Blink: The Power of Thinking Without Thinking

the issue sideways, which, he has found, can be a lot quicker and a more efficient path to the truth than coming at it head-on.

What those observers of dorm rooms were doing was simply a layperson’s version of John Gottman’s analysis. They were looking for the “fist” of those college students. They gave themselves fifteen minutes to drink things in and get a hunch about the person. They came at the question sideways, using the indirect evidence of the students’ dorm rooms, and their decision-making process was simplified: they weren’t distracted at all by the kind of confusing, irrelevant information that comes from a face-to-face encounter. They thin-sliced. And what happened? The same thing that happened with Gottman: those people with the clipboards were really good at making predictions.

5. Listening to Doctors

Let’s take the concept of thin-slicing one step further. Imagine you work for an insurance company that sells doctors medical malpractice protection. Your boss asks you to figure out for accounting reasons who, among all the physicians covered by the company, is most likely to be sued. Once again, you are given two choices. The first is to examine the physicians’ training and credentials and then analyze their records to see how many errors they’ve made over the past few years. The other option is to listen in on very brief snippets of conversation between each doctor and his or her patients.

By now you are expecting me to say the second option is the best one. You’re right, and here’s why. Believe it or not, the risk of being sued for malpractice has very little to do with how many mistakes a doctor makes. Analyses of malpractice lawsuits show that there are highly skilled doctors who get sued a lot and doctors who make lots of mistakes and never get sued. At the same time, the overwhelming number of people who suffer an injury due to the negligence of a doctor never file a malpractice suit at all. In other words, patients don’t file lawsuits because they’ve been harmed by shoddy medical care. Patients file lawsuits because they’ve been harmed by shoddy medical care and something else happens to them.

What is that something else? It’s how they were treated, on a personal level, by their doctor. What comes up again and again in malpractice cases is that patients say they were rushed or ignored or treated poorly. “People just don’t sue doctors they like,” is how Alice Burkin, a leading medical malpractice lawyer, puts it. “In all the years I’ve been in this business, I’ve never had a potential client walk in and say, ‘I really like this doctor, and I feel terrible about doing it, but I want to sue him.’ We’ve had people come in saying they want to sue some specialist, and we’ll say, ‘We don’t think that doctor was negligent. We think it’s your primary care doctor who was at fault.’ And the client will say, ‘I don’t care what she did. I love her, and I’m not suing her.’”

Burkin once had a client who had a breast tumor that wasn’t spotted until it had metastasized, and she wanted to sue her internist for the delayed diagnosis. In fact, it was her radiologist who was potentially at fault. But the client was adamant. She wanted to sue the internist. “In our first meeting, she told me she hated this doctor because she never took the time to talk to her and never asked about her other symptoms,” Burkin said. “‘She never looked at me as a whole person,’ the patient told us. . . . When a patient has a bad medical result, the doctor has to take the time to explain what happened, and to answer the patient’s questions—to treat him like a human being. The doctors who don’t are the ones who get sued.” It isn’t necessary, then, to know much about how a surgeon operates in order to know his likelihood of being sued. What you need to understand is the relationship between that doctor and his patients.

Recently the medical researcher Wendy Levinson recorded hundreds of conversations between a group of physicians and their patients. Roughly half of the doctors had never been sued. The other half had been sued at least twice, and Levinson found that just on the basis of those conversations, she could find clear differences between the two groups. The surgeons who had never been sued spent more than three minutes longer with each patient than those who had been sued did (18.3 minutes versus 15 minutes). They were more likely to make “orienting” comments, such as “First I’ll examine you, and then we will talk the problem over” or “I will leave time for your questions”—which help patients get a sense of what the visit is supposed to accomplish and when they ought to ask questions. They were more likely to engage in active listening, saying such things as “Go on, tell me more about that,” and they were far more likely to laugh and be funny during the visit. Interestingly, there was no difference in the amount or quality of information they gave their patients; they didn’t provide more details about medication or the patient’s condition. The difference was entirely in how they talked to their patients.

It’s possible, in fact, to take this analysis even further. The psychologist Nalini Ambady listened to Levinson’s tapes, zeroing in on the conversations that had been recorded between just surgeons and their patients. For each surgeon, she picked two patient conversations. Then, from each conversation, she selected two ten-second clips of the doctor talking, so her slice was a total of forty seconds. Finally, she “content-filtered” the slices, which means she removed the high-frequency sounds from speech that enable us to recognize individual words. What’s left after content-filtering is a kind of garble that preserves intonation, pitch, and rhythm but erases content. Using that slice—and that slice alone—Ambady did a Gottman-style analysis. She had judges rate the slices of garble for such qualities as warmth, hostility, dominance, and anxiousness, and she found that by using only those ratings, she could predict which surgeons got sued and which ones didn’t.

Ambady says that she and her colleagues were “totally stunned by the results,” and it’s not hard to understand why. The judges knew nothing about the skill level of the surgeons. They didn’t know how experienced they were, what kind of training they had, or what kind of procedures they tended to do. They didn’t even know what the doctors were saying to their patients. All they were using for their prediction was their analysis of the surgeon’s tone of voice. In fact, it was even more basic than that: if the surgeon’s voice was judged to sound dominant, the surgeon tended to be in the sued group. If the voice sounded less dominant and more concerned, the surgeon tended to be in the non-sued group. Could there be a thinner slice? Malpractice sounds like one of those infinitely complicated and multidimensional problems. But in the end it comes down to a matter of respect, and the simplest way that respect is communicated is through tone of voice, and the most corrosive tone of voice that a doctor can assume is a dominant tone. Did Ambady need to sample the entire history of a patient and doctor to pick up on that tone? No, because a medical consultation is a lot like one of Gottman’s conflict discussions or a student’s dorm room. It’s one of those situations where the signature comes through loud and clear.

Next time you meet a doctor, and you sit down in his office and he starts to talk, if you have the sense that he isn’t listening to you, that he’s talking down to you, and that he isn’t treating you with respect, listen to that feeling. You have thin-sliced him and found him wanting.

6. The Power of the Glance

Thin-slicing is not an exotic gift. It is a central part of what it means to be human. We thin-slice whenever we meet a new person or have to make sense of something quickly or encounter a novel situation. We thin-slice because we have to, and we come to rely on that ability because there are lots of hidden fists out there, lots of situations where careful attention to the details of a very thin slice, even for no more than a second or two, can tell us an awful lot.

It is striking, for instance, how many different professions and disciplines have a word to describe the particular gift of reading deeply into the narrowest slivers of experience. In basketball, the player who can take in and comprehend all that is happening around him or her is said to have “court sense.” In the military, brilliant generals are said to possess “coup d’oeil”—which, translated from the French, means “power of the glance”: the ability to immediately see and make sense of the battlefield. Napoleon had coup d’oeil. So did Patton. The ornithologist David Sibley says that in Cape May, New Jersey, he once spotted a bird in flight from two hundred yards away and knew, instantly, that it was a ruff, a rare sandpiper. He had never seen a ruff in flight before; nor was the moment long enough for him to make a careful identification. But he was able to capture what bird- watchers call the bird’s “giss”—its essence—and that was enough.

“Most of bird identification is based on a sort of subjective impression—the way a bird moves and little instantaneous appearances at different angles and sequences of different appearances, and as it turns its head and as it flies and as it turns around, you see sequences of different shapes and angles,” Sibley says. “All that combines to create a unique impression of a bird that can’t really be taken apart and described in words. When it comes down to being in the field and looking at a bird, you don’t take the time to analyze it and say it shows this, this, and this; therefore it must be this species. It’s more natural and instinctive. After a lot of practice, you look at the bird, and it triggers little switches in your brain. It looks right. You know what it is at a glance.”