The Giving Tree

I've never been a fan of the book, The Giving Tree, which was written and illustrated by Shel Silverstein.  As it turns out, I'm not alone.  Even though the book is frequently given as a present for milestone events such as graduations (I think I may have received it for my high school graduation), it's been described as "one of the most divisive books in children's literature."  The book ranks high in either the "most favorite" or "least favorite" lists of children's books, and it was even banned in the state of Colorado in 1988 for apparently being sexist (read about that here).  For those individuals who love the book, it is a story of friendship, generosity, sacrifice, and selfless love.  For those of us who hate the book, it is a story of selfishness and narcissism.  See for yourself - either read the book (remember, it's a children's book, so it's very short) or listen to a reading of the book here.    

Both Silverstein and his publishers were actually surprised by the initial success of the book.  Reportedly, the publisher initially printed just seven thousand copies of the book - the book has gone on to sell over 5 million copies!  Silverstein himself once claimed the book had no message, and when asked to defend the book's theme said, "It’s just a relationship between two people; one gives and the other takes."

That last comment leads right into the point of my discussion today.  I've written a number of posts about the Wharton professor Adam Grant's three books, the first of which was Give and Take.  Grant recently talked about The Giving Tree in an article that he co-wrote with Allison Sweet Grant (who just so happens to be his wife) in the New York Times, "We Need to Talk About 'The Giving Tree'", in which he brought in key concepts from his book.  Basically, people at work generally belong to one of three groups - givers, takers, and matchers.  Givers are those individuals who contribute their time and energy to help others without expecting anything in return, while takers try to get everything they can from others.  Matchers trade their time and energy evenly (think quid pro quo).

What Adam Grant finds in his research, perhaps surprisingly, is that givers are usually the most successful individuals in the workplace.  It is usually the case that there are always exceptions to these kinds of statements, and there is certainly a few caveats here.  Grant also noted that givers can be taken advantage of or exploited.  There is also a limit to what an individual giver can give - if they give too much, they are at risk for burning out.  In other words, being generous doesn't mean that you have to be selfless to the point of self-sacrifice, as in the case of the apple tree in The Giving Tree.  Being strategic about giving turns out to be incredibly important.  Grant calls these strategic givers, otherish givers!  Otherish givers are strategic about how, when, and who they give to and understand that every "no" frees them up for a "yes" that matters more.

Givers, then, are further sub-classified into otherish givers (who are indeed the most successful of all the groups that Grant has studied) and the self-sacrificing givers, who suffer from what the author Barbara Oakley calls pathological altruism, which she defines as "an unhealthy focus on others to the detriment of one's own needs."  Bill Gates once argued at the World Economic Summit that "there are two great forces of human nature: self-interest and caring for others."  The most successful individuals - the otherish givers - are the ones who strike a balance between these two forces.

 

As Grant and his wife Allison write in their New York Times article, "Paradoxically, being less selfless actually allows you to give more: Instead of letting other people sap your energy, you maintain your motivation."  Here is one potential explanation to the growing epidemic of burnout in health care workers that I discussed in a recent post ("Mindfulness training?").  For example, selflessness to the point of self-sacrifice predicts emotional exhaustion among nurses.  The Grants go on to write, "Generosity is not about sacrificing yourself for others - it's about helping others without harming yourself."  A study of 161 employees of a large engineering firm found that those employees who give selfishly and without thinking of their own needs were the least productive - they made more errors, missed more deadlines, and failed to finish more projects than their counterparts.  I suspect that similar results would be found in health care.

Successful givers - the otherish givers - are both altruistic and ambitious.  If you analyzed their personalities, they would score high on being "other-oriented" and "self-interested" compared to their peers.  They've learned to navigate in a world of matchers and takers, and they are less likely to be taken advantage of in the workplace.  Grant often references a study of nearly 700 Belgian medical students who were followed during their medical school training.  Medical students whose personality traits matched up with being a giver performed well during medical school.  However, those who scored unusually high on the giver personality actually did worse.  Again, being an otherish giver means giving strategically where and when it counts the most.  It also means striking a balance between giving to others and giving to yourself.   

Clearly there are some important lessons in Shel Silverstein's book, The Giving Tree.  Giving is not one-sided.  As William Cole, an editor at the book publisher Simon & Schuster said when he famously turned the book down, "My interpretation is that that was one dum-dum of a tree, giving everything and expecting nothing in return."  Perhaps that is the secret - don't be a dum-dum.  Be an otherish giver.

Buridan's ass

Robert Greenleaf, author and founder of the "Servant Leadership" movement wrote, “On an important decision one rarely has 100% of the information needed for a good decision no matter how much one spends or how long one waits. And, if one waits too long, he has a different problem and has to start all over. This is the terrible dilemma of the hesitant decision maker.”  

I am reminded of the old proverb, "He who hesitates is lost."  It's actually not that old.  I was thinking it came from ancient Greece or Rome, but it actually was adapted from the 18th century play Cato by Joseph Addison, which was reportedly one of George Washington's favorite plays!  The line was modified from its original, which read as follows: "“The woman that deliberates is lost."  

Apparently there is a famous paradox in philosophy known as Buridan's ass (the "ass" here refers to the animal, not the body part).  It is named after the 14th century French philosopher Jean Buridan (notably the word "ass" never appears in his writings), though several other philosophers described similar concepts, most notably the ancient Greek philosopher, Aristotle and the 12th century Persian philosopher, Abu Hamid al-Ghazali.  The paradox refers to a hypothetical situation in which an ass (donkey) who is equally hungry and thirsty is placed exactly midway between a stack of hay and a pail of water.  Given that the donkey is just as hungry as it is thirsty, Buridan's philosophy of moral determinism would say that the donkey would choose whichever is closer, the water or the hay.  As both are the same distance, the donkey is unable to choose and therefore dies of starvation and thirst.  Buridan wrote "Should two courses be judged equal, then the will cannot break the deadlock, all it can do is to suspend judgement until the circumstances change, and the right course of action is clear.”  In some variants of the paradox, the donkey is forced to choose between two piles of hay instead.

The story of Buridan's ass is commonly used to describe situations in which an individual is unable to choose between two otherwise equally reasonable and good choices.  It was even featured in a 10th season episode of the television show, The Big Bang Theory.  Basically, the lesson here is that leaders will never have a nice, neat packet containing all the relevant information to review and ponder before making a key decision.  There is almost no such thing as "perfect information" , and the competition will never wait long enough anyway.  If leaders wait too long (like an ass / donkey), they will lose out and may even metaphorically starve to death.  Leaders who hesitate are lost.

"Uncommon valor was a common virtue"

Seventy-seven years ago today, six Marines raised the second and largest American flag atop Mount Suribachi on the island of Iwo Jima.  Three of the Marines who raised the flag were killed in action later in the battle.  The first flag that was raised was felt to be too small to be seen by the Marines fighting below, so a second flag was raised later that morning.  A combat motion picture cameraman, Sergeant Bill Ganaust recorded the events in color, while Associated Press combat photographer Joe Rosenthal took the iconic photograph that inspired the Marine Corps War Memorial (the original photograph, as well as a photograph of the Memorial is shown below):

The Battle of Iwo Jima began with an amphibious landing on February 19, 1945 and would last until March 16, 1945.  By the time it was over, it would be one of the bloodiest battles in all of World War II.  Victory was achieved at great cost, with more than 6,800 U.S. Marines and Sailors losing their lives and another 19,200 being wounded (the Japanese death toll was far greater, approaching 18,500 lives lost).  Twenty-seven Americans were awarded the Congressional Medal of Honor, the U.S. military's highest honor, more than for any other battle in our country's history.  In a famous quote from March 1945, Fleet Admiral Chester A. Nimitz said, "Among the Americans who served on Iwo Jima, uncommon valor was a common virtue."

Iwo Jima proved to be of limited strategic value to the U.S. war effort, as either a forward staging base or Navy base, although some of the rebuilt airstrips were used for emergency landings of U.S. bombers later in the war.  Given the staggering numbers of lives lost, military historians have asked whether the battle was worth it.  Many expert have argued that it was not worth its cost, citing the island's limited strategic value and use later in the war.

My first and most important point is that today, we honor those brave Marines who gave their “last full measure of devotion” in the service of their country.  We also honor those Marines who fought bravely and lived valiantly as part of that “greatest generation” of Americans.  “Uncommon valor was a common virtue.”  

My second point focuses on the responsibility of leaders to consider the costs of achieving an objective.  Fortunately, few leaders will ever have to make the kinds of life-or-death decisions that our nation's military and governmental leaders had to make during World War II.  However, even today's leaders, regardless of the industry, has to consider if the potential benefits of a major initiative outweigh the potential costs.  I think that the Battle of Iwo Jima is a really great example of this concept.

My last point is more personal.  If you've never visited the U.S. Marine Corps War Memorial in Washington, D.C., I would urge you to do so.  It is inspiring and humbling at the same time.  You won't be disappointed.  It is a beautiful memorial to "The Marine Dead Of All Wars, And Their Comrades Of Other Services Who Fell Fighting Beside Them."  Semper Fidelis.

The bureaucracy paradox

There's a great scene in the original Star Wars: A New Hope in which all of the bad guys are meeting for the first time (or at least it seemed that way) on the new Death Star (check out the video here).  Here is the short dialogue:

General Tagge: The rebellion will continue to gain support in the Imperial Senate.

Grand Moff Tarkin (entering with Darth Vader): The Imperial Senate will no longer be of any concern to us.  I have just received word that the Emperor has dissolved the council permanently.  The last remnants of the Republic have been swept away.

General Tagge: That's impossible.  How will the Emperor maintain control without the bureaucracy?

Grand Moff Tarkin: The regional governors now have direct control over their territories.  Fear will keep the local systems in line - fear of this battle station.

A few minutes later, Darth Vader strangles one of the other generals.  And the rest, as they say, is history.  Here's my question though.  If you had to choose the ideal form of governance in this situation, which would be better - a fairly decentralized bureaucracy or a highly centralized autocracy?  At least in General Tagge's mind, the bureaucracy was necessary to maintain control of all the disparate star systems spread all over the galaxy.  Perhaps he failed to understand that the Emperor was a Sith Lord?  But I digress...

If you wanted a more realistic version of this question, look no further than ancient Rome during its transition from a republic to empire (perhaps this is what George Lucas had in mind when he developed his plot for Star Wars).  Ancient Rome had two major periods in history. The first was the Roman Republic, which lasted from about 509 BC to 27 BC, during which time the government was run by elected officials (the Senate) and there was no single leader of Rome (instead, there were two consuls who were elected by and presided over the Senate). The second period was the Roman Empire, which lasted until 476 AD.  During this period, Rome was governed by an emperor.  As anyone who has read ancient history or Shakespeare knows, the transition from Republic to Empire was anything but smooth.

Enough history - let's get back to the question I posed earlier, only this time focusing on the ideal governance of organizations, not nation-states.  The German sociologist Max Weber argued that a bureaucracy is the most efficient and logical way to set up an organization.  The term comes from the French word bureau meaning desk and literally translates as "rule from a desk or office."  I should emphasize that a bureaucracy is not a kind of government or political organization in the strictest sense (we don't think of bureaucracy in the same way that we think of democracy or monarchy, for example).  Rather, bureaucracy refers to a system of management, which assists the democratic government or monarchy in managing the political organization of a country.

As Weber described, a bureaucracy has a few important defining characteristics (he mentioned a few others, but I don't think they are relevant to the present discussion):

1. Task Specialization (with Division of Labor)
2. Hierarchical Layers of Authority
3. Formal Selection
4. Rules and Regulations

Unfortunately, regardless of what Mr. Weber thinks, the term bureaucracy has become synonymous with "red tape" and "obstruction."  The term has a negative connotation and is frequently viewed as anything but efficient.  Is that fair, though?  Most modern organizations meet nearly all of Weber's defining characteristics, so then are all organizations inefficient and plagued by "red tape" and obstruction to progress?  I would like to explore some proposed alternatives to the way organizations are structured today, but for now I want to focus on something that Charles Perrow (who is perhaps better known to me for coming up with the theory of Normal Accidents) called the "bureaucracy paradox."

The title of Perrow's paper is incredibly interesting - The Bureaucratic Paradox: The Efficient Organization Centralizes in Order to Decentralize.  He says, "The efficient organization is both centralized and decentralized."  Huh?  I know that doesn't necessarily make sense, but Perrow is talking about a paradox here.  He talks about the fictional example of an information services department at a large organization with a manager named, Mr. Able.  Mr. Able has 20 direct reports, and he managed all of them closely.  If you asked his direct reports, they would say that Mr. Able micromanaged way too much.  Decision-making was far too centralized, and his direct reports felt that he didn't trust them enough to make decisions on their own.  

The department was inefficient, staff morale was low, and turnover and absenteeism was off the charts.  A management consultant was brought in and quickly identified the source of the problems - there was a bottleneck at the top.  Mr. Able clearly couldn't deal with the amount of information coming in or the amount of information that needed to go out.  The consultant suggested creating a more hierarchical structure, with two Assistant Supervisors, Mr. Baker and Mr. Charles.  Mr. Able first resisted - creating an extra layer of supervision would only increase the degree of bureaucracy (read "red tape" and "inefficiency").  The organization's executive leadership made the change anyway.

Rather than slowing decision-making down, the additional layer of supervision created a buffer between the different division leaders within the department and Mr. Able.  He no longer micromanaged, and Baker and Charles controlled the flow of information between the different division leaders and Mr. Able.  Mr. Able delegated more of the decision-making responsibilities, out of necessity, to Baker and Charles, who in turn delegated more of the day-to-day decision-making to the division leaders.  Operational efficiency improved, as did staff morale (with lower staff turnover and absenteeism as a direct result).

Here is yet another great example of the High Reliability Organization principles of "Deference to Expertise" and "Sensitivity to Operations".  As Perrow says, "...the more bureaucratized an organization, the more possibilities there are for decentralized decision-making...You decentralize, we might say, by centralizing."  He concludes his paper with the central admonition, "My message to managers is to delegate."

Going back to the Star Wars example above.  The Emperor will maintain control, even without the bureaucracy, General Tagge, by giving the Regional Governors control of their local systems.  In other words, he will delegate!

The Ripple Effect

Several years ago, my wife started a dinnertime tradition in our household.  We would ask everyone (kids as well as parents) to state their favorite thing that happened that day.  It was a great way to focus on the positives of the day, rather than spending too much time talking about the negatives.  As she always said (and continues to tell me to this day), "It's the power of a positive attitude."

I am often amazed on just how powerful a tool that a positive attitude can be, both in our personal lives and our professional ones.  Focusing on positive energy, at least in my experience, often leads to a ripple effect that only leads to more positive energy that spreads to everyone else around.  When I think of positive attitudes and ripple effects, I often think of Mother Teresa and the Dalai Lama.  Mother Teresa once said, "I alone cannot change the world, but I can cast a stone across the waters to create many ripples."  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."  While both quotes, I think, are talking about the impact that one single individual can have on changing the world, they also can refer to the impact of that same individual on the people that he or she works with on a daily basis.  Importantly, that impact can be either positive or negative.

I suspect that just about everyone has lived or worked with someone who is generally negative all the time (these individuals remind us of the Disney character, Eeyore, from the Winnie the Pooh series).  What is unfortunate is the effect that being around these individuals have on our own level of energy or mood.  On the other hand, I am sure that everyone has lived or worked with someone who is generally positive all the time too (these individuals often remind us of the Disney character Tigger, again from the Winnie the Pooh series).  It's amazing how the different personalities and/or moods of the individuals that we work with can affect us in both positive and negative ways.

Dr. Sigal Barsade from the Wharton School at Penn published a study a number of years ago that is relevant to this discussion, "The Ripple Effect: Emotional Contagion and Its Influence on Group Behavior".  The working hypothesis for this study is that (1) individuals working in a group setting can transfer emotions to others in the group and (2) the transfer of these emotions can adversely impact group dynamics.  Simply stated, one individual's mood can lead to a shift in the overall mood of the group ("emotional contagion").  

The study was conducted in a laboratory setting using undergraduate business students working in small groups during a management simulation.  Study participants played the role of a department manager working on a salary committee who were negotiating the allocation of a limited sum of bonus money to their employees.  Each "department manager" had to advocate for one of his or her employees with the objective of getting as large a bonus as possible while allocating the available funds to maximize the benefit to the organization as a whole.  Each group also included a confederate (in this case, an undergraduate drama student) who was told to play a department manager with either a positive or negative mood or a high or low level of energy.  Groups were randomized using a 2x2 table, to "cheerful enthusiasm", "serene warmth", "hostile irritability", or "depressed sluggishness" depending on the confederate's mood/energy level.

Each simulation lasted only thirty minutes.  Participants self-rated their mood and energy level before and after the exercise.  All simulations were videotaped and later analyzed by the members of the research team, who also rated the mood/level of energy, as well as the level of cooperation amongst the group members.  Participants also rated the level of cooperation of each individual member in the group.

The results showed that emotional contagion does occur in that the confederate's emotions and level of energy changed the emotions of the other members within the group.  Similarly, emotional contagion either positively or negatively (depending on the mood and level of energy of the confederate) impacted the level of cooperation within the group, as well as whether the group successfully achieved its objective.  

In other words, when we work with glum, pessimistic, or irritable people at work, it affects us in a negative way.  Conversely, when we work with cheerful, optimistic, or high-energy people at work, we respond in a positive way.  The implications of this study should be fairly intuitive.  Try to focus on the positives, in order to stay positive!  With that in mind, I want to leave you with another old Wheeler family favorite, the "Happy Happy Joy Joy" song!  Enjoy.

The Leader of the Pack

There is a popular leadership post that's been circulating around social media for a number of years.  The post starts with a photograph of a group of wolves traveling in a pack:

The photograph is accompanied by a paragraph explaining its meaning, particularly with regards to leadership, which typically says something like the following:

We can all learn an invaluable lesson on leadership from this wolf pack.  The first three wolves in front are the old and sick.  They set the pace for the entire pack.  If it was the other way around, they would be left behind, losing contact with the pack.  In the case of an ambush, they would be sacrificed.

Then come five strong ones, the front line.  In the center are the rest of the pack members, then the five strongest following.  

Last is alone, the alpha.  He controls everything from the rear.  In that position, he can see everything and decide the direction.  He sees all of the pack.  He ensures no one is left behind.  He keeps the pack tight and on the same path.  He is ready to run in any direction to protect his pack.

Being a leader is not about being in front.  It's about taking care of your team.

It's a beautiful metaphor for leadership and teamwork.  Unfortunately, it's just not true.  Apparently, the photo was taken by Chadden Hunter in 2011 for the BBC series Frozen Planet.  What it actually shows, at least according to the International Wolf Center, is a large pack of wolves traveling through deep snow.  In order to save energy, the group is traveling in single file, with the wolf in front cutting a path through the snow.  With this in mind, it would make no sense for the weaker wolves to be leading up front, as cutting a path through the snow takes a lot of energy and stamina.  

Here is the actual caption for the photograph:

A massive pack of 25 timberwolves hunting bison on the Arctic Circle in northern Canada.  In mid-winter in Wood Buffalo National Park temperatures hover around -40°C.  The wolf pack, led by the alpha female, travel single-file through the deep snow to save energy. The size of the pack is a sign of how rich their prey base is during winter when the bison are more restricted by poor feeding and deep snow. The wolf packs in this National Park are the only wolves in the world that specialize in hunting bison ten times their size. They have grown to be the largest and most powerful wolves on earth.

Note that there is even a dispute about the use of the term "alpha male" or "alpha female".  David Mech (a researcher who founded the International Wolf Center) argued in his 1999 paper "Alpha Status, Dominance, and Division of Labor in Wolf Packs" that the social dominance observed in captive wolves with an "alpha male" and "alpha female" actually doesn't exist in the wild.  Instead, the typical wolf pack is a family with the adult parents guiding the rest of the family in a division-of-labor system.  As I've written in the past, "The strength of the pack is the wolf, and the strength of the wolf is the pack.  

Humans are a lot like wolves, in that we are both social animals (more or less).  And, there is a lot we can learn about leadership and teamwork from wolves.  Perhaps the most important lesson is the one that's in the last line of the caption of the viral photograph above.  "It's about taking care of your team."

Vox Populi

Have you ever played a game where you were asked to guess how many cookies or pieces of candy were in a jar?  Did you come close to the answer?  As it turns out, you would have had a much better chance of guessing the correct answer if you had been part of a large group with everyone submitting a guess and the final answer being an average of all the guesses.   

   
All the way back in 1906, the English polymath, Sir Francis Galton, attended "The West of England Fat Stock and Poultry Exhibition" in Plymouth.  While there, he discovered a "guess the weight" of a cow game, similar to the ones described above.  The game attracted more than 800 people, all of whom paid half a shilling to write down their guesses.  They wrote their guess on a ticket (along with their name and address).  Galton apparently became interested in the guesses, because he paid the ticket master for all of the tickets at the end of the game.  Unfortunately, only 787 of the tickets were usable.  He averaged all of the guesses together, which resulted in an overall average guess of 1,207 pounds.  The actual weight of the cow was 1,198 pounds - the average guess was only 9 pounds off!  He published his results in the journal Nature (the original article can be found here).  The "crowd" showed a lot more "wisdom" compared to the individual participants.

Whether you call it the "wisdom of crowds", "collective intelligence",  "crowdsourcing", or "vox populi", it really doesn't matter.  What is well-established is that large groups of people are collectively smarter than individuals when it comes to problem-solving, decision-making, innovating, and predicting (see last year's post, "How groups make can make better decisions...").  The theory is that individuals are inherently biased - taking the average from a much larger group of individuals theoretically eliminates this bias and noise, leading to more accurate decisions.

It’s not quite that simple though.  As I mentioned in a post last year, there is something known as the "common information effect", which could place groups at a disadvantage relative to individuals.  Here, groups lose the purported benefits of diversity and the "wisdom of crowds" effect because the individuals in the group focus primarily - almost exclusively - on the information that they share with each other.  Similarly, groups are subject to social influence effects (individuals adopt their peers' opinions and copy their solutions to problems), particularly under conditions of something known as network clustering (like-minded individuals tend to work together more).  Together, these effects decrease the benefits of group diversity and can lead to premature convergence on a suboptimal solution to a problem.

So then, which interpretation is correct?  Do groups really make better decisions than individuals?  And if so, does context matter?  We are left to question whether it is possible to leverage the benefits of group decision-making ("the wisdom of the crowds" effect) without the accompanying loss of group diversity due to social influence effects and/or the common information effect.

It is with all of this in mind that I want to talk about a study ("How intermittent breaks in interaction improve collective intelligence") published by the Harvard Business School professor Ethan Bernstein with his colleagues Jesse Shore from Boston University and David Lazer from Northeastern University.  They conducted a set of experiments in which three-person groups tried to solve the famous traveling salesperson problem.  The problem here is to find the shortest travel distance between 25 different cities (it's a surprisingly difficult problem that requires higher level mathematics).  Each group completed the task seventeen times (each "round" lasted just under one minute), so theoretically they could improve their performance by learning from past rounds.  

One set of groups never interacted with the other groups, working on the traveling salesperson problem in complete isolation (i.e. no social influence effects).  Another set of groups constantly interacted with the other groups (i.e. social influence effects were present all the time), while the final set of groups interacted only intermittently with the other groups.  Based upon the previous research summarized above, Bernstein and colleagues predicted that the groups in which members never interacted would be the most creative, coming up with a lot of different solutions to the traveling salesperson problem with varying degrees of quality - some of the solutions would be really good and others would be really bad.  They also predicted that the groups that constantly interacted would find an overall higher quality of solutions (groups would learn from each other, so there would be potentially fewer "bad solutions" as observed with the groups that never interacted).

The results of the study were consistent with their predictions.  The groups working alone and never interacting came up with some really great solutions to the traveling salesperson problem, but they also came up with some really terrible solutions as well.  They also found that the groups that were constantly interacting with other groups came up with a better overall solution to the problem on average, but they found a solution in each round less frequently.  

The best results were found in the groups that intermittently came together - the best of both worlds, if you will.  They came up with an optimal solution more frequently, and the best solutions were generally much better (i.e. shorter distances between the 25 cities) compared to the other sets of groups.  In other words, when the effects of social influence are intermittent, it provides all the benefits of group decision-making (potentially with the additional benefit of collective learning between the different groups) without the associated costs.

Based on these results, Bernstein argues that organizations should be redesigned to intermittently isolate people from each other's work for the best collective performance.  When asked about the study in an interview, he said, “It provides real instruction for business practice because that’s not where we’re going.  We’re not naturally going to be in a world of intermittency anymore. We’re naturally in a world of always on.”  The conventional thinking is that we should be leveraging the "wisdom of crowds" by connecting groups as much as possible.  However, this study suggests that we should also be giving groups time by themselves to work on problems.

Bernstein's co-author, David Lazer adds, "People are used to thinking and believing that we want to maximize how much people learn from each other; we want to maximize transparency.  I don’t want there to be zero communication, but I do think that transparency and communication do have downsides, especially for certain kinds of problems; problems where you need certain kinds of creativity and you want to avoid rapid convergence because that convergence reduces how much the group explores and considers alternatives.”

There are examples of this concept of intermittency in the business world.  For example, "sprints" are used by agile teams, where people come together for a period of time and then separate again.  One of the growing trends is for companies to build open floor plans, yet even in these open spaces, they create nooks where workers can isolate themselves when needed. 

The switch to remote work during the COVID-19 pandemic has undoubtedly changed the way that we work together.  I spend more time in hybrid meetings now than I ever did before the pandemic, and with tools such as Microsoft Teams, Zoom, and Skype, groups can always connect with each other.  The research by Bernstein and colleagues suggests that this may not be a good idea.  There is no question that we can leverage the "wisdom of the crowd" to make better decisions - we just have to do it in a way that maximizes all of the benefits while minimizng the associated costs.

Mindfulness training?

Here are a few important facts.  Health care workers were suffering from burnout even before the COVID-19 pandemic.  Some studies suggested that close to half of all physicians in the United States met the criteria for at least one of the three dimensions (emotional exhaustion, depersonalization, and loss of sense of personal accomplishment) of burnout in the Maslach Burnout Inventory.  The percentage is even higher for physicians in training (residents and fellows).  However, burnout is not limited to physicians - more than one-third of nurses in the U.S. met these same criteria.  After nearly two years of a global pandemic, physician burnout has become even worse, with a recent survey in Medscape reporting burnout affected more than 2/3 of the nearly 7,500 physicians completing the survey.

The increased awareness on the issue of widespread burnout among health care workers is a necessary step in the right direction.  Just as important are the growing number of studies that seek to address this issue (see for example, a systematic review and meta analysis published in the journal Lancet in 2016).  Tait Shanafelt, the Chief Wellness Officer at Stanford Medicine and one of the world's leading authorities on physician burnout proposed nine organizational strategies to address burnout in health care today:

1. Acknowledge and assess the problem
2. Harness the power of leadership
3. Develop and implement targeted interventions
4. Cultivate community at work
5. Use rewards and incentives wisely
6. Align values and strengthen culture
7. Promote flexibility and work-life integration
8. Provide resources to promote resilience and self-care
9. Facilitate and fund organizational science

I want to draw particular attention to organizational strategy #8, particularly as concepts such as mindfulness, self-care, and resilience have received a lot of negative attention lately (see my own post from last year, "Don't ask me to to take resilience training!").  I fully recognize that as a physician executive, I advocate self-care, mindfulness, and resilience at my own peril - they are very, very unpopular (perhaps because some health care organizations have required education and training focused on these aspects without doing anything else to address burnout).

Here's the important point, though.  Even if physicians are already more resilient (as a group) compared to the general population, strategies to promote resilience and self-care can still be effective.  Recall that in Maslow's Hierarchy of Needs, individuals must meet their most basic needs (primarily physiologic needs, such as the need for food, water, and rest, but also the need for both physical and psychological safety) first.  Self-care is important, but organizations absolutely must provide the necessary support and resources so that physicians can meet their basic needs - providing breaks for meals (breakfast, lunch, or dinner) and access to water during the work shift; providing the necessary tools (e.g. patient lifts, personal protective equipment, etc) to prevent injuries while at work; limiting the duration of the work shift and providing sufficient recovery time for rest between shifts; and establishing a culture of psychological safety.  

Perhaps it's a surprise that there is a growing body of evidence suggesting that things like mindfulness and resilience training can be effective at relieving the stress of burnout.  Mindfulness training teaches techniques such as meditation, breathing, and guided imagery to relax the body and mind and reduce stress.  Mindfulness training is currently the only evidence-based approach to reduce burnout in the Accreditation Council for Graduate Medical Education and American Academy of Pediatrics call for system-level change to address burnout in physicians in training.  

Of interest, a group of investigators recently conducted a multicenter cluster randomized clinical trial at 15 pediatric residency training programs in the United States.  The sudy subjects, a group of 340 pediatric interns (first year out of medical school) were randomized to the intervention (mindfulness training) or control.  The mindfulness training consisted of seven monthly one-hour sessions, while the control arm consisted of seven monthly one-hour social lunches.

The primary outcome of the study was the emotional exhaustion dimension (EE) as measured by the Maslach Burnout Inventory.  Secondary outcomes, including mindfulness and empathy were measured using a standardized and widely accepted tool.  EE scores significantly increased at both 6 months and 15 months in both the intervention and control arms of the study (which is not surprising, given what we know about burnout in physicians in training).  However, the increase in EE scores was not different between the intervention and control groups.  Moreover, none of the secondary outcome measures (depersonalization dimension, personal accomplishment dimension, burnout, empathy, or mindfulness) differed between the two groups.

So, unlike previous studies, mindfulness training did not seem to make a difference in this study of first-year pediatric residents.  There are a number of important differences between this study and previous studies.  First, the mindfulness curriculum was not facilitated by an experienced mindfulness practitioner.  Second, previous studies have been relatively more intensive, in terms of the number of hours of training provided.  Third, and perhaps most importantly, participation in the mindfulness training was not required.  Conceivably then, one could just as easily argue that the training was insufficient to improve mindfulness (and notably, mindfulness scores were not different between the two groups).  

To these study limitations, I would also add one more caveat.  As I discussed above (and as proposed by Dr. Shanafelt), addressing burnout likely will require a multi-step approach that addresses factors at the personal (mindfulness, work-life integration, resilience, self-care), team (resources, leadership), and organizational (culture, leadership) levels.  I am actually not too surprised that an intervention focusing on just one of the nine strategies listed above failed to relieve burnout.

Clearly we have more work to do.  Burnout is an important issue for health care leaders.  And we need evidence-based strategies and tools to address this growing (and unfortunately, worsening) epidemic.

"Fish out of water!"

The Wheeler family used to play a lot of "Sharks and Minnows" in our younger days.  Basically, in our version, the game was played in the pool.  One player was designated as the shark, while the remaining players were designated as minnows.  The minnows lined up on one side of the pool, and the shark treaded water in the middle of the pool.  The object of the game, if you were a minnow, was to get safely to the other side.  If you were a shark, the goal was to "capture" as many minnows as possible before they crossed to the other side of the pool.  

A "capture" occurred when the shark tagged the minnow - though the minnow had to be on the surface.  In other words, the minnows could try to cross the pool by swimming underwater while holding his or her breath.  Once the kids were older, there was usually a wrestling match between the shark and minnow in order to try to bring the minnow to the surface.  Each "captured" minnow would become a shark (so the number of sharks increased, while the number of minnows decreased).

Occasionally, one of the minnows would jump out of the pool to try to run to the other side.  The shark would respond by calling out, "Fish out of water!" I think that we brought that into our own version of the game (it was originally one of the rules in another game, Marco Polo).  

As it turns out, the phrase "fish out of water" is more than just a saying from a fun children's pool game.  The phrase has become an idiom used to refer to an individual who is in unfamiliar, and often uncomfortable, surroundings or situations.  But here is the important point.  There is absolutely no better way to learn, develop, and grow than pushing beyond your comfort zone!  Importantly, you don't have to go very far (and some experts would suggest that you shouldn't get to far out of your comfort zone).

First of all, what is the "comfort zone"?  The phrase was first coined by the management thinker, Judith Bardwick in her 1991 book, Danger in the Comfort Zone.  She said, “The comfort zone is a behavioral state within which a person operates in an anxiety-neutral condition, using a limited set of behaviors to deliver a steady level of performance, usually without a sense of risk.”

One of the reasons why we get so uncomfortable being a "fish out of water" is that we are afraid to fail.  See failure for what it actually is, a teacher.  Just as important, leaders need to make sure that they create an environment and culture of psychological safety, where failure is viewed as a learning opportunity.  I learned about the so-called "Inverted U Hypothesis" (more commonly known as the Yerkes-Dodson Law) in one of my undergraduate sports psychology classes.  Basically, if you graph stress or anxiety on the x-axis and performance on the y-axis, you generally observe an inverted U shape.  Too little stress/anxiety leads to boredom, while too much stress/anxiety leads to panic.  The ideal point is in the middle.  In other words, pushing just past our comfort zone can actually help us learn and perform better!

Last comment.  While researching this topic, I came across an interesting study that has absolutely nothing to do with what I just talked about!  There was a study published just a few weeks ago in the journal Behavioural Brain Research entitled, "From fish out of water to new insights on navigation mechanisms in animals".  What's interesting about this study is that they taught goldfish to drive a special car in order to prove that fish can purposefully navigate and explore their environment.  As my undergraduate chemistry professor used to say, "Well damn!  That's science!"  But perhaps too far out of my comfort zone!

Prisoner 24601

One of my favorite musicals is Les Misérables, based upon the classic novel of the same name by Victor Hugo.  A few years ago, I downloaded the free ebook from Amazon with the hopes (or goal) of finally reading the novel.  I didn't make it past the first chapter, not because I thought it was boring, but because I had too many other things going on in my life at the time.  I still have hopes to try reading it again at some point in the future, because it is a great story.

The main character and protagonist in the story is a man named Jean Valjean ("Prisoner 24601"), who goes to jail for stealing a loaf of bread to feed himself, his sister, and her seven children (technically, he served only five years for stealing the bread - the remaining fourteen years were served as punishment following a number of failed escape attempts).  It's a great story with a lot of lessons on social justice, the law, and the nature of grace.  Victor Hugo himself described his purpose and motivation for writing the story in the novel's preface:

So long as there shall exist, by reason of law and custom, a social condemnation, which, in the face of civilization, artificially creates hells on earth, and complicates a destiny that is divine with human fatality; so long as the three problems of the age—the degradation of man by poverty, the ruin of women by starvation, and the dwarfing of childhood by physical and spiritual night—are not solved; so long as, in certain regions, social asphyxia shall be possible; in other words, and from a yet more extended point of view, so long as ignorance and misery remain on earth, books like this cannot be useless.

While conducting some research for another blog post, I came across an interesting study by Dan Ariely and colleagues in the journal, Emotion ("The Valjean Effect: Visceral States and Cheating").  The concept here is that when individuals are under the influence of a so-called visceral state (e.g., hunger, thirst, and fatigue), they are more apt to behave unethically to fulfill that state (similar to Jean Valjean stealing bread to assuage his family's hunger).  For the same reasons, individuals in these visceral states suffer from a kind of "motivational myopia" and focus solely on the goal of alleviating the visceral state, often at the expense of achieving other goals.  Ariely's team calls this phenomenon, the Valjean effect.

Ariely's team conducted three different studies to demonstrate the Valjean effect.  They used the visceral state of hunger in the first study (participants were recruited near a campus food court and had either just finished or were about to eat lunch).  Participants first rated their own degree of hunger and answered when they had last eaten, and then they participated in a contest of sorts.  They could win a snack pack (consisting of potato chips, a granola bar, a candy bar, and a mint) if they rolled an even number on a standard six-sided die.  Finally, they were asked how much they would be willing to pay for the snack pack (the hungrier they were, the more they would be willing to pay for the snacks).  Here is the fun part - participants were instructed to "take a couple of practice throws" before the contest.  The research personnel then made it quite obvious that they weren't paying attention to the participants, so conceivably the participants could cheat without getting caught.

Nearly three-fourths of participants stated that they rolled a winning (even) number - which is clearly more than what would be expected based upon chance (the odds of rolling an even number are 3/6, or 50%).  Participants who were hungrier or who reported a greater willingness-to-pay were much more likely to report a winning number, possibly consistent with the Valjean effect.  They repeated a similar design in the second study, this time using the visceral state of thirst (they recruited participants going in and out of the campus fitness center, and instead of a snack pack, they handed out a bottle of water).  Again, similar to the first study, thirsty students were more likely to report a winning number.

With the last study, participants were again recruited going in or out of the campus fitness center.  This time, however, participants could "win" either a bottle of water or a souvenir pen.  Thirsty participants were more likely to report a winning number when the prize was a bottle of water, but not when the prize was a pen.  In other words, the visceral state of thirst didn't lower participants general inhibitions against cheating (to win a pen).  Rather, they only cheated when they could win a prize (a water bottle) that would alleviate their visceral state (thirst).

Collectively, the results of these three studies support the concept that people will behave in potentially unethical ways when they are in a visceral state of hunger, thirst, or fatigue.  These visceral states lower our inhibitions against unethical behavior.  All of this brings to mind something known as Maslow's hierarchy of needs, first described by the American psychologist, Abraham Maslow in 1943 in his publication, "A Theory of Human Motivation".  The "hierarchy of needs" is often portrayed in the shape of a pyramid, although Maslow never displayed his theory using a pyramid.  The concept is that individuals must satisfy their most basic needs (primarily physiologic needs, such as the need for food, water, and rest, but also the need for both physical and psychological safety) before they become motivated to achieve higher-level needs (which focus primarily on the need for professional growth and development, self-actualization, etc).  

Building upon Ariely's study above, when these foundational physiological and psychological needs are absent, not only are individuals less likely to be motivated to work at other tasks, they are also more likely to do whatever it takes (even if by unethical means) to address these needs.  What's the leadership take-home message?  I hope it is fairly intuitive - take care of your people!  Make sure that their basic physiological and psychological needs are met (and this is not as easy as it sounds, particularly in health care when providers frequently skip meals while at work, don't get enough sleep at night, or work in a psychologically unsafe environment).  As Abraham Maslow himself said,  “The fact is that people are good. Give people affection and security, and they will give affection and be secure in their feelings and their behavior.”  And they will be motivated to work hard for the team.

"If society will not admit of a woman's free development, then society must be remodeled."

Today, February 3rd, is the 201st birthday of Dr. Elizabeth Blackwell, the very first woman in the United States to earn a medical degree.  Dr. Blackwell was famously allowed to attend medical school as a joke.  She had applied to a number of medical schools, only to be told that medicine was a profession that was neither meant for or suitable for women.  She applied to Geneva Medical College (now known as Norton College of Medicine at SUNY Upstate Medical University).  Apparently the faculty asked the other medical students to vote on whether to accept her or not (the stipulation was that the vote had to be unanimous).  The students voted for her acceptance as a funny way to get back at the faculty.  Dr. Blackwell entered medical school with the 1847 class and graduated in 1849 (during those days, medical school consisted of a one year course of study that was repeated in the second year).  The faculty and students eventually came around, and when the dean of the medical school awarded Dr. Blackwell her diploma, he stood up and bowed to her.

 
Dr. Blackwell encountered prejudice throughout her career, and later left the United States to continue her training in Europe.  There, while caring for an infant with opthalmia neonatorum, she accidentally contaminated her own eye and contracted the infection.  Unfortunately, she became blind in that eye, which forced her to abandon her goal of becoming a surgeon.  However, surgery's loss was the rest of medicine's gain.  Dr. Blackwell would become a passionate advocate for social justice, women's health, and pediatrics for the rest of her distinguished career.
 
Dr. Blackwell would later return to the United States, where she founded the New York Infirmary for Women and Children with her younger sister, Emily Blackwell (who incidentally was the third woman to graduate from a U.S. medical school).  Both Drs. Blackwell focused on women’s health, pediatrics, and social justice.  National Women Physicians Day was established just a few years ago to honor Dr. Elizabeth Blackwell and all women in medicine.

If you would like to learn more about Drs. Elizabeth and Emily Blackwell, I highly recommend Janice Nimura's book, The Sisters Blackwell, published last year.  We are thrilled to be hosting Ms. Nimura for our hospital's celebration of National Women Physicians Day later today!

I have posted each year about the growing number of women in medicine every year on National Women Physicians Day (in fact, one of my most popular posts of all time was "Do we need a National Women Physicians Day in 2018).  While the culture in medicine is changing slowly (at a snail's pace really), it is changing for the better.  Yet, there is still a lot of work to be done.  We need more women on the podium at national society meetings, more women on editorial boards and in medical society leadership.  We need more women in leadership positions at medical schools, hospitals, and academic medical centers.

Today, let us congratulate, recognize, and celebrate all women in medicine.  And let us re-commit to increasing diversity, equity, and inclusion in medicine.  I can't think of a better way of celebrating and honoring Dr. Elizabeth Blackwell and her contributions to our profession.

"Without a ruler to do it against..."

The ancient Roman Stoic philosopher Seneca wrote, "There is a need for someone against which our characters can measure themselves.  Without a ruler to do it against, you won't make crooked straight."  He was talking metaphorically about role models and mentors.  

Undoubtedly, most of you have heard about the origins of the term mentor.  Mentor was a character in Homer's Odyssey.  He was an old, senile man, though the goddess Athena assumed his appearance to guide Telemachus during his father Odysseus' long absence.  A mentor, then, is an individual who teaches or gives help and advice to a less experienced and (often, but not always) younger person.  Almost every leader I know, including the ones at the top of organizations, have identified mentors that they can trust and rely upon for advice and counsel.  So if I could offer some very simple advice, whether you aspire to leadership or you are already an established leader, find someone who will stand behind you in times of trial and triump.  Identify someone who will provide you with perspective and advice.  

I have benefited from mentors at almost every stage of my career.  I still keep in contact with almost all of them.  I am thinking about all of my mentors, particularly this past week after losing one of them ("No words").  Another bit of advice - take time this week to thank your mentors for all they have done for you.  While I was able to thank one of my mentors, Hector Wong, before he died, I would have liked to have done so again.

It's just as important, in my mind, for leaders to have role models as well (incidentally, see last year's post, "The Board of Directors for Me, Inc.").  Webster's Dictionary defines "role model" as "a person looked to by others as an example to be imitated."  It's completely acceptable for your mentor to serve as a role model too, though I think it's important to have others as well.  Role models can be leaders in your organization (or other organizations), national leaders, or historical figures.

According to Ryan Holiday, author, blogger, Stoic philosopher, and bookstore owner (I subscribe to his Daily Stoic email newsletter), the French emperor Napoleon had his own "Hall of Heroes" at the royal Tuileries Palace in Paris, which contained statutes of his role models throughout history.  While you certainly do not need a long hallway filled with statues of your role models, every leader should have his or her own version of the "Hall of Heroes."

Leaders need mentors and role models.  Indeed, they are Seneca's "rulers" by which we measure ourselves.  Identify your mentors and build your own "Hall of Heroes."  I guarantee you will be glad that you did.