Book Review: White Coats and Black Swans: A Doctor’s Descent Into Misdiagnosis and Madness

Europeans believed every swan was white until Dutch explorers reached Australia in 1697 and found birds that were not. Scott Standage borrows the figure for the kind of event that remains impossible right up until the moment it happens to you. In his case, the impossible thing was being misdiagnosed and then badly mistreated by his own colleagues, inside the healthcare network where he had practiced for years.

Standage is a Stanford-trained physician in physical medicine and rehabilitation who came to the field late, entering medical school at forty-one after earlier careers in coaching and hospitality. He arrived exhausted and stayed that way. He fell asleep in lectures. He stood at the back of movie theaters to avoid nodding off in his seat, telling friends he had a bad back. He assumed the fatigue was the ordinary tax of medical training. It was not. A colleague who ran a sleep lab suspected obstructive sleep apnea and confirmed it with an overnight study: a common condition, serious if ignored, manageable with the right care.

What happened when he carried that finding back into his own healthcare system is the substance of the book. The sleep diagnosis was set aside in favor of a rarer and far more contested one, and he was started on powerful psychoactive medications. His condition worsened. More drugs were added to manage the effects of the earlier drugs. The deterioration that followed was then read as confirmation that the psychiatric label had been right from the start, and his objections were taken as further evidence of the illness he was objecting to.

The middle chapters are difficult reading, and Standage does not soften them. Involuntary holds. A practice lost. A financial conservator appointed to keep his house from being sold out from under him. Friends and family who concluded, reasonably enough on the evidence in front of them, that he was simply sick. He is clear-eyed about how ill he actually became, which is what keeps the account from reading as self-justification: the question he presses is not whether he was unwell but why no one asked what was causing it.

Vindication arrives late. A malpractice arbitration found in his favor in 2015, and the ruling appears in the appendix. By then his mother had died, still believing her son had an incurable mental illness. The book is dedicated to her, and that dedication does more work than any argument in it.

​Buy it on Amazon

There are places where the anger is close to the surface and the narrative loops back over ground it has already covered. Readers looking for a dispassionate treatment of diagnostic error should look elsewhere. What this book offers instead is something harder to get: a detailed account, from inside the profession, of how a treatable problem becomes a catastrophe when no one is willing to ask the most basic question in medicine, which is what else could it be. Standage had the credentials, the vocabulary, and the colleagues to push back, and none of it saved him. The obvious implication, which he states plainly and the reader arrives at anyway, is that a patient without those advantages would have had no chance at all.

Nicole Killian