"Don't ask me to take resilience training!"

Professional burnout has had a lot of attention recently, both in the medical literature as well as the media.  For example, a recently published survey of U.S. physicians using the Maslach Burnout Inventory, a commonly used instrument to assess burnout, noted that 44% of the physicians surveyed reported at least one symptom of burnout in 2017.  The Maslach Burnout Inventory (MBI) assesses "burnout" based upon the presence of emotional exhaustion, depersonalization, or a sense of a loss of personal accomplishment.  

Importantly, an individal meets criteria for "burnout" when he or she meets threshold criteria in all three categories.  The media has erroneously reported in the past that "nearly half of physicians in the U.S. are burned out" - this is technically not correct, and it would be more accurate to state that "nearly half of the physicians in the U.S. meet at least one criteria for burnout."

There are a number of factors that have been associated with physician burnout.  Dr. Tait Shanafelt, one of the foremost authorities on physican burnout, breaks these factors down into individual factors, work unit factors, organizational factors, and societal factors.  For example, improving diet, exercise, sleep, and mental wellbeing have all been suggested as potential strategies to alleviate individual factors leading to physician burnout.  A number of health care organizations have responded to the growing problem of physician burnout by implementing strategies to improve personal resilience.  While all of these strategies are certainly helpful, by themselves they are not nearly enough.

Some experts have suggested that focusing only on the individual factors that lead to burnout can lead to a sense of blame (for example, see the Harvard Business Review article, "Burnout is about your workplace not your people").  I see their point and tend to agree - focusing on system-level factors are probably more important.  However, solely focusing on system-level factors is insufficient as well.  At the end of the day, eating a balanced diet, getting enough sleep and exercise, and focusing on mental wellbeing are necessary too.

Here's the crux of the issue though.  Resilient individuals are less likely to suffer symptoms of burnout.  The problem is that physicians, as a group, are more resilient than the rest of the population at large.  The journey to become a physician is long and arduous.  It's an intense experience that probably self-selects for personal resilience.  By that token, trying to alleviate physician burnout by improving resilience is probably not going to be that impactful.  Physicians are already resilient enough.  

Health care organizations instead should focus on the system-level factors that drive burnout - decreasing some of the regulatory burdens on physicians, improving the ease of use of the electronic health record, and focusing less on the volume of patients seen and emphasizing the value of the care that is delivered.  Health care organizations would do well to address these system-level issues first.  And perhaps most important of all, don't ask physicians to take resilience training!   

"Singin' in the Rain"

There's an iconic scene in the 1952 classic, Singin' in the Rain starring Gene Kelly, Donald O'Connor, and Debbie Reynolds.  It's a great scene and a great movie.  The problem is that the scene really doesn't have anything to do with the movie's plot.  Aside from the fact that the song that Kelly sings during the scene is the title of the movie itself, it seems oddly placed.  Call me silly or just plain dense dumb, because I just don't understand why the scene is necessary to the rest of the story.

Kelly seems awfully happy, even though it's pouring down rain.  And maybe that is the point of the scene that I am missing.  "I'm singin' in the rain, just singin' in the rain.  What a glorious feeling I am happy again."  Admittedly though, he is wearing a heavy rain coat and has his umbrella with him (more on that below).  He must have been expecting it to be a rainy day, as he was well-prepared for the worst sort of weather.  Maybe he would have felt differently had he been wearing just his suit and had forgotten an umbrella.  

Imagine how much easier it would be if we could accurately predict the weather!  The physicist Stephen Hawking once said, "One can't predict the weather more than a few days in advance."  I read on the Internet (so it must be true, right?) that a seven-day forecast is accurate about 80% of the time, while a five-day forecast is accurate almost 90% of the time.  That should mean that the weather folks should be more than 90% accurate with the weather forecast 24 hours in advance, right?  

The weather forecast for the Chicago area yesterday (Saturday) called for 80 degree weather and partly sunny skies.  Sunday's forecast, on the other hand, was overcast skies and slightly colder weather.  I think the weather folks got a little mixed up and confused.  The weather was the exact opposite.  Saturday was overcast, windy, and cooler, while today (Sunday) it is partly sunny, warm, and generally very pleasant!  Of course, we planned a boat tour out on the Chicago River and Lake Michigan for Saturday afternoon, rather than Sunday.  Perhaps I should have listened to Dr. Hawking more.  

While the boat tour turned out just fine anyway, I am reminded of another time in the past couple of weeks when things didn't turn out so well.  I am fortunate enough to be able to walk to and from work every day right now.  I generally check the weather forecast before I leave in the morning, just in case.  If the forecast calls for rain, I throw an umbrella into my shoulder bag.  A few weeks ago, I checked the weather forecast for the day and it said "Partly Sunny in the morning with increasing clouds in the afternoon."  But not a word was said about the possibility of rain.  It started pouring down rain on the walk home, and I got soaked.  No umbrella.  No rain coat.  So I definitely didn't "sing in the rain" - I just walked faster to get home as quickly as I could.  Mark Twain famously said, "Climate is what we expect, weather is what we get."  The weather got the best of me on that particular day.

There are at least three lessons here.  I'll start with Dr. Hawking's lesson first.  Even with all of the technology and scientific knowledge available today, we still can't reliably and consistently predict the weather with 100% accuracy.  What is true for the weather is actually true for life in general.  We really can't predict everything that is going to happen to us.  We may have a reasonable idea of what might happen on any particular day, week, or month, but we can never know everything that's going to happen before it actually does happen.  The lesson here is that we shouldn't try.  Life will throw us a few curveballs every so often, and that is okay.  Some times it just happens to rain unexpectedly on the way home from work.

Mr. Twain would probably agree with Dr. Hawking, but I think he would have taken things one step further.  I think Mark Twain would have argued that we should be better prepared for those times when it unexpectedly rains on the walk home.  In other words, we should come up with a more reliable plan to deal with the unexpected events as they occur.  In my case, perhaps I should throw a small umbrella and carry it with me every day.  Or, I could always make sure that I have a spare umbrella at work, just in case.  Either choice would be more reliable.  Perhaps that is exactly how Mr. Kelly found himself with a rain coat and umbrella in the movie, "Singin' in the Rain," which brings me to my third and final lesson.

There are times when it's just going to rain.  We shouldn't let a little rain bother us or ruin an otherwise happy day.  I think Mr. Kelly said it best, "Let the stormy clouds chase everyone from the place.  Come on with the rain, I've a smile on my face."  If it's raining, just smile and be happy anyway.  Who cares if it's raining anyway?

 

Wash your hands!

 James Garfield, the 20th President of the United States of America died on September 19, 1881 (I knew this because someone posted it this past Saturday on Twitter).  President Garfield, as many of you learned in school, was one of the four U.S. Presidents that have been assassinated (Lincoln, Garfied, McKinley, and Kennedy).  What's unique about Garfield is that he was actually shot on July 2, 1881 (all the other Presidents died shortly after being shot - in William McKinley's case, he died about 8 days after being shot twice in the abdomen).  

I've always been interested in President Garfield.  He was a Civil War hero (he was a Major General in the Union Army), lawyer, college professor, and an accomplished mathematician!  Well, at least he published a proof for the Pythagorean Theorem (see his proof here).  After the Civil War, he served in the U.S. House of Representatives for the state of Ohio, and he later became a U.S. Senator.  He was nominated to run for President at the 1880 Republican Party Convention as a compromise candidate (he actually wasn't seeking to run for President) and just barely beat Democrat Winfield Scott Hancock (another famous Civil War General) to become our 20th President.

President Garfield was shot by Charles J. Guiteau, a disappointed office seeker, at the Baltimore and Ohio Railroad Station in Washington, D.C. on July 2, 1881.  Garfield was shot twice, once in the arm and once in the back, exclaiming, "My God, what is this?"  Ironically, Robert Todd Lincoln, surviving son of President Abraham Lincoln was a witness to the assassination.  Garfield was removed from the scene and examined by doctors - who probed the wound with unwashed hands (handwashing was not a common practice at that time).  Several doctors, in fact, probed the wound with unwashed hands and unsterile instruments, but unfortunately no one could find the bullet (X-rays would not be invented until 14 years later).  Alexander Graham Bell, the inventor of the telephone, apparently used a primitive metal detector in an unsuccessful attempt to locate the bullet.  All of this uncleanliness later caused an infection ("blood poisoning"), and the President ultimately died of sepsis on September 19th, just over 2 months after being shot.

In all likelihood, if President Garfield's physicians had washed their hands or sterilized their surgical instruments, Garfield probably would have survived - one can only speculate.  Handwashing was first proposed as the best way to minimize the risk of infection in hospitals by the Austrian physician, Ignaz Semmelweis in the late 1840's.  Semmelweis found that handwashing significantly reduced the risk of mortality from puerperal fever (an infection that occurred after childbirth).  

As the story goes, Semmelweis operated two labor and delivery wards at Vienna General Hospital.  The First Clinic had a much higher rate (and mortality) of puerperal fever compared to the Second Clinic.  The only difference was the personnel - there were more medical students working in the First Clinic, while there were mostly midwifes working in the Second Clinic.  Semmelweis noticed that the medical students often came directly to the clinic from the autopsy room, and they almost never washed their hands or cleaned their instruments.  The midwifes, on the other hand, never worked in the autopsy room and almost always washed their hands.  Once Semmelweis changed the practice, so that everyone washed their hands, the rate of puerperpal fever in the First Clinic declined precipitously.

Unfortunately, most physicians didn't believe Semmelweis's data.  They ridiculed him, and the harder he pushed, the harder they pushed back.  He eventually went insane, and in the ultimate irony, died of sepsis in 1865.  So by the time President Garfield was shot, handwashing was still not an accepted practice in medicine.

I can't help but wonder if there is a lesson here.  Even today, hospitals still (believe it or not) struggle to reach universal handwashing (compliance with handwashing practices almost never reach 100%).  Even now, during the COVID-19 pandemic, evidence-based practices such as handwashing and universal masking have not been universally accepted (while most, if not all, hospital workers have accepted universal face masking, the public has certainly not).  

Change is hard - even with overwhelming evidence.  But that shouldn't excuse the fact that (1) washing your hands and (2) wearing a mask can dramatically reduce your risk of acquiring COVID-19.  Wash your hands.  Wear your mask.

Is Michael Scott a bad boss?

Our youngest daughter binge-watched all nine seasons of the television series, The Office during quarantine.  She enjoyed it so much that she started watching it again, this time pulling me in to watch it as well.  I didn't really pay much attention to the television show when it was actually on, but I have to confess that I've enjoyed watching it (I just finished season 3).  As my wife now claims, our daughter "has created a monster!"

One of the series' main characters is regional manager Michael Scott, played by the actor Steve Carell.  He is not a very good boss.  In fact, he is a terrible boss.  It's not that he is mean or disrespectful, nor is he unsupportive.  As a matter of fact, there are times when he actually shows that he cares about some of his employees and can actually be quite supportive.  For example, episde 17 of season 3 is called "Business School" and has a great scene where the character Pam has her first art show.  None of her co-workers show up, but Michael does and actually purchases one of her paintings as he tells her that he is very proud of her.  No, Michael Scott is not mean, unsupportive, or disrespectful at all - he is just plain incompetent!

Benjamin Artz, Amanda Goodall, and Andrew Oswald conducted a survey of over 28,000 European workers, asking them to rate their managers on seven leadership categories - providing feedback, being respectful, offering recognition, getting the job done, encouraging employee development, facilitating teamwork, and supporting workers.  The employees rated their bosses on a scale of 1 to 5, with lower scores being worse.  The study was conducted in over 35 European countries and found that approximately 13% of workers have "bad bosses."  As the investigators conclude, "bad bosses are rated least-bad on 'respect for workers' and worst on their ability to get the job done."  In other words, "lack of competence, not lack of consideration, appears to be the key problem."  

There's a well-known principle, known as the "Peter Principle" that states, "Everyone in an organization keeps on getting promoted until they reach their level of incompetence."  Apparently, Michael Scott was promoted one time too many!  But what happens if the boss is a competent jerk, or even worse, an incompetent jerk?  Apparently, that is an all too common scenario as well.  One study found that 56% of American workers work for a boss who is mildly or highly toxic.  Another study by the American Psychological Association reported that 75% of Americans say that their "boss is the most stressful part of their workday."  

What do you do if you find yourself working for a terrible boss?  The quick solution would be to just quick - a recent study by the Gallup organization found that one out of every two employees surveyed admitted that they had left a job at least once during their career with for the sole reason of getting away from a toxic manager.  Surprisingly though, another study found that employees actually may end up working longer for a toxic manager (on average, two years longer) compared to a nontoxic one.  Why would that be the case?

Mary Abbajay, writing for the Harvard Business Review (see "What to do when you have a bad boss") lists several reasons employees stay with toxic managers:

1. The employee just doesn't have the energy to look for a new job.

2. The employee really likes the job, colleagues, or the commute to work.

3. The employee needs the money and can't afford to take a pay cut.

4. The employee doesn't want to lose the benefits.

5. The employee feels that he or she doesn't have the skills to get a different job.

There's also the feeling that employees have invested too much time to start over in a new job in a different organization (this is a great example of the "sunk cost fallacy" by the way).  Finally, there is always the hope that the job will eventually get better (maybe the boss will get fired or promoted to a different position in the company).  

The problem here is that working for a bad boss (toxic or just incompetent) is not healthy.  Working for a bad boss increases the risk of burn-out, depression, and anxiety, as well as contributing to poor physical health (a study conducted in Sweden suggested that employees who work for a bad boss increases the risk of heart attack or stroke by 60%).

  

Mary Abbajay provides some great advice for how to deal with a bad boss:

First, engage with a support network.  Chances are that your fellow co-workers are also having issues dealing with the boss.  It's good to look for support outside of work as well, and you may even need to get help from a professional coach, therapist, or psychologist.  First and foremost - take care of yourself!

Second, make sure that you are getting plenty of exercise and sleep.  As stated above, working for a bad boss can contribute to increased risk of physical health problems, so don't compound those risks by not getting enough sleep, exercise, or a healthy diet.

Third, try getting feedback from the boss.  Maybe there's something going on that you can address.  It's always a good idea to make requests in writing and to be specific about the resources and support you need from your boss.

Fourth, don't be afraid to explore other opportunities within the same organization, particularly if your reasons for staying (described above) have more to do with pay/benefits or the fact that your skills match well with the needs of the organization.

Fifth, remember that the Human Resources department is available to help!  Even if you are not filing a formal complaint (and I would argue that if you are working for a boss who is a jerk, you should), the HR department may have some ideas to help you.

Finally, don't be afraid to explore opportunities outside of the organization.  Occasionally, the best option is to move on and find a new boss in a new organization.  

There's too much going on in the world right now to have to deal with a toxic boss too.  If you do happen to be working for a toxic boss, please know that (1) you are not alone (see the statistics that were reported above) and (2) there is a path to making your work life better.  Here's hoping that you work for a competent boss who will support you, mentor you, and provide what you need to grow and develop as a great employee!

"A plague is a formidable enemy..."

"A plague is a formidable enemy, and is armed with terrors that every man is not sufficiently fortified to resist or prepared to stand the shock against."  So writes Daniel DeFoe in his novel, A Journal of the Plague Year.  He goes on to write, "...such a time as this of 1665 is not to be paralleled in history."  

It is tempting to state that we are going through an experience in 2020 that is "not to be paralleled in history."  The simple fact is, however, that we've been here before - many, many times.  One only has to read through DeFoe's historical novel to notice that almost everything that has occurred over the last six months has happened before.  Let me explain.

DeFoe writes an account of the Great Plague of London in the year 1665.  While A Journal of the Plague Year is a work of fiction, it is believed to have been based on the memoirs of DeFoe's uncle, Henry Foe.  The book was originally published under the initials "H.F." who is the narrator.  Regardless of whether fact or fiction, most historians have verified most of the events reported in the novel, and the work is often cited as one of the best and most accurate depictions of the plague that wreaked havoc in London that year.

Initially, towards the beginning of the epidemic, people were skeptical and refused to accept the reality of the coming infection.  Once the number of cases started to increase significantly, however, skepticism gave way to panic.  DeFoe writes, "When any one bought a joint of meat in the market they would not take it off the butcher's hand, but took it off the hooks themselves.  On the other hand, the butcher would not touch the money, but have it put into a pot full of vinegar, which he kept for that purpose."  During the COVID-19 pandemic, individuals were quick to downplay the severity of the illness (myself included), suggesting that influenza was far more deadly.

The plague affected the poor and downtrodden the most.  In contrast, the wealthy citizens of London were able to "social distance" by leaving the city and moving to the countryside.  Similarly, COVID-19 has disproportionately impacted those individuals in lower socioeconomic classes, both in terms of risk of actually getting the infection, having a more severe clinical course, and experiencing greater mortality.  

Just as with the COVID-19 pandemic of today, people questioned the numbers of those who died from the plague in 1665.  There were a number of cases in London in 1665 in which individuals who had the plague failed to show symptoms, thus contributing to the further spread of the disease.  Again, we have experienced asymptomatic transmission of COVID-19 in the year 2020.  

Individuals in 1665 ignored recommendations from public health officials to quarantine or social distance - just as in 2020.  Apparently, public officials hired "watchers" to stand guard by the doors of houses under quarantine, mostly to keep those in quarantine inside.  DeFoe gives several accounts of individuals who would break quarantine by "sneaking out the back door."

Hopefully, by now, I have at least somewhat convinced you that many of the events described by DeFoe in his novel are happening today.  Have we experienced more than just COVID-19 in 2020?  Yes - it seems that every day we read about some other calamity in the newspaper.  Guess what happened after the Great Plague of London - the very next year, the people of London experienced Great Fire of London.  

There's hope in this story.  Historians have speculated that the fire ended up saving lives in the long run by burning down some of the unsanitary, rat-infested buildings (note that the rats carried the fleas that transmitted the plague).  The plague had killed off so much of the population, leaving far fewer workers to meet the demands posed by the need to rebuild the city after the fire.  In other words, there was an incredible demand for workers, and employment conditions greatly improved.    The London economy was saved and became the envy of the world.

We can only hope that we will emerge from 2020 stronger and more unified.  

"The score takes care of itself..."

 I just finished a superb book by the legendary NFL football coach, Bill Walsh, called "The Score Takes Care of Itself: My Philosophy of Leadership".  It is, by far, one of the best leadership books that I have read in a very long time.  Even if you aren't a football fan, the lessons and advice that Coach Walsh talks about in his book are instructive.

The title of his book says it all - "the score takes care of itself."  In other words, football players and coaches shouldn't necessarily focus on winning or losing.  Instead, they should focus on execution of the fundamentals, in Walsh's terms a "Standard of Performance."  If a team is living up to these high standards of excellence, the points will come and the team will win.  If not, the other team will score more points and the team will lose.

The same recommendation is true when running a business.  Executives shouldn't focus directly on profits, revenues, and expenses.  If they bring a great product to market and provide superior customer service, the profits will undoubtedly follow.  Similarly, when running a hospital, leaders should focus on providing safe, effective, patient- and family-centered care.  If the hospital is providing easy access to care and a great service with excellent outcomes, the revenues and positive margins will follow.

It seems relatively simple - because it is simple!  In football and in life, the score does take care of itself.

Striking out of your comfort zone

Jennie Finch is one heck of a softball pitcher.  She is a former collegiate All-American and Olympian (Team USA won the gold medal in softball at the 2004 Summer Olympics and the silver medal at the 2008 Summer Olympics), as well as a two-time professional softball All-Star.  Time magazine called her "the most famous softball player in history."  Her list of accomplishments is impressive, and she co-authored a book with Ann Killion, Throw Like a Girl: How to Dream Big and Believe in Yourself in 2011, which offers a collection of life lessons Finch learned through playing sports.

Finch played in a celebratory softball game (2004 Pepsi All-Star Softball Game2004 Pepsi All-Star Softball Game) which featured several major league baseball players.  Finch struck out future Hall of Fame baseball players Albert Pujols and Mike Piazza, as well as two-time major league baseball All-Star, Brian Giles.  Giles said, "Her fastball was the fastest thing I've ever seen, from that distance.  It rises and cuts at the same time."

Major league slugger Barry Bonds watched all of this with amazement and challenged Finch to a pitching duel - "You faced all them little chumps...You gotta face the best."  Finch traveled to Arizona for spring training.  Bonds watched several pitches go by without even touching them, and it was only after she told him which pitches were coming that he even came close (here's a great video).  That same spring training season, she traveled to the Texas Rangers' spring training site to challenge slugger Alex Rodriguez, who was playing for the Rangers at that time.  He refused to swing at even one pitch saying, "No one's going to make a fool out of me."

During her professional softball career, Finch faced a number of major league baseball players as part of a regular segment on the television show, "This Week in Baseball."  Only two players, in fact, managed to hit one of her pitches during the segment's run - Scott Spiezio and Sean Casey.  Apparently, Finch faced Casey again 14 years later and struck him out.

Why was Finch so successful against these major league baseball players.  Her average pitch speed is about 65 mph.  The average major league baseball pitching speed is about 92 mph.  That seems pretty different until you factor in that the softball pitcher's mound is 43 feet away from home plate versus a distance of 60 feet 6 inches in baseball.  Based on that difference, Finch's pitches appear to be closer to 90 mph than the actual 65 mph, but that still doesn't explain why major leaguers couldn't even touch her pitches.

The answer may be found in a great book by the author, David Epstein, called The Sports Gene (on a side note, his more recent book, Range is perhaps the best book that I've read in the last year).  According to Epstein, it takes about 400 milliseconds from the point the baseball leaves the pitcher's hand for it to reach home plate.  Major league baseball players therefore have about 200 milliseconds to decide whether to swing at the pitch or not.  Two-hundred milliseconds is slightly less than the time it takes for you to blink an eye, so baseball players don't have very long to make their decision.  It seems impossible until you factor that hitters take into account other contextual factors (the pitch count definitely comes into play, but hitters also know what kinds of pitches the pitcher generally throws, both in general and in that specific pitch count scenario).  Hitters use this information (much of it learned via data analytics), as well as the pitcher's delivery motion to try to determine what kind of pitch is being thrown.

Therein lies the rub.  Major league pitchers have very little experience with fastpitch softball pitchers.  Most of them probably have never even faced a good fastpitch softball pitcher, let alone one of the greatest of all time.  As it turns out (and as Epstein explains in his book), most professional athletes use this kind of contextual information to make their decisions.  For example, top tennis players can predict whether a serve is going to their forehand or backhand based on the the movement of their opponent's torso (the research was conducted by Bruce Abernathy at the University of Queensland and was featured in a 2011 Sports Illustrated article, also by David Epstein).  Similarly, professional boxers can avoid their opponent's punches by watching for subtle movements of the other boxer.  How do they learn to do this?  Through thousands and thousands of hours of repetitive practice!

Context, as it turns out, is incredibly important.  No wonder individuals don't like to leave their comfort zones!  We know from a number of studies performed in a variety of different circumstances that the fear of failure, oftentimes combined with a fear of humiliation in front of one's peers, is a powerful impediment to trying something new.  Throw in the effects of loss aversion and the endowment effect (see "The only person who likes change is a wet baby") and suddenly you have a seemingly insurmountable barrier to change.  

So what can a leader do?  While there are a number of things a leader can and should do to create incentives for change (see for example, John Kotter's 8-step change model), perhaps the most important is creating psychological safety.  Simply put, leaders need to create a learning culture where failure is not only acceptable, it is encouraged.  Leaders need to embrace the concept that when teams fail, they learn.  And when teams learn, they improve.  The inventor Thomas Edison famously claimed to have tried over 10,000 different models for the light bulb.  When asked by a reporter how he felt about failing so many times, Edison replied, "I have not failed once.  I've just found 10,000 ways that won't work."

We may not need to fail 10,000 times on a task in order to ultimately find success.  But we shouldn't be afraid to fail.  If we embrace the learning that comes with failure, we will strike out beyond our comfort zone.  And we will grow and develop as a result.