A Response to "Medical Taylorism"

There has been a lot of back and forth chatter on social media the last couple of weeks since Pamela Hartzband and Jerome Groopman published "Medical Taylorism" in the January 14 issue of the New England Journal of Medicine.  Don't get me wrong, Drs. Hartzband and Groopman make a lot of important points in the commentary.  For example, they argue that some of the best moments in a physician's career are the ones spent just talking to patients and sharing their joys, as well as their sorrows.  I still cherish  the cards, letters, and e-mails that I receive from former patients, telling them about what is going on in their lives.  I do enjoy spending time talking to my patients and their family members.  So, on this point, I agree with Drs. Hartzband and Groopman.  They also argue that there is a growing dissatisfaction with the practice of medicine - physicians are experiencing burn-out at an alarming rate, or so they claim.  Drs. Hartzband and Groopman believe that standardization and measurement of process and outcomes, all in the name of efficiency, have caused this physician burnout.  There have been a number of studies that suggest that physicians are experiencing burnout.  A survey of over 6,000 physicians published recently in the Mayo Clinic Proceedings (Mayo Clinic study) concluded that (1) physician burnout is more common now than it was in 2011 and (2) more than half of all physicians in the U.S. experience burnout.  So again, I agree with Drs. Hartzband and Groopman here too.  However, I would like to point out that several recent studies performed in other industries outside health care have shown similar trends in professional satisfaction.  In other words, it's not just physicians who seem to be dissatisfied with their chosen profession!  Moreover, it is probably not the focus on efficiency, standardization, and measurement of outcomes that is to blame.  The RAND Corporation published a report on the factors that most impacted physician professional satisfaction (Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy).  Major factors impacting professional satisfaction included (1) perceptions of the quality of care provided, (2) dealing with electronic health records, (3) degree of autonomy and control of their practices, (4) practice leadership, (5) collegiality and respect among staff, (6) quantity and pace of work, (7) support staff, and (8) payment, income, and practice finances.  Conceivably, a focus on efficiency at the expense of spending time with patients could impact physician satisfaction, but it is certainly not the only reason nor is it the most important factor.

Perhaps the most common criticism of Drs. Hartzband and Groopman stems from their mischaracterization of Taylorism and the principles of Lean and the Toyota Production System.  Frederick Taylor (Frederick Winslow Taylor) is considered the "father of scientific management" and revolutionized the manufacturing industry.  Taylor was one of the first to apply engineering principles to manufacturing, many of which were later adopted by Henry Ford at his automobile plant (see Frederick Taylor and Henry Ford).  When we think of Frederick Winslow Taylor and Henry Ford, we often think of the assembly line, one of Henry Ford's most outstanding achievements.  Many physicians, including me, will vehemently argue that we should not be modeling patient care based upon the assembly line.  We are not making brand-new automobiles - we are taking care of patients!  Think of this - when you have a broken down automobile, you take it to the local mechanic.  Once there, the mechanic will run a series of test in an attempt to diagnose what is wrong with the car.  Once a diagnosis is made, the mechanic will fix the car.  Taking care of sick patients is more like repairing a broken down automobile than it is building a brand new one on an assembly line.  When talking about his assembly line, which revolutionized the automobile industry (as well as many other manufacturing industries), Henry Ford once said, "People can have the model T in whatever color they choose, as long as it is black."  The assembly line worked so effectively because everything was the same!  Rather than dealing with one specific make and model of automobile (say, all Chevrolet Corvettes or Ford F-150 trucks) or even a specific color of car, automobile mechanics work on a wide variety of different cars (from Ford, Chevrolet, Honda, Toyota, etc) and models (Mustang, Camaro, Accord, or Camry) all at the same time.  On any given day, a mechanic could  be changing the oil on a Honda Accord (preventive maintenance!), replacing the transmission on a Ford Escort, or repairing the brakes on a Toyota Camry.  I guess what I am trying to say is that if you are going to make a comparison between the practice of medicine and the automobile industry, it makes more sense to compare it to the automobile mechanic than the automobile assembly line!  If Drs. Hartzband and Groopman are going to make that argument, then I will support them 100%, but they do not make that argument.

There is an important distinction between the work of Frederick Winslow Taylor and Lean.  Yes, Lean is based upon the Toyota Production System (the automobile manufacturing industry).  However, the two are not one and the same.  In fact, Lean has been successfully adopted by a number of health care organizations.  Mark Graban, one of the foremost authorities on applying Lean methods in health care recently wrote a blog explaining how different Lean is from Taylorism (Mark Graban's Lean Blog).  Standardization (which can be easily accomplished with many aspects of health care without jeopardizing the physician-patient relationship or impacting either innovation or a personalized approach to care) and the application of Lean principles have been shown to improve efficiency, minimize costs, increase patient satisfaction, and improve the overall quality of care.  Recall that perceptions about the quality of care provided is one of the most important drivers of physician satisfaction (see the RAND study again here).  By extension (If a=b and b=c, then a=c!), standardization and the application of Lean principles to health care will improve physician satisfaction and reduce burnout!

Back to that Vision thing....NASA, Cathedrals, and an Automobile Executive

I have been reading about Alan Mulally, former President and CEO of the Ford Motor Company.  Mulally's story is fairly interesting.  He was an aeronautical engineer by background and had worked for more than 30 years for Boeing.  Hiring a relative industry outsider at a time when the Ford Motor Company had just lost over $12.7 billion and the price of Ford stock had dropped to $1.01 per share (prompting a few stock brokers to joke, "Did you want fries with that?" when selling Ford stock) caused a lot of head scratching.  Mulally was not even the company's first choice to succeed William Clay Ford, Jr, the great-grandson of Henry Ford and the Executive Chairman of the Board of Directors.  At one of Mulally's first meetings with his executive leadership team, someone asked "How are you going to tackle something as complex and unfamiliar as the auto business when we are in such tough financial shape?"  Mulally answered, "An automobile has about 10,000 moving parts, right?  An airplane has two million, and it has to stay up in the air."  

A large measure of Mulally's success at Ford (see Bryce Hoffman's book, American Icon: Alan Mulally and the Fight to Save Ford Motor Company) was due to his leadership of change management.  The fact that he virtually re-invented a company as old as Ford is a testament to his ability to share a compelling vision and create the necessary "sense of urgency" (see John Kotter's article in the Harvard Business Review, "Leading Change: Why Transformation Efforts Fail").  Mulally says that creating a compelling vision is one of the most important jobs that a leader can do in any organization ("Planes, Cars, and Cathedrals" by Adam Bryant, New York Times).  He tells the famous story of the three bricklayers (The tale of the three bricklayers).  As the story goes, a casual passerby stops to watch three bricklayers. She asks the first bricklayer, "What are you doing?" and the first bricklayer responds, "Well, I'm making a living laying these bricks."  She asks the same question to the second bricklayer, who responds. "I am practicing the profession of bricklaying.  I want to be the best bricklayer to ever live."  Finally, she asks the same question to the third bricklayer, who responds, "I am building a cathedral."  What a great story!  Somehow, an effective leader has to make the connection between what his or her team is doing to the outside world.  We are not just laying bricks.  We are building a cathedral.  What we are doing here is something much bigger than anyone of us can imagine. 

I am also reminded of another famous story.  As this story goes, President John F. Kennedy was visiting NASA in 1962 and came across a janitor who was sweeping in the break room.  President Kennedy stopped and walked over to the janitor and reached out his hand, "Hi, I am Jack Kennedy.  What are you doing today?"  The janitor set aside his broom, shook the President's hand, and said, "I am sending a man to the moon, Mr. President."  To a casual observer, the janitor was simply doing his job and cleaning the break room.  However, somewhere and somehow, the janitor's supervisor had formed a connection between what the janitor was doing and the greater mission of the entire organization (NASA) to send a man to the moon.

We as leaders need to be able to create a vision, a shared sense of purpose, and communicate that vision effectively throughout all layers of the organization.  Alan Mulally was able to do that at Ford.  And when the economic crisis of 2008 hit all three major U.S. automobile makers, Ford was the only company that did not have to be bailed out by the U.S. government.  Through Mulally's vision (and more importantly, through his ability to communicate that vision to the rest of the organization), Ford had positioned itself in such a way that they were able to weather the storm. 

Gooooooaaaaallllllll!

There are a countless number of articles on goal-setting - Edwin Locke and Gary Latham have written many of these articles and are considered the experts in this field (the following link is an excellent overview of over 35 years of research in goal setting theory: Building a Practically Useful Theory of Goal Setting and Task Motivation: A 35-year Odyssey).  Locke and Latham emphasize that setting goals increases an individual's motivation to achieve that goal, which translates to future success in attaining that same goal.  Could it really be that simple?  I briefly discussed creating a personal vision, mission, and core values on the previous post.  Just as an organization's goals and strategic objectives come directly from the organization's mission, vision, and values, your own goals should directly support your personal mission, vision, and values.  If one of your goals doesn't fit with your mission, vision, and values, then you probably should not waste a lot of time trying to achieve that goal. 

I like to follow a few simple steps when setting my personal goals.  It is easier to develop long-term goals first - again, these should be consistent with your personal vision.  Think of your personal vision as defining what you wish to achieve in your lifetime and then build 5-year goals that will position you for success in achieving that lifelong goal.  After you list your 5-year goals (and you should definitely write them down), you can then develop more short-term goals (for example, your annual goals).  In keeping with the concept of a vision (long-term) and mission (shorter term), your annual goals should be consistent with your personal mission.   Your annual goals should be written in the form of a SMART goal.  SMART is an acronym for Specific, Measurable, Actionable, Relevant, and Time-bound.  In other words, your goal should be as specific as possible (nothing should be vague here).  A goal should be defined in such a way that it is easily measured - if you can't measure it, how will you know whether you have achieved your goal?  The goal should be actionable (in other words, it should be a goal that you can personally achieve).  The goal should be relevant to you and your personal mission, vision, and values.  Finally, the goal should be time-bound (most annual goals, for example, should be achieved by the end of the year).  For example, here is an example of a SMART goal:  "I will run my first marathon and finish in under 4 hours and 30 minutes by December 31, 2016."  Note here that the goal is specific, measurable, actionable (assuming that the individual has been running, of course), relevant (perhaps - I didn't state what the individual's mission, vision, and values were), and time-bound (there is a definite deadline to achieving the goal).  Finally, personal goals should be written down - post them where you can see them every day.  Some experts even suggest that you should share your personal goals with someone, which will further motivate you to work hard towards achieving the goal. 

Some experts recommend setting a so-called "stretch goal", i.e. a goal that may be slightly out of reach.  There have been a number of studies addressing this question, which I will review on my next blog post.  Until then, thank you for sharing and learning with me!

Your personal mission, vision, and values

Several studies performed by the management consulting firm, Bain and Company have consistently shown that one of the most popular management tools used by companies today is the mission statement.  A good mission statement has been shown to correlate directly with engaged employees, achievement of strategic objectives, and company profits (for example, see one study here).  Defining a mission statement, along with developing a clear vision statement and shared set of corporate values, are a critical part of setting an organization's overall strategy for success.  But what is the difference between a mission statement and a vision statement?  Believe it or not, the difference is not intuitive.   Many organizations, from Fortune 500 companies to non-profit organizations and government agencies frequently use vision statements as mission statements, and vice versa.



A vision statement should define the optimal desired future state, i.e. what the organization would like to achieve over the long term (typically 5-10 years or even longer).  A company's vision should function as the "North Star" of what all employees and members of the organization strive to achieve.  The vision statement should be succinct but inspirational, such that every employee or member of the organization can repeat it verbatim at any point in time.  James M. Kouzes and Barry Z. Posner wrote an excellent article in the Harvard Business Review on how to write vision statements ("To Lead, Create a Shared Vision").  A mission statement, on the other hand, answers the "what, who, and how" of a particular organization.  The mission statement explains, again very succinctly, what the company does, who it does it for, and how it does what it does.  Again, the employees and members of the organization should be able to easily recall the mission statement, so writing a simple, succinct mission statement is imperative.  Finally, the core values are really the defining or principles that guide all of a company's actions.  A company's core values are sacrosanct - they should never be compromised ("Make Your Values Mean Something").  Core values help the employees to know what is right versus wrong and build upon the mission and vision statements.  Together, the mission, vision, and values help define the overall organizational strategy.  Importantly, a company's strategic objectives and goals should never deviate from the mission, vision, and core values.


I happen to believe that individuals should have their own personal mission, vision, and core values.  Just as the mission, vision, and core values of a firm helps its employees know the company's overall purpose and reason for being, a personal mission, vision, and values will help an individual develop his or her own professional career.  For example, if a new or unique job opportunity comes up, the first question that you should ask is whether that job opportunity fits with your overall mission, vision, and values.  If it does not, then you should not accept that job opportunity.  Similarly, if the job you are currently working on does not fit with your mission, vision, and values, there is a high likelihood that no matter how hard you work, your success will be limited.  We are motivated and driven to succeed because we believe in the job that we are doing - these beliefs absolutely have to be consistent with our personal mission, vision, and values.  There are numerous articles available that discuss the best approach to developing your personal mission, vision, and values statement.  I happen to like the following article in Forbes magazine ("Personal mission statement of 13 CEOs and lessons you need to learn").  Having a personal mission, vision, and values brings a certain focus and purpose to your life, both professionally and personally.  Your own mission, vision, and values will help you to become a better leader in the future.  What is your mission, vision, and values? 

What can we learn about leadership from a movie?

Will Rogers once said, "A man only learns in two ways, one by reading and the other by association with smarter people."  We can learn a lot about leadership by reading about the experiences of history's greatest leaders.  One of my other resolutions for 2016 is to actually finish reading the tall stack of books that I purchased in 2015!  However, we don't always have the time to sit down and read a book.  That is why I am a firm believer in the power of all forms of media - we can learn through the experience of others by watching a movie or television program, listening to a documentary on the radio or the Internet, watching a lecture, or enjoying a play.  For example, the TED talks (www.ted.com) are a great way to learn, especially when you don't have a lot of spare time.  TED's mission is to disseminate ideas in the form of short (less than 18 minutes), inspirational talks on a variety of subjects, including leadership and management.  There are also a number of great movies that provide excellent lessons on leadership.   One of my favorite movies of all time is the 1993 movie Gettysburg, which was based on Michael Shaara's historical novel The Killer Angels.  The movie has an all-star cast, with Martin Sheen as General Robert E. Lee, Tom Berenger as Lieutenant General James Longstreet, and Jeff Daniels as Colonel Joshua Chamberlain.  I have read the novel (just once) and watched the movie many, many times.  While the novel was superb, this may be one of those rare instances in which the movie is as good as, or maybe even slightly better than the book!  The movie is packed with lessons on leadership.

One of my favorite scenes in the movie occurs when the Union forces are marching towards the town of Gettysburg, Pennsylvania.  Colonel Joshua Chamberlain, the regimental commander of the 20th Maine, is preparing his troops for the long march ahead, when 120 deserters from another Maine regiment (2nd Maine) are brought to him.  The 2nd Maine Regiment had been decommissioned, as many of the men in the regiment had signed 2-year enlistments.  The 120 "deserters" had signed 3-year enlistments.  However, they felt that because their regiment no longer existed, they should be allowed to return home as well.  Chamberlain's 20th Maine regiment was short-handed, so the addition of 120 experienced soldiers was very welcome.  The problem was that the "deserters" were refusing to fight in the coming battle.  Moreover, because the Union army considered these men deserters, Chamberlain was free to administer punishment for desertion, which in this case was death.

Chamberlain talks to the 120 men of the 2nd Maine and convinces most of them to join his 20th Maine and fight (Chamberlain's speech to the men of the 2nd Maine).  If you take a good look at what Chamberlain does, I think you will see a great example of Abraham Maslow's "Hierarchy of Needs" (Maslow's Hierarchy of Needs).  The concept here is that individuals are personally motivated to satisfy certain needs - there is a hierarchy of needs, such that when an individual satisfies the basic needs on the lowest level, then and only then will he or she seek to satisfy the needs on the next level.  The lesson for a leader is that in order to motivate other individuals, a leader needs to make sure that the lower basic needs are satisfied first.  In Chamberlain's case, one of the first things that he does is to make sure that the 120 men from the 2nd Maine have something to eat (satisfying one of the most basic physiological needs) before he even addresses their other concerns.  He pulls their spokesman aside to listen to his explanation of the overall group's concerns - he sets a tone of psychological safety for the spokesman to be able to talk openly and honestly about their concerns.  Chamberlain also tells the men that he isn't going to shoot them for desertion (again, establishing safety).  After satisfying the men's need for safety, he moves to the next level in Maslow's hierarchy ("social").  He talks to them as a  fellow soldier from Maine - he tells them about the proud history of the 20th Maine.  He tells them that he will let them choose their fate (basically, fight or remain a prisoner), which earns their trust and respect.  He allows them to maintain their own self-worth.

The movie Gettyburg has many more lessons on leadership, which we will discuss in future posts.  Read the book, watch the movie, or do both!  I can promise you that you will learn a lot.

First blog post!

One of my New Year's resolutions this year was to write more.  I have often thought it would be fun to write a blog (as well as a lot of work), so I thought I would fulfill my resolution to write more this year by starting my own blog. 

While I do not claim to be an expert in leadership or management, I have spent a lot of time reading about great leaders throughout history.  I have often looked for a place to collect stories and lessons about leadership, so this blog page will hopefully serve that purpose, even if I am the only one who will ever benefit from it. 

Tom Peters (http://tompeters.com), a noted expert in management and author of the book "In Search of Excellence" once said, "Leaders don't create followers, they create more leaders."  I would have to agree.  One of the greatest things that we can do is to share our stories, lessons, and wisdom with other leaders.  I hope this blog will at least partly serve that purpose. 

Finally, Thomas J. Watson (Chairman and CEO of  IBM from 1914-1956) said, "Nothing so conclusively proves a man's ability to lead others as what he does from day to day to lead himself."  Leadership has to start by looking inward at what you do with your own life.

I look forward to learning more...