Iron Horse

 They said it was a record that would never be broken.  Ever.  Lou Gehrig was a Hall of Fame first baseman for the New York Yankees from 1923 to 1939.  He was twice voted as Major League Baseball's Most Valuable Player, played in the World Series seven times (winning six times), won the Triple Crown (awarded to the player who finishes first in batting average, RBI's, and home runs), and was an All-Star seven consecutive years in a row.  He had a career .340 batting average and hit 493 home runs.  He is one of only 20 players to ever hit four home runs in a single game.  He was elected to the Baseball Hall of Fame in 1939 and was the first player to have his uniform number retired by a team, when his number 4 was retired by the Yankees.  But he is perhaps most remembered for his durability, which earned him the nickname "Iron Horse".  Gehrig played in 2,130 consecutive games.  

Gehrig's consecutive game streak ended on May 2, 1939.  His consecutive game record would stand for for 56 years, broken by another Hall of Famer, Cal Ripken, Jr, who would go on to break Gehrig's consecutive game record in 1995.  Gehrig stunned fans and teammates alike when he voluntarily took himself out of the line-up due to an undiagnosed ailment.  He would later be diagnosed with the incurable neuromuscular disease amyotrophic lateral sclerosis (now sometimes referred to as "Lou Gehrig's Disease").  He officially retired shortly after removing himself from the line-up, and the New York Yankees - and really all of baseball - honored him with "Lou Gehrig Appreciation Day" on July 4, 1939.  Gehrig ended the day with his now legendary farewell speech, in which he stated, "Fans, for the past two weeks you have been reading about the bad break I got.  Yet today I consider myself the luckiest man on the face of this earth."  

Gehrig's final words in the speech are incredibly poignant, "So I close in saying that I may have had a tough break, but I have an awful lot to live for."  Call it luck if you want, but Gehrig also chose to view all of the positives in his life instead of the negatives.  He had every reason to be angry, or even depressed.  His disease had robbed him of his career and perhaps everything that made him great.  His disease dramatically changed his life and would eventually rob him of that too.  Yet, he still looked back on his life and felt he was lucky.  He felt that he was fortunate.  Life was good.

We can learn a lot from Lou Gehrig.  Even if we may never be faced with a serious or even fatal illness, how Lou Gehrig chose to live out the rest of his life is something that we can all learn from.  You only have one life to live, so make it a good one.  Count your blessings.  Stay positive, even if or when things all around you are falling apart.

Is the Flint Water Crisis finally over?

I read an online news story a couple of days ago that said that the city of Flint, Michigan recently completed the replacement of almost all of the lead pipes providing water to the people living there.  The project was ambitious in scope, and long overdue, lasting almost 10 years from start to finish.  While the lead pipe replacement project closes one chapter of this story, the long-term public health impact of this incident is far from clear.  

I wrote about the Flint Water crisis in a brief editorial for the journal Current Treatment Options in Pediatrics in 2016.  I wrote then, "For its entire history, the city of Flint's fortunes have been closely tied with the fortunes of the automobile industry."  The automobile manufacturer General Motors was founded in Flint, and both the company and the city grew considerably during World War II and beyond.  However, when General Motors declared bankruptcy in 2008, so too did the city of Flint fall into hard times.  The city ranks near or at the bottom of the state of Michigan in almost every social (unemployment, domestic violence, violent crime, drug abuse) and public health (preterm birth, infant mortality, life expectancy) statistic.  However, it was after then Governor Rick Snyder declared a state of financial emergency in 2011 that Flint's problems with lead in the water began.  Governor Snyder appointed an Emergency Manager who was charged with cutting costs and reducing the city's $15 million budget deficit.

Flint previously obtained its water from the city of Detroit, whose source of water was nearby Lake Huron and the Detroit River.  The cost of water had nearly doubled by 2013, prompting Flint's city council to approve a proposal to switch to the Karegnondi Water Authority on March 25, 2013, which would allow the city to obtain its water directly from Lake Huron, bypassing Detroit (essentially, they were cutting out the middle man in the deal).  While the new deal would save the city approximately $19 million over an 8-year period, the new proposal would require completion of a new regional water pipeline, which would not be completed until 2016.  At the same time, the Detroit Water and Sewerage Department gave the Flint city council a one-year termination of contract notice.  The city council scrambled and signed a contract to use the water from the nearby Flint River until the new regional pipeline could be completed.

Almost immediately after the switch occurred in April, 2014, Flint residents began to complain and express concerns about the color, taste, and odor of their water.  Notably, the water from the Detroit Water and Sewerage Department was far less corrosive than the water from the Flint River.  City officials had failed to apply corrosion inhibitors to the water, possibly in yet another cost-cutting move.  In fact, General Motors had recently stopped using the Flint River water at one of their nearby engine assembly plants because the water quickly corroded the engine parts.  The corrosive water leached lead from the city's aging network of lead-based waterpipes, which had two adverse effects.  First, the lead levels in the water rose to dangerous levels.  Second, the lead and other heavy metals inhibited the chlorine-based disinfectants in the water, causing bacterial contamination.  Just four months after the switch, the city government put out a warning to residents to boil their water due to high levels of E. coli and Legionella.

As detailed in two outstanding books, The Poisoned City: Flint's Water and the American Urban Tragedy by journalist Anna Clark and What the Eyes Don't See: A Story of Crisis, Resistance, and Hope in an American City by pediatrician Mona Hanna, MD, MPH, local pediatricians started to report increased blood lead levels in children under 5 years of age, with neighborhoods with the highest water lead levels reporting the greatest number of cases.  Lead's neurotoxic effects can adversely impact a child's motor and cognitive development, so the disturbing increase in blood lead levels was a public health nightmare.  Dr. Hanna was instrumental in helping to make the connection between the increase in lead concentrations in the city water supply and the increase in the number of lead poisoning cases in Flint's pediatric population (notably, there were at least three separate studies establishing this link).

Somewhere between 6,000 to 14,000 children were exposed to drinking water contaminated with high levels of lead.  Children are particularly susceptible to the long-term effects of lead poisoning, so we will likely not know the true impact of this incident until several years from now.  Dr. Hanna, who is currently the Associate Dean for Public Health and and C. S. Mott Endowed Professor of Public Health at Michigan State University College of Human Medicine was  named one of Time magazine’s 100 Most Influential People in the World and recognized as one of USA Today’s Women of the Century for her role in uncovering the Flint water crisis and leading recovery efforts.  She stated, "Investment in our children's future, and in their health, is not just an economic necessity, but it is the bedrock of public health and a just society."

After nearly $400 million in both state and federal spending, the city of Flint has finally secured a clean water source and laid modern, safe, copper-based pipes to nearly every home in the city.  The late Reverend Allen C. Overton of Concerned Pastors for Social Action, one of the plaintiffs in the subsequent federal lawsuit said, "Thanks to the persistence of the people of Flint and our partners, we are finally at the end of the lead pipe replacement project.  While this milestone is not all the justice our community deserves, it is a huge achievement."

For me, the story of the Flint water crisis perfectly illustrates the critical linkage between public health and medicine.  As the health economists David Cutler and Grant Miller suggested in an article published in the journal Demography in 2005 ("The role of public health improvements in health advances: The twentieth century United States"), "clean water was responsible for nearly half the total mortality reduction in major cities" during the late 19th and early 20th century.  Similarly, Marcella Alsan and Claudia Goldin published an article in the Journal of Political Economy in 2019 ("Watersheds in child mortality: The role of effective water and sewerage infrastructure, 1880-1920") and concluded that one-third of the decline in child mortality from 1880 to 1920 was directly related to investments in clean, safe water.  As I have stated many times in the past, health delivery is not just about health care.  The so-called social determinants of health account for anywhere between 30-50% of reported health outcomes, particularly mortality.  As these studies - and the Flint water crisis - prove yet again, you can't drive improvements in health by focusing only on health care.  

The world is changed...

I am going to borrow the Elvish queen Galadriel's opening monologue to the 2001 movie The Fellowship of the Ring (the first movie in Peter Jackson's epic masterpiece trilogy, The Lord of the Rings):

The world is changed.  I feel it in the water, I feel it in the earth, I smell it in the air...Much that once was is lost, for none now live who remember it...

Okay, perhaps the last part is a bit of an exaggeration, as most of the changes that I am going to talk about in today's post are not all that old.  Apparently, the Gallup Poll has been asking the same question every year since 1939: "Do you have occasion to use alcoholic beverages such as liquor, wine, or beer, or are you a total abstainer?"  You can tell that the question was first written in 1939, as we wouldn't ask that question in the same way in 2025.  What is surprising is that the number of Americans who say that they do "have occasion to use alcoholic beverages" hit an all-time low of 54% in this year's survey, which came out earlier this month.  Just as important is that the decreased consumption coincides with a growing belief that moderate alcohol consumption is bad for one's health, which is a majority view for the first time in the history of the survey.

Alcohol consumption, even among young adults, has been steadily declining since 2023, when 62% of Americans reported drinking alcohol, which decreased to 58% in 2024.  The trend towards decreased alcohol consumption coincides with the latest research reporting that, contrary to previous opinions, any degree of alcohol consumption may negatively affect health.  Importantly, the decline in alcohol consumption does not appear to be caused by a shift towards other drugs, such as recreational marijuana, which is now legal in about half of U.S. states.

The alcohol consumption patterns among those Americans who do drink are also shifting.  A record low of 24% of alcohol drinkers say that they had a drink in the past 24 hours, while 40% say it has been more than a week since they last consumed alcohol (the highest percentage since 2000).  The average number of alcoholic drinks consumed over the past week has decreased to 2.8 drinks/week, which is the lowest reported since 1996 (and decreased from 3.8 drinks/week in last year's survey).  

Americans appear to prefer beer over liquor and wine, which is consistent with the pattern over the last six years.  Wine remains in third place, though there are differences in age and gender.  For example, in general, men prefer beer over wine and liquor, while women generally tend to choose wine over beer. This is perhaps surprising given the so-called "French Paradox" and prior research suggesting potential heart-healthy benefits to wine consumption (see my post, "Raitis tammikuu").  

The French population, as a whole, consumes a diet that is much higher in saturated fats (think of all the cheese and butter that they consume compared to Americans - one blogger basically said, "They eat butter like it's a food group...Their cheese selection could stock a small grocery store."  Yet,  compared to the French, Americans have much higher rates of heart disease and obesity.  The classic explanation has been that the anti-oxidants in wine, specifically compounds known as polyphenols (including one called reservatrol), are "heart healthy".  However, Dr. Kristie Leong recently wrote a blog on Medium ("Why French people eat butter and stay lean (the paradox that broke nutrition science)") that suggested other factors are responsible for the "French Paradox".  Dr. Leong says that the explanation isn't what the French people are eating, but rather how they are eating:

1.  French meals average 22 minutes compared to 14 minutes for Americans.  Eating slower gives our brains time to tell our stomachs that we are full.

2.  French portions are 25% smaller than American servings, yet satisfaction levels are identical.  Dr. Leong says that a typical French dinner plate is about 9 inches in diameter compared to a typical American dinner plate, which has a diameter of 12 inches.  That three inch difference translates to a 44% increase in surface area available to pile food on the plate for Americans.  

3.  French people stop eating when they feel satisfied, while Americans stop when their plate is empty.  Given the differences in plate sizes mentioned above, Americans are just going to eat more, regardless of whether they feel full or not.

4.  French food culture prioritizes ingredients over convenience.  They eat a lot less processed foods compared to Americans.

5.  Americans eat an average of 2.2 snacks per day.  The French?  Less than one.  

6.  French culture prioritizes leisure in ways that seem almost alien to Americans (lunch breaks are sacred, vacation time is mandatory, and work-life balance isn't just a buzzword).  Less stress leads to better health.

7.  French wine consumption averages one glass per day, typically with meals.  Americans tend to binge drink, and alcoholic beverages tend to have a lot of calories.

As I've stated previously, more recent research suggests that "no amount of alcohol is safe", which is becoming the majority belief, at least according to the Gallup survey.  More importantly, there is a lot more to the "French Paradox" than just wine consumption.  The French have better dinner habits than Americans, which according to Dr. Leong is playing the most important role here.

It will be interesting to monitor the trend towards decreased alcohol consumption in the future.  I suspect that we will start to see studies reporting on the economic impact of decreased alcohol consumption very soon.  And perhaps we will also see a consolidation in the beer, wine, and liquor industry?  Time will tell.  But clearly, the world is changed...  

Blue Lights

You tend to hear all kinds of crazy stories (and believe them) when you are young!  When I was growing up in Indianapolis, we used to hear about a haunted house known as "The House of Blue Lights".  The house was the former residence of an eccentric local millionaire and philanthropist named Skiles Edwards Test, who died in 1964.  The story goes, at least the way that I heard it, Test kept the house decorated with blue Christmas lights all year round.  That doesn't seem too eccentric, but I also heard that he kept his deceased wife in a glass coffin inside the house, also surrounded by blue lights.  While the former story was mostly true, the latter was definitely not.  Incidentally, the house at the northeast side of Indianapolis had nothing to do with the popular boogie-woogie blues song that was released by, among others, Chuck Miller, Chuck Berry, and George Thorogood. 

Well, it was exactly the story of "The House of Blue Lights" that came to mind when I read a recently published article in The New York Times.  Journalist Caroline Hopkins Legaspi wrote an interesting article that summarizes a lot of research on the effects of blue light on sleep (see "Why do screens keep you up? It may not be the blue light.").  Smart phones primarily use blue light for their displays, and there are all kinds of studies out there suggesting that using your smart phone before going to bed is the absolute worst thing that you can do, primarily because of the adverse effects of blue light on circadian rhythm.  Blue light has a shorter wavelength and higher energy than other colors, which allows for better visibility, particularly with bright ambient light.  Blue light is naturally emitted by the sun and plays a role in regulating our body's natural sleep-wake cycle (the technical term for which is called our circadian rhythm).  Blue light helps us feel alert and awake during the day, though too much blue light at night has been reported to inhibit the release of melatonin, which is a hormone that helps us sleep.

Caroline Hopkins Legaspi suggested that the relationship between blue light and sleep is not as straightforward as we think .  She reported research by Lauren E. Hartstein, an assistant professor of psychiatry at the University of Arizona that suggests that the content of what's on the screen before bedtime is probably more important than the type of light used by the smart phone.  Some of us are perhaps more sensitive to blue light than others, while others just don't seem to be affected by blue light.  Finally, Dr. Hartstein questions whether it is appropriate to generalize findings from sleep studies performed in a laboratory versus what actually happens when those same individuals are at home.

So, what can we conclude from the available research?  First, scrolling through social media or playing video games before bedtime probably aren't helpful for our circadian rhythms.  Second, many of us just can't seem to "calm our brains" at night, and reading a book (not a suspense or murder mystery) or watching a television show (again, not a murder mystery) could actually help in these situations.  Third, if you aren't having any trouble falling asleep, even if you are checking things on your smart phone, the smart phone is probably not causing any problems.  As Dr. Hartstein says, "If you are able to fall asleep quickly, you sleep well throughout the night, and you feel rested the next day, then that's great.  You don't need to constantly adjust your behaviors."  In other words, if you want to bask in the glow of blue light, just like ole Skiles Edwards Test did, it's probably okay to do so.  Just don't put your dead wife in a glass coffin, and definitely don't listen to haunted house stories before bedtime!

The "Walkman Effect"

The psychologist Stanley Milgram wrote an essay in the journal Science in 1970 called "The Experience of Living in Cities".  In the essay, he talked about the concept of overload from systems theory, which refers to a system's inability to process inputs from the environment when there are too many inputs for the system to cope with.  He wrote, "City life, as we experience it, constitutes a continuous set of encounters with overload, and of resultant adaptations...One adaptive response to overload is the allocation of less time to each input."  He then referred to the sociologist, Georg Simmel, who pointed out as long ago as 1903 that individuals who live in cities come into contact with so many other individuals that in order to conserve their cognitive attention, they largely keep to themselves or maintain only superficial relationships with their acquaintances compared to those individuals who live in more rural areas.  

We've known for a long time that individuals who live in cities tend to keep to themselves, at least when compared to those individuals living in rural areas (see my recent post, "The Quiet Commute").  One of my high school friends wrote a novel called East Fifth Bliss.  The author says of the protagonist in the novel, Morris Bliss, "Morris rarely converses with the neighbors.  A greeting, good morning, or 'Hey, how are you?' at most.  Rarely more.  A crowded city is often isolating."

While cognitive overload is an important factor, particularly when it comes to living in a crowded city, what's also clear is that technology has also had an adverse impact on how we interact with one another.  The writer Jonathan Haidt in particular writes about the dangers of social media and the adverse impact that social media has had upon society today in his book, The Anxious Generation.  Haidt's book is still relatively new (it was published in 2024), but the concerns about technology's adverse impact on society are not - look no further than the Sony Walkman, a portable cassette player first introduced in the late 1970's.  

At the time it was first introduced, the Sony Walkman was revolutionary in concept.  Shuhei Hosokawa published an essay about the Walkman and its impact on society in the journal Popular Music in 1984 entitled "The Walkman Effect".  Hosokawa claimed (and I think he was correct) that the Walkman created a private auditory space within public spaces, allowing users to detach from their environment and mentally withdraw into a private world of music.  

Of interest, the original model of the Walkman played cassette tapes and included a second earphone jack as well as an extra set of headphones.  There was a curious orange button labeled "Hot Line" that when pushed, allowed the two users to speak to each other through a microphone.  According to Akio Morita, one of the Sony co-founders, the company was anxious about the solitary nature of their new product, and they included the orange button to provide an emergency "share" feature.  

In other words, the company that released the Sony Walkman was concerned enough that the new technology would further isolate its users that they created a feature to try to create "togetherness".  Ironically, the orange button was soon removed and the Sony Walkman became hugely popular, primarily because of its solitary nature (hence, the "Walkman Effect").  

I remember when the Sony Walkman first came out.  As a matter of fact, I owned a later model of the Walkman and used it literally all the time.  What's clear to me (again) is that our tendency for self-imposed isolation is not a new phenomenon.  It was there before social media, the smart phone, and the Internet.  And to be honest, we've been talking about these issues since the time of the ancient Greeks (see my recent post, "Today's Phaedrus moment").  I even bet that the earliest humans were once sitting in a cave, lamenting a younger generation of cavemen and cavewomen who were spending too much time alone drawing pictures on the cave walls.

Technological advances often bring welcome changes to society.  However, as with just about everything else, there can be drawbacks to technological change too.  I don't pretend to have all the answers here, but I do think that we need a more balanced discussions about the pro's and con's of technology, particularly social media, the smart phone, and the Internet.

One more time on the elites...

I wanted to finish off the discussion on elite individuals from my two previous posts last week, "What makes elite individuals elite?" and "The 40% rule", hopefully generating less controversy (see "Controversy") than the last time.  Specifically, I wanted to re-visit the topic on whether elite athletes are born with elite skills and physiologic tools that make them markedly superior to everyone else or whether they develop those elite skills and physiologic tools with practice and training.  In other words, is it "nature" or "nurture".  There is also a third possibility that it's a combination of both "nature" and "nurture".  The author David Epstein wrote a fascinating book on this exact subject called The Sports Gene: Inside the Science of Extraordinary Athletic Performance, which I've mentioned a few times in related posts from the past (see "What makes a champion?" and "Peak").

It would be helpful to start out with a brief discussion on something that is known as the mammalian dive reflex.  I first learned about the so-called dive reflex during one of my undergraduate biology courses (I think it was a class called "Comparative Animal Physiology").  The dive reflex is a normal and protective physiologic response to water submersion.  It's found in almost all mammals, which includes, of course, humans.  When mammals (or humans) dive underwater, they have to hold their breath, which causes the concentration of oxygen in their bodies to decrease.  That's usually not good!  However, the body responds to being submerged in water by lowering the heart rate (bradycardia), slowing down or even stopping the normal breathing reflex (bradypnea or apnea), and shunting blood flow from the arms and legs to the brain, heart, and kidneys to preserve the body's core functions (increased peripheral vascular resistance).  All of these responses decrease the body's consumption of oxygen, allowing mammals (and humans) to survive, for at least a time, underwater without a source of oxygen.

As you will no doubt acknowledge, some mammals are much better at diving underwater than humans (think about how long whales and dolphins can hold their breaths underwater compared to humans).  These mammals evolved, through natural selection, bodily mechanisms to help them dive underwater for much longer periods of time.  As it turns out, some humans are better at diving underwater than others.  Dolphins and whales developed a robust dive reflex over thousands of years, but what about humans?  As it turns out, two distinct populations of humans have appeared to develop remarkable adaptations over time that allow them to hold their breath underwater for much longer than most of us.  These populations are the Bajau people of Southeast Asia (known as "sea nomads") (see "Physiological and genetic adaptations to diving in sea nomads") and the Haenyeo people of Korea (see "Genetic and training adaptations in the Haenyeo divers of Jeju, Korea").  Both populations have appeared to develop over thousands of years genetic modifications that allow them to dive underwater for long periods of time.  In the first study, the Bajau people were shown to have increased spleen size, providing a reservoir of oxygenated red blood cells during diving.  In addition, they appear to have inherited a specific gene modification that affects the so-called dive reflex.  The second study showed that the Haenyeo women divers also have developed a superior dive reflex (pronounced bradycardia) compared to everyone else who lives in Korea.

The scientists in both studies suggest that their results provide convincing evidence that the Bajau and Haenyeo divers evolved their remarkable adaptation to diving underwater over thousands of years.  I find these results incredibly remarkable, as it suggests that "nature" is playing a major role in their abilities.  However, the studies I mentioned in the two posts last week ("What makes elite individuals elite?" and "The 40% rule"), as well as a number of studies mentioned in David Epstein's book The Sports Gene: Inside the Science of Extraordinary Athletic Performance suggest that "nurture" plays a major role as well.  In other words, rather than an either/or when it comes to the "nature versus nurture" debate, it's a both/and!  Elite athletes are the result of great genes and practice, practice, practice!

I mention all of this, as one of the most frequently debated topics in leadership and management is whether leaders are born with a unique ability to practice the art of leadership, or do they develop those skills with practice and training?  Most of the studies and articles on leadership that I've read strongly suggest that great leaders develop their skills over time with extensive education and training.  That's certainly reassuring, but given the discussion on elite athletes above, I am still left to ponder if we will ever find a so-called leadership gene.  Stay tuned for more!

A Kodak "moment"...

Pay close attention over the next few days on what is happening with the Eastman Kodak Company.  I've read a couple of news stories suggesting that the 133 year-old company's demise is imminent.  Just this past Wednesday, media outlets such as CNN and MSNBC reported on the company's ongoing financial struggles, specifically pointing out statements that company representatives made in a quarterly earnings report that the company didn't have "committed financing or available liquidity to meet debt obligations coming due within 12 months."  

If these reports are true, it would be a tragic end to a company that was once one of the stalwarts of American industry.  Kodak was the fourth most valuable brand in the U.S. (after Disney, Coca-Cola, and McDonald's) with just over $15 billion in revenue as recently as 1996.  The company declared bankruptcy in 2012 (see the graphic below from The Economist magazine).

Following declaration of bankruptcy in 2012, the company shifted from the photographic film business and focused on commercial printing, packaging, and advanced materials and chemicals (including pharmaceuticals).  The company sold off most of its businesses and patents.

Kodak has been the subject of countless business articles, case studies, and graduate theses on disruptive innovation (see, for example, the Harvard Business Review article, "Kodak's Downfall Wasn't About Technology").  Kodak's core business was selling photographic film.  Once cameras went digital, people became less interested in film.  And when cell phones became cameras, digital cameras became much less popular.  

The ironic twist in all of this was that an engineer at Kodak actually invented the digital camera.  Kodak's response at the time was to focus on their core business.  Therein lies the reason for all of the articles and case studies!  It's a classic example of Clayton Christensen's "disruptive innovation", how a smaller company with a new, often simpler product, can initially target low-end, niche markets, gradually improve, and ultimately displace leading companies.

The company recently issued a press release that countered the claims made in the last few days, stating that it had no plans of ending operations or filing for bankruptcy.  Whether this is true or not, remains to be seen.  I will be watching with great interest to see how this all plays out.

Controversy

A reader commented on my last two posts ("What makes elite individuals elite?" and "The 40% rule") pointing out the controversy surrounding Diana Nyad's 2013 swim from Cuba to Florida.   I certainly knew about this controversy before writing both posts, and after reading some of the reports, I am still not sure who or what to believe.  If you are interested, you can read both a Time magazine article and an online post by the World Open Water Swimming Association (WOWSA) that came out around the time of the release of the 2023 Netflix movie Nyad.  Of note, Nyad's swim has never been officially recognized by WOWSA.

I used Nyad's swim to highlight peer-reviewed and published research on the biological basis of willpower, suggesting that we can be trained to perform beyond our own self-perceived physiological limits.  Whether Diana Nyad completed the entire swim across the Strait of Florida without assistance is a question that will likely be never fully answered.  That being said, as a former competitive swimmer, I can still appreciate the extraordinary willpower and perseverance of anyone who swims in open water for more than a few miles.  I do not feel that a retraction of either post is warranted, as both posts used Nyad's story as an introduction to a much more important and recognized concept.  However, I will in the interest of full transparency point out the controversy surrounding Nyad's swim.

The 40% rule

Last time (see "What makes elite individuals elite?"), I posted about Diana Nyad and the studies performed by Martin Paulus and his team suggesting that perhaps there is a little bit of Diana Nyad in all of us.  While we may never swim across the Straits of Florida like Nyad did on her fifth attempt in 2013, the work by Paulus and his team strongly suggest that we can train our minds to push beyond our own self-perceived limits.  

I am reminded of a story that I heard about the American entrepreneur, author, ultramarathoner, and former rapper (under the name "Jesse Jaymes") Jesse Itzler.  Incidentally, Itzler also happens to be married to another entrepreneur, Sara Blakely, the founder of Spanx.  Itzler was running in a 100 mile ultramarathon as part of a relay team of five other runners, when he "met" former Navy SEAL David Goggins, who was running the entire 100 mile ultramarathon by himself!  I've posted about Goggins in the past (see my post "GoRuck").  Goggins is a freak of physical fitness - he apparently joined the U.S. Air Force in the 1990's, gained a lot of weight after he left the Air Force, and then lost 106 pounds before joining the U.S. Navy and signing up for the U.S. Navy SEAL entry program, Basic Underwater Demolition/SEAL training ("BUD/S").  After completing training and qualifying as a Navy SEAL, Goggins completed U.S. Army Ranger School.  He would serve in the military for 20 years, and he has since become an ultramarathoner, triathlete, ultra-distance cyclist, motivational speaker (of course), and author.  And oh, did I mention that he once held the world pull-up record?  He once did 4,030 pull-ups in a 17 hour period.  He has since written two excellent memoirs, Can't Hurt Me: Master Your Mind and Defy the Odds and Never Finished: Unshackle Your Mind and Finish the War.

Back to Itzler.  After meeting Goggins, Itzler did what only a billionaire could do - he hired Goggins to live with him for the next 30 days and teach his family the art of mental toughness.  Itzler's experience is the subject of his book, Living with a SEAL.  Itzler writes, "The first day that “SEAL” came to live with me he asked me to do — he said how many pull-ups can you do?  I did about eight.  And he said all right. Take 30 seconds and do it again. So 30 seconds later I got up on the bar and I did six, struggling. And he said all right, one more time. We waited 30 seconds and I barely got three or four and I was done. I mean couldn’t move my arms done. And he said all right. We’re not leaving here until you do 100 more. And I thought there’s no — well we’re going to be here for quite a long time because there’s no way that I could do 100. But I ended up doing it one at a time and he showed me, proved to me right there that there was so much more, we’re all capable of so much more than we think we are. And it was just a great lesson."

Goggins refers back to a statement that the American psychologist William James made in his book, The Energies of Man.  James wrote, "Beyond the very extreme of fatigue and distress, we may find amounts of ease and power we never dreamed ourselves to own; sources of strength never taxed at all because we never push through the obstruction."  Goggins calls it "the 40% rule". Itzler explains further that the "40% rule" simply means that when your brain is telling you that you can't go on anymore, you are really only 40% done.  Deep down, your body can handle more stress and you can face even greater challenges.

I'd love to see what Goggins' right insula looks like on fMRI!

What makes elite individuals elite?

I posted last year (see "It's a team") about the 2023 movie Nyad starring Annette Bening and Jodie Foster.  The film is based upon open water swimmer Diana Nyad's 2015 memoir, Find a Way (which I've since had a chance to read) and tells the story of Nyad's multiple attempts in the early 2010's to swim from Cuba to Florida across the treacherous Straits of Florida.  Nyad was successful on her fifth attempt at the age of 64 years, which is absolutely incredible!

When she finally made it all the way to Key West, Nyad proudly told the crowd that had gathered at the beach to welcome her and cheer her on, "I got three messages.  One is we should never, ever give up.  Two is you are never too old to chase your dreams.  Three, it looks like a solitary sport, but it's a team."

I am not going to argue that Nyad's accomplishment was a team effort!  While my personal and professional accomplishments will never equate to swimming across the Straits of Florida, I will readily admit that everything that I've achieved in life has required a great deal of help from my wife, my family and friends, and my colleagues.  However, today I wanted to focus more on Diana Nyad the person.  There is no question that her own personal perseverance and resilience played a major role in her success.  Elite athletes are just wired differently.  The question I have is whether that is nature, nurture, or a combination of both.

The writer Elizabeth Svoboda wrote an article for Discover magazine in 2014, "The Brain Basis of Extraordinary Feats of Will" in which she wrote, "It’s easy to assume that Nyad and other champions of endurance — Olympic medalists, Navy SEALs, marathon dancers — are freaks of nature, capable of feats of will the rest of us could never accomplish. But according to University of California, San Diego, psychiatrist Martin Paulus, who studies how the brain responds to stress, perseverance isn’t just an inborn trait. His work suggests that toughing it out Nyad-style is a specialized skill that’s potentially accessible to all of us — with a little training."

Now THAT caught my attention!  One of the reasons that I find science so cool is that every new finding builds upon the last one.  Martin Paulus (now head of the Laureate Institute for Brain Research at the University of Tulsa) and his team conducted a number of studies, each building upon the last one in an iterative fashion, before Svoboda was able to make that statement.  They first used functional magnetic resonance imaging (fMRI) to show that elite military personnel in the U.S. Navy (Navy Sea, Air, Land Forces - SEALs) showed greater activation in the right insular region of the brain and attenuated activation in the left insular region of the brain when shown angry and/or happy emotion faces compared to normal subjects (see "Differential brain activation to angry faces by elite warfighters: Neural processing evidence for enhanced threat detection").  In a follow-up study, when compared to normal subjects, Navy SEALs showed an attenuated activation in the right insular region when exposed to angry emotion signals (see "Altered insula activation in anticipation of changing emotional states: neural mechanisms underlying cognitive flexibility in special operations forces personnel").

The next study (see "Subjecting elite athletes to inspiratory breathing load reveals behavioral and neural signatures of optimal performers in extreme environments") studied what is compared the interoceptive response between elite adventure racers and normal subjects.  Interoception is what the body does to sense or perceive the internal state or physiological condition of the body and is heavily involved in how we perceive effort and exertion.  Elite athletes, for example, could have an attenuated interoceptive response allowing them to push past what others "feel" as maximum effort.  Again, Paulus' team performed fMRI while subjects performed a cognitive task requiring focus and attention and while wearing a specially fitted mask that significantly increases the difficulty of breathing (without causing an increase in blood carbon dioxide or oxygen levels).  There were three key findings: (1) breathing through a straw (basically) was difficult and very unpleasant and resulted in "profound" activation of the bilateral insula, dorsolateral prefrontal cortex, and anterior cingulate; (2) adventure racers, compared to normal subjects, showed greater accuracy on the cognitive task with fewer mistakes in spite of having to breathe through a straw; (3) adventure racers showed decreased activation of the right insular cortex during the breathing load.  In other words, as predicted, elite athletes actually do show an attenuated interoceptive response, allowing them to push past the pain and discomfort of vigorous exercise or activity that would cause the rest of us to stop.

All of these findings are very interesting and make sense.  Maybe elite athletes, like Diana Nyad, and special forces military personnel, like the U.S. Navy SEALs are just wired differently from the rest of us.  But here's where things get even more interesting.  Paulus' team took things one step further and enrolled more than 200 U.S. Marines in an eight week Mindfulness Based Mind Fitness Training (MMFT) course.  Those Marines who participated in MMFT showed an attenuated right insular and anterior cingulate response after a stressful combat training session (see "Modifying resilience mechanisms in at-risk individuals: A controlled study of mindfulness training in Marines preparing for deployment").  Similarly, in yet another follow-up study, using the same inspiratory breathing load used in the Navy SEALs experiments above, Paulus' team were able to show that Marines who had participated in the MMFT course had an attenuated right insular response compared to those who did not participate in the course (see "Mindfulness-based training attenuates insula response to an aversive interoceptive challenge").  In other words, we can be trained to ignore the signals that our bodies generate to tell us that we are exerting maximal effort!

Please don't get too excited.  I'm not going to say that with extensive training, any one of us could swim across the Straits of Florida.  Diana Nyad probably does have some physiologic tools that she inherited from her parents and that allowed her to be successful at long-distance swimming.  However, the suggestion that we can all train ourselves to push beyond our self-perceived limits is an important one.  Perhaps there is a little bit of Diana Nyad in all of us.

The finest things in life...

My wife and I recently took a trip to the Willamette Valley in Oregon for some hiking and wine tasting.  Neither one of us had ever been to Oregon, so we were able to cross the state off our bucket list.  More importantly, we had a great time!  Of course, I also learned a few things about wine that I didn't know.  I've never been a huge fan of sparkling wine, but after tasting some really good sparkling wines in Oregon, perhaps I will reconsider.

I will admit that until a few years ago, I never knew that there was a difference between champagne and sparkling wine.  I thought that there was "Champagne" with a capital C (made in France), as well as "champagne" with a lower-case C (which was made everywhere else).  Contrary to popular belief, there's a difference between champagne (regardless of whether it is spelled with a capital or lower-case letter) and sparkling wine.  "Champagne" refers to a sparkling wine that is specifically made in the Champagne wine region in northeastern France.  All other varieties should just be called sparkling wine and not champagne, even though most of us do so.  

Sparkling wine is usually white (wine produced by the fermentation of the grape pulp minus the skins) or rosé (an intermediate between red and white wine), but there are also examples of red (wine produced by the fermentation of the grape pulp with the skins) sparkling wines, including the Italian sparkling red wines, Brachetto and Lambrusco.  Sparkling wine can range from dry (which is actually a technical term for wine that contains very little sugar, so it's not sweet) - also known as brut (French for "hard") to sweet (which of course is a wine containing a lot of sugar) - also known as doux (French for "soft").    

The sparkling (fizzy) nature of sparkling wine is due to higher content of carbon dioxide which is produced during secondary fermentation, either in a bottle (which is the traditional method) or in a large stainless steel tank (which is the more commonly used method today).  Apparently, the effervescence or "fizziness" of certain wines was noted as far back as Ancient Greece, but the cause was often misunderstood.  Ancient winemakers thought that the presence of bubbles was due to phases of the moon or to the influence of good versus evil spirits.  

The French Benedictine monk Dom Pierre Pérignon actually did not invent the French sparkling white wine that we now call "champagne".  As a matter of fact, his superiors at the Abbey of Hautvillers once tasked him with trying to remove the fizziness out of the sparkling wine, because the bottles had an uncanny tendency to bursting in the cellar.  Even though he didn't invent champagne, Dom Pérignon did a lot to perfect how champagne was made, which is why even today Dom Pérignon champagne is considered one of the finest brands of champagne out there.

I also recently learned another bit of trivia about champagne.  Apparently, a group of divers found a crate of 70 bottles of champagne from a 19th century shipwreck in the Baltic Sea in 2010.  The champagne was 172 years old and thought to be worth at least $4 million.  The bottles were still corked, and the champagne was perfectly preserved due to the cold temperatures in the Baltic Sea.  Imagine drinking a bottle of "shipwreck champagne" from the 19th century!

So, what is the take-home message from all of this talk about sparkling wine?  Great question!  Both the history of champagne and Dom Pérignon, as well as the story about "shipwreck champagne" prove to me once again that some of the finest things in life were once thought to be flaws.  Sometimes, when we see a flaw, we should change our perspective.  The effervescence that makes champagne so appealing to many of us was originally thought to be a flaw.  When viewed in a different way, it became the defining characteristic of a whole family of fine wines.  I am also reminded that some of our most important advances came about as a result of mistakes and accidents.  It is true that we can learn a lot by taking risks and making mistakes.  There is no better way of learning and growing.  And every once in a while, we may find ourselves with 200 year-old champagne worth millions!

"The clothes really do make the person..."

I was working late last Friday night and caught one of the last commuter trains back to the suburbs.  I happened to be wearing a suit that day, and one of my fellow commuters noticed and acknowledged that the two of us were "probably the only two people on the train wearing a suit that night".  He was correct - everyone else was dressed for going out for a fun Friday night.  My fellow commuter told me that whenever he worked downtown, he usually wore a suit.  I don't remember his exact words, but he said something to the effect that we should always dress for the occasion and how we dress makes an impact on how we feel and how we are perceived.

His comments reminded me of the old adage that "the clothes make the man", which is often attributed to the American author, Mark Twain.  It is true that Twain wrote the following passage in his short story "The Czar’s Soliloquy" in 1905:

[One] realizes that without his clothes a man would be nothing at all; that the clothes do not merely make the man, the clothes are the man; that without them he is a cipher, a vacancy, a nobody, a nothing… There is no power without clothes.

  

Regardless of its origin, there is now scientific proof to suggest that how we dress truly impacts how we feel, and how we feel has an impact on how we show up, how we portray ourselves, and how we are perceived by others.  It's called "enclothed cognition", a term first used by the American psychologists Hajo Adam and Adam Galinsky in a study published in the Journal of Experimental Social Psychology.  Adam and Galinsky cite other examples to support their findings, including the popular book, Dress for Success by John T. Molloy or the television series, What Not to Wear.  They write, "...the clothes we wear have power not only over others, but also over ourselves."

In the first experiment, Adam and Galinsky randomly assigned college undergraduate students to one of two conditions - wearing a lab coat versus not wearing a lab coat.  Subjects were next asked to perform a series of selective attention tasks (known as the Stroop test), in which they had to focus on relevant stimuli while ignoring irrelevant stimuli.  Those students wearing a lab coat made about half as many errors as those who weren't wearing a lab coat.  It was almost as if wearing a lab coat (a status symbol of knowledge authority and expertise) increased the students' level of confidence, allowing them to successfully perform their task.

In the second experiment, Adam and Galinsky again randomly assigned college undergraduate students, this time to one of three conditions - wearing a lab coat versus wearing a painter's coat versus seeing a lab coat.  The students were told that local officials were thinking about making certain clothes mandatory for certain professions in their area, and one of the purposes of the study was to determine what people think about the clothes.  The interesting part about this experiment was that students in the lab coat and painter's coat group actually wore the same coat, it was just described as a doctor's coat in the first group and a painter's coat in the second.  Students in the third group merely saw a lab coat displayed on a table across the room.  The students were next asked to perform a sustained attention task.  Again, students in the lab coat group were more successful at the task compared to the other two groups, consistent with Adam and Galinsky's concept of "enclothed cognition".

The results of the second experiment demonstrated that wearing a lab coat led to greater success in the sustained attention task and that this effect depended on whether (1) the clothes were worn and (2) the symbolic meaning of those clothes.  Of interest, there was no difference between the painter's coat group and the group who saw the doctor's coat.  In the last experiment, college undergraduate students were randomized to one of three conditions - wearing a doctor's coat versus wearing a painter's coat versus identifying with a doctor's coat.  The experimental set-up was very similar to the second experiment, except in the "identifying with a doctor's coat", students saw the doctor's coat during the entire experiment and were asked to write an essay about how the coat represents them and has a personal meaning (this was to "prime" the students to closely identify with the lab coat).  Students who wore the doctor's coat still performed better on the sustained attention task, however this time, the students who identified with the doctor's coat performed better than those students who wore the painter's coat.

I remember once during residency at the Naval Medical Center in San Diego several years ago a fellow resident asking me why I was wearing a lab coat in clinic over my Navy uniform.  I responded, "Because I am a doctor."  I do think that there is something to this concept known as "enclothed cognition".  I do think that we should all be "dressing for success".  Regardless of our own opinions, the clothes that we wear do have an impact, not only on how we feel, but how we are perceived by others.  I can't help but wonder how the recent trends towards a "casual workplace" have adversely impacted how different professions are perceived.  

"What does not kill me makes me stronger..."

Long before American pop singer Kelly Clarkson said it, the 19th century German philosopher Friedrich Nietzsche said "What does not kill me makes me stronger."  Whenever I hear this quote, my mind goes back to my high school Physical Education teacher, who first taught me "the principle of progressive overload".  Simply stated, if you want to get better at anything, you have to push yourself past your zone of comfort.  For example, if you want to build up your muscle strength so that you can increase your maximum bench press, add 5-10 pounds to your bench press work-out every few days.  Alternatively, if your goal is to run a marathon, start out with running one long run every Saturday and add 1 mile every week.  Slowly but surely, over time, you will build up your muscle strength (so you can bench press a couple of hundred pounds) or increase your stamina to the point where you can run that marathon.

Not surprisingly, "the principle of progressive overload" applies to more than just sports and exercise.  If you are afraid to speak in public, you have to challenge yourself by actually starting to speak in public.  You should start out with something relatively short, maybe giving a toast at a dinner with friends.  As you gain confidence and with further practice and experience, you can eventually challenge yourself with a speech in front of a small crowd.  

The same principle applies to leadership.  Sarah Horn starts off her recent article for Forbes magazine, "Why Discomfort Builds Better Leaders" by stating, "In today’s hyper-optimized world, comfort and convenience are often prized. But in doing so, we may evade the very experiences that enable deep leadership growth...Uncomfortable or challenging experiences teach leaders to perform under pressure, nurture teamwork in adversity, and recover quickly after failure.  This creates a virtuous cycle: mastering setbacks builds confidence and resilience, which enables faster progression and greater impact, which in turn attracts more growth opportunities."

Horn references a study by Kaitlin Woolley and Ayelet Fishbach, published in the journal Psychological Science ("Motivating personal growth by seeking discomfort").  Over two thousand study participants participated in five studies in which they intentionally and actively sought out personal discomfort - by taking improvisation classes, engaging in creative writing, or even exploring alternative political viewpoints.  These study participants consistently reported greater perceived goal achievement, engagement, and personal long-term growth.  

Horn writes, "Leaders who cognitively engage with discomfort learn to understand their limits, recognize their triggers, and manage their responses when stakes are high."  When they push and challenge themselves beyond their personal zone of comfort, they learn how to deal better with uncertainty, anxiety, and fear.  She continues, "The key is intentionality. Hardship does not automatically create better leaders. However, deliberately chosen challenges – whether physical, emotional, or intellectual – can strengthen neural pathways that serve leaders in high-stakes situations."

Rather than being afraid to challenge ourselves, we should embrace the opportunity to push ourselves and learn, grow, and develop.  When we take risks and move out of our own personal comfort zone, we will likely fail.  But when we fail, we learn, grow, and develop into better leaders.  Even if she didn't say it first, Kelly Clarkson maybe said it best, "What doesn't kill you makes you stronger!"

The Siren's Call

Earlier this year, my wife and I attended a lecture by Chris Hayes, Emmy Award-winning host of "All In with Chris Hayes" on MSNBC.  Hayes was touring in support of his new book, The Siren's Call: How Attention Became the World's Most Endangered Resource.  I've never actually watched Chris Hayes, but I thought he was a good speaker.  I ended up reading the book, which I also enjoyed.  He wrote an article based, in part, on his book for The Atlantic, "You're Being Alienated From Your Own Attention".  Hayes claims that "Attention is a kind of resource: It has value, and if you can seize it, you seize that value."  He goes on to suggest that "Every single aspect of human life across the broadest categories of human organization is being reoriented around the pursuit of attention."

The Canadian-American journalist Robert MacNeil was perhaps best known for co-founding (with fellow journalist Jim Lehrer) the public television news program, the MacNeil/Lehrer News Hour, which aired from 1975-1995 (the show has since been renamed the PBS News Hour).  MacNeil wrote an essay in 1993 entitled "The Trouble with Television" (you can find it relatively easily on the Internet).  He raises many of the same issues that Neil Postman wrote about in his book Amusing Ourselves to Death: Public discourse in the Age of Show Business, which I discussed in a recent post (see "Amusing Ourselves to Death...").  

MacNeil wrote, "The trouble with television is that it discourages concentration.  Almost anything interesting and rewarding in life requires some constructive, consistently applied effort...but television encourages us to apply no effort.  It sells us instant gratification.  It diverts us only to divert, to make the time pass without pain...In short, a lot of television usurps one of the most precious of all human gifts, the ability to focus your attention yourself, rather than just passively surrender it."

There is a fight for our attention.  And we are losing.  Hayes writes, "Those who successfully extract it [attention] command fortunes, win elections, and topple regimes.  The battle to control what we pay attention to at any given instant structures our inner life - who and what we listen to, how and when we are present to those we love - and our collective public lives: which pressing matters of social concern are debated and legislated, which are neglected..."  

I've caught myself in the past "doom-scrolling" through various social media sites and wasting precious time that could have been better spent on a more productive activity.  I started to find that a lot of what I was reading was garbage, which prompted me to quit both X and Facebook a few months ago (see my post "Liberation").  

I think I agree with most of the arguments that Chris Hayes makes in his book.  He admits that his job is to capture our attention, and certainly most (if not all) media today is all about capturing attention.  Like Hayes, I'm not sure that there is a straightforward and easy fix to this dilemma.  We've been traveling down this road for quite some time (hence the article by Jim Lehrer that appeared over 30 years ago).  I think the first step is to recognize and clearly state the problem, if any, that we are needing to solve.  Once the problem is recognized, the next step is to begin a frank dialogue about the problem itself.  Once there, we can start talking about potential solutions.

Has Gen X lost out when it comes to the C-suite?

The Wall Street Journal columnist Callum Borchers wrote an interesting article a few days ago entitled, "The Gen Xers Who Waited Their Turn to Be CEO Are Getting Passed Over".  It's well worth a read on your own, but the very first sentence in the article summarizes Borchers' point perfectly.  He writes, "When it comes to the C-suite, Gen X might be doomed to live up to its "forgotten generation" moniker."

Apparently, there are two trends happening simultaneously in the corporate world.  First, baby boomers are working past the traditional retirement age and staying on in their current leadership roles in the C-suite.  For example, 41.5% of chief executives of companies in the Russell 3000 are at least 60 years of age or older, which represents an increase from 35.1% in 2017.  As Borchers explains, many organizations have played it safe in recent years, particularly during and immediately after the COVID-19 pandemic, by either keeping their current CEOs in place or hiring experienced and/or well-established (read "older") CEOs.

Second, given the rapidity of technological change, especially with advances in computing and, in particular, artificial intelligence, companies are beginning to hire younger CEOs in their 30's and 40's.  Again, by way of example, the share of CEOs in the Russell 3000 in their 30's and 40's increased from 13.8% in 2017 to 15.1% more recently (please see the figure below from the WSJ article). 

As Matteo Tonello from the Conference Board said, "We're starting to see a barbell phenomenon in the CEO role where Gen X is being squeezed in the middle."  Gen X is typically defined as those individuals born between 1965 and 1980.  They are starting to reach their late 50's, an age which, at least historically, many first-time CEOs have been hired.  What's happening instead is that companies are skipping a generation and hiring younger first-time CEOs.  Borchers further notes that Gen Xers are looked upon as skilled tacticians rather than visionary leaders.  They are just not being viewed by Boards as transformational leaders or rising stars with big ideas about what the future could look like.

I've previously commented on the so-called "youth movement" when it comes to head coaches in the National Football League (see my post "Youth Movement").  At that time, I also commented on the growing trend for companies outside of football to hire younger CEOs.  Similarly, Becker's Hospital Review reported last year that the average age of hospital CEOs has decreased slightly over the last decade, but it still remains higher than it was in 2014.  Health care organizations are subjected to the same challenges and trends that companies in the Russell 3000 encounter, so it wouldn't surprise me at all to see a growing "youth movement" with respect to hospital CEOs.  Whether this is the right or wrong approach is a decision that most hospital boards will have to make in the best interests of their organization.  

Give trust to build trust...

A few weeks ago, I wrote a post entitled "Deference to expertise builds trust..."  What's interesting is that, in at least the way that it is used in the High Reliability Organization (HRO) literature, the word deference has almost the same meaning as the word trust.  Please allow me to explain.

The Merriam-Webster Online Dictionary defines deference as a readiness or willingness to yield to the wishes of others.  By comparison, the word trust is defined in three ways as a verb - first, to give a task, duty, or responsibility to (as to "entrust"); second, to put (something) into the possession or safekeeping of another (as in "to hand"); and third, to regard as right or true (as in "to believe").  However, the word trust may also be used as a noun, as in a firm belief in the integrity, ability, effectiveness, or genuineness of someone or something (as in "confidence") or alternatively, responsibility for the safety and well-being of someone or something (as in "custody").

So, by deference then, we mean are placing our belief, our confidence, and our trust in someone to make the right decisions for their team(s) and organization.  We are entrusting and empowering them with taking responsibility for not only their actions but for the actions of their teams.  We are giving them responsibility, and with responsibility comes accountability.  It follows then, that by entrusting (empowering) others, we are establishing an interdependence that is based on mutual respect and trust.  When we show others that they have our confidence, we in turn increase the likelihood that they will share that confidence by trusting us in return.

If you want an example that perfectly illustrates the concept of "giving trust to build trust", look no further than the "Open Prison" concept in India.  An "open prison" is one in which prisoners serve their sentences with minimal supervision and security.  Think of a prison without walls, towers, and barbed wire.  Prisoners are not even locked up in cells.  They are essentially free to come and go as they please, often leaving the prison to go to a job outside the prison during the day, only to return at night.  In some cases, their families are allowed to stay with them.  

The "open prison" concept started in the late 1950's and early 1960's in the Indian state of Rajasthan, where it remains a popular model today.  As Kavitha Yarlagadda writes (see "India's 'Open Prisons' Are a Marvel of Trust-based Incarceration"), "Designed to foster reform as opposed to punishment, the system is based on the premise that trust is contagious. It assumes — and encourages — self-discipline on the part of the prisoners. On a practical level, letting incarcerated folks go to work also allows them to earn money for themselves and their families, build skills, and maintain contacts in the outside world that can help them once they’re released."  In other words, "trust begets trust".  

Now, what does an open prison in India have to do with HROs?  I think they illustrate a key principle that is foundational to the concept of deference to expertise.  Deference to expertise is built upon mutual trust.  By giving trust, we build further trust.  Just like what happens with the open prisons in India.  "Trust begets trust, which then begets even more trust."  It's a virtuous cycle that leads to high performance teams and high reliability organizations.