"You don't need to answer right away!"

I enjoy reading about current events in newspapers and magazines, but unfortunately I don't always have the time do so.  However, this past weekend, I came across a really great article in the weekend edition of the Wall Street Journal by Laura Giurge and Vanessa Bohns ("The Curse of Off-hours Email").  These two authors know what they are talking about, as they conducted the original study upon which the WSJ article is based.  

The WSJ article begins with the following case scenario:

Imagine it's the end of the workday and you have a non-urgent question to ask a colleague.  You know this colleague has already gone home for the day, but you send off an email to them anyway.

How many times have you found yourself in a similar situation?  Conversely, if you are that colleague who is the recipient of the email, when do you respond?  There is no question that the lines separating work from home have been considerably blurred during the COVID-19 pandemic, particularly early on during the pandemic when so many teams were forced to work remotely from home.  Even now, a number of teams continue to work remotely (I read one report that suggested that 1 in 4 Americans will be working remotely through the end of 2021 and slightly less than that will be working remotely by the end of 2025).  In other words, the lines separating work from home will get more blurred (and not less) with the passage of time.

I want to be clear though.  The question of whether to respond to a work email when you are at home did not arise because of the pandemic.  Individuals struggled with this question even before COVID-19.  For example, according to reports by the Radicati Group, employees spend, on average, more than 2 hours a day sifting through and reading emails - that's 28% of the normal work week!  Unfortunately, the number of emails that individuals receive is expected to increase by approximately 3% every year.  I suspect that this isn't a surprise to most of you.  What's even more concerning is the fact that over half of employees send or respond to emails outside of normal working hours!  Again, I suspect that's not a surprise.

Here's the surprising (maybe) statistic.  Even though the vast majority of after-hours emails do not require an after-hours response, over three-fourths of employees (at least in one survey) typically respond within an hour (and just under one-third respond within 15 minutes!).

Drs. Giurge and Bohns conducted a series of studies involving over 4,000 subjects to further address the question posed in their WSJ article above.  They had subjects answer surveys from the perspective of an individual sending versus receiving an after-hours, non-urgent email.  Receivers assumed they needed to respond 36% faster than the senders expected.  Importantly, these receivers were more stressed by having to respond (or more specifically, feeling like they needed to respond), which they also felt contributed to greater degrees of burnout.  

The results were similar no matter how they varied the experimental conditions.  For example, in one study, emails were marked as either "urgent" or "non-urgent."  Labeling the email as "urgent" certainly increased the recipient's feeling that he or she needed to respond right away (as you would expect, I think).  And this was true regardless of whether the email was sent during normal work-hours or after-hours.  What is more suprising is that even when the email was marked as "non-urgent", recipients still felt that the sender expected a quick response!  Again, it didn't matter whether the email was sent during normal work-hours or after-hours.

I completely understand both perspectives.  I often send email after normal working hours (admittedly, it's one of the only times that I feel that I can catch up with my Inbox), but I don't expect anyone to respond until they return to work.  However, unless I specifically state "Do not respond until tomorrow", this study suggests that the recipient will feel like I am waiting for a response.  Taking the perspective of the recipient, I feel if I don't respond immediately to an email, the sender may feel like I am ignoring him or her (regardless of whether that sender is a direct report or my boss, but especially if it's my boss).

Drs. Giurge and Bohns label this phenomenon as the email urgency bias.  It's an extension of something that is described in a whole body of literature (that they reference in the article) called an ego-centric bias.  As they describe it in the WSJ article, "People tend to be anchored in their own perspective in the moment and often fail to appreciate the ways in which someone in a different position might be interpreting the same situation."

The important lesson from this article is that there is an effective method (tested and proven in the last study that Drs. Giurge and Bohns conducted) to mitigate the email urgency bias.  Rather than marking the email as "Urgent" or "Non-urgent" (which doesn't work apparently), try starting an after-hours email with one of the following statements:

"Even though I'm sending this email outside regular work hours, which fits my own work-life schedule best, I don't expect a response outside of your own work hours."

"Note that you might receive this message outside of my office hours but that I have no expectation to receive a message outside of your office hours."

"Please know that I respect boundaries and personal time.  If you receive an email from me during your personal time, please protect your time and wait to respond until you are working.  It's important that we all prioritize joy over email whenever possible."

As it turns out, these kind of statements work!  There was no evidence of the email urgency bias in the final study - both the sender's and recipient's expected response time aligned nicely.  Alternatively, many email providers provide a nice little feature that you can hold an email until a certain time.  With that kind of feature, email messages can be written by the sender at whatever time is convenient for him/her, but the message doesn't get delivered until normal work-hours.

Granted, these small changes don't address the fact that emails are becoming more frequent (and I've not even touched the culture of "Reply to All").  That is a topic for another day.  I will end, as I frequently do, with a quote.  Television personality and journalist Willie Geist once said, "I'm pretty sure people are going to start writing letters again once the email fad passes."  Maybe he is on to something...

"As a leader, you leave a wake..."

The clinical psychologist, New York Times bestselling author, and leadership expert, Henry Cloud frequently talks about the "wake" that a leader leaves behind.  He wasn't talking about the social gathering that family members and friends hold to honor the death of a loved one.  Rather, he was talking about the wave patterns left on the water surface behind a moving object (usually a boat or ship).  I've never really thought much about 'wakes' per se, but there is apparently a whole science behind them.  As objects move through incompressible fluids (such as water), waves are formed because as the object displaces and disperses the water as it moves forward (think of the object as 'pushing away' the water ahead to the sides).

It's a beautiful metaphor when you think about it.  Dr. Cloud said, "As a leader, you leave a 'wake' behind you in every interaction, relationship, project, and season.  Your wake encompasses the results of your leadership, and the relationships with those you lead.  One without the other is ineffective."

Imagine a boat or ship moving through the water.  What kind of wake does it leave?  I think about a sailboat that moves swiftly, yet gracefully through the water, leaving a smooth, organized wake behind.  Contrast that with a motorboat that is moving quickly and chaotically through the water.  The boat is moving so fast, that it is violently bouncing up and down over the waves as it travels forward.  The wake that it leaves behind is just as chaotic.  None of the other boats want to follow behind it.  

So too, some leaders leave nothing but chaos behind.  Abraham Lincoln said, "Nearly all men can stand adversity, but if you want to test a man's character, give him power."  It's almost 100% assured that each and every one of us has either worked for or at least knew of a leader who created chaos.  It's not fun. 

 Dr. Cloud emphasizes that the results and the relationships both contribute to a leader's wake.  They are equally important and co-dependent.    The Dalai Lama said, "Just as ripples spread out when a single pebble is dropped into water, the actions of individuals can have far-reaching effects."  So too with wakes.  Think about it.  The crazy motorboat in my example above leaves the kind of wake that disturbs everyone else who's on the same lake.  It causes other boats to violently rock back and forth on its waves.  The people playing on the shore or standing on the dock might even get wet.  The effects of a poor leader are far-reaching and often long-lasting.

Dr. Cloud goes on further with his analogy, "The wake is the results we leave behind.  And the wake doesn't lie and it doesn't care about excuses.  It is what it is.  No matter what we try to do to explain why, or to justify what the wake is, it still remains.  It is what we leave behind and is our record."

I bet that you will know what question I will end with today.  It's a fairly simple question, but it is an important one to ask.  What kind of wake will you leave?

How much time are physicians and nurses spending together at the bedside?

I recently came across a very interesting study conducted by a group of investigators at Stanford University ("How much time are physicians and nurses spending together at the patient bedside?").  The investigators took advantage of the hospital's real-time locator system using radio frequency identification (RFID) to measure the amount of time physicians spent on rounds in three acute medical/surgical units.  Both the attending physicians and nursing staff wore the RFID locators.

The physician rounding teams (attending physician, residents, medical students) were encouraged to include the patient's bedside nurse on rounds, but this was not mandatory.  The study was conducted over 90 consective days, leading to a total of 739 different rounding events.

On average, physicians spent close to seven minutes at each bedside.  There were no differences in the duration of rounds between weekdays or weekends.  Of the physician rounding events observed in single-patient rooms (i.e., double patient rooms were excluded from the analysis), a nurse was present during rounds only 30% of the events.  The duration of physician-nurse overlap in each room was only about three-and-a-half minutes.  There was no difference in physician-nurse overlap between weekdays and weekends.

All three of the medical/surgical units had the same configuration - nineteen beds in a linear layout,  There was a central nursing station across from the 10th patient room.  Of note, for each additional room farther away from the nursing station, the likelihood that the nurse attended rounds decreased by almost 2%.

Studies have consistently shown that when physicians and nurses round together, patient care improves.  Interdisciplinary rounds (physicians rounding with the nurses present at the bedside) have been shown to improve the perception of teamwork, reduce the number of pages for the physician team, better involve the patient in developing a plan of care, and decreasing the hospital length of stay.  Better communication and teamwork also improves patient satisfaction, as well as nurse satisfaction and retention.  Nurse retention is particularly relevant considering the current nursing staffing crisis (there are not enough nurses to go around).

Clearly, including the nurse on rounds is a win-win!  The natural question follows - why do physician rounding teams continue to round in isolation?  I completely admit that this is just one study, but there are others that show even worse nurse inclusion in physician rounds.  Another   study using medical students as observers showed that the physician teams communicated with the nurses during rounds only 12% of the time!  In full disclosure, another study showed that multidisciplinary rounds were much more common (physician-nurse overlap was 63% to 81%).

We need to do a better job of including the patient's bedside nurse on rounds.  Will it make rounds last longer?  Probably (and at least in the study above, it did increase the average duration of rounds from 5.68 minutes per patient to 9.56 minutes per patient).  However, if care is better, patients are happier, and nurses are happier, this doesn't seem like all that much of a sacrifice.  Just as important, if including the nurse also leads to less pages for clarifications or questions later in the day, the efficiency of physician rounds AND physician satisfaction will improve.

Health care is a team sport.  And we do better when everyone on the team works together.  More hospitals should bring the physician rounding teams and bedside nurses together at the bedside.

Sorting out the heroes from the bums...

I wanted to continue with the theme of crisis leadership.  Vice Admiral James Stockdale, naval aviator, prisoner of war, and winner of the Congressional Medal of Honor said, "It is in disaster, not success, that the heroes and the bums really get sorted out."  That may be a little harsh, but I think it is absolutely true.  Times of crisis are when leadership is really tested.  

I would like to go back to the article published a few months ago in Nursing Administration Quarterly by Drs. Renee Thompson and Mitchell Kusy ("Has the COVID pandemic strengthened or weakened health care teams?").  The two authors of this article highlighted one of the unique challenges of the COVID-19 pandemic.  Early on during the pandemic, the leadership mantra was "We got this!"  We all believed that their was a finish line in sight, particularly when new treatments and a number of vaccines became available.  Unfortunately, the crisis continued for longer than perhaps anyone had anticipated.  As the delta variant became the dominant strain of the virus this past summer and cases started to increase (again), the leadership mantra became, "Here we go again."  

Drs. Thompson and Kusy interviewed over 400 nursing leaders throughout the pandemic and learned that there were two common leadership mistakes that increased dysfunction among their teams.  There is no question that, particularly early on, there were a lot of unknowns.  Some leaders, rather than acknowledging that they didn't have all the answers, tried to alleviate their teams' anxieties and concerns by making promises that they could never hope to keep.  For example, the supply chain disruptions early in the pandemic led to shortages of surgical masks, hand sanitizer, and N-95 masks (the two largest manufacturers of N-95 masks were located in China and Italy, which were two of the early COVID-19 hotspots).  Given these shortages, leaders claimed that universal masking was not necessary, and N-95 masks were only required for certain high-risk situations.  I fully recognize that these statements were made with the best intentions and, at the time, with the best, available evidence (I will also admi that I made these kinds of statements myself).  However, I can't help but wonder if these early statements, which were later followed by statements recommending - actually, requiring - universal masking and N-95 for all COVID-19 patients created mistrust.

As Dr. Thompson and Kusy state, "Trust is one of the most critical elements for team succcess."  When leaders don't have all the answers (and that will happen), it is better to admit it and not make declarative statements or promises that they can't keep.  I know leaders were reluctant to talk about the limited supply of personal protective equipment early in the pandemic, but perhaps we should have been more forthright about our lack of knowledge on the evidence and the limitations in assets.  

Several leaders in Thompson and Kusy's study stated that they were uncomfortable delivering information that they didn't necessarily agree with.  This is one of the most difficult positions to be in, but unfortunately one that is not so uncommon, especially for middle managers.  There are a couple of caveats here.  Leaders should never do or support something that is ethically or morally wrong.  On the other hand, there will be times when the leader has no choice but to follow some governmental mandate or legal regulation (even when they don't agree).  What I am talking about is the situation where a leader has to convey information on a change to their teams that they don't necessarily agree or support.

So, how do you lead a change you don't agree with?  Blog writer Kevin Eikenberry offers a couple of recommendations:

1. Give it a little time. There is no question that change is difficult.  Your first response to a change initiative is frequently, "You've got to be kidding me!"  However, in many cases, once you allow your initial reaction to pass and have time to think and reflect on the change, you will realize that the change is necessary.

2. Ask for more information.  If you don't understand the rationale, ask questions!  Again, once you hve time to collect more information, you will often realize that the change makes sense.

3. Understand the why.  I think this follows from the first two points above.

4. Recognize the source of your concern.  Are you simply holding on to the past?

5. Influence the outcome if possible.  As the saying goes, "There are many ways to skin a cat."  Look for opportunities to influence how the change is implemented.  Perhaps you have more control than you think.

6. Implement the change.  Eikenberry suggests (and I agree with him here) that if you follow steps #1-#5 above, you should be in a good position to proceed with the change.

The second most common mistake that leaders made, according to Drs. Thompson and Kusy, was ignoring or allowing disruptive behaviors.  As they write, "During the crisis, we saw the best and worst in people."  We've all observed, I think, an increase in disruptive or unprofessional behaviors.  Individuals are incredibly stressed, and unfortunately, at times stress leads to bad behavior.  

Again, Drs. Thompson and Kusy observed that, "leaders tried to accomodate, defend, rationalize, or ignore disruptive behaviors when they showed up."  While admittedly this was likely a common reaction, it was unfortunately the incorrect response.  There are no excuses for bad behavior, and leaders who do not address these behaviors actually condone and encourage them. 

Thomas Jefferson said,  "The most fortunate of us all in our journey through life frequently meet with calamities and misfortunes which greatly afflict us. To fortify our minds against the attacks of these calamities and misfortunes should be one of the principal studies and endeavors of our lives."  Those of us who have been privileged to be in a leadership position during this pandemic (and despite how difficult it has been to be a leader in this crisis, it is still a privilege) have learned a lot, both about ourselves and our teams.  There will be time in the near future to "fortify our minds" by studying and reflecting on what worked well during this pandemic.  We should not miss that opportunity.

"Rest easy shipmate, we have the watch..."

I was saddened to learn earlier today of the death of General Colin Powell.  He had an amazing career, serving as our 16th United States National Security Advisor (1987-1989), 12th Chairman of the Joint Chiefs of Staff (1989-1993), and 65th U.S. Secretary of State (2001-2005).  There will be all kinds of opportunities to celebrate and honor General Powell in the days to come.  I have always admired General Powell, and I have personally learned a lot about leadership from his speeches, public appearances, and books.

He was a servant leader, in every sense of the term, who put the needs of his country ahead of his own.  He led with honor, integrity, and wisdom through some of our country's greatest challenges.  All but one of the currently living ex-Presidents had something to say to honor General Powell.

Joe Biden: "Over our many years working together - even in disagreement - Colin was always someone who gave you his best and treated you with respect...Time and again, he put country before self, before party, before all else –in uniform and out – and it earned him the universal respect of the American people."  

George W. Bush: "He was such a favorite of presidents that he earned the Presidential Medal of Freedom – twice. He was highly respected at home and abroad...and most important, Colin was a family man and a friend."

Barack Obama: "Everyone who worked with General Powell appreciated his clarity of thought, insistence on seeing all sides, and ability to execute. And although he’d be the first to acknowledge that he didn’t get every call right, his actions reflected what he believed was best for America and the people he served."

Bill and Hillary Clinton (in a joint statement): "He lived the promise of America, and spent a lifetime working to help our country, especially our young people, live up to its own ideals and noblest aspirations at home and around the world."

Jimmy Carter: "A true patriot and public servant, we were honored to work beside him to strengthen communities in the United States, help resolve conflict in Haiti, and observe elections in Jamaica. His courage and integrity will be an inspiration for generations to come."

If you haven't heard of his famous "Thirteen Rules of Leadership", I would encourage you to take a look at them.  They first appeared in a Parade magazine profile of General Powell in 1989 and subsequently provided the opening chapter for his 2012 best-selling memoir, It Worked For Me: In Life and Leadership.  The book elaborates on each of the rules in much greater detail, but I will list them here:

1.  It ain’t as bad as you think. It will look better in the morning.

2.  Get mad, then get over it.

3.  Avoid having your ego so close to your position that when your position falls, your ego goes with it.

4.  It can be done!

5.  Be careful what you choose.

6.  Don’t let adverse facts stand in the way of a good decision.

7.  You can’t make someone else’s choices.

8.  Check small things.

9.  Share credit.

10. Remain calm. Be kind.

11. Have a vision. Be demanding.

12. Don’t take counsel of your fears or naysayers.

13. Perpetual optimism is a force multiplier.

General Powell also is credited with a number of leadership aphorisms that have appeared in his writings, including his autobiography My American Journey.  Here are a few of my favorites:

“If you are going to achieve excellence in big things, you develop the habit in little matters.”

“Control enthusiasm in the face of victories, large or small.”

“There is no end to the good you can do if you don’t care who gets the credit.”

“Leadership is solving problems. The day soldiers stop bringing you their problems is the day you have stopped leading them.”

These aphorisms really resonate with me.  There is no question that General Powell made some mistakes in his life (some really big ones).  Today, we should remember him for all of the great things he did in service to our country.  I realize that General Powell was in the Army, but I still think the following passage fits:

Today we are here to say

"Shipmate...the watch stands relieved.

Relieved by those You have trained, Guided, and Led.

"Rest easy shipmate, we have the watch..."

"Anyone can lead when the plan is working..."

The Canadian writer Robin Sharma said, "Anyone can lead when the plan is working.  The best lead when the plan falls apart."  Former heavyweight boxing champion, Mike Tyson would agree and would offer, "Everyone has a plan until they get punched in the mouth."  Well, if I could summarize what the last 19 months have felt like, I think "getting punched in the mouth" fits perfectly!

I came across a really good article by Paul Kempinski, Presidet and CEO of Children's Mercy in Kansas City, Missouri in this past month's issue of the Journal of Healthcare Management.  It's called, "The culture imperative: Preserving your organization's soul" - I believe every leader in health care should read this article!  Kempinski was still relatively new in his role (16 months) when the COVID-19 pandemic was declared in March, 2020, and one of the discussions was whether to modify their new 5-year strategic plan, which had been approved by the hospital Board just one day prior to the official pandemic declaration.  

Here is what Kempinski said, "Our plan was toast, at least for the moment.  Overnight, we sent 2,300 employees home to work.  Over the next few weeks, our surgical and outpatient volumes dropped more than 70%.  Our emergency department and urgent care volumes decreased 57% and 67%, respectively.  Admissions slid 32%.  We were losing $1 million a day, every day, for nearly 3 months."  

Children's Mercy's experience was not unique.  Almost every other children's hospital experienced the same decrease in volumes, as hospitals deferred elective surgeries and admissions.  In addition, with everyone working remotely and going to school remotely, children were just not getting sick.

Rob Lane, MD, the physician-in-chief at Children's Mercy spoke up during one of the executive leadership meetings, "When we get through this, we want our employees to look back on the pandemic and say, 'Our organization cared for us.  It had to make tough decisions.  We didn't always agree, but we got through this, and our collective soul and our culture remained intact.'"

Every decision that Children's Mercy's executive leadership team made during the early crisis days of the pandemic were guided by their mission, vision, and core values (which, incidentally, they had just updated and re-committed to).  Kempinski goes on to say, "It has been said that adversity does not build character in an individual; it reveals it.  The same is true for organizations."  Confronting a crisis was not the time to abandon their mission, vision, and core values.  Instead, the crisis reaffirmed them - they remained the North Star for the way forward.

The American author and social activist Grace Lee Boggs said, "Finding the leaders of the future is a question of recognizing those people who give leadership in a crisis."  With that in mind, there is another article that I highly recommend, published a few months ago in Nursing Administration Quarterly by Drs. Renee Thompson and Mitchell Kusy ("Has the COVID pandemic strengthened or weakened health care teams?").  Both authors suggest that teams confronting a crisis should conduct a "purpose audit" - in other words, focus on the mission, vision, and core values!  

There's a lot to unpack in this article too (and I want to come back to it again in the next post).  However, they found that the leaders who were most successful at keeping their teams together and becoming stronger in the crisis could be characterized by five behaviors:

1. They were honest about what they didn't know ("They admitted that they did not have all the answers and were learning just like their staff.  They told the truth and increased the frequency of their communication.").

2. They were visible and "got dirty" first (see also "Leaders eat last"; "The leaders who managed to successfully lead their teams through the crisis made visibility a priority.").

3. They continued to address any incidents of disruptive behaviors (Unfortunately, almost every organization, particularly those in health care, have witnessed an increase in disruptive behaviors.  The most effective leaders addressed these behaviors quickly and told their teams, "It's not okay for you ro behave this way.").

4. They focused on the present ("Leaders reminded their teams that they had control over today and to focus today on doing the best that they could for their patients and for each other.").

5. They showed their team they cared about them ("Leaders who strengthened their teams took the time to show they cared by giving them permission to express emotions and encouraging them to talk.").

Pope Francis wrote in his book, Let Us Dream: The Path to a Better Future, "The basic rule of a crisis is that you don't come out of it the same.  If you get through it, you come out better or worse, but never the same."  I believe that if we don't lose sight of our mission, vision, and values - our purpose, to use another term - we will not only come out of this crisis, but we will also emerge as stronger and better organizations.  

Elevators, M&M's, dust balls, and toilet paper

What do elevators, jelly beans (specifically brown M&M's), and toilet paper have in common?  Surprisingly, more than you would think.  A couple of years ago, I posted about something I heard at my daughter's college graduation, "The way a person does one thing is the way they do everything."  I mentioned the story about the rock-n-roll band, Van Halen having a "M&M clause" in their touring contract.  Apparently, in the early days they would tour with these very elaborate sets that required a lot of attention to detail in order to safely assemble them at the concert venue (lots of pyrotechnics, lights, heavy equipment, etc).  There was a clause deeply embedded in their contract that stated that they required a bowl of M&M's as one of their snacks before the concert.  However, they specifically requested "ABSOLUTELY no brown ones!"  If they ever found Brown M&M's in their candy bowl, the band would know that the local concert venue hadn't read through the contract in full.  The lack of attention to detail would increase the risk of their performance not going smoothly (or worse, it increased their personal risk of safety).  Brown M&M's meant that the contract was null and void, and they would go on to play in the next tour location.  The band created this small detail to ensure that every little detail was taken care of.

I also mentioned another seemingly small trivial practice that signaled "attention to detail."  Have you ever noticed that the toilet paper in a hotel room is neatly folded over into a triangle ("toilet paper origami")?  That's the housekeeping staff's way of letting you know that they've thoroughly cleaned your room.  Some hotels (and most cruise lines) have started to create towel animals (towels that are neatly folded to create an animal sculpture) for the same purpose.  Again, these small details let you, the customer, know that "this company takes 'attention to detail' to a whole different level!"

Now, let's talk about elevators.  I am reading a great book right now called, World Class: A Story of Adversity, Transformation, and Success at NYU Langone Health by William Haseltine (here is an online discussion about the book by the Brookings Institution).  The book is about how a large academic medical center went from near bankruptcy to become one of the leading health care institutions in America.  One of the stories mentioned early in the book stood out in particular to me.  The new (at the time) CEO and Dean (of the medical school), Robert Grossman used a data-driven approach to transform the medical center.  However, he also recognized the importance of small, early wins that were largely symbolic.  Haseltine writes, "While Grossman went to great lengths to ground decisions in data and focus on improving major components of NYU Langone's activities, he also understood the importance of symbolic gestures and actions.  He understood that people need early wins to build enthusiasm and gather momentum."

What did Grossman do that was so symbolic?  He fixed the elevators at the hospital!  Here is what New York University's board chair, William Berkley said about the hospital elevators, "Everybody hated the elevators.  They were detrimental to the quality of life for everyone who worked here."  The elevators were apparently very slow, unreliable, and frequently inoperable.  They were always crowded (a much bigger deal nowadays with COVID-19), and passengers frequently had to go down a couple of floors in order to eventually go up to the right floor.  

Shortly after he became CEO, Robert Grossman led the construction of a whole new, separate, freestanding elevator tower that was connected to the main hospital.  He doubled the number of elevators, renovated the main entrance, and modernized the technology.  Berkley said of Grossman, "he understood how important it was for the employees to know that we were willing to spend money to fix what needed fixing."  Grossman would later tell the board, "While the money we spend on the elevators will not help make a patient better tomorrow, it changes how people feel about what we do."  

Again, it's often the small "attention to detail" kind of things that matter most.  Spending money to fix the elevators - a major source of frustration for both Langone's employees and patients - signaled to the rest of the institution that Grossman would "go the extra mile" to making sure that the staff was supported.  It was a costly investment for the institution, at a time when the institution wasn't do well financially.  But in the end, Grossman felt it was worth it.

One final example.  A few years ago, I was walking up the stairwell of my hospital's parking garage.  There were a number of dust balls along the stairwell.  I called our facilities department to have them clean up the stairwell.  They pushed back more than a little bit - "Doc, it's a parking garage, people will expect it to be dirty."  I countered, "If you were bringing your child here and noticed that the stairwells were this dirty, what would you think?"  The facilities manager thought about it for a minute and replied, "I guess I would be concerned.  If a hospital didn't think it was necessary or worth the cost to clean the stairwell, where else were they cutting corners?"  Bingo.  Lesson learned.

Attention to detail matters.  These small, seemingly trivial (though admittedly the elevator project at Langone was not trivial) practices - brown M&M's, toilet paper origami, dust balls, and elevators - served as a signal that the organization would do everything possible to make sure that the end-user experience was the best it could be, whether the end-user was a rock-n-roll band, a hotel customer,  a patient or visitor, or a hospital employee.  As the 17th century writer and preacher, Francis Atterbury said, "It's attention to detail that makes the difference between average and stunning."  Or if you prefer a more modern quote, the late John Wooden said, "It's the little details that are vital.  Little things make big things happen."

Was Darth Vader a good leader?

Joseph Campbell was an American professor of literature at Sarah Lawrence College in New York who is best known for his work, "The Hero with a Thousand Faces", in which he proposes that all mythological hero stories share the same structure.  He called this structure a "monomyth", or hero's journey.  Cambell described a number of stages on this hero's journey:

1. The hero's adventure begins in the ordinary world.

2. The hero must depart from the ordinary world and receives a call to adventure.  

3. With the help of a mentor, the hero will cross a guarded threshold, leading to a supernatural world.

4. The hero will embark on a road of trials.  

5. Sometimes the hero is assisted by allies.

6. The hero eventually is faced with the greatest challenge or ordeal.

7. The hero passes the challenge and receives a reward.

8. The hero returns to the ordinary world.  The reward will help the hero to improve the ordinary world.

Does any of this sound familiar?  If you have ever watched the original Star Wars movie trilogy, it should.  Apparently George Lucas, who created the Star Wars universe, was greatly influenced by Campbell's theories.  The Star Wars trilogy had all of these elements and more.  Perhaps that is why these movies are still popular even today.  As it turns out, we can learn a lot about leadership by enjoying these movies!

When Anakin Skywalker succumbed to the Dark Side of the Force, he became the trilogy's supervillain Darth Vader.  As it turns out, leadership has its own dark side too.  The three personality traits of narcissism, Machiavellianism, and psychopathy comprise what has come to be called the Dark Triad.  Importantly, every one of us have varying degrees of these three personality traits, some more than others.  And a number of studies have linked these three traits with leadership (see the Harvard Business Review article, "Why Bad Guys Win at Work").  

Psychopathy (also known as sociopathy) is not a trait that immediately comes to mind when you think of good leaders.  Psychopaths in general more bold, egocentric, reckless, and remorseless than the rest of us.  Machiavellianism is related to superficial charm ("fake" charm), deceit, ruthlessness, and impulsivity.  Individuals who score high on this trait would suggest that "the ends always justify the means" and "it is hard to get ahead without cutting corners."  Finally, narcissism is characterized by an inflated, grandiose sense of self-worth and an overabundance of pride.  

Most studies would suggest that these three personality traits develop early in life.  In what is perhaps the best study of all time ("The making of Darth Vader: Parent-child care and the Dark Triad"), one group of investigators surmised that Anakin Skywalker (who scores high on all three of the personality traits that comprise the Dark Triad) became Darth Vader because of the loss of his mother.  If you've watched the Star Wars prequel trilogy, that should come as no surprise. 

Here's where things get really interesting.  As Tomas Chamorro-Premuzic wrote in the aforementioned HBR article, "there is clearly a bright side to their dark side."  A number of studies have suggested that individuals who score high on the psychopathic, narcissistic, or Machiavellian traits often end up in positions of leadership.  Several investigators have used biographical data to rate the U.S. Presidents from Washington to Reagan on the three traits that comprise the Dark Triad.  In general, Presidents scoring high on narcissism, Machiavellianism, and psychopathy are the ones that are more often rated to be among the nation's most successful Presidents.  

There are clearly advantages to having some degree of the Dark Triad traits.  But at what cost?  I would argue that Darth Vader was a great leader (as others have also done).  Perhaps the character Ollivander in the Harry Potter movies said it best when he said that Voldemort (who has a similar personality profile to Darth Vader, I might add) did "great things - terrible yes, but great."  And there is a tremendous down side to narcissistic, Machiavellian, and psychopathic leaders - they are often associated with job dissatisfaction, turnover, absenteeism, and even lower productivity (not to mention the associations with embezzlement, fraud, and corruption).  

I will leave this discussion with where I started - with a quote by Joseph Campbell.  He said, "Opportunities to find deeper powers within ourselves come when life seems most challenging."  He followed with, "If the path before you is clear, you're probably on someone else's."   Perhaps those are the best leadership lessons of them all.

"Where were you when the world stopped turning...?"

About three weeks ago or so, we honored the nearly 3,000 men and women who were killed in the deadliest terrorist attack in history on September 11, 2001.  All of us who were alive on that day were changed forever.  September 11, 2021 marked twenty years since that fateful day, and it is surreal to think that there are young adults today who weren't even alive at that time.  The pivotal event in history for them will likely be the COVID-19 pandemic.  

The country music singer, Alan Jackson, released a song shortly after 9/11/2001 called "Where Were You (When the World Stopped Turning)" that perfectly (at least in my mind) encapsulated what a lot of us were feeling at that time.  Most of us who were old enough to remember the events that day felt that we would never forget what we were doing or who we were with at the moment that the twin towers of the World Trade Center were attacked.  Even now, over 20 years later, I can play back those events in my mind like it was a movie, recalling exactly how the events unfolded throughout the day from minute to minute, or hour to hour.

Or so I believe.  As it turns out, there is a whole body of research on this topic - the investigators in this area use the term flashbulb memory (originally coined by the investigators, Roger Brown and James Kulik in 1977) to describe a highly vivid and detailed memory of a moment in time in which a consequential, surprising, or emotionally arousing piece of news was either experienced or learned.  For example, the original study by Brown and Kulik starts out as follows:

"Hardly a man is now alive" who cannot recall the circumstances in which he first heard John Kennedy had been shot in Dallas.  Not just the fact that John Kennedy was shot and died...but the memory of one's own circumstances on first hearing the news.

The term that Kulik and Brown used (flashbulb memory) builds upon the concept of a photographic memory (long before the digital age, cameras used a flashbulb as a light source).  Individuals with an eidetic, or photographic, memory can recall things from their memory in almost perfect detail even after seeing it only once.  The concept of a flashbulb memory comes from the observation that individuals can relate their experiences of a particularly consequential or newsworthy event (like the Kennedy Assassination), similar to an individual with a photographic memory.  However, as opposed to a photographic memory where all items can be recalled, the event triggering the flashbulb memory must be consequential, newsworthy, and otherwise very important.  

Here's the tricky part.  Our recollection of events in the past - even ones that supposedly lead to flashbulb memories - isn't as good as we think.  Take, for example, the 1986 Space Shuttle Challenger disaster.  The American teacher Christa McAuliffe was one of the seven astronauts on that particular Challenger mission, so it is not an exaggeration to say that almost every school classroom in America was watching the disaster unfold on live television.  The psychologist Ulric Neisser (known as the "father of cognitive psychology") surveyed the students in his college class about their memories of the event the day after the disaster and then again three years later.  Contrary to the discussion above on flashbulb memories, less than 7% of the memories three years later matched the ones on the day after the disaster.  Fifty percent of the memories were wrong in the majority (2/3) of the reported details, while 25 percent were wrong in every single detail.  In other words, Neisser found very little evidence to support the flasbulb memory phenomenon.

If I were to be completely honest, other than knowing that the Challenger disaster occurred when I was in college, I don't really remember too many details of that day either.  But what about the events that occured on 9/11/2001?  How accurate were the flashbulb memories associated with that day?  As it turns out, our recollections of the details on even this momentous occasion are not as accurate as we think.  A group of psychologists from across the country surveyed over 3,000 individuals from 7 different U.S. cities to find out how well they remembered details on 9/11/2001 at 1 week, 11 months, and 35 months after the event.   The results of this study were similar to Neisser's Challenger study above.  Our flashbulb memories aren't as accurate as we think.

All of this is very interesting, but what's the point?  What I take away from this discussion is that if we can't recall an event as powerfully historical as the terrorist attacks on 9/11, then why would we expect that our memories of less momentous occasions be any better?  In fact, they are likely to be a whole lot worse.  I don't think that this should come as a surprise - after all, we are only human.  And humans are known to make mistakes.  In fact, making mistakes is part of what makes us human - "Fallor, ergo sum."

Sour grapes and sunk costs...

I am particularly fond of Aesop's Fables - I have been since my childhood.  Aesop was apparently (at least according to tradition - there are some who suggest that he was a fictional character) a slave who lived in ancient Greece, sometime between 620 and 564 BCE.  His stories have been passed down through a number of sources and remain popular to this day.  Like all such stories, Aesop's fables always end with a moral or lesson.

I came across Aesop's fable of "The Fox and the Grapes" while doing some background research for my post ("Fallor, ergo sum") on Being Wrong: Adventures in the Margin of Error by Kathryn Schulz.  Please feel free to read the story in its entirety (I provided the link above), but I will summarize here:

A fox is walking around and sees a beautiful bunch of grapes hanging from a vine on a tree.  The grapes are just out of reach, so the fox jumps up to try to bring them down.  After several unsuccessful attempts, the fox gives up and walks away, saying "What I fool I am - those sour grapes are not even worth the trouble."

And with that, we have the common idiom "sour grapes," which we use to explain why we often put something down in a negative way or make it out to be unimportant solely because it is unattainable or out of our reach.  Let me give you an example from my own personal experience.  Several years ago, I interviewed for a Division Head job at another children's hospital.  Admittedly, in retrospect, I was still a little junior for the job, but I had been approached by a couple of other hospitals about similar positions.  I thought the interview went very well.  A few weeks later the head of the search committee called to let me know that while they were very impressed, they wanted someone with a little more experience (actually, to be more specific, at the time, I was still on a NIH training grant and they wanted someone with independent NIH funding).  I reassured myself that I really wasn't interested in the position at that particular hospital anyway ("sour grapes").

I don't think anyone will argue that all of us have a need to feel wanted.  As Kathryn Schulz discusses at length in her book, the need to be "right" is just as powerful.  Not only do we hate to make mistakes, at times we will justify, explain away, rationalize, downplay, shrug off, and disregard the fact that we have made a mistake.  There are powerful psychological impulses at play here.  

In her book, Schulz talks about a famous case from mid-nineteenth century America called the "The Great Disappointment".  William Miller was a Baptist preacher who founded a religious movement known as Millerism, predicated on the belief that the Second Coming of Jesus Christ would occur some time between 1843 to 1844 (at one time, he actually predicted the exact date, October 22, 1844).  Miller published his teaching and prediction, and Millerism grew to become a national movement.  Apparently, people believed his predictions enough to sell all of their worldly belongings.  Farmers stopped harvesting their crops - what was the point, the world was coming to an end!  When the day of Jesus' expected day of return came and went, the believers tried to rationalize or explain away Miller's mistaken prophecy.  It was almost as if they had believed in the prediction so much, that they could not ever come to terms that the prediction was wrong.

A psychologist named Leon Festinger conducted a study in the 1950's that is relevant here.  Apparently, Festinger and his research team infiltrated a cult-like group that followed the doomsday prophecies of a suburban housewife named Marian Keech (a pseudonym).  Similar to the Millerism movement (but on a much smaller scale), Keech's followers quit their jobs, sold their possessions, and prepared for the end of the world on December 21, 1954.  Again, when it became clear that the world was not ending, rather than abandoning their now discredited beliefs, the members of the group actually adhered to them more strongly!  Festinger would go on to label this psychological phenomenon, "cognitive dissonance".  According to his theory, when two actions or ideas are not consistent with each other, individuals will do all in their power to change them until they become consistent.  In other words, if we believe in something and find it to be untrue, we may rationalize, justify, or explain away the error in such a way that our belief only grows more powerful.

There is a similar concept in economics, called the "sunk cost trap" ("throwing good money after bad").  The "sunk cost trap" is also known as the Concorde fallacy, the idea that we should continue to spend money on a project, product, etc in order not to waste the money that we've already invested in it (apparently, the French and British governments continued to spend money on the Concorde plane even after it was abundantly clear that the program was losing money).  Say, for example, that you have purchased a used car for your children.  A few months after you buy the car, the transmission goes out and needs to be replaced.  Even though it costs a ton of money to fix the car, you go ahead and do so.  A few months after that, the brake system needs to be replaced.  You rationalize to yourself, "Well, I've spent all this money so far, I guess I need to go ahead and fix the brakes."  A couple of months after that, the power steering needs to be fixed.  Soon, you have spent more in repairs and the original cost of the car than it would take to purchase a brand new car.  You have fallen into the sunk cost trap (this actually happened to me!).

Sour grapes.  Cognitive dissonance.  Sunk costs.  The Concorde fallacy.  All of these concepts are inter-related, and all of them occur because, at the end of the day, we really hate to be wrong.  Leaders in particular hate to be wrong.  We need to be okay with making mistakes, after all we are only human ("Fallor, ergo sum").  By accepting that, we can minimize the risk that we will fall into the sunk cost trap or Concorde fallacy.

My particular story (above) has an interesting aside.  Approximately one year after being told "no", the same hospital (the same individual on the search committee actually) reached out to me again and asked if I would be interested in coming back for an interview.  I politely declined, thinking to myself, "If I wasn't good enough for you last year, why should you be good enough for me now?"  Of note, my NIH funding status had not changed.  Talk about "sour grapes"!  I turned down a potential leadership opportunity for no other reason than "sour grapes."  

"Fallor, ergo sum"

Several years ago, I was honored to be invited to speak at a "Risky Business" patient safety conference in London.  One of the most memorable highlights of the trip, at least for me, was going to the Tower of London to witness a time-honored ceremony called the "Ceremony of the Keys" with the other invited speakers (I wrote about this trip a while ago in my post "Risky Business").  While we waited for the "Ceremony of the Keys" to begin, we shared a meal and a few beers with the legendary Yeoman Warders.  We also had some time to talk to each other.  One of the speakers there was the American author and journalist Kathryn Schulz who won the 2016 Pulitzer Prize for a piece she wrote in The New Yorker on the risks of a massive earthquake in the Pacific Northwest ("The Really Big One").  Schulz was giving a talk on her (at the time) newly released book, "Being Wrong: Adventures in the Margin of Error" (see also her TED talk "On being wrong").  I enjoyed briefly talking to her, and I really enjoyed her talk at the conference.

Well, after spending years on my list of books to read, I finally checked Being Wrong out at the local libary and sat down to read it.  The book takes a little while to start getting really good, but it does in fact get really good!  I have definitely learned a lot so far (I am just about three-fourths through it).  First of all, did you know that about 1,200 years before the philosopher and mathematician Rene Descartes stated his famous Cogito, ergo sum, meaning "I think, therefore I am"), the philosopher Saint Augustine said, Fallor, ergo sum, meaning "I err, therefore I am."  There is perhaps nothing more innately human than the fact that all of us make mistakes.  Saint Augustine would take it one step further and say that we are human because we make mistakes.  

Schulz cites several studies in cognitive psychology that give different explanations for why we make mistakes.  As it turns out, we are prone to mistakes because we are subject to a number of cognitive biases.  A cognitive bias is a systematic error in our thinking that occurs when we are trying to make sense of the world around us.  Our brains try to simplify all of the incoming information by taking a shortcut, if you will.  The shortcut might be the right one, but occasionally it is not, and we make an error.  There have been at least 180 different cognitive biases described in the literature. 

Let me provide an example of one common type of cognitive bias.  Answer the following riddle:

A father and son get in a car crash and are rushed to the hospital. The father dies. The boy is taken to the operating room and the surgeon says, “I can’t operate on this boy, because he’s my son.”  How is this possible?

Apparently, between 40-75% of individuals can't solve this riddle!  How about you?  Many of us can't get past the unconscious bias (or implicit stereotype) that the surgeon in this riddle has to be a man.  We shouldn't be too hard on ourselves.  Even though more women are entering medical school than men, there are still more men than women entering general surgery residency (and male surgeons already outnumbered female surgeons in the U.S.).  Just to close the loop, the surgeon in the riddle is the boy's mother!  

Sometimes we make errors, just because we don't pay close enough attention.  Have you heard of this riddle?

A plane crashed right on the border between the U.S. and Canada.  Where do they bury the survivors?  In Canada or in the United States?

Did you get the answer right this time?  I've seen individuals struggle with this one, at times providing me with very detailed legal explanations of why they would bury individuals in one country or the other.  But of course, they don't need to bury the survivors!

 

Kathryn Schulz didn't actually use these two riddles in her book.  Regardless, they perfectly illustrate some of the concepts that she discussed at length.  I would encourage you to at least watch the TED Talk, or better yet, read her book.  I hope to provide more examples from her book in future posts!  For now, as these two riddles probably illustrated (unless you've seen them before), we all make mistakes.  It's a part of who we are as humans - Fallor, ergo sum.