"Stick to the code"

Disney has probably made one "Pirates of the Caribbean" movie too many, but I sure did like the first one!  I was fortunate enough to go to Walt Disney World in Orlando, Florida several times when I was growing up (I had one aunt who lived in Orlando - still does - for most of my childhood, and another aunt who lived there for a little while).  My wife and I lived in Southern California for a few years during my residency training, so we took our family to Disneyland a couple of times as well.  The "Pirates of the Caribbean" ride was my favorite ride - still is as a matter of fact.  One of my favorite lines in the movie was the advice that Captain Jack Sparrow always gave his men whenever they weren't sure what exactly they should do - "Stick to the code."  There is even a scene in one of the later movies (I forget which one) where Keith Richards (from the Rolling Stones) makes a cameo appearance.  Richards' character shoots one of the other pirates who refused to live by the code.  Unfortunately, the "Pirate's Code" is not a very honorable one ("Any man who falls behind, gets left behind") - they are, after all, pirates.

My point here is that even pirates, scallywags, rapscallions, buccaneers, raiders, privateers, and picaroons live by a code.  A code is like a vision statement.  It answers the simple questions of "what do you stand for?" or "how do you want to live?"  We all have "codes" of one form or another.  Physicians have the Hippocratic Oath or even the American Medical Association's Code of Ethics.  I have talked about my involvement with the Boy Scouts in the past and have mentioned the Boy Scout Oath.  The American Nursing Association also has a "Code of Ethics".  In fact, just about every organization will have some form of "Code of Ethics" or at least a mission, vision, and core values statement.  These are all codes. 

I have also talked in the past about having a personal mission, vision, and values statement - a personal code, if you will.  Explicitly stating your mission, vision, and values helps provide a framework for how you work, how you act in your life, and what things matter to you.  Having a personal code (maybe even a "code of ethics") will help you address some of life's toughest challenges, and you will do so without compromising your own personal values.  Living by a code is important - being a leader who lives by a certain set of rules and obligations is important. 

So, the next time you are facing a particularly challenging set of circumstances, always remember what Captain Jack Sparrow says to his crew - "Stick to the code."

The seven deadly sins of leadership

The seven deadly sins (also know as the seven cardinal sins) of Christian theology are pride, greed, lust, envy, gluttony, wrath, and sloth.  I have noticed a number of Internet articles and blog posts listing different reasons and/or characteristics that cause leaders to fail at their job.  While I certainly do not claim originality, here are my "seven deadly sins of leadership" in no particular order:


1.  Duplicity

Duplicity is a great word - it covers hypocrisy, deceit, and fraud.  Leaders should never say one thing in a public forum ("We are going to give everyone raises this year!") and then state the completely opposite thing in private ("There is no way we are going to be able to give everyone a raise this year!").  Say what you mean, and mean what you say.  Leaders engender trust and respect by telling the truth.  Don't lie.  Tell the truth.  More importantly, don't "stretch" the truth by providing incomplete facts - that is just as bad as telling a lie.  Leaders should not accept credit for a successful project that someone else (especially someone on their team) completed.  Leaders should give the credit to their team and accept the blame for when their team fails. 


2.  Otiosity

Otiosity is a great word that essentially means laziness (recall that "sloth" is one of the original seven deadly sins of Christian theology).  Some of the best advice that I have heard - "don't ask someone to do something that you are not willing to do yourself."  Leaders should work just as hard, if not harder, than the rest of the individuals on their team.  Lead by example.  Work hard.  Do not take the easy way, just because it is the easy way.   


3.  Torpidity

Leaders should be enthusiastic.  Leaders should believe in themselves and in their organizations.  Nothing kills progress more than an apathetic leader. 

4.  Truancy

Leaders should be present and in the moment.  There is a commonly used phrase that applies here known as "management by walking around."  Leaders should not spend all of their time in the executive office suite.  Leaders need to "be around" and interacting with the front line employees in the organization.

5.  Melancholy

There is no place for gloominess, pessimism, and negativity in leadership.  Leaders should be optimistic for the future (if they don't think that the organization can succeed, then how can they lead the organization - more importantly why?).  Be positive.  Be optimistic.  Trust that your team will succeed.

6.  Hesitancy

Leaders should not hesitate or be reluctant to make decisions, even risky ones.  As the old saying goes, "He who hesitates is lost."  Indecisiveness leads to lack of confidence, and lack of confidence leads to lack of trust.  Leaders have to be able to make decisions.  "Paralysis by analysis" is not the right approach.  "Extinct by instinct" (making a hasty decision completely based upon a gut reaction) is probably not the right approach either.  There is a balance to be found somewhere between these two opposite extremes.  There will never be time to make a decision with 100% of the facts in front of you - make a decision with the best available evidence and move forward.

7.  Impetuosity

Leaders should not make rash decisions either (see the above comment on "extinct by instinct").  Leaders do not act upon emotions or impulse.  The good leaders remain calm, take account of the situation, carefully weigh options, and act.

"Keep your heads up"

Wow, there is nothing like a string of challenges and disappointments to test your resolve.  We all face our share of disappointments and challenges.  The important thing is that we keep our chin up and continue to forge ahead.  There are going to be days when it seems that nothing goes right and everything goes wrong.  The important thing is that we stay in the game.  That is the true test of leadership.

Everyone knows, or should know, that I am a die-hard Cubs fan.  Those of us who follow the "Lovable Losers" have had our share of disappointments - they are too numerous to catalog here.  However, our long string of disappointment finally ended last year, when the Cubs fought back from a 3 games to 1 deficit to win the World Series for the first time in 108 years.  Theo Epstein, President of Baseball Operations for the Cubs gave a speech (it's not really a commencement address, but he delivered it at an event called "Class Day" at Yale University).  It really is a good speech, even if you are not a Cubs fan. 

For those of you who don't follow baseball or remember the game, the Cubs seemed to take a commanding lead over the Cleveland Indians in the pivotal game 7 of the best of seven World Series.  Then everything fell apart.  The Indians tied the game, and the game went into extra innings.  A perfect storybook ending - for the Cleveland Indians!  The rain started falling, and the game went into a rain delay.  Theo Epstein talks about how he went back to the locker room and saw that the players were having their own meeting.  The players were all trying to cheer up the pitcher who gave up the lead, Aroldis Chapman.  What is important to know is that Chapman had started the year playing for the Yankees - he didn't join the Cubs (and therefore was not part of the team from the beginning) until the second half of the season.  But the Cubs players embraced him anyway.  They told him that "we wouldn't be here if it wasn't for you." 

And then Jason Heyward spoke.  Jason Heyward was a superstar having a sub-par year.  Theo Epstein talks about Heyward in particular - he says that Heyward could have just put his head down and attended to his own personal business, trying to struggle through his poor statistical year.  Instead, he emerged as a team leader and "rallied the team" in one of its darkest moments.  True leaders emerge in some of the most difficult times.  True leaders are resilient.

The rain delay ended, and the Cubs won the game and the Series.  It was a great moment for me, and it was a great moment for Cubs fans everywhere.  I will remember that game for the rest of my life.  But the lessons from that game hold an even deeper meaning for me personally - when times are tough, when things are not going right, the true leaders are the ones that emerge.  As Epstein closed his speech, "And finally, when things go really, really wrong - and when it rains on top of everything else - I ask you to choose to keep your heads up and come together, to connect, and to rally around one another, especially those who need it the most."  Keep your heads up.  Be resilient.  Be like Young.

 

Leadership Aphorisms I

After all of the events from last week, I decided to keep it light-hearted today.  The Merriam-Webster online dictionary defines "aphorism" as "a concise statement of principle" or "a terse formulation of a truth or sentiment."  With that definition in mind, I would like to record some of my favorite leadership aphorisms that I have learned over the years.  These aphorisms aren't listed in any particular order of importance, but they all in some way have very deep and personal meaning to me personally. 

1.  "Be Prepared." 

Some of my fondest memories growing up as a young boy came from my involvement with the Boy Scouts of America.  I realize that there has been a lot of controversy surrounding this organization lately, but I still do believe that the fundamental precepts of the organization remain sound.  I still remember the Boy Scout Oath, the Boy Scout Law, the Boy Scout Slogan, and the Boy Scout Motto, even though I haven't been involved in scouting for over 30 years (see here).  The Boy Scout motto is "Be Prepared."  Simple.  Elegant.  Clear and concise.  As Eisenhower once said, "Plans are useless, but planning is indispensable."  Never be caught off guard.  Make sure that your team and organization are well-equipped, well-trained, and well-prepared for whatever contingency that they may face. 

2.  "The biggest room in the world is the room for improvement."

Michael Fisher, the President and CEO of Cincinnati Children's Hospital Medical Center likes to share this saying that he learned from his grandfather. "Continuous improvement" is a buzz word that we hear a lot in health care these days, but the concept is a really good one.  Health care organizations, leaders, and individuals all share one thing in common - they can always do things better.  Don't be satisfied with "the way we've always done things around here" - always look for opportunities to improve.  I guarantee you that even the most well run organizations have things that they can always do better. 

3.  "We work for a democracy, not in one."

Residency training can be a frustrating time - it can also be one of the best experiences that you will ever have as a physician.  My residency training was no different.  I completed my pediatrics residency training while on active duty as an officer in the United States Navy.  I learned a lot about pediatrics, leadership, and service during my three years of training.  I also learned a lot about myself.  I have always remembered a lesson I learned (the hard way) while a pediatrics resident.  One of my attendings, who happened to be the Department Chair at the time told me after a particularly frustrating series of events - "Derek, you will do well to remember that we work for a democracy, not in one."  In other words, what is best for the Naval Medical Center San Diego may not necessarily be what is best for LT Derek S. Wheeler (at the time)!  This particular lesson has stuck with me.  As a physician and a health care administrator, patients come first, then the organization, then me.  At times, the interests of the patient, the organization, and me don't necessarily align.  If that is ever the case, the patient comes first, then the organization, then me.

4.  "Do your best."

When I said that I was a Boy Scout, I meant that I went all the way.  I started out as a Cub Scout (there was no such thing as "Tiger Cubs" when I was young), earning my Bobcat, Wolf, and Bear badge.  As a Webelo, I earned both the Webelo badge and the Arrow of Light.  I became a Boy Scout when I turned 11 years old and went all the way through to earn my Eagle Scout award.  The Cub Scout motto is "Do your best."  I think that is fairly self-explanatory - always, always, always, give it your best effort, no matter what the occasion.  It doesn't matter whether you are tired or bored, give it your all.  As the saying goes, "Anything that is worth doing is worth doing well."

5.  "Never ask someone to do something that you are not willing to do yourself."

 I realize that he wasn't the first to say it (it is actually a fairly well known phrase), but I learned this aphorism from my one of my mentors.  Never ask someone, especially someone who reports to you, to do something that you would not do yourself.  I believe this aphorism is about respect.  If you respect someone, you would never ask them to do more than what you would do.  "Leaders lead."  "You can't lead from behind."  "Leaders should be visible."  They all relate to this same aphorism, and it is an important one.

I hope to share many more aphorisms in the future.  If you have some personal favorites, please feel free to share as well!

A life of privilege - part III

A group of physician-scientists from the Mayo Clinic recently published a rather thought-provoking study, that I believe is relevant to my last two blog posts.  The group reviewed the video recordings of the Department of Internal Medicine's Grand Rounds at both the Arizona and Minnesota campuses.  For those of you who are not familiar with academic medicine, speaking at Grand Rounds is quite an honor.  Most academic departments hold Grand Rounds on a weekly basis.  Speakers from around the country are invited to speak on their particular area of expertise.  Even the most well-established physician-scientists only receive 1-2 invitations to give Grand Rounds on an annual basis, so it is one of those unique privileges that indicates that "you have hit the big time."  What the group found surprised me, at least at first.  They reviewed 321 speaker introductions (in most cases, someone from the speaker's specialty gives the introduction, reviewing the speaker's academic credentials and curriculum vitae) over a 2-year period.  Male introducers used professional titles for female physicians only 49% of the time (i.e., rather than introducing the female physician as "Dr. Jane Doe", the individual would introduce the female as "Jane Doe").  Male physicians were introduced by professional title 72% of the time.  Conversely, female introducers used professional titles in the vast majority of cases (96% of all introductions, regardless whether the speaker was male or female versus 66% of all introductions for male introducers). 

So, what's the big deal?  Actually, it is a really a big deal.  It would be one thing if we all just dropped the formalities and introduced physicians by their first and last names all the time - but we don't.  Using the professional title, "Doctor" is still a sign of respect.  By introducing female physicians by their first and last names only, we are subconsciously saying that we do not respect them as much as we do male physicians.  We marginalize female physician's professional contributions and status when we treat them differently.  Like it or not, there is a discrimination bias in academic medicine (whether intentional or not, it doesn't matter).  Female physicians are less likely to hold more senior academic rank (Professor versus Associate Professor and Assistant Professor) and are generally paid less compared to their male colleagues.  It's just not right.  We need to do better.

After reading this particular study, I actually thought to myself, "Have I ever introduced a female physician for the first time by her first and last name, rather than using the term "Doctor"?  I apologize profusely if I have ever done that in my career.  I asked one of my female colleagues what she thought of the study and whether she had ever heard me introduce female physicians differently than male physicians.  She thought about it briefly, and told me, "I think I have even done that."  She told me how she usually calls male surgeons by their last name (e.g., "We should ask Walker if he is going to take our patient to the OR today...") and female surgeons by their first name (e.g., "We should ask Molly if she is going to take our patient to the OR today...").  Subconscious biases seem to affect us all.

It seems so simple to fix this particular issue, but I know that it is more complicated than that.  Subconscious biases seem to affect us all.  We may treat female physicians differently and not even know that we are doing it - but that does not excuse the behavior.  Since reading this study, I have been very explicit whenever I introduce a female physician (think to myself, "Doctor, Doctor, Doctor").  When we speak about physicians (in general), we need to be careful to use gender neutral language (use the pronoun "her" more than you use the pronoun "him" as an example).  The journal, "Annals of Surgery" recently retracted the publication of the presidential address of the European Surgical Association because the author (in this case, the incoming president of the association) exclusively used pronouns such as "he" and "him."  These biases don't just impact physicians - we need to be more explicit about using gender neutral language when we talk about nurses (historically, a profession dominated by females). 

Prejudice.  Bias.  Even overt racism.  The solution has to start with simple things.  The solution has to start with us.  We need to do better.  We can do better.  And we will do better.

A life of privilege - part II

As most of you have probably guessed, I am a big fan of the HBO mini-series "Band of Brothers."  I am currently reading the book by the historian Stephen Ambrose on which the series was based.  The book and mini-series tells the story of Easy Company (E company, 506th Regiment, 101st Airborne Division) from boot camp all the way through the end of World War II. 


The men of Easy Company parachuted into Normandy on D-Day. There is a passage in the book that seems relevant to the ongoing discussions in our country today.  In this case, the passage talks about a letter that First Lieutenant Thomas Meehan (the commanding officer of Easy Company) wrote his wife Anne a few days before D-Day (May 26, 1944 to be exact - recall that D-Day was on June 6, 1944):


"We're fortunate in being Americans.  At least we don't step on the underdog.  I wonder if that's because there are no 'Americans' - only a stew of immigrants - or if it's because the earth from which we exist has been so kind to us and our forefathers..."


He goes on to write:


"And for each of us who wants to live in happiness and give happiness, there's another different sort of person wanting to take it away... We know how to win wars.  We must learn now to win peace...If I have a son, I don't want him to go through this again, but I want him powerful enough that no one will be fool enough to touch him.  He and America should be strong as hell and kind as Christ."


Lt. Meehan never made it to Normandy.  His plane and all of the paratroopers it carried was hit by anti-aircraft fire and crashed into the countryside.  There were no survivors.  But the points that he made in one of the last letters he wrote to his wife are poignant and provide lessons for us, even today.


1.  With the notable exception of the Native Americans, all of us are descended from individuals who weren't born here originally.  We are all immigrants, in a manner of speaking.  The anti-immigration sentiments we here today have no place in America.


2.  Our diversity is what has made us strong.  America has been called "the melting pot" - we are a blend of different racial and ethnic groups, gender, sexual orientation, and religious beliefs.  That is what makes us so special.  That is what makes us American.


3.  What defines us as Americans is that we stand up for what's right.  We stand up for the oppressed.  We stand up for those who can't.  We have gone to war - our citizens, from all walks of life and background, have been willing to give their lives for those who can't stand up for themselves.  That has been what we have always done, that's what makes us Americans, and that's what we will continue to do in the days, weeks, months, and years to come.

A life of privilege - part I

I have never been on the wrong side of discrimination.  I have lived a life of relative privilege.  Don't get me wrong, I have worked very hard in my life to get where I am today.  However, I had a great start in life.  Both my parents and my sister were there to support me every step of the way.  Both my parents had steady jobs, and we ate together as a family almost every night.  I went to school in one of the finest public school systems in the city of Indianapolis where my teachers and coaches challenged me to think and to always take the next step to reach my highest potential.  While I may not have worn the latest in fashion, I had new clothes to wear at the beginning of every school year.  I went to a great public college, where the only thing that I really had to worry about was to study hard, have fun (though not too much fun), and challenge myself.  I am a product of my environment.  I have been one of the lucky ones.  Thankfully, my wife and I have been fortunate to be able to provide even better lives for our four children than we experienced.  So, yes, I have lived a life of privilege, and I have taken advantage of the things I have received in order to hopefully give back to society and serve the greater good.

Unfortunately, not everyone has had the same advantages that I have been fortunate to have received.  The world we live in is not always fair.  But I would like to think that we are doing what we can to level the playing field, so that everyone has a chance at the American dream.  That is why I have always believed in America.  That is why I am proud to be an American.

What happened in Charlottesville, Virginia this past weekend is not my America.  The individuals who carried torches, shields, and Nazi and Confederate flags are not my America.  White nationalists are white supremacists.  They are not my America.

While I would like to believe that no one is defined by the color of their skin, I am not naïve enough to discount that I, as a white man, have enjoyed distinct advantages over men and women of color.  I am not naïve enough to discount that I have enjoyed distinct advantages over white women.  And because of Charlottesville, while I am proud to be an American, I am ashamed to be a white man.

Bigotry and discrimination has no place in my America.  Race, ethnicity, gender, sexual orientation, religion - it doesn't matter.  We are all equal in my America.  There was a time when I thought that we had come so far as a country.  But the events of the past weekend have shown us all that we have not come nearly far enough.

I remember visiting the Holocaust Memorial on Boston's Freedom Trail this past summer.  There is a poem inscribed on one of the monuments there, that I believe is also inscribed on the U.S. Holocaust Museum in Washington, D.C.  The poem is called, "First they came..." and was written by a German Lutheran pastor who had initially supported Adolph Hitler's rise to power in Nazi Germany.  Martin Niemoller eventually spoke out against Hitler and was subsequently arrested and placed in a concentration camp.  He was later liberated by the Allied Forces in 1945.  The poem is one of my favorites, and I think it summarizes what many of us are feeling right now:

"First they came for the Socialists,
and I did not speak out -
Because I was not a Socialist.

Then they came for the Trade Unionists, and I did not speak out -
Because I was not a Trade Unionist.

Then they came for the Jews, and I did not speak out -
Because I was not a Jew.

Then they came for me - and there was no one left to speak for me."

Let the events of this past weekend serve as a reminder - we are all Americans.  It doesn't matter whether you are white, black, brown, yellow, or red.  It doesn't matter whether you are gay or straight.  It doesn't matter whether you are male, female, or transgender.  It doesn't matter whether you are Catholic, Jewish, Protestant, Hindu, Buddhist, or Muslim.  It doesn't matter whether you first learned to speak English or another language.  It doesn't matter whether you were born here or whether you moved here later.  We are all Americans.  That is what this country stands for - and we need to stand up.  Or some day there will be no one left to stand up for us.

"Small changes can lead to big impacts"

The ancient Chinese philosopher, Lao Tzu, once said about change, "If you do not change direction, you may end up where you are heading."  I like that a lot.  I've written a number of posts in the past on the concept of change.  Change is hard.  Change is constant.  No one likes change.  In reality, though, if you really think about it, change is not all that hard. 

I recently finished a really good book called "Resilience: Hard-Won Wisdom for Leading a Better Life"  by former Navy SEAL and Rhodes scholar, Eric Greitens, who is now the governor of the state of Missouri.  The book is actually a series of letters that Greitens wrote to a former fellow Navy SEAL named Zach Walker (a pseudo-name) who was experiencing difficulties adjusting to life outside of the military.  One of the analogies that Greitens uses in the book is a story from one of the courses that they had to take during "Land Navigation" training.  "Land navigation" provides basic and advanced instruction in how to use a compass, a map, and terrain recognition to be able to know where you are, where you are going, and how best to get there.  Greitens told his friend, Zach, that if you take a compass bearing and travel in one direction a certain distance, you will end up in a specific point.  Change the compass bearing by just one degree (remember that there are 360 degrees on a compass dial) and you end up some place completely different.  In other words, if you don't like where you are heading, you will end up in a completely different place by making just a very small change in your direction.  Just one degree makes a huge difference! 

It's a nice analogy.  Small, even seemingly trivial changes, can lead to big impacts.  Do you believe me?  Well, there is actually a tragic story that proves my point (sort of).  Back in the late 1970's, there was a regularly scheduled sightseeing trip run by the airline, Air New Zealand that would leave Auckland, New Zealand in the morning and fly over the continent of Antarctica before heading back to New Zealand.  On November 28, 1979, Air New Zealand Flight 901 took off from Auckland on the fourteenth sightseeing flight over Antarctica.  Unbeknownst to the flight crew, someone (it may actually have been one of the pilots) had made a course correction in the flight computer that resulted in a two degree change in course in the flight plan.  The two degree course change would place the flight 28 miles east of where they thought they would end - instead of passing over McMurdo Sound, the DC-10 flew directly into the side of Mount Erebus, a 12,500 ft volcano on Ross Island, killing everyone on board (237 passengers and 20 crew members).  A seemingly small error of 2 degrees resulted in a 28 mile course correction, leading to the death of 257 individuals. 

The lesson here - it doesn't take much of a change in the direction you are heading to make a significant change in where you end up going.  As Eric Greitens told his friend, Zach Walker, if you want to change, start by making a small, seemingly trivial change in your approach.  It's really good advice when you think of it.  Small changes can lead to big impacts. 

"...plans are useless, but planning is indispensable"

General Dwight D. Eisenhower once stated, "In preparing for battle I have always found that plans are useless, but planning is indispensable."  Eisenhower certainly knew what he was talking about - he is credited (rightfully) with masterminding Operation Overlord, better known as the invasion of Normandy, France on D-Day (June 6, 1944).  No one but a brilliant strategist and tactician with superb organizational and managerial skills could have possibly orchestrated and supervised combat operations that began with an airborne invasion involving over 1,200 paratroopers, followed by a multi-national amphibious assault involving over 5,000 ships and boats and nearly 160,000 soldiers from the United States, Great Britain, Canada, Australia, Poland, France, and other forces from the Allied nations of World War II.  The invasion of Normandy set off a chain of events that led to the eventual defeat of Hitler's Nazi Germany and the end of the war in Europe.  I highly recommend the historian Stephen Ambrose's two books, D-Day and Band of Brothers (Tom Hanks and Steven Spielberg produced a HBO mini-series based upon "Band of Brothers" - one of my all-time favorites!).

So what exactly did Eisenhower mean?  Did he think that plans were useless?  Absolutely not.  Eisenhower simply meant that if you relied solely on the "plan" (whatever the "plan" involved), you would ultimately fail (for a light-hearted look at this concept, see this movie clip from "Pooh's Grand Adventure: The Search for Christopher Robin" in which Rabbit relies way too much on his map).  Conditions change.  Assumptions prove to be wrong.  In short, by the time that you are ready to execute your "plan", things have changed to the point where you will likely have to change your plans.  In combat, this is known as the "fog of war".    In a sense, Eisenhower is arguing for the high-reliability principle of "deference to expertise".  In essence, decision-making should be pushed down as close to the so-called "sharp end" as possible - front-line leaders and managers are best-positioned to have real-time situation awareness and knowledge of the rapidly changing dynamics of any situation and are therefore in the best position to make the best possible decisions.  I have talked about this before in a previous post, but in the military, "deference to expertise" is also known as "commander's intent" and, in the German army during World War II as "auftragstaktik".

There is more here though.  Eisenhower ALSO said that "planning is indispensable."  In other words, relying solely on plans leads to failure, but failure to plan also leads to failure.  Benjamin Franklin may have said it best, "By failing to prepare, you are preparing to fail."  Planning for Operation Overload took place over the span of about 13 months (the decision was made to invade France in May, 1943).  Troops were drilled over and over and over again.  The landing boats practiced amphibious landings over and over and over again.  There was even an elaborate decoy led by General George Patton at an alternative landing location (fake tanks, ships, and planes were massed across the English Channel from France).  Planning was not only "indispensable" - it led to the Allied victory.

The lessons here are two-fold:  Don't rely 100% on your plan.  Don't rely on dumb luck.  There are certainly going to be rare occasions in which individuals don't plan ahead and just get lucky.  My favorite example here is an anecdote that Karl Weick (a leading organizational science authority and one of the early researchers on high-reliability organizations) has shared on a number of occasions.  The story is probably not true, but it is instead based upon a poem called "Brief Thoughts on Maps" written in 1977 by the poet, Miroslav Holub:

The young lieutenant of a small Hungarian detachment in the Alps
sent a reconnaissance unit out onto the icy wasteland.
It began to snow
immediately,
snowed for two days and the unit
did not return.
The lieutenant suffered:
he had dispatched
his own people to death.

But the third day the unit came back.
Where had they been? How had they made their way?
Yes, they said, we considered ourselves
lost and waited for the end.  And then one of us
found a map in his pocket.  That calmed us down.
We pitched camp, lasted out the snowstorm and then with the map
we discovered our bearings.
And here we are.

The lieutenant borrowed this remarkable map
and had a good look at it.  It was not a map of the Alps
but of the Pyrenees.

Don't rely on the "map" (or "plan"), especially if it's the wrong one.  But regardless, plan ahead.

"The Medical Waiting Game"

The medical anthropologist, physician, and humanitarian, Paul Farmer once wrote, "I mean, everybody should have access to medical care.  And you know, it shouldn't be a big deal."  Access to medical care is so important to delivering (and receiving) quality medical care.  Drs. Jaewon Ryu and Thomas Lee recently wrote an editorial in the New England Journal of Medicine ("The Waiting Game - Why Providers May Fail to Reduce Wait Times") that focused on the need to improve access to medical care - in this case, the "waiting game" referred to the time it takes to schedule an appointment and be seen by a physician, not the amount of time that you spend waiting to see the physician at the office in his or her waiting room (I briefly talked about this other issue in a blog post from 2016, "Sometimes, sorry is the best thing to say", which happens to be my most viewed blog post). 

Imagine that you, as a patient, have been told that you may have a serious diagnosis (e.g. cancer, heart disease, asthma, or another chronic illness).  Now, how would you feel if you were told to call and schedule an appointment with the specialist, and the specialist is unable to see you for a couple of weeks?  Now, imagine that you have been waiting for a couple of weeks to see the specialist, you showed up for your appointment on time, and now you are waiting well past your appointment's scheduled time before you actually see the specialist.  Finally, now imagine that the specialist spends only a few minutes with you, answers some of your questions, but then asks to see you back in a couple of months.  How does all of this make you feel?  Unfortunately, this sort of thing happens in the U.S. health care system just about every day.  And it is not always the provider's fault - some times it is just the inefficiencies that are inherent in our complex health delivery system.

As Drs. Ryu and Lee emphasize, long waits before appointments (in other words, poor access to care) result in missed appointments (patients are much more likely to not show up for their scheduled appointment).  Long waits before appointments are also associated with a greater risk of developing complications, which in the end result in worse outcomes at a much higher cost.  Finally, long waits before appointments often encourage patients to seek medical care in the costlier emergency department setting.  Improving access to care results in better outcomes, lower costs, and more satisfied patients (the so-called "triple aim"). 

We live in an age where people are not used to waiting.  If you want to purchase something online, you can order it with the simple click of a mouse and have it delivered the next day (Amazon is even starting to explore same day delivery in several markets).  If you have a question about something, all you have to do is search the Internet on your smart phone and the answer is right there.  We have grown accustomed to instant access, all the time.  It is no wonder, then, that patients are starting to demand better access to medical care.  Some institutions (the Cleveland Clinic, IU Health, and UCLA Health are some quick examples, but there are many others) have started offering "Same Day Appointments" to improve the quality of care, lower costs, and improve the patient experience.  If you want a good reason why so-called "Retail Clinics" have been so successful (some would even call them a disruptive innovation), look no further than access - having same-day access to a location that conveniently located on your way home from work or school at all hours of the day is really unbeatable.

Last week, I had my annual exam with my Dermatologist (I am paying for the sins of my youth - I was a lifeguard all through high school and college).  My appointment was scheduled for 6:15.  In the morning!  I showed up at 6:00 AM, I went back to the exam room at 6:10, and my dermatologist entered the room at 6:15.  I was done in 15 minutes and on my way out the door by 6:30 AM.  I made it to work about 30 minutes later than I usually do.  THAT is what I call access! 

We need to get over the concept that having long access times is a badge of honor ("I am so important, patients will wait months to see me!").  We have to improve the access to both primary care and subspecialty physicians and providers - our patients are going to demand it.  More importantly, they deserve it.

Gratitude

Earlier this week, I posted about gratitude ("Real leaders say 'thank you' a lot...").  The more gratitude that leaders show (saying "thanks" for a job well done), the happier leaders will feel, and the happier that the leaders feel, the more likely they are to do nice things for their teams, such as showing gratitude.  Gratitude sets up a virtuous cycle that feeds upon itself.  Leaders that show gratitude will be more optimistic and more self-confident.  Leaders that show gratitude will have less anxiety and stress, even during difficult times.  Gratitude is an amazing virtue - the Roman philosopher Cicero said it best, ""Gratitude is not only the greatest of virtues, but the parent of all others" (recall the four cardinal virtues of antiquity - prudence, courage, temperance, and justice).

What is even more impressive, managers who show gratitude by providing specific, timely, positive feedback will actually be seen as more effective leaders by their teams.  Jack Zenger and Joseph Folkman conducted a study involving 328 managers and their direct reports (published on the "Harvard Business Review" blog "Why Do So Many Managers Avoid Giving Praise?").  An average of 13 direct reports were surveyed for each manager.  Managers who gave positive feedback more often were more likely to be rated as effective in giving honest, helpful feedback.  Interestingly enough, these same managers felt that they were more effective at providing honest, helpful feedback when they gave negative feedback!  In other words, the managers have it all wrong!  Leaders should be giving positive feedback, praise, and encouragement much more often than they give negative feedback and criticism. 

I once heard something known as the 5:1 rule ("The Ideal Praise-to-Criticism Ratio") - top-performing teams have leaders that provide positive feedback and praise five times as often as they provide negative feedback.  As it turns out, the 5:1 rule even predicts successful marriages.  John Gottman's research showed that couples that provide positive comments five times as often as negative comments are much more likely to have long-lasting marriages (the ratio is about 0.77 to 1 in couples that end up divorced).  Another study showed that John Wooden, arguably the greatest basketball coach of all time, used positive reinforcement 87% of the time (in other words, pretty darn close to the 5:1 rule).  By giving positive feedback and praise, leaders are providing the psychological safety and building the kind of loyalty and trust that will allow them to be much more successful when they have to provide negative feedback.  In other words, if you give positive feedback the majority of the time, your team will really pay attention and take seriously when you have to provide some negative feedback (as all leaders and managers will eventually have to do). 

How do you provide positive feedback?  What sort of gratitude is appropriate?  Most experts will suggest that the feedback and praise should occur as soon as possible after the deserving incident or job.  Ideally, the praise should be made in public - staff meetings are a great time to recognize team members who are doing a good job.  Most importantly, the praise should be specific rather than just simply saying, "Thank you" or "Good job" (for example, "Derek, I really liked the way that you completed that last project on time.  More importantly, you did a really great job spreading the new central line maintenance bundle to the rest of the hospital, and I think that is going to make a huge difference in lowering our central line infection rates.")

Gratitude is easy.  Gratitude makes you happy.  Gratitude is fun.  And gratitude is a great example of leadership.