The Triumphs And Perils Of 'Going Big'

Jun 11, 2017
Originally published on June 12, 2017 11:58 am
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We tend to like stories of leaders who have big ideas and strong convictions, the kind of visionaries who stop at nothing in pursuing their goals. But what happens when a leader's vision is the wrong one? NPR's Shankar Vedantam brings us the story of an ambitious surgeon who was a pioneer in his field and also made a grave mistake.

SHANKAR VEDANTAM, BYLINE: From a very early age, Don Laub was driven by a big idea. He wanted to help people. He wanted to help a lot of people. As a small child, when kids in high school were asked to donate money to a charity, his classmates contribution a dime. Don worked in a vegetable garden an entire summer to raise a whopping $10.

DON LAUB: Now, I got a letter that my mother wrote for some of her friends saying Don has done something that nobody has ever done.

VEDANTAM: Don's father feared his little boy was consumed with being a do-gooder and would turn out to be a failure in business. His father was right. Don Laub became a doctor. By the 1960s, Don was a young, ambitious plastic surgeon at Stanford University, very much in awe of his prize-winning colleagues. He was looking for a place to make his mark. One day, a colleague walked out of an examination room and came up to him.

LAUB: He said, Don, I want you to see a patient. It's a good case that you might not like it. It's a sex change.

VEDANTAM: This was 1968 well before the modern transgender rights movement.

LAUB: I said send that patient away. I'm a Catholic boy from the Midwest, and I'm at Stanford. We don't do those things.

VEDANTAM: Don's colleague insisted he meet the patient, and although Don initially blanched at the idea of gender reassignment surgery, he also felt a shiver of excitement. So he didn't send the patient away. Instead, he consulted with psychiatrists and the few surgeons around the world who performed this kind of work.

LAUB: It was a wonderful opportunity to do a big thing and to help a lot of people.

VEDANTAM: Altruism and ambition were always tightly woven in Don's identity. He wanted to change the world. In other words, Don Laub was a hedgehog. Here's what I mean by that. Thousands of years ago, the Greek poet Archilochus said the fox knows many things, but the hedgehog knows one big thing.

PHIL TETLOCK: That parable has been the subject of much debate over the last 2,500 years. What exactly are Archilochus meant.

VEDANTAM: This is University of Pennsylvania psychology professor Phil Tetlock.

TETLOCK: Various people have offered various interpretations. Some people coming out on the side of the hedgehog and other people saying no it really means the fox is going to do better.

VEDANTAM: There are different ways to think about the metaphor, but here's how I see it. If a fox wants dinner, 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. Don't get eaten. Phil Tetlock thinks this metaphor describes two cognitive styles of people. Foxes have different strategies for different problems. They're comfortable with nuance. Hedgehogs focus on the big picture.

TETLOCK: The hedgehogs are more the big idea of people who are decisive. In most MBA programs, they'd probably be viewed as better leadership material.

VEDANTAM: In November 1968, Don Laub made a very hedgehoggy decision. He performed California's first gender reassignment surgery.

LAUB: And we were more than prepared for all of certain things that might happen.

VEDANTAM: Don soon became one of the world's leading experts on gender reassignment surgery or what today is called gender confirmation surgery. His reputation grew, a reputation for being a good surgeon and a tough gatekeeper. One of his patients, Sandy Stone, vividly remembers an encounter.

SANDY STONE: At some point, he asked me if I were 100 percent committed to wanting surgery. And I said, no, I'm not. I'm probably 99.9 percent. I think anyone who is 100 percent committed to anything is probably crazy. And Don said, well, in that case you're not eligible for surgery.

VEDANTAM: 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 percent commitment. Sandy underwent surgery in 1977. It was a success. When she considers Dan's influence on her life, she says it all comes down to the pursuit of a big idea.

STONE: Do you go for the big one or do you accept something less? And many of us accept something worse because we don't want to take the risk, and then we may go through life 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, but I didn't. I beat the odds. And I went on to be gloriously happy. And Don brought that to many people.

VEDANTAM: Don's leap into the unknown, his confidence in his own judgment, it had all paid off. But pursuing a big idea with determination doesn't always lead to victory. And when a hedgehog fails, the fall can be painful. Before Don 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.

LAUB: This was a 14-year-old boy who had no other deformity than his cleft lip and palate.

VEDANTAM: But because of it, the boy was shunned.

LAUB: He had not gone to school. He had no educational advancement. He had no friends.

VEDANTAM: The surgery to repair the gap in his palate and lip was simple and quick, and it gave this child a real chance in life. Don felt this was the kind of patient he wanted to serve. He turned to the priest who had brought the boy to Stanford all the way from Mexico.

LAUB: 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 Mexicali and asked for a clinic.

VEDANTAM: He soon found himself in a dusty border town whose main medical facility was an old, wooden home.

LAUB: It had a dirt floor part of it in. The back part of that clinic was used to raise fighting cocks.

VEDANTAM: A rational fox might have calculated the odds and backed down, not Don. He recruited local health officials to get word out that they would be providing free surgeries for children with cleft palates and bone scars. The clinic was quickly packed.

LAUB: The first patient I saw was sitting there with a bag on his head with two little peep holes. I said what's with the - why the bag?

VEDANTAM: Behind those peepholes was a little boy named Eugenio hiding his face in shame. Don asked if he could take a look.

LAUB: So he got the bag off and he had a burn scar that pulled this eyelid down, a simple thing to repair.

VEDANTAM: Don repaired the scarred eyelid and still remembers the boy's first reaction.

TETLOCK: He had a very nice, huge smile.

VEDANTAM: On a follow up trip, Don tracked Eugenio down.

LAUB: He shook hands and everything like that even as a young kid. And he said I have friends in school now.

VEDANTAM: Don loved it.

LAUB: It's a real happiness. It's a source of happiness is the best description.

VEDANTAM: Don's medical missions formally started in 1966. They grew quickly. One day, a woman arrived at the clinic with her young son Salvador. He had bilateral clefs two clefts rather than one. 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.

LAUB: His mother brought him in and the pediatrician listened and it was whoosh, whoosh, whoosh, the heart sounds.

VEDANTAM: 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.

LAUB: We can't operate because we don't have the equipment in Mexicali to do the heart catheterization or anything like that or even get an EKG today. So...

VEDANTAM: I should say here that we're going only on Don's account of what happened. The medical records from that era are incomplete, and we weren't able to find the mother. A few months after sending the child away, Don and his team were back in Mexicali. The mother and her son were waiting. Salvador she told him was shunned. He had no friends. Other children called him the monster.

LAUB: The mother said this child has no chance in life. You've got to fix it.

VEDANTAM: Don's heart went out to the little boy. He explained the danger again. The risk was small, but it meant things could go seriously wrong. So the answer again was no. More months passed. Don returned to the clinic. So did the mother.

LAUB: Por favor, please doctor.

VEDANTAM: 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 heart surgeons could have assisted with his care? Maybe but that would have been 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 deep breath that said, OK, we'll do it.

LAUB: 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.

VEDANTAM: The morning of the surgery, Salvador went through the standard pre-surgery lab tests and checkup. And then the boy walked by himself into the operating room.

LAUB: And he gets on the operating table himself because he trusts the whole world.

VEDANTAM: The surgery began. First, Salvador was anesthetized then Don and his team began the surgery.

LAUB: When we were operating, everything was going perfect.

VEDANTAM: And then just like that it wasn't.

LAUB: Anesthesiologist said, boys, we have no pulse.

VEDANTAM: They tried everything - CPR, medicine to jumpstart the heart. Nothing what. The child was dead. Outside the operating room, the boy's mother was waiting anxiously for news of her son. Dawn told her they'd had complications that they 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.

LAUB: She said you should be happy because the child is seeing God with a complete face.

VEDANTAM: Don expected accusation, anger and deep sorrow. Instead, he encountered a mother who leaned heavily on her faith. He was speechless, not just because of what she'd said but because he was struck by another thought. 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? Don conferred with this team about finishing the surgery on the little boy.

LAUB: I said it's against the law, but I think in this case we should.

VEDANTAM: The rest of the team unanimously agreed. Salvador was brought back from the morgue.

LAUB: The child came back in a body bag, and we did the whole thing as if the child was awake.

VEDANTAM: I interviewed Don several times for the story. I pushed hard to understand why he decided to operate on Salvador.

LAUB: I thought this is what I am for. This is my purpose.

VEDANTAM: Don still thinks about Salvador. He has turned the case over in his head in every possible way. I asked him over and over whether he felt regret.

LAUB: No, well, of course, I do. Of course, I do. Yes, I do.

VEDANTAM: Here's the thing about foxes and hedgehogs. We tend to want the best of both worlds. We love bold visionaries who take big risks except when the risks don't work out, then we prefer the visionaries to be more cautious, filled with a little self-doubt. The day after Salvador died, Don Laub was back in the operating room. He remembers looking out the windows at the sky.

It was he says a perfect azure blue. At 10:30, the time when Salvador was to be buried, everyone on the team fell silent and paused. There was no sound except for the whoosh of the anesthesia machine. Shankar Vedantam, NPR News. Transcript provided by NPR, Copyright NPR.