Swan Theory
Swan Theory began with a simple question: if medical errors are among the leading causes of death in the United States, how much of that harm stems from preventable breakdowns in physician–patient communication? After more than a decade in practice—learning from my own complications and failures, observing colleagues, and noticing the gap between initial recommendations and what ultimately helps—I’ve concluded that communication is central. Not only to protect patients from harm but also to protect us from litigation.
Borrowing from Chris Voss’s “black swan” idea in negotiation, I built a clinical framework that helps me slow down, widen my aperture, and uncover truths that actually drive outcomes. I call it Swan Theory.
The premise is straightforward. Swans are a way of thinking about thinking. We can sort the swans into three groups: white, red, and black. Clinicians focus their attention heavily on the first two: white and red. In reality, the black swans change everything.
White swans are the known knowns. They include what we learn in training: pathophysiology, diagnostic criteria, evidence-based guidelines, interpretation of labs and imaging, how to examine a patient, and the steps of surgery. White swans exist both in the real world and in our minds. They are tried and true. They allow us to standardize treatment plans and surgeries. If we only needed white swans to do our job, we could run care pathways like software: input history, exam, labs, imaging; output a recommendation. In that world, AI could handle most diagnosing and prescribing.
Red swans are the known unknowns. They exist in the clinician’s mind but do not exist in reality. At least not yet. They are possibilities, projections, and anticipated risks derived from experience and statistics. We disclose them during consent: post-tonsillectomy hemorrhage, CSF leak, facial nerve injury, vocal cord paralysis. Red swans are essential for informed consent. Of course, patients deserve to know what could happen if a treatment or surgery does not go as planned. But problems arise when red swans dominate our attention. An overemphasis on fearing the known uknowns drives “cover your ass” medicine and leads us to order unnecessary tests. Fear of red swans pulls us into hypervigilance and urgency in the OR, precisely when we need presence and intuition.
Black swans are the unknown unknowns. They exist in the real world but not yet in our mind—unless we look for them. Black swans are the beliefs, fears, constraints, anxieties, biases, social realities, and expectations that determine whether a plan will work for a particular patient. They are why guidelines alone cannot deliver outcomes. Until we identify black swans, we practice with blind spots, and those blind spots create disconnection between clinician and patient. Disconnection breeds missed diagnoses, unnecessary testing, nonadherence mislabeled as “noncompliance,” one-star reviews, complaints, and lawsuits. Even if we do everything right...those of us who have had board complaints and lawsuits can tell you how blindsiding it is to be retaliated against by a patient. So how can you both become a more effective diagnostician and protect yourself from retaliation? By looking for and finding the unknown unkowns, the black swans. And you do that by fostering curiosity, presence, and connection in all of your communications.
Here it helps to acknowledge the origin of the term, black swan. Philosopher-statistician Nassim Nicholas Taleb popularized “black swans” as events that are outliers, carry extreme impact, and are rationalized in hindsight as if they should have been obvious all along. His point was not that we can predict every outlier, but that we should build habits and systems that are alive to hidden information. In clinical practice, black swans are not rare birds. They are ordinary truths hiding in plain sight.
Because we have been trained to overvalue white swans, fear red swans, and ignore black swans, we risk rupturing trust with patients. Without rapport, or “know, like, and trust”, we cannot do our jobs effectively. The remedy is curiosity.
In clinic, that means I keep my white swans in my back pocket and meet the patient in front of me with a beginner’s mind. I enter an exam room free of preconceived notions, judgments, expectations, and agenda. I listen to the whole story and place myself in the movie of the patient’s life. I learn who they are, what they fear, how they live, what their goals are, and what success means to them.
Swan Theory is not an argument against standards. White swans are nonnegotiable; they keep patients safe. Red swans matter; honest risk framing is ethical and essential. The shift is about widening our aperture and seeing the world through our patients’ eyes. When we prioritize finding black swans early, white swans become more effective and red swans become right-sized. Shared decision making stops being a script and becomes the work of converting a patient’s black swans into white ones: surfacing the realities that will govern their outcome.
Black swans are ordinary truths hiding in plain sight. We miss them because we don’t ask. When we build the habit of finding them, we reduce avoidable harm, restore trust, and choose plans patients can actually carry out. Negotiation and medicine share the same heart: discover what is real for the other person and shape a path that works in the world they inhabit.
Swan Theory will not eliminate all complications or lawsuits. It will not spare us from every surprise. What it offers is a clearer way to see. White swans show us what usually works. Red swans remind us what can go wrong. Black swans reveal the personalized plan that best serves each specific patient. Put them together, and the conversation changes—from paternalism and fear to partnership and desirable results.
