"Hit the showers - and make it a cold one!"

One of the most important jobs for any leader is to take care of the individuals on his or her team, and that happens with the leader first taking care of him- or herself.  Please do not misunderstand me - I am not talking about "taking care of oneself" in terms of making sure that you, as a leader, get proper credit or recognition for doing a good job or making sure that you get paid fairly.  I am talking about "taking care of oneself" from a health standpoint - getting enough sleep at night, exercising regularly, and eating a balanced, nutritious diet.  All of these things are critically important for all leaders, as well as the individuals on their teams.


The ancient Stoics used to practice self-denial or voluntary discomfort in order to "quiet their appetites for material goods" and help them better appreciate all of the things that they had in their life.  They weren't masochists - they did not prescribe self-mutilation or self-torture at all.  Rather, the ancient Stoics would run barefoot, take cold baths, or fast.  All of these things made the Stoics, or so they believed, stronger and better prepared to handle anything that happened in their lives.  Here we have the ancient version of "What doesn't kill you, makes you stronger."  Although, to be fair, the things that the ancient Stoics did to practice self-denial or voluntary discomfort were fairly mild and would never increase the risk of death.  Epictetus, in his "Discourses" wrote, "But neither a bull nor a noble-spirited man comes to be what he is all at once; he must undertake hard winter training, and prepare himself, and not propel himself rashly into what is not appropriate to him."


As it turns out, doing things like taking a cold shower actually makes some sense.  Most modern Stoics suggest that taking a cold shower will improve self-awareness, self-control, and health.  There is even some evidence, based on at least one randomized, controlled clinical trial, that taking a cold shower every day will improve overall health.  Investigators from the Netherlands randomly assigned over 3,000 participants, all previously healthy, to one of three experimental groups or one control group.  The individuals who were assigned to the experimental groups would add 30 seconds, 60 seconds, or 90 seconds, respectively, of a cold shower (the coldest setting on the shower faucet, which happened to be around 10-12 degrees Celsius) to their normal shower routine every day for a prescribed period of 30 days.  At the end of the 30 days, these individuals were then free to do whatever they wanted to (from a showering standpoint) for the next 90 days (i.e., they could take a cold shower for as little or as long as they wanted to).  Individuals assigned to the control group just took regular showers for the entire study.  Compliance with the shower protocol was self-monitored and self-reported (the individuals were "on their own honor" so to speak), though nearly 80% of the individuals complied with the protocol for the full 30 days and 64% actually continued for the next 90 days of the study.  At the end of the study, the investigators compared the number of days of lost work due to illness and found that taking a cold shower (regardless of duration) decreased the number of days of lost work due to illness by 29%!  The most commonly reported benefit to taking a cold shower was an increase in perceived energy levels (many of the individuals compared taking a cold shower to drinking a hot cup of coffee).  Unfortunately, the treatment effect did not last after the end of the 30 days.  Interestingly, 13% of the study participants reported problems with a persistent cold sensation in the hands and feet.


So, after reading this study, I decided to start taking a cold shower for 30 seconds at the end of my normal morning shower.  It's only been two days so far, but I can tell you that I absolutely feel great!  It probably helps that the temperature outside the past few days have been well in the 90's (the Dutch study actually occurred during the middle of winter!).  Regardless of the health benefits (or lack thereof), I can certainly appreciate why the Stoics, both ancient and modern, believed in the power of a cold shower.  Try it!

"Decoration Day"

Today is Memorial Day, which was once known as Decoration Day.  In honor of those who have died in service to their country, the American poet Henry Wadsworth Longfellow wrote a poem he called "Decoration Day", which I have copied below:

Sleep, comrades, sleep and rest

On this Field of the Grounded Arms,

Where foes no more molest,

Nor sentry's shot alarms!

 

Ye have slept on the ground before,

And started to your feet

At the cannon's sudden roar,

Or the drum's redoubling beat.

 

But in this camp of Death

No sound your slumber breaks;

Here is no fevered breath,

No wound that bleeds and aches.

 

All is repose and peace,

Untrampled lies the sod;

The shouts of battle cease,

It is the Truce of God!

 

Rest, comrades, rest and sleep!

The thoughts of men shall be

As sentinels to keep

Your rest from danger free.

 

Your silent tents of green

We deck with fragrant flowers

Yours has the suffering been,

The memory shall be ours.

 

 

"Lest we forget."

It's Memorial Day weekend, so I am taking a brief break from my usual Sunday evening blog post.  Instead of a new topic, I would like to leave you with one of my favorite poems, one that I learned a very long time ago.  It is called, "In Flanders Fields" and was written by a Lt. Colonel John McCrae during World War I.   Lt. Colonel McCrae was a physician in the Canadian Army and wrote the poem for the funeral of a friend and fellow soldier, Lieutenant Alexis Helmer, who died in May, 1915 in the Second Battle of Ypres.  One of the poem's lines, perhaps its most famous one, references red poppies, which has led to the practice of the remembrance poppy (my wife and I purchased one from a local high school group at Kroger's last night).  It is a great poem, and I will leave it here for you today, to honor all of those who have fallen in the service of their country:

In Flanders fields the poppies blow
Between the crosses, row on row,
That mark our place, and in the sky,
The larks, still bravely singing, fly,
Scarce heard amid the guns below.

We are the dead; short days ago
We lived, felt dawn, saw sunset glow,
Loved and were loved, and now we lie
In Flanders fields.

Take up our quarrel with the foe!
To you from failing hands we throw
The torch; be yours to hold it high!
If ye break faith with us who die
We shall not sleep, though poppies grow
In Flanders fields.

"We are all caregivers..."

There is a famous story that supposedly happened when President John F. Kennedy visited the National Aeronautics and Space Administration headquarters at Cape Canaveral, Florida (I have written about this story in a very early post, "Back to that Vision thing...NASA, cathedrals, and an automobile executive").  President Kennedy was walking around on a tour and introduced himself to a janitor that was mopping the floor.  The President asked the janitor what he did at NASA, and the janitor replied, "Mr. President, I am helping put a man on the moon!"


I've been thinking a lot about this story the past few days.  Academic medical centers are facing a lot of challenges.  Recall that most academic medical centers have a three-fold mission - clinical care (frequently both highly specialized, technology-dependent, and expensive clinical care for patients with complex or rare medical problems, as well as medical care for those with either no insurance or public insurance), education (teaching medical students, residents, and fellows), and research (both laboratory-based basic science research, as well as clinical research).  While the American health care system may not be idolized for its cost (we are the most expensive health care delivery system in the world), efficiency (there is a lot of waste in our system that adds to the often exorbitant costs associated with care delivery), or outcomes (we rank far below many other countries in disease-specific outcomes), our efforts at research and education have achieved far more success.  Unfortunately, we don't always work together in achieving our three-part mission.  Ask anyone who works at an academic medical center and they will tell you about the so-called "haves" and "have-nots" when it comes to certain disciplines and specialties.  They will also tell you, depending upon where they stand, that clinicians who provide care and generate the most revenue for the hospital are valued more than researchers, or that researchers that generate grant revenue are valued more than the clinicians.


When I think about all of these things, I can only wonder why we have to segment ourselves in this way?  In my mind, we are caregivers.  Clinical care, research, and education in an academic medical center is directed at one thing only - saving lives and improving outcomes.  I could also say that we are all researchers.  Some of my proudest moments as a physician have occurred when a colleague that I know and work closely with has been successful in coming up with some new discovery, getting a grant, or publishing a manuscript.  I know that the work I do as a clinician can help provide support so that he or she can have the necessary time to build a successful research program.  I am also proud of our medical students, residents, and fellows.  I have seen the future in their eyes, and I can honestly say that our future is bright.  I am proud that I have played a small role in their training and education, even if the majority of their training and education was provided by our educators.  In this light, we are all educators too.


It doesn't matter whether you are a physician, a nurse, or an allied health professional.  It doesn't matter if you are an administrator, a security guard, or even a janitor.  It doesn't matter whether you are a gifted clinician, researcher, or educator.  We are all here to make a difference in someone's life - either now or at some point in the future.  We are all caregivers.  We are all researchers.  And we are all educators.

"The Tyranny of Choice"

Have you ever found yourself in a restaurant wondering what to order?  I often have this problem.  Even after carefully reviewing the menu and finding a number of dishes that look really appetizing and good, I am still unable to decide.  The server comes back a few times and gives me his or her recommendation ("This is my absolute favorite dish on the menu!"), and I still can't make a selection.  I can usually narrow my selection down to two dishes, and invariably my wife will pick one and then I will pick the other.  As it so happens, if I have been to the restaurant before, I usually pick "an old standby" dish that I've had again and again.  The same thing happens when I pick a beer or wine - I usually go with what I have selected in the past.

I know what you are thinking, and you are wrong.  It's not that I have trouble making decisions.  Nor am I afraid to try new things.  I think it all comes down to something that has been called "the tyranny of choice."  The American psychologist, Barry Schwartz wrote an article in Scientific American ("The Tyranny of Choice", as well as a book called The Paradox of Choice.  There is also a TED talk of the same name, if you are interested in hearing from Schwartz directly.  The premise of the article, the book, and the TED talk is essentially this - the prevailing viewpoint in our modern society that the more choices that an individual has (i.e., more personal freedom), the happier he or she will be in life is a wrong one.  As multiple studies by a number of different investigators in a variety of context (in fact, almost every context examined, both in the laboratory setting and in field studies), the greater the number of choices, the lower the satisfaction and the greater the regret with the decision that is ultimately made.  In other words, having a greater number of choices in life actually makes us feel worse!

We often have a seemingly infinite number of choices in life.  Just walk down the grocery aisle and look at how many kinds of shampoo that you can buy or even how many different kinds of dog food your pet can enjoy!  Ice cream parlors have "31 Flavors" and fast-food chains tell us to "Have it Your Way!"  We even have a number of choices when we select our health insurance plans at work, and just think about how many dentists or physicians we can go see on these plans. 

Sheena Iyengar and Mark Lepper actually studied consumer choice in a field experiment performed in a grocery store ("When Choice is Demotivating: Can One Desire Too Much of a Good Thing?").  In the experiment, consumers were asked to select a gourmet jam from either a limited set of choices (only six choices of gourmet jam) or an expanded set of choices (up to 24-30 types of gourmet jam).  Consumers were more likely to buy the gourmet jam when they were given a limited number of choices AND they reported greater subsequent satisfaction after they made their selection when they have a limited number of choices.

The lesson here is this (quoting Schwartz from his TED talk) - "some choice is better than no choice, but it doesn't follow that more choice is better than some choice."  Why do I always choose the "old standby" at the restaurant?  There are just too many choices on the menu.  Rather than trying to choose from all of the menu choices, I end up selecting what I usually choose.

What's the leadership lesson here?  Giving your teams a choice, whenever possible, is a good thing.  "Some choice is better than no choice."  But be careful about the number of options that you provide, because "more choice is NOT better than some choice."

"Perseverance is not a long race; it is many short races one after the other."

I was searching on the Internet for a catchy quote that would go with today's blog post, and I happened to find this one by someone named Walter Elliot (who could be a number of individuals, including a Scottish politician, a Roman Catholic priest, the former Canadian Surgeon General, or a Scottish naturalist - the website did not specify).  Anyway, I think it fits for what I wanted to talk about today.

If you are familiar with ancient Greek philosophy, you have probably heard of an individual named Zeno of Elea and his set of nine paradoxes (there were likely several more, but only nine have survived through antiquity).  All nine surviving paradoxes came down to us through the writings of the ancient Greek philosopher, Aristotle.  Zeno described several paradoxes to support a doctrine reportedly first proposed by Parmenides (another ancient Greek philosopher who founded the Eleatic school of philosophy and who was the subject of Plato's dialogue, Parmenides) that essentially stated that motion is nothing but an illusion, so change is also an illusion.  Okay, I get it - this is probably more ancient Greek philosophy than you wanted to hear, but bear with me! 

Zeno's most famous paradoxes is frequently called "Achilles and the tortoise" (the so-called "dichotomy paradox" is very similar - so much, in fact, that Aristotle believed that they were one in the same).  Aristotle described the paradox simply as, "In a race, the quickest runner can never overtake the slowest, since the pursuer must first reach the point whence the pursued started, so that the slower must always hold a lead."  As the story goes, Zeno imagined that the Greek hero, Achilles was challenged to a footrace by a tortoise.  Achilles was a gracious and fair fellow, so he gave the tortoise a head start of 100 paces.  If both Achilles and the tortoise start at exactly the same time ("On your mark, get set, go!"), and if both Achilles and the tortoise run at constant speeds (Achilles being very fast and the tortoise being very slow), then after a finite period of time, Achilles will reach the point where the tortoise started (100 paces away).  Importantly, the tortoise will no longer be there!  He has moved, albeit slowly, to a new place, just a little farther away.  Now, it will take Achilles a finite period of time to cover the new distance that separates him from the tortoise, and he will eventually reach where the tortoise was after the race started.  Again, the tortoise will not be there, as he has moved to a new position, just a little farther away.  In this manner, whenever Achilles arrives at the point where the tortoise has been, he will still have some distance to go before he can reach the tortoise.

Kind of strange logic, right?  Well, here is how Aristotle described the "dichotomy paradox" (again, Aristotle claims that the "dichotomy paradox" and the "Achilles and the tortoise paradox" are basically saying the same thing).  Aristotle describes this paradox as, "That which is in locomotion must arrive at the half-way stage before it arrives at the goal."  In other words, if you are walking from point A to point B, you will cover a certain distance, say half the distance, in a certain amount of time.  If you cut the distance from your new location to point B in half yet again, you will be at a new point, which is still not at point B.  If you keep cutting the distance by a half, you will never, in fact, reach point B!

So what's my point?  We are always talking about goals in the health care industry.  There are a number of organizations that have proudly announced the laudable goal of eliminating all patient harm (for example, eliminating all central line infections or eliminating all pressure ulcers).  I once wrote an editorial about getting to zero harm ("Getting to 'zero' harm on central-line infections in the PICU") and basically described some of the elements of Zeno's paradox.  In the world of continuous improvement, can we ever really get to zero harm events?  Thinking about the two paradoxes described above (especially the "dichotomy paradox"), if our goal every year is to reduce, say the number of central line infections by 50%, we will never, in fact, get to zero (for example, if we have 100 central line infections per year and decrease that by 50%, we will now have 50 infections; if we reduce that by 50% the following year, we will have 25 infections, etc, etc).  Don't get me wrong - the goal to eliminate patient harm is clearly justified and appropriate.  However, in the editorial I questioned what we mean when we say that our goal is zero harm.  What exactly does zero mean?  Can we say that we have reached the goal of zero harm when we have no events for 1 month?  How about for 6 months?  1 year?  The problem is that we really can't define "zero harm" clearly, and we end up with something akin to Zeno's paradox.

W. Edwards Deming, one of the founding fathers of quality improvement, claimed that "zero defects" should never be the goal, stating "A goal that lies beyond the means of accomplishment will lead to discouragement, frustration, and demoralization."  Motorola's "six sigma" standard is not zero defects, but rather 3.4 defects per million chances (which admittedly is pretty close to zero).  Both Deming and Motorola were talking about manufacturing defects and not patient harm, but I do think there is something here for us to learn nonetheless. 

Zero harm is the right goal.  However, I think we need to be clear about what we mean when we say "zero," otherwise I think we end up with a version of Zeno's "dichotomy paradox."  Mr. Elliot's quote perfectly describes my take-home message.  The goal to eliminate patient harm in health care is "not a long race."  Perhaps the goal to eliminate patient harm is a series of "many short races one after the other" instead.

"Ambiverts of the world, unite!"

The Los Angeles Dodgers promoted one of their Triple-A Oklahoma City affiliate minor league pitchers to the majors on this past Saturday.  Normally, this kind of roster move during the middle of a baseball season doesn't get a lot of attention - in fact, these kinds of moves happen all of the time throughout the season.  However, this particular roster move was different.  The player in this case was a 32 year-old pitcher named Pat Venditte.  Again, the name Venditte shouldn't necessarily mean anything, unless your last name also happens to be Venditte or if you happen to take a closer look at his personal Wikipedia page.  Pat Venditte is known as a switch pitcher - in other words, he can pitch equally well with either his right arm or left arm!  A switch pitcher (also called an ambidextrous pitcher) is rare - the last switch pitcher to play in the major leagues as Greg Harris, who was known as a right-handed pitcher throughout his career until his penultimate (next to the last) game, when he pitched left-handed.  Venditte regularly pitches with both arms, though it will be interesting to see how well he does pitching both right- and left-handed.


Webster's online dictionary defines the word "ambidextrous" as the ability to use both the right and left hands equally well.  True ambidexterity is fairly uncommon - only about 1 percent of all individuals are naturally ambidextrous.  However, the ability to switch back and forth between dominant hands is definitely a useful skill that is often encouraged in many activities such as typing, juggling, playing a musical instrument, batting a baseball, martial arts, and surgery.


I've talked about introverts and extroverts in the past (see my previous post on the Lemon Juice Test as one example).  As we discussed, there are certain advantages to being an introverted leader as well as an extroverted leader.  After reading about Pat Venditte, I started asking myself whether there was the "ambidextrous" equivalent to the introvert/extrovert personality typology.   Well, it turns out (of course - why else would I be writing this post!) that there is an ambidextrous equivalent to this personality dimension - some individuals just don't classify well as either an introvert or an extrovert.  Wharton's Adam Grant calls these individuals "ambiverts."  Grant found in his studies that up to two-thirds of all individuals do not strongly identify as either introverts or extroverts (i.e., most of us are ambiverts).  Granted (no pun intended), most ambiverts will lean towards the introvert or extrovert side, but in the majority of cases, whether they show more introvert tendencies or extrovert tendencies is context-dependent.  Grant also found that, at least when it comes to individuals in marketing and sales, ambiverts are 51% more productive than the average salesperson. 


Grant explains, "Because they naturally engage in a flexible pattern of talking and listening, ambiverts are likely to express sufficient assertiveness and enthusiasm to persuade and close a sale, but are more inclined to listen to customers' interests and less vulnerable to appearing too excited or overconfident."


Travis Bradberry wrote an article for Forbes magazine ("9 Signs That You're an Ambivert") and listed 9 statements that if they describe you, you are likely to be an ambivert:


"1. I can perform tasks alone or in a group.  I don't have much preference either way.


2. Social settings don't make me uncomfortable, but I tire of being around people too much.


3. Being the center of attention is fun for me, but I don't like it to last.


4. Some people think I'm quiet, while others think I'm highly social.


5. I don't always need to be moving, but too much down time leaves me feeling bored.


6. I can get lost in my own thoughts just as easily as I can lose myself in a conversation.


7. Small talk doesn't make me uncomfortable, but it does get boring.


8. When it comes to trusting other people, sometimes I'm skeptical, and other times, I dive right in.


9. If I spend too much time alone, I get bored, yet too much time around other people leaves me feeling drained."


Do these statements describe you perfectly?  If so, you are likely to be an ambivert.

"If you want to remember something, don't type it, write it!"

The novelist, James A. Michener, once said, "If you type adeptly with 10 fingers, you're typing faster than your mind is working."  He may have been more correct than he could have possibly imagined.  It seems like writing by hand is a lost practice.  No one writes out letters anymore.  Short messages or reminders have turned into texts or Tweets.  The handwritten prescription or medical record is almost a thing of the past.  Cursive handwriting is no longer taught in school, and penmanship grades, the bane of my childhood elementary school years, have long since faded from memory.  No matter where you turn, it seems as if handwriting is a vestige of a bygone age. 


What, if any, is the impact of this shift from handwriting to typing (analog to digital, if you will)?  Funny you should ask.  As it turns out, there are a number of studies that strongly suggest that things that are written out by hand are better remembered compared to things that are typed.  More and more schools (even in elementary school) are providing laptops or tablet computers for their students - taking notes on a tablet computer is much quicker than say, writing out the notes by hand.  However, it appears that students who write out notes by hand during class will learn the material and commit it to memory better than those students who type out their notes into a computer (see "Students, put your laptops away!" for more information). 


If you work in the health care industry, you probably use an electronic medical record.  The purported benefits of the electronic medical record are numerous - the reality is that most physicians and health care providers over the age of 50 years would rather go back to paper charts (I actually don't know if that statistic is true or not, it just feels like it is the case based on my own anecdotal experience!).  I wonder - and I have not seen a study on this question - if medical students, residents, fellows, and physicians would remember their patients' medical histories better if they wrote out the history by hand as opposed to typing it into a computer?  There are probably too many variables that play into this (for one, patients are often handed off from one physician to another multiple times during their stay), but it is a very interesting question.  I will leave the answer for someone else to figure out.


There seems to be something about handwriting that helps move information from our working memory to our long-term memory.  Perhaps Mr. Michener was right - it may be that when we type, our brains just can't keep up.  For now, if you really want to remember something, don't type it - write it!

What do you want your tombstone to say?

A few months ago, I joined a Presidential biography book club.  We started with a biography about George Washington, and the plan is to complete a biography about every subsequent President in order from Washington to the current President (whoever that will be, as we estimate that we will need about six years to finish).  I am currently reading a book about Thomas Jefferson, our nation’s third President.  I was interested to learn that Thomas Jefferson’s tombstone at Monticello, his home, reads as follows:

Here was buried Thomas Jefferson
Author of the Declaration of American Independence
Of the Statute of Virginia for religious freedom
& Father of the University of Virginia.

Pretty interesting, isn’t it?  Of all the things Jefferson could (and should) be remembered for, he selected these three (albeit very important) contributions.  Nowhere does it say that he served in a number of important government positions, including Secretary of State, Vice President, and President.  He doesn’t mention that he was an accomplished architect, naturalist, inventor, and patron of the arts.  Nor does he mention the words, husband, father, and grandfather.  At one time or other, Jefferson was all of these, and more.  But he chose these three.

I started thinking, what would I want on my tombstone?  What do I want to be most remembered for? What lasting contributions to society do I want to make?  It’s a good exercise, and leads me to ask, “What do you want your tombstone to say?”

"A rising tide lifts all boats..."

According to popular belief, John F. Kennedy first used the phrase, "A rising tide lifts all boats" in a speech in 1963.  Actually, according to his speechwriter, Ted Sorensen, Kennedy first noticed the phrase at the New England Council and liked it so much that he used it over and over on a number of occasions.  The phrase is commonly used to defend free-market principles and refers to the idea that a strong, healthy economy benefits everyone. 

I have been thinking about this phrase a lot in the last couple of weeks.  Most academic medical centers are working on their budgets for the next fiscal year (the academic calendar usually starts around July 1st, so many academic medical centers start the new fiscal year on that date).  It is a well known fact that a relatively small number of medical and surgical specialties generate a positive margin (remember, margin = revenue - expenses).  For example, the surgical specialties and a few medical specialties (e.g., cardiology, oncology, neonatology, intensive care) usually generate enough margin to cover the expenses of some of the medical specialties that do not generate sufficient revenue to cover their expenses (e.g., primary care and endocrinology).  In fact, it is frequently true that one or two subspecialties generate a significant proportion of the total revenue for an academic medical center.  However, here is the important point to keep in mind - many of these so-called high revenue programs rely upon some of these less profitable specialties to help provide quality care. 

One of the great things about having highly specialized care at some of these hospitals is that they provide excellent care that leads to outstanding outcomes.  But that benefit can come at a great cost - care is so fragmented that any particular patient in the hospital may have a number of different teams providing his or her care.  Medicine has truly become a team sport.  I have worked in one of these highly specialized fields for most of my medical career, and I once took care of a patient who had 10 different medical and surgical specialties participating in her care (I actually counted them, and I think we had almost every medical specialty, with the exception of dermatology and adolescent medicine, covered!). 

Patients today require (indeed, they rightfully demand) that their providers work collaboratively together to provide excellent care.  But it goes beyond just patient care.  In today's academic medical center (and I suspect the same is true for any health care organization), all of the medical and surgical specialties need to work collaboratively together to provide high-value care.  No one medical or surgical specialty can do it on its own.  We are all tightly linked, and we are only as strong as our weakest link.

So what do I mean when I think of the phrase, "A rising tide lifts all boats"?  It's pretty simple actually.  Each and everyone of us needs to be successful - we are all in it together and we cannot do it alone.  Rather than trying to justify a particular request (a capital investment or any other investment of resources) with a phrase, such as "We generate 25% of the hospital revenue", the specialties that generate a positive margin need to understand that their success, both in the short-term and the long-term, is going to depend upon the success of all the other specialties, even the ones who don't generate enough revenue to cover their own expenses.  Just imagine.