The curse of expertise

My wife and I have been binge-watching old seasons of the Amazing Race, in our minds one of the best reality television shows of all time!  The other night, as we were sitting down and getting ready to watch, I started humming the theme song to the show.  Well, I guess I wasn't really humming.  It sounded more like this: "Dunt - dunt - dunt - dun-dun-dun - dunt - dunt - dunt" (hey - you be the judge, check out the theme song here).  My wife gave me one of those "I can't believe I've been married to you for so long, you are too weird" looks.  And I guess I deserved that look.  She really had no idea of what I was humming.  As I write this post, I realize that the way I wrote how I hummed the song is exactly how she heard it.  It just doesn't make any sense now, and it definitely didn't make any sense then.

A few years ago, Dr. Elizabeth Newman conducted a study for her PhD dissertation (see "The rocky road from actions to intentions" at Stanford University that will be incredibly relevant to this post, at least so far.  She randomized 80 Stanford undergraduates to two groups - the "Tappers" and the "Listeners."  Tappers selected three different tunes from a list of 25 common songs (e.g. Yankee Doodle, The Brady Bunch theme, This Land is Your Land, Twinkle Twinkle Little Star, It's a Small World (after all), etc).  They then performed the three tunes - by tapping out the tune with their knuckles - to a group of Listeners.  Newman asked the Tappers to predict what percentage of the Listeners would be able to name the tune after each performance.  

I don't think that my wife would be surprised by Dr. Newman's results!  The Tappers predicted that 50% (on average, the predictions ranged from 10 to 95%) of the Listeners would be able to name each tune.  However, in reality, only 2.5% of the Listeners were able to correctly name a tune (3 tunes were identified correctly out of a total of 120 different songs).  Just to confirm her findings, Dr. Newman had also recruited a group of observers who were informed in advance of the tune that was going to be tapped out.  The Tappers played to both the Observers and the Listeners.  The Observers predicted that 50% of the Listeners would be able to correctly name each tune, similar to the Tappers' prediction.  

Chip and Dan Heath summarized it best in an article published in the Harvard Business Review: "The problem is that once we know something - say, the melody of a song - we find it hard to imagine not knowing it.  Our knowledge has "cursed" us.  We have difficulty sharing it with others, because we can't readily re-create their state of mind."  

What the Tappers (and the Observers) experienced - what I experienced more recently in my futile attempts to convince my wife that I was humming the Amazing Race theme song - is known as the "the curse of knowledge" (it's also known as the "curse of expertise").  The term was first used by the  economists Colin Camerer, George Loewenstein, and Martin Weber in a study published in a 1989 article in the Journal of Political Economy.  The "curse" is actually a type of cognitive bias in which those of us who are better informed about a particular subject (i.e., the experts) find it next to impossible to consider that subject from the point of view of someone who is less informed about it.  So, the Tappers find it impossible to understand why the Listeners can't identify the tunes that they are tapping out.  

I am reminded of the old adage in medicine (which summarizes a teaching philosophy that is thankfully no longer practiced), "See one.  Do one.  Teach one."  In other words, if you can understand and comprehend something well enough that you can explain it to others, you've probably mastered the concept or skill.  The problem, as explained by the "curse of expertise" is that once you go well past the "Teach one" stage, the concept or skill becomes almost second nature.  You perform the skill without really thinking about it.  At this point, the nuances of the concept or skill are so deeply embedded in the dark corners of your mind, that it becomes almost impossible for you to teach the concept or skill well enough to others.  As Chip and Dan Heath explain, "Our knowledge has 'cursed' us. We have difficulty sharing it with others, because we can’t readily re-create their state of mind."  It's impossible for us to fathom not knowing the concept or skill.  

All of us are subject to cognitive biases that can affect how we make decisions or interpret the world around us.  The so-called "curse of expertise" is just one example of many possible biases.  Knowing about these biases is just the first step, but it's an important one.

"Be a goldfish!"

After binge-watching the new series "Ted Lasso" on Apple TV+ last year, I couldn't wait for season 2 to start!  Last Friday night's season 2 premiere did not disappoint!  In the midst of a seven-game streak of ties, AFC Richmond striker Dani Rojas takes a penalty kick to try to win the game in the closing seconds.  Unfortunately, the team's mascot "Earl Greyhound" picks the wrong moment to try to catch a wayward pigeon and is killed by the ball (RIP Earl).  Rojas ends up with a bad case of the yips until he sees a sports psychologist, Dr. Sharon.  He summarizes it best, "Dr. Sharon helped me remember that even though football is life, football is also death.  And that football is football too.  But mostly that football is life!"  Classic.  And my new favorite show!

I took a class in college called "The Psychology of Sports" and never once heard the term yips.  Apparently, the term is widely accepted and refers to the sudden and unexplained loss of skills by an experienced athlete.  The term was originally coined by the professional golfer, Tommy Armour, known in the 1930's as "The Silver Scot" and winner of the 1927 U.S. Open, 1930 PGA, and 1931 Open Championship.  Armour claims that he left the professional golf circuit as a result of this condition, which has also been described by golfers by the terms, twitches, staggers, jitters, and jerks. Surprisingly, the yips affects anywhere from a quarter to half of all mature golfers - and the longer you play, the more likely you are to suffer from the yips.  The yips have been described in other sports too (in professional darts, it's called dartitis).  You've probably heard of the term choking in sports like basketball (e.g., when players miss an important free throw), American football (e.g., when place kickers miss the game-winning or game-tying field goal), and even soccer/football (e.g., when a player misses a penalty kick).  It sounds like "choking", "dartitis", and the "yips" are all related!

As it turns out, psychologists love to study why athletes, particularly professional athletes, "choke under pressure".  In order to continue this discussion, I need to define a couple of terms.  First, loss aversion was originally described by the cognitive psychologists, Amos Tversky and Daniel Kahneman and refers to the simple concept that individuals prefer to avoid losses rather than acquiring equivalent gains.  In other words, we hate to lose more than we love to win!  

Second, the endowment effect is related to loss aversion and refers to the tendency that people would rather keep something that they own as opposed to acquiring (by either purchasing or receiving as a gift or reward) that same item when they do not own it.  We tend to place a higher value on items that we already have in our possession (think of the concept of "sentimental value" when you are selling something at a garage sale).  For further explanation on both loss aversion and the endowment effect, see my post "The only person who likes change is a wet baby!".  

Finally, both loss aversion and the endowment effect are critically important to Tversky and Kahneman's Prospect Theory, which explains why people are so bad at making decisions at times.  According to this theory, we generally over-weight both low and high probabilities and under-weight medium probabilities.    

Now, back to sports!  Investigators in a now classic study ("Is Tiger Woods Loss Averse?") analyzed over 2.5 million putts by professional golfers on the PGA Tour - the investigators specifically compared the putts golfers attempted for par (the typical number of shots a golfer takes to complete a hole) versus putts golfers attempted for a score different from par (a birdie, which is one shot better than par or a bogie, which is one shot worse than par).  They found that when putting for a score better than par (a birdie or better), golfers are significantly less accurate and are more likely to miss their putt compared to when they are shooting for worse than par (a bogie or worse).  In other words, the way that professionals approach putting is consistent with the concept of loss aversion and the endowment effect  Even the best golfers (e.g. Tiger Woods) succumb to this loss aversion.

Human performance under pressure is a complex topic.  At the end of the day, most, if not all of us are loss averse.  And, probably related to that fact, we are all at risk of the yips.  If you do happen to develop a case of the yips and fail on some big task, it's good to remember that Ted Lasso is in your corner!  As he told one of his football players, "You know what the happiest animal in the world is?  It's a goldfish.  It's got a 10 second memory.  Be a goldfish."  In other words, learn from your mistake.  Put the past behind you.  Move on.

The Linda Problem

There is a famous problem first posed by the cognitive psychologists Amos Tversky and Daniel Kahneman called the "Linda Problem".  Here is the problem:

Linda is 31 years old, single, outspoken, and very bright.  She majored in philosophy.  As a student, she was deeply concerned with issues of discrimination and social justice, and also participated in anti-nuclear demonstrations.

Which is more probable?

1. Linda is a bank teller.

2. Linda is a bank teller and is active in the feminist movement.

Which answer do you think is correct?  If you chose option number two, you are in great company.  The vast majority (80% in fact) of study participants in Tversky and Kahneman's original study selected the second option, regardless of whether they were experts or not.  The "Linda Problem" is a classic case of what Tversky and Kahneman called a conjunction fallacy.  In lay terms, we fail to recognize in our minds the concept that the probability of two events occurring in conjunction is less than or equal to the probability of either one occurring alone.  Here is another example that might help make this point more clear:

Which of the following is more likely?

1. You will have a flat tire tomorrow morning.

2. You will have a flat tire tomorrow morning, and a man in a black care will stop to help you out.

Clearly, the second scenario is less likely to occur than the first one.  One of the fundamental laws of probability is that the likelihood of two events occurring at the same time (i.e., in conjunction) is always less than (usually) or equal to (possible, but still less likely) than the likelihood of either event occurring alone.  Written formally in mathematical symbols:  P(A^B) ≤ P(A) and  P(A^B) ≤ P(B).

Going back to the "Linda Problem", it just makes sense that someone who was "deeply concerned with issues of discrimination and social justice" and participated in anti-nuclear war demonstrations while in college would be active in these issues later in life.  Given no other career choice (both options said that Linda would become a bank teller), the second option seems more plausible, even though by the laws of probability and statistics it is not.

As I stated above, in Tversky and Kahneman's original study, even experts in statistics succumbed to the conjunction fallacy.  Here again we have support for Philip Tetlock's study published in his book, Expert Political Judgement and discussed in my last post, "Dart-throwing monkeys".  If experts in probability and statistics are fooled by the conjunction fallacy, the rest of us don't stand a chance!  That should at least provide us with some level of comfort (hey - even the experts fail to answer problems similar to the "Linda Problem").  It also should make us think twice before we make the same mistake.

Dart-throwing monkeys

 I don't particularly care for monkeys.  I remember a trip our family took to Bali when I was on active duty in the military.  We visited several local temples, and I vividly remember the monkeys at each temple that tried to steal sunglasses, cameras, food, and pretty much anything that they could get their hands on quickly (which was everything).  Even to this day, my wife and I are haunted (perhaps a bit of an exaggeration) by our short hike through the Ubud Monkey Forest.  We were by ourselves, and there were literally hundreds of monkeys up in the trees following us as we we walked along the path.  So yes, the monkey is not my favorite kind of animal, but wow do they make great metaphors for leadership!

I've written about "The Tale of the Five Monkeys" (about the infamous "the way we doing things around here" problem in organizations), lessons on motivation from monkey experiments, "The Invisible Gorilla" (which talks about inattentional blindness with lessons on multi-tasking), "Chimpanzee Politics" (which involves group dynamics), and even about the anthropologist Jane Goodall and "The Power of One".  Just a few days ago, I expanded my previous discussion about invisible gorillas in my post, "Monkey Business".  Perhaps not too surprisingly then, today I want to go back to my monkey metaphor to discuss the nature of expertise.

The psychologist Philip Tetlock has written two books (Expert Political Judgement and Superforecasting) on the science of prediction and forecasting.  Tetlock claims that experts are not any better at predicting future events than dart-throwing chimpanzees!  His study was simple, yet elegant (and incidentally, for those of us in academia who have to deal with tenure, he once claimed, "The project dates back to the year I gained tenure and lost my generic excuse for postponing projects that I knew were worth doing, worthier than anything I was doing back then, but also knew would take a long time to come to fruition...").  Bryan Caplan summarized Tetlock's experimental plan as follows:

1. Ask a large, diverse sample of political experts to make well-defined predictions about the future.

2. Wait for the future to become the past.

3. See how accurate the experts' predictions were; and figure out what, if anything, predicts differences in experts' degree of accuracy.

Tetlock selected 284 people whose job called for "commenting or offering advice on political and economic trends" and started asking them to make different kinds of predictions.  These predictions generally involved changes in nation's borders, economy, or political leadership; economic growth (measured by changes in the Gross Domestic Product); stock-market closing prices; and exchange rates.  After these experts made their predictions, Tetlock simply waited.

By the end of his 20-year study in 2003, Tetlock's group of experts had made over 82,000 different predictions.  He evaluated the accuracy of their predictions based on three alternative outcomes - the status quo, more of something (e.g., a rise in GDP), or less of something (e.g., a fall in GDP).  The results were not very impressive.  Tetlock concluded experts are relatively poor forecasters.  In fact, his so-called experts actually performed worse than if they had just assigned an equal probability to each outcome (e.g., GDP stayed the same 1/3 of the time, GDP increased 1/3 of the time, or GDP decreased 1/3 of the time).  In other words, his group of experts' success rate performed no better than a group of chimpanzees throwing darts at a board displaying the different outcomes (don't worry, he didn't actually make chimpanzees throw darts!).  He published his study results in his book, Expert Political Judgement.  

Tetlock also found that there was an inverse relationship between the accuracy of an expert's predictions and his or her self-confidence, renown, and depth of knowledge.  He consistently found a point of diminishing returns, where increasing the level of expertise actually made the predictions worse.  In other words, the greater the expertise (either real, or imagined in the expert's own head), the worse the prediction!  This finding seems counter-intuitive, but it is actually not a new finding.  Scott Armstrong calls it his "seer-sucker theory of forecasting" ("No matter how much evidence exists that seers do not exist, suckers will pay for the existence of seers").  Expertise beyond a minimal level is actually of limited value in making predictions about the world.

I will spend the next couple of blog posts talking about why experts fail to accurately predict the future. Tetlock also found that some experts are better than others at making predictions, which I will also discuss.  For now, let's just give the chimpanzees their day in the sun.  

Who IS buried in Grant's tomb?

It's amazing what we all used to think was so funny during our childhood.  For example, do you remember the riddle, "Who is buried in Grant's tomb?"  The answer is that no one is buried in Grant's tomb.  Keep the emphasis on the word buried.  Technically, no one is buried there, but rather both Ulysses S. Grant and his wife Julia are entombed there and not buried (they are entombed in sarcophagi, raised on a dais).  I'm not sure why that was so funny, and I can't find any information on how, where, or when the riddle got started.  Oh well.

The riddle came to mind yesterday, as my wife and I were walking through the streets of downtown Chicago.  We ended up at the Lincoln Park Zoo, which is now fully open after months of limited operations due to the COVID-19 pandemic.  The zoo doesn't charge for admission, so we didn't spend a lot of time there.  As we were walking through Lincoln Park, we came across a very large monument topped by a statue of what appeared to be a Civil War general riding on his horse.  We walked around the statue to try to figure out who it was - it was a statue of Ulysses S. Grant!  My wife and I are still relatively new to Chicago, so we quickly searched to see if we were actually in Grant Park.  It would make sense, right?

Apparently, we were still in Lincoln Park (we kind of knew that all along).  So, there is a statue and monument to U.S. Grant (see Ulysses S. Grant Monument) in Lincoln Park, which begs the question, "Is there a statue of Lincoln in Grant Park?"  As it turns out, there is indeed a statue of Abraham Lincoln in Grant Park!  It's called the Abraham Lincoln: The Head of State (or alternatively, Sitting Lincoln).  Go figure!  Incidentally, there is also a fairly large statue of Abraham Lincoln in Lincoln Park (this one is called, Lincoln: The Man, or just simply Standing Lincoln to distinguish it from the Lincoln statue in Grant Park).

After my wife and I finished our walk, I looked up and read more about all of these different monuments.  First, don't poke too much fun at Chicagoans.  Both Lincoln and Grant are claimed by the State of Illinois (we are the "Land of Lincoln" after all), and both individuals played a major, if not definitive role in the Union victory over the Confederacy during the American Civil War.  Second, Grant Park was originally known as Lake Park, so the fact that there is a statue of Lincoln in what was originally known as Lake Park doesn't seem all that strange.

Okay, I know what you are thinking.  Where's he going with all of this?  Trust me, there is a point here!  During my reading about these different monuments, I learned a couple of new things.  First, the Sitting Lincoln statue in Grant Park (originally Lake Park) was intended by the artist, Augustus Saint-Gaudens, to evoke the loneliness and burden of command felt by Lincoln during his presidency.  I have written about the loneliness of leadership in the past (see "It's lonely at the top", "Tap Code", and "Now is the time to lead").  A number of Lincoln's biographers have discussed his feelings of loneliness and, at times, outright depression, during some of the longest days and nights of the American Civil War.  It is poignant, for me at least, that an artist chose this theme when he honored Lincoln's memory.  I too have felt the loneliness of leadership at times, and it is both humbling and inspiring to think about what Lincoln went through during his Presidency.  

Second, in regards to the Ulysses S. Grant Monument (again, in Lincoln Park - I know, it's all really confusing!) and circling back to my original question about Grant's Tomb.  There is an inscription on Grant's Tomb that is somewhat faded and hard to discern, but really important.  It says simply, "Let us have peace."  Apparently that was Grant's campaign slogan for the Election of 1868.  As Rosa Inocenio Smith wrote in an article on Grant's Tomb in The Atlantic, "Having won the Civil War as the “Unconditional Surrender” general, Grant ran on a platform of black civil rights and reconstruction, promising, essentially, to make America whole again."  Bearing in mind what the United States of America has gone through in the past year or so and recognizing how divided we are as a nation right now, "Let us have peace," so that we can recover, heal, and "make America whole again."

The third point I would like to make, and it's more of a question really than an actual point, builds upon the theme of making America whole again.  I also read last night that all three statues mentioned above are listed among the 41 statues that a recent commission in Chicago listed as "problematic" and identified for further public discussion.  The commission came in the aftermath of the removal of a controversial statue of Christopher Columbus.  I don't want to dive into these difficult questions (so I won't), other than to repeat what Chicago Tribune writer, Jenny Whidden, said this past year, "...it’s healthy for communities to revisit monuments, grapple with complex histories and make decisions about who they want commemorated in their neighborhoods."

So all of this came about from a long walk on a sunny day.  Leadership is lonely.  Let us have peace.  

Monkey Business

 A couple of years ago, I wrote about a classic study in cognitive psychology (see my post, "Sometimes, we are blind to what is going on around us...") by Daniel Simons and Christopher Chabris.  There's a good chance that you've at least watched the video associated with the study, and perhaps you may have even read the book that Simons and Chabris wrote, called The Invisible Gorilla.  They published their findings in the journal Perception in 1999 (see here).  The study explored what Simons and Chabris called "inattentional blindness" - basically, we frequently fail to recognize or detect changes that in objects or scenes that are going on around us, which in some cases, leads us to completely and subconsciously ignore objects in our environment.  

In this study (and if you've not heard of this study, please do me a favor and watch the video to perform the experiment yourself), subjects were asked to count the number of times in the video that players dressed in white passed a basketball back and forth to each other.  It sounds easy enough, but I have shown this video on a number of occasions to others who have often miscounted the number of passes.  What is surprising is that more than half of the time (in my experience), individuals fail to recognize that a gorilla walks across the screen about halfway through the video!

About ten years later, Simons repeated the same study, this time with a new twist.  Even if you've already watched the video and know about the gorilla, do me another favor and watch the new video.  Did you notice anything different?  Now that you are "programmed" to see the gorilla in the video, you probably saw the gorilla clearly and easily.  Did you notice that the number of players wearing black shirts decreased from three at the beginning to only two at the end of the video?  Take another look at the video.  Did you notice that the curtains changed colors (from red to gold)?

I've watched the original "Invisible Gorilla" countless times in the past, but I failed to notice either the curtain changing colors or the change in the number of players.  There's a pretty good chance that you failed to notice these subtle changes too.  Simons found (see study here) that even when 100% of the study subjects noticed the gorilla, only 11% of subjects noticed the curtain change and 16% noticed the change in the number of players.  As Simons states, "Knowing that unexpected events might occur doesn't prevent you from missing unexpected events."

Okay, this is all very interesting, isn't it?  It's even kind of fun!  What is the real-world implication of all of this though?  Well, apparently, on January 25, 1995, a Boston police officer named Kenny Conley was chasing a shooting suspect when he passed (and failed to notice) an active assault occurring on an undercover police officer.  Apparently, while Conley was climbing a chain-link fence, an undercover officer named Michael Cox joined the chase.  Another group of police officers had mistaken Cox for the suspect, assaulted him from behind, and brutally beat him.  Conley claims that he ran right past the assault without noticing anything out of the ordinary.  The subsequent investigation didn't believe Conley, and he was subsequently tried and convicted, serving about 4 months in jail for perjury.

Chabris and Simons noticed the similarities between this story and their "Invisible Gorilla" study and replicated the Conley-Cox case in the laboratory setting (see study here).  They simulated the Boston incidents by having study subjects run past a staged fight.  Only 35% of study subjects noticed the fight at night.  During the day, just over half (56%) of the subjects noticed the fight!  In other words, inattentional blindness is not just about gorillas - it has real-world implications and subsequently proved that Officer Conley's story was potentially true.

Bottom line.  There is no such thing as multi-tasking.  If you are focused on one particular task, there's a good chance that you will fail to perceive important cues or changes in your immediate environment.  As I stated a few years ago in the original post, "If you ever find yourself in a situation where you are trying to multi-task, please remember that there are gorillas in our midst!"  Alternatively, remember its all monkey business!

"Experience is a brutal teacher..."

My wife and I have been binge-watching the television series, "Criminal Minds".  Each episode (at least through season 5) starts and ends with a famous quote.  One of the recent episodes started with a quote by the British author and theologian, C.S. Lewis.  Lewis is perhaps most famous for writing the children's fantasy series, The Chronicles of Narnia.  Here was the quote:

"Experience is a brutal teacher. But you learn, my God, do you learn."

Unfortunately, there is no record that C.S. Lewis ever said this quote.  Regardless, it is a great quote.  I am reminded of a similar quote by former major league baseball player, Vern Law (who won the Cy Young Award in 1960 while pitching for the Pittsburgh Pirates), who said:

"Experience is a hard teacher because she gives the test first, the lesson afterwards."

And finally, there is one more quote that I want to share.  I promise I will move on to an actual discussion or vignette to try to tie these three quotes together.  The science fiction author, Terry Pratchett once said:

“Wisdom comes from experience.  Experience is often a result of lack of wisdom.”

Hopefully, I can convince you that (1) living through a time of crisis, struggle, or hardship will help you learn, (2) learning through these life experiences is the best way to gain wisdom, and (3) through wisdom, you will be better equipped and prepared to deal with the next crisis in the future!  As I often do in these posts, I would like to illustrate my point with a lesson from an important historical figure - in this case, two famous polar explorers from the Heroic Age of Polar Exploration (which roughly began at the end of the 19th century and lasted until shortly after the First World War), Robert Falcon Scott and Ernest Shackleton.  

I have posted about Ernest Shackleton several times in the past (see most recently, "Better a live donkey than a dead lion...").  Shackleton is clearly someone that I have enjoyed reading and writing about for quite some time.  If you are interested, there is a documenary (actually, there are several) of a recent expedition in which the modern-day explorer, Tim Jarvis leads a team that attempted (successfully) to re-create Shackleton's famous voyage in the Endurance.  It's called Chasing Shackleton - you will be amazed!

Anyway, as I previously talked about in my post, "Better a live donkey than a dead lion...", Shackleton actually accompanied Robert Falcon Scott on his attempt to reach the South Pole for the first time on the Discovery Expedition of 1901-1904 (Shackleton was Third Officer on the Discovery).  The expedition was both a failure and a success - they failed to reach the South Pole, but they did set a new Farthest South record (82°17′ S).  Scott, Shackleton, and Edward Wilson left on the final push for the South Pole on November 2, 1902.  Despite passing the existing Farthest South record of 78°50′ S just 9 days later, the rest of the journey was slow-going.  The three men suffered snow blindness, frost bite, and scurvy.  They eventually had to kill the 22 sled dogs due to poor diet and overwork (the weakest dogs were killed early on to feed the other dogs).  They eventually reached set the new Farthest South record on December 30, 1902, but gave up on reaching the South Pole.  Even though all three explorers were suffering, Shackleton was the weakest of the three.  Scott reported (and Shackleton corroborated) in his journal that Shackleton was unable to pull a sledge on his own (he also reported that they had to carry him on their sledge, although Shackleton disputed this account).  

Shackleton and Scott remained respectful and cordial in public, but in private their rivalry became more heated.  Shackleton wanted to beat Scott to the South Pole in order to salvage his wounded pride.  Shackleton would lead his own expedition - the Nimrod Expedition of 1907-1909.  While Shackleton again failed to achieve his ultimate objective, he set a new Farthest South record of 88° 23' S, coming within just 97.5 miles from the South Pole.  He recorded in his diary, "We have shot our bolt and the tale is 88° 23' S."  He had learned from his previous experiences, a successful expedition was one in which they would reach their objective (the South Pole) and return home alive.  He knew that there was no way that they would have made the South Pole and survive on the return journey.  As he told his wife, "Better a live donkey than a dead lion."

Scott, on the other hand, did not learn his lesson.  Shortly after Shackleton's failure, he led the Terra Nova Expedition of 1910-1913 (officially called the British Antarctic Expedition).  Again, the expedition was both a success and a failure.  Scott and a small team would reach the South Pole, but they would not be the first to do so.  The Norwegian explorer, Roald Amundsen and his team beat Scott by 34 days.  More importantly, Scott's entire party of five died of starvation and exposure on the return trip.

Shackleton had learned from his previous two trips to Antarctica.  To paraphrase Vern Law above, he not only passed the test, but he learned from his experiences as well.  He would also learn from Scott's experience on the Terra Nova Expedition.  In this case, again to paraphrase one of the three quotes above, Shackleton's gained important experience (and wisdom) through Scott's own lack of wisdom (pushing so hard to achieve his goal of reaching the South Pole that his team ran out of food for the return journey).  Shackleton would use these lessons in leadership for the ultimate test of his life with the Imperial Trans-Antarctic Expedition of 1914-1917 aboard the Endurance.  It was not his final expedition to Antarctica (he would die of a heart attack on his last trip to Antarctica in 1922), but it was the one for which he was the most famous.

Should hospitals be like hotels?

It was a long time ago, but I remember the details very well.  I was a third year medical student on one of my very first clinical rotations (not that it matters, but it was my general surgery rotation).  I was about a week into a rotation on the Pediatric Surgery service.  Rounds started very early, and I had completed all of my pre-rounds (the rounds before the rounds - don't ask) on all of my patients, except one.  The patient's mother told me that she had been admitted to the hospital very late the night before, and she had asked me if I could come back in another hour or so and let her daughter sleep.  She was a post-op appendectomy patient who was otherwise doing quite well, so I told the mother that I would respect her wishes.  During the rounds, the pediatric surgery fellow questioned why I hadn't examined the patient prior to rounds.  When I told him about the mother's request, he became annoyed and replied, "This is a hospital not a hotel.  Next time go in and examine the patient."

I have often thought about this specific case.  Even now, almost 30 years later, I don't know who was right in this case.  Would it have been all that bad to let my patient sleep for another hour?  After all, rest leads to recovery.  On the other hand, I was going to be in the operating room later that morning, and chances are that I wouldn't have been able to examine her until late morning.  So I can certainly see the surgery fellow's side too.  Now, as an attending physician, I would have just made the effort to come back later.  Let the patient sleep!  I still think that is the best approach, but I am not 100% certain.

As it turns out, if you ask the patients and families, they would prefer that hospitals would be more like hotels.  Dana Goldman and John Romley at the RAND corporation published a study for the National Bureau of Economic Research (NBER) in 2008 entitled "Hospitals as Hotels: The Role of Patient Amenities in Hospital Demand".  They later published an editorial piece about their study in the New England Journal of Medicine.  What they found may surprise you!

Goldman and Romley surveyed several local hospitals in the Los Angeles, California market on patient amenities (which they defined as "good food, attentive staff, and pleasant surroundings").  They used a national survey to rate each of the 117 hospitals in the local market based upon their hospital amenities (households were asked to rate individual hospitals on whether it was their first choice based upon the hospital accomodations and amenities).  Similarly, they used each hospital's mortality rate from community-acquired pneumonia as their marker of the quality of care.  

The study involved almost 9,000 Medicare patients (so that hospital price was not a factor in the choice of hospital) who presented to one of the 117 hospitals for treatment of pneumonia.  Patients under 65 years of age were excluded.  When hospital amenities improved by one standard deviation, the demand for that hospital increased by close to 40%.  The impact of amenities was smaller at hospitals that were farther away, so clearly patients prefer to be admitted to hospitals that are closer to home.  A similar one standard deviation improvement in pneumonia mortality improved hospital demand as well, but only by 12%.  

There are several factors that impact patients' selection of a hospital.  Certainly one factor is proximity to where they live, as suggested by this study.  It's also important that a particular hospital accepts a patient's health insurance, though that was not a factor in the current study, given that all of the patients were on Medicare.  We can hope that patients select hospitals based upon the quality of care delivered there.  While quality of care does appear to be a factor, it's by no means the most important.  At least in this study, the hospital's amenities were more important than the quality of care delivered.

So, what does all of this say about whether hospitals should be like hotels?  Well, I would draw the conclusion that the patient and family experience at a hospital is incredibly important.  A recently published systematic review in the Journal of Healthcare Management establishes a definite business case for improving the patient and family experience.  The authors of this review found that patients were more likely to return to the same hospital or ambulatory clinic if they had a positive experience.

Perhaps I was right to wait to examine my patient as a third-year medical student?  Regardless, it's clear that quality of care is just one factor in attracting patients, and unfortunately it may not even be the most important factor.  Hospitals should focus on trying to improve their patient and family experience scores, and one way to do that may be to evaluate the quality of their accomodations and amenities.  To that end, maybe there is something that we can learn from the hotel industry? 

Independence

Today in the United States of America, we celebrate the Fourth of July holiday.  Independence Day.  Fireworks.  Picnics.  Family get togethers.  It all happens today.  July 4, 2021 feels different to many of us, at least when we remember what we were doing last year at this time (most of us probably weren't celebrating, as we were still in the midst of a global pandemic).  

Today we celebrate our independence.  Just only 245 years ago, 56 patriots signed one of the greatest documents in history, our Declaration of Independence.  "When in the course of human events, it becomes necessary for one people to dissolve the political bands which have connected them with another..." And with that statement, 13 colonies declared their intention to the King of England, George III, that they were colonies no longer.  With that statement and the sentences to follow, the 13 colonies became the United States of America. 

The Declaration continues with the immortal words, "We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness."  Beautiful, inspiring words for sure.  Unfortunately, the phrase "all men are created equal" rings less true when you consider the fact that the majority (forty-one, in fact) of the Signers owned slaves.  

It's hard for many of us to reconcile the fact that so many of the Signers owned slaves with the words, "All men are created equal."  I encourage you to read Frederick Douglass' speech, "What to the Slave is the Fourth of July".  Douglass delivered his speech just one decade before the American Civil War, at the end of which he would say that while gaining our independence from England following the American Revolutionary War was great, it paled by comparison to what was achieved at the end of the Civil War and the passage of the 13th Amendment that ended slavery once and for all. 

We acknowledge that the document is flawed, particularly in regards to this point.  History is like that.  And we continue to learn from the past, as we look towards a new and better future.

At the end of the day, the 56 men who signed the Declaration were committing treason.  Benjamin Franklin, one of only six men to sign both the Declaration of Independence and the Constitution acknowledged that fact when he said, "We must all hang together, or most assuredly we shall all hang separately."  In other words, these men were putting their lives on the line.  As such, they end their Declaration with, "And for the support of this Declaration, with a firm reliance on the protection of divine Providence, we mutually pledge to each other our Lives, our Fortunes and our sacred Honor."

We have so much to celebrate this Fourth of July.  But we also have to remember where we are as a country today.  Imagine what we could accomplish as a nation if we truly lived by the words, "all men and women are created equal."   

So tonight, take a moment before the fireworks and read the Declaration of Independence.  And then reflect on the hard work that still lies ahead.

The Board of Directors for Me, Incorporated

I recently came across a superb article by Jenny Fernandez and Luis Velasquez that was published online by the Harvard Business Review ("5 Relationships You Need to Build a Successful Career").  I will summarize the article here and offer a few additional insights from my own experience.  The article starts with the old African proverb, "It takes a village to raise a child."  To a similar extent, it takes the proverbial village of relationships to build a successful career.  Fernandez and Velasquez recommend having five different kinds of relationships in your own personal village (if you don't like the village metaphor, think of these relationships as your own personal Board of Directors for "Me, Inc."):

1. The Mentor:  

In Homer's Odyssey, the character "Mentor" was an old friend of Odysseus.  When Odysseus left to go fight in the Trojan War, he placed Mentor in charge of looking after his son, Telemachus.  Both the word and definition of "mentor" come directly from the relationship between Mentor and Telemachus (note that this relationship wasn't really discussed in Homer's Odyssey, but this important backstory is discussed in greater detail in a novel by the French author, François Fénelon that was popular in the 18th century called Les Aventures de Télémaque).  Later on in the Odyssey, the Greek goddess Athena assumes Mentor's appearance to guide Telemachus during a time of personal hardship.  The term "mentorship" similarly refers to the guidance or direction provided by someone with more experience or knowledge (i.e., the mentor).   

I have been fortunate to have a number of different mentors throughout my career.  As I look back on my professional career so far, there have been individuals all along the way who I've grown to trust, admire, and respect and who have helped me grow and develop when I have failed.  They have always been there to share in my successes too.  As Fernandez and Velasquez state in their article, "Think of a mentor as the north star that will keep you on track when're you're feeling lost at work."  I have continued to rely upon their wisdom, experience, and counsel whenever I've had an important decision to make in my professional life.  

2.  The Sponsor:

Fernandez and Velasquez state it this way, "While mentors give you advice and perspective, sponsors advocate on your behalf, and in some cases, directly present you with career advancement opportunities."  They further reference Morgan Stanley's Managing Director Carla Harris' TED Talk, who says, "A mentor, frankly, is a nice-to-have, but you can survive a long time in your career without one.  You are not going to ascend in any organization without a sponsor."

The research supports the importance of having a sponsor.  A junior manager with a sponsor is 21% more likely to be promoted compared to a colleague in the same position who doesn't have one.  The author, Sylvia Ann Hewlitt writes in her most recent book, The Sponsor Effect that there are three things that sponsors do for their proteges.  First, sponsors "endorse noisily" - they bring their proteges to meetings and help them make the kind of connections to build their network.  Second, sponsors "advocate behind closed doors."  If there are new positions or projects that are coming up, sponsors can help make sure that their proteges are considered for them.  Third, sponsors "provide air cover" when things go wrong, as they inevitably do.  Sponsors can help with both damage control and recovery efforts.

Again, I have been fortunate to have individuals who have suggested me to lead different projects or initiatives, or even encourage others to consider me for promotional opportunities.  In the majority of cases, I would not consider these individuals to be mentors, but yet their advocacy on my behalf has been just as instrumental to my success.  They've invested just as much time in me, though in ways different from my mentors.

3.  The Partner:

While an individual's mentor and sponsor are the seasoned veterans, it's also important to have someone to collaborate with that is at a similar stage in their career.  Finding a peer who you can trust, bounce ideas off of, collaborate with on different projects, and help connect you with individuals outside your normal sphere is just as important as finding a mentor and sponsor.  Fernandez and Velasquez tell how the women in President Obama's administration used an "amplification strategy" where if one woman on the team made a key point during a meeting, the others would repeat the point and give credit again to the idea's author.  

Try to find a partner who not only complements your skills, he or she may also fills in the gaps where you are weak.  Together, both of you can be a powerful force for innovation and succcess.  Here again, I have been fortunate to have a number of collaborators and colleagues have assisted me throughout my career.  

4.  The Competitor:

Larry Bird played against Magic Johnson throughout his career, starting with the 1979 NCAA College Basketball Championship (Indiana State versus Michigan State) and throughout their NBA careers.  Magic said, "People wanted to see us play against each other...If you like competition you want to play against the best, and that's what we wanted to do."  They made each other better.

A little competition is not only healthy, it can lead to a win-win situation.  Both Larry Bird and Magic Johnson were better basketball players because of their competition with each other.  Embrace your competitors - learn from what they do.  You may even want to reach out to them and learn from them.

5.  The Mentee:

As the old saying goes, "See one.  Do one.  Teach one."  Cal Tech Professor Richard Feynman, who won the Nobel Prize in Physics in 1965 said, "If you want to master something, teach it."  Serving as a mentor can be incredibly helpful for your own career.

Fernandez and Velasquez write, "As a mentor, you are a leader and role model.  You learn to bring out the best in others, recognize their strengths, give feedback, and coach."  You will strive to be better because of your relationship with your mentee.  How about this statistic, again from Sylvia Ann Hewlitt (this time writing in the Harvard Business Review), leaders with mentees are 53% more likely to be promoted to the next level compared to leaders without mentees.  The mentor-mentee relationship is absolutely reciprocal.  Having mentees has not only been valuable for my own professional development, but also it has been incredibly rewarding!  

The five individuals listed above are a great place to start developing your “support team.”  Think about how you build your own personal Board of Directors.  It is absolutely time well spent.