It's déjà vu all over again...

The Yankee legend and baseball Hall of Famer Yogi Berra famously once said, "It's like déjà vu all over again!"  It's one of his most famous Yogi-isms, which he said after watching Yankee teammates Mickey Mantle and Roger Maris hit back-to-back home runs during the 1961 baseball season (this was the season that Maris broke Babe Ruth's longstanding record for most home runs hit during a single season).  The phrase is now a colloquialism used when someone is experiencing a situation that feels like an exact repetition of something that happened in the past.

Eric Poon, Andrew Rosenberg, Adam Landman, and Tejal Gandhi published an article this past year that asked whether we are experiencing a "déjà vu" moment with the implementation of artificial intelligence (AI) in health care (see "Déjà Vu? How Might Lessons Learned from Electronic Health Record Implementation Apply to Artificial Intelligence?").  Poon, Rosenberg, and Landman are the Chief Information Officers from Duke University Health System, Michigan Medicine, and Mass General Brigham, respectively, while Gandhi is the Chief Safety and Transformation Officer at Press Gainey.  They offer several recommendations on how we should be applying lessons learned from the widespread adoption and implementation of electronic health records (EHRs) to the implementation of AI in health care today.  

The authors cite statistics showing that the widespread adoption of EHRs have contributed to an estimated $150 billion per year in health information technology spending in the U.S. alone.  That would certainly be okay if EHR implementation was associated with significant improvements in quality of care, patient safety, and clinician productivity, though the results here have been mixed at best.  In addition, the EHR (perhaps unfairly) is often cited as a major cause of burnout amongst health care workers.  Suffice it to say, there are likely some lessons that we can learn from EHR implementation that are translatable to adoption of AI.

The authors first begin with discussing the key differences between the era of EHR implementation and now.  First, the HITECH Act of 2009 provided substantial financial incentives for hospitals and providers to adopt EHRs and included delayed penalties for failing to do so.  These incentives and delayed penalties pushed health care organizations to adopt EHRs in a short period of time.  While some executive leaders are mandating AI adoption and use, to date at least, there have been no federal mandates or incentive programs to do so.  Rather than following the EHR "big bang" approach to widescale adoption, AI implementation could occur in a more phased and flexible manner.  That being said, while EHR implementation occurred in a top-down fashion, the bottom-up adoption of AI could outpace what organizations are actually ready to implement, particularly in the absence of an overall roadmap to help guide AI implementation.  

Second, the overall computer literacy of the health care workforce is quite different today compared to when EHRs were first rolled out.  Technology, including AI, already plays a major role in our personal and professional lives.  For example, smartphones are ubiquitous now - they were much less so back when EHRs were being implemented.  In addition, many health care workers are likely already using AI in some form at home (and in work).  However, while the workforce is likely already facile and comfortable with technology, the levels of burnout amongst health care workers is high enough that they will have diminished capacity and interest to take on additional work.  There is also significant concerns that AI could replace humans when it comes to certain clinical tasks, leading to fears about some clinical jobs being eliminated (I've discussed this topic to some extent recently - see my post, "Is AI going to replace us?").

Third, as I alluded to earlier, the pace of change in regards to AI implementation is likely going to be much faster.  EHR technology evolved slowly over decades, and up until the HITECH Act, implementation was relatively slow and infrequent.  AI technology, in contrast, is proliferating at a much faster pace and has been particularly fueled by interest in industries outside of health care.  

Poon, Rosenberg, Landman, and Gandhi discuss five key lessons learned based on their collective (and extensive) experience and the available literature on EHR and AI implementation:

1. Respect the Human Element

Processes and workflows need to be designed in advance for optimal efficiency and use.  Automating a flawed process will only perpetuate inefficiencies and lead to frustration.  A key lesson from EHR implementation comes from the human factors field - the distinction between work-as-imagined or work-as-prescribed versus work-as-done.  AI systems should be designed so that they are intuitive, user-friendly, and tailored to the specific needs of the end users.

2. Build Strong Organizational Governance

Particularly during the early days of EHR implementation, governance was loose and decentralized.  Robust governance around AI implementation will be crucial so that we do not end up with tools with overlapping and redundant capabilities that interoperate poorly with each other.  The "problem to be solved" should be identified beforehand, rather than bringing in a technology first and finding a problem to be solved later.

3. Adapt Leadership and Culture to Enable Change

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."  I would paraphrase General Mattis slightly, and say that a leader's role is about leading and managing change.  If you don't like change, stay out of leadership!  Upfront investments to prepare both leaders and teams to deal effectively with the rapid pace of change involving AI technology will pay huge dividends in the long-run.

4. Ready the Workforce for an AI-Enabled Future

Many health care organizations failed to invest in computer literacy and typing skills when they made the shift from paper-based medical records to electronic ones.  We should not repeat that mistake.  Health care organizations should invest in AI and digital literacy in order to adequately prepare the workforce and fully leverage the benefits of AI.

5. Avoid Short-term Hype and Build for the Long Term

Remember that it's a marathon, not a sprint.  AI is here to stay.  Health care organizations should commit to measuring the impact of AI implementation.  If an AI tool is not working, these same organizations should be prepared to either modify the tool or move on from it.

"The Science of Talking to Strangers"

This past February, I wrote a blog post (see "Mistakenly seeking solitude") about an interesting study published in the Journal of Experimental Psychology by Nicholas Epley, a social science researcher at the University of Chicago.  The study ("Mistakenly Seeking Solitude") is about twelve years old, though Epley recently wrote about his research in a short article published this past month in the Wall Street Journal (see "The Science of Talking to Strangers").  Of note, Epley just released a new book earlier in May this year, A Little More Social: How Small Choices Create Unexpected Happiness, Health, and Connection.

Epley and his colleague Juliana Schroeder conducted a total of nine experiments, both in the field and in the laboratory setting.  Study participants were Chicago commuter train and public bus riders who were asked to talk to a stranger, to sit in solitude, or to do whatever they normally would do, then fill out a survey to measure how they felt afterwards.  Even though the study participants reported greater well-being when they did engage with strangers, they predicted precisely the opposite pattern of experiences.    Based on the survey results, study participants were reluctant to engage with strangers, because they felt that other people wouldn't be interested in talking.  Again, Epley and Schroeder found that the opposite was the case.  Not only were people open to making idle conversation, they found the experience much more pleasurable when they did, particularly compared to choosing silent solitude. 

In the Wall Street Journal editorial, Epley wrote about his own personal experience on a train commute, in which he reluctantly initiated a conversation with a complete stranger.  He writes:

A woman who looked more than a decade older than I, wearing a fabulous red hat, sat next to me. I put other people in experiments for a living, but that morning I decided to put myself in one. Instead of ignoring my neighbor, I would try to connect in a conversation. My brain immediately shut down the idea: "She doesn’t want to talk; you’ll have nothing to talk about; she’ll probably think you’re a creep trying to hit on her." Nevertheless, I worked up my courage and said, "Hi, my name is Nick. I love your hat. I have one just like it!"

To his surprise, the woman engaged in a full conversation with him for the entire commute, and then she thanked him afterwards.

He writes again:

This conversation wasn’t only good, it was surprisingly good. The gap between my pessimistic fears and my positive experience was massive. That gap also suggested a resolution to the paradox of highly social creatures’ avoiding each other. Social connection isn’t something that just happens to us. It’s a choice we make: to be bold and connect with someone or to hold back and avoid. It may be the most important choice we make routinely because it determines so much of our happiness, health and success. If we’re overly pessimistic about how someone will respond to us, then we might choose to hold back too often.

Interestingly enough, this conversation further prompted Epley's interest and directly led to his research study.  Epley goes on to write that our pessimism about talking to strangers extends beyond simple conversation.  He writes, "Asking for help, performing an act of kindness, giving someone a compliment, expressing your gratitude, or calling an old friend to reconnect is more favorably received than those who are reaching out expect. How much more often would you reach out in kindness if you knew how much good you could actually do?"

He ends his article with a quote from Fred Rogers, who said, "Imagine what our real neighborhoods would be like if each of us offered, as a matter of course, just one kind word to another person."  Imagine indeed.

Why do giraffes have long necks?

One of the things I've learned from studying history is that concepts that fell out of favor in the past never seem to go completely away.  It's a topic that I've discussed a number of times in the past (see "Past is Prologue", "Study the past", "...all of this has happened before", and "The past is never dead...").  As the philosopher, George Santayana famously said, "Those who cannot remember the past are condemned to repeat it."  

Look no further than the concept of Lamarckian Inheritance or Lamarckism, the concept that physical and personal improvements that humans acquire during their lifetime can be passed down to their children in subsequent generations.  The French zoologist Jean-Baptiste Lamarck first proposed the concept describing the inheritance of acquired characteristics in 1809.  Lamarck famously argued that a blacksmith's sons inherit the strong muscles that he acquires from his work as a blacksmith.  

Lamarck's ideas began to fall out of favor with Charles Darwin's theory of evolution by natural selection, first described in his book, On the Origin of the Species in 1859.  Lamarck would say that early giraffes continually stretched their necks to reach the highest leaves in the trees by physically stretching their necks.  The physical stretching caused their necks to grow, which was passed on to as a "longer neck" to subsequent generations.

In contrast, Darwin's theory of natural selection would explain that some giraffes would be born with a longer neck by random chance.  These giraffes would be able to reach more food higher up in the tree.  The longer neck conferred a survival advantage, allowing these giraffes with the longer necks to pass on their genes to subsequent generations, who would in turn have longer necks.  Over time, the giraffes with the longer necks "replace" the giraffes born with the shorter necks.

Lamarckian Inheritance has also been called "soft inheritance" to differentiate from the so-called "hard inheritance" that occurs via the transmission of genetic mutations to subsequent generations.  What's interesting is that we now know that at least some acquired characteristics can, in fact, be passed down to subsequent generations via a mechanism known as transgenerational epigenetic inheritance.  "Transgenerational epigenetic inheritance" describes the process by which environmental factors, such as stress or diet, can affect gene expression in such a way that these changes are passed down to future generations.  More generally, "epigenetics" describes the way that changes in gene expression occur without altering the underlying structure of DNA (basically, the chemical structure of the genes themselves).

I came across a recent report in Nature Reviews Urology that suggests Lamarck may have been at least partially correct, at least when it came to the blacksmiths passing down their strong muscles to their children.  The report comes on the heels of evidence showing that physical exercise can trigger epigenetic changes in muscle that can be passed on to subsequent generations.  In other words, mothers who exercise during pregnancy can pass on some of their overall fitness and health to their children.  The current study shows that fathers can pass on some of the epigenetic changes associated with fitness via their sperm through so-called exercise-responsive microRNA (miRNA), similar to what has been observed with mothers who exercise during pregnancy.  As the authors of the study conclude, "...in addition to well-established maternal influences, paternal exercise before conception can shape the metabolic trajectory of offspring, pointing to the paternal germline as a biologically meaningful conduit of environmental information."

I think there are two points that I would like to make here.  First, once again, we see an older concept, one that was even widely discredited at one point, come back, albeit in a re-packaged form, with new knowledge advances.  It's a common scenario that I frequently encounter both in my clinical practice and in my administrative one.  Second, one can only wonder if we will ever find certain leadership traits passed down from one generation to the next?  I've mentioned a study in the past (see my post, "Once again...are leaders born or made?") that found that genetic factors explained 24% of the difference between individuals in leadership occupancy in a large clinical database (specifically the single nucleotide polymorphism found at rs4950 on the CHRNB3 gene.  Specifically, having one more rs4950 A allele (instead of a G allele) increased the odds of being in a leadership role by 50 percent!  One wonders if we will find certain epigenetic modifications in so-called "leadership genes" that can be passed down from one generation to the next.  It sounds far-fetched now, but then, no one probably ever thought that a study would show that physical fitness can be transmitted to our children either!

"Self-trust is the first secret of success..."

I want to re-visit the book The Speed of Trust: The One Thing That Changes Everything by Stephen M.R. Covey, former CEO of the Covey Leadership Center.  Covey's main argument is that building trust is a key leadership competency that confers a major strategic advantage.  I introduced the topic in a post last November, "Change happens at the speed of trust..."

Covey compares trust to the well-known ripple effect, in which waves start out small at the center and become larger and more powerful as they move and expand outward.  He describes five "waves of trust" to drive home the point that trust begins with oneself and expands outward to relationships, organizations, the market, and society.  I'll cover the first wave of trust today, and I will discuss the remaining waves in subsequent posts.  

The first wave, Self Trust, deals with the confidence we have in ourselves and our abilities.  It addresses our ability to set goals, keep commitments, "walk our talk", and inspire trust in others.  We can't build trust with each other unless we first trust ourselves.  As Jean François Paul de Gondi, who served as the Cardinal of Paris from 1654 to 1662 said, "A man who doesn't trust himself can never really trust anyone else."  The American philosopher Ralph Waldo Emerson said, "Self-trust is the first secret of success...the essence of heroism."

Covey emphasizes that the key to Self Trust is Credibility, which comes from the Latin word root credere, meaning to believe.  He suggests that Self Trust is built on four Cores of Credibility - Integrity (being honest), Intent (having good motives), Capabilities (being competent), and Results (delivering on promises).  

1. Integrity

Integrity is about being honest, both with yourself and with others.  It is defined by the Merriam-Webster online dictionary as the quality of being honest, having strong moral principles, and consistently adhering to ethical standards, regardless of who is watching.  Covey says, "The problem in organizations is that many 'ethics' solutions focus on compliance.  The compliance definition of 'ethics' is not one of integrity or interrelatedness; it is a watered-down, devalued definition that essentially means 'follow the rules'."  Integrity is more than just simply following the rules.  As Alan Greenspan, former Chair of the Federal Reserve of the United States said, "Rules cannot take the place of character."

Covey suggests that there are three components to Integrity - Congruence, Humility, and Courage.  Congruence means that someone acts in harmony with their beliefs and values.  These leaders are authentic - "what you see is what you get" and does not depend upon the situation.  These leaders always do the right thing, even when no one else is watching.  Mahatma Gandhi said, "To believe in something, and not to live it, is dishonest."

The leadership expert Jim Collins talks a lot about a concept that he calls "Level 5 Leadership".  He writes, "These leaders [the Level 5 Leaders] are a paradoxical blend of personal humility and professional will.  They are more like Lincoln and Socrates than Patton and Caesar."  He goes on to say, "Level 5 leaders display a powerful mixture of personal humility and indomitable will. They're incredibly ambitious, but their ambition is first and foremost for the cause, for the organization and its purpose, not themselves."  Confidence is okay - and more than acceptable, we often want our leaders to be confident.  However, Humility is so important that I often combine the two sentiments into one critical leadership characteristic, Confident Humility.  Level 5 Leaders are "humbly confident" (see my post, "The Four C's of Leadership" and "The ignorance of arrogance") - they have the self-confidence to step up and lead, yet they also have the Humility to know that they don't know everything and will seek help when appropriate.  They care more about what is right than being right, more about building the team than getting credit, and more about principles than their own self-interest.

Courage (see my posts, "The Four C's of Leadership" and "Benjamin Franklin's thirteen necessary virtues...") is the last component to Integrity.  Courage is not the absence of fear, but acting despite it. The word Courage derives from the Latin word cor, which means heart.  To say that someone has heart or showed heart is to suggest that they were courageous.  The author Brené Brown said, "Courage is a heart word. The root of the word courage is cor – the Latin word for heart. In one of its earliest forms, the word courage meant To speak one’s mind by telling all one’s heart. Over time, this definition has changed, and today, we typically associate courage with heroic and brave deeds. But in my opinion, this definition fails to recognize the inner strength and level of commitment required for us to actually speak honestly and openly about who we are and about our experiences – good and bad. Speaking from our hearts is what I think of as ordinary courage."  Leaders with Courage "speak their heart" by telling the truth and standing up for what is right, even when it is difficult (or even dangerous) to do so.

2. Intent

According to Covey, Intent encompasses Motive ("your reason for doing something"), Agenda ("what you intend to do"), and Behavior ("what you do").  People will judge you on what you do, rather than what you say.  When a leader's Motive shows genuine concern for others, he or she will build trust.  Similarly, when a leader's Agenda is to find solutions that are mutually beneficial to all, he or she will engender trust.  Finally, a leader whose Behavior acts in the best interest of others will foster trust.  The Prussian philosopher Immanuel Kant said, "In law, a man is guilty when he violates the rights of another.  In ethics, he is guilty if he only thinks of doing so."    

3. Capabilities

Covey uses the acronym TASKS to explain the various dimensions that comprise our Capabilities.  Talents are our natural gifts and strengths.  Attitudes explain our way of viewing events that happen in the world.  Skills are the things that we do well.  Knowledge explains what we have learned, as well as our insight, understanding and awareness.  Finally, Style represents our own unique approach and personality.  A leader's Capabilities are what will build confidence that he or she is competent to do the job of leading.  Remember, at least one side of the "Trust Triangle" is that our teams are confident that we can lead them.

4. Results

Covey says, "My motto is: Whenever possible, finish, and finish strong."  A leader who does not produce results will have no credibility.  Without credibility, there is no trust (see my comment above on the "Trust Triangle").  Everyone - including even ourselves - will judge credibility based on what you have done in the past, what you are producing now, and what you can do in the future.  If trust depends upon delivering on our promises, there's perhaps no better way of doing so than producing the results that we say we are going to produce.

The first wave of trust (there are five total) is perhaps the most important.  Going back to Covey's analogy of the well-known ripple effect, the bigger the first wave, the bigger the ripple!  And if change happens at the speed of trust, the speed of trust depends first and foremost on trusting yourself.  Look out for the remaining four waves of trust in future posts.

Is AI going to replace us?

I am going to avoid using the cliché that "AI won't replace humans, but humans using AI will replace humans who don't use AI", because frankly, I am sick of hearing it.  I've heard a lot about how AI is going to replace a lot of white collar jobs.  It could happen.  But it may not.  

There is ongoing discussion on whether AI will increase productivity at work.  The reporter Sasha Rogelberg wrote an excellent article for Fortune magazine, "Thousands of CEOs admit AI had no impact on employment or productivity - and it has economists resurrecting a paradox from 40 years ago".  The paradox referred to involves an observation by economist and Nobel laureate Robert Solow, who famously said, "You can see the computer age everywhere but in the productivity statistics."  Solow observed that despite massive investments in new technologies - originally personal computers and information technology (IT), and now AI - fail to immediately translate into measurable increases in worker and national productivity.  

Apparently, many economists, including at least one recent winner of the Nobel Prize in Economics, still question whether AI will increase productivity (see the excellent overview on this topic that was published earlier this month in The Wall Street Journal).  I happen to think that implementation of AI will eventually result in increased productivity, but whether or not this will lead to workers being replaced by AI is an altogether different question.

The computer scientist and Nobel laureate Geoffrey Hinton, who some have called "the godfather of AI" advised people to get a job plumbing.  He said, "The jobs that are going to survive AI for a long time are jobs where you have to be very adaptable and physically skilled, and plumbing is that kind of job."  He may be right.  Plumbing is a very hands on kind of job that requires a unique skillset.  I agree with Hinton that plumbers, at least for now, are probably safe!

But what about health care?  Is there ever going to be a time when AI replaces physicians, nurses, and allied health professionals?  I think we are a long way off from that as well.  Anyone who has held the hand of a dying patient or comforted a family member during a medical crisis will understand that there is just no way that AI can replace the empathy and compassion that only a fellow human being can provide.  Will AI replace some of the jobs (and when I say jobs, I am referring to some of the simple tasks that health care workers perform every day, like documenting care in the medical record, reviewing laboratory and/or imaging studies, auditing or reviewing old medical charts, etc) that health care workers perform?  Absolutely!

There are three recently published studies that warrant consideration here.  The first study published in the New England Journal of Medicine (see "MedAgentBench: A virtual EHR environment to benchmark medical LLM agents") tested several different large language models (LLMs) to determine if they could perform in a simulated clinical setting (and replace the human clinician).  These investigators asked whether AI can take a patient history and identify key symptoms, generate a differential diagnosis, decide what laboratory or imaging tests to order (and then interpret these same tests), propose a treatment plan, and revise the plan if necessary as new data arrives.  The best model was only successful just under 70% of the time.  Notably, the study did not compare AI's performance to live humans (and we are certainly not perfect), but I don't think a 70% success rate is good enough yet.

The next two studies were conducted by investigators at Mass General Brigham Hospital in Boston.  The first study was published in the Journal of Medical Internet Research (see "Assessing the clinical utility of ChatGPT throughout the entire clinical workflow: Development and usability study") and found that ChatGPT to be nearly 77% accurate in making a final diagnosis when performing similar clinical workflows reported in the aforementioned study.  As a follow-up, the investigators reported (see "Large language model performance and clinical reasoning tasks" published in JAMA Open) that publicly available LLMs generated an appropriate differential diagnosis 80% of the time and made a correct diagnosis greater than 90% of the time.  They concluded that AI definitely has promise, but they also suggested that their results reinforced the necessity of having "human in the loop" involvement for medical decision-making.

So, back to my original question.  Is AI going to replace us?  And by us, I mean health care workers.  The quick and simple answer is probably not in the immediate future.  AI tools are getting better every day, but as I stated above, there is no replacement for human interaction that compromises the necessary art of medicine.  But are health care workers who use AI going to replace those who do not?  My bet is a simple yes.  I want to come back to the topic of the productivity paradox mentioned above, as I do think it is both an interesting and important question. Stay tuned for that post in the not too distant future. 

The power to command or the courage to serve?

Last year I wrote a post called "The Death of Command and Control" based on a number of articles proclaiming the end of the so-called "command-and-control" style of leadership.  Quickly, "command-and-control" or C2 as it is occasionally called refers to a style of leadership frequently associated with the military.  The "command" refers to the process of directing or issuing orders, while the "control" refers to the process of monitoring and enforcing compliance with these directives and orders.  It is a more top-down, hierarchical, authoritarian/autocratic style of leadership.  

In my post, I mentioned an article by Kathy Miller Perkins in Forbes magazine ("Shift your leadership style: Guidelines for agile leadership") that advocated for a more situational or context-specific style of leadership, in which leaders adapt their style to the specific requirements of a given situation or problem to be solved.  Perkins writes, ""Steering through the complex waters of modern leadership requires more than a single, go-to approach.  It demands the skill to adapt swiftly, changing your leadership style on the fly to tackle constantly shifting conditions and challenges." 

Perkins ended her article by writing, "Leadership in this century is not about clinging to a single, comfortable style but about developing the situation awareness and flexibility to switch between approaches as the context demands."  Most leadership experts would agree that there are certain situations that demand a more authoritative style of leadership, such as "command-and-control."  I ended my post by writing, "Rather than being dead, "Command and Control" leadership is here to stay, even if used relatively sparingly and for specific situations or contexts.

With all of this in mind, I read a thought-provoking article in Fast Company with the title, "Is command-and-control leadership back in fashion? And was it ever a good idea?"  The article was co-written by Harvard Business School professor Amy Edmondson and Tomas Chamorro-Premuzic, the Chief Science Officer at the recruiting firm, Russell Reynolds.  Edmondson and Chamorro-Premuzic opens their article by writing, "Open almost any newspaper, scroll through LinkedIn, or listen to the latest business podcast, and you will encounter a familiar theme: the return of the strong leader.  From 'wartime CEOs' to hard-charging founders and authoritarian coaching styles in elite sports, and the virtues of 'hands-on' leaders, there is a growing narrative that command-and-control leadership is not only back, but necessary.  The appeal is intuitive.  When the world feels volatile and uncertain, decisiveness offers comfort, and centralized authority promises clarity."

The Austrian neurologist Sigmund Freud once argued that we all have a tendency to idealize strong leaders, whose decisiveness, authority, and "take-charge" attitude can lower our anxiety and provide a sense of comfort in a volatile and uncertain world.  Freud argued that in groups regress psychologically and take on the personality of the leader through a process of transference.  Individuals in the group tend to idealize strong, charismatic, self-confident, decisive leaders, because that is the way in which they would like to be viewed.  And, as Edmondson and Chamorro-Premuzic suggest, "uncertainty increases our preference for certainty," so that when we groups encounter uncertainty and ambiguity, they tend to gravitate towards leaders who are confident and sure of themselves.

Unfortunately, decades of research also strongly suggest that authoritarian and autocratic leadership tends to suppress initiative, decrease motivation, and erode a climate of psychological safety, all of which can lead to lower employee satisfaction and engagement, lower productivity, and lower retention.  As Edmondson's research has found, "cultures that discourage dissent and concentrate decision-making power tend to suppress information, limit experimentation, and increase the risk of strategic error.  By contrast, environments characterized by psychological safety, leader humility, and distributed input are more likely to foster innovation, adaptability, and sustained performance."

Edmondson and Chamorro-Premuzic have found that the most effective leaders "do not necessarily decentralize authority, but they do decentralize input."  These leaders actively seek input from their teams, who provide a diversity of perspectives, opinions, and even dissenting views.  However, these same leaders retain responsibility for the final decision.  They created a 2x2 matrix of leadership styles with two key dimensions - decision process and ownership (ranging from non-consultative to consultative) and the source of authority and input (ranging from centralized to distributed, or decentralized):

There is an important difference between the leadership style in the top-left quadrant, in which authority is centralized and the decision process is non-consultative (i.e. "Command and Control") and the leadership style in the top-right quadrant, in which authority remains centralized but the decision process is consultative.  Whereas the "Command and Control" style of leadership is directive and autocratic, in which decisions are made unilaterally at the top with very little input gathered from others, the "Decisive but Inclusive" style of leadership is authoritative (leaders still retain authority to make the decisions) and open (consultative, collaborative).  These leaders actively engage their teams and seek their input, differing perspectives, and expertise.  These leaders even encourage active dissent, in order to minimize groupthink and improve the decision-making process.

The least ideal style of leadership is found in the bottom-left quadrant, in which authority is de-centralized and decision-making is non-consultative.  The bottom-right quadrant, known as "Participatory Leadership" can be effective in certain situations and contexts, particularly with knowledge-intensive settings with skilled teams.  However, the need to generate consensus here can slow down the decision-making process.

Edmondson and Chamorro-Premuzik emphasize that there will always be situations in which one style of leadership works better than the others (with the notable exception of "Leaderless Chaos" which is likely not ideal in any setting).  They state that "balance is key" - the most effective leaders are able to flex back and forth between the three leadership styles, depending upon the specific needs of the situation or scenario.  

Edmondson and Chamorro-Premuzik conclude by stating, "Whatever style or model leaders employ, it will always be easier for them to get things done and have a positive long-lasting impact if they are capable of bringing people along, motivating them to change their beliefs, and inspire rather than force them to action...Effective leadership in complex systems relies less on formal authority and more on influence.  It requires persuasion rather than command, curiosity rather than certainty, and a disciplined focus on long-term consequences rather than short-term control."

The ancient Greek philosopher Plato reportedly once said, "Leadership is not the power to command but the courage to serve."  It's not easy being a leader in today's society.  Leadership requires courage - courage to be confident, yet humble at the same time.  Leadership requires the courage to be willing to listen to different and even dissenting views and perspectives, yet being willing to make the final decision at the same time.  The best leaders are balanced in their approach, and versatile and adaptable.  They do not default to a single leadership style, but rather adapt their approach between different styles to balance control and inclusion as circumstances require. 

It's a wonderful life

I mentioned a new book by Arthur C. Brooks in a recent post (see "Magic Power"), called The Meaning of Your Life: Finding Purpose in an Age of Emptiness.  Brooks argues that a meaningful life is built through four key pillars - faith, family, friendship, and meaningful work.  Brooks has previously suggested that happiness depends upon enjoyment, satisfaction, and meaning (Happiness = Enjoyment + Satisfaction + Meaning) (see also my post "The mathematics of happiness"), meaning depends upon coherence, purpose, and significance (Meaning = Coherence + Purpose + Significance).  In other words, our happiness depends, at least in part, on having coherence, purpose, and significance in our life.

Brooks defines coherence as "how the events of your life fit together".  Through coherence, we understand that things happen in life for a specific reason.  When we think that things happen to us - either good or bad - more or less by random chance, our life can seem meaningless.  He defines purpose as "the existence of goals and directions in your life."  Lastly, Brooks defines significance as "the inherent value of your life to yourself and to others."  Think about Frank Capras's 1946 Christmas film, It's a Wonderful Life.  The main character, George Bailey (played by the actor Jimmy Stewart) feels that he has given up on his dreams and all is lost.  He tries to kill himself by jumping off a bridge on Christmas Eve, but he is stopped by his "guardian angel" Clarence.  Clarence shows him what would have happened to all of the people in his life had he never lived.  George's life had significance, and as a result, his life had meaning.

Frank Martela, a faculty member in the Department of Theology at the University of Helsinki in Finland wrote a review article in the Journal of Positive Psychology entitled "The three meanings of meaning in life: Distinguishing coherence, purpose, and significance".  Martela states that to have meaning in life, humans need three things:

1. They need to comprehend the world around them [Coherence]

2. They need to find direction for their actions [Purpose]

3. They need to find worth in their lives [Significance]

As I mentioned in a post last year (see "A life with meaning and purpose..."), Martela and his research team published a study ("Which predicts longevity better: Satisfaction with life or purpose in life?") in which they compared "satisfaction with life" (subjectively determined using a validated measure) or "purpose in life" (again, using a validated measure) with mortality.  Having a purpose in life was a much better predictor of living a longer life than simply being satisfied with life.  As the Austrian neurologist, psychiatrist, author, and Holocaust survivor Viktor Frankl famously said in his classic book Man's Search for Meaning, "Life is never made unbearable by circumstances, but only by lack of meaning and purpose."  He also said, "Those who have a 'why' to live, can bear with almost any 'how'."

In a similar study, a research team at Rush University Medical Center in Chicago found that a greater purpose in life is associated with a significantly reduced risk of mortality!  The relationship between purpose and mortality persists even when controlling for other mortality risk factors, such as age, number of chronic medical conditions, history of depression, and presence of disability.

Meaning and purpose also makes it easier to navigate life's many challenges.  I came across an interesting study ("Leveling mountains: Purpose attenuates links between perceptions of effort and steepness") that found that having a sense of purpose in life makes performing difficult tasks easier.  In other words, when we are confronted with a challenge, having a sense of purpose inspires and drives us to push on and keep going.  In this particular study, the difficult task was walking up a steep hill.  Taking into account all of the factors that can affect whether an individual can successfully walk up a steep hill (age, whether someone exercises regularly, etc), the study's authors found that (1) people overestimate the steepness of a hill because their brains calculate how much physical effort it will take to climb (the more daunting the effort, the steeper the hill appears), but (2) having a strong sense of purpose alters this relationship, such that when individuals are focused on a meaningful goal, they no longer automatically link the effort required to the severity of the slope.  To borrow and flip an overly used cliché, having a strong sense of purpose makes molehills out of mountains!

In his book The Meaning of Your Life: Finding Purpose in an Age of Emptiness, Brooks once again talks about the importance of (see "The Five Pillars of Happiness") of faith or transcendence (noting that it doesn't have to be a religious faith, but rather having a moral purpose, philosophy, or "North Star" that shifts your focus away from your own self to something bigger), family, friendship, and meaningful work.  He talks about how success almost never guarantees happiness.  Indeed, in some cases, success or achievement in life becomes a sort of addiction, where an individual is always looking for more achievement or more success rather than being satisfied with what he or she has in life.  He also talks about how suffering (for whatever reason - hardship, loss, or struggle) can deepen life's meaning.  Finally, he specifically states that finding meaning in life requires intention.  We actually have some control over whether our life has meaning, and we increase meaning and purpose through daily habits of gratitude, service, reflection, and developing strong relationships.

The book's overall message is that a good life (i.e. a meaningful life) is built through love, service, connection (and the kind of connection Brooks talks about is in-person connection not through technology), and transcendence, not through status, achievement, or pleasure alone.  He concludes with the following (and I am quoting him verbatim here) recommendations:

1. If any technology substitutes for in-person experiences, it should be used with extreme caution, like a dangerous and addictive drug.

2. If something makes you focus on yourself instead of others, shun it immediately.  It is poison.

3. If you are afraid of love in real life, it means you need to take more risks with your heart.

4. If the material world is crowing out your sense of the supernatural, rebalance your time and priorities.

5. If your work is not a calling, no matter what it pays, start plotting your exit.

6. If beauty is missing from your life, go outside in nature immediately.  Without your phone.

7. In the morning, as you start your day, say to yourself in the mirror: "The trials I face this day are evidence that I am living my life to the fullest."

Find your meaning.  Develop your sense of purpose.  Embrace transcendence.  It is a wonderful life.