1. Young, Robert C. MD

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In my review of Brothers Emanuel (3/25/14 issue), to help explain the remarkable accomplishments of the three brothers, I noted some ideas expressed in a recent opinion piece in the New York Times by Amy Chua and Jed Rubenfeld entitled "What Drives Success" ( At the time, I had not read their just-published controversial book, The Triple Package, but the Times piece tweaked my interest. After all, every physician has at least one of the three characteristics that are noted as being necessary for success.

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For example, physicians uniformly have "Impulse Control"-not perhaps for new car purchases or larger and larger flat-screen TVs, but certainly, for "the capacity to resist temptation to quit when a task is arduous, daunting, or beyond one's immediate abilities." We all had to have impulse control to get through medical school, years of post-graduate training, and the seemingly endless competition between the demands of medicine and the normal pleasurable activities of life.


In addition, many physicians come from the specific groups highlighted by the authors as having the seemingly paradoxical traits of Superiority and Insecurity. So since the book did seem to have potential relevance for oncologists, I decided to read it.


The thesis by Chua (author of The Battle Hymn of the Tiger Mother) and Rubenfeld, her husband and fellow Yale Law Professor and a novelist, is a deceptively simplistic one: Three traits, they say, determine a high probability of success. In addition to Impulse Control, they are "Superiority-the belief that one's group is superior based upon theology, history, or imported social hierarchies that most American's know nothing about; and "Insecurity-a persistent painful feeling of not being good enough, either because of family pressure to succeed or from societal expectations or ethnic anxiety."


These three traits are developed in the book using selected examples of specific societal groups. Not limiting themselves to just their own ethnic groups, Chua and Rubenfeld site Indians, Iranians, Cuban-Americans, Mormons, Nigerians, and Lebanese as examples of groups possessing the "triple package" of all three characteristics.


The book is very well referenced (76 pages) and accurately documents the source of the specific statements and quoted data. What is missing, though, is an accurate assessment of what is happening in the entirety of each group. The authors wish to convince the reader that these are truly group traits, but the fact that there are more successful people than might be expected given their representation in the population is not sufficient.


An alternative explanation, which seems to get limited attention, is the particular makeup of the first wave of immigrants in some of these cultures. For example, the first groups of Cuban immigrants were actually exiles and came selectively from the educated, wealthy, upper middle class leadership classes. They came with substantial personal and tangible resources and with U.S government assistance. One suspects that this "self-selected" population might well explain the remarkable impact of first- and second-generation Cuban-Americans in this country. The pattern of success of subsequent groups of Cuban-American immigrants is little discussed in the book but the success of the Cuban groups who came later has been less impressive.


Many of the other groups noted such as Indians and Nigerians have often come commonly through foreign student visas or employment-based visas, and again represent a "self-selected" group of uniquely skilled populations with social networks to assist with job openings, financial opportunities, and social assistance.


Another group noted, Mormons, who of course are not immigrants, but the authors claim they have the group superiority in their belief of divine selection, that they have a sense of inferiority because of their historical feeling of being outsiders and a rigorous structured self-denial system built into their early training. Fair enough, but it seems a leap of faith to use that to explain why there are more Mormon CEOs than might be expected.


Quite frankly, these three traits were explored more convincingly in the New York Times piece, where the focus was on individuals, rather than in the book.


To be complete, though, in chapter six, the authors do explore the potential dangers of a triple package driven population. Here they assert that the force may be a blessing or a curse but that it always comes at a price. They argue that it "works at making people very good at attaining conventional success. So everything depends upon how much you believe that conventional success is worth." For instance, the Amish have many of the triple package characteristics but do not fit the pattern because they have a different metric for success.


The triple package mentality can be the source of neuroses, stress, anxiety, and intolerance. It can also be "imprisoning" because of the way it defines achievement. There is also no built-in limit and is by nature insatiable. There will always be someone better, smarter, richer, and more powerful.


There is an undercurrent of concern expressed throughout the book that this triple package vigor is difficult to sustain across generations and that our present society, with its instant gratification focus, has lost the triple package intensity of earlier generations. Hard to say-we still have people like Steve Jobs, Mark Zuckerberg, and Barack Obama bubbling up in our society where meritocracy still seems as strong as it is anywhere in the world.


The major difficulty with broad-based arguments based upon cultural groups is that it requires ignoring the obvious inherent heterogeneity in every group. For this reason, the case made in the Times piece with the focus more on individuals seems more persuasive and credible. Still, even when applied to individuals, the argument fails to provide evidence that the vast majority of successful individuals have only those three traits in common and not others. The authors claim that all three traits are required and that even two are not enough, but provide no data for that conclusion.


All that said, though, there does seem to be some face validity to the importance of the three traits in driving successful people. My recommendation, though, is that to explore the argument sufficiently and with a focus on individuals rather than on groups, read that New York Times Opinion piece and skip the book.




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