I came across a good TED talk the other day by an Italian developmental economist named Ernesto Sirolli. Oddly enough, I heard about this particular TED talk at our church this summer. I can't remember what exactly the priest was talking about, but he did recommend Sirolli's book, Ripples from Zambezi: Passion, Entrepreneurship, and the Rebirth of Local Economies as well as the TED talk, "Want to help someone? Shut up and Listen!" Sirolli tells of one of his early experiences with an Italian non-governmental organization (NGO) - every one of the projects that the NGO attempted in Africa had failed. He tells one particularly poignant story of an early project that involved teaching the local African population how to grow food. The NGO brought Italian seeds to southern Zambia in order to teach the locals how to grow Italian tomatoes and zucchini. The area was located along the Zambezi River, and Sirolli tells how the tomatoes grew to two or three times the size of even the best tomatoes in Italy. He goes on to say how the locals really weren't that interested in learning how to grow tomatoes and zucchini. They tried paying them, which did work for some, at least on occasion. Sirolli and his team were obviously very frustrated with the Zambians, but "instead of asking them how come they were not growing anything, we simply said Thank God we're here!" The Italian aid workers were really proud of how well the tomatoes and zucchini were growing - "just think what we can accomplish here! We will save the Zambian people from starvation." But then, overnight, 200 hippos came out from the river and ate all the tomatoes and zucchini. "And we said to the Zambians, My God, the hippos! And the Zambians said, Yes, that's why we don't try to grow things along the river." The Italians asked why the Zambians didn't warn them of the hippos. "And the Zambians said, You never asked!"
Sirolli's message really struck home with me. How many times do we experience a similar phenomenon with any kind of change initiative? The most successful projects or initiatives that I have observed (in fact, nearly all of them) usually have two elements in common. Number one - the project team is super-engaged and passionate about the work. Number two - the project team takes complete ownership of the project - the planning and design of the project, as well as the implementation and execution of the work. On the other hand, the projects that are 100% led in a top-down fashion almost invariably end in failure. So, I guess it really does pay to "shut up and listen." Incidentally, Sirolli's advice is a really great example of the High Reliability Organization principle of "deference to expertise," which we will discuss next.
Wednesday, November 30, 2016
Sunday, November 27, 2016
A night at the theatre
Last night, I let my daughter talk me into taking the family to go see "Phantom of the Opera." My youngest daughter has seen the movie, listened to the soundtrack countless times, and read the book (Le Fantôme de l'Opéra by Gaston Leroux), I think (I can't remember exactly - my response "It was a book!?!?!?"). She had always wanted to see the musical on stage, but until last night she had not been able to do so. Therefore, our family (minus a daughter who had returned to college) all saw the musical for the first time together. It was really quite an enjoyable experience.
I actually used to go see musicals fairly often as a child - my parents took my sister and I to see Oklahoma!, Camelot, The Music Man, The Sound of Music, Show Boat, Seven Brides for Seven Brothers, The Stephen Foster Story, South Pacific, and many more at a place called "Starlight Musicals"in Indianapolis, Indiana. I mention this as I reflect that for the past several years, I have heard concerns about how children in the United States lag behind children from other countries in science and mathematics. I fully understand and agree that in order to be competitive in today's global environment, we as a nation need to narrow the gap in the so-called STEM subjects (Science, Technology, Engineering, and Mathematics). Our educational system needs to do better. However, I am also reminded (yet again - please see my previous blog post, September 7, 2016) that subjects such as Literature, Art, Music, Drama, History, and Philosophy matter too.
The Abbe Faria, one of the characters in one of my favorite novels, "The Count of Monte Cristo" by Alexandre Dumas, teaches the main character, Edmond Dantes, "everything he knows" during their imprisonment. He teaches Dantes mathematics, economics, physics, but also history, philosophy, and "three or four modern languages." The Abbe tells Dantes, "...to learn is not to know; there are the learners and the learned. Memory makes the one, philosophy the other." He seems to paraphrase the Greek philosopher, Socrates here, who defined wisdom as knowing what you don't know rather than knowing everything ("The only true wisdom is knowing you know nothing.").
I believe that leaders need to broaden their horizon. I see nothing wrong with being a "Jack of all trades, but the Master of none" here - some leadership gurus have referred to this as a "T-shaped" leaders, i.e. leaders who are deep in knowledge and skills for one particular area of focus (usually the discipline in which they lead) but well-versed in a broad range of knowledge and skills (expert in one area, highly competent in a number of areas). Leaders should be well read in a variety of subjects - a broad knowledge base acquired through a professional reading program (focusing on subjects outside the leader's traditional area of expertise) has been scientifically proven to improve memory, increase creativity, reduce stress, develop verbal and non-verbal skills, and increase compassion.
We, as leaders, need more exposure to the arts and humanities - my visit to the theatre last night once again emphasized that to me, and for that, I guess I owe my daughter a simple, "Thank you."
I actually used to go see musicals fairly often as a child - my parents took my sister and I to see Oklahoma!, Camelot, The Music Man, The Sound of Music, Show Boat, Seven Brides for Seven Brothers, The Stephen Foster Story, South Pacific, and many more at a place called "Starlight Musicals"in Indianapolis, Indiana. I mention this as I reflect that for the past several years, I have heard concerns about how children in the United States lag behind children from other countries in science and mathematics. I fully understand and agree that in order to be competitive in today's global environment, we as a nation need to narrow the gap in the so-called STEM subjects (Science, Technology, Engineering, and Mathematics). Our educational system needs to do better. However, I am also reminded (yet again - please see my previous blog post, September 7, 2016) that subjects such as Literature, Art, Music, Drama, History, and Philosophy matter too.
The Abbe Faria, one of the characters in one of my favorite novels, "The Count of Monte Cristo" by Alexandre Dumas, teaches the main character, Edmond Dantes, "everything he knows" during their imprisonment. He teaches Dantes mathematics, economics, physics, but also history, philosophy, and "three or four modern languages." The Abbe tells Dantes, "...to learn is not to know; there are the learners and the learned. Memory makes the one, philosophy the other." He seems to paraphrase the Greek philosopher, Socrates here, who defined wisdom as knowing what you don't know rather than knowing everything ("The only true wisdom is knowing you know nothing.").
I believe that leaders need to broaden their horizon. I see nothing wrong with being a "Jack of all trades, but the Master of none" here - some leadership gurus have referred to this as a "T-shaped" leaders, i.e. leaders who are deep in knowledge and skills for one particular area of focus (usually the discipline in which they lead) but well-versed in a broad range of knowledge and skills (expert in one area, highly competent in a number of areas). Leaders should be well read in a variety of subjects - a broad knowledge base acquired through a professional reading program (focusing on subjects outside the leader's traditional area of expertise) has been scientifically proven to improve memory, increase creativity, reduce stress, develop verbal and non-verbal skills, and increase compassion.
We, as leaders, need more exposure to the arts and humanities - my visit to the theatre last night once again emphasized that to me, and for that, I guess I owe my daughter a simple, "Thank you."
Tuesday, November 22, 2016
HRO: Commitment to Resilience
High reliability organizations (HROs) are 100% fully committed to resilience. Resilience is defined as the capacity to quickly recover or "bounce back" from difficulties. By their very nature, HROs are highly complex and tightly coupled. In other words, these organizations are highly interdependent - a small error in one part of the organization can impact a completely separate part of the organization. Furthermore, these small errors are often compounded and magnified. HROs also exist in unforgiving environments where learning by experimentation is often neither feasible or safe. In reality, by developing resilient systems with multiple back-ups and mitigation plans, HROs have made themselves even more complex and more tightly coupled!
When I think of resilience, I am drawn to a particular quote by the martial artist, television and movie celebrity, and philosopher, Bruce Lee. Lee used the analogy of water in one of his most famous quotes ("Be like water my friend"). The quote actually comes from a very short-lived TV series, "Longstreet" in which Lee explained one of the tenets of his philosophy of Gung Fu. He explains how he came to this analogy:
After spending many hours meditating and practicing, I gave up and went sailing alone in a junk. On the sea I thought of all my past training and got mad at myself and punched the water! Right then — at that moment — a thought suddenly struck me; was not this water the very essence of gung fu? Hadn’t this water just now illustrated to me the principle of gung fu? I struck it but it did not suffer hurt. Again I struck it with all of my might — yet it was not wounded! I then tried to grasp a handful of it but this proved impossible. This water, the softest substance in the world, which could be contained in the smallest jar, only seemed weak. In reality, it could penetrate the hardest substance in the world. That was it! I wanted to be like the nature of water.
Suddenly a bird flew by and cast its reflection on the water. Right then I was absorbing myself with the lesson of the water, another mystic sense of hidden meaning revealed itself to me; should not the thoughts and emotions I had when in front of an opponent pass like the reflection of the birds flying over the water? This was exactly what Professor Yip meant by being detached — not being without emotion or feeling, but being one in whom feeling was not sticky or blocked. Therefore in order to control myself I must first accept myself by going with and not against my nature.
Professor Yip was Lee's martial arts instructor before he became famous. Yip taught Lee the Chinese philosophy Wing Chun, which he adapted into his own philosophy of Gung Fu. It really is a beautiful metaphor for resilience:
Be like water making its way through cracks. Do not be assertive, but adjust to the object, and you shall find a way around or through it. If nothing within you stays rigid, outward things will disclose themselves.
Empty your mind, be formless. Shapeless, like water. If you put water into a cup, it becomes the cup. You put water into a bottle and it becomes the bottle. You put it in a teapot, it becomes the teapot. Now, water can flow or it can crash. Be water, my friend.
High reliability organizations are like that. They adapt to their circumstances. They roll with the punches, so to speak. They can be anything at anytime, as circumstances dictate. "Be water, my friend."
When I think of resilience, I am drawn to a particular quote by the martial artist, television and movie celebrity, and philosopher, Bruce Lee. Lee used the analogy of water in one of his most famous quotes ("Be like water my friend"). The quote actually comes from a very short-lived TV series, "Longstreet" in which Lee explained one of the tenets of his philosophy of Gung Fu. He explains how he came to this analogy:
After spending many hours meditating and practicing, I gave up and went sailing alone in a junk. On the sea I thought of all my past training and got mad at myself and punched the water! Right then — at that moment — a thought suddenly struck me; was not this water the very essence of gung fu? Hadn’t this water just now illustrated to me the principle of gung fu? I struck it but it did not suffer hurt. Again I struck it with all of my might — yet it was not wounded! I then tried to grasp a handful of it but this proved impossible. This water, the softest substance in the world, which could be contained in the smallest jar, only seemed weak. In reality, it could penetrate the hardest substance in the world. That was it! I wanted to be like the nature of water.
Suddenly a bird flew by and cast its reflection on the water. Right then I was absorbing myself with the lesson of the water, another mystic sense of hidden meaning revealed itself to me; should not the thoughts and emotions I had when in front of an opponent pass like the reflection of the birds flying over the water? This was exactly what Professor Yip meant by being detached — not being without emotion or feeling, but being one in whom feeling was not sticky or blocked. Therefore in order to control myself I must first accept myself by going with and not against my nature.
Professor Yip was Lee's martial arts instructor before he became famous. Yip taught Lee the Chinese philosophy Wing Chun, which he adapted into his own philosophy of Gung Fu. It really is a beautiful metaphor for resilience:
Be like water making its way through cracks. Do not be assertive, but adjust to the object, and you shall find a way around or through it. If nothing within you stays rigid, outward things will disclose themselves.
Empty your mind, be formless. Shapeless, like water. If you put water into a cup, it becomes the cup. You put water into a bottle and it becomes the bottle. You put it in a teapot, it becomes the teapot. Now, water can flow or it can crash. Be water, my friend.
High reliability organizations are like that. They adapt to their circumstances. They roll with the punches, so to speak. They can be anything at anytime, as circumstances dictate. "Be water, my friend."
Sunday, November 20, 2016
"A few appropriate remarks..."
When I was in eighth grade, our Social Studies teacher gave us an assignment - recite from memory Lincoln's Gettysburg Address. In hindsight, it really wasn't that difficult of an assignment, given the fact that there are only 272 words of text to memorize. Unfortunately, even though I had memorized the speech, I never fully appreciated (at least until many years later) the significance of the text itself. These words are powerful, and they are packed with symbolism.
The speech was delivered on November 19, 1863 (yesterday marks the 153rd anniversary of the speech) at the dedication of the Soldier's National Cemetery in Gettysburg, Pennsylvania. Gettysburg had been the site of an epic battle between the Union's Army of the Potomac and the Confederate's Army of Northern Virginia only four and a half months prior to the dedication ceremony. The battle marked a turning point in the Civil War and was at the time (and until the Battle of the Argonne Forest in World War I) the deadliest battle, in terms of lives lost, in our nation's history.
The dedication ceremony's program started with a two-hour long speech by Edward Everett (who served as a U.S. Representative, U.S. Senator, Governor of Massachusetts, Minister to Great Britain, U.S. Secretary of State, and President of Harvard University). The quality of a speech at that time was measured largely by its length - so by all measures of the day, Everett's speech was a great one! Lincoln stood up at the end of Everett's speech to give "a few appropriate remarks." In just 10 sentences and in a speech lasting just over 2 minutes, Lincoln was able to re-iterate the principles of liberty and equality originally stated in the Declaration of Independence. In these 272 words, Lincoln redefined the Civil War not just as a struggle to maintain the Union (keeping all Confederate states as part of the United States of America), but also as a fight to preserve the individual rights of freedom and equality:
Four score and seven years ago our fathers brought forth on this continent a new nation, conceived in liberty, and dedicated to the proposition that all men are created equal. Now we are engaged in a great civil war, testing whether that nation, or any nation so conceived and so dedicated, can long endure. We are met on a great battlefield of that war. We have come to dedicate a portion of that field, as a final resting place for those who here gave their lives that that nation might live. It is altogether fitting and proper that we should do this.
But, in a larger sense, we can not dedicate, we can not consecrate, we can not hallow this ground. The brave men, living and dead, who struggled here, have consecrated it, far above our poor power to add or detract. The world will little note, nor long remember what we say here, but it can never forget what they did here. It is for us the living, rather, to be dedicated here to the unfinished work which they who fought here have thus far so nobly advanced. It is rather for us to be here dedicated to the great task remaining before us—that from these honored dead we take increased devotion to that cause for which they gave the last full measure of devotion—that we here highly resolve that these dead shall not have died in vain—that this nation, under God, shall have a new birth of freedom—and that government of the people, by the people, for the people, shall not perish from the earth.
Everett himself wrote Lincoln the following day, stating, "I should be glad if I could flatter myself that I came as near to the central idea of the occasion, in two hours, as you did in two minutes."
It is a great speech - perhaps one of the greatest speeches ever delivered by a U.S. President. Lincoln was a gifted orator, but the beauty and the power of his Gettysburg Address rests in its simplicity and its brevity. I think the speech demonstrates the power of just a few simple words.
With many of the struggles that we are going through as a country today, it is my hope that we will all rediscover Lincoln's Gettysburg Address and re-dedicate our lives to the principles espoused in the Declaration of Independence, that we are all equal and that "government of the people, by the people, for the people" will endure forever.
The speech was delivered on November 19, 1863 (yesterday marks the 153rd anniversary of the speech) at the dedication of the Soldier's National Cemetery in Gettysburg, Pennsylvania. Gettysburg had been the site of an epic battle between the Union's Army of the Potomac and the Confederate's Army of Northern Virginia only four and a half months prior to the dedication ceremony. The battle marked a turning point in the Civil War and was at the time (and until the Battle of the Argonne Forest in World War I) the deadliest battle, in terms of lives lost, in our nation's history.
The dedication ceremony's program started with a two-hour long speech by Edward Everett (who served as a U.S. Representative, U.S. Senator, Governor of Massachusetts, Minister to Great Britain, U.S. Secretary of State, and President of Harvard University). The quality of a speech at that time was measured largely by its length - so by all measures of the day, Everett's speech was a great one! Lincoln stood up at the end of Everett's speech to give "a few appropriate remarks." In just 10 sentences and in a speech lasting just over 2 minutes, Lincoln was able to re-iterate the principles of liberty and equality originally stated in the Declaration of Independence. In these 272 words, Lincoln redefined the Civil War not just as a struggle to maintain the Union (keeping all Confederate states as part of the United States of America), but also as a fight to preserve the individual rights of freedom and equality:
Four score and seven years ago our fathers brought forth on this continent a new nation, conceived in liberty, and dedicated to the proposition that all men are created equal. Now we are engaged in a great civil war, testing whether that nation, or any nation so conceived and so dedicated, can long endure. We are met on a great battlefield of that war. We have come to dedicate a portion of that field, as a final resting place for those who here gave their lives that that nation might live. It is altogether fitting and proper that we should do this.
But, in a larger sense, we can not dedicate, we can not consecrate, we can not hallow this ground. The brave men, living and dead, who struggled here, have consecrated it, far above our poor power to add or detract. The world will little note, nor long remember what we say here, but it can never forget what they did here. It is for us the living, rather, to be dedicated here to the unfinished work which they who fought here have thus far so nobly advanced. It is rather for us to be here dedicated to the great task remaining before us—that from these honored dead we take increased devotion to that cause for which they gave the last full measure of devotion—that we here highly resolve that these dead shall not have died in vain—that this nation, under God, shall have a new birth of freedom—and that government of the people, by the people, for the people, shall not perish from the earth.
Everett himself wrote Lincoln the following day, stating, "I should be glad if I could flatter myself that I came as near to the central idea of the occasion, in two hours, as you did in two minutes."
It is a great speech - perhaps one of the greatest speeches ever delivered by a U.S. President. Lincoln was a gifted orator, but the beauty and the power of his Gettysburg Address rests in its simplicity and its brevity. I think the speech demonstrates the power of just a few simple words.
With many of the struggles that we are going through as a country today, it is my hope that we will all rediscover Lincoln's Gettysburg Address and re-dedicate our lives to the principles espoused in the Declaration of Independence, that we are all equal and that "government of the people, by the people, for the people" will endure forever.
Wednesday, November 16, 2016
"Five Things"
Last night, I had the honor and privilege of attending a special ceremony in Columbus, Ohio - my mentor, colleague, and friend, Richard J. Brilli, MD, MCCM received the John F. Wolfe Endowed Chair in Medical Leadership and Pediatric Quality & Safety. Rich has taught me so much and has done so much for my career over the years, that I would not have missed this ceremony for the world.
Those of you who have worked with Rich in the Pediatric Intensive Care Unit (PICU) will remember that he always taught about "five things." For example, there are "5 causes of arterial hypoxemia," "5 reasons that children get admitted to the PICU following spinal fusion surgery" (at least in the old days), and at least "5 bugs that can kill you." I used to joke with Rich about this when I was a PICU fellow - however, the joke was always on me. I had to laugh (inwardly, of course) on my first day of clinical service as an attending when all of the residents were waiting for me to say something half-way intelligent. I quickly reverted to the "five things" method of bedside teaching!
As I was thinking last night, there are at least "five things" that Rich has taught me about leadership. Specifically, there are "5 leadership values" that Rich taught me - these remain personal values for me to this day.
1. Honor: Rich said it best last night during his acceptance speech. "It is a blessing. It is a gift. It is a privilege to do what we do every day. Honor it." Above all else, honor the patient in front of you.
2. Courage: Rich always taught me to have the courage to stick to your core principles and your core values. Everything else flows from your core values. Stand up for what you believe in. Stand up for those who can't.
3. Commitment: Making clinical decisions about someone else's critically ill child is frightening. But you owe it to the patient to make that decision, and once you do make the decision, be strong and stay committed to it. I think the same is true in health care administration. If you honor the patients your organization is taking care of (#1) and stick to your core principles (#2), the decision you make is more than likely the correct one. Stay committed to that decision and course of action, until the information tells you it is time to make a new one.
4. Humility: Working in the PICU is difficult - on any given patient, there are probably at least 100 different ways that you can make a mistake or error and cause harm to the patient. Be humble. We work in a difficult field in healthcare - there is no place for haughtiness and ego here.
5. Patience: Rich joked last night that he had some "idiosyncracies" - he does! But he was always patient, especially with the residents and fellows. Have patience with those who work for you. Give them breathing room. Give them enough autonomy to develop (some of the best ways to learn is by making a mistake) without placing the patient in harm's way. Again, there is something here for those of us in health care administration as well. Leadership is a learned skill - it takes time and practice. Be patient with new and emerging leaders.
Again, thank you Rich for everything you have done - for your patients and their families, for all of the medical students, residents, fellows, and junior attendings that have worked with you, and for me personally. We owe you a lot more than you will ever know. Congratulations! Here's to the almighty Fick equation and "five things"!
Those of you who have worked with Rich in the Pediatric Intensive Care Unit (PICU) will remember that he always taught about "five things." For example, there are "5 causes of arterial hypoxemia," "5 reasons that children get admitted to the PICU following spinal fusion surgery" (at least in the old days), and at least "5 bugs that can kill you." I used to joke with Rich about this when I was a PICU fellow - however, the joke was always on me. I had to laugh (inwardly, of course) on my first day of clinical service as an attending when all of the residents were waiting for me to say something half-way intelligent. I quickly reverted to the "five things" method of bedside teaching!
As I was thinking last night, there are at least "five things" that Rich has taught me about leadership. Specifically, there are "5 leadership values" that Rich taught me - these remain personal values for me to this day.
1. Honor: Rich said it best last night during his acceptance speech. "It is a blessing. It is a gift. It is a privilege to do what we do every day. Honor it." Above all else, honor the patient in front of you.
2. Courage: Rich always taught me to have the courage to stick to your core principles and your core values. Everything else flows from your core values. Stand up for what you believe in. Stand up for those who can't.
3. Commitment: Making clinical decisions about someone else's critically ill child is frightening. But you owe it to the patient to make that decision, and once you do make the decision, be strong and stay committed to it. I think the same is true in health care administration. If you honor the patients your organization is taking care of (#1) and stick to your core principles (#2), the decision you make is more than likely the correct one. Stay committed to that decision and course of action, until the information tells you it is time to make a new one.
4. Humility: Working in the PICU is difficult - on any given patient, there are probably at least 100 different ways that you can make a mistake or error and cause harm to the patient. Be humble. We work in a difficult field in healthcare - there is no place for haughtiness and ego here.
5. Patience: Rich joked last night that he had some "idiosyncracies" - he does! But he was always patient, especially with the residents and fellows. Have patience with those who work for you. Give them breathing room. Give them enough autonomy to develop (some of the best ways to learn is by making a mistake) without placing the patient in harm's way. Again, there is something here for those of us in health care administration as well. Leadership is a learned skill - it takes time and practice. Be patient with new and emerging leaders.
Again, thank you Rich for everything you have done - for your patients and their families, for all of the medical students, residents, fellows, and junior attendings that have worked with you, and for me personally. We owe you a lot more than you will ever know. Congratulations! Here's to the almighty Fick equation and "five things"!
Sunday, November 13, 2016
It's "gut check" time!
It has been an interesting week! The results of the recent U.S. Presidential election came as quite a shock (and dare I say, quite a disappointment) to many of us in the United States. Just about every major poll in the days and weeks prior to last Tuesday had predicted that Hillary Clinton would win a very tight race. Several political pundits had even predicted that she would win the Electoral College but lose the popular vote. The exact opposite happened - Donald Trump won the Electoral College (fairly easily) but will likely lose the popular vote by about 200,000 votes (there are still absentee votes to be counted). What happened with the predictions? How could the pollsters have been so wrong? There are a number of theories that have been put forth - for example, some experts have suggested that some of the individuals who were polled before the election were not completely honest with who they were going to support in the election. Regardless, I think that many of us will look at polls and predictions in the future with a healthy dose of skepticism.
I have talked about a number of studies that show that statistical analyses and computer algorithms are more accurate than humans in decision making in a variety of circumstances (see "Humans versus computers in decision making" from one of my earlier blog posts). I would like to suggest, however, that there is a time and place for so-called "gut feelings" - even in health care. Narayan Kandasamy and colleagues recently published a very interesting study on "gut instinct" and "gut feelings" ("Interoceptive ability predicts survival on a London trading floor"). The investigators in this study analyzed whether interoceptive ability (the ability to detect and respond to somatic signals, such as quickening heart rate, breathlessness, "butterflies in the stomach", or sweating - basically everything that a lie detector test measures) could predict whether a high-frequency trader is successful making profitable investments. High frequency trading requires quick thinking - these traders have to make a decision in a matter of seconds on whether to buy or sell a particular stock investment. Their individual livelihoods depend upon their ability to predict the right stock. Kandasamy's team of investigators theorized that successful traders used "gut instinct" to make their decisions. Those traders who could "detect" (unconsciously, of course) an increase in their heart rate would be more attuned to their gut-level instincts - these investigators, would in turn, be more likely to make the correct (i.e. profitable) decisions on their investments. The results of this study suggested the following:
1. High-frequency traders had a better interoceptive ability (i.e. they could tell the investigators their heart rate without measuring their own pulse) compared to age- and gender-matched control subjects (graduate students).
2. Interoceptive ability predicted which high-frequency traders were the most successful (as determined by their individual profit-loss statements).
3. Experienced (in terms of the number of years on the job) high-frequency traders had a better interoceptive ability than less experienced traders.
4. The traders were asked how confident they were in determining their individual heart rates - unfortunately, there was no relationship between their degree of confidence in their heart rate predictions and the accuracy of these predictions, or in the accuracy of their decision making.
This is a great study that raises a number of interesting points to ponder further. It is clear that "gut instinct" can play a role in making accurate decisions. The dilemma here is that we really can't know whose "gut feeling" is accurate. The study suggested that the traders with a lower body mass index, lower resting heart rate, and lower beat-to-beat variability had a greater degree of interoceptive ability than the rest of the traders. I am not sure what this means, but I would surmise that those traders with a lower, more consistent heart rate would be more likely to "pick up" even a subtle increase in their heart rate when trying to make a decision (the lower resting heart rate and beat-to-beat variability, in effect, improves the signal-to-noise ratio). This would suggest that we could potentially "train" an individual to respond to "gut feelings." This is, in effect, what we are doing when we perform drills and simulations (e.g. mock codes and mass casualty exercises in health care, flight simulations in aviation, and war games in the military).
We have learned to pay attention to "gut feelings" in health care. For example, Beth Crandall published a study several years ago that suggested that nurses in the neonatal ICU respond to "gut feelings" to diagnose infants with life-threatening sepsis, often before more obvious signs and symptoms manifest. We have operationalized "gut feelings" in our hospital by teaching bedside providers to verbalize their concerns about particular patients who may get sicker and require transfer to the ICU using the term "watcher" (we published this work in the journal, Pediatrics).
So, which is better - gut instinct or computerized algorithms? The answer is probably both. I think we need to work with both cognitive psychologists and human factors engineers to develop techniques and methods to fully utilize all of the information available to the bedside provider to provide the best care to our patients - both the "Big Data" available in the electronic medical record, published literature, and Internet, as well as the information provided by so-called hunches and gut feelings. We need to identify the best way to reduce the signal-to-noise ratio of our "gut feelings" through repetitive simulation training (the more realistic the better). We also need to train providers to pay attention to their "gut feelings." And perhaps most importantly, we need to identify useful indicators of whose "gut feeling" is accurate and whose is not. Humans will never be able to pull together all of the information available as rapidly (and as accurately) as a computer can do, but computers will never be able to completely replace the human providers at the bedside. For this reason, there will always be a place for "gut feelings" and "gut instincts".
I have talked about a number of studies that show that statistical analyses and computer algorithms are more accurate than humans in decision making in a variety of circumstances (see "Humans versus computers in decision making" from one of my earlier blog posts). I would like to suggest, however, that there is a time and place for so-called "gut feelings" - even in health care. Narayan Kandasamy and colleagues recently published a very interesting study on "gut instinct" and "gut feelings" ("Interoceptive ability predicts survival on a London trading floor"). The investigators in this study analyzed whether interoceptive ability (the ability to detect and respond to somatic signals, such as quickening heart rate, breathlessness, "butterflies in the stomach", or sweating - basically everything that a lie detector test measures) could predict whether a high-frequency trader is successful making profitable investments. High frequency trading requires quick thinking - these traders have to make a decision in a matter of seconds on whether to buy or sell a particular stock investment. Their individual livelihoods depend upon their ability to predict the right stock. Kandasamy's team of investigators theorized that successful traders used "gut instinct" to make their decisions. Those traders who could "detect" (unconsciously, of course) an increase in their heart rate would be more attuned to their gut-level instincts - these investigators, would in turn, be more likely to make the correct (i.e. profitable) decisions on their investments. The results of this study suggested the following:
1. High-frequency traders had a better interoceptive ability (i.e. they could tell the investigators their heart rate without measuring their own pulse) compared to age- and gender-matched control subjects (graduate students).
2. Interoceptive ability predicted which high-frequency traders were the most successful (as determined by their individual profit-loss statements).
3. Experienced (in terms of the number of years on the job) high-frequency traders had a better interoceptive ability than less experienced traders.
4. The traders were asked how confident they were in determining their individual heart rates - unfortunately, there was no relationship between their degree of confidence in their heart rate predictions and the accuracy of these predictions, or in the accuracy of their decision making.
This is a great study that raises a number of interesting points to ponder further. It is clear that "gut instinct" can play a role in making accurate decisions. The dilemma here is that we really can't know whose "gut feeling" is accurate. The study suggested that the traders with a lower body mass index, lower resting heart rate, and lower beat-to-beat variability had a greater degree of interoceptive ability than the rest of the traders. I am not sure what this means, but I would surmise that those traders with a lower, more consistent heart rate would be more likely to "pick up" even a subtle increase in their heart rate when trying to make a decision (the lower resting heart rate and beat-to-beat variability, in effect, improves the signal-to-noise ratio). This would suggest that we could potentially "train" an individual to respond to "gut feelings." This is, in effect, what we are doing when we perform drills and simulations (e.g. mock codes and mass casualty exercises in health care, flight simulations in aviation, and war games in the military).
We have learned to pay attention to "gut feelings" in health care. For example, Beth Crandall published a study several years ago that suggested that nurses in the neonatal ICU respond to "gut feelings" to diagnose infants with life-threatening sepsis, often before more obvious signs and symptoms manifest. We have operationalized "gut feelings" in our hospital by teaching bedside providers to verbalize their concerns about particular patients who may get sicker and require transfer to the ICU using the term "watcher" (we published this work in the journal, Pediatrics).
So, which is better - gut instinct or computerized algorithms? The answer is probably both. I think we need to work with both cognitive psychologists and human factors engineers to develop techniques and methods to fully utilize all of the information available to the bedside provider to provide the best care to our patients - both the "Big Data" available in the electronic medical record, published literature, and Internet, as well as the information provided by so-called hunches and gut feelings. We need to identify the best way to reduce the signal-to-noise ratio of our "gut feelings" through repetitive simulation training (the more realistic the better). We also need to train providers to pay attention to their "gut feelings." And perhaps most importantly, we need to identify useful indicators of whose "gut feeling" is accurate and whose is not. Humans will never be able to pull together all of the information available as rapidly (and as accurately) as a computer can do, but computers will never be able to completely replace the human providers at the bedside. For this reason, there will always be a place for "gut feelings" and "gut instincts".
Tuesday, November 8, 2016
HRO: Sensitivity to Operations
Okay, I confess. I have seen the movie, "Top Gun" more times than I would like to admit. The movie is a bit cheesy in parts and totally unrealistic, but it is classic 1980's. The movie does have unique appeal - in fact, the United States Library of Congress placed the film in the National Film Registry in 2015, calling the movie "culturally significant." There is a quote towards the beginning of the movie - in the infamous bar scene ("You've lost that loving feeling!"). The two protagonists of the movie, Maverick (an F-14 pilot, played by Tom Cruise in one of the roles that made him famous) and Goose (the Radar Intercept Officer, played by Anthony Edwards, who later starred in the TV series, "ER") are talking about one of the other F-14 pilots, following up on an earlier question in which Maverick had wondered who was the best pilot among all the other pilots at Top Gun. The quote goes something like this:
Goose: Mav, you want to know who's the best? That's him. Iceman. It's the way he flies - Ice cold. No mistakes. Wears you down. After enough time, you just get bored and frustrated, you do something stupid, and he's got you.
Iceman (played by the actor, Val Kilmer) is Maverick's nemesis throughout the movie (spoiler alert: they, of course, become the best of friends at the end of the movie) and does everything "by the book." One could argue that his flying is highly standardized with little variation from the textbook (if such a book on F-14 combat tactics existed) and little variation from minute-to-minute. In other words, Iceman focuses on "operational excellence", what High Reliability Organizations would call "sensitivity to operations."
Operational excellence is characterized by standardization of best practices and elimination of waste, through continuous process improvement. It is a scientific management philosophy embedded in quality improvement methodologies, such as Lean, Six Sigma, Zero Defects, Total Quality Leadership (TQL) / Total Quality Management (TQM), and the Model for Improvement. Operational excellence has developed from concepts originally described by quality control engineers, management gurus, and scientists such as Walter Shewhart, Joseph Juran, Frederick Winslow Taylor, Taiichi Ohno, and W. Edwards Deming.
Practically, operational excellence in a nuclear power plant (to use a different example of HRO) means that the technicians follow standard operating procedures, each and every time. The nuclear power plant technicians use checklists and other cues to help them follow highly technical procedures in the exact same sequence from shift to shift, day to day, year to year. Performance is monitored closely (monitoring is also standardized) - any deviations from normal are quickly recognized and corrected, again according to a defined, standardized protocol. The nuclear power plant technicians understand measurement and statistical process control. These technicians use measurement and statistical process control charts in order to understand what is happening in their work environment.
Operational excellence has a role to play in today's health care environment. I whole-heartedly agree that "patients are not widgets" and that "we shouldn't practice cookbook medicine." Standardization, one of the key elements in operational excellence, is NOT "cookbook medicine." There is simply no justification for why we should not standardize the care of common conditions (e.g. management of diabetic ketoacidosis, acute chest pain, or acute asthma exacerbation) or processes (e.g. care and maintenance of central lines, urinary catheters, surgical time-outs) - these are the kinds of conditions and processes that should be managed the same way, every day, by each and every member of the health care team. With the care of common conditions, there is some room to maneuver, so to speak. For example, if a patient deviates from the expected clinical course, then and only then should we deviate from a standardized treatment protocol. However, there is no reason why we should deviate from standardized protocols for surgical time-outs, shift hand-offs, or maintenance of central lines.
If hospitals are to become high reliability organizations, we must embrace the core tenets of operational excellence. We must be sensitive to operations - what is happening on the front lines of health care. The good news is that many health care organizations have demonstrated that standardization of best practices and elimination of waste through operational excellence can lead to sustained improvement in outcomes and lower costs.
Goose: Mav, you want to know who's the best? That's him. Iceman. It's the way he flies - Ice cold. No mistakes. Wears you down. After enough time, you just get bored and frustrated, you do something stupid, and he's got you.
Iceman (played by the actor, Val Kilmer) is Maverick's nemesis throughout the movie (spoiler alert: they, of course, become the best of friends at the end of the movie) and does everything "by the book." One could argue that his flying is highly standardized with little variation from the textbook (if such a book on F-14 combat tactics existed) and little variation from minute-to-minute. In other words, Iceman focuses on "operational excellence", what High Reliability Organizations would call "sensitivity to operations."
Operational excellence is characterized by standardization of best practices and elimination of waste, through continuous process improvement. It is a scientific management philosophy embedded in quality improvement methodologies, such as Lean, Six Sigma, Zero Defects, Total Quality Leadership (TQL) / Total Quality Management (TQM), and the Model for Improvement. Operational excellence has developed from concepts originally described by quality control engineers, management gurus, and scientists such as Walter Shewhart, Joseph Juran, Frederick Winslow Taylor, Taiichi Ohno, and W. Edwards Deming.
Practically, operational excellence in a nuclear power plant (to use a different example of HRO) means that the technicians follow standard operating procedures, each and every time. The nuclear power plant technicians use checklists and other cues to help them follow highly technical procedures in the exact same sequence from shift to shift, day to day, year to year. Performance is monitored closely (monitoring is also standardized) - any deviations from normal are quickly recognized and corrected, again according to a defined, standardized protocol. The nuclear power plant technicians understand measurement and statistical process control. These technicians use measurement and statistical process control charts in order to understand what is happening in their work environment.
Operational excellence has a role to play in today's health care environment. I whole-heartedly agree that "patients are not widgets" and that "we shouldn't practice cookbook medicine." Standardization, one of the key elements in operational excellence, is NOT "cookbook medicine." There is simply no justification for why we should not standardize the care of common conditions (e.g. management of diabetic ketoacidosis, acute chest pain, or acute asthma exacerbation) or processes (e.g. care and maintenance of central lines, urinary catheters, surgical time-outs) - these are the kinds of conditions and processes that should be managed the same way, every day, by each and every member of the health care team. With the care of common conditions, there is some room to maneuver, so to speak. For example, if a patient deviates from the expected clinical course, then and only then should we deviate from a standardized treatment protocol. However, there is no reason why we should deviate from standardized protocols for surgical time-outs, shift hand-offs, or maintenance of central lines.
If hospitals are to become high reliability organizations, we must embrace the core tenets of operational excellence. We must be sensitive to operations - what is happening on the front lines of health care. The good news is that many health care organizations have demonstrated that standardization of best practices and elimination of waste through operational excellence can lead to sustained improvement in outcomes and lower costs.
Sunday, November 6, 2016
Happy Guy Fawkes Day!
I was texting my son last night while watching college football on the television. When I asked him what he had been doing, he told me that he had just finished watching the movie, "V for Vendetta". I have never seen this movie, but I have seen enough trailers to know that the movie's protagonist wears a "Guy Fawkes" mask. "Ahhh - today is November 5, Guy Fawkes Day," I texted. I have to admit, I thought I was being particularly clever here and didn't think he would make the connection. To my surprise, my son texted back, "Yes, I know. Ever since we watched 'V for Vendetta' in my high school religion class on November 5th, I have made it an annual tradition." In other words, not only was I not being clever, my son apparently knew more about Guy Fawkes than I thought.
Guy Fawkes was one of the English Catholics who helped plan and (unsuccessfully) orchestrate the infamous Gunpowder Plot of 1605 (also known as the Jesuit Treason). The plan was to blow up the House of Lords and assassinate King James I of England, and in so doing, install James' daughter, Elizabeth (a Catholic) as the new head of state. The plot failed, and the perpetrators (including Guy Fawkes) were hanged, drawn, and quartered. Apparently, Fawkes fell from the scaffolding where he was to be hanged, breaking his neck and dying before being drawn and quartered. His name has become synonymous with the annual celebration of the failure of the Gunpowder Plot on November 5, now known as "Guy Fawkes Day." Apparently, the movie, "V for Vendetta" is an allegory for oppressive government, but that is a discussion for another day!
What struck me about this entire conversation was the importance of annual traditions - the English celebrate "Guy Fawkes Day" every year on November 5th. My son watches the movie, "V for Vendetta" every year on November 5th, remembering fondly one of his favorite high school teachers. Conceptually, we use traditions to share our common links with the past. The word tradition comes from the Latin noun, traditio which is based on the Latin verb, tradere, meaning to transmit, to hand over, to give for safekeeping. Traditions are beliefs and customs that originated in the past that are passed down from one generation to the next, more or less in the same form in which they originated.
I frequently talk about "high reliability organizations" and use the United States Navy's aircraft carrier flight operations as an example of a "high reliability organization." One of the most common criticisms that I hear is how health care is completely different than the military. "In the Navy, if you aren't compliant with the rules, you get in big trouble!" The mistaken belief is that the Navy uses strict hierarchy and authoritarian leadership to enforce strict discipline and compliance with policies, rules, and regulations. Nothing could be further from the truth. While there are certain elements of hierarchical and authoritarian leadership in the military, the most important unifying element that keeps daily operations running exactly (more or less) the same way from ship to ship across the fleet, year after year, are the traditions and customs that are handed down from past generations of sailors. Traditions are the glue that holds the Navy together.
I am not saying that all traditions are good. Some of the traditions in the Navy are no longer appropriate (perhaps they never were) - as one example, the "crossing the line" ceremony" is not quite as violent as it was in the distant past. However, for the most part, traditions are how the right "culture" is instilled in new sailors and how "culture" is maintained throughout the ship.
Most health care organizations have some important traditions. However, I would suggest that traditions are not used nearly enough. Traditions can and should be an important way to set the proper tone, encourage the proper attitudes, and build the culture that is necessary for a high-performing health care delivery organization.
Guy Fawkes was one of the English Catholics who helped plan and (unsuccessfully) orchestrate the infamous Gunpowder Plot of 1605 (also known as the Jesuit Treason). The plan was to blow up the House of Lords and assassinate King James I of England, and in so doing, install James' daughter, Elizabeth (a Catholic) as the new head of state. The plot failed, and the perpetrators (including Guy Fawkes) were hanged, drawn, and quartered. Apparently, Fawkes fell from the scaffolding where he was to be hanged, breaking his neck and dying before being drawn and quartered. His name has become synonymous with the annual celebration of the failure of the Gunpowder Plot on November 5, now known as "Guy Fawkes Day." Apparently, the movie, "V for Vendetta" is an allegory for oppressive government, but that is a discussion for another day!
What struck me about this entire conversation was the importance of annual traditions - the English celebrate "Guy Fawkes Day" every year on November 5th. My son watches the movie, "V for Vendetta" every year on November 5th, remembering fondly one of his favorite high school teachers. Conceptually, we use traditions to share our common links with the past. The word tradition comes from the Latin noun, traditio which is based on the Latin verb, tradere, meaning to transmit, to hand over, to give for safekeeping. Traditions are beliefs and customs that originated in the past that are passed down from one generation to the next, more or less in the same form in which they originated.
I frequently talk about "high reliability organizations" and use the United States Navy's aircraft carrier flight operations as an example of a "high reliability organization." One of the most common criticisms that I hear is how health care is completely different than the military. "In the Navy, if you aren't compliant with the rules, you get in big trouble!" The mistaken belief is that the Navy uses strict hierarchy and authoritarian leadership to enforce strict discipline and compliance with policies, rules, and regulations. Nothing could be further from the truth. While there are certain elements of hierarchical and authoritarian leadership in the military, the most important unifying element that keeps daily operations running exactly (more or less) the same way from ship to ship across the fleet, year after year, are the traditions and customs that are handed down from past generations of sailors. Traditions are the glue that holds the Navy together.
I am not saying that all traditions are good. Some of the traditions in the Navy are no longer appropriate (perhaps they never were) - as one example, the "crossing the line" ceremony" is not quite as violent as it was in the distant past. However, for the most part, traditions are how the right "culture" is instilled in new sailors and how "culture" is maintained throughout the ship.
Most health care organizations have some important traditions. However, I would suggest that traditions are not used nearly enough. Traditions can and should be an important way to set the proper tone, encourage the proper attitudes, and build the culture that is necessary for a high-performing health care delivery organization.
Thursday, November 3, 2016
The world has changed ("Fly the W")
I woke up this morning to a brand new world. Things changed overnight. The sun still rose up in the East. The sky was blue. The grass was green. I started the day with a cup of coffee and the morning newspaper. But things were different. On this morning, my beloved Chicago Cubs were no longer the "Loveable Losers" of the North side. Chicago Cubs - 2016 World Series Champions. It has a nice ring, don't you think?
Without a doubt, game 7 last night was the best baseball game that I have ever seen - period. It had everything. Two teams fighting for their first World Series title in many, many years. An untouchable pitcher from the Cleveland Indians became touchable. An untouchable pitcher from the Chicago Cubs also became touchable. A blown save. Extra innings. A rain delay. Every pitch seemed like it would make one team a champion and one team a runner-up. Epic. It was simply unbelievable.
For this long-suffering Cubs fan, last night was truly magical. Even now, I wonder if it was all just a dream. Cubs fans just think that way. But this team just never gave up. They didn't quit. Even down three games to one with their backs to the wall. They found a way to win. Even after blowing a three run lead in the 8th inning of game 7, they found a way to win. What a game! What a team!
But this post isn't really about the Cubs. My hat goes off to the Cleveland Indians. They never gave up. They never quit. They fought until the bitter end. Unfortunately, there had to be a winner and there had to be a loser. But the Cleveland Indians didn't lose this game. The Chicago Cubs won it. As much as I was inspired by my Cubs, I was even more inspired by the Cleveland Indians' manager, Terry Francona. He gave a truly remarkable, inspirational, humble, honorable post-game interview. What a class act. Here is some of what he said:
"You know, we ask our players to play the game with respect and to leave it on the field. That was it. They gave everything they had. And I kind of talked about it before the game, what an honor it was, but it really was. To go through that with this group and these people, it was an honor."
Well, Mr. Terry Francona, the honor was ours. You showed us everything that we could ever ask of a leader last night. You are a great manager, and you deserve your place in the Hall of Fame. I will never forget how you led your team throughout the play-offs and throughout the World Series. I will never forget your humility, your pain in losing, and your respect for this great game.
It is an unfortunate truth that even great leaders fail at times. But I think that what makes these leaders really great is how they fail. They fail with class. They fail with humility. They fail with respect. They fail with honor.
So close to Election Day, I am also reminded of another great leader who failed with class. President George H.W. Bush left a letter for the incoming President Bill Clinton on his last day of office. He said:
Dear Bill,
When I walked into this office just now I felt the same sense of wonder and respect that I felt four years ago. I know you will feel that, too.
I wish you great happiness here. I never felt the loneliness some Presidents have described.
There will be very tough times, made even more difficult by criticism you may not think is fair. I’m not a very good one to give advice; but just don’t let the critics discourage you or push you off course.
You will be our President when you read this note. I wish you well. I wish your family well.
Your success now is our country’s success. I am rooting hard for you.
Good luck – George
Respect. Honor. Humility. Class. These are the characteristics that separate the great leaders from the good leaders.
Without a doubt, game 7 last night was the best baseball game that I have ever seen - period. It had everything. Two teams fighting for their first World Series title in many, many years. An untouchable pitcher from the Cleveland Indians became touchable. An untouchable pitcher from the Chicago Cubs also became touchable. A blown save. Extra innings. A rain delay. Every pitch seemed like it would make one team a champion and one team a runner-up. Epic. It was simply unbelievable.
For this long-suffering Cubs fan, last night was truly magical. Even now, I wonder if it was all just a dream. Cubs fans just think that way. But this team just never gave up. They didn't quit. Even down three games to one with their backs to the wall. They found a way to win. Even after blowing a three run lead in the 8th inning of game 7, they found a way to win. What a game! What a team!
But this post isn't really about the Cubs. My hat goes off to the Cleveland Indians. They never gave up. They never quit. They fought until the bitter end. Unfortunately, there had to be a winner and there had to be a loser. But the Cleveland Indians didn't lose this game. The Chicago Cubs won it. As much as I was inspired by my Cubs, I was even more inspired by the Cleveland Indians' manager, Terry Francona. He gave a truly remarkable, inspirational, humble, honorable post-game interview. What a class act. Here is some of what he said:
"You know, we ask our players to play the game with respect and to leave it on the field. That was it. They gave everything they had. And I kind of talked about it before the game, what an honor it was, but it really was. To go through that with this group and these people, it was an honor."
Well, Mr. Terry Francona, the honor was ours. You showed us everything that we could ever ask of a leader last night. You are a great manager, and you deserve your place in the Hall of Fame. I will never forget how you led your team throughout the play-offs and throughout the World Series. I will never forget your humility, your pain in losing, and your respect for this great game.
It is an unfortunate truth that even great leaders fail at times. But I think that what makes these leaders really great is how they fail. They fail with class. They fail with humility. They fail with respect. They fail with honor.
So close to Election Day, I am also reminded of another great leader who failed with class. President George H.W. Bush left a letter for the incoming President Bill Clinton on his last day of office. He said:
Dear Bill,
When I walked into this office just now I felt the same sense of wonder and respect that I felt four years ago. I know you will feel that, too.
I wish you great happiness here. I never felt the loneliness some Presidents have described.
There will be very tough times, made even more difficult by criticism you may not think is fair. I’m not a very good one to give advice; but just don’t let the critics discourage you or push you off course.
You will be our President when you read this note. I wish you well. I wish your family well.
Your success now is our country’s success. I am rooting hard for you.
Good luck – George
Respect. Honor. Humility. Class. These are the characteristics that separate the great leaders from the good leaders.
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