"The Man Who Thinks He Can"

The Internet is really a great thing!  When I was in high school, my parents had a poem or at least part of a quotation taped to our refrigerator door.  I was thinking about what to post on the blog last night and remembered the first line of the quotation.  I never knew who really had said it - one of my friends (a Green Bay Packers fan) thought it sounded like something that the great football coach, Vince Lombardi would say.  He certainly said something like it when he said, “It’s not whether you get knocked down, it’s whether you get up.”  I tried hard to remember the quotation and just could not remember enough of it, so I looked up the first line and found it all over the Internet.  As it turns out, Vince Lombardi didn't say it - the quotation is actually from a poem written by a man named Walter Wintle (as an aside, I did not find any details on the poet, even on the Internet).  The poem is called "Thinking" and was published in 1905 (the poem is also known by the title, "The Man Who Thinks He Can").  You may have heard it, but if not, here it is:

If you think you are beaten, you are;
If you think you dare not, you don't.
If you'd like to win, but you think you can't,
It is almost a cinch that you won't.

If you think you'll lose, you're lost;
For out of the world we find
Success begins with a fellow's will
It's all in the state of mind.

If you think you're outclassed, you are;
You've got to think high to rise.
You've got to be sure of yourself before
You can ever win the prize.

Life's battles don't always go
To the stronger or faster man;
But sooner or later the man who wins
Is the one who thinks he can!

I only learned the first and last stanzas of the poem.  The poem itself reminds me a lot of the classic story, "The Little Engine That Could" ("I think I can, I think I can, I think I can...").  And who knows, maybe Vince Lombardi used it to motivate the great Packers teams of the 1960's.  It really is a powerful poem.  I do believe in the absolute power of a positive attitude.  A positive attitude is one of the key drivers of success.  And in the end, it is the man (or woman) who believes in him- or herself that accomplishes his or her goals. 

Winnie the Pooh and the Navy SEALs

There was a book that came out several years ago called, The Tao of Pooh that was written by Benjamin Hoff  (believe it or not, the book spent 49 weeks on the New York Times bestseller list).  The book used A.A. Milne's characters from the Hundred Acre Wood to explain the tenets of the Eastern philosophy of Taoism.  I never read the book (it seemed like a stretch to me, but then I don't know much about Taoism), but I do vividly remember a quote from one of Disney's Winnie the Pooh movies that has always rang true with my own belief system.  I can't remember which movie it was, but I do remember that Christopher Robin was the character who said it:

"Always remember.  You are braver than you believe.  Stronger than you seem.  And smarter than you think."

What a beautiful, poignant quote!  Basically, Christopher Robin is telling us that deep down inside of all us, there is a heart of a champion.  If we put our mind to something, we can and will accomplish anything.  The American philosopher, psychologist, and physician, William James wrote something similar along those lines in his essay, The Energies of Men:

"Beyond the very extreme of fatigue and distress, we may find amounts of ease and power we never dreamed ourselves to own; sources of strength never taxed at all because we never push through the obstruction."

Finally, there is a former Navy SEAL named David Goggins who talks about something that he calls the "40 percent rule".  In essence, when your mind is telling you that you can't go on anymore, you are really only 40% done.  Deep down, your body can handle more stress and you can face even greater challenges.  Goggins explains this is why the vast majority of individuals (he claims 99%) who start a marathon race actually finish the race.

So what does this all have to do with leadership?  More than you think.  Winnie the Pooh, William James, and the "40 percent rule" tell us that we, as leaders, can push our teams farther than they think is possible.  It's not an easy thing to do (convince someone that they can push harder past the point of physical or mental exhaustion), but it can be done.  These three examples also suggest that so-called "stretch goals" are certainly achievable with the kind of leadership that motivates, supports, and pushes individuals and teams to success.  The drive that allows marathon runners to push past "hitting the wall" at mile marker 16 or Navy SEAL candidates to survive 5 1/2 days of cold, wet, physically brutal operational training on less than 4 total hours of sleep during "Hell Week" is the same drive that will help teams to achieve aspirational, "stretch" goals in just about any other discipline. 

"You can't lead from behind..."

I am reading a book right now about the famous Civil War Battle of Gettysburg called (oddly enough), The Battle of Gettysburg.: A Comprehensive Narrative.  It is an older book, written and published in 1913 by a former Union officer who served there named Jesse Bowman Young.  One of the book's strengths is the fact that it is more or less a firsthand account of the events that occurred by someone who was actually there during those fateful three days in July of 1863.  The battle itself is famous for the fact that it was by far the deadliest battle of the entire Civil War (and if you consider that Americans died on both sides of the battle, it was by far the deadliest three days in any war in our nation's history) and for being the turning point of the Civil War.  Young's book's other major strength is that it provides several lengthy lists of key statistics and detailed biographical sketches of the officers who served in the battle.  It is a great book, and I am really enjoying the read.


I was particularly struck by the number of field officers who died or were seriously injured during the battle.  I once read a statistic that Civil War generals were 50 percent more likely to be killed in combat than privates (the lowest rank).  Brigadier generals, who either led divisions (on rare occasions), or most commonly, brigades (note that a brigade in the Civil War comprised approximately 2,600 soldiers and a division most commonly consisted of 3 brigades). 


Related to this point, there is an exchange between General Robert E. Lee and Lieutenant General James Longstreet in another one of my favorite books, Michael Shaara's novel, The Killer Angels (the movie, Gettysburg was based upon this novel) that I believe is rather poignant.  Lee starts, "General, in the fight that's coming, I want you to stay back from the main line.  You are my only veteran commander."  After talking some more, Lee continues, "You have a very bad habit, General, of going too far forward."  Longstreet replies, "You cannot lead from behind."


Here is an important lesson for us all.  The fact that generals had a much higher chance of being killed during the Civil War than privates was simply due to the fact that during that particular war, generals usually led the battle from the actual battlefield.  In many cases, the generals led the battle by being out in front of their men, where they would be most likely to be shot at from the opposing side.  However, there was no other good way at that time in our history to motivate and direct the troops and place them in a position to win the battle.  There was no better position than out front to observe the events of the battle as they unfolded. 


There are certainly lessons for us here today.  First, leaders should lead by example.  Leaders set the tone for the whole organization - in reality, leaders (or at least how the leaders "lead") determine the overall culture in an organization.  Leaders "practice what they preach" - so many times, I hear from good leaders the phrase, "If I am not willing to do this myself, then I cannot expect my team to do it either."  Second, leaders should be out and about - it is hard, if not impossible, to lead (by example or otherwise) from an office desk.  Good leaders should subscribe to the practice of "management by walking around."  Leaders should get to know all of the members of their team - but the really great leaders also get to know people outside of their teams, all over the organization.  Leaders provide real-time feedback, which is very difficult to do if the leader is not out of his or her office and observing team members where they are doing their jobs.  Finally, and perhaps most importantly, having a leadership presence on the organization's front line is not enough.  At least one study has shown that leaders also have to help their teams with problem-solving and elimination of barriers.  One of the best ways that leaders can do this is to be great teachers, mentors, and role models.  Good leaders don't simply solve the problems on their own.  Rather, the most effective leaders enable their teams and front line employees to solve problems  on their own.  Just as General Longstreet claimed, "You cannot lead from behind."    

"Brace for Impact"

Okay, I finally was able to go see the new Tom Hanks movie, "Sully" with my wife yesterday evening.  We both enjoyed the movie.  If you haven't seen it (and if you are planning on seeing it), perhaps you shouldn't read any further (SPOILER ALERT).  The movie tells the story of the "Miracle on the Hudson" and Captain Chesley "Sully" Sullenberger.  Sullenberger was the captain of US Airways Flight 1549 on January 15, 2009.  Shortly after taking off from New York's LaGuardia Airport en route to Charlotte Douglas International Airport (about 3 minutes into the actual flight), the plane struck a flock of Canadian geese, which caused both engines to immediately lose power.  As Sullenberger and First Officer Jeffrey Skiles ran through their checklists to determine what had gone wrong, they made the incredibly difficult decision to ditch the plane in the Hudson River.  All 155 passengers and crew remarkably survived the forced water landing.  The movie tells of the subsequent investigation by the National Transportation Safety Board (NTSB accident report) and the initial effects of what can only be described as post-traumatic stress disorder on both Sullenberger and Skiles.  I don't know if the events happened exactly as portrayed in the film, but the story suggests that the NTSB initially felt that the forced water landing was not necessary and that the plane could have been landed safely at either LaGuardia or nearby Teterboro Airport.  The NTSB had conducted several computer models and simulations to back up their initial impression, though as the movie progresses to its climax, they eventually side with Sullenberger and Skiles and conclude that it was only through Sullenberger's crisis leadership that the 155 passengers and crew survived.  One of the NTSB officials states, "Remove you from the equation and the math fails."  True to most crisis leaders, Sully responds, "It was all of us.  We did this together.  We were a team.  We did our job."

One of the most important plot points in the movie was the fact that Sully and Skiles had a grand total of 208 seconds after the bird strike to (1) figure out what had happened, (2) determine what systems were still operational, (3) decide whether they had enough power and altitude to return to LaGuardia or an alternative airport, and (4) after deciding that they did not have sufficient power and altitude, conduct a controlled water ditch on the Hudson River.  Military strategist and former Air Force colonel, John Boyd, would describe their decision making process as a perfect example of his now famous OODA loop (Observe, Orient, Decide, Act).  As the movie suggests, initial computer models using all of the information obtained from the flight recorder, coupled with the pilots' description and clarification of the events suggested that the plane had sufficient forward momentum and altitude to allow a safe landing at either LaGuardia or Teterboro Airport.  A subsequent simulation performed by test pilots also confirmed this initial impression.  However, as Sully emphasizes in direct testimony in the movie's climactic scene, these test pilots had been fully briefed on what had happened (in fact, they had even been told where to land the plane) and were fully expecting the initial bird strike (the element of surprise was completely removed from the simulation itself).  Even with all of that information, they were only able to successfully land the plane in 8 out of 15 attempts (again, after being fully briefed and told exactly how to respond to the bird strike).  Sully says that in the actual event, "There was no time for calculating."  He and his first officer had to rely upon their experience, their "gut feeling", and the only available information they had - the data on the instruments right in front of them.  He told the NTSB, "If you are looking for human error, make it human."  When the test pilots were forced to wait 35 seconds before starting their landing sequence (the approximate time that both Sullenberger and Skiles spent trying to figure out what had happened), they were unsuccessful in landing the plane.  As it turns out, Sullenberger had made the right decision and was the hero after all.

So what lessons does this movie have for us?  First, in a crisis, it is best to remain calm and follow standardized procedures.  Immediately after the bird strike, Sully assumed control of the plane ("My plane") and asked First Officer Skiles to pull out the specific checklist for how to respond.  As they worked through the checklist, Sully quickly reviewed all of the information available, reviewed his options with the Air Traffic Control tower (see the audio recording of the conversation with the flight controller here), and made the decision to ditch the plane on the Hudson.  Second, during a crisis, it is best to defer to the expertise of the leaders on the front line.  Sully was fully accountable for the decisions that he made (which took an emotional toll on him in the days and weeks following the rescue), but the important concept is that he had the authority to make those decisions.  This is a perfect example of the "deference to expertise" that characterizes high reliability organizations (more about HRO's in later posts!).  Third, Sully recognized the contributions of all the members of his team - in the movie's final scenes, he tells the NTSB investigators that everyone involved, including the flight attendants, the passengers, the rescuers (police, fire, Coast Guard, passenger boats from the New York Port Authority) were all responsible for the fact that everyone survived the accident.  Fourth, we see here the example of the so-called "sterile cockpit."  Communication is clear, concise, and direct.  During the emergency, there is no wasted conversation other than what is relevant to the situation.  Even when Sully talks to the passengers, his communication is clear, pointed, and specific ("Brace for impact.").

Finally, I think that another important lesson here is that simulations should include the human element and should try to replicate, as closely as possible, all of the nuances of actual events.  In my own work, we use simulation to prepare health care providers to respond to medical emergencies.  The lesson for us here, is that these simulations should be as realistic as possible and include the element of surprise, as much as possible.

"Failure is not an option!"

I can't wait to go see the new Tom Hanks' movie, "Sully."  Tom Hanks is a great actor who has been in a lot of great movies.  I will drop whatever I am doing and sit down and watch "Saving Private Ryan" whenever it is playing on the television.  I quote lines from "Forrest Gump" and "Cast Away"so often that I have probably ruined both movies for my wife and kids.  But hands down, one of my all time favorites is the movie, "Apollo 13."  To this day, I tear up every time that Tom Hanks' character says, "Houston this is Odyssey, it's good to see you again."  It's just an incredible movie about an even more incredible story.  Ron Howard did an absolutely brilliant job of directing the movie.

There are so many quotes in the movie that I have found inspirational.  The story itself is a perfect example of crisis leadership.  While Tom Hanks plays the hero (astronaut Jim Lovell),  Gene Kranz, played by the actor Ed Harris, really is the behind-the-scenes, unsung crisis leader.  Gene Kranz was the Flight Director at the National Aeronautics and Space Administration (NASA) during the Gemini and Apollo programs.  The movie just briefly touches upon the failed Apollo 1 mission, in which the astronauts Virgil "Gus" Grissom, Roger Chaffee, and Edward White II all perished during a fire accident on the launch pad during a launch rehearsal on January 27, 1967.  There was an in-depth review by NASA following the accident, and I think Gene Kranz himself was particularly introspective. 

He said, "Space flight will never tolerate carelessness, incapacity, and neglect.  Somewhere, somehow, we screwed up. It could have been in design, build, or test. Whatever it was, we should have caught it. We were too gung ho about the schedule and we locked out all of the problems we saw each day in our work." 

In other words, rather than trying to pass blame, Kranz took personal responsibility and accepted full accountability for the actions of his team.  Some times, it is only through our worst failures that we learn and improve. 

Kranz went on further to say, "Every element of the program was in trouble and so were we. The simulators were not working, Mission Control was behind in virtually every area, and the flight and test procedures changed daily. Nothing we did had any shelf life. Not one of us stood up and said, ‘Dammit, stop!’ I don’t know what Thompson’s committee will find as the cause, but I know what I find. We are the cause! We were not ready! We did not do our job. We were rolling the dice, hoping that things would come together by launch day, when in our hearts we knew it would take a miracle. We were pushing the schedule and betting that the Cape would slip before we did." 

"From this day forward, Flight Control will be known by two words: 'Tough’ and 'Competent.’ Tough means we are forever accountable for what we do or what we fail to do. We will never again compromise our responsibilities. Every time we walk into Mission Control we will know what we stand for. Competent means we will never take anything for granted. We will never be found short in our knowledge and in our skills. Mission Control will be perfect."

"When you leave this meeting today you will go to your office and the first thing you will do there is to write 'Tough and Competent’ on your blackboards. It will never be erased. Each day when you enter the room these words will remind you of the price paid by Grissom, White, and Chaffee. These words are the price of admission to the ranks of Mission Control."

I truly believe (as do many safety experts and leadership gurus) that there is absolutely NO WAY that NASA could have saved the three astronauts on Apollo 13 without first going through the tragic moments on January 27, 1967 with Apollo 1.  Apollo 1 was NASA's first major accident - they had a string of successes that made them complacent and perhaps a little cocky.  After Apollo 1, with Gene Kranz's leadership, they changed their culture and became the kind of organization that could quickly adapt and deal with the crisis that occurred 3 years later with Apollo 13.  Apollo 1 provided the kind of culture change where "Failure is not an option" and allowed Kranz to confidently state, "I believe this is going to be our finest hour."

I am not saying that every organization needs to go through a tragic moment like NASA did with Apollo 1.  But I do think that we absolutely need to learn from each and every one of our failures.  Some times, it takes a crisis to focus an organization's attention on its culture, resiliency, competency, and accountability.

Leadership during a crisis - Remembering 9.11.01

I remember exactly where I was on  September 11, 2001 at around 9 AM.  I was a second-year PICU fellow and was working in the laboratory doing sepsis research.  I had one of those pagers that received news and sports updates periodically throughout the day - I received an update that a plane had crashed into the World Trade Center's North Tower (WTC 1) at 8:46 AM.  My first response was that this had been a horrible accident, but when I received a second update that another plane had crashed into the World Trade Center's South Tower (WTC 2) at 9:03 AM, I knew that we were under attack.  My wife called me with the news that a plane had crashed into the Pentagon a little later.  Several of us left our work in the laboratory and walked upstairs to the Pediatric Intensive Care Unit and found an empty room and turned on the television.  We all stood there in shock for the next several hours, watching the events unfold throughout the day.  So much has happened since that awful day, but what I remember now is how we, as a collective United States of America, responded.  I have never witnessed so much patriotism, national pride, and sense of "togetherness" before or since that fateful day.  I also remember how well some of our leaders responded, particularly Mayor Rudolph Giuliani and President George W. Bush.  While many would disagree with some (or most) of President Bush's decisions and policies during his time in office, I think he did an amazing job pulling the country together during this difficult time. 

Crisis leadership is of particular interest to many investigators in a number of disciplines.  What can we learn from other leaders who served in times of crisis?  What did these leaders do, or what characteristics did they possess that allowed them to weather the storm?  How did these leaders react to the difficulties that they faced during the crisis?  In general, I have found that these leaders were prepared.  They had rehearsed or trained how to respond to a number of different scenarios, such that even if they were facing a rare event that no one could have ever envisioned happening, they were able to bring different elements of their training and experience to help deal with the situation.  These leaders remained calm.  They understood that many things were not under their direct control and focused instead on the things that were under their control.  These leaders were decisive, but they also listened to the experts on the front-line.  They made decisions "promptly but not hurriedly". In other words, they used the best available information available and were not subject to "paralysis by analysis." 

When I think of crisis leadership, I think of President Abraham Lincoln.  I don't think any other President has faced such a crisis as he faced during the Civil War.  The future of the United States of America depended to a significant extent upon how he handled adversity, the decisions that he made, and how he led our country throughout the war.  The poet Edwin Markham immortalized Lincoln in a poem entitled, "Lincoln, Man of the People".  One of my favorite lines in the poem is in the final stanza:

So came the Captain with the mighty heart; 

And when the judgment thunders split the house,

Wrenching the rafters from their ancient rest,

He held the ridgepole up, and spiked again

The rafters of the Home.   

 

I think these lines summarizes what it means to be a leader in a time of crisis.  Everyone stood on

Lincoln's shoulders.  He held our divided house together.  He was the rock upon which we rebuilt

our country.

 

On this day, I remember all of those who died on 9.11.01.  I remember the brave men and women on

United Flight 93 who fought back, ultimately giving their lives so that others might be saved.  I

remember all the brave rescuers who charged into the burning World Trade Center and Pentagon to

save as many people as they could.  I remember how the events on that day 15 years ago changed our

lives forever.  But most of all, I remember how well our leaders kept our country united together. 

And I remember Abraham Lincoln, who "held the ridgepole up" and who provided us with the model

of crisis leadership.

 

What do Robert Frost, Hippocrates, and Daniel Drake have in common?

I have always liked the Robert Frost poem, "The Road Not Taken" (you know the one - it ends with the quote, "Two roads diverged in a wood, and I - I took the one less traveled by, and that has made all the difference.").  I fancy myself as someone who, at least on occasion, takes the "road less traveled."  For example, while the traditional path to get to medical school often involves an undergraduate degree in Biology (though this is becoming less the norm than it used to be), I ended up majoring in something called Movement and Sports Science - basically Exercise Physiology with a little Physical Education, Kinesiology, and Sports Psychology thrown in for good measure.  After taking all of the necessary pre-requisites for medical school, I decided to go ahead and major in Biology as well (so maybe I am a traditionalist after all!).  Anyway, my primary major was in the School of Liberal Arts and Humanities.  Humanities is distinguished from the natural sciences and focuses on subjects such as history, literature, sociology, psychology, philosophy, and political science.  My undergraduate college experience brought with it exposure to a lot of different subjects in the humanities.  It is interesting to note that the word "humanity" is defined in the dictionary as the quality or condition of being human.  The study of humanity (i.e., the humanities), therefore, teaches us everything about what it means to be human.  It begs the question then, if patients today treasure qualities such as compassion, empathy, and understanding in their physician (see my last blog post), why do we focus so much on the natural sciences in medical education at the expense (frequently) of a broad education in the humanities? 

Fortunately, there is a reason to be optimistic and hold out hope for the future.  In the past few years, there has been a growing emphasis on the humanities, both during preparation for medical school in the undergraduate years, as well as during medical school itself.  As of 2015, the MCAT now includes a section on psychology and the social sciences, particularly how these subjects pertain to a career in medicine.  Several colleges now offer minors in the medical humanities, and some medical schools are now offering a brief exposure to these subjects.  We are also starting to see advocacy groups and organizations bring things like the Schwartz Rounds to hospitals all across America.  Schwartz Rounds is designed to help health care workers from all disciplines (medicine, nursing, and allied health) become more compassionate, empathetic caregivers.  We are starting to bring back the so-called "art of medicine."  Perhaps we never really lost it, but it seems that with all of the major advances in science and technology that we were focusing too much on the "scientific aspects of medicine."

We are all human.  Nothing is more important than learning about what that means in today's complex world.  The ancient Greek physician, Hippocrates provides us with a long list of quotes (his aphorisms) on how to be a more compassionate, empathetic physician:

"Wherever the art of medicine is loved, there is also a love of humanity."

"Cure sometimes, treat often, comfort always."

"It's far more important to know what person the disease has than what disease the person has."

I also recently came across a quote from Daniel Drake, an American physician who was the first President of the University of Cincinnati College of Medicine.  The quote is on a plaque at the medical school which lists the recipients of the Drake Medal, a prestigious award given in Dr. Drake's honor every year.  He said: "The reason that so many branches of human knowledge unite in the medical profession is to be found in the varied and intimate relations of man with all of the objects and operations of nature, all the works of art, and all the events of society and the world."

It seems that Robert Frost, Hippocrates, and Daniel Drake have more in common than we realize.  Collectively, these three individuals, from different places and from different times, are all encouraging us to "take the road less traveled" and study the medical humanities.  Whether it is just a professional hobby or an area of research interest, I think that a deep regard for the medical humanities will make a difference in how the collective "we" practice medicine, and I truly believe it will make us better, more well-rounded, compassionate, and empathetic physicians.

The Top 7 Ideal Physician Behaviors

I came across an interesting article the other day, published in the journal, Mayo Clinic Proceedings.  The authors of the study were physicians and researchers at the Mayo Clinic who surveyed a group of patients over the course of 2 years who had presented for care at the Mayo Clinic in Rochester, Minnesota and Scottsdale, Arizona.  The study was small (there were only 192 patients surveyed), but the results were quite interesting and important.  The survey focused on the personality traits and characteristics that made a "good doctor."  The patients most commonly reported that they wanted their physician (in no particular order) to be confident, empathetic, humane, personal, forthright, respectful, and thorough.    These were the seven ideal physician behaviors, at least from the patient's perspective!  I think it is rather interesting that technical knowledge and intelligence were not listed in the "top 7."  For example, admission to medical school, residency, and subspecialty fellowship training are frequently based largely on academic standing, performance on standardized tests (MCAT, USMLE, board certification test scores, etc), and face-to-face interviews.  While some would argue that medical schools and residency programs do, in fact, screen for these behaviors during the interview process, at least in my opinion, it is very difficult to gauge how an individual will react to the everyday stressors in the clinical setting.  I do think the medical profession needs to do a better job emphasizing both the so-called art and science of medicine.  To this end, there has been a growing number (based on my own anecdotal experience) of medical humanities programs offered at both colleges and medical schools. 


Incidentally, the same study also reported the top 7 most undesirable physician behaviors, again from the patient's perspective.  These were essentially the mirror image opposite of the ideal physician behavior.  Patients reported that they did not like it when their physician was timid, uncaring, misleading, cold, callous, disrespectful, or hurried.