It's better to give than receive...

There's an old adage that says that it's better to give than to receive.  I used to hear that a lot when I was growing up, particularly around Christmas time!  I actually didn't know this, but the saying comes from a Bible verse from the Acts of the Apostles.  And as it turns out, there's now scientific proof for this statement!  Ed O'Brien from the University of Chicago Booth School of Business and Samantha Kassirer from Northwestern University published a study in the journal Psychological Science (see "People are slow to adapt to the warm glow of giving").  They found that giving to others makes you happier in the long run and that the feeling of joy from giving lasts for a long time compared to the joy of receiving.

O'Brien and Kassirer gave college students $5 for five days in a row with the instructions that they could spend the money however they wished, though they had to spend the money the same way for all five days.  Half of the students were told to spend the money on themselves, while the other half of the students were told to spend the money on someone else.  At the end of each day, students completed a survey that assessed their level of happiness.

As shown in the graph below, the happiness level of students who spent money on themselves declined over the course of the five days, while that of the students who spent money on someone else actually stayed the same.

O'Brien and Kassirer conducted a second experiment, in which the students carried out 10 online word-search tasks, for which they were paid 5 cents.  Again, half of the group had to donate their total earnings ($0.50) to the charity of their choice, while the other half had to keep the money.  This time, the students completed the happiness assessment following each task.  Similar to the earlier results, the happiness level of the students who donated their earnings faded slightly over the course of the 10 word-search tasks, while that of the students who kept their money decreased quickly.

Admittedly, both studies were performed in the highly contrived setting of a laboratory and the study sizes were fairly small (113 students in the first experiment and 502 students in the second).  However, the size of this study was much greater than the famous study of lottery winners (which I've mentioned in the past - see "California Dreaming") that has been continually cited since the late 1970's as proof that winning the lottery doesn't make you happy (and more recent studies actually suggest otherwise).  Just as important, the staying power of the adage "It's better to give than to receive" has to count for something.  So, in my opinion, the results of the O'Brien and Kassirer study are compelling and important.  When it comes to happiness, it is far better to give than to receive...

Chiliad

According to Merriam-Webster's online dictionary, the word chiliad is defined as a group of 1,000.  The ancient Greeks defined a period of 1,000 years as a chiliad, though we now use the Latin derivation and call 1,000 years a millennium.  I chose the title for today's post because I have officially reached 1,000 posts in Leadership Reverie.  

When I first started contributing to this blog on January 2, 2016 ("First blog post"), I never actually thought that I would ever make it to 1,000 posts.  As I stated then, I've never claimed to be an expert on leadership and management.  That is just as true today as it was back then.  However, I consider myself a student of leadership.  Thomas J. Watson, former Chairman and CEO of  IBM for 42 years (1914-1956) said, "Nothing so conclusively proves a man's ability to lead others as what he does from day to day to lead himself."  Leadership has to start by looking inward at what you do with your own life.  As leaders, we owe it to ourselves and our organizations to work hard to perfect our craft.  We all should be students of leadership.

I've always liked the poem "The Road Less Traveled" by Robert Frost.  It's an easy poem to like, as Frost's message is simple and profound at the same time.  You've probably heard it before - it's the one that ends with:

Two roads diverged in a yellow wood, and I - 

I took the one less traveled by,

And that has made all the difference.

I am often asked by younger physicians and leaders what they should do to position themselves for a future career as a hospital executive.  I always chuckle a little (in a respectful way, of course) and confess to them that I never planned out my career with the intent of doing what I am currently doing now.  As a matter of record, I once told my wife that I wouldn't be caught dead being an administrator!  She reminds me of that frequently!  My journey throughout my career has been a road less traveled of sorts, and just as Robert Frost said so eloquently, THAT has made all the difference in the world.

Throughout my career, I've used writing as a way to help me remember things.  And organizing my thoughts on paper has always helped me think, reflect, and prepare myself for whatever challenges lie in front of me.  As I stated in my first post, I would write this blog even if nobody ever read it.  The fact that so many of you have read my posts is both humbling and deeply gratifying.  I thank you from the bottom of my heart.  And I look forward to chiliad #2! 

What would you think about a 12,900% ROI?

Organizations frequently use what is called the Return on Investment (ROI) as a performance metric to evaluate the profitability of a program or investment.  The ROI measures the amount of return (in monetary terms) on a particular program or investment relative to its initial cost.  It's calculated simply by dividing a program's net profit (revenue generated by the program minus the cost of the program itself) by the cost of the program.  For example, an investment that cost $100 and generated $100 in net profit (i.e. over the initial cost of $100) would have a ROI of 100%. Generally, any positive ROI is good.  However, while a good ROI can vary depending upon the type of investment, the target ROI in most cases is generally in the range of 5-10%.  

So what would you say about a program or investment that generated a 12,900% ROI?  That would be incredible, to put it mildly.  That is exactly the ROI that a group of Stanford students achieved on a project several years ago that has lessons for all of us today.  Back in 2009, Stanford professor Dr. Tina Seelig placed her students in the Stanford Technology Ventures Program into 14 teams and gave each team an envelope that contained $5 of "seed funding."  Each team had five days to develop any idea that would generate money.  Once they opened the envelope and officially received their "seed funding", they had 2 hours to execute that plan and generate as much money as possible.  

Each team was asked to send Dr. Seelig one slide describing their project, and she then gave each team 3 minutes to present their project to the rest of the class.  She heard several different ideas, including "Going to Las Vegas" or "Purchasing a lottery ticket" (both with the potential to generate a significant ROI, though with a small chance of actually generating any return).  She also heard about projects that set up a car wash or a lemonade stand, which all generated a positive ROI, even if fairly small.    

Dr. Seelig said, "Most of my students eventually found a way to move far beyond the standard responses.  They took seriously the challenge to question traditional assumptions, exposing a wealth of possibilities in order to create as much value as possible."  Dr. Seelig further explained (see her video here), "The teams that made the most money didn't use the $5 at all.  They realized that $5 was actually a limitation.  They realized that framed the problem way too tightly, and if they looked at the skills they had and the opportunities around them, that was worth a lot more."

Here are some of the more innovative projects:

• One team used the $5 to purchase several inexpensive items at a discount store and then tried to re-sell them for a profit.
• One team set up a stand in front of the student union and pumped up bicycle tires for $1. Actually, this project was so successful at first that they switched from a fixed pricing model and asked for donations instead.  Their income soared.  Dr. Seelig said, "The iterative process where small changes are made in response to customer feedback, allowed them to optimize their strategy on the fly."
• One team booked reservations at popular restaurants and then re-sold their places in line to people eager to skip the wait. This particular team also iterated quickly.  Male team members ran around town making reservations, while the female team members did the "selling" when the team noticed people were more comfortable being approached by women than men.  The team also discovered that focusing on restaurants that provided buzzing pagers was more profitable - physically switching one pager with a long wait time for one with a shorter wait time made people feel they were receiving something tangible (and also gave the team members another reservation that they could sell).

Each of the projects listed above generated a few hundred dollars.  However, the team that did the best generated $650 for a 12,900% ROI!  The students on this team determined that the most valuable asset that they could sell was their three-minute presentation time scheduled the following class day.  They decided to sell that 3 minutes to a company that wanted to recruit students in the class.  The team created a 3 minute "infomercial" for the company and showed it to all the other teams in the class.

Here is my take.  First, learning through experimentation and iteration based upon experience is absolutely essential to the success of any project or business venture.  Second, "thinking outside the box" drives innovation.  Third, challenging assumptions and avoiding framing a problem too tightly can often lead to low-risk / high-reward actions that generate incredible returns.

How to avoid criticism

I came across a great quote by the ancient Greek philosopher Aristotle.  He said, "There is only one way to avoid criticism. Do nothing. Be nothing. Say nothing."  That's it.  That's the post for today.

Handle With Care

There's a great song by the rock-n-roll supergroup The Traveling Wilburys called Handle With Care.  I remember when "Handle With Care" was stamped across cardboard shipping boxes to alert everyone that the contents within the box were fragile ("It must be Italian!").    I've been thinking a lot about the concept of "fragility" lately, particularly in the context of systems thinking.  The writer Nassim Taleb wrote a book called Antifragile, in which he defines "antifragility" as a property of systems that increase their capability to thrive as a result of stressors, shocks, mistakes, failures, or disorder.  Importantly, Taleb distinguishes "antifragility" from robustness (the ability to resist failure) and resilience (the ability to recover from failure).  I've not read any of Taleb's books (see my post "Anti-Library" for an explanation), and while I don't think he explicitly defines "fragility" as a concept of systems, I suppose that he implicitly would define a fragile system as one that performs worse as a result of stressors, shocks, mistakes, or failures.

With that in mind, I would describe our nation's commercial aviation infrastructure as "fragile". That is particularly painful for me to say, as commercial aviation is one of the prototypical High Reliability Organizations, at least when it comes to aviation safety.  Consider this.  Literally millions of computers running Microsoft's Windows operating system crashed this past Friday (July 19th) when the cybersecurity company CrowdStrike updated its software, causing widespread disruptions in airlines, banks, hospitals, and hotels.  For the next four days, thousands of commercial flights into, within, or out of the United States were canceled.  Those flights that weren't canceled experienced significant delays.

I have firsthand knowledge of these issues, as our family's flight from Seattle to Chicago on Saturday was canceled at the last minute (we were literally getting ready to board).  The airline representative told us that we would likely not be able to get on another flight until Wednesday this week.  Thankfully, we were able to get the last seats on a flight to St. Louis (thank you Alaska Airlines!), at which point we rented a car and drove to Chicago.  Our bags are still somewhere in Seattle, and who knows when we will see them again.  The Seattle airport was an absolute mess!

Hopefully we will learn from this incident.  As I reflected this weekend, it seems that flights are canceled more frequently now than they were in the past.  Even The Traveling Wilburys know about flight cancellations and delays (it says so right in their song Handle With Care - "Been stuck in airports..." they say).  However, when I reviewed the data, the number of cancellations have actually decreased over the past twenty years.  It may be that there are just more flights now than in the past, or maybe I fly more frequently now than I did in the past.  Who knows?  But as I think about this issue from a systems perspective, one thing is clear.  As the different subcomponents in a system become more tightly coupled, they become less resilient and more fragile.  There's no question that today's commercial aviation industry is highly complex, interconnected, and tightly coupled.  Under these conditions, the safety researcher Charles Perrow would suggest that accidents and disruptions are not only more common, they are inevitable - in essence, they are normal (see my post, "The Razor's Edge" for an explanation of Perrow's Normal Accident Theory).  

Fragility is an interesting concept and relatively easy to understand.  From a systems perspective, however, it is far more difficult to address.  The difficulties that our family (and many, many others) personally encountered in the aftermath of the CrowdStrike network outage is just the latest example.

"All life is an experiment"

Natural experiments have been around for a long time in public health research.  They are defined as observational studies in which an event or situation occurs allows for the seemingly random assignment of study subjects to different groups to be leveraged to try to answer a specific question.  Importantly, natural experiments are used when the traditional method of a prospective, randomized, controlled study is not feasible, due to financial, logistical, or ethical reasons.  Perhaps Ralph Waldo Emerson had natural experiments in mind when he said, "All life is an experiment.  The more experiments you make the better."

Perhaps the greatest natural experiment of all was that of the founders of the United States, who designed a form of government that they referred to as an experiment.  For example, Thomas Jefferson said, "I have no fear that the result of our experiment will be that men may be trusted to govern themselves without a master."  Notably, still to this day, politicians refer to the American system of government as an experiment!

Susanna Galli and colleagues conducted just such a natural experiment, which they discussed in a Harvard Business Review article (see also their working paper "Incentives, Peer Pressure, and Behavior Persistence"), "Incentives Don't Help People Change, but Peer Pressure Does".  Galli and her team took advantage of a particular set of circumstances to try and answer the age-old question on whether financial incentives can be used to help change behavior.  They studied the impact of a one-time employee incentive bonus on hand hygiene compliance at one California hospital.  Hand hygiene is one of the most effective ways of preventing the spread of infections in the hospital setting.

The California hospital used a team of "secret shoppers" to directly monitor hand hygiene compliance over a 90 day period.  Employees received biweekly progress reports on hand hygiene compliance.  If a specific target was achieved by the end of the 90 days, all employees would a one-time $1,200 bonus.  Uniquely, California is one of a growing number of states that employ what is known as a "corporate practice of medicine law" that prohibits hospitals from directly employing physicians.  Instead, hospitals form contracts with medical groups that employ the physicians.  As a result of this situation, physicians would not be eligible for the one-time $1,200 bonus.  At the same time, however, the hospital's hand hygiene compliance, and most importantly, the ability of the hospital to achieve the target performance that would trigger the one-time bonus, was highly dependent on physician hand hygiene compliance.  

Hospital employees (nurses, allied health professionals, etc) came up with creative ways to encourage physicians to comply with good hand hygiene practices.  For example, employees who observed physicians that demonstrated good hand hygiene practices would send celebratory emails and hand-written notes to the individual physicians.  Conversely, employees would send reminders and "nudge" emails to physicians who failed to practice good hand hygiene.  

On average, hospital employees significantly improved their hand hygiene compliance at the end of the 90-day intervention period.  They met their target and received the monetary bonus. Unfortunately, however, improved hand hygiene was short-lived, as compliance slowly fell towards historical levels and in some cases even lower levels!

Again, physicians weren't eligible for the bonus incentive.  However, hand hygiene compliance improved slowly but significantly in physicians too.  More importantly, the improvements continued even after the 90-day intervention period.  In summary, then, providing a financial incentive certainly changed behavior for the better, but the improved behavior was short-lived.  Peer pressure resulted in similar degrees of improvement in behavior, though the improvements were sustained beyond the intervention period.  

I've talked about this study in the past (see "Wash Your Hands!"), particularly in the concept of extrinsic motivation versus intrinsic motivation.  What's important to realize here is that so-called natural experiments are frequently used in the management literature to answer questions that may not be amenable to traditional methods of research.  As suggested by Emerson, "all life is an experiment."

"In theory, there is no difference between theory and practice..."

My wife and I watched the Netflix documentary ("It Ain't Over") on the legendary New York Yankees baseball catcher Yogi Berra the other night.  I highly recommend it!  There was a segment of the documentary that questioned why Berra wasn't included among the four greatest living baseball players (Willie Mays, Johnny Bench, Sandy Koufax, and Hank Aaron), as voted by the fans and announced at the 2015 MLB All-Star Game in Cincinnati, which my wife and I were lucky enough to attend!  While I did not participate in that vote, I told my wife that had I voted, I probably wouldn't have thought to vote for Berra either (I regretfully admit that I actually wasn't sure that he was still alive then).   

Today Berra is remembered more for his so-called Yogi-isms than his prowess as a ball player, which is both unfortunate and unfair.  He is arguably one of the greatest catchers to ever play the game, and he should rank right up there with some of the all-time Yankee greats.  He played 19 seasons in total, eighteen of which were with the Yankees.  He was selected to the MLB All-Star game 18 times, won the World Series as both a player and manager/coach 13 times (out of 21 total), won the American League Most Valuable Player three times, and had his number 8 retired by the Yankees.

So I feel a little guilty using one of his Yogi-isms as the title of today's post, but I do so with the greatest of respect for who he was as a player, manager/coach, and person.  While there's no evidence that he actually ever said it, the Yogi-ism goes like this, "In theory, there is no difference between theory and practice, but in practice there is..."  It certainly sounds like something Yogi Berra would say!  Regardless of its origin, it's a great quote!

There is a clear difference between the idealized state, where several different variables can be controlled as much as scientifically possible, and the real state, where we simply cannot control what happens.  We see this over and over again in research, where therapies that appear to be quite promising in early-stage clinical trials, end up falling far short of expectations in later and larger clinical trials.  Here is one of the reasons why I like quality improvement science so much.  Rather than trying to control all of the variables, we observe a system and follow what happens when we make small changes to it, which, in essence, is very similar to what clinical research does, right?  

Rather than trying to control the dependent variable by controlling for all of the independent ones, quality improvement science observes what happens to the whole system over time, using statistical process control.  If you plot the outcome of interest on the y-axis over time on the x-axis, you basically have what is called a run chart.  Even if you've never heard of a run chart, there is a good chance you have seen one before.  Daily fluctuations in stock prices are often depicted as a run chart.  For example, take a look at the run chart below of the S&P 500 price fluctuations during a certain period of time:

Even though there was a clear decrease in the S&P 500 on February 2, 2014, it doesn't appear that it has changed all that much from the beginning of January, 2014 to the beginning of April, 2014.  Traditional methods used in clinical research today would arbitrarily select a certain time period, calculate the mean and standard deviation values, and compare using a specific kind of statistical test.  But what time period do you use?  Let's look at two different ways to analyze the data above - the top graph is the monthly average while the bottom graph is the price at the start of each month:

The two graphs look very different, don't they?  The top graph makes it appear that there was an increase in the S&P 500 from February to March, which was sustained in April.  However, the bottom graph makes it appear that the S&P 500 during February was very different compared to the other three months.  Either conclusion in this case would be wrong - go back and look at the run chart in the original graph!  There really is not that much of a change in S&P 500 over the time-period of interest!

How would we know whether there was a change in the S&P 500 over time?  For this, we would need to plot the data using a control chart.  Control charts are run charts that have a couple of important and additional features - a trend line (usually the median) and upper / lower control limit lines (calculated using specific formulas, depending upon the kind of data that you have) - see the example below:

   

With control charts, there are specific rules (often called "Western Electric Rules", because they were first developed and used by the Western Electric Company in the late 1950's) to determine if there is common cause or special cause variation.  "Common cause variation" suggests that a process is stable and in control - any variation in the data over time represents normal fluctuations that often occur (such as the beat-to-beat variability in your own pulse when you are sitting down while reading blog posts!).  In contrast, "special cause variation" occurs when the process is unstable or out of statistical process control due to a specific or unique circumstance (going back to the previous example, the increase in your pulse when you go out for a run around the block on a hot day). 

If we used statistical process control rules ("Western Electric Rules") in the S&P 500 example above, the change in price over time would be shown to represent common cause variation.  Special cause variation would occur if, say there was an economic recession.  If you are interested in learning more about statistical process control, I highly recommend the following three books:

Understanding Variation: The Key to Managing Chaos by Donald Wheeler (no relation)

The Improvement Guide: A Practical Approach to Improving Organizational Performance by Gerald Langley, Ronald Moen, Kevin Nolan, Thomas Nolan, Clifford Norman, and Lloyd Provost

The Health Care Data Guide: Learning from Data for Improvement by Lloyd Provost and Sandra Murray

Statistical process control allows us to monitor changes in our process over time, i.e. in real world practice, as opposed to what happens in the strict constraints of an experiment.  So, "In theory, there is no difference between theory and practice", except for the fact that there is...  

Striking out swinging...

Shortly after starting medical school, I accepted a commission in the United States Navy on a U.S. Armed Forces Health Professions Scholarship.  During the summer between my first and second years of medical school, I attended what was then called Officer Indoctrination School (OIS, which is affectionately known as "knife and fork" school), now known as Officer Development School (ODS).  The school is one of five officer training programs at the Navy's Officer Training Command located in Newport, Rhode Island.  

I've posted about my experiences at OIS several times in the past (see "You know what to do", "Tap Code", "12 O'Clock High", and most recently "Diamonds in the Rough"), so needless to say the experience was both memorable and formative.  I remember in particular our training at the Damage Control Wet Trainer, better known as the USS Buttercup, a mocked up ship in one of the buildings at Officer Training Command that is 48 feet long, 24 feet wide, with a deck height of 8 feet and weighs approximately 38 tons. The pool that the USS Buttercup rests in is 5 feet deep on the starboard side and 8 feet on the port side, which causes the trainer to take a sharp list during training.  The pool holds approximately 37,000 gallons of fresh water. Two of the compartments in the trainer are subject to controlled flooding, and I would have to say that the whole experience seemed to be fairly realistic (see a video of Damage Control training aboard the here).  

The Navy feels that its important to provide everyone with at least some knowledge and experience in shipboard damage control, because well, you just never know when it will be required.  Even specialists (i.e. physicians in the Medical Corps) require some level of general training (i.e. damage control training).  Incidentally, our group failed miserably (I am pretty sure that the Buttercup filled up with more water than she could handle and would have sunk if not for the fact that we were in an indoor pool).

I was thinking exactly of this experience last week, when the high winds and rains in Chicago caused about a ten foot section of our fence to fall into our yard.  We called someone to come out and repair the fence (it's going to require more extensive repairs than we are comfortable doing ourselves), and of course they can't come out for another 2 weeks.  So, with my wife's assistance, I put my USS Buttercup training to good use, and using some materials that we had on hand, we created a brace to keep the fence in a stable position.  Voila!

I've been very interested in the concept of expertise (see my favorite definition here) and the differences between generalists and specialists.  I've talked about one of my favorite books on this subject in a number of posts in the past (see "Be like the Renaissance", "Jack of all trades, Master of none", and "Cool Runnings").  It's called Range: Why Generalists Triumph in a Specialized World by the author David Epstein. It's really a great book that focuses on the particularly germane argument - is it better to be a generalist or a specialist?  Epstein provides support that suggests that it's better to be good at many things than being great at just one thing.  

Which brings me to a recent study I found by Brittany Bond and Ethan Poskanzer, published in the journal Organization Science ("Striking out swinging: Specialist success following forced task inferiority").  Bond was apparently watching the 2018 MLB World Series between the Los Angeles Dodgers and Boston Red Sox (which the Red Sox won) and watched Red Sox starting pitcher David Price struggle at bat.  At that time, the American League used what is called a Designated Hitter, so that pitchers never had to bat during the regular season.  Pitchers in the National League were required to bat during the regular season, as they did not use the Designated Hitter (incidentally, the National League, much to my dismay, instituted the Designated Hitter Rule in 2022).  So, the only time that Price had to bat was during the World Series, when the National League team (Dodgers) was playing at home.  Bond said, "He was getting so visibly upset when he had to bat and then still looked very angry when he returned to the mound to pitch.  And there was one instance where he had just been up to bat and had failed pretty miserably, and then he went to the mound and got three straight outs with just seven pitches."  

Watching Price struggle led to an interesting idea for a research study - are specialists in a field helped or hindered by engaging in non-specialist tasks?  More to the point, are specialists in a field helped or hindered by failing in tasks that they are not normally required to perform (which Bond and Poskaner call "task inferiority").  Bond and Poskanzer analyzed data from 22 years of MLB games and conducted interviews with former players and coaches.  First (and not surprising to most baseball fans), pitchers over this period of time performed significantly worse at batting compared to other players:

The graph above shows the career batting performance (as measured by the proportion of total bats in which that player reached base, or On Base Percentage) for pitchers versus position players and designated hitters.  The career average for pitchers is 0.148, which is significantly below the career average of players at all the other positions.  The clear distinction in performance here reflects the specialization of the pitchers relative to the other players.

Second, Bond and Poskanzer found that specialized players (pitchers) perform better in their specialty after obligatory tasks (batting) outside of their specialization.  The graph below shows that pitchers are more likely to get an out in the first bat of the inning after they had to bat in the previous inning and that the positive effect of pitching after batting fades with time.  Eventually, the pitchers returned to their baseline performance level.

In subsequent analyses, they found that pitchers perform even better after an unsuccessful at-bat in the previous inning (i.e. after failing in a task in which they do not specialize).  After an unsuccessful bat, pitchers were significantly more likely to record an out against the first batter they face, less likely to give up a walk against the first batter they face, and more likely to throw pitches in the strike zone.

During interviews with retired pitchers, they consistently heard that when pitchers failed to get on base in an inning, their level of motivation to be successful in getting opposing batters out in the next inning was much higher.  In other words, when they failed at a task in which they did not specialize, they were more motivated to be successful in the one that they did specialize.  One pitcher said, "I took my at bats personal, they fueled my pitching..."  Another pitcher said, "When you screw up, you're pushing yourself more next time.  It's not going to happen again."  Finally, one more pitcher claimed that after a failed at bat, "I'm going to lock it in a little bit more with pitching, I want to have value for the team. I want to help my team someway somehow or another. It's like in basketball - if my shooting sucks, I'm going to get the rebound or help with great defense."

Bond and Poskanzer suggest that their findings aren't limited to baseball.  They wrote, "...we illuminate how nonspecialized tasks can generate heightened drive and lead to better performance in specialized tasks...Even top performers can improve in their own domain by coming up short outside their specialty."  When asked to explain further, Bond concluded, "Our study suggests that employers should not keep their specialists isolated.  There can be this added upside. Even if the specialist maybe didn’t do the best work on this ‘everyday’ task, it was necessary for them to complete it as part of a team. That’s fine. It was necessary, and now you’re going to get an extra benefit for when that specialist goes back to their specialization. They’re going to go back with vigor that hadn’t been there."

I'm not sure that the Navy had the concept of task inferiority in mind when they decided to require future members of the Medical Corps to go through damage control training.  However, perhaps by failing (miserably in our case) at this one task outside our specialty helped us to become better Medical Corps officers.  By failing (striking out swinging), we ended up better in the end.  

Three Sieves

There's another story that keeps coming up from time to time on various social media feeds about the ancient Greek philosopher Socrates.  From what I can determine, the story is perhaps wrongly attributed to Socrates (there's no mention of the story in any of his writings), but it's regardless one that I think is worth repeating here.  It's message is important, and there is no question that it's an old story (just maybe not as old as Socrates!).

Here is the story of Socrates and the Three Sieves:

One day a man ran up to Socrates and said, “I have to tell you something about your friend who…”

Socrates interrupted him and asked, “Just wait.  About the story you’re about to tell me, did you put it through the three sieves?"

The man was not familiar with the three sieves, so Socrates continued.  "The first is the sieve of Truth. Are you sure that what you are going to tell me is true?"

The man responded, "Actually, I am not sure.  I just overheard it."

Socrates continued and asked, "What about the sieve of Goodness? Will you tell me something good or positive about this man?"

The man shook his head.

Socrates continued and asked, "Now, what about the last sieve? The sieve of Necessity.  Is it necessary to tell me what you’re so excited about?"

When the man bowed his head in shame, Socrates smiled and said, "Well, if the story you’re about to tell me is neither true, good or necessary, just forget it and don’t bother me with it."

So there you have it.  The three sieves are Truth, Goodness, and Necessity (I've also seen the last sieve called Useful).  Whenever we hear about some bit of information and before we pass that information on, we should first see if it passes through the three sieves.  Can we be sure it's true?  Will it be something good or positive?  And is it information that will be useful or necessary to share?  Incidentally, before writing today's post, I actually did determine if it passed through the three sieves - except for the fact that I can't verify that Socrates ever used the test (which I admit above), it definitely does!

Imagine what our world would be like if we used this most ancient of tests...

Study the wind

As I mentioned in a recent post ("It's better to be a warrior in a garden..."), I've been watching the television series Shogun, based upon James Clavell's classic novel that takes place in Japan in the year 1600 during the Azuchi–Momoyama period.  Once again, I am reminded of Japan's fascinating cultural history.  Without giving anything away (no spoiler alerts here!), I wanted to share a quote by one of the main characters, Lord Yoshii Toranaga, played masterfully by the actor Hiroyuki Sanada and historically based upon the historical figure Tokugawa Ieyasu, the founder and first shogun of the Tokugawa shogunate of Japan, which ruled from 1603 until the Meiji Restoration in 1868.  The character Yabushige asks, "How does it feel to shape the wind to your will?"  To which Toranaga replies, "I don't control the wind.  I only study it." 

In other words, Toranaga doesn't see himself as directly controlling the events around him.  Rather, he studies them so that he can understand all of the forces at play, which he uses to to adapt his actions to his personal advantage.  It's not a reach to say that Toranaga is practicing a form of what we now call contingency leadership (see also my post, "Connecting the dots..."), which states that the right style and form of leadership is the one that is most appropriate for the specific situation at hand.  I also see elements of commander's intent (see my post "We rely upon your ability...you know what to do") and the High Reliability Organization (HRO) principle of "Deference to Expertise".  But mostly a see a brilliant strategist and tactician who is exercising all of his leadership prowess.  

As I've mentioned in several posts in the past (see, for example, "Good luck is the twin of hard work" and "Lucky Breaks"), leaders create their own luck.  Thomas Jefferson once said, "I'm a great believer in luck, and I find the harder I work, the more I have of it."  In other words, if you work hard and do your best, you will have a greater chance of success in whatever endeavor you choose.  Peter Economy wrote an article for "Inc." magazine entitled, "5 powerful ways to make your own luck every day".  He lists five ways to "make your own luck" which I think we can all agree:

1. "Tap into your optimism" - hard work and a great attitude go a long way!

2. "Be open to the possibilities" - take advantage of whatever life throws your way.

3. "Listen to your inner voice" - follow your intuition as much as you can.

4. "Shoot for the moon" - aim high, set your goals in advance and work hard to achieve them.

5. "There is no finish line" - never stop!  Be persistent and continue to grow and learn. 

Create your own luck.  Connect the dots.  And study the wind.

Sustainability

Regardless of what you believe are the causes at play, there is no question that the world is getting warmer.  According to data analyzed by the University of California Berkeley, the average mean land and ocean temperature has been steadily and significantly increasing since the 1960's.  Like it or not, our climate is changing.  There are significant public health risks to climate change, which is one of the best reasons why those of us in health care should care about environmental sustainability.  

The vast majority of scientists state that climate change is driven by the release of greenhouse gases.  The United Nations' Paris Climate Agreement adopted by 195 countries in 2015 (the United States withdrew from the agreement in 2020 but rejoined in 2021) states that we need to reduce greenhouse gas emissions by about 45% by 2030 and to net zero by 2050 in order to limit global warming to 1.5 degrees Celsius.  The health care industry accounts for a significant percentage of greenhouse gas emissions, with U.S. healthcare driving about 10% of all greenhouse gas emissions in our country.  Recent data suggests that healthcare is becoming more, not less, polluting, and hospitals are the biggest offenders of all in this regard.  Here is another good reason why those of us in health care should care about environmental sustainability. 

We generate a lot of waste in health care.  Don't believe me?  The artist Maria Koijck was diagnosed with breast cancer in 2019 and had to undergo a mastectomy.  More than a year later, she underwent breast reconstruction.  She asked her surgeon if she could have the waster from this operation, and she worked with her daughter to create an art video.  Just watch the video at her website using the link here.  She said, "This is the waste from one operation...my operation." 

It's a powerful video and a powerful statement.  We need to do better - all of us.  If your hospital is not investing in environmental sustainability, now is the time to urge them to do so.  

Five Whys

There are four similar but important tools that organizations, including hospitals, use to learn from failure and improve their key processes and procedures following accidents and near-misses (I've talked about these in two previous posts, "The Failure of Foresight" and "Hotwash") - they are Root Cause Analysis, Apparent Cause Analysis, "After Action Review", and "Hotwash".  

One of the techniques that is common to all four of these techniques is the "Five whys technique" developed in the 1930's by Sakichi Toyoda, the founder of Toyota.  It's relatively straightforward and simple to use.  When a problem occurs, you can drill down to the root cause by asking "Why?" at least five times.  The advantage of asking "Why?" at least five times is that we avoid making incorrect assumptions based on past biases and other traps.  

The "Five whys technique" has increased in popularity in health care in the last several years, and it is now recommended by the World Health Organization, the National Health Service in England, the Institute for Healthcare Improvement, the Joint Commission, and a number of other organizations focused on health care quality and safety.  According to Taiichi Ohno (whose Toyota Production System inspired Lean manufacturing), "The basis of Toyota's scientific approach is to ask why five times whenever we find a problem … By repeating why five times, the nature of the problem as well as its solution becomes clear. The solution, or the how-to, is designated as ‘1H.’ Thus, ‘Five whys equal one how’ (5W=1H)."

Here is one common example (from Wikipedia):

Problem: Our vehicle doesn't start in the morning for work.  

First Why?  The battery is dead.  

Second Why? The alternator is not functioning.  

Third Why? The alternator belt has broken.  

Fourth Why? The alternator belt was beyond its useful service life and wasn't replaced.  

Fifth Why?  We did not follow the manufacturer's recommended service schedule.

  

Root cause: We did not follow the manufacturer's recommended service schedule.

Solution: Follow the manufacturer's recommended service schedule.

By asking "Why?" five times, we didn't stop our analysis too early.  In this case, if we would have stopped after the second "Why?", we would have just taken the car in to replace the alternator, when the better long-term solution was to follow the manufacturer's recommended preventive maintenance schedule, which would have prevented the problem in the first place.

There's a great article in the journal BMJ Quality and Safety that calls into question the "Five whys technique" (see "The Problem with 5 Why's" by Alan Card).  Card talks about one of the most famous case studies of the "Five whys technique" which focused on the problem of the Washington Monument slowly deteriorating.  I've seen a few different versions (some involving the Washington Monument, others involving the Lincoln Monument), and I suspect that the story isn't completely true.  However, it's still interesting to review and illustrates a potential problem with the "Five whys technique":

Problem: Washington Monument is deteriorating.

First Why? Harsh chemicals are being used to clean the monument.

Second Why? The monument is covered in pigeon droppings.

Third Why? Pigeons are attracted by the large number of spiders on the monument.

Fourth Why? Spiders are attracted by the large number of midges on the monument.

Fifth Why? Midges are attracted by the fact that the monument is lit up at night.

Root cause: Lighting up the monument at night attracts midges.

Solution: Stop lighting up the monument at night.

As you hopefully can see, in this particular case, the "Five whys technique" oversimplifies the problem, and the solution is neither realistic or perhaps appropriate.  Now, I would first state that the "Five whys technique" is just a tool, and tools are only good if they are applied correctly and in the right situation.  Card argues that it shouldn't be used at all because it forces us into a direct cause-and-effect relationship to a single root cause, which may not be appropriate (and certainly wasn't appropriate in the Washington Monument case).  I think that is perhaps overstated, but it's clear that you have to use all of the tools in the proverbial quality improvement toolbox.  I wouldn't abandon the "Five whys technique" just yet.

I think part of the issue is also in how the problem is stated.  We need content and/or subject matter experts to help us and make sure that we are solving the correct problem.  For example, let's look at the famous case of the RMS Titanic, which sank in the North Atlantic after striking an iceberg on April 15, 1912.  Two different problem statements result in two different solutions - let's take a look:

Problem: The Titanic sank.

First Why? It ran into an iceberg.

Second Why? The crew didn't see the iceberg in time.

Third Why? The lookouts didn't have binoculars.

Fourth Why? One of the ship's officers left the shift in Liverpool with the key to where the binoculars were stored.

Fifth Why? He forgot.

Root cause: The ship officer forgot to unlock the binocular locker prior to leaving the ship in port.

Solution: All officers should follow a checklist prior to leaving the ship.

I am not making this story up (for more details, see the Wikipedia post on David Blair) - the fact that the lookouts didn't have binoculars is one commonly cited reason that contributed to the loss of the Titanic.  But would anyone be satisfied with the proposed solution here?  Let's re-phrase our problem statement in a different way and see if our solution is better:

Problem: 1,500 people died when the Titanic sank.

First Why? Not enough passengers got into lifeboats.

Second Why? There weren't enough lifeboats.

Third Why? White Star Line chose to meet only the minimum requirements (at the time) for the number of lifeboats.

Fourth Why? Too many lifeboats clutter the decks.

Fifth Why? Lifeboats are large and unwieldy.

Root cause: Lifeboats are large and unwieldy.

Solution: Increase the number of collapsible lifeboats.

Here we are attacking a different problem and proposing a completely different solution.  But again, would anyone be satisfied with the solution proposed this second time?  Probably not.  I would argue that if you gathered a multidisciplinary team of subject matter experts, you would likely come up with more than one root cause and, hence, more than one solution.  Incidentally, the BMJ Quality and Safety journal published another great article ("The problem with root cause analysis") on some of the drawbacks to the Root Cause Analysis technique, one of which trying to focus on just one single root cause.

In summary, I want to conclude by emphatically stating that I do not think that these techniques should be completely abandoned.  Both the "Five whys technique" and Root Cause Analysis technique have not only helpful in my experience.  We just need to be careful about placing all of our eggs in one basket and apply the right technique to the right context and at the right time.

"True Spirit"

I once thought it would be fun to learn how to sail.  We were moving to San Diego for my first active duty assignment in the U.S. Navy in 1994, which also happened to be around the same time that I had finished reading the book, Comeback: My Race for the America's Cup by Dennis Conner.  The book told the story about how American yachtsman Dennis Conner first lost the America's Cup in 1983 and then winning it back in 1987.  

The America's Cup is the oldest international sailing competition that had been won by the New York Yacht Club from 1857 until 1983, when Conner and his team on the Liberty lost 4-3 to the Royal Perth Yacht Club sailing the Australia II.  At the time, the 132 year reign was the longest winning streak in all of sports (and I believe it is still the longest winning streak in any sport).  Conner left the New York Yacht Club and formed his own group, raised funds, and mounted a challenge on behalf of the San Diego Yacht Club.  The Stars and Stripes 87 defeated the Australian defender Kookaburra III, 4-0.  Losing and winning back America's Cup was also the subject of the 1992 film Wind, starring Matthew Modine, Jennifer Grey, and Cliff Robertson.

Living in San Diego, which hosted the America's Cup race in 1988, 1992, and 1995 (Dennis Conner successfully defended the Cup in the 1988 race) further fueled my desire to learn to sail.  I remember my wife gave me a sailing jacket and a book on sailing for my birthday around that same time.  I ended up taking sailing classes through the Navy's Morale, Welfare, and Recreation (MWR) program (one of the many perks of being in the military).  I passed the land-based training with flying colors.  Even the boat training went fairly well, until my first solo attempt at sailing.  We were sailing in San Diego Harbor, and even though the winds weren't too bad that day, I somehow ended up caught in a blind alley of the marina.  While tacking back and forth to get out, I ended up scraping my bowsprit against another boat that was docked (with the owners apparently having a party at the same time).  Apparently the owner of the boat had just installed a new teak transom, so he wasn't happy with me (or with the Navy).  Thankfully, one of his friends jumped into the boat and helped me get back on course.  I returned back to the dock, and I don't think that I have been sailing since.

There's probably a lesson somewhere here about not accepting failure.  I'd love to be able to say that my experience didn't stop me from learning to sail, but I can't.  It was certainly not the only reason (and one could say that I invested more time learning to go under the sea than on top of it).  Incidentally, my wife ended up taking lessons after me, but unfortunately we just never made the time to go sailing together.  Everything that we both learned has long been forgotten.

Regardless of my own lack of experience sailing, I still do enjoy reading about sailing and watching movies about sailing.  Perhaps that's a reflection of my love of the ocean (see my last post "The sea is dangerous...").  With that in mind, my wife recently watched the Netflix movie "True Spirit", which tells the story of Australian teenager, Jessica Watson, who on May 15, 2010 and after 210 days at sea, completed a more than 22,000 nautical mile around-the-world sailing voyage by herself.  At the time, she was 16 years of age, making her the youngest person to sail solo, unassisted, and nonstop around the world.  The movie was really good, but the book (as they always say) was much better!  I just finished it.

Watson wrote a blog during her 210-day voyage, and several of these blog entries made it verbatim into her book.  The book goes into some length discussing the more than 2 years of preparation for her journey, as well as explaining her motivation for making the attempt.  Importantly, she didn't necessarily set out to be the youngest person to sail solo, unassisted, and nonstop around the world.  Rather, she loved to sail (and in fact, grew up sailing) and wanted to challenge herself and achieve something that she could be proud of.  She also wanted to inspire people, saying "I hated being judged by my appearance and other people's expectations of what a 'little girl' was capable of. It's no longer just my dream or voyage. Every milestone out here isn't just my achievement, but an achievement for everyone who has put so much time and effort into helping getting me here."

True Spirit begins with a great quote by Helen Keller, who said "Security is mostly a superstition.  It does not exist in nature, nor do the children of men as a whole experience it...Avoiding danger is no safer in the long run than outright exposure...Life is either a daring adventure, or nothing" (and I would finish the quote from Keller's book, The Open Door, with "To keep our faces toward change and behave like free spirits in the presence of fate is strength undefeatable").  The theme of persisting, even in the face of danger, is one that I briefly mentioned in my last post.  Jessica Watson never gave up on her dream, even after colliding with a large container ship in the middle of the night on her first run out on a test run.  During the voyage itself, she persevered and sailed on through stormy seas, despite having seven knockdowns (where the mast basically is pushed into the water), one of which her boat flipped completely upside down and nearly capsized.

As Mark Twain said, "Twenty years from now, you will be more disappointed by the things you didn't do than those you did.  So throw off the bowlines. Sail away from safe harbor. Catch the wind in your sails. Explore. Dream. Discover."  Mountains are meant to be climbed.  Seas are meant to be sailed.  Challenges are meant to be overcome.  Barriers are meant to be faced.  

I am reminded of something that Ryan Holiday writes in his book The Obstacle is the Way: "This is one thing all great men and women of history have in common. Like oxygen to a fire, obstacles became fuel for a blaze that was their ambition. Nothing could stop them, they were (and continue to be) impossible to discourage or contain. Every impediment only served to make the inferno within them burn with greater ferocity."  

Jessica Watson would certainly agree with this sentiment.  After one knockdown she writes, "But on the upside, these waves are just amazing.  I spent years dreaming about what waves like this looked like, and they are ten times more incredible than I'd ever imagined."  She uses the term "Happy Glasses" (also more commonly known as "rose-colored glasses") and keeps a great attitude throughout the voyage, even in the most difficult of circumstances.  She writes, "As silly as they sound, I really do believe in happy glasses. One thing I learned at sea was there are very, very few situations that can't be turned around and made more positive and less threatening by just looking at things in a different way.  Sure, I had my mopey, wallowing moments when I was scared or sad, but eventually I would realize it was up to me to change how I was feeling (no one else could do it for me), and I would manage to shift my head to a better place."  Again, as Ryan Holiday writes, "We blame our bosses, the economy, our politicians, other people, or we write ourselves off as failures or our goals as impossible. When really only one thing is at fault: our attitude and approach."

I learned a lot by reading this book (and watching the movie).  At the end of her journey, Jessica Watson was posed with the question, "Was it all worth it?"  To which she replied, "I didn't realize it at the time, but it's an incredible thing to have a goal you're so completely focused on that nothing is too much effort and you never stop to question it.  I'm also realizing how lucky I was to have people around me who felt the same."  Indeed. 

"The sea is dangerous..."

I have always loved the sea!  Apparently there is a term for that (of course) - lovers of all things related to the sea are known as thalassophiles.  The word thalassophile comes from the Greek word thalassa, meaning sea, which in turn comes from the ancient Greek goddess Thalassa.  Legendary oceanographer and thalassophile Jacques Costeau once said, "The sea, once it casts its spell, holds one in its net of wonder forever."  I've certainly found that to be true in my case.

The logical next question is why?  Why do so many people find the ocean so alluring.  I've posted (see "Back to Nature") in the past on a great book (Blue Mind) that addresses this exact question by the marine biologist and author Wallace J. Nichols, who unfortunately just passed away last month.  In that book, Nichols writes about the health and wellness benefits people derive from working and playing around water (rivers, lakes, and especially oceans).  I've also posted about Nichols' "Blue Marble Project" in the past as well, which is based upon the concept that our Earth is often referred to as a Blue Marble, particularly when viewed by astronauts in outer space.  The Apollo astronaut James Irwin said (when referring to Earth), "As we got farther and farther away it diminished in size. Finally it shrank to the size of a marble, the most beautiful marble you can imagine. That beautiful, warm, living object looked so fragile, so delicate, that if you touched it with a finger it would crumble and fall apart."

Why is our planet so blue?  It's covered by water!  Traditionally, sailors who traveled around the world would say that they had sailed the "Seven Seas".  In reality, there are more than seven seas around the world, and this was just an expression.  In fact, the "Seven Seas" of antiquity referred to different bodies of water at different periods of time in history, which were often the main bodies of water traveled most frequently at a particular time.  For example, the ancient Greeks considered the "Seven Seas" to include the Aegean Sea, Adriatic Sea, Mediterranean Sea, Black Sea, Red Sea, Caspian Sea, and the Persian Gulf, while in more modern times the "Seven Seas" refer to Arctic Ocean, Atlantic Ocean, Indian Ocean, Pacific Ocean, Mediterranean Sea, Caribbean Sea, and the Gulf of Mexico.  Today, the oceans are divided geographically into the Pacific, Atlantic, Indian, Arctic, and Southern (previously known as the Antarctic) Oceans, which collectively cover roughly 71% of Earth's surface.  The water contained in these five oceans account for 97% of all of the water on our planet.  As the science fiction writer Arthur C. Clarke said, "How inappropriate to call this planet Earth when it is clearly Ocean."

We are drawn to water because the oceans are beautiful, alluring, and mysterious.  For as much of our planet is covered by water, we still know very little about the ocean.  Only 20% of the ocean has been mapped, explored, or touched by humans.  The oceanographer Paul Snelgrove has said, "We know more about the surface of the Moon and about Mars than we do about the deep sea floor, despite the fact that we have yet to extract a gram of food, a breath of oxygen or a drop of water from those bodies."  The ocean is our next frontier, and perhaps our final frontier.

But for as beautiful and mysterious at it is, the sea can be just as dangerous.  And that simple fact has led to a number of quotes that are in large measure a metaphor for life.

"The sea is dangerous and its storms terrible, but these obstacles have never been sufficient reason to remain ashore."     Ferdinand Magellan

"The fishermen know that the sea is dangerous and the storm terrible, but they have never found these dangers sufficient reason for remaining ashore."     Vincent Van Gogh

"We must free ourselves of the hope that the sea will ever rest.  We must learn to sail in high winds."     Aristotle Onassis

"Twenty years from now, you will be more disappointed by the things you didn't do than those you did.  So throw off the bowlines. Sail away from safe harbor. Catch the wind in your sails. Explore. Dream. Discover."     Mark Twain

Even if our lives are never quite in immediate danger, we will undoubtedly encounter "high winds" and "rough seas" in our journey through life.  But as Magellan, Van Gogh, Onassis, and Twain attest, that is never reason to give up or quit.  "We must learn to sail in high winds."  And we will be better off for it.  As the historian Edward Gibbon said, "The wind and the waves are always on the side of the ablest navigator."  Or as William Arthur Ward claimed, "The pessimist complains about the wind; the optimist expects it to change; the realist adjusts the sails."

So for me, the ocean is an apt metaphor for the work we do as leaders.  There is beauty.  There is mystery.  There is uncertainty.  When you encounter a storm, adjust your sails.

Leadership Reaction Course

As I have previously shared, I spent six years on active duty in the U.S. Navy - three years as a pediatrics resident at Naval Medical Center, San Diego and three years as a general pediatrician.  During my first year of residency training, I spent just over a week at Fort Sam Houston (specifically, Brooke Army Medical Center) and Camp Bullis in San Antonio, Texas at the Combat Casualty Care Course (C4).  One of the week's highlights was the Leader's Reaction Course (see an example here), an obstacle course consisting of a series of ten, increasingly complex and physically demanding stations designed to test the participants' ability to work together as a team and think under pressure.

Apparently the concept for the Leader's Reaction Course (LRC) was developed by the German military in the 1920's as a method to help select future army officer candidates.  Following World War II, the British Army adopted the LRC for their own officer selection program.  U.S. Air Force Colonel Russell V. Ritchey became interested in the LRC after seeing into action at the Royal Air Force Academy and was later instrumental in bringing the LRC to the Squadron Officer's Course at Maxwell Air Force Base in Alabama.  By September, 1953, the Army designed and built their LRC at Fort Benning, which was used for the first time by the Officer Candidate Class of 1954.  Since that time, the LRC concept has been used throughout the military, and it is now even used for leadership development and training in the corporate world.

The LRC uses several different scenarios.  Facilitators first give a briefing and set of instructions to teams, who then have a certain amount of time to complete the scenario.  As one example, in my own experience, our team was told that we were Prisoners of War and had to escape by crossing a moat and then climbing over the wall.  We were told that we could not talk during the scenario, as talking would alert the guards to our presence!  We had to build a "people bridge" over the moat and then work as a team to get everyone over the wall (we failed on the first attempt).  

In another scenario, we had to use a set of boards of various lengths to carry ourselves and our equipment over a mine field (see the picture below for an example).

Incidentally, there are a few medical schools that have adopted what is called the Multiple Mini Interview (MMI) process in lieu of the more traditional 1:1 interview format during the application and selection process for admission.  The MMI apparently does a better job at assessing an applicant's critical thinking, problem-solving, and communication skills. I know that some medical schools have incorporated a problem-solving skills station, similar to the some of the stations used in the LRC.  Moreover, these schools generally require applicants to work together in small teams.  

Whether used for leadership selection or leadership education and development, I've found that the LRC and similar obstacle courses to be a fun and engaging way to learn how to work together in teams!  I suspect that this method will become more commonly used outside the military (see the MMI as one quick example) in the future, particularly as organizations invest more resources in leadership education and development.