What are your strengths?

Have you ever been asked in a job interview, "What are your strengths?"  I can tell you how the character Michael Scott from The Office would answer that question (here's the scene).  He would say, "Why don't I tell you what my greatest weaknesses are - "I work too hard.  I care too much.  And sometimes I can be too invested in my job."  And when asked by the interviewer David Wallace about his strengths, Michael responds with, "Well, my weaknesses are actually strengths."

It's probably best to avoid gimmicks like the one Michael Scott used.  For example, I've also heard some individuals respond to the question, "What are your weaknesses?" by answering with, "I am a perfectionist."  Again, we see the gimmick of answering a question about a weakness by talking about a strength.  But is perfectionism really a strength?  Perfectionists are usually highly motivated, conscientious, hard-working individuals who strive for flawlessness.  On the other hand though, perfectionists can also be seen as rigid, inflexible, and overly critical too.  Moreover, given that perfection is rarely achieved, perfectionists tend to experience high levels of stress, anxiety, and burnout.  So which is it?  Strength or weakness?

A group of investigators analyzed over four decades of research, involving 95 studies and over 25,000 working age individuals in a variety of contexts (see "Is perfect good? A meta-analysis of perfectionism in the workplace") and found that perfectionism is actually a much bigger weakness than most of us assume (see also their summary "The Pros and Cons of Perfectionism" in Harvard Business Review).  First, the results of their analysis supported that perfectionism does have significant benefits, as these individuals do tend to be more motivated, work longer hours, an be more engaged at work.  However, the results also suggested that these benefits come at significant cost, with perfectionists demonstrating higher levels of burnout, stress, and depression.

Importantly, there are likely to be two kinds of perfectionism.  Individuals with the first kind, which is called excellence-seeking perfectionism, tend to fixate on and demand excessively high standards, not only of themselves but of their co-workers too.  Individuals with the second kind, which is called failure-avoiding perfectionism, constantly worry about making failing to live up to their own and others' expectations.  Importantly, the "beneficial" effects of perfectionism are generally stronger for those with excellence-seeking perfectionism, while the "detrimental" effects are stronger for those with the failure-avoiding perfectionism.  Most importantly, the investigators of this study showed that in general, performance and perfectionism are not related - perfectionists are not any better nor any worse than non-perfectionists when it comes to job performance.  They conclude, "Taken as a whole, our results indicate that perfectionism is likely not constructive at work."

So there you have it.  Michael Scott was wrong all along!  I am as shocked as you are...

  

"You're OUTTA HERE!!"

When I think of Major League Baseball managers who had a reputation for getting ejected from the game for arguing with umpires, I think of the greats Earl Weaver, Billy Martin, and Lou Piniella.  So I was surprised to learn that the all-time leader in ejections was Atlanta Braves Hall of Famer Bobby Cox with 162 total ejections, which may be one of baseball's most unbreakable records!  Baltimore Orioles Hall of Famer Earl Weaver actually ranked fourth in the number of ejections, and Lou Piniella tied for thirteenth on the list.  Billy Martin, who managed the New York Yankees on five different occasions, wasn't even in the top twenty!  Oh well - perhaps I was just remembering some of the most epic manager ejections in history!

I realize that some managers just have a temper and cross the line because of it.  However, I also believe that some managers think that they are accomplishing something by getting ejected (for one of my all-time favorites, check out the scene from the 1986 movie Hoosiers where Coach Norman Dale for Hickory High School gets ejected on purpose so that his assistant can coach the rest of the game).  As a general strategy, I think yelling and cussing and losing your temper on purpose is flawed.  Or is it?  

A group of investigators from the University of Quebec analyzed over 153,000 pitches over ten Major League Baseball seasons (2010-2019) to see if there was any impact on the umpire's calls after someone, either the manager or a player, was ejected for specifically arguing about a called strike or ball (see "Verbal Aggressions Against Major League Baseball Umpires Affect Their Decision Making" published in the journal, Psychological Science).  They found that (1) umpires who experience verbal abuse resulting in an ejection do, in fact, tend to alter their decision-making when it comes to calling strikes versus balls; (2) the alteration in decision-making only occurs when the object of criticism involves whether a pitch was a ball or strike; and (3) the alteration in decision-making does not appear to be in an attempt to compensate the team for the loss of the ejected individual.

What I found particularly interesting about this study was that after ejecting a manager or player, umpires tended to call fewer strikes for the offending team (i.e. the one in which a manager or player was ejected) and more strikes for the opposing team!  The investigators suggest that the offending team (i.e. the team in which a player or manager was ejected) is responding to a perceived injustice, believing that the umpire is making the wrong call.  They further suggest that umpires change their decision-making in order to avoid further social punishment from the offending team.  What's also interesting is that the offending team argues in most cases is correct about the perceived injustice - in other words, prior to being ejected, most of the umpire's calls are going against them (and are actually the wrong calls).  

While the sport of baseball is a unique situation, the investigators do suggest that their findings can be generalized to other contexts.  Managers (not the baseball kind) and decision-makers should be cognizant of the tendency to bias their decisions after being aggressively criticized.  Managers should not reward bad behavior by changing their approach to decision-making, solely in an attempt to avoid further aggressive criticism.  It's an interesting perspective and an important suggestion, even if it's one that is difficult in practice.  

“Lest we forget…”

It's Memorial Day, so my post today is a repeat of an old favorite.  Here is one of my favorite poems, one that I learned a very long time ago.  It is called, "In Flanders Fields" and was written by a Lt. Colonel John McCrae during World War I.   Lt. Colonel McCrae was a physician in the Canadian Army and wrote the poem for the funeral of a friend and fellow soldier, Lieutenant Alexis Helmer, who died in May, 1915 in the Second Battle of Ypres.  One of the poem's lines, perhaps its most famous one, references red poppies, which has led to the practice of the remembrance poppy.  It is a great poem, and I will leave it here for you today, to honor all of those who have fallen in the service of their country:

In Flanders fields the poppies blow
Between the crosses, row on row, 
That mark our place, and in the sky, 
The larks, still bravely singing, fly, 
Scarce heard amid the guns below. 

We are the dead; short days ago
We lived, felt dawn, saw sunset glow, 
Loved and were loved, and now we lie
In Flanders fields. 

Take up our quarrel with the foe! 
To you from failing hands we throw
The torch; be yours to hold it high! 
If ye break faith with us who die
We shall not sleep, though poppies grow
In Flanders fields.

"These go to eleven..."

One of the classic scenes from the 1984 mockumentary film "This is Spinal Tap" involves Rob Reiner (playing the documentary director Marty Di Bergi) and Christopher Guest (playing guitarist Nigel Tufnel) talking about guitar amplifiers.  Nigel proudly shows Di Bergi the band's amplifiers, which all turn up to eleven.  Here is the sequence (watch the clip here):

Nigel Tufnel: The numbers all go to eleven. Look, right across the board, eleven, eleven, eleven and...

Marty DiBergi: Oh, I see. And most amps go up to ten?

Nigel Tufnel: Exactly.

Marty DiBergi: Does that mean it's louder? Is it any louder?

Nigel Tufnel: Well, it's one louder, isn't it? It's not ten. You see, most blokes, you know, will be playing at ten. You're on ten here, all the way up, all the way up, all the way up, you're on ten on your guitar. Where can you go from there? Where?

Marty DiBergi: I don't know.

Nigel Tufnel: Nowhere. Exactly. What we do is, if we need that extra push over the cliff, you know what we do?

Marty DiBergi: Put it up to eleven.

Nigel Tufnel: Eleven. Exactly. One louder.

Marty DiBergi: Why don't you just make ten louder and make ten be the top number and make that a little louder?

Nigel Tufnel: [pause] These go to eleven.

It's a great scene!  It's an incredibly funny scene, because Nigel and his bandmates actually think that their amplifiers are louder than any other band's amplifiers - "These are special."  I think of this scene whenever I hear someone talking about giving an 110 percent effort.  

Hall of Fame baseball player Yogi Berra said, "You have to give 100 percent in the first half of the game.  If that isn't enough, in the second half, you have to give what's left."  Yogi was famous for these kinds of quotes, which have been called "Yogi-isms" (perhaps his most famous one is "It ain't over 'til it's over") - this particular one is a "Yogi-ism" because, as everyone knows, it is impossible to give more than a 100 percent effort.

The quote by legendary UCLA Basketball Coach John Wooden is perhaps more accurate, but certainly not as witty.  Coach Wooden once said, "Give me 100 percent.  You can't make up for a poor effort today by giving 110 percent tomorrow.  You don't have 110 percent.  You only have 100 percent, and that's what I want from you right now."

1 + 2 + 3 + 4 + ... = ?

I’ve already told you that I don’t really fully understand mathematics.  With that in mind, I came across a mathematical series known as the Ramanujan Summation the other day.  It’s named after the Indian mathematician Srinivasa Ramanujan and states that if you add all the natural numbers to infinity, 1 + 2 + 3 + 4 + 5 + 6…, you will find that it is equal to -1/12!  That seemed impossible to me, so I kept reading further.  The proof makes sense, even as someone who is not mathematically inclined. Please allow me to elucidate!

In order to build the proof for the Ramanujan Summation, I first need to convince you of the following mathematical proofs (trust me on this - you will see why at the end):

1 – 1 + 1 – 1 + 1 – 1 … = ½

1 – 2 + 3 – 4 + 5 – 6 … = ¼

Okay, are you ready? Let’s prove that the first infinite series above is equal to ½, which seemed fairly unlikely to me (at least until I read the proof).

Let A = 1 – 1 + 1 – 1 + 1 – 1 …

Now, let's use a trick from algebra and subtract both sides of the equation from 1 (we can do that if it's done on both sides of the equation):

1 – A = 1 – (1 – 1 + 1 – 1 + 1 – 1 …)

Now as my math teacher wife always tells her students, "When in doubt, simplify!"  Simplifying the above equation results in:
 
1 – A = 1 – 1 + 1 – 1 + 1 – 1 …
 
See that?  The series on the righthand side of the equation is actually our original series A.  Through a mathematical sleight of hand, we have shown that 1 – A = A.  Now, use simple algebra to simplify the rest:
 
1 – A = A
 
1 – A + A = A + A
 
1 = 2A

 
½ = A
 
In other words, we have shown that the sum of the original infinite series (which we called A) is ½, which doesn’t really make intuitive sense to me, but hey that’s mathematics!  Apparently this infinite series is named after the Italian mathematician Luigi Guido Grandi and is called Grandi’s series.
 
Now let’s tackle the second infinite series above.  We will follow the same method that we used to prove Grandi’s series:
 
Let B = 1 – 2 + 3 – 4 + 5 – 6 …
 
Let’s now use A to help us out.  We subtract both sides of the equation from A (remember that we can do this as long as we do it on both sides of the equation), as shown below:
 
A – B = (1 – 1 + 1 – 1 + 1 – 1 …) – (1 – 2 + 3 – 4 + 5 – 6 …)
 
A – B = (1 – 1 + 1 – 1 + 1 – 1 …) – 1 + 2 – 3 + 4 – 5 + 6…

Using more mathematical sleight of hand, we can rearrange the above equation to:
 
A – B = (1 – 1) + (-1 + 2) + (1 – 3) + (-1 + 4) + (1 – 5) + (-1 + 6)…
 
The above equation simplifies further to:
 
A – B = 0 + 1 – 2 + 3 – 4 + 5 …

A - B = 1 – 2 + 3 – 4 + 5 …
 
Note that the series on the right side of the equation above is actually our original series B.  So, substituting B where appropriate yields the following:
 
A – B = B
 
A – B + B = B + B

A = 2B

But wait!  We know that A = 1/2 (proved above).  Let's substitute 1/2 for A in the above equation, which yields:
 
½ = 2B

Now all we have to do is solve for B:
 
¼ = B
 
Tuh-dah!  There’s not a fancy name for this infinite series, but that’s okay.  It’s also apparently very well-known and commonly used throughout the fields of mathematics and physics.
 
Okay, let’s get back to the original point of this entire discussion, proving that the infinite series 1 + 2 + 3 + 4 + 5 … = -1/12.  Let’s start again by defining a new series:
 
C = 1 + 2 + 3 + 4 + 5… 
 
Let’s now subtract C from B (similar to what we’ve done in the previous two proofs) and simplify using more mathematical sleight of hand:
 
B – C = (1 – 2 + 3 – 4 + 5 – 6 …) – (1 + 2 + 3 + 4 + 5 + 6…)
 
B – C = (1 – 2 + 3 – 4 + 5 – 6 …) – 1 – 2 – 3 – 4 – 5 – 6…
 
B – C = (1 – 1) + (-2 – 2) + (3 – 3) + (-4 – 4) + (5 – 5) + (-6 + 6)…
 
B – C = 0 – 4 + 0 – 8 + 0 – 12 …
 
B – C = -4 – 8 – 12 …
 
Alright, that’s not what you were probably expecting, but it’s still a long way off from our result of -1/12.  Or is it?  Note that all the numbers on the righthand side of the equation are multiples of 4.  We can use simple algebra to factor the 4 out as follows:
 
B – C = -4 (1 + 2 + 3…)
 
Whoa!  Now we have our original series C on the righthand side of the equation.  We can now simplify further:
 
B – C = -4C
 
B = -3C

Again, we know that B = 1/4, so we can substitute and then solve for C:
 
¼ = -3C
 
-1/12 = C.
 
Voila! It seems impossible to me that the sum of all natural numbers up to infinity can equal not only a negative number but also a fraction!  However, the “proof is in the pudding” so to speak, and hopefully you can follow the intuition above.  Apparently the Ramanujan Summation is used throughout mathematics and physics, but that's for another day (okay, the likelihood that I will be writing anything more about the Ramanujan Summation is fairly low, so you will have to just research it yourself, if you are so inclined).  However, according to Wikipedia, a mathematician from the University of Alberta, Terry Gannon, calls the Ramanujan Summation "one of the most remarkable formulae in science" in a monograph on - wait for it - moonshine theory!  Who knew that mathematics and moonshine can be used in the same sentence!?!

Once again, things aren't always as obvious as they seem.  Just like the High Reliability Organization principle of Reluctance to Simplify!  The simple explanations are usually the wrong ones, particularly when it comes to complex systems.  The answer may be hidden beneath the surface.  Dig deeper.  Always take the next step. 

A National Treasure

My wife and I attended a book tour event last night with the Presidential historian and author Doris Kearns Goodwin sponsored by Chicago Humanities as part of their 2024 Spring Festival.  The event was hosted by the author Jonathan Eig who won the Pulitzer Prize for his most recent book, King: A Life.  It was actually the first time that we've done something like this since we moved to Chicago a few years ago.  We actually heard Ms. Goodwin speak a few years ago at an event in Cincinnati, and we both thought that she was incredible then.  She was just as incredible now!  She talked about her most recent book, An Unfinished Love Story: A Personal History of the 1960's, which was released about a month ago.  The book is part memoir, part biography (of her late husband Richard Goodwin, a writer and former aide and speechwriter to President Lyndon B. Johnson and Senator Robert Kennedy), and part history of one of the most turbulent decades in our nation's history.  Of course I purchased a copy of the book at the event, but it will have to wait until I finish one of her other books, Leadership in Turbulent Times, which has been waiting on my nightstand for several months now.

Ms. Goodwin is 81 years old, which is surprising giving how much energy and passion she brought to bear to the event tonight.  She is a gifted speaker and one of our most brilliant minds - she is, to me, a national treasure.  What's also evident is that she dearly loved her husband and misses him terribly.  To hear her tell stories about her husband was absolutely awe-inspiring.  What impressed my wife and I the most tonight was her story about how her husband wrote a speech that President Johnson delivered to a Joint Session of Congress following Bloody Sunday, the violent police suppression of civil rights marchers on the Edmund Pettus Bridge in Selma, Alabama on March 7, 1965.  Goodwin had about 8 hours to draft the speech, the formal title of which was "The American Promise" but is commonly known as the "We Shall Overcome" speech.  The speech is considered Johnson's "greatest oratorical triumph" and led to the passage of the 1965 Voting Rights Act.  Ms. Goodwin recited the opening and powerful first paragraph of the speech by memory - the words are powerful and poignant:

I speak tonight for the dignity of man and the destiny of democracy.

I urge every member of both parties, Americans of all religions and of all colors, from every section of this country, to join me in that cause.

At times history and fate meet at a single time in a single place to shape a turning point in man’s unending search for freedom. So it was at Lexington and Concord. So it was a century ago at Appomattox. So it was last week in Selma, Alabama.

Read the text of his speech.  It's just an incredible speech.  It seems that people don't talk like that much anymore.  

I encourage you to read the books by Doris Kearns Goodwin.  I have yet to be disappointed.  I encourage you to watch her recorded talks that are widely available on the Internet.  I encourage you to watch her Master Class on Leadership.  My wife and I left the event with a new sense of hope and purpose.  As we walked to our car, my wife turned to me and said, "We should do more of this."  I agreed.  It was a great night listening to a great American.

  

"For the seafood lover in you..."

I just read that the casual dining seafood restaurant chain Red Lobster filed for Chapter 11 bankruptcy on May 19, 2024.  Last week, in preparation for that filing, they closed nearly 100 restaurants in at least 27 states.  One has to wonder if Red Lobster will go the way of so many other retail stores and restaurants that I remember growing up.  While there were many factors cited for the bankruptcy filings, one of the leading root causes was a disastrous "endless shrimp" promotion (a "$20 all-you-can-eat shrimp deal") that apparently resulted in $11 million in losses. 

Following the closure of several restaurants earlier this week, CEO Jonathan Tibus said, "This restructuring is the best path forward for Red Lobster.  It allows us to address several financial and operational challenges and emerge stronger and re-focused on our growth."  A company spokesperson stated that they would continue to operate its over 600 restaurants (551 restaurants in the U.S., 27 restaurants in Canada, and 27 restaurants in other international locations) through the bankruptcy proceedings, which will be focused on simplifying operations, closing low-performing locations, and pursuing a sale.  

As you probably guessed, the "endless shrimp" promotion isn't the sole reason for today's bankruptcy filing.  Industry experts say that today's news is the culmination of over two decades poor management in the face of increasing competition from faster, cheaper restaurant chains such as Chipotle and Panera.  For example, the company apparently tried to lower prices as a way to compete with other chains by offering an "endless crab" promotion in 2003, but the company lost millions as the price of crab rose.  I guess the company didn't learn, as they tried a similar strategy with the same disastrous results with the "endless shrimp" promotion.  While they increased the number of people dining in their restaurants, more people opted for the all-you-can-eat promotion.  Unfortunately, the restaurant doesn't make enough of a profit margin on shrimp when the costs are factored in.  Aaron Allen, founder of the restaurant consulting firm Aaron Allen & Associates said, "The fact that they would have this kind of corporate amnesia is a fascinating case study in corporate food service."

Red Lobster achieved better success in the mid-2000's when they tried to reposition themselves as a more upscale restaurant by raising prices and renovating restaurants.  Unfortunately, they continued to struggle with rising lease and labor costs, as well as changing consumer tastes.  Since 2019, they've experienced a 30% decline in annual guest counts.  Allen suspects that Red Lobster will decrease the number of restaurants by about one-third to one-half as part of the bankruptcy proceedings.  And he suspects that "Most likely whoever buys it is not going to want to fix up Red Lobster."

The lessons here are (1) remember the lessons of the past, as history generally repeats (i.e. if a promotion failed miserably in the past, it will probably fail again in the future) and (2) it's hard to dig out of a 20 year hole, so don't try to do that using a gimmick like an all-you-can-eat promotion.  Organizations should always strive for operational efficiency (preferably using High Reliability Organization principles!).  bIt's sad to see another well-known company go under, but it's hard to argue that it's the right move when the company has been struggling for so long under what Allen describes as "a slow-moving train wreck that has been in motion for 20 years."

Reviewer 2

Peer review has been called the "bedrock of academic publishing."  Whenever you submit a manuscript for potential publication in an academic journal, the editorial staff conducts a quick review to see if the manuscript should be reviewed further.  The next step is for experts in the field (typically anywhere from 2 to 4 reviewers) to review the manuscript to offer both positive and negative (usually more negative than positive) feedback.  The really good reviewers often offer suggestions on how to improve the manuscript.  The manuscript is then returned to the lead author, who then attempts to address the reviewers' feedback.  Once the authors are finished revising the manuscript, they re-submit it to the journal and the same reviewers take a second look in order to decide whether to proceed with publication or not.  I am simplifying the process somewhat, but what I've described is basically the process that all academicians must go through in order to publish their articles.

My experience with peer review (both as an author and as a reviewer) has usually been quite positive.  I've found that in most cases, the reviewers have done a great job helping my fellow co-authors and I to produce a much better article.  I will admit that I've had some reviewers who have been difficult to satisfy, but in most cases I've found that the reviewers were fair, honest, and professional.

There's a claim going around on social media that Reviewer #2 is always the harshest critic.  There are even memes on the Internet about "Reviewer #2" - here's just one example:

So, imagine my surprise (and delight) to find that someone actually published an analysis of 2546 open peer reviews of 796 manuscripts submitted and published in the prestigious journal, British Medical Journal (see "An Empirical Assesment of Reviewer 2").  The authors of this incredible study found that there was no difference in the content of peer reviews between Reviewer 2 and other reviewers for word count, use of negative phrases, use of positive phrases, use of question marks, and use of the word "please".  In other words, Reviewer #2 was indistinguishable from the other Reviewers!

I don't know if this kind of study will lead to any groundbreaking advances in science, but I applaud the authors of the study for adding some levity to the whole world of academic publishing!  And it's reassuring that Reviewer #2 is a good person too!

"Billions and Billions"

I recently found a website (not Amazon Prime, Netflix, or Hulu) that has all of the episodes of the 1980 television series Cosmos: A Personal Voyage, a thirteen episode series written and starring the astronomer Carl Sagan.  I believe that it first aired on public television, and there was also a book that accompanied the series.  I remember reading the book (and I think that I even owned a copy of the original hardback version), and I remember watching at least the first few episodes.  As difficult as it may seem, back then if you didn't catch an episode when it aired, you were out of luck!

I watched the first episode again, and the first half wasn't very interesting.  Basically, Sagan was flying around space in an imaginary spaceship and naming various celestial bodies like pulsars, quasars, nebula, etc.  I kept pausing the show, which jogged my memory of the first time that I watched it - I lost interest back then too!  However, I kept coming back to it, just to see if my memories of some of the episodes were in fact true.  Having watched a few episodes now, it's all coming back.  I must have watched more of the show than I thought.

What's amazing to me is how much we didn't know back then.  Sagan talks about how the dinosaurs suddenly disappeared and how scientists still didn't know the reason why.  We now believe, and there is strong evidence to support it, that the dinosaurs were wiped out when a giant meteor or comet struck the Earth.  In another episode, he talks about how some day we will be able to manipulate different sequences of DNA, in order to cure certain diseases.  Today, it's relatively straightforward to change different sequences of DNA, and gene therapy is fast becoming reality.  It's amazing when I think about how much we have advanced as a society since I was a child.  And I can only imagine how more advanced we will be as a society in the not so distant future.  

A lot has happened in the last forty plus years, and we definitely know a lot more about the cosmos now than we did back then.  For that reason, I'm not really sure why I am watching (? re-watching) a science show from 1980, other than for a feeling of nostalgia.  Perhaps I am trying to re-capture that sense of wonder that I felt back then.  I am reminded of a great lyric by the rock-n-roll artist Bob Seger, "Wish I didn't know now what I didn't know then."

The 80 hour work week

I've been working in the Pediatric Intensive Care Unit (PICU) for the past week, which is my excuse for not posting anything since May 9th.  While it was a relatively calm week in the PICU (at least on my team), I decided to take a short break from writing.  I'm looking forward to getting back into my normal cadence soon.

I am currently working on a talk that I will be delivering at the 2024 meeting of the World Federation of Pediatric Intensive & Critical Care Societies (WFPICCS 2024).  The title of my talk was supposed to be, "Next PICU Generations: Is the quality of personal life more important than the quality of training & education?"  I was told I could change the title as a condition of my agreement to participate, particularly after I expressed concern about the topic.  I think I said something like, "I wouldn't touch this question with a ten foot pole!"  I think I settled on a compromise that hits some of the program committee's request, and I will be certain to provide a follow-up report!

Sparing the details of my presentation (since I haven't quite finished it yet), I felt that I should at least touch upon the different generations that are working in the hospital today, with a specific focus on the fact that there are a lot of misconceptions (as I mentioned in my post, "Talkin' 'bout my generation!").  One of the most common misconceptions about Millennials is that they are too focused on work-life balance and don't want to work hard.  Given the fact that Millennials will soon comprise the greatest percentage of our workforce (if they haven't actually already done so), I thought that this would be an important discussion.  Next, I wanted to talk about some of the changes that have occurred in graduate medical education and whether this has had an impact on the quality of care that is delivered in the PICU.  I've certainly had some fun putting this talk together, so I hope that it will be an interesting discussion!

Medical education and training typically consists of four years of medical school after completion of an undergraduate degree (also typically four years), followed by three to six years of residency training (depending upon the specialty) and an additional one to three years of subspecialty fellowship training (again, depending upon the subspecialty).  For example, PICU physicians complete four years of medical school, three years of pediatric residency training, and three years of pediatric ICU fellowship training.  Prior to 2003, physicians in most residency and fellowship programs worked more than 80 hours per week, with shifts often lasting 30 hours or more in the hospital.  No one seemed to be too concerned about the high number of hours spent in the hospital until some high profile deaths (the most famous was the case of Libby Zion, whose death in 1984 at age 18 years was blamed on overworked residents in the hospital) that occurred in teaching hospitals due to medical errors committed by overworked residents.  In respone to these growing concerns, the Accreditation Council for Graduate Medical Education released a set of reforms in 2003 that restricted resident physicians to a maximum of 80 hours of work per week, as well as limiting single shifts to 24 hours.  Subsequent reforms were enacted again in 2011 (capping shift lengths at 16 hours for first-year residents) and 2017 (which allowed longer shifts for first-year residents, but imposed other limits).

While these restrictions have generally resulted in better resident and fellow wellbeing, better work-life balance, and reduced burn-out, they have not had a dramatic effect on hospital outcomes.  Several studies have shown that hospital mortality, length of stay, cost of care, and incidence of complications haven't really changed much since these restrictions were put in place.  On the other hand, these restrictions have led to concerns about the quality of education and training that residents receive, particularly in surgical fields where studies have shown a decrease in the number of surgeries that residents have performed upon completion of their training.  Even if the critical threshold is not specifically known, most experts in graduate medical education agree that building sufficient expertise requires physicians to see a minimum number of similar cases or perform a minimum number of procedures (think of Malcom Gladwell's 10,000 hour rule - see also my post, "Practice makes better, but does practice make perfect?").  The question becomes whether physicians have taken care of the minimum number of similar cases or performedd the minimum number of surgical procedures by the time that they complete residency or fellowship training and become independently practicing physicians!

My background research led me to a Harvard Business Review article by the economist Anupam Jena, "Is an 80-hour work week enough to train a doctor?"  The article is based upon two research studies that Jena and his team published in Health Affairs and British Medical Journal, respectively.  Using a difference-in-differences analysis of two cohorts (one from the state of Florida and the other from a national database), Jena and his colleagues found that 30-day hospital mortality, length of stay, and cost of care did not change after the 80 hour work week was imposed in 2003.  Specifically, hospital outcomes for patients cared for by internal medicine physicians during their first year out of residency training did not change after the work hour restrictions were imposed.  In other words, these newly independent physicians apparently received enough training during their residency, even with the 80 hour work week restriction, to provide excellent care for their patients.  Jena also found that "spending fewer hours in the hospital during training had, on average, no effect on internists' hospital readmission rates or costs of care when they subsequently entered independent practice."  He further wrote, "At a minimum, the data suggest that the incremental experience gained from working more than 80 hours per week as a resident doctor doesn't generally translate into improved patient outcomes later."

Jena and his colleagues were careful not to generalize their findings to surgical patients, arguing that the decrease in the number of surgeries performed during residency due to the 80 hour work week could have an adverse impact on outcomes after graduation.  However, Rachel Kelz and her colleagues published a similar study in the journal, Annals of Surgery ("Duty Hour Reform and the Outcomes of Patients Treated by New Surgeons") that addresses this question.  Dr. Kelz found that the 80 hour work week restrictions did not have a significant effect on 30-day mortality following surgery using a Medicare database of close to 1.5 million patient encounters, though she did find some impact on length of stay, duration of the procedure, and costs of care.

These three studies are incredibly important, but they are not sufficient to make any definitive conclusions.  It's tempting to argue that physicians are less experienced when they graduate from residency and fellowship, but these three studies suggest that may not necessarily impact the care that they provide.  It could be that those of us who completed residency training prior to the 80 hour work week saw more patients and performed more procedures than what was necessary to become competent physicians.  I think more studies are necessary, and I suspect that this will be an important discussion for many years to come.

L2M

I mentioned in my last post about how I've been an Indiana Pacers fan since childhood.  Game 1 of the Eastern Conference Semi-Finals did not go well for us.  During a very close game, the game officials made a couple of critical and questionable calls during the closing minutes of the game that arguably had a significant impact on the game's outcome.  With the game tied 115-115 in the final minute, the Pacers stole an errant pass and turn-over, but the referees whistled a kicking call on the Pacers (which did not occur, by the way).  Knicks ball.  A few seconds later, the Knicks scored to take a 118-115 lead that they would never relinquish.  Former NBA Coach and television commentator Stan Van Gundy said this about the kicking call, "That is shocking.  You never see that call at this point in the game. I mean, never."  The Pacers challenged the call, but lost it.  After the game, the NBA admitted that they got the call wrong.

I am never one to argue that a game is lost over bad officiating.  However, in this case, the wrong call resulted in a potential five point swing.  The Pacers would have likely scored on a fast break to take a 117-115 lead.  Instead, they fell behind by three points.  And that is a tough pill to swallow.

Sports talk radio was all over this story, both on my afternoon commute yesterday and the morning commute today.  What was news to me, though, was that the NBA recently started analyzing the final two minutes of every game, specifically to review the officiating calls that were made.  It's called a "L2M" or "Last Two Minute" report, and the NBA has been issuing them since March 2015.  Effectively since the 2017-2018 season, the NBA has issued a L2M for any game in which one team’s lead over the other is three points or fewer at any point during the last two minutes of the fourth quarter or overtime.  The NBA states that the purpose of the L2M reports is to increase transparency and accountability, as well as to build a greater awareness and understanding of the rules and processes that govern the game of basketball.  As the sports talk radio hosts also emphasize, given the closer ties with professional sports associations and sports gambling, the added layer of transparency provided by these reports is also of significant importance.

My interpretation is that the L2M reports are all about the High Reliability Organization principle of "Preoccupation with Failure".  I don't believe for a second that the NBA is trying to specifically become a High Reliability Organization.  They are just trying to improve how their game officials referee their games!   Remember, High Reliability Organizations (HROs) do not consider failures as things to avoid at all cost.  Rather, HROs believe that failures represent opportunities to learn and improve their systems.  As Thomas Watson, founder of International Business Machines (IBM) once said, "If you want to increase your success rate, double your failure rate."  Individuals in HROs report their mistakes, even when nobody else is looking!  HROs do not punish individuals who make mistakes.  On the contrary, in many cases, individuals who report their mistakes are often rewarded!

By publicly acknowledging their officiating mistakes, particularly in the most critical portions of a close game, the NBA is stating that they (1) made a mistake, (2) will learn from the mistake, and (3) will take the necessary steps to prevent those same kind of mistakes in the future.  What the NBA chooses to call transparency, accountability, and awareness is really what I would call the HRO principle of "Preoccupation with Failure".  Oh, and incidentally, there were four key errors from the Pacers-Knicks Game 1 the other night listed in the official L2M report.

Be like the Worm...

I really enjoy Chicago sports.  I consider myself a die-hard Chicago Cubs fan, I really like the Chicago Blackhawks, and I am very excited about what the Chicago Sky and the Chicago Bears did in their recent respective drafts.  However, I've never really been a huge fan of the Chicago Bulls, mostly because I grew up watching (and loving) my hometown team, the Indiana Pacers.  When I was young, the Pacers were the only professional sports team in Indianapolis (the Colts were the Baltimore Colts until 1984 and the WNBA didn't even exist).  Regardless of whether I like them or not, I have to admire and respect what the Bulls did during the 1990's.  They were by far the best team of that decade, and there is a pretty strong argument that they were one of the greatest teams of all time.  One of their most unusual players (and at times, an absolute disaster both on and off the basketball court) was Dennis Rodman, aka "The Worm".  

Just consider Rodman's resume.  He was selected to the NBA All-Defensive First Team seven times, and he won the NBA Defensive Player of the Year twice.  He led the NBA in rebounds per game a record seven years in a row (despite being "only" six feet seven inches tall).  He won five NBA World Championships (two with the Detroit Pistons and three with the Chicago Bulls).  He was selected to Naismith Memorial Basketball Hall of Fame in 2011 and to the NBA 75th Anniversary Team in 2021.  His No. 10 jersey was retired by the Detroit Pistons.  He was one of the best defensive players in NBA history, and he is arguably the best rebounding forward ever to play the game.  

He only averaged more than 10 points per game (PPG) once, during his second year in the league with the Detroit Pistons.  During his three-year tenure with the Chicago Bulls, he averaged 5.5, 5.7, and 4.7 PPG, respectively.  The Bulls didn't need him to score, but he was an integral member and important contributor to the team's overall success.  He understood his role, and he played it extremely well.

If you watch the docuseries "The Last Dance", pay attention to Episode 3, which covers Rodman's time with the team in depth.  He approached rebounding very scientifically.  He studied film extensively - and what he studied most intensely was what happened to the ball when opposing players missed the basket.  There is a famous video of former teammate Isiah Thomas discussing Rodman's approach to rebounding.  Rodman apparently used to stand by the basket during warm-ups, just to watch how the ball came off the rim.  Of course, his teammates just thought he was being lazy, and when they asked him what he was doing, he told them.  "I am counting your spins."  He would know how many spins the ball would make in the air after each player shot the ball.  He used that information to try to better predict where the ball would end up, so that he could position himself in exactly the right spot to make the rebound.  

Rodman would apparently go the gym late at night with his friends and ask them to shoot, just so he could study how the ball moved off the backboard or rim.  Michael Jordan, arguably the greatest player in history, once called Rodman "one of the smartest guys I played with."  Rodman was the best at rebounding because he worked the hardest to perfect his craft.

If Rodman had tried to make his living scoring baskets, he probably wouldn't have lasted very long in the NBA (and maybe he wouldn't have even played in the NBA).  He understood his role and how best he could contribute to the team.  Just as in basketball, in any organization there are going to be superstars and role players.  If you happen to be a role player, be the best at that role that you can possibly be (see my previous posts on this exact point, "I play not my eleven best, but my best eleven", "He's the glue", and "In search of David Ross").  Be like the Worm.

Turning around the ship...

I was recently asked to give a talk on High Reliability Organizations to our foundation and marketing teams.  Normally this would be a relatively straightforward request for me, as I have several prepared or "canned" talks on this subject.  However, I was asked to talk about how the HRO principles apply to non-clinical areas.  To be more specific, our foundation and marketing teams wanted to learn how to apply HRO principles to think differently and work more effectively at their jobs.  So, I spent the allotted time (about 20 minutes) without mentioning safety at all.

The question really is whether HRO principles can be applied so that organizations can perform at their best and not just at their safest.  In my opinion, High Reliability Organizations can also be called "High Performing Organizations."  The five characteristics, which include Deference to Expertise, Preoccupation with Failure, Sensitivity to Operations, Commitment to Resilience, and Reluctance to Simplify (and I previously added a sixth characteristic, Comfort with Uncertainty and Chaos to this list), help organizations to operate at the highest level of performance.  I have studied "high performing organizations" in a variety of different industries, including health care, and I consistently find that these organizations operate at the highest levels of safety, efficiency, consistency, and success.

As an example, I mentioned the book Turn The Ship Around! by David Marquet.  I've mentioned this book a couple of times in the past (see "Classic Rookie Manager Mistakes", "The definition of power is the transfer of energy...", and "The power of empowerment"), and if you haven't read it yet, it's definitely worth a look.  Marquet assumed command of the USS Santa Fe, a nuclear-powered submarine which was perhaps one of the worst commands in the fleet.  Using what you will recognize essentially as High Reliability Organizations leadership principles, Captain Marquet turned the USS Santa Fe into one of the best commands in the fleet.  Prior to Captain Marquet, the reenlistment rate on the USS Sante Fe was well below the average for the rest of the Navy (only three members of the crew reenlisted the year before Captain Marquet took over - by the time Captain Marquet finished his tour as the Commanding Officer (CO), thirty-three sailors signed up for another tour of duty, far above the Navy's average).  Similarly, on average, about two or three officers on a submarine will ultimately go on to become CO's.  During Captain Marquet's tenure, nine out of his fourteen officers eventually became submarine CO's.  

One of Marquet's key concepts is "pushing authority to information".  In most organizations, decisionmaking authority is based upon rank or hierarchy.  However, most of the key information necessary to make those decisions is at the lowest ranks, i.e. on the front-lines.  In most organizations, information is pushed to authority (up the chain of command to those who have the authority to make decisions).  Marquet "flipped the script" so that authority was pushed to information - in other words, he gave decisionmaking authority to those individuals on the front-lines who had access to the information needed to make those decisions.  Sound familiar?  It's exactly what High Reliability Organizations would call Deference to Expertise!  

As you read Marquet's book, you will recognize several of the key principles that define highly reliable organizations.  Similarly, if you study high performing organizations, you will find that almost all of them are also High Reliability Organizations.

The Last Toast

Just over 82 years ago, on April 18, 1942, a group of 16 B-25B Mitchell medium bombers, each with a crew of five, launched from the flight deck of the aircraft carrier USS Hornet.  They were led by Army Lieutenant Colonel James Doolittle, who was later awarded the Congressional Medal of Honor for leading the mission.  The "Doolittle Raid" was conceived shortly after the Japanese attack on Pearl Harbor on December 7, 1941 as a way to boost American morale following that devastating surprise attack.  Navy Captain Francis S. Low, Assistant Chief of Staff for anti-submarine warfare is credited with the idea for the attack.

The plan required an aircraft that would be able to take-off from the flight deck of an aircraft carrier with a cruising range of 2,400 nautical miles carrying a 2,000 pound bomb load.  The B-25B Mitchell had a range of about 1,300 miles, so the bombers had to be extensively modified to hold nearly twice their normal fuel reserves.  Early flight tests with the B-25B Mitchell suggested that it could be successfully launched from the short runway of an aircraft carrier.  The plans further called for the planes to bomb Tokyo and then fly on to China, with the likely landing spot of Chongqing.

The 16 modified bombers with their respective five-man crews (80 pilots and crew) and support personnel departed on the USS Hornet and Task Force 18 left San Francisco, California on April 2, 1942.  They joined Task Force 16, commanded by Vice Admiral William "Bull" Halsey a few days later.  The USS Enterprise and her escort cruisers and destroyers with Task Force 16 would accompany the Hornet in order to provide air cover and support, as the Hornet's normal complement of fighters could not be launched from its flight deck that was crowded with the 16 bombers.  

At approximately 0738 on the morning of April 18, while still 650 nautical miles away from Japan, the task force was spotted by a Japanese patrol boat, which radioed an attack warning to Japan before the boat was sunk.  Doolittle and the Hornet's captain decided to launch the B-25Bs immediately, 10 hours (and 170 nautical miles) earlier than planned in order to maintain some element of surprise.  All sixteen aircraft safely launched, even though none of the pilots had ever flown off the deck of an aircraft carrier.  They flew in groups of two to four aircraft at wave-top level in order to avoid radar detection.  Despite encountering some light anti-aircraft and a few enemy fighters, all 16 bombers reached Tokyo safely and released their bombs.  

One bomber was running very low on fuel and had to head towards the Soviet Union to avoid ditching in the East China Sea.  The remaining 15 bombers flew towards China, all running low on fuel and flying in deteriorating weather conditions.  A lucky tail wind allowed all 15 bombers to reach the coast after 13 hours of flight and either crash-landed or bailed out (they didn't have sufficient fuel to reach Chongqing).  One crewman died during the bailout.  In the end, the bombers flew just around 2,250 nautical miles!

Sixty-nine airmen escaped capture or death (three were killed in action).  The Chinese people who helped them were later tortured or executed by the Japanese (an estimated 250,000 Chinese lives were taken by the Japanese Imperial Army during the search for the Doolittle raiders).  Eight raiders were captured by the Japanese, and their fate would not be known until 1946 (three were executed, 1 died in captivity, and 4 were repatriated).  

Doolittle believed that the mission had failed - they had inflicted relatively minor damage and had lost all 16 aircraft.  He expected a court martial upon return to the United States.  Instead, he was promoted two grades to Brigadier General and received the Congressional Medal of Honor.  All 80 raiders were awarded the Distinguished Flying Cross.

After the war, the Doolittle Raiders held a reunion almost every year from the late 1940's until 2013.  Every year, they would perform a roll call and toast their fellow raiders who had died during the previous year.  Specially engraved silver goblets, one for each of the 80 raiders, were used for this annual toast.  The goblets of those who had died were inverted (each raider's name was engraved on the goblet twice, so that it could be read right side up or upside down).  The goblets and a special bottle of cognac (a 1896 Hennessy VS cognac, 1896 being Doolittle's birth year) were held at the site of the annual reunion at the United States Air Force Academy until 2006, after which time they were transferred to the National Museum of the United States Air Force at Wright-Patterson AFB in Dayton, Ohio.  I visited the museum at some point afterwards, and the display of these goblets was a very special memory.

On April 18, 2013, a final reunion for the last four surviving raiders was held at Eglin Air Force Base (only one surviving raider failed to attend due to poor health).  The final toast took place at the National Museum on November 9, 2013, preceded by a B-25 flyover, with three raiders - Richard Cole, Edward Saylor, and David Thatcher in attendance.  The 1896 bottle of cognac was opened, and the "final toast" was given by Cole: "Gentlemen, I propose a toast to those we lost on the mission and those who have passed away since.  Thank you very much and may they rest in peace."  Saylor would die in 2015, while Thatcher died in 2016.  Richard Cole, Doolittle's co-pilot, was the last surviving raider and died on April 9, 2019 at the age of 103.  Shortly after his death, his family and Air Force dignitaries gathered together to turn over his silver goblet, thus closing the book on a famous chapter of American military history.

Mike and Mary Anne

I came across an article the other day (see "Why Mike Mulligan and His Steam Shovel Still Charms All Ages" by Janice Harayda) about the children's book Mike Mulligan and His Steam Shovel that I vividly remember from my childhood.  

It's an old book - I was surprised to learn that it was actually written and illustrated by Virginia Lee Burton in 1939.  I'm not sure if the book is still as popular today, but I know that my own kids enjoyed reading it too.  According to a 2007 online poll by the National Education Association, the book is listed as one of the "Teacher's Top 100 Books for Children."  

The story is about Mike Mulligan, owner of Steam Shovels, Inc and his steam shovel, which he affectionately named Mary Anne (whose name is apparently a reference to the real life Marion Power Shovel Company).  Mike Mulligan used to brag that Mary Anne "could dig as much in a day as a hundred men could dig in a week" (though he had never proven this).  Mike and Mary Anne soon face competition from more modern gasoline, electric, and diesel-powered shovels, and so they end up finding work in a small town that wants to build a new town hall.  Mike offers to dig the cellar in a single day, even though the town's selectmen think that it would take 100 men the entire week to do so!  He even goes as far as saying that if Mary Anne doesn't finish the work in a day, the town won't have to pay them.  

Everyone has doubts, including Mike.  But in the end, Mary Anne finishes the job in a single day!  Unfortunately, Mike forgot to build a ramp to get Mary Anne out.  No one knows what to do, but eventually a little boy suggests that they could build the new town hall around Mary Anne, converting her into the boiler.  Mike Mulligan could then be the janitor.  And that's just what happened in the end!

It's a wonderful story, and reading it again after so many years brought back a lot of memories.  I guess I never thought that the story could be a metaphor for technological change!  Samuel Arbesman wrote an article for The Atlantic entitled, "Lessons About the iPhone, Courtesy of a Depression-Era Children's Book".  As Arbesman writes, "In Mike Mulligan, inexorable technological progress renders Mary Anne an outdated machine...but Mike Mulligan simply can't bear to get rid of his beloved Mary Anne, even when the rest of the steam shovels are discarded."  

Mike and Mary Anne have one last hurrah, and then they get to spend the rest of their days together doing something completely different.  It's a happy ending after all.  As so often happens, there's a deeper meaning in this simple story from a classic story book.  Perhaps technological change doesn't have to be a zero-sum game.  Maybe there's an opportunity to re-use or re-purpose the old technology for something different.