"Billions and Billions"

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

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

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

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

The 80 hour work week

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

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

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

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

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

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

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

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

L2M

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

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

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

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

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

Be like the Worm...

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

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

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

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

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

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

Turning around the ship...

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

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

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

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

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

The Last Toast

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

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

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

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

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

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

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

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

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

Mike and Mary Anne

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

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

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

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

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

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