The 20,000-Foot View

The 20,000-Foot View

George W. Sledge, MD, FASCO

Sep 21, 2011
I was taking off from the airport in Indianapolis the other day, headed for Cleveland, and on the way I passed over the Indianapolis Motor Speedway, the home of the Indianapolis 500 race. It has a characteristic look from the air, familiar to all who fly in and out of the city regularly, with its pagoda and its huge oval.

I don’t know how far up in the air we were by this point—two miles or so would be my guess. Far below, down on the track, a white dot traveled at high speed around the oval. It was only a white dot, and I couldn’t make out any more than that, but I assume it was a car going around the track.

The car sped along, and so did my imagination. There wasn’t any race scheduled any time soon, so who was driving the car, and why? Perhaps some track official, checking the condition of the track? A driver of one of those incredibly powerful Indy cars, getting ready for next May? Or (I’ve spoken to people who’ve done this) some duffer like me, allowed to circle round the track in a car driven by someone who understands the uses of speed? Was it an Indy car, or one of the stock cars used in the Brickyard 400, or just some service van?

I’ll never know, and in truth it doesn’t matter, but I’m curious nevertheless. We’re often exhorted, in committee meetings and advisory boards and the like that I sit in on, to “get out of the weeds” and “give us the 20,000 foot view”. Mere detail is to be avoided in such meetings, and the world takes on a pristine purity when you can ignore the tiny white dot circling the tracks.

There is some wisdom in this approach, no doubt. We can get mired in detail, in the infinity of small things that can obscure the big picture. The 20,000-foot view allows you to see a great deal of landscape, and grand strategy is important.

But I remember the early 20th Century English writer G.K. Chesterton, describing the New Testament story of the devil bringing Jesus to a great height and showing him all the kingdoms of the world. Satan’s joy in standing on a peak, said Chesterton, “is not a joy in largeness, but a joy in beholding smallness, in the fact that all men look like insects at his feet. It is from a valley that things look large; its is from the level that things look high.”

Or more practically, as the philosopher Ludwig Wittgenstein wrote, “The world is the totality of facts.” To discuss the world without understanding the facts gets you into trouble in a hurry. I’ve seen this happen a great deal in medicine over the years, particularly where cool molecular biology derived from two-dimensional cell cultures is thought to represent a true map of the world. The inability to “respect the disease,” to understand the “totality of facts” that make up a particular world (lung cancer, say, or colorectal cancer), has doomed more than one clinical trial.

This is particularly true in cancer biology, as opposed say to high-energy physics. Biology is a messy place, because evolution has left us with such a kludge, and when you layer cancer’s genomic instability on top of that, beautiful theories are often killed by ugly facts. The 20,000-foot view is often just too high up.

But even more than that, I am curious about that white dot moving around the track. I like the stories attached to those white dots. Most of the stories, I admit, tell us little about the wider world, or little that would change anything if studied. But sometimes they turn out to be important, or at least fun.

NIH study sections never acknowledge the “fun” part of chasing, or understanding, those tiny white dots. But it is, in my experience, one of the main reasons scientists (in lab or clinic) do science. We get fascinated by some detail, some fact that sticks out in the wrong direction, like when you see a band in the wrong place on a Western blot, or big when it should be small. “Cherish your exceptions” is a valued and valuable science dictum, and you rarely perceive the exceptions if you are not down in the valley of facts.

This is true in the world of politics. Our greatest President, Abraham Lincoln, was notoriously interested in detail. He was a great career politician, focused intently on the subtle levers of power at every point of his career. He spent much of the Civil War in the War Department’s telegraph office, gathering in data (try to imagine a current leader doing this). We remember, and are inspired by, the Gettysburg Address and the Second Inaugural address, with their simple but powerful rhetoric; but it is the bland, lawyer-like, detail-oriented and uninspiring Emancipation Proclamation that changed American history.

That he was able to offer the 20,000-foot view, in glorious English never surpassed in public discourse, was possible only because of his immersion in facts. His closest 20th Century equivalent, Winston Churchill, also combined soaring oratory with the passionate pursuit of facts. The 20,000-foot views that produce something of lasting value, the mountain peaks that do not turn us into insects, are all built on mountains of facts. I distrust ideologues of all stripes, because they see nothing but the 20,000-foot view.


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