Castles and Bullet Holes

I want to conduct a quick thought experiment.  Please indulge me for a moment.  Close your eyes and picture in your mind a European Medieval castle.  Now describe it for me out loud (and pretend I can actually listen).  How did you describe it?  Chances are that you told me that the castle was made out of stone.  Your castle probably had towers and parapets, and there's a good chance that it had a drawbridge and a moat too.  Here's the interesting plot twist.  The kind of castle that you described was actually not very common during the Middle Ages.  As a matter of fact, most castles were made out of wood!

The so-called Motte-and-bailey castle is a fortification consisting of a wood (most commonly) or stone structure built on a raised area of ground (the motte), accompanied by a walled courtyard (the bailey) and surrounded by a protective ditch and palisade.  They were first built in the 10th century and were first introduced to England and Wales following the Norman invasion of 1066.  Most of the castles that were built in the Middle Ages have not survived to the present day.  Only the ones made out of stone have survived.  As such, when we think of castles today, we almost always think of the ones built out of stone.  It's a cognitive bias known as survivorship bias, a form of selection bias in which we tend to concentrate on the people or things that made it past some selection process (e.g. the stone castles) and overlook those that did not (e.g. the wooden castles).

There's another well-known example of survivorship bias from World War II.  Abraham Wald was a mathematician working at Columbia University during World War II.  Wald and his team of mathematicians were trying to determine how best to prevent U.S. airplanes from being shot down.  Engineers could add steel armor plates to the airplanes to protect the pilot and crew and other vital areas of the plane, but the problem was that steel armor plates also made the airplanes heavier and slower to fly.  Wald's team was tasked with figuring out where to strategically place the armor plates so as to keep the planes from getting shot down without sacrificing speed, which clearly was also important.

Wald's team examined the damage done to all of the airplanes that returned at the end of a mission.  These airplanes were often riddled with bullet holes, so Wald's team determined where the bullet holes were concentrated the most.  Here is what they found (the plane's location is on the left, the concentration of bullet holes, in terms of the number of holes per square foot, is on the right):

Engine                    1.11

Fuselage                 1.73

Fuel system            1.55

Rest of the plane    1.80

The team reviewed data that looked something like this:

At first glance, the military engineers recognized an opportunity to maximize protection without sacrificing speed, thinking that they could get the same protection with less armor if the armor was concentrated on the places with the greatest need, i.e. where the planes were getting hit the most.  Abraham Wald disagreed.  He told the military engineers that the armor plates don't go where the bullets are but where they are not.  He recognized that the military engineers were making a mistake due to survivorship bias.  Rather than focusing on the actual bullet holes, Wald suggested that it was the missing bullet holes that were most important.

It didn't make sense to Wald that the bullet holes would be concentrated in different parts of the plane.  They should be distributed evenly.  So where were the missing bullet holes (the ones that should have been on the engine casing if the damage had been spread equally all over the plane)?  Wald suggested that the missing bullet holes were on the missing planes - the ones that didn't make it back. The reason planes were coming back with fewer hits to the engine is that those were the planes that didn't make it back.  The large number of planes returning to base with most of the bullet holes concentrated on the fuselage was really solid evidence that hits to the fuselage weren't likely to cause the plane to crash.  Hits to the fuselage could therefore be tolerated.  In other words, the armor plates go where the bullet holes are not - on the engine casing!

There are many more examples of survivorship bias.  We should recognize and remember that the survivorship bias is a statistical artifact - in other words, we should ignore it.  The next time someone tries to imply that a correlation between an observation and an outcome implies causality, we should look for evidence of the survivorship bias.  Chances are that we will find it.  And then we will remember about castles and bullet holes.  

"I think I literally have a better understanding of who killed Kennedy than what is offside."

Okay, thanks once again to COVID-19, my wife and I binge-watched another television series this past week!  We just happened to be watching the Golden Globes for a brief hot minute last weekend when actor Jason Sudeikis won the Golden Globe Award for Lead Actor in a Comedy or Musical Series.  We decided to give the show a watch, and exactly one week later, we are eagerly anticipating the hopeful release of season two!

Sudeikis plays the lead role in the Apple TV + television series, Ted Lasso.  Lasso is an American football coach (who recently won the Division II NCAA College Football National Championship for the Wichita State Shockers) who is hired to coach for AFC Richmond, an English Premier League football team.  The key point here is that while he was a successful coach of American football, he knows absolutely nothing about what those of us in the United States call soccer (and what everyone else in the world calls football).  The idea for the series came out of a series of television promos for NBC Sports' coverage of the English Premier League.

What's interesting to me is that Lasso actually exhibits several key characteristics of great leadership.  Now I will admit, there is probably zero chance that an American football coach who knows nothing about soccer could be successful in the English Premier League.  At the end of the day, domain-specific or technical expertise is fairly important.  However, just as important to the success of any leader are the soft skills of leadership.  I have commented on this topic a few times in the past (see, for example, "Cool Runnings" or "My shoes are brown and those are wings of gold on my chest").  

It's actually a question that comes up a lot.  For example, Amanda Goodall and colleagues published results that suggest that the best hospitals are managed by doctors.  Goodall has also published a study ("Why do leaders matter? A study of expert knowledge in a superstar setting") that suggested that NBA teams who are coached by former NBA players are more successful than the ones who are not coached by former players.  More importantly, Goodall and her colleagues also found that NBA teams who are coached by former NBA All-Stars are particularly successful.  Dr. Goodall has also published the results of a study ("Do economics departments improve after they appoint a top scholar as chairperson?") suggesting that academic departments (in this case, economics departments) do better when the chair of the department is a successful academician (in terms of research productivity, as measured by grant funding and number of publications).  Collectively, these studies, which in fact are only a few examples (there are several more examples here), strongly advocate that technical expertise is very important for success in a leadership position.  In other words, Dr. Goodall and her colleagues would argue that Ted Lasso would be a terrible football coach!

So does this mean that someone without technical expertise is doomed to fail?  As it turns out, not necessarily.  Michael Roberto, a former faculty member at the Harvard Business School and currently at Bryant University in Smithfield, Rhode Island would argue that technical expertise is not as important.  In a 2017 blog post ("Are technical experts better leaders?") argued that most NBA championships have been won either by non-players or players who never made the NBA All-Star team).  He followed that post up with a similar analysis ("Do technical experts make better leaders part 2") conducted with NFL head coaches.  At the time of this analysis, the overwhelming majority of Super Bowls had been won by either coaches who were not superstar players.  As a matter of fact, in a more recent post ("Super Bowl coaches, the curse of expertise, and the importance of perspective taking"), he argues the exact opposite - success as a player may, in fact, lead to failure as a NFL head coach.  

Clearly, this is an argument that is far from over.  Ted Lasso is, after all, a fictional character, so we can't make any definitive conclusions about his success or failure as a soccer coach.  What is important to recognize, however, is that the "soft skills" of leadership are just as important!  If you don't put the needs of your team above your own, you are probably not going to be a successful leader.  One of my favorite scenes in Ted Lasso occurs when one of his players makes a mistake on the field.  Coach Lasso recognizes this moment for what it is - a teaching moment.  He pulls the player aside and asks, "You know what the happiest animal in the world is?  It's a goldfish.  It's got a ten second memory.  Be a goldfish."

Coach Lasso recognizes that there is more to life than football (regardless of what one of his players, Dani Rojas says all the time, "Football is life!").  He tells a reporter, “For me, success is not about the wins and losses. It’s about helping these young fellas be the best versions of themselves on and off the field.”  By doing that, he is successful in the end.

"Let us speak no more of this..."

I was having a conversation with someone about a concept known as 5:1 feedback, the concept that (1) there is an ideal praise-to-criticism ration and (2) that ratio is 5:1.  I've posted about this concept before (see Gratitude).  Providing feedback well is a critical leadership skill (see also, Real leaders say "thank you" a lot... and Magical Feedback).  But what is so special about 5:1 feedback?  Let me explain by talking about one of my favorite movies, the 1993 film Gettysburg based on Michael Shaara's superb historical novel, The Killer Angels. 

There is a scene about half way through the movie (see "Lee Chews Out Stuart" for the clip).  It's the evening after the second day, July 2 of the three-day battle.  The Confederate Army of Northern Virginia under General Robert E. Lee has invaded the North.  General J.E.B. Stuart commands the Confederate cavalry - one could say that he has been gallivanting around "getting his name in the papers" while the Army of Northern Virginia confronts the Union Army of the Potomac at the Pennsylvania town of Gettysburg.  There have been multiple casualties on both sides, but the battle has not gone well for the Confederates.  It's important to realize that during the Civil War, the cavalry would protect the infantry's flanks and provide intelligence on the whereabouts of the enemy.  Many historians feel that Stuart did not fulfill his responsibilities, which forced the Confederates to fight a battle that Lee would rather have not fought.  

During the scene, General Lee provides a textbook example of outstanding feedback.  He first gives the facts, explaining what Stuart's mission was and why he did not fulfill that mission.  He tells Stuart, "You sir, with your cavalry, are the eyes of this army.  Without your cavalry, we are made blind.  That has already happened once.  It must never, never happen again."

Stuart responds by trying to offer General Lee his sword (basically resigning his commission).  Lee, of course refuses.  He then compliments General Stuart, "You must take what I have told you and learn from it as a man does.  There has been a mistake.  It will not happen again.  I know your quality.  You are one of the finest cavalry officers I have ever known, and your service to this army has been invaluable.  Now, let us speak no more of this.  The matter is concluded.  Good night General."

Criticism followed immediately by praise.  Lee knew that Stuart had made a mistake.  He wanted to make sure that Stuart understood that mistake, but he also wanted him to learn from it.  Lee also knew that Stuart was a very good officer, and he couldn't afford to lose another officer.  So he refused his resignation, he made sure that he softened the blow, and he made his point.  And then he moved on, "The matter is concluded."

It is absolutely one of my favorite scenes in the movie, and it provides a textbook lesson in leadership.  Discipline (which, incidentally, comes from the Latin word discipulus meaning pupil, in other words, to teach or instruct) is about providing positive feedback (i.e. praise).  We should recognize, first and foremost, that all humans make mistakes.  We shouldn't punish individuals for making a mistake - but we should teach them what to do the next time in order to prevent that same mistake from happening again.  Discipline also requires that we hold individuals accountable for bad behavior.  

The whole purpose of 5:1 feedback is to make sure that we have the kind of "just culture" that allows our teams to learn from their mistakes and be recognized when they are doing a good job.  It also allows leaders to correct bad behavior (for example, if someone does not follow standard operating procedures or willfully does something that is widely accepted, such as washing their hands before seeing a patient).  If we are providing praise, it's really difficult to provide criticism.  Five-to-one feedback establishes the kind of psychological safety that we need to build a just culture.

Now, "let us speak no more of this.  The matter is concluded."

"Guitar groups are on the way out, Mr. Epstein."

History is riddled with irony.  Take, for example, the story of the English rock band, The Beatles and the story of how they first "made it big."  The story begins with their long-time manager, Brian Epstein, who tried to set up an audition for his artists with a number of record companies in London in December, 1961.  After multiple rejections, he secured an audition with Decca record executive Mike Smith on New Year's Day, 1962.  The Beatles (which at that time consisted of John Lennon, Paul McCartney, George Harrison, and Pete Best) performed and recorded 15 songs, most of which they had performed in various clubs over the years.  However, the set list also included 3 original Lennon-McCartney tunes.  Decca would ultimately reject the Beatles - one executive (reportedly Dick Rowe, even though he denied it until his dying day) told their manager, "Guitar groups are on the way out, Mr. Epstein."

If you listen to The Beatles Anthology Volume 1, Epstein goes on to tell how he took the audition tapes over to EMI records, where he met producer George Martin, "the man who would produce 20 number one hits by my artists."  Imagine being the individual who said "no" to the Beatles.  It's not exactly known for sure who ultimately rejected the Beatles - it could have been either Mike Smith, Dick Rowe, or producer Tony Meehan, though most contemporary sources suggest it was Rowe.  Which group did Decca records choose instead? The group was called Brian Poole and the Tremeloes (you may have heard their hit, "Do you love me?" which appeared in the 1987 movie Dirty Dancing).  I guess things could have turned out worse - still, there is no comparison between the Tremeloes and the Beatles!

There are other examples in the sports and entertainment world.  Can you imagine missing out on professional basketball player, Michael Jordan, one of the greatest players to ever play the game?  He was drafted third, after Hakeem Olajuwon (drafted number 1 overall by the Houston Rockets) and Sam Bowie (drafted second by the Portland Trailblazers).  Olajuwon had a Hall of Fame career too, but Sam Bowie was plagued by injuries throughout his 10 year career in the NBA and never led his team to a championship.  The Trailblazers already had Clyde Drexler and weren't interested in another guard.

Seven-time Super Bowl winning quarterback Tom Brady was drafted in the sixth round of the 2000 NFL draft.  There were 198 other players that were drafted ahead of him!  I don't know for certain, but there's a good chance that he's outlasted every single one of them, and no one has come close to matching any of his records or championship wins.  

These are just a few examples.  I haven't even talked about some of history's biggest missed opportunities in the business world,  For example, there is the story of how Kodak had an opportunity early on to invest in digital cameras (one of Kodak's own engineers, Steven Sasson, actually came up with the idea - Kodak declined because they felt it would threaten traditional film).  There's also the story of how billionaire Ross Perot had a chance to buy Microsoft in 1979 for between $40 million to $60 million.  The social media company MySpace had an opportunity to purchase Facebook, and the home video store chain Blockbuster could have purchased Netflix and declined to do so.  As I stated at the beginning, history is indeed riddled with irony.  And as it turns out, people throughout history have a lot to say about missed opportunities.

First, when it comes to making a bet on the future, it's a gamble.  It's difficult to predict the future and how things will eventually turn out.  Graydon Carter, editor of Vanity Fair from 1992 until 2017, once said, "History is nothing if not an epic tale of missed opportunities."  And, at times, opportunities are staring us right in the face and we fail to recognize them.  Mark Twain said, "I was seldom able to see an opportunity until it had ceased to be one."  

Second, and perhaps more importantly, these examples should tell us that if we are faced with an opportunity, we should carefully consider it.  "Opportunities of a life-time" don't come often for a reason.  There's a really good chance that if we don't take advantage of an opportunity, someone else will do so.  As Andy Rooney said, "...opportunities are never lost; someone will take the ones you miss."

Third, we shouldn't be afraid that taking advantage of an opportunity will bring change.  Opportunities require investment of time, energy, and resources.  Thomas Edison said, "Opportunity is missed by most people because it is dressed in overalls and looks like work."  

Finally, don't be afraid if you take advantage of an opportunity and find out it was the wrong decision.  We tend to be too worried about failure.  Failure can be costly for sure, but we only learn when we fail.  

Just as important, if you fail to take advantage of an opportunity, learn from that and move on.  The architect I.M. Pei said, "Stop worrying about missed opportunities and start looking for new ones."  Abraham Lincoln said, "I don't really have any regrets because if I choose not to do something there is usually a very good reason.  Once I've made the decision, I don't view it as a missed opportunity, just a different path."

Black Box

If you are a leader who works anywhere in the realm of patient safety, there is a great chance that you are familiar with the commercial aviation industry.  The aviation industry, as a whole, has a safety record that those of us in health care wish that we had!  Commercial aviation is frequently cited as a so-called High Reliability Organization.  In other words, despite the inherent dangers of flying, there are surprisingly very few accidents.  

It's important to distinguish between "error-free" and "accident-free" here.  While the aviation industry has done a great job reducing errors, errors still occur on a daily basis.  As a matter of fact, most studies have documented that errors are made during every single flight.  High Reliability Organizations, like the commercial aviation industry, minimize the impact of the errors that are made, resulting in "accident-free" operations.

Another important distinction is that High Reliability Organizations invest time, money, and resources in order to learn as much as possible when the rare accident does occur.  It seems like every time that a plane has an accident (and again, this is very uncommon), the media starts asking a lot of questions about something called the flight recorder or "black box".  This is actually a misnomer - the flight recorder isn't black.  Instead, it is usually painted bright orange so that they can be easily found after an accident.  There are actually two components to the flight recorder.  The flight data recorder (FDR) records dozens of individual parameters (air speed, pitch, lattitude/longitude, wind speed, etc) several times per second, so that the recent history of the flight is preserved.  Conversely, the cockpit voice recorder (CVR) records all of the sounds (e.g. alarms) and conversations between the pilots and air traffic controllers.  Using the data from the "black box", investigators can determine what exactly happened to the plane and why it crashed.

I actually didn't know this, but after reading about the golfer Tiger Woods' recent automobile accident, I learned that cars now have cars now have data recorders.  They've actually been around for quite some time!  It's essentially the same concept as the "black box" used in aviation.  Investigators can use the data stored by the "black box" to learn how and why an automobile accident occurred.

I know what you're probably thinking.  Is there a health care version of the "black box"?  The answer may surprise you.  With the advent of the electronic health record, we have access to more data than we've ever had - but having access to data is not the same thing as having access to real-time event recorders like the "black box" used in aviation.  I would say that here, health care has a lot to learn from the aviation AND the automobile industry.  We are moving in that direction, but we're not there yet.

Just as important, in my opinion, is having access to a "black box" for leadership.  I'm not talking about having access to second-by-second recordings of everything that is going on around you, similar to the flight recorder or automobile data recorders.  Here, I am talking specifically about taking an in depth look at the decisions you've made, the conversations that you have had with your team, or the presentations that you make to your own supervisor.  Leadership is a constant, never-ending, continual learning process.  John F. Kennedy said that "Leadership and learning are indispensable to each other."  He was absolutely correct.  An important aspect of leadership is learning through reflection and analysis about your own performance.  

Here's an example of what I'm talking about.  Every time that I have the opportunity to go back and watch or listen to a presentation that I have made, I do so.  Just this past Friday morning, I watched myself giving a lecture to our Department of Surgery on - you guessed it - "High Reliability Organizations"!  I took the time to watch specifically to evaluate how I communicated, both verbally and non-verbally.  I wanted to see if there are any points that I made that were confusing.  Finally, I reviewed the slide deck that I used and watched carefully how the presentation flowed (in one case, I glossed over a slide so quickly that I have now taken it out for future presentations on this topic).  

Leaders need a "black box" too.  Take advantage of all the data that you have in front of you to learn how to become a better leader in the future.  Chances are that we will likely never wear a "leadership black box" that records our every decision, but there is a good chance that we will have access to data that can help us become better leaders.  As the American philosopher John Dewey said, "We do not learn from experience, we learn from reflecting on experience."  We learn from our "black box."

"A wise man once said nothing..."

There is an old proverb that goes, "A wise man once said nothing."  The political activist and writer Anne Lamott said, "Lighthouses don't go running all over an island looking for boats to save; they just stand there shining."  Contrary to popular notions of leadership, whether someone is an extrovert or introvert doesn't determine one's ability to lead.  For anyone who has doubts, I would point them to Susan Cain's 2013 book  Quiet: The Power of Introverts in a World That Can't Stop Talking.  I have mentioned this book a few times in the past (see Have you heard about the lemon juice test?).

I've talked about the fact that I was a shy kid in previous posts.  I used to hate being called out in class.  I hated it so much that when I was in first grade, I refused to read out loud in small reading groups.  One of my teachers thought that I couldn't read and placed me in the lowest reading group (see my post "Don't pigeon hole me!").  One day, a new teacher came in and figured out that I was just shy.  She encouraged me in the right way, and I moved to the top reading class very quickly (basically, she figured out that I could read very well, and I moved from group-to-group to the top reading group by the end of the day).  

I will admit that this story provides a great example of how shyness adversely impacted my learning and development.  In other words, someone who is so shy that they don't want to be acknowledged publically or can't speak in front of a group is never going to do well in a leadership position.  That's not my point.  Susan Cain would argue that shyness and introversion aren't necessarily the same thing.  They can certainly co-exist, though whereas shyness is inherently uncomfortable (remember - I "hated" being reading out loud), introversion is not.  Introverts tend to prefer a more quiet, minimally stimulating environment.  They may even prefer to spend their free time reading a book instead of going out to dinner with a large group - this doesn't make them anti-social.  

My point is that most introverts - even the ones who were shy at one point - can function perfectly well in positions of leadership.  Cain lists a number of notable individuals who she describes as introverts - including Abraham Lincoln (arguably one of our country's greatest Presidents), Rosa Parks (whose actions started the Civil Rights movement), and Barack Obama, among many others.  Would you believe that David Letterman and Barbara Walters are introverts?  How about the entrepreneurs, Bill Gates, Steve Wozniak, Warren Buffett, and Larry Page?  All of these individuals have two things in common - they are all introverts and they have all been extremely successful in their professional lives.

If you happen to be an introvert - you are not alone!  More importantly, there is no reason why you, as an introvert, can't develop into a great leader!  Some times, silence speaks volumes.  As the ancient Greek philosopher Plato said, "Wise men speak because they have something to say; Fools because they have to say something."  So when the introverts speak, be sure to listen!

"Leader...ship"

As I've mentioned, one of the side effects of the COVID-19 pandemic - though it's probably more accurate to blame the lockdown - has been the significant increase in binge-watching at our house.  I learned that I really like the television series The Office, which aired on NBC from 2005 to 2013, played again on Netflix, and most recently made its way to the Peacock Network.  During episode 17 (episode 11 of season 2, "Booze Cruise"), regional manager Michael Scott (played by the actor, Steve Carell) said:

Leader… ship. The word “ship” is hidden inside the word “leadership,” as its derivation. So if this office is, in fact, a ship, as its leader, I am the captain. But we’re all in the same boat. Teamwork!

It's a funny quote, but I think there is a lot more to unpack here than what it seems at first glance.  Michael Scott isn't exactly a great leader (see a post from last year, "Is Michael Scott a bad boss?").  While taking your team on a "booze cruise" in lieu of a retreat might be popular, as this episode shows, it's not likely to be effective.  I would argue further that perhaps Michael Scott doesn't really understand what leadership is all about.  In the beginning of the quote, he suggests that leadership is all about being the so-called "captain of the ship" or the "boss."  While there is no question that leadership and management comes with some degree of authority and power, there is a lot more to being a leader than being the "captain" or the "boss."

There used to be a legal doctrine in health care law known as the "captain of the ship doctrine".  Basically, this doctrine was established with a case decided by the Pennsylvania Supreme Court in q 1949 case, (McConnel v Williams), which stated "...it can readily be understood that in the course of an operation in the operating room of a hospital, and until the surgeon leaves that room at the conclusion of the operation... he is in the same complete charge of those who are present and assisting him as in the captain of a ship over all on board."  Essentially, the Pennsylvania Supreme Court said that the primary surgeon is responsible for the actions of everyone else in the operating room, including other surgeons and the anesthesiologist.  This particular legal doctrine has largely fallen out of favor.  More importantly, the complex nature of medical care today, even in the operating room environment, requires a more collective, team-based approach in order to achieve the best outcomes.  While a surgeon is still an important piece of the puzzle (and maybe one of the most important pieces), there is no way that a patient can achieve a good outcome from surgery if the rest of the health care personnel aren't working together as a team.

I think we are long past the concepts such as "women and children first" and "the captain going down with the ship".  These are anachronistic concepts no longer seem relevant in the world in which we live today.  The same holds true for leadership.  And here is where Michael Scott nails it in the second half of his quote - "...we're all in the same boat.  Teamwork."  There is something magical about leading a team that is working together.  For a great read on this subject, I highly recommend General (retired) Stanley McChrystal's book, "Team of Teams".  If you want a book with a more nautical theme, check out "The Boys in the Boat" by Daniel James Brown.  

Most of the time, Michael Scott was a poor leader (and a poor manager).  But every once in a while, he came up with something great.  It is absolutely true that the word "ship" is hidden inside the word "leadership" - it's only meaningful if you apply the analogy that everyone on a team is on the same boat, and in order for the team to achieve its goal, they need to work together.