Happy Doctor's Day

National Doctor’s Day is celebrated every year on March 30th.  The first Doctor’s Day was observed more than 90 years ago, on March 30, 1933 by the Alliance to the Barrow County Medical Society in Winder, Georgia (a small town located just east of Atlanta).  Members of the Alliance selected the date to honor all physicians on the anniversary of Dr. Crawford W. Long’s first administration of anesthesia in 1842 (Dr. Long used ether during surgery to remove a tumor from the neck of James Venable).  The first Doctor’s Day was observed by sending cards to all the physicians and their spouses, and a red carnation flower was placed on the graves of deceased doctors.  Through a series of resolutions in the years that followed, Doctor’s Day was widely celebrated throughout the southern United States, with sponsorship by the Southern Medical Association.  Eventually, a resolution was adopted and approved by both the U.S. House of Representatives and the U.S. Senate on October 30, 1990 and signed by President George H.W. Bush, designating March 30 as “National Doctor’s Day."  The red carnation remains as the symbol of Doctor’s Day.

I have never been more proud to be a member of this great profession.  We've all had a difficult past few years with everything that has been going on in our world.  Regardless, physicians have been at the forefront leading societal change during one of the most difficult periods in our history.  Importantly, our influence is due in large measure to the trust and respect that society has for our profession.  Physicians are still one of the most trusted of all professions.  As a matter of fact, we are second only to nurses, who have ranked as the most trusted of all professions for twenty years in a row.

I can honestly say that if I had the chance to do it all over again, I would still choose medicine as my life's work.  Medicine has been my passion and my calling.  Being a physician has made me a better person, and I am incredibly proud to be a member of this esteemed profession.

To all Doctor's - thank you for what you do, each and every day!

"When you invent the ship, you also invent the shipwreck"

The French philosopher Paul Virilio said, "When you invent the ship, you also invent the shipwreck; when you invent the plane you also invent the plane crash; and when you invent electricity, you invent electrocution.  Every technology carries its own negativity, which is invented at the same time as technical progress."  I've been thinking a lot about this quote for the past day or two.  If you haven't heard, RaDonda Vaught, a nurse at Vanderbilt University Medical Center was just convicted of gross neglect and negligent homicide for commiting an error.  

I believe that this verdict will have profound implications on American health care.  I know there are individuals (mostly outside of the health care industry) who would argue that justice has been done, but this verdict and those responsible for it just made our health care system less safe.  It is a well-established fact that reporting mistakes and errors is absolutely critical to learning, improving, and creating safer conditions.  Both the commercial aviation and NASA have drastically improved safety by instituting blame-free reporting of mistakes and errors.  

Near-misses are events in which harm is averted, due to either just plain old luck or active intervention.  They are virtually indistinguishable from adverse events, with the sole exception of the outcome (harm).  As such, they represent golden opportunities to address underlying defects and gaps in critical safety processes.  Experts estimate that near-misses are up to 300 times more common than adverse events in health care, and most adverse events are preceded by a near-miss event.  Unfortunately, near-misses are underreported in health care due to the fear of litigation and/or punishment.  The case of RaDonda Vaught will lead to an even greater reluctance to report mistakes and errors.

W. Edwards Deming, one of the original founders of the quality improvement movement once said, "Eighty-five perscent of the reasons for failure are deficiencies in the systems and process rather than the employee.  The role of management is to change the process rather than badgering individuals to do better."  Deming would be aghast at the recent verdict in the RaDonda Vaught case.  Janie Harvey Garner, the founder of a nursing advocacy group on Facebook called "Show Me Your Stethoscope" said, "Health care just changed forever.  You can no longer trust people to tell the truth because they will be incriminating themselves."

Back to the quote by Paul Virilio.  "When you invent the ship, you also invent the shipwreck."  We have a major problem in health care today - we created a system where people are afraid to come forward and admit when they make a mistake.  The verdict this past week has only made that worse.

"Fewer jobs, more machines"

If you are about my age, give or take a few years, you likely have watched an episode or two of the Hanna-Barbera television show, The Jetsons.  If The Flintsones and Fred Flintstone were about the past, the Jetsons and George Jetson were all about the future.  I remember watching an episode where the youngest member of the Jetson family, Elroy, was sick.  His doctor saw him virtually through a space age cartoon version of telemedicine (see my previous post, "What can health care learn from Uber?" for more) - except I'm not sure why the doctor needed to wear a mask in this case:

Amazing how so much has changed!  Several months ago, in the middle of the COVID-19 pandemic, I read an article in Time magazine by Alana Semuels entitled, "Fewer Jobs, More Machines".  The article focused on how automation is making certain jobs obsolete, citing the statistic that nearly 400,000 jobs have been lost to automation from 1990 to 2007.  Here's more evidence - the most valuable company in America in 1964 was the American Telegraph and Telephone Company (now known as AT&T), with 758,611 employees.  At the time that Semuels wrote her article, the most valuable company in America was Apple, Inc with just under 137,000 employees.  That's quite a difference!  And the difference is due to the changing and evolving technology landscape.

With these statistics in mind, it's easy to suggest that the major impact of automation on the labor market will be through job destruction.  However, the World Economic Forum argued that by 2025, technology will create 12 million more jobs than it destroys.  Ashley Nunes recently argued in the Harvard Business Review, automation doesn't just create or destroy jobs, it transforms them.  Regardless of whether the principle effect of automation will be creating versus destroying jobs, there is no question that technology will have a dramatic impact on how we work in the future.

It's tempting for those of us in health care to say that our jobs cannot be automated.  The patient-doctor relationship is sacrosanct and is critically dependent on a human-to-human connection.  The art of medicine requires human touch on the most personal of levels.  Or so we thought.  COVID-19 has changed how we practice medicine, and these changes are likely permanent.  Just think about it - the vignette I mentioned above about Elroy Jetson has more or less come true!  Shortly after the World Health Organization officially declared the start of the pandemic, most businesses (outside of health care) went virtual.  Elective surgical cases were canceled, and most doctor's visits also went virtual!  My own institution significantly ramped up the number of our telemedicine visits, which were more or less nonexistent before the pandemic.

Let's talk about artificial intelligence.  There are clinical studies showing that computer programs do better at diagnosing certain clinical diseases compared to humans (see for example the following reviews on the use of artificial intelligence in dermatology and medical imaging).  Will machines ever replace doctors and nurses?  I don't know the answer to that exactly, but I can say that it's almost certain we will be using some sort of artificial intelligence in our daily work.  It's exciting and scary at the same time.

It's also easy to say that the current generation of patients will drive the implementation of digital health options (telemedicine, remote monitoring, online scheduling - the list goes on).  We live in a world where consumers demand constant (24/7) access to information.  They also want easy access to care.  Ignoring the changing health technology landscape is simply not an option for leaders in health care.

I'm certainly not an expert in this area.  As most of the members on my team know, I am challenged by technology!  Things seem to break a lot when I use them!  Health care leaders really have two options - either become an expert in digital health technology or surround themselves with experts.  Thankfully, I've surrounded myself with a number of experts in the digital health domain.  And I am lucky to have two children who work in this field!  

I think that, rather than being afraid of how automation and technology will impact the health care workforce, we should embrace it.  It's really an exciting time to be in health care.  Digital health will improve the care that we provide to our patients, and for that reason alone, we should not be afraid of what the future may hold.  

London Hackney

My wife and I love the CBC television reality show, The Amazing Race.  We routinely binge watch some of the seasons we've missed (actually, we haven't missed too many).  During Season 31, the contestants who made it to the 11th leg of the race in London, England experienced the "Detour" ("a choice between two tasks, each with its pros and cons"), "Know or Row."  In "Know" contestants had to ride in one of the famous London black taxicabs ("hackneys") and memorize fifteen streets and seven landmarks that their taxi driver pointed out to them during the ride. At the end of the ride, contestants had to correctly recite their route to another cab driver in order to receive their next clue.  It sounded very hard (the other option "Row" was more physical in nature).

Apparently, the test that prospective London cab drivers have to pass to obtain a license is one of the most difficult tests in the world!  Basically, the cab drivers have to memorize a detailed map of the city of London and pass a series of progressively more difficult oral examinations before they are allowed to drive a taxi cab.  The entire process can take up to four years, and in many cases prospective cab drivers spend even longer.  Some experts have quipped that it might be easier to pass a test to become a lawyer or physician!  

The guidebook issued to prospective cab drivers by the London Taxi and Private Hire (LTPH), which oversees the test, summarizes the requirements as follows:

To achieve the required standard to be licensed as an “All London” taxi driver you will need a thorough knowledge, primarily, of the area within a six-mile radius of Charing Cross. You will need to know: all the streets; housing estates; parks and open spaces; government offices and departments; financial and commercial centres; diplomatic premises; town halls; registry offices; hospitals; places of worship; sports stadiums and leisure centres; airline offices; stations; hotels; clubs; theatres; cinemas; museums; art galleries; schools; colleges and universities; police stations and headquarters buildings; civil, criminal and coroner’s courts; prisons; and places of interest to tourists. In fact, anywhere a taxi passenger might ask to be taken.

Notably, the six-mile radius of Charing Cross "only" contains 25,000 streets, and cab drivers have to know which ones are one-way and which ones are not.  They also have to know what's the best way to get on or off a particular street, in addition to everything on these streets.  One cab driver reported that he was asked to locate a rather obscure statue of two mice eating a piece of cheese - the statue was only 1 foot tall!

For more than a century, the test has been known as "The Knowledge of London" or simply, "The Knowledge."  The Season 31 Amazing Race Detour "Know" gave contestants and television viewers just a glimpse of the test.  "The Knowledge" is testament to the incredible capacity of the human brain to acquire and store a vast amount of information.  Here is where things get really cool!  Apparently, the volume of the hippocampus (a structure located deep within the brain's temporal lobe that plays a major role in learning and memory) relative to the body size of small mammals (mice, rats, and birds have been studied in particular) varies based on the demands placed on spatial memory (even from year to year).  So, for example, during seasons when animals need to remember how to go back to the place that they stored food, the volume of the hippocampus will increase (the volume of the brain meets the demands placed on it).

The natural question is (1) whether the hippocampus of individuals who pass "The Knowlege" is larger than those who haven't passed it and (2) whether the hippocampus increases in size as individuals study and prepare to pass "The Knowledge."  Cognitive neuroscientist Eleanor Maquire and her team have published a number of studies using advanced magnetic resonance imaging (MRI) and positron emission topography (PET) techniques to answer these questions.  These studies can be summarized by the following key points:

1. The right hippocampus of the brain is most active (shown with PET) during spatial memory tasks (London taxi cab drivers asked to recall famous London landmarks and/or street directions).

2. Structural MRI shows that the posterior hippocampus is larger in volume in London taxi cab drivers compared to control subjects (moreover, the gray matter volume of the posterior hippocampus correlates directly with the number of years spent as a taxi cab driver).

3. Structural MRI shows that the posterior hippocampus is larger in volume in London taxi cab drivers compared to London bus drivers.

4. The gray matter volume of the posterior hippocampus increases over time as London taxi cab drivers study for "The Knowledge" from start to finish.

Collectively, these studies illustrate the remarkable ability of the brain to adapt to the demands of its environment over time (called plasticity in the neuroscience literature).  What's the take-home message here, you ask?  First, no matter what age we are, our brains can continue to develop with practice and experience.  Second, if we want to get better at something - even learning how to navigate the city streets of London, but more relevant, perhaps leading others - we have to practice!

"Before I make a mistake..."

Legendary Dutch football player and manager Johan Cruyff is widely regarded as one of the greatest football players in the history of the sport, having won the Ballon d'Or (a player of the year award which current football stars Lionel Messi and Cristiano Ronaldo have won seven times and five times, respectively) three times in the 1970's.  After retiring as a player, he became one of the greatest managers of all time, leading the professional clubs, Ajax (1985-1988), Barcelona (1988-1996), and Catalonia (2009-2013).  Cruyff has had a major influence on the sport and has been a strong proponent of a style of play known as "total football" (for all of you Ted Lasso fans out there, the formation known as the "False 9" mentioned in the second season of the show is a major tactic in this style).

Cruyff is also known for often stating the obvious in a rather humorous and lighthearted way (similar to the legendary New York Yankees player Yogi Berra).  For example, Cruyff once said, "You have got to shoot, otherwise you can't score."  He also said, "To win you have to score one more goal than your opponent."  And here is one of my favorites, "I'm not religious.  In Spain, all 22 players make the sign of the cross before they enter the pitch.  If it works all matches must therefore end in a draw."

More germane to what I most frequently write about it here in this blog, Cruyff once said, "Before I make a mistake, I don't make that mistake."  Again, on the surface it seems that Cruyff is stating the obvious.  If you unpack the quote a little more though, it actually is quite a profound statement.  How can someone not make a mistake before they actually make it?  It's easier than it sounds, and it comes down to two safety concepts borrowed from other so-called High Reliability Organizations - the time-out and the huddle.  

Time-outs have become the standard before and after every surgical or bedside procedure performed in the hospital.  While pre-procedural time-outs were originally designed to confirm the right patient, the right procedure, and the right surgical site, they have evolved far beyond their original intended use.  Time-outs make sure that all members of the surgical care team know each other by name and by role.  During the time-out, the plan for the procedure is clearly communicated to all of the members of the team, and any concerns that are raised get addressed before proceeding further.  When performed well, the team develops a shared understanding (known in the safety world as a "shared mental model") of the plan.  

Time-outs were initially performed at the beginning of the procedure, but now they are performed at each critical stage of the procedure, as well as at the end as a final debrief.  The Joint Commission has identified some of the most common errors when performing time-outs:

1. Time-outs occurring before all staff members are ready or before prep and drape occurs

2. Performing time-outs without full participation of the staff

3. Lack of senior leadership engagement in the time-out

4. Staff feeling passive or unable to speak up (an issue of psychological safety)

5. Distractions or rushed time-outs

When done well, time-outs reflect a patient-centered safety culture and create an environment of trust and psychological safety, so that team members feel empowered to report patient safety concerns without fear of reprisal.  Huddles are related to the time-out, though they are generally a little longer in duration than the time-out and generally occur at the beginning of a hospital shift or clinic.  The overall goal of the huddle is to review the scheduled events of the day and highlight any areas of potential concern.  Huddles are used in a number of industries outside health care (see my previous post "The morning huddle").

Huddles can be structured in a number of different ways, and some hospitals (notably The Cleveland Clinic and Intermountain Healthcare) have adopted the concept of tiered huddles, which generall start at the unit (microsystem) level, eventually rolling up through the meso- and macro-system levels.  For example, here is what tiered huddles look like at our children's hospital (more or less - I've simplified the structure slightly):

Tier One: Unit-based Huddle (team members working on an inpatient unit huddle at the start of a nursing shift )

Tier Two: Inpatient Huddle (representatives from each inpatient unit huddle together shortly after the unit-based huddles end)

Tier Three: System-wide Huddle (representatives from the inpatient, ambulatory, peri-operative, and emergency department huddle together, along with key stakeholders from security, safety, information technology, etc huddle together at 9:45 AM every morning)

Huddles generally work best when they occur in person, however hospitals have experimented with virtual and hybrid models as well.

So you see, Cruyff's statement wasn't really that far off base.  With time-outs and huddles, we can stop mistakes before they occur.  Recognizing that we can't prevent every mistake from occurring, time-outs and huddles can mitigate the impact of these mistakes and stop them from compounding and causing harm.

The Law of Continuous Improvement

Have you seen the following figure circulating around social media?

I will admit that I am not mathematically gifted.  Luckily, our children inherited their mother's mathematical abilities and not mine!  Regardless, even I can appreciate the poetic beauty here.  The figure is a great illustration (in mathematical terms) of the so-called Law of Continuous Improvement.  In this case, small, incremental improvement over time results in significant improvement of a process, as opposed to the "breakthrough" improvement that occurs all at once.  

W. Edwards Deming, an American industrial engineer and statistician who is one of the founding fathers of the modern quality improvement movement, preferred the term "continual improvement" as it was broader and more general in scope.  "Continual improvement" includes both "discontinuous improvement" and "continuous improvement."  The philosophy here is that while continuous improvement is preferable, any improvement is good.  I prefer to use the term "continuous improvement" as it aligns with other concepts, such as kaizen (the Japanese word meaning literally "change for the better" but generally referring to "continuous improvement"), operational excellence, and the High Reliability Organization principle of "Sensitivity to Operations".  

Continuous improvement is a scientific management philosophy embedded in quality improvement methodologies, such as Lean, Six Sigma, Zero Defects, Total Quality Leadership (TQL) / Total Quality Management (TQM), and the Model for Improvement.  Operational excellence has developed from concepts originally described by quality control engineers, management gurus, and scientists such as Walter Shewhart, Joseph Juran, Frederick Winslow Taylor, Taiichi Ohno, and the aforementioned W. Edwards Deming. 

As I stated above, I really like the mathematical illustration of "continuous improvement" above.  However, as I thought about it in greater detail, I realized that the mathematics behind this explanation is not accurate.  The mathematical equation above suggests that a little extra effort every day produces a much larger gain over the course of a year than the same level of effort applied every day.  I am reminded of the concept of simple interest here.  If we are improving in small, daily (i.e. "continuous") increments, the equation would look more like the equation for compound interest.  In other words, when we build upon our improvement every single day (even by just a tiny bit), we improve our performance by a much greater degree over the course of a year. 

We are essentially trying to calculate the sum of what is known in mathematics as an arithmetic sequence.  The sequence increases by 0.01 every day for 365 consecutive days:

1, 1.01, 1.02, 1.03, ...,

So, the sum of this sequence would be calculated by:

Sum = 1 + 1.01 + 1.02 + 1.03 + ...

In this case, the nth term in the sequence is 365 (if we improve every day for a year).  According to my mathematician wife, the formula for the sum of an arithmetic sequence (which is called an arithmetic series) is:

  

So, in our case, where a1=1, n=365, and d=0.01, the sum is then:

Sn = (365/2) x [(2 x 1.0) + (364)(0.01)] = 1,029.3

Wow! Performance significantly (maybe it's appropriate to say astronomically) improves over the course of a year, just by incrementally improving every day for the entire year!  Talk about the power of continuous improvement!  Incidentally, I butchered the calculation and came up with an even larger number during an initial draft.  Thanks to our math whiz kids who corrected my mistake!

The American author Mark Twain said it best, "Continuous improvement is better than delayed perfection."  Or, if you prefer the American statesman, Ben Franklin, "Without continual growth and progress, such words as improvement, achievement, and success have no meaning."  When you look at the concept of continuous improvement from a mathematical standpoint, both Twain and Franklin are correct!

"The times they are a changin'"

I realize that he may be an acquired taste, but I really enjoy listening to the American singer-songwriter Bob Dylan.  I've blogged about him in the past (see the post about my absolute favorite Dylan song, "The Chimes of Freedom").  Several years ago, I watched him play live at an outdoor music venue in Indianapolis (truthfully, the concert wasn't great - Dylan acted like he didn't want to be there, but the music was good).  He is often regarded as one of the greatest songwriters of all time, and he even won the Nobel Prize in Literature in 2016.  The New York Times reported, "Mr. Dylan is the first musician to win the award, and his selection on Thursday is perhaps the most radical choice in a history stretching back to 1901."  Dylan initially remained silent about the award, and many people believed that he would refuse to accept it.  While he did not attend the ceremony in person, he graciously accepted the award and later published a rather poignant essay in lieu of an acceptance speech.

Another favorite Dylan song of mine is The Times They Are a-Changin', which also is one of his most famous songs.  It is a beautiful song that captures the essence of the social and political upheaval of an entire generation who lived through the 1960's:

As the present now

Will later be past

The order is rapidly fadin'

And the first one now

Will later be last

For the times they are a-changin'

Beautifully poetic!  I'm not the first to say it, but the world is constantly changing.  The ancient Greek philosopher Heraclitus said it better than I ever could, when he said that "No man ever steps in the same river twice, for it's not the same river and he's not the same man."  Change is the only constant in our universe.

Yesterday (March 14th) was the two year anniversary of our pediatric hospital's first patient who tested positive for COVID-19.  Since that time, we have tested over 75,000 patients for COVID-19.  Almost 7,000 of those patients tested positive, and we admitted close to 1,000 of these patients to our children's hospital.  The experience at most of the adult hospitals in our city was quite different, but COVID-19 still had a major impact on us.  I took a moment yesterday to reflect on all that has happened in the last two years.  I have changed.  Our hospital has changed.  Our city has changed.  Our world has changed.

We will never be the same.  And that's okay.  As I thought about it more, our hospital, our city, and our world (and yes, even me) would have been different today compared to two years ago, even if COVID-19 had never happened.  Just like Heraclitus' river, with the water constantly moving downstream, we are all moving through our lives and changing every minute.

The ancient Stoic philosopher, Marcus Aurelius said in his book Meditations, "The universe is transformation; life is opinion."  Stated more simply (and perhaps less elegantly), "The universe is change; our life is what our thoughts make it."  Recognize that everything is changing - and accept that there is nothing we can do to prevent it.  And most importantly, with change comes hope.  "Oh, there been times that I thought I couldn't last for long.  It's been a long long time coming, but I know a change gonna come."

The GOAT is coming back...

I woke up this morning to the news that former (and I say "former" since he officially retired about two months ago) Tampa Bay Buccaneers quarterback Tom Brady is returning to football for at least one more season.  I know that Brady is a polarizing figure - most people either love him or hate him!  However, I don't think there is any question or controversy that Brady is one of the, if not the, greatest quarterbacks who ever played the game.  

Brady is a seven-time Super Bowl champion (in fact, he's won more Super Bowls as a player than any other team in the history of the NFL - his former team, the New England Patriots and the Pittsburgh Steelers have each won the Super Bowl six times), five-time Super Bowl Most Valuable Player (MVP), three-time NFL MVP, and college football National Champion (he led the University of Michigan to the college football national championship in 1997).  Brady holds the NFL records for most career quarterback wins, most career passing attempts, most career passing completions, most career passing yards, and most career passing touchdowns.  

We tend to throw around labels such as "greatest of all time" loosely.  Based on the evidence, I think that when it comes to Tom Brady, such labels are appropriate.  Here's the question though.  Even if there's no argument that Brady is the greatest quarterback of all time, is it fair to say that he is the greatest football player of all time?  In order to answer that question, we have to decide whether the quarterback is the most important player on the team.

Harvard Business School professor, Boris Groysberg, recently answered this question in a study published in the Harvard Business Review.  I've posted about Groysberg in the past (he previously conducted a number of studies on the so-called "Portability Paradox", the concept that "superstar employees" fail to achieve a similar degree of success when they move to new organizations).  More specifically, Groysberg and his colleagues set out to determine which individual was the most important for the success of an NFL franchise - the quarterback, the head coach, the general manager, or the owner.  

The quarterback position has become increasingly important over the last couple of decades.  Since the 1970 NFL draft (which was the year that the Pittsburgh Steelers selected Hall of Fame quarterback Terry Bradshaw with the number one pick), teams have selected a quarterback with the first overall pick in the draft 26 times.  Quarterbacks are usually the highest-paid players on the team by a substantial margin.  The quarterback is the leader on the field, and most quarterbacks also serve as one of the team captains (making them leaders off the field too).

However, one could certainly argue that the head coach, general manager, and owner are equally important too.  The head coach influences all three phases of the game - offense, defense, and special teams, making key decisions both on and off the field.  It's no coincidence that the NFL's championship trophy is named after legendary head coach Vince Lombardi!  The general manager is in charge of evaluating and recruiting talent, through free agency, the draft, or via trades.  The general manager puts the team together (including the quarterback), so that the head coach can implement and execute the strategy for winning.  Finally, the owner is the individual who sets the ultimate tone for the team's identity and mission. 

Groysberg's team analyzed 38 seasons worth of data and found that the four leaders (quarterback, head coach, general manager, and owner) accounted for 68% of the variance in NFL team performance.  Owners were the least important (accounting for 11% of the variance), while the quarterback was the most important (accounting for 37% of the variance).  General managers and head coaches accounted for 22% and 29% of the variance, respectively.

They analyzed the data further, dividing the 38 seasons into two groups in half (19 seasons in the 20th century versus 19 seasons in the 21st century).  Quarterbacks significantly increased in level of performance in the 21st century.  The NFL game has changed significantly, with greater emphasis on offense (and passing, in particular), which likely accounts for this trend.

What are the lessons for those of us who aren't working in the NFL?  Groysberg suggests that the capability to execute has become critically important for all organizations, not just for teams in the NFL.  The classic view of leaders of coming up with great ideas, visions, and strategy is certainly still true today, but the need to execute on the vision and strategy is equally important.  The take-home message is that organizations need to have strong "quarterbacks" who excel when it comes to execution and operations.

Is Tom Brady the greatest quarterback of all time?  Absolutely.  Is he the greatest football player of all time?  In my mind, it's hard to argue otherwise.  

Soup bowls and light bulbs

During the early days of the pandemic, I picked up a biography of the inventor Thomas Edison by Edmund Morris.  By all accounts, Edison was a genius and prolific inventor with over 1,000 patents to his name.  He is credited with the invention of the phonograph, the motion picture camera, and most famously, an early version of the electric light bulb.  

Edison was once asked by a reporter how it felt to have failed 1,000 times when trying to invent the light bulb, and he is said to have replied, "I didn't fail 1,000 times, I just found 1,000 ways how not to build a light bulb."  There are so many different versions of this quote, that I suspect that's not exactly what he said.  Regardless, his persistence and resilience are without question and ultimately were foundational to his prolific success as an inventor.  Here are a few additional quotes:

"Our greatest weakness lies in giving up. The most certain way to succeed is to try just one more time."

"Many of life's failures are people who did not realize how close they were to success when they gave up."

"When you have exhausted all possibilities, remember this - you haven't."

"Negative results are just what I want. They’re just as valuable to me as positive results. I can never find the thing that does the job best until I find the ones that don’t."

There's no question that Edison was a man who was far ahead of his time.  He is also known for applying the scientific principles of management and organizational behavior to the process of invention.  Edison established his laboratory in Menlo Park, New Jersey in 1876, and while he is credited with most of the inventions produced there, the team of scientists and engineers that he directed performed most of the work.

I recently learned about another of Edison's innovations in a Medium post by Andrew Martin.  He had a unique way of interviewing potential job candidates for his Menlo Park laboratory (which reminds me a lot of the way that Google famously interviews potential employees).  Consistent with his tendency to micromanage everything at Menlo Park, Edison insisted on being personally involved with choosing every member of his staff.  He reportedly would ask job candidates to eat a bowl of soup in front of him!  

I know what you are thinking.  No, candidates didn't show up at Menlo Park, sit in front of Edison in his office, and have a bowl of soup placed in front of them.  Rather, they were invited out for dinner as part of the interview, and Edison would order a bowl of soup for the candidate (note that going out to dinner is a frequent part of every job interview, particularly after the initial screening interview).

Edison would closely observe whether the candidate added salt and pepper to their soup before first tasting it.  He immediately rejected the individuals who seasoned their soup before tasting it!  He reasoned that these individuals relied too much on assumptions.  Martin explained further, "Edison immediately rejected the premature seasoners, as he reasoned he didn't want employees who relied on assumptions. In his opinion, those who were content to abide by preconceived notions had no place in his business, because the absence of curiosity and willingness to ask questions were antithetical to innovation."

Apparently, Edison also liked to ask candidates (during the dinner conversation) random trivia questions, such as where prunes came from, what was felt, and who invented printing.  These questions were his informal way of assessing the individual's intelligence and creativity.

Again, Edison's interview technique reminds me a lot of how Google approaches interviews.  While a bit bizarre, Edison's technique is pure genius.  The overwhelming evidence suggests that interviews, at least as they are typically conducted, are pretty much useless!  Even so-called behavioral-based interviewing techniques aren't as effective as most people think (see this Inc post by Adam Grant).  Most studies suggest that the best way to identify the best person for a job is to actually have that individual perform the job.  For a lot of reasons, the "on the job" test is not very practical (however, medical schools and residency training programs have started using the multiple mini interview technique, which frequently includes some kind of skills assessment using simulation).  

The important point here, and my take-home message, is that (1) unstructured interviews are useless, (2) structured interviews are better than unstructured ones, but still not quite as helpful, and (3) more research needs to be performed on the best ways to identify talented individuals who are an appropriate fit for a particular position in an organization.  I suspect that we will continue to see more research in this area, which is desperately needed.  For now, perhaps we should take a cue from the "Wizard of Menlo Park" and require everyone to eat soup!

Murphy's Law, the U.S. Navy SEALs, and High Reliability Organizations

The word "mindfulness" is thrown around a lot these days.  I have both personally used and have come across this term in my own research in a couple of different contexts, most recently referring to the epidemic of burnout in health care workers, with "mindfulness" being one recommended strategy to mitigate burnout.  Here in this context, the word generally refers to a number of different techniques, including meditation, relaxation, deep breathing, and stress reduction, all with the goal of reducing stress, anxiety, and emotional exhaustion.

"Mindfulness" has also been used in the context of organizational safety.  Mindfulness, in this context, is an important attribute of what the organizational psychologist Karl Weick and many others call high reliabilty organizations (HROs).  I generally prefer the term "situation awareness", a concept from the human factors literature first popularized by the industrial engineer Mica Endsley.  "Mindfulness" and "situation awareness" essentially describe the same concept.

Merriam-Webster's dictionary defines "mindfulness" as "the quality or state of being mindful" or "the practice of maintaining a nonjudgmental state of heightened or complete awareness of one's thoughts, emotions, or experiences on a moment-to-moment basis."  On a side note, don't you just love how dictionary's define words using other words that you have to look up too! "Mindful" here means "awareness."  Today, I want to focus on the former Merriam-Webster dictionary definition, which seems to refer to the Karl Weick / Mica Endsley version, as opposed to the latter definition, which seems to refer to the burnout version.

Keith Grint (see also his work on "wicked problems" and my post, "What style of leadership works best?" for more about Grint's work on leadership and management) and his colleagues, Amy Fraher and Layla Jane Branicki recently examined the role of mindfulness in high reliability organizations in a study involving United States Navy SEALs, an elite commando unit whose main function is conducting small-unit special operation missions in a variety of different environments.  The selection and training of U.S. Navy SEALs continues to be a subject of interest for investigators in psychology, leadership, and organizational behavior (see, for example, studies on resilience, mindsets, and combat stress and the so-called "fog of war").  Given the level of high performance exhibited by Navy SEALs in their day-to-day operations, it's easy to understand why there is so much interest in learning from this prototypical high reliability organization.

Pertinent to the topic of discussion, most high reliability organizations (aircraft carriers, nuclear power plants, and air traffic control towers) are usually highly regulated through the use of rules and regulations, standardized processes, and checklists.  However, Karl Weick and Kathleen Sutcliffe have shown that the reliable performance of these organizations is more often due to "mindfulness", which they define as the capacity to detect and correct errors (awareness) and the ability to adapt to unexpected events before small events turn into catastrophic failures (resilience).  They describe five hallmarks of "mindfulness" in their classic book, Managing the Unexpected: Resilient Performance in an Age of Uncertainty:

1. Preoccupation with failure

2. Reluctance to simplify

3. Sensitivity to operations

4. Commitment to resilience

5. Deference to expertise

Grint and his colleagues extend Weick and Sutcliffe's findings further, adding a sixth hallmark of high reliability organizations - Comfort with uncertainty and chaos.  As Weick and Sutcliffe explain, "ugly surprises are most likely to show up."  I am sure you've heard of Murphy's Law - "If anything can go wrong, it will."  The world is filled with uncertainty, and high reliability organizations not only understand this, but they also are comfortable with it.

They conducted their study in three phases.  During the first phase, the research team conducted semi-structured interviews with twelve active or retired Navy SEALs, focusing specifically on how these SEAL teams work in such a high-risk field and make sense of unusual and escalating crisis situations.  Two broad themes emerged from this initial phase - "comfort with uncertainty and chaos" and "a positive orientation toward failure."  

Were these common characteristics of all Navy SEALs?  If so, were these characteristics identified in individuals who were selected as SEAL candidates, or did SEALs develop these characteristics during the rigorous training program? In order to answer these questions, the team collected over 600 pages of research documents from governmental studies involved SEAL recruitment, selection, and training processes during the second phase of the study.  Notably, while several SEAL candidate screening tests had been developed over time, none of them identified or screened for attitudes towards uncertainty, chaos, failure, or even the other HRO characteristics listed above.

During the third and final phase of the study, the research team reviewed and analyzed over 6 hours of video footage from a number of documentaries and government-sponsored recruiting videos that were in the public domain (see the Discovery television mini-series, Navy SEALs: BUDS Class 234, as one example (Basic Underwater Demolition/SEAL Training, or BUD/S is a 24-week selection and training course for all Navy SEALs, with a completion rate of less than 25%).  Three broad areas emerged for further categorization and analysis - physical failure, mental failure, and team failure.  

Importantly, the researchers found that Navy SEALs were indeed preoccupied with failure, one of the defining characteristics of a high reliability organization.  However, what they didn't expect to find was that the SEALs were more focused on adjusting to failure.  They had accepted that failure is not only likely, but it is also highly probable.  All the SEALs acknowledged that it was most important not to quit after failing, but to use that failure as a learning opportunity and moving on.  The researchers stated that "learning from failure implies a willingness to take risks and embrace unconventional thinking."  Key to this "learning from failure" was the acceptance and comfort with uncertainty and chaos, which "allows them [the Navy SEALs] to innovate, experiment, and even fail as long as they prepared as much as possible, gave their best effort, and learned from the experience."

Building upon the HRO research performed to date, the research team developed a concept they called "mindfulness in action" to explain their observations, which consists of attributes of both individual mindfulness (comfort with uncertainty and chaos) and collective (group) mindfulness (freedom to fail - a positive orientation towards failure).  In so doing, they added "comfort with uncertainty and chaos" as the sixth characteristic of high reliability organizations.

Before I end this post, I would like to return to the definitions of mindfulness that I mentioned in the first few paragraphs.  As I think about both the "burnout version" of the definition (think meditation and deep breathing) and the "HRO version" of the definition (think "situation awareness"), it seems that they are maybe not as different as I originally stated.  Let me explain.  You can't begin to (1) pay attention to discriminatory detail, (2) engage in the present, (3) be flexible to opportunities, and (4) be open to emerging realities (to use the oft cited definition of mindfulness by Ellen Langer, known as the "Mother of Mindfulness", i.e. the "HRO version") unless you have first opened your mind and placed yourself in a different state (as in the "burnout version" of mindfulness)!  As it turns out, Karl Weick thought so too (see "Organizing for Mindfulness: Eastern Wisdom and Western Knowledge").

I believe there is a lot we can learn from high reliability organizations.  But then, if you've been reading my post over the years, you already know how I feel!  Grint and his team ended their research paper with a very powerful statement, and so I will end with it as well.  "If we can manage to maintain high levels of safety, reliabilitym and success in HRO environments such as nuclear safety, aviation, and in this case, Navy SEALs, it is likely that equivalent levels of high performance are achievable within a wide range of reliability-seeking organizations in less risky contexts."  In other words, there's hope for us!

International Women's Day 2022

Today, March 8th, we celebrate International Women's Day!  While there were forerunners to this special day, International Women's Day was first celebrated officially by the United Nations in 1977.  While we celebrate the social, economic, cultural, and political achievements of women, today also serves as a call to action for accelerating women's equality. The theme for this year's celebration is "Gender equality today for a sustainable tomorrow."

The COVID-19 pandemic has had a disproportionate impact on women in the workforce (please see the links to reports by McKinsey & Company and the Brookings Institution for more information on this particular issue).  However, in spite of these challenges with the pandemic, according to McKinsey's "Women in the Workplace 2021" survey, gender diversity improved on almost every level in the corporate hierarchy during 2020.  Unfortunately, while we've made demonstrable progress in the past several years, it's clear that we have a long way to go to achieve the vision of gender equality, both within and outside of the health care industry.  

McKinsey & Company calls it the "broken rung" (referring to the "corporate ladder").  Women are promoted to manager, which is often the entry level to the upper echelons of management, at far lower rates than men.  For every 100 men promoted to manager, only 86 women are promoted, which means that far fewer women are available for promotion to higher level management positions.  As a result, women are underrepresented at the senior-manager, director, and vice-president levels compared to men.  

There is no question that a diverse workplace is a better workplace.  Several studies have shown the benefits of having women in the workforce, particularly in positions of leadership.  Organizations with women in leadership positions have been shown to outperform organizations with less diversity.  On average, these organizations have 48% higher operating margins and 45% higher earnings per share compared to their peers.  Gender-diverse teams make better business decisions up to 73% of the time when compared to their less diverse peers.  

As it turns out, one of the most effective ways that we can address gender diversity and equality issues in the workforce is to increase the number of women in leadership positions.  It seems obvious, but the studies show that when women are in leadership positions, the number of women in the workforce also increases.  Again, McKinsey's "Women in the Workplace 2021" survey found that women leaders are more supportive of their teams compared to their male peers (see the Figure below).

Women leaders are twice as likely as men to spend time outside of their normal job responsibilities to focus on diversity, equity, and inclusion at least weekly.  They are also more likely to champion work-life integration and actively intervene to address burnout.  A study just published in the Proceedings of the National Academy of Sciences found that hiring women into senior leadership positions is associated with a reduction in gender stereotypes in organizational language.  In other words, hiring women into leadership creates a work environment that is more inclusive and favorable to fostering the growth and development of future women leaders!  There is a "critical mass" or tipping point (probably occurring when 20% of the individuals in an organization are women) at which the work environment becomes more inclusive and less tolerant of bias, discrimination, and outright harassment.  When women are in positions of leadership, this "critical mass" likely occurs at a much lower percentage of the workforce.  

Gender inequality has been deemed the "greatest human rights challenge of our time" by the United Nations.  What can we as leaders do to celebrate International Women's Day every day?  Mary Sharp Emerson, writing in a post earlier this year for the Harvard Professional Development blog suggested that senior leaders (who are still predominantly white men) can lead the way forward by making sure that women have the same opportunities for advancement, promotion, and career growth as their male co-workers:

1. Establish clear (and transparent) job performance evaluation criteria

2. Analyze corporate HR data by gender and by race

3. Actively prepare women for leadership roles

4. Develop nuanced strategies for sponsorship

5. Discover the value of diverse leadership styles

6. Be willing to engage in honest discussions of gender and racial bias

Today, we celebrate women everywhere and remind ourselves of the work that still lies ahead.  "Gender equality today for a sustainable tomorrow." #BreaktheBias

Don't lose your cool!

If you've been reading my blog posts in the past, you know that I have been reading a lot about the philosophy of Stoicism (see for example, "To be a Stoic in today's world - part 1", "Hard winter training", or  "I wish" for posts specifically covering topics on Stoicism).  I subscribe to the Daily Stoic blog by Ryan Holiday, and I read passages from his book, The Daily Stoic: 366 Meditations on Wisdom, Perseverance, and the Art of Living every day.  I recently started reading several books from some of the ancient Stoic philosophers (for example, Meditations by Marcus Aurelius, The Enchiridion by Epictetus, and Letters from a Stoic by Seneca).

Today's lesson from Stoicism included the following passage from Marcus Aurelius' Meditations, which he in turn copied from the ancient Greek tragedy Bellerophon, by Euripides:

"You shouldn't give circumstances the power to rouse anger, for they don't care at all."

Bellerophon was a hero from Greek mythology (considered "the greatest hero and slayer of monsters, alongside Cadmus and Perseus, before the days of Heracles").  He is best known for killing the Chimera, a fire-breathing monster with a lion's head, a goat's body, and a serpent's tail.  He also captured the winged horse, Pegasus and earned the disfavor of the gods after he tried to ride Pegasus to Mount Olympus.  It is this latter feat that is the subject of Euripides' lost tragedy, Bellerophon.  

Enough of the history lesson, let's get back to Stoicism.  One of the fundamental tenets of Stoic philosophy is the concept of control.  Specifically, you should always (and only) focus on what is inside your control, not on what is outside your control.  Epictetus famously stated, "Some things are in our control and others not. Things in our control are opinion, pursuit, desire, aversion, and, in a word, whatever are our own actions. Things not in our control are body, property, reputation, command, and, in one word, whatever are not our actions."  

We are in control of our actions and our response to events, and not to the events or circumstances themselves.  Have you ever sat in an airport waiting for a flight that has been delayed?  It seems to be a fairly common occurrence these days.  The last time my wife and I were on vacation at the beach (which seems like ages ago), there was a large storm moving slowly across the southeastern portion of the United States.  Our flight back home kept getting delayed - the inbound aircraft was apparently waiting on the tarmac in Atlanta.  We waited for several hours in the airport.  Finally, late in the evening, we heard from the gate attendant that the inbound aircraft was landing shortly and that we would be boarding soon.  As we waited in line to board, we watched as the flight crew exited the plane and slowly walked away from the gate.  The gate attendant then announced that the flight crew had "timed out" and that the flight was going to be re-scheduled for the morning.  Ugh!

My wife and I watched as a number of passengers on our flight became quite unruly.  One woman started yelling at the gate attendant.  Admittedly, both the airline and the gate attendant could have handled the situation better.  However, regardless of how much yelling the woman did, she was still not going to fly out that night.  

Marcus Aurelius would argue that the woman made the mistake of giving her circumstances the power to rouse her anger.  As Ryan Holiday writes, "Circumstances do not change as a result of how angry you get at them."  Epictetus tells us that we have the power to choose how we respond to circumstances.  We don't have any power over how those circumstances arise or play out.  We can choose to be angry - but why?  Will that make the situation any different?  Probably not.

We should always focus on what we can control and what we can change.  If something is out of our control (or if we can't change it), the Stoics tell us that we shouldn't waste any time or energy on it.  It's not easy to do, but there is no point in losing your cool over something that you have absolutely no control over.

"It's better to be lucky than good..."

One of our daughter's elementary school teachers used to give all the students in her class a peppermint candy before every test.  She claimed that the peppermint "woke everyone up" (i.e. increased their level of alertness), so that they would perform better on the test.  Later, that same daughter tested that theory in her science fair project (just for the record, she concluded that peppermints didn't improve test performance).  Regardless, my wife, who is a middle school math teacher, still gives her students a peppermint before every major test.

We are all superstitious to some extent.  Most of us believe in luck, and a lot of us own "good luck charms."  Famously, the basketball superstar, Michael Jordan, used to wear his old University of North Carolina gym shorts underneath his Chicago Bulls uniform for good luck.  If you're a golf fan, you know Tiger Woods always wore a red shirt on Sundays (typically the last day of the tournament), again for good luck.    The University of Notre Dame football team famously has worn green jerseys (the official school colors are blue and gold) for big games.

If you have ever crossed your fingers, uttered the phrase "knock on wood", searched the ground for a four-leaf clover, or carried any form of "good luck charm" (rabbit's foot, medallion, etc), there's a good chance that you believe, at least partially, in superstitions.  The dictionary defines superstition as a widely held but unjustified belief in supernatural causation leading to certain consequences of an action or event, or a practice based on such a belief (as an aside, the singer Stevie Wonder has a great song called Superstition that lists a number of common superstitions - check it out here).  

Studies have shown that people are more likely to resort to superstitions when they are feeling uncertain, stressed, or lack control.  We experience a number of these feelings when we are in situations where we have to perform at our best (e.g. before a major exam or an important game).  It is during these same situations where we often resort to our belief in good luck, and it is that belief in luck that gives us a reason to be optimistic, hopeful, and confident that things will work out in our favor.  That, in essence, is what gives "luck" its power.  Feeling optimistic, hopeful, and confident actually increases the chance that we will be successful - optimism, hope, and confidence fuels better performance.  If "luck" is the source of that optimism, hope, and confidence, by extension it is that same "luck" that drives us to better performance!

Three investigators from the University of Cologne actually tested this relationship in a study published in the journal, Psychological Science ("Keep Your Fingers Crossed! How Superstition Improves Performance").  They conducted four separate experiments, all of which tested performance on a certain skill-based task (e.g., putting a golf ball or a memory task similar to the game Concentration).  Study participants were randomized to one of two groups - experimental group, in which luck-related superstitions were activated by a saying ("break a leg"), action ("cross your fingers"), or a lucky charm and a control group (no luck-related superstitions).  Activating a good luck superstition in these ways all significantly improved subsequent performance on one of these skill tasks or tests of memory.  Based on surveys conducted during these experiments, the investigators showed that the performance-enhancing effects of luck were mediated by an increase in the participants' perceived level of confidence in completing the task!

This is obviously just one study, but other investigators have found similar results and made similar conclusions.  I still believe, rather strongly, that there is no substitute for talent, hard work, dedication, and commitment.  As Thomas Jefferson once said, "I'm a great believer in luck, and I find the harder I work, the more I have of it."  I also believe, again rather strongly, that we make our own luck (see one of my older posts from 2017, "Good luck is the twin of hard work").  Perhaps this study (and the others like it) suggest that we all use a little superstition too.  

Givers and Takers - One Last Time

You've probably figured out by now that I really, really enjoyed Adam Grant's book, Give and Take.  It's probably one of those books that I will read over and again many times - it's really that good.  While researching some of the points he made in his book, I came across a couple of interesting quotes that build upon what I talked about in my last post, The Giving Tree.

An anonymous person said, "Givers need to set limits, because takers rarely do."  

The author Mary Anne Radmacher said, "As we work to create light for others, we naturally light our own way."

Grant's concept again, as I discussed last time, is that the workforce can be divided into givers, takers, and matchers.  The givers are the ones who are most successful, but only if they are what Grant calls otherish givers and not self-sacrificing givers.  Otherish givers balance serving others with serving themselves.  They clearly are more altruistic than either the takers or the matchers, but they avoid the pathological altruism that contributes to burnout and loss of productivity.  Here then is one potential strategy to avoid burnout - set limits and balance your own welfare with that of the ones you are trying to help.  

Grant frequently talks about a study he conducted at a telephone call center.  The call center solicited donations from alumni, and the rate of rejection was very high (approaching 90%).  Callers were required to ask for a donation at least three times during a call, and as you can imagine, the simple act of facing constant rejection was burning them out.  The rate of turnover at the center was very high, even though the job was one of the highest paying jobs for students on campus.

Grant found that, contrary to his previous research, the givers were dropping out and failing at a much higher rate than the takers!  When he visited the center, he noticed a sign on one of the caller's desks (clearly one of the givers):

What was going on here?  Grant thought that the givers were burning out because they weren't able to see a connection between what they were doing (soliciting donations from alumni) and who they were helping (the students at the university).  The takers were completely fine with working at a job with a high wage.  The givers were not motivated by the money - they needed something more.

Grant brought in letters from some of the students who had received scholarship money from the school (which came from alumni donations).  When these letters were read aloud at the weekly staff meetings, the givers quickly caught up with the takers.  Calls increased, and more importantly, donations increased too.  Next, Grant actually brought in some of the scholarship recipients to meet with the callers face-to-face.  Shortly thereafter, givers doubled the number of calls per hour and minutes on the phone per week, and average weekly donations increased from $185 to just over $500!  Making a connection between the work and the individuals they are trying to help was one of the key factors in avoiding burnout.

The researchers Olga Klimecki and Tania Singer go on to suggest that givers develop signs of burnout (and even compassion fatigue) when they work with people in need and are unable to make a difference, for whatever reason.  I suspect that this is a major driver of burnout in health care, particularly when our health care delivery system is measured by things that may not necessarily be in our span of control (I've posted on this subject before, see for example, "You give to get to give" and "Invest your money wisely...").  There is nothing more frustrating, more de-motivating, more stressful than being held accountable for something that is beyond your control.  Unfortunately, physicians and nurses are often placed in that exact situation.  And it's not just in health care - I suspect that the so-called Great Resignation (also known as the "Big Quit") is in large measure due to employee burnout.

Susan Scott, author of Fierce Leadership said, "Burnout happens, not because we're trying to solve problems but because we've been trying to solve the same problem over and over and over," which brings me to my final point about the key drivers of burnout in health care.  Health care providers are more likely to develop burnout when they feel like they are not making a difference.  As just one quick example, I once had a long conversation with a frustrated pediatrician whose patient with chronic lung disease kept getting worse because her parents refused to quit smoking.  The child kept getting admitted to the hospital for lung problems that were directly attributable to secondhand smoke exposure.

We have a lot of work to do in health care to address the burnout epidemic.  Building on my last post, we can all start by being otherish givers.  As leaders, we need to do a better job at "connecting the dots" so that our workers can witness the impact of what they do on a daily basis.  Also, we should stop holding individuals accountable for things that are just not under their control.  Lastly, we need to find a way to break the repetitive cycle where we force our workers to solve the same problems over and over and over again.