wild black hair.

I'm wearing a blue shirt, jeans, and engineer's boots. I do not exactly look like I'm thinking of myself as a stereotypical woman. And Don looks at me and says, really? And I say, what should I do? I mean I'm totally, I'm completely open to anything. I really don't know what I should do, what direction I should move in, what's right, what's wrong, and I'm looking to Donald to tell me. And in my memory of the thing Donald then says, well the first thing you should do is there's the beard." That was the beginning of Sandy's long transformative journey. It was a tough

journey. Don wanted Sandy to be sure she was making the right decision. So before he would even consider surgery, Sandy says he told her she would have to live openly and fully as a woman for one full year. It was a requirement based on the reality of the time. No one, not Sandy, nor Dawn knew what might come from these surgeries in the long term. These were early days. It was all a bit of an experiment, a shot in the dark. It was fraught. It was fraught for everyone. And it was fraught because at that time it was not clear what would happen later. We didn't have very many examples of transgender people who had had surgery, who went on to

have fulfilling lives and lived to tell about it, which is to say, came back later and reported back to the program. They were experimenting on the fringe of what both medicine and society thought was acceptable. Don was taking risks with his professional reputation. Sandy was taking risks with her life. There was one moment Sandy says when she and Don clashed, the conflict boiled down to their cognitive styles. At some point he asked me if I were a hundred percent committed to wanting surgery. And I said no, I'm not, I'm probably 99.9 percent. I think anyone who is 100% committed to anything is probably crazy. You have to have

some reservations in life. You have to have an overview of everything that you're doing and have alternative plans if what you're looking for doesn't work out. And Don said, well, in that case, you're not eligible for surgery. You have to be 100% committed. It took a mediated session with Don's assistant for the two of them to resolve the conflict. But the incident revealed something about the way a hedgehog moves through the world. Hedgehogs are decisive. Don could not understand anything less than 100% commitment, even if the 0.1% of doubt was simply a way to say, I'm human. How can I be absolutely sure?

Sandy tells another story of a time she came in for an appointment wearing jeans and a t-shirt. Dawn asked her why she wasn't dressed like a woman. He'd missed the bell-bottom jeans and tie-dye revolution happening right outside his window. It was the kind of thing that could have led to a fight, except for one thing. Sandy understood where Dawn was coming from. She knew that underneath the tough exterior, he really wanted to help, and not just in a medical sense. More than anything, Dawn wanted Sandy to live a life where she didn't feel like an outcast. He wanted his people to be totally remarkable to just fit in to be

able to live their lives to be able to be inconspicuous and just get along and that's a good thing to want for 99% of your waking day is just to be able to live your life, to be able to live with other people and not rub people the wrong way. Sandy Stone successfully underwent surgery in 1977. When I interviewed Sandy, I told her that her story reminded me of another case that Don told me about. It's interesting because I don't first came to my attention because of another case involving cleft lip surgery and it's so striking that as you're saying this I'm sort of hearing

echoes of that other work as well. There's a drive that he had to just help people to essentially live what he would think of as being a normal life, a life that they're not ostracized, a life that they're not feeding like they're outcasts, that they're functioning, they can get an education, if they're a child, that they can get a job, if they're an adult, that they can be, that they can be happy. And I feel there's something, something actually very midwestern about that idea. That's the word, that word you said is correct. Don wanted people to be happy. Don did it professionally.

His job was to help people to be happy. And for that, I owe him a lifetime debt. I would not have done anything I think that I did after the 1980s, if it weren't for Don Laub, or the 70s, rather, if it weren't for Don Laub. Sandy went on to become a prominent writer and theorist and eventually helped found the academic discipline of transgender studies. When she considers Don's influence on her life, she homes in on his willingness to pursue a big idea with single-minded purpose. Do you go for the big one or do you accept something less?

And many of us accept something less because we don't want to take the risk. And then we may go through life, maybe, maybe we'll be happy with our measure, or maybe we'll say, what if I had gone for what I really wanted? What would that have been like? Maybe I would have died. Yeah, maybe I would have, but I didn't. I beat the odds, and I went on to be glory as I happy. That's something in life.

And Don brought that to many people. I don't see how one could do better than that. Don's leap into the unknown, his willingness to bet his professional reputation on a big idea, his confidence in his own judgment, it had all paid off. The hedgehog had won. But pursuing a big idea with determination doesn't always pay off, and when a hedgehog fails, the fall can be painful. Don Lobb knows about that part of the story too. Stay with us.

knows about that part of the story too. Stay with us. According to the ancient Greek poet Arkelicus, the fox knows many things, but the hedgehog knows one big thing. Psychologists feel tech locks as the metaphor describes two kinds of people. Small picture tacticians are foxes. Big picture strategists are hedgehogs. Before Don Lobb became a world-renowned gender reassignment surgeon, he had another big idea. It started this way. One day a colleague asked him if he could help with the surgery. The patient was a child from Mexico. This was a 14-year-old boy who had no other deformity than his cleft lip and palate.

But because of it, the boy was shunned. A group of priests had driven him north all the way to Stanford to get him help. Don immediately understood that the cleft lip wasn't just a medical problem. He had not gone to school. He had no educational advancement. He had not gone to school, he had no educational advancement, he had no friends. The surgery to repair the cleft lep and pallet was simple and quick. It was so easy and it gave this child a real chance in life. Don says performing the surgery made him feel really good. As someone with deep religious roots

and a Catholic education that emphasized helping the poor, Don felt this was the kind of patient he wanted to serve. He turned to the priest who brought the boy from Mexico. I asked him, are there other patients in Mexico? Like this? They said, the place is full of them. So we bought an airplane ticket and went down to

Mexicaly and asked for a clinic. Just like that, where a fox may have calculated the odds, considered the upside and the downside, the hedgehog simply picked up and went. In Mexicali, dawn found a dusty border town in the desert, where the people were very poor. I mean most of the houses were made of packing crates at that time, and there was no paving in Mexicali of 200,000 people. Mexicali's main medical facility was an old wood home.

It had a dirt floor for part of it. The back part of the clinic was used to raise fighting cocks. A rational fox may have calculated the risks and back down, not done. He recruited local health officials to get word out that they would be providing free surgeries for children with cleft lips and burn scars. The clinic was quickly packed. It was 10.30 in the morning.

In that desert, there had not been rain there for three years. The hot in the morning was about 106 degrees already. You couldn't touch anything metal because you burned your hand. The first patient I saw was sitting there with the bag. I just had two little peep holes. I said, what's with the, why the bag? Behind those peep holes, the boy was hiding his face in shame. Don asked if he could take a look.

So he got the bag off, and he had a burn scar to pull this island down. A simple thing to repair. As with Sandy, Don wanted to make the little boy, undremarkable. He wanted him to lead an ordinary life, unmarked by stigma and shame. That first trip was just a fact-finding mission, a way to see if there was a need. By the time Don went back to Stanford, a plan had formed in his mind. He wanted to recruit the best doctors from the United States and fly them to Mexico to perform free surgeries on children with birth defects. He recruited surgical residents to join skilled surgeons on the trips. He found pilots willing to transport medical equipment.

Hejogs have charisma. They can see the shining city on the hill so clearly that everyone around them starts to see it too. Everybody jumped on it. the hill so clearly that everyone around them starts to see it too. In 1966, the official medical missions began. Now it's important to remember that at this time, the idea of plastic surgeons going abroad to provide free surgery was almost unheard of. There were fewer parameters of how international aid organizations should operate. Don was flying by the seat of his pants. Every few months the doctors would descend on Mexicali.

They'd throw themselves into four marathon days of back-to-back surgeries and consultations. Over the years they'd come back, again and again, performing more than 2,000 surgeries in all. One of Don's first patients was a little boy named Eugeneio. He was the boy who'd worn the bag over his head. Don repaired the scarred eyelid, and still remembers the boy's first reaction. He had a very nice, huge smile. On a follow-up trip, Don tracked Eugene you down. He shook hands and everything like that, even as a young kid. And he said,

I have friends at school, no. Don loved it. He's a real happiness. It's a source of happiness. It's the best description. If anything, Don and that I would describe it as a very, and I think he would accept it, I think it was a very sort of a missionary zeal. This is plastic surgeon Howard Holdeness. He was part of the team of residents helping perform surgeries in Mexicali. Howard says that Don's vision drove the whole team. I think he felt very close to trying to do things that not only practiced medicine and all of its forms of science and everything, but the art of medicine and some of the spiritual

aspects of being a good doctor. He was doing more than surgeries. Don was developing a program that could set an example for others to follow around the world. One day about two years into the Mexico program, a woman arrived at the clinic with her young son. His name was Salvador. Compared with the other patients, Salvador had a more severe birth defect.

He had bilateral clets, clefts rather than one. When you have this bilateral, the muscles are cut twice. So, when you smile, they pull out. If they're repaired, they pull in. See? So, every time he would have a facial expression, it would be awful. You'd see these teeth on both sides. Salvador was a perfect candidate for surgery.

That is, until a doctor on the team gave the boy a thorough physical and listened to his heart with a stethoscope. His mother brought him in and the pediatrician listened and he was, whoosh, whoosh, whoosh, the heart sounds. These were not normal sounds. The boy's heart had a hole in it. The risk of proceeding with surgery was small, but potentially fatal. They gave the mother the bad news.

We can't operate because we don't have the equipment in Mexico, do the hard catheterization or anything like that or any, even get the E.K.G. today. So Dawn and his team turned away the mother and the little boy. I should say here that we're going only on Dawn's account of what happened, the medical records from that ERR incomplete and we weren't able to find the mother. A few months after sending the child away, Dawn and his team were back in Mexico. The mother and her son were waiting for them again.

Salvador, she told them, was shunned. He had no friends. Other children called him El Monstre. The monster. The mother said, this child has no chance in life. You got to fix it. Don's heart went out to the little boy. He explained the danger again. The risk was small, but it did mean that things could go seriously wrong. Don held the stethoscope up to the mother's ears.

Listen, she can hear it, whoosh, whoosh, whoosh. So the answer again was no. More months passed. Don returned to the clinic, so did the mother. Poor for war. Please, doctor. Can you see the child has no life? This was a critical moment. Don could again have said no.

Medical protocol said that was the right call. But Don also knew that without surgery, Salvador would always be an outcast. Could he have tried to take the boy back to Stanford where hot surgeons could have assisted with his care? Maybe. But that would have been complicated, expensive, and a drain on critical resources from the project in Mexico,

resources that were helping hundreds of other children. So Don did what Don always did. He took a look at the child, took a deep breath and said, okay, we'll do it. I feel like that's why I existed. Is for this judgment. I mean, I'm not there to take care of little pimples. I'm there to do the tough cases. So this was putting it right on the line.

You got to do it or put your tail between your legs and get out of there. It's been nearly 50 years since Don Law performed that surgery on a six-year-old boy in Mexicali, Mexico. He's had thousands of patients since then, but the details of that day are still vivid in his mind. The morning of the surgery, the boy went through the standard pre-surgery lap test and check-up, and

Ivy was started, and he received extra glucose in case his blood sugar was low from stomach worms, and then the boy walked by himself into the operating room. And he gets an anaphyring table himself. Because he trusts the operating room. And he gets on the operating table himself. Because he trusts the whole world. The surgery began. First, the child was anesthetized. So that went fine. When perfect, no problem at all. Then Dawn and his team began the surgery. When we were operating, everything was going perfect. And then, just like that, it wasn't. And I see jealous and boys.

We have no pulse. They tried everything. CPR, medicine to jumpstart the heart, nothing worked. Don suspected a blood clot. The boy was dead. They put away their surgical tools. They wheeled the body to the morgue. All the while, Dan's heart was starting to race. He was working in a foreign country, and he had made a risky judgment call in violation of medical protocol. And my mind is going a thousand miles an minute. Why am I here in Mexico? Why did I get into this? What the hell is the matter with you? Here you are in a foreign country.

You can end up in jail. It's just a goddamn disaster. An awful thing. And of course, there God damn disaster! An awful thing! And of course, there was the boy's mother, waiting anxiously outside for news of her son. Don remembers stepping out of the operating room and walking up to her. He told her they'd been complications that they had tried hard, but the boy had died. The mother began to sob, but then Don says, she did something surprising. She asked him why he was upset. She said, you should be happy because the child is seeing God with a complete face. Don had expected accusation and anger.

Instead he encountered a mother who leaned heavily on her faith. Don said she was comforted by the thought that her child was now repaired and beautiful and at home with God. Salvador was finally at peace. Don stayed at the mother. He was speechless, not just because of what she said, but because he was struck by another thought. The mother didn't know this, but Salvador's face was not repaired. He died before the surgery was complete. What would the mother say when she saw her son at the funeral? Again, the medical protocol was clear. Don had to turn the body over to Salvador's mother. But he felt he couldn't bring himself to do this. It would only compound the first tragedy. He conferred with his team about finishing the surgery

on Salvador. I said it's against the law, but I think in this case we should. The rest of the team unanimously agreed. The little boy was brought back from the morgue. The child came back on a body bag, and we did the whole thing as if the child was awake. I interviewed Don several times for the story. I pushed hard to understand why he decided to operate on Salvador. What were you telling yourself, again, emotionally, that made you change your mind, that made you say, yes, I recognize this is a risk, but I have to do this. I thought this is what I, what I am for. This is my purpose. And you said it's worth it standing there and I couldn't say no again. I didn't I couldn't. But I made it to see what I said that. Let's go ahead and do the case.

I didn't have any second thoughts. Emotionally I figured out that this is what I should do. Don still thinks about Salvador has thought about him thousands of times over the years. He's turned the case over in his head in every possible way. I asked him over and over whether he felt regret. No. Well, of course I do. Of course I do. Of course I do.

Yes, I do. I mean, you said just a minute ago, it was a mistake. But I don't have, I don't, I don't, I'm not whipping myself. Not whipping himself, Don says, because he was trying to do the right thing. That's the reason he decided to operate. That's the reason he completed the surgery after the child was dead.

What was more important than being on the right side of the law? Doing the right thing. By the mother and by the child. Yes, yeah. No, you must always do the right thing. That is the highest priority over all different laws and commandments or any of that thing. You have to do the right thing. The day after Salvador died, Don Lab was back in the operating room. There were more children

waiting for surgery. He remembers looking out the windows of the sky, it was, he says, a perfect, asuar blue. At 10.30 the time when Salvador was to be buried, everyone on the team felt silent and paused. There was no sound except for the whoosh of the Anasthesia machine. When we think of foxes and hedgehogs, it's completely understandable that we want the best of both worlds. We love bold visionaries who take big risks, except when the risks don't work. At moments like that, we prefer the visionaries to be more cautious,

filled with a little self-doubt. Now people don't always fall neatly into one camp or the other. Some of us can be both Fox and Hedgehog, we can think and dream big, but also change course, adapt to circumstances. But it may be that we can't have our cake and eat it too. If we want the visionary Steve Jobs who helped usher in the age of the iPhone, we might also get the tyrannical CEO who nearly ran Apple computers into the ground in the 1980s. It's odd to think of Gandhi and Napoleon and Churchill and Mao in the same breath, but

they are cut from the same cloth of Messianic vision. It's easy not to like the kind of people who create history's greatest failures, but it turns out they're also the people who produce our greatest triumphs. This week's show was produced by Jenny Schmidt and edited by Tara Boyle. Our team includes Maggie Penman, René Clarre and René Cohen. The music in today's show was composed by Rampti and Arab Louis. Our unsung hero this week is another hedgehog and another Don. Donal Drake was a colleague and friend of mine at the Philadelphia

in Quarra many years ago. He taught me many things about writing and storytelling. We even wrote a play together. Don's in poor health right now in Philadelphia, and I wanted to give him a shout out for all that he's done for me. Thanks, Don. For more hidden brain,

you can follow us on Facebook and Twitter and listen for my stories on your local public radio station. I'm Shankar Vedanthantham, and this is NPR.