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The Messy Middle

The Messy Middle
By Mustafa Sultan • Issue #23 • View online
Hello friends,
Getting your paper rejected hurts. A double paper rejection hurts even more. Here’s where I went wrong—

I think the paper’s watershed moment was right at conception. Instead of aiming big — we aimed for the middle (and missed). I’ve been caught by the messy middle several times in my life.
During school, I aimed for As -> missed -> got Bs and didn’t get into Medical School. That’s the tragedy of the messy middle. Better to aim for 4 A*s -> miss -> get 3 A*s and 1 A and end up in the Keighley Gazette like my friend.
Loonshots 🚀
I submitted the second ever paper I ever wrote to the New England Journal of Medicine. Surprise, surprise:
Probably thought I was an Uber shill 😤
Probably thought I was an Uber shill 😤
This was a great experience. Aiming big didn’t work but it was fun trying.
Selling Cars 🚗
Something one of my business school lecturers taught me comes to mind: the dissatisfaction of having your first offer accepted.
When, for example, selling a car — accepting someone’s first offer might actually make them less satisfied than if you pushed back:
When negotiators’ first offers are immediately accepted, negotiators are more likely to generate counterfactual thoughts about how they could have done better and therefore are less likely to be satisfied with the agreement than are negotiators whose offers are not accepted immediately
I actually think it’s a better experience, generally, to be rejected — drop down a level — and then be accepted. You know you did your best.
Go Big or Go Home ⚾️
I’ve noticed (n=1) that loonshots are sometimes easier than the messy middle.
I sent Eric Topol three emails to get a yes. In the same time, I’ve sent one of my lecturers six emails, one handwritten letter and three messages on LinkedIn and heard nothing back (maybe I should take a hint?).
My theory on this? Eric Topol has an assistant and is used to doing interviews. Saying yes is frictionless.
My lecturer probably gets 200–300 emails a day and manages all of these himself. An interview requires him to set aside time to prepare and organise logistics.
When the New England Journal of Medicine rejected me, they did so in three days (it was that bad). One messy middle journal is still making a decision on my paper 13 months later.
The messy middle is a chronic time waster.
Avoiding The Messy Middle 🧼
I recently interviewed Professor Shafi Ahmed; the most watched surgeon in the world. He was kind, generous and gave a great interview.
At the end of my interviews, I ask a question off record:
What I ask: is there anyone else you think I should speak to?
What I mean: can you intro me to someone in your network?
Prof Ahmed’s a hustler — he knew what I meant: “Sure Mustafa. Let’s just go straight to the top”. He email-introed me to someone on the board of Google Health (episode incoming 🤞).
It would have been just as much work and effort for him to introduce me to the ‘messy middle’ in his network — but he went straight to the top.
I think about this a lot when I’m writing emails and letters to potential guests. It’s probably a very similar amount of effort to get the Chief Executive of an NHS Trust vs Ben Goldacre.
Blackstone ⚫️
Stephen Schwarzmann wrote a book on how he came to found Blackstone (this is like crack for me). A quote:
If you’re going to commit yourself to something, it’s as easy to do something big as it is to do something small. Both will consume your time and energy, so make sure your fantasy is worthy of your pursuit, with rewards commensurate to your effort.
A Caveat ❌
I write this newsletter to 93 of you every week. A short newsletter takes about 1–2 hours. A well researched deep dive takes about 5–6.
Objectively, it’s a total waste of time. I don’t think it’s contributed to the growth of my podcast one iota. I was speaking to a friend who runs a much more successful newsletter. He made a good point: He actually thinks I’m harming growth of my podcast by spending so much time on this this. Spending those hours promoting the podcast would be much more beneficial.
And that’s where everything I’ve spoken about in this email falls apart, a little.
I write this because I enjoy doing it. It’s nice to share thoughts with friends and the resulting conversations are priceless. People reply and teach me things that weren’t even on my radar. I get to write once a week. It pressures me into reading more (or I have nothing to talk about). If I do this for two years, I calculated that I would have written about 50,000 words. That’s nearly a book.
My point? Treating everything like #thehustle and going big (or go home) is of course, silly. I think however, it is worth being cognisant of when I’m entering the messy middle and doing so voluntarily.
Commitments for the Future 🙅🏽‍♂️
  1. Generally avoid the messy middle
  2. When I do enter it — do so cognisantly
  3. Try for one level above what seems reasonable otherwise
#022 The VR Surgeon 🥽 — Professor Shafi Ahmed
#021 NHS Referrals are Broken — Dr Owain Hughes CEO Cinapsis
That’s it. Hit reply and tell me what you think.
All the best,
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Mustafa Sultan

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