Behind every one of us...

I came across a post on social media last week that I thought was interesting.  I was not able to verify that this story was actually true or not, so take it with the proverbial grain of salt.  The story involves Winston Churchill, the legendary Prime Minister of the United Kingdom from 1940 to 1945 during World War II (and again from 1951 to 1955) and his equally legendary spouse, Clementine Churchill.  Among all of the other things she did for her husband throughout their lives together, Clementine once even literally saved Winston's life (see the story here).  Here is the story, copied verbatim from the Internet:

One day, Mr. and Mrs. Churchill were walking through a smart neighborhood in London.  People greeted and exchanged a few words with the Prime Minister.

A street sweeper, however, greeted Mrs. Churchill in particular, and the two stayed aside for a while in familiar conversation.  Afterwards, Churchill asked his wife what had taken her so long to discuss with a street sweeper.

"Oh...he was in love with me once a long time ago," she replied.

Churchill smiled and said, "You see, if you had married him, you'd be the wife of a street sweeper today."

Mrs. Churchill looked at her husband in amazement and said the legendary words:

"But no darling, if I had married him, he would be Prime Minister today."

What a great story!  Leaders often take for granted how much their spouse or significant other influences their success.  I can't imagine where I would be today without my wife's influence, support, advice, and commitment.  Throughout my career, she has been the one person who has always been there for me, through good times and bad.  

Take a moment today (and every day) to thank that one special person in your life who has always been there for you.

"If you don't like problems, stay out of leadership"

Retired Marine Corps General and former Secretary of Defense James Mattis once wrote, "A leader's role is problem solving.  If you don't like problems, stay out of leadership."  Right on!  Of course, problems come in all shapes and sizes, and unfortunately not all problems can be easily, or quickly, solved.

I've read a couple of books and watched several online lectures by the University of Michigan Ross School of Business professor, Scott Page.  He uses a particularly useful metaphor (in my opinion) to describe the different kinds of problems that leaders may face.  The first kind of problem, and perhaps the most easiest to solve, is what he calls a Mount Fuji problem.  Take a look at a picture of Mount Fuji on the Internet (see here).  Mount Fuji is kind of like J.R.R. Tolkien's fictional Lonely Mountain (from his book, The Hobbit) - sorry, I couldn't resist the reference - in that it seemingly appears out of nowhere.  It is the single highest peak in all of Japan with an altitude of just over 3,776 meters, and it is just over 100 km outside of Tokyo and easily visible from there on a clear day.  Consider a problem as a landscape, with the highest peak representing the best, or optimal solution, to that problem. A Mount Fuji problem, with a single, solitary peak, is the most straightforward problem to solve.  

Let's use an example to further explain.  Page refers to a theory known as scientific management (first described by Frederick Taylor in the late 1800's and early 1900's (scientific management is also known as Taylorism - for a more in-depth explanation, please see my previous post A response to "Medical Taylorism").  In one of Taylor's classic problems, he was asked to find the optimal weight of a shovel.  At one extreme, you can use a stick, which is not very useful.  The amount of material you can pick up and move with a stick is very small (almost zero).  As you increase the size of the shovel, you can increase the amount of material that can be picked up and moved.  However, at some point, the shovel becomes heavier to lift, and the amount of material that can be picked up and moved actually decreases.  Graph this out on a chart (the x-axis is the size of the shovel and the y-axis is the amount of material that can be lifted and moved) and whola - you will see an almost perfect rendition of Mount Fuji.  To use Page's metaphor, Mount Fuji problems can be solved with the principles of scientific management.  Observe.  Measure.  Improve.  Repeat.

Unfortunately, not all problems are Mount Fuji problems - in fact, very few problems these days are Mount Fuji problems!  And most mountains aren't like Tolkien's Lonely Mountain, they are part of a mountain range.  So now we move to Page's Rugged Landscape problem.  Think of the Rocky Mountains or Appalachian Mountains.  Here you have several peaks and valleys, so finding the highest peak (which is analagous to the most optimal solution to the problem) is much more difficult.  Finding the solution to these kinds of problems often require a higher level of mathematical analysis (using my own analogy, if Mount Fuji problems can be described using a simple linear equation or binomial equation, Rugged Landscape problems often require polynomial equations with a much larger number of variables).

What makes a landscape "rugged"?  Usually these kinds of problems involve multiple variables.  I'm thinking right now of one of my business school classes on operations management (operations engineering) - think of your classic optimization problem (see this YouTube video for a really good explanation of this kind of problem).  Many of these problems involve literally hundreds of variables and complex mathematical formulas (think multiple regression on steroids), simulations (e.g. Monte Carlo simulations), and /or methods such as linear programming.  You don't have to know anything about these techniques and tools, but just realize that these kinds of problems can be solved for the best possible solution.  

Unfortunately, even with all of these techniques to solve Rugged Landscape problems, we are left with the simple fact that most problems are what Page refers to as Dancing Landscape problems.  Here we have a rugged landscape (again, think of the Rocky Mountains with multiple peaks and valleys) that changes from moment to moment - it literally dances!  We can use the tools and techniques of operations engineering to find the optimal solution to a problem, even one as complex as finding the right flight schedule that maximizes profits for an airline company (there are numerous examples and published articles on this topic available online, but I particularly like this 1990 article from the Chicago Tribune).  The important point that these optimization problems tend to neglect, however, is that there are other airlines that are trying to maximize their profits at the same time!  In other words, if Delta starts a new flight route from Chicago to San Francisco, United may do the same thing to compete with Delta!  The choices one company makes to maximize profits may cause (and frequently does) its competitors to act to maximize their own profits.  Dancing Landscapes add a whole new dimension to the Rugged Landscape problems, and as a result, they are almost impossible to find the best optimal solution.  

There are other analogies (which I will discuss in a future post) on the kinds of problems that leaders face, but I particularly like this one by Scott Page.  His area of expertise is in something known as complex adaptive systems, which is a fascinating area that encompasses Chaos theory, Systems theory, Complexity theory, and Network science, among many others.  If you are interested in just an introduction to this fascinating area of science, particularly as it relates to leadership and management, there are a number of free online courses provided by the Sante Fe Institute.  What is clear after this discussion (at least I hope it's clear), is that we live in a world today where simple decisions for leaders are no longer the norm.  It would seem appropriate for leaders to learn more about how we can make better decisions in a world full of complex adaptive systems.  And if you don't like solving these kinds of problems, it's probably best to get out of leadership!

How groups can make better decisions...

Several months ago, I read a really good article in Harvard Business Review called "Begin with Trust" by Frances X. Frei and Anne Moriss.  While the entire article is just outstanding, one of the statements really piqued my interest.  I've had the article in a stack of papers on my desk, just waiting for the time to dig in a little deeper.

Here is the passage that I wanted to learn more about (with my own editorial comments in brackets):

Diversity can be a tremendous asset in today's marketplace, and the companies that get it right often enjoy powerful competitive tailwinds [Okay, I've heard that and the research that I've seen definitely backs up that statement].  

But this advantage isn't automatic.  Simply populating your team with diverse perspectives and experiences doesn't always translate into better performance [Interesting...please tell me more].

In fact, the uncomfortable truth is that diverse teams can underperform homogenous teams if they're not managed actively for differences among members [Whoa - now I need to read more].

The authors are referring to something known as the common information effect.  Basically, whenever we are in a group (defined as two or more individuals), we tend to focus primarily (and at times, exclusively) on things we have in common.  Allow me to illustrate with an example.  Say there are three employees working in a group (#1, #2, and #3).  The group has been tasked with hiring a new employee for the team.  There are four candidates - A, B, C, and D.

All three employees interviewed the three candidates.  However, let's look at two different scenarios.  In the first scenario, each employee  knows as much about the three candidates as the other two.

Worker #1 - A, B, C, D

Worker #2 - A, B, C, D

Worker #3 - A, B, C, D

In other words, the collective information about each candidate is shared equally amongst the three employees.  In a perfect world, this would always be the case, but unfortunately we do not always have equal access to information as in this scenario.  From a decision-making standpoint, however, the group should be able to come to a collective decision, as they all have the same knowledge of each candidate.

Let's look at the more realistic case, where each employee knows something unique about one or two of the candidates, through either personal experience working with that candidate in the past or through a recommendation from a trusted colleague or friend.  Here is the breakdown of knowledge in this scenario:

Worker #1 - A, B, C

Worker #2 - B, C

Worker #3 - C, D, A

In this second scenario, information on candidate C is shared by all three workers, information on candidates A and B are shared by two workers, and only one worker (#3) has any personal knowledge or history with candidate D.  According to the common information effect, the group of workers will spend the most time talking about candidate C and the least amount of time on candidate D.  They will likely spend some time talking about candidates A and B, but it will be less than the time they spend on candidate C.

The four candidates in the first scenario, in which the group of workers is less diverse in their experience with the four candidates (they all share equal knowledge), will likely have the same chance of being discussed by the group during the hiring process.  However, where the group of workers are more diverse (different background knowledge on each candidate), the discussion will be skewed more heavily towards candidates A, B, and C, with candidate C likely receiving the most attention.

I've never really thought about the common information effect, but as I read more about it, it makes sense.  And I've perhaps witnessed examples of this group bias in my own experience.  The natural follow-up question is this - what can leaders do to avoid falling into the common information trap?  Surprisingly, increasing the size of the group only tends to make the common information effect worse!  A laboratory-based study based upon the exact model that I described above (in this case, groups of undergraduate students were selecting a class President), the three-person group discussed 46% of the shared information but just 18% of the unshared information.  Adding 3 more members to the group made this difference even worse.  

So, if increasing the size of the group doesn't mitigate the common information effect, what does help?  First and perhaps most importantly, team leaders have to be aware of the common information effect (and other group biases) and should monitor and manage the flow of information during group discussions.  Similarly, leaders should make sure that everyone has a chance to speak up and participate.  Studies have shown that in a five-person group, two people do more than 60% of the talking!  Even in larger groups, a minority of the participants do most of the talking (in a six-person group, three people do 60% of the talking, while in an eight-person group, four people do 80% of the talking!).  

Second, team leaders can help mitigate the common information effect by considering each alternative one at a time.  Using our scenario above, rather than asking a generic question at the start of a meeting ("Who did you like best?"), the team leader could make sure that the group discusses each candidate at the start.  Giving equal time to each candidate would help draw out more information on each one, particularly in the second scenario where not everyone shares equal information on the candidates.

Third, back to the article ("Begin with Trust") by Frei and Moriss, teams that are familiar with one another and, more importantly, trust one another typically make better decisions and avoid the common information effect.  One way to build trust is to flatten the hierarchy.  Team leaders should try to minimize status differences between individual members of the group - one of the best ways to flatten the hierarchy is to refer to each member by his or her first name, avoiding the use of titles as much as possible.  

Lastly, a meta analysis of 94 studies involving over 5,500 groups suggested that teams that met virtually, as opposed to face-to-face, were less prone to the common information effect.  In other words, holding a virtual meeting increased the sharing of unique information!  Given what we have learned over the course of the pandemic with holding most meetings virtually, I found that surprising!

Clearly, I have a lot to learn about how groups can work together more effectively.  It's not something that is taught in medical school for sure, but at least in my personal experience, it was not taught in business school either.  Given the importance of group dynamics in almost every aspect of medicine today, perhaps we should rethink how we prioritize and teach how to work well in groups?

Be like the Sequoia

As I mentioned in a recent post, my wife and I recently took a trip for our wedding anniversary.  Our typical vacations usually involve a lot of sitting on a beach and relaxing with a good book or two, but this time we checked out some great places to visit in Northern California.  One of the most impressive things we saw were the Sequoia trees in both Yosemite National Park and Muir Woods.  The term Sequoia actually refers to a genus of trees which includes both the Giant Sequoia (which I think is what we saw in Yosemite) and the Coast Redwood (which I think is what we saw in Muir Woods).  Regardless, these trees are massively beautiful and awe-inspiring!

The sequoia trees (here referring to both species) are massive - they grow to an average height of between 150-300 feet and trunk diameters approaching 25 feet.  The famous General Sherman tree living in Sequoia National Park is the largest currently living tree at 275 feet in height and 25 feet in diameter (at height - it's close to 37 feet in diameter at the base).  During our trip, we learned two fascinating things.  First, despite the fact that the sequoia trees are massive, the seed cones are surprisingly small relative to the size of other seed cones (see the photo below - the sequoia seed cones are on the right):

So, out of something very small comes something incredibly big!  Here we have a powerful metaphor for what has been said so many times in the past.  T.E. Lawrence famously said (at least he said it in the 1962 movie, Lawrence of Arabia starring Peter O'Toole in the title role), "Big things have small beginnings" (at the time referring to the impact of a small army of Bedouins in the war against the Turks).  The ancient Chinese philosopher, Confucius said, "The man who moves a mountain begins by carrying away small stones."  The ancient Greek statesman and orator, Demosthenes, said "Small opportunities are often the beginning of great enterprises."  The American writer, Mark Twain, said, "The secret of getting ahead is getting started.  The secret of getting started is breaking your complex overwhelming tasks into small manageable tasks, and starting on the first one."

All of these quotes - and the story of the Giant Sequoia that begins with the tiniest of seed cones - are a powerful metaphor for leadership.  Even the biggest problems that seem like they will be impossible to solve can be broken down into smaller (and presumably easier to solve) steps.  Just as relevant, one person can have a tremendous impact.  As leaders, we have the opportunity and the privilege to help others and make that impact.

The second thing that we learned about the sequoia is that despite the height and girth of these trees, their root systems are surprisingly quite shallow.  As a matter of fact, they are so shallow that Muir Woods built an elevated wooden path around its redwood grove and the Yosemite park rangers ask that visitors not walk off the trial, so that these fragile root systems are not disturbed.  Apparently the roots only go about 6 to 20 feet deep into the ground before spreading out over an area of 200 to 300 feet.

Even more impressive is that these trees are so tall, and despite the shallow root system, they rarely fall over (e.g. with heavy winds).  Apparently, these trees share their root systems with one another!  As John Maxwell said, "Beneath the surface of these humongous, tall, statuesque trees are roots like a army of men who have their arms interlocked, standing and supporting each other. They are preventing the adversaries of life from knocking each other down. They are also making sure there is plenty of nutrients for growth to continue."  What an amazing metaphor!  We are stronger together than we are alone.  As the old African proverb says, "If you want to go far, go together!"  

We had a great time in Northern California.  And we learned a lot about the Sequoia trees - and like many things in life, there were lessons there in leadership!

The power of negative online reviews (?)

My wife and I recently booked a trip for our wedding anniversary (more about that in a future post).  We were checking out several online reviews of the hotels at our desired location.  There were a number of negative reviews which involved almost every single hotel we considered!  Most of these negative reviews were very recent (within the last month), and almost all of the reviews were focused on the timeliness and/or quality of service.  Some of the reviews seemed almost inappropriate or way over the top.  When you factor in that almost every industry right now, but especially the restaurant and hotel industry, is short-staffed due to lay-offs and cut-backs during the early COVID-19 pandemic, it seems that some of these reviews were a little unfair.  My wife and I ended up ignoring most of them, and we looked at the older reviews instead.

As it turns out, our anecdotal experience here has a solid foundation in research.  Psychologists call it the "just world" theory, which is a cognitive bias that the world is fair and that people will get what they deserve in life.  Applied to the current situation, we felt that the hotels were being treated unfairly - the guests who provided overly negative reviews weren't taking into consideration that these hotels were likely understaffed to deal with the increased demand for rooms and service.

Business leaders - including those of us in health care - have to manage negative reviews all the time. Studies show that more than half of all consumers refer to online reviews ("word-of-mouth" communication) before making a purchase, and three-fourths of consumers say that they trust an online review just as much as a personal recommendation from someone who they know.  And while positive reviews are great, negative reviews tend to be more impactful.  

But, what happens when these reviews are unfairly negative?  A group of studies ("Negative reviews, positive impact: Consumer empathetic responding to unfair word of mouth") published recently in the Journal of Marketing provides some answers.  In one of these studies, the investigators randomized 223 graduate students to read one of three online reviews from the same fictional company.  The reviews involved the timeliness of getting an answer from the company on a service query.  In the positive review, the customer was answered within 24 hours, while in the negative/fair review, the customer had to wait two weeks for a response.  However, in the negative/unfair review, the customer complained about not getting a response, even though it was Christmas Eve.  

What the investigators found might surprise you, but it does seem consistent with the anecdote I shared at the beginning of this post.  Study subjects who read the negative/unfair review were just as likely to say that they would purchase the product from the company as the subjects who read the positive review!  In subsequent experiments, the investigators made the negative reviews even more unfair - in these cases, the subjects were more likely to purchase the product than even those subjects in the positive review.

In other words, consistent with the "just world" theory, fairness matters.  Even if an organization receives a negative online review, it may not be the end of the world.  If the review is unfair, it may actually result in a positive gain for the organization.

I don't necessarily want to make this post about online reviews of physicians or hospitals.  However, one of the biggest concerns I hear about publishing patient/family experience scores or reviews online is that they may be unfairly negative.  It would be interesting to know if this "just world" theory applies to online physician and hospital reviews as well.

"Does leadership matter?"

We spend a lot of time reading and talking about leadership.  Just conduct a random search on Google or Amazon using the key word "leadership" and you will get an idea of just how much time we spend on reading or talking about leadership.  The natural follow-up question is whether all this reading and talking about leadership makes any difference.  In order to answer that question, we first need to ask, "Does leadership matter?"  At least in regards to health care, the answer to this particular question appears to be "Yes!"

A group of investigators at the University of Surrey School of Economics (Shimaa Elkomy, Zahra Murad, and Veronica Veleanu) published the results of a study ("Does leadership matter for healthcare service quality?") involving the National Health Service in England in the International Public Management Journal.  They determined the overall quality of leadership in 152 hospitals during a 5-year period from 2010 to 2014 using a previously validated leadership framework.  The quality of clinical care at each hospital was assessed using staff-rated quality of care ("How likely are you to recommend treatment here?"), patient-rated quality of care (based upon patient/family experience data), and clinical quality (age-standardized hospital mortality rates within 30 days of emergency surgery).  

Using what I like to call "fancy statistics" (multiple regression analysis), they showed convincingly (at least in my mind - read the article and judge for yourself) that the quality of leadership significantly and positively affected staff-rated quality of care, patient-rated quality of care, and clinical quality!  In other words, leadership matters!

Health care is going through a critical time right now.  The challenge of the COVID-19 pandemic has certainly affected all of us, but it has hit the health care industry particularly hard.  The pandemic has also illustrated, quite effectively, that having the right leader in place makes all the difference.

There are also a number of studies suggesting that hospitals with clinically trained executives generally perform better than those who do not have leaders with a clinical background.  I've posted about these studies in the past (see "My shoes are brown and those are wings of gold on my chest!"), so I won't repeat myself here.  Elkomy, Murad, and Veleanu also do a good job of reviewing the literature that consistently shows superior performance (clinical as well as financial) when hospitals are led by executives with clinical backgrounds.

I believe, and most of the relevant studies would support, that leadership can be taught.  Given then that (1) leadership has a positive impact on clinical quality, (2) hospitals do better when clinicians are leading them, and (3) leadership can be taught, we should spend more time talking about how to build up the leadership skills in our clinical workforce.  We need strong leadership at all levels of the organization - to borrow a phrase from Elkomy, Murad, and Veleanu, "Boards to Wards" leadership.  As we emerge (and despite the recent trends, we are still doing better now than at the start of the pandemic) from COVID-19, we should look again at how much time and money we are investing for leadership development.  With all of the concerns about our health care system, it seems like it would be a great investment!  

"A fox knows many things, but a hedgehog knows one big thing..."

I've been pretty hard on experts as of late.  Actually, to be more precise (maybe like an expert?!?!), I've been hard on experts who try to predict the future.  I've been writing for the past couple of weeks or so on Philip Tetlock's book, Expert Political Judgement in which he discussed the results of his 20-year study on forecasting (for a description of the book, see my post Dart-throwing monkeys or check out Louis Menand's review in The New Yorker).  Tetlock found that experts weren't all that good at forecasting the future.

Here's the part where I totally contradict everything I've said so far.  I am only kidding.  Taken as a whole, Tetlock's experts weren't very successful at forecasting future events.  However, he did find that there were some experts that were more successful than others - or perhaps it's better to say that some experts weren't as bad as the others!  He divided his group of experts into hedgehogs and foxes, based on the philosopher Isaiah Berlin's 1953 essay, The Hedgehog and the Fox.  Berlin's title is in turn borrowed from the ancient Greek poet,  Archilochus who wrote that "A fox knows many things, but a hedgheog knows one big thing."  As an aside, the management guru Jim Collins also borrowed from Berlin and Archilochus when he developed his own hedgehog concept in his book, Good to Great.  

Okay, back to Tetlock.  Tetlock describes hedgehogs as follows:

...thinkers who "know one big thing," aggressively extend the explanatory reach of that one big thing into new domains, display bristly impatience with those who "do not get it", and express considerable confidence that they are already pretty proficient forecasters, at least in the long term.

Conversely, Tetlock described foxes as:

...thinkers who know many small things (tricks of their trade), are skeptical of grand themes, see explanation and prediction not as deductive exercises but rather as exercises in flexible "ad hocery" that require stitching together diverse sources of information, and are rather diffident about their own forecasting prowess.

Importantly, Tetlock's hedgehogs performed worse in those areas in which they specialized!  He did find that when hedgehogs did make a correct prediction (which again was rare), they were spectactularly right!  They predicted really rare and at times society-changing events.  Tetlock further elaborated on these themes in his most recent book, Superforecasting.

So what's the take-home message here? First, remembering The Linda Problem, we should all spend more time learning about probability and statistics.  Second, perhaps we should all be more like foxes and less like hedgehogs.  Tetlock describes a few lessons on how to be a better fox:

1. Don’t believe the world can be explained by one or two ideas. Reality is more complex.

2. When forming judgments, consult a diverse range of sources.

3. As the facts change, change your mind.

4. Question that on which everyone seems to agree

All in all, excellent advice.