Real leaders say "thank you" a lot...

Elie Wiesel, Holocaust survivor, professor, author, political activist, and winner of the 1986 Nobel Peace Prize once said, "When a person doesn't have gratitude, something is missing in his or her humanity.  A person can almost be defined by his or her attitude toward gratitude."  We hear a lot about gratitude these days, but unfortunately we don't see much of it in today's society.  Gratitude is defined as "being thankful" and "a readiness to show appreciation for and to return kindness."  Real gratitude is more than just saying "thank you" - it is much deeper than that.  We show our gratitude by saying "thank you", but more importantly we show our gratitude by truly appreciating when someone has done something nice for us and by re-paying and reciprocating that kindness in return. 

Do you remember the movie, "Pay It Forward"?  The movie starred Helen Hunt, Kevin Spacey, and Haley Joel Osment and told the story of a 12 year-old boy who started a goodwill movement called "Pay it forward."  The concept was as simple as it was elegant - for every favor that you receive, you return to the favor by doing a favor for three different individuals.  How much better would our world be if we followed that simple rule in life?  We hear of similar stories in the real world, but they are few and far between.  Just recently, I heard of a case in my home state of Indiana in which a McDonald's customer purchased her meal and the meal for the car behind her in the drive-through window.  It was Father's Day, and she told the McDonald's employee that she was going to buy the father's and his children's meal behind her in celebration of Father's Day.  Once the father heard what the woman had done, he in turn paid for the meal in the car behind him.  Each driver in succession repeated the gesture until 167 drivers in a row had paid for the meal behind their car.  The "chain of gratitude" only stopped when the restaurant closed at midnight. 

Gratitude is contagious!  And more importantly, gratitude makes you happier.  Remember how good you feel inside when you give a loved one a present on his or her birthday?  You are almost as excited as they are at times ("It's better to give than to receive" as the old adage goes).  I remember how good I felt after writing thank you cards for a number of our physicians who had been recognized in our local business magazine.  It was a simple, easy gesture for me, and I know they appreciated it (many thanked me afterward), but I think I got just happiness out of it as they did, in the end.  As it turns out, there are a number of studies that show that gratitude improves your overall mood, reduces stress and anxiety, and improves your self-confidence.

Showing gratitude is something simple that we, as leaders can do to demonstrate for our teams that we really do care.  Showing our appreciation for our teams will improve their moods, reduce any stress or tensions that they may be feeling, and ultimately make our teams more successful.  As an extra bonus, showing gratitude will improve our moods too!  There are so many good reasons to show gratitude, and as Elie Wiesel suggested, a true leader's attitude can be defined by the level of gratitude that he or she shows.

Superstars and the mess in Cleveland

I have been following the drama (and wow, if any word ever fit what is happening, "drama" is it) involving the NBA basketball team, the Cleveland Cavaliers this week.  For those of you who don't follow basketball, one of the star players (he is the starting Point Guard and the second-leading scorer) for the team, Kyrie Irving, recently requested a trade to another team.  It is important to remember that the Cleveland Cavaliers were the World Champions of basketball just one year ago, having won the NBA Finals in 2016 (they beat the Golden State Warriors, who won the NBA Finals in 2014 and again, most recently, in 2017).  As a matter of fact, the Cleveland Cavaliers played in the NBA Finals for the third year in a row in 2017.  So why would Kyrie Irving want to leave the best team in the NBA's East Conference, a team that has appeared in 3 straight NBA Finals, and a team that actually won the NBA Finals in 2016?  One answer - LeBron James.  Love him or hate him, LeBron James is currently the best basketball player on the planet - some would argue that he is one of the five best players all-time.  Some would even argue that he is THE best player all-time.  Apparently, Kyrie Irving no longer wants to play with James and wants to be more of a focal point on a team - in other words, Kyrie Irving wants to be "the guy."  Being the second best player on one of the best teams in the NBA and playing beside the world's greatest player is apparently no longer enough.  Winning apparently no longer matters.  Kyrie Irving wants to be the best player on the team. 


GIVE ME A BREAK!  I thought the whole point of playing the game was to WIN.  Apparently, winning only matters if you can get all of the attention and all of the credit.  In my opinion (and it's not just my opinion), this is what is wrong with the National Basketball Association - maybe even professional sports in general.  We have reached a point where the personalities are more important than being part of a team.  We have reached a point where personal accolades matter more than winning.  In other words, playing basketball in the NBA is no longer a sport - it's entertainment.  What is more fascinating to me (and certainly more relevant to leadership) is how the Cleveland Cavaliers management team will handle this particular issue.  An entirely different question is how did the Head Coach of the Cleveland Cavaliers let things get this far. 


First question first.  I have heard three potential ways that the Cavaliers will move forward - three options, if you will.  The first option is to make Kyrie Irving and LeBron James get in a room and work their issues out for the best of the team.  In other words, make these two grown men act like adults and put their personal goals aside and achieve something much greater than they will be able to achieve by themselves.  The second option is to go ahead and give Kyrie Irving what he has asked for - trade him, in this case for another superstar.  Put all of your eggs in one basket (knowing that you may only have one more chance at winning the NBA Finals) and go for it this next year.  The third option is to go ahead and give Kyrie Irving what he has asked for - trade him, but in this case, trade him for young, promising players and draft picks in order to build for the future.  There are a number of rumors out there that this will be LeBron James' last year in Cleveland (he is a free agent at the end of next season and reportedly is looking to play for the Los Angeles Lakers or someone else).  So, rather than be caught at the end of next year without your two best players, look to rebuild for the future.  I think it will be fascinating to watch what the Cleveland Cavaliers end up doing.


Now, to the second question - how did it all end up like this?  There is a clear lesson here on how (in this case) not to manage superstars.  For anyone who thinks this is not an issue that is relevant to health care, think again.  I just read an article about a children's hospital that hired a new prominent pediatric cardiothoracic surgeon - the surgeon actually is the third highest paid individual in the entire state!  In other words, it is a very common scenario to have a prominent physician (usually, but not always a surgeon) getting paid a higher salary than the hospital CEO. 


There have been a number of articles on this issue (check out some really good articles here, here, here, and here).  James Kerr wrote a piece for "Fast Company" that makes an interesting point - in many cases, managers (or using the sports analogy, coaches) of highly successful, championship-caliber teams leverage and enable their so-called superstars to lead (think here of Tom Brady on the New England Patriots, Magic Johnson of the Los Angeles Lakers, or Derek Jeter of the New York Yankees - all three were great superstars, but all three were also great leaders on the team).  While not every superstar is a great team leader (perhaps this explains some of the recent issues with the Cleveland Cavaliers), if the superstar does show signs that he or she is willing to adopt a "team-first" as opposed to a "me-first" attitude, they should be encouraged to do so.  As many championship teams have found (most notable example, especially recently, has been the New England Patriots and the widespread adoption of "The Patriot Way""), most personality and team chemistry issues can usually be best addressed by the leaders on the team as opposed to the coach. 


Rebecca Knight provided these recommendations in a recent Harvard Business Review blog post:


1. "Think about development."  In other words, ask the superstar about his or her personal goals.  If the goals align with the organization's goals, perfect.  If not, decide whether there is an opportunity to align the goals better and (if mutually aligned goals are not possible) whether the organization is the best place for that individual.  In addition, ask what you as the leader can do to help leverage the superstar's talent and provide additional development opportunities for that individual.


2. "Offer autonomy."  Delegate authority where possible - the best example here is what Coach Bill Belichik has done with his superstar, Tom Brady.  Don't micromanage the superstar - given him or her responsibility and authority, but then also make sure that the superstar understands that he or she will be held accountable.


3. "Don't go overboard with positive feedback."  Positive feedback is great - and we don't provide enough of it in most organizations.  However, don't provide feedback merely to feed the superstar's ego.  Make it count. 


4.  "Manage your star's workload - and everyone else's."  Divide up the work fairly.  We have a tendency to keep dumping more and more responsibilities on the superstars.  Make sure that they are successful by providing them with ample opportunities to demonstrate what they can do, but not so many that they never can get anything done.


5. "Be mindful of group dynamics."  Superstars and favoritism can lead to discontent.  Make sure that the superstar is treated fairly.  It's okay to recognize his or her contributions to the team, but don't do it to the exclusion of recognizing the contributions from the rest of the team.


6. "Encourage your star to build relationships."  Hopefully the superstar will provide mentorship to some of the younger, emerging leaders on the team.  Encourage the superstar to build relationships with other members based upon mutual trust and respect (think Michael Jordan and Scottie Pippen, but NOT Kobe Bryant and Shaquille O'Neal!).


7. "Don't be selfish."  It's great when you have a superstar on your team - but part of the development process for that individual is to seek opportunities at greater levels within the organization.  Don't make the mistake of not providing those opportunities, else the superstar leaves the organization to find those same opportunities elsewhere.


Clearly there is more to learn about dealing with superstar employees.  However, I do think this is a good place to start.  Bottom line, if things had been handled better within the Cleveland Cavaliers organization, they may be in an entirely different place right now.

VORP WAR

I had an interesting conversation with one of our physician leaders this past week.  We were both looking at some medical staff turn-over data (which, incidentally, showed that there is no significant physician turn-over at our organization), and he asked whether we should look at "VORP".  My first response was "What in the world does VORP have to do with medical staff turn-over and hospitals?"  However, as I started to think more about his question, I wondered to myself, "Why wouldn't we look at VORP?"

Unless you are a baseball statistics geek like me, you may not have heard about "VORP".  "VORP" is an acronym for a statistic called "Value over replacement player" and is very similar to another statistic (perhaps more well known) called "WAR," or "Wins above replacement player."  The idea is that you can determine how valuable an individual player's contributions are to the team's overall win-loss record by assessing how valuable he is compared to an otherwise average professional baseball player.  Both of these statistics have grown in popularity with the growing popularity of "Sabermetrics" in baseball.  The term "Sabermetrics" is in turn derived from another acronym (SABR) for the Society of American Baseball Research and was first used by the professional sports writer, Bill James.  You may be more familiar with Sabermetrics and the story of how the General Manager of the Oakland Athletics, Billy Beane, put together a winning team based upon these statistics (this particular story was the subject of the book, Moneyball, by Michael Lewis which was made into a popular movie starring Brad Pitt as Billy Beane).

The sport of baseball lends itself very well to statistics - even the most casual baseball fans are familiar with the commonly used statistics, such as Batting Average, Runs Batted In (RBI), and Earned Run Average (ERA).  Sabermetrics takes these relatively easy to understand and commonly used statistics one step further (okay, maybe two steps further) to incorporate "Big Data" techniques and advanced statistics and mathematical modeling into statistics such as VORP, WAR, and OPS (On Base % + Slugging %).  Sabermetrics really seemed to take off when General Manager Theo Epstein reportedly used them to build a Boston Red Sox team that won the World Series twice in five years, ending an 86 year World Series drought for the team (ending the "Curse of the Bambino").  Epstein would go in to put together a Chicago Cubs team that would win the World Series in 2016 for the first time in 108 years!

So there is no doubt that "Big Data" techniques and advanced statistical modeling methods such as Sabermetrics are here to stay, at least in regards to baseball.  But back to my original question - could something like "VORP" ever be used in health care?  Should we be using more advanced statistical methods to more objectively measure the effectiveness and/or productivity of our medical staffs?  The answer is clearly (at least in my opinion) "yes!"  Productivity measurements have traditionally used the amount of revenue generated by an individual physician based upon billing (specifically, something called RVU's, or work Relative Value Units are used to assess physician productivity).  There are, in fact, benchmark data for almost every medical specialty, that are stratified according to the region of the United States, among other factors.  Unfortunately, while the RVU method is commonly used, it is not very good.

The RVU's that an individual physician generates in any given day contributes to an incentive to see a large number of patients and/or provide a large number of services ("fee for volume" as opposed to "fee for value").  Have you ever complained that you didn't spend a lot of time with your physician?  Physicians are not incentivized to spend long periods of time with any one patient, largely as a result of how they are reimbursed for care and how they are being measured from a productivity standpoint.  In addition, RVU's says nothing about how productive an individual physician is in regards to time spent on teaching medical students or residents or time spent conducting research or writing academic papers.  In other words, perhaps we are incentivizing physicians for the wrong things!

So, what would VORP look like in medicine?  Ideally, we would first start with a set of objective measures for delivering safe, affordable, and excellent care that generates high quality outcomes (both in terms of quality of life and survival, as well as patient satisfaction).  These objective measures would hopefully reward physicians who spend all the time that an individual patient requires at the bedside.  Physicians are in a great position to identify ways to improve care using improvement science - in many cases, quality improvement is not factored into RVU's or other rudimentary measures of academic productivity.  Our medical version of VORP would need to consider how much time an individual physician contributed to improving health care delivery through quality improvement.  Moreover, physicians who were good teachers (for patients/families, nursing and allied health staff, medical students and residents) would be rewarded with a measure that took these important aspects of medicine into account.  Finally, physicians would also be measured (where appropriate) on how many academic papers that they published or for generating quality research that contributes to improvements in care.  Unfortunately, until these kinds of activities, all of which are both important and necessary to the future of medicine, are measured objectively, it would be hard, if not impossible, to come up with a medical version of VORP.

While I was certainly intrigued by my colleague's suggestion last week, I just don't think we have progressed to the point where something like "VORP" or "WAR" could be used to determine how important an individual physician's contributions are to any one particular institution. I would be ecstatic, and I think we will have come a long way, when we use something other than RVU's as a measure of physician productivity.

"Take a deep breath, count to ten..."

I came across an article in Forbes magazine earlier this week, entitled "7 Ways Leaders Maintain Their Composure in Difficult Times".  There is no question that we are faced with perpetual, constant, and at times, rapid change.  In many ways, both health care and society at large are changing in ways that make it more and more difficult to navigate our way around.  During these difficult times, we look to our leaders for guidance and inspiration.  We want - and in many cases, we desperately need - leaders with grace, composure, and poise.  It's interesting to me that Webster's Online Dictionary defines the word "poise" in two ways.  In the first definition listed, "poise" is defined as a "graceful or elegant bearing in a person."  More relevant in the current context is the second definition.  Here, "poise" is defined as "balance or equilibrium."  We want our leaders to remain balanced - they don't necessarily need to be in 100% control of their emotions all the time, but we certainly don't need our leaders to "lose it" when times are tough.


So, here are the 7 recommendations to help leaders maintain their composure in difficult times, at least according to the article in Forbes magazine:


1. Don't allow your emotions to get in the way.
2. Don't take things personally.
3. Keep a positive mental attitude.
4. Remain fearless.
5. Respond decisively.
6. Take accountability.
7. Act like you have been there before.


Grace.  Composure.  Poise.  There are three examples of grace, composure, and poise that immediately come to my mind, and I would like to share them here.


Example #1 (from my own personal files!)


I remember when I was a Pediatric Critical Care Medicine fellow, and while I don't remember the exact time (it probably was during my second or third year), I remember almost every single detail.  In fact, I am almost 100% positive that if I started to talk about the case now with the physician who was my attending physician at the time, he would immediately remember the specifics of the case as well.  I can't share specific details of the patient, but suffice it to say that we were called upon to place what is known as a central line (basically, a larger intravenous catheter that is placed in a large, so-called central vein, such as the internal jugular vein, subclavian vein, or femoral vein, as opposed to a normal "IV" which is placed in a small, peripheral vein in the arm or foot) in a critically ill infant who did not have vascular access.  The patient was not doing particularly well, so this was an emergency and time was of the essence.  We were using a commonly employed technique known as the Seldinger technique, in which a guidewire is used to help place the catheter through the skin and into the vessel (the guidewire is removed after the catheter is placed).  We are always taught to never let go of the guidewire!  The attending physician was standing right behind me as I successfully placed the guidewire into the subclavian vein.  As I was withdrawing the dilator from the patient, I accidentally pulled out the guidewire too - in other words, back to square one!  My attending dropped his head, slowly walked away to the corner of the room, sat down, buried his face in his hands, and muttered what I think (though I can't be 100% sure), "Derek.  Derek.  Derek."  We really needed that line.  The patient really needed that line.  My attending physician was obviously very frustrated, but he took a deep breath, stood up, walked back towards me, smiled, and said, "You got it once, you can do it again."  He nodded his head, and I successfully placed the central line.  Rather than yelling at me or criticizing me in the middle of a very busy Intensive Care Unit, he took a deep breath, waited a few moments, and came back to positively encourage me to do my job.


Example #2

One of my favorite movies (of all time even) is the movie, Gettysburg based upon the novel, The Killer Angels by Michael Shaara.  There is a scene in the middle of the movie when General Robert E. Lee has to speak with one of his generals, in this case General J.E.B. Stuart.  Stuart led the cavalry for the Army of Northern Virginia, and at times, was guilty of being too overly confident and too self-gratified.  During the few days leading up to the battle, General Stuart was nowhere to be found (an army's cavalry was often its "eyes and ears"), and several other officers in the Army of Northern Virginia were probably correct to say that General Stuart had left them "high and dry" while he was off enjoying his celebrity status and seeking fame.  Lee has a fairly "crucial conversation" with Stuart - in private - in which he reprimands General Stuart for not doing his duty.  As you watch the video clip, notice that General Lee (played by Martin Sheen) starts to lose his temper, quickly retreats ("take a deep breath, count to ten"), and redirects the conversation back to his original point.  He then tells General Stuart that "you are one of the finest cavalry officers that I have ever known," and that "your services to this army have been invaluable."  Lee tells Stuart that he is confident that he will learn from his errors and that "it will never happen again."  It is a fairly minor scene in the movie, but it is an excellent example of grace, composure, and poise in a leader during a very stressful time.


Example #3

Another example from the Battle of Gettysburg.  In this case, the example involves the Union Army of the Potomac, and the main characters are President Abraham Lincoln and General George Meade.  General Meade was given command of the Army in the days immediately prior to the Battle of Gettysburg (he actually tried to refuse command, so he was a reluctant leader for sure).  The battle is fought for three days.  The Union Army of the Potomac wins the battle, and the Confederate Army of Northern Virginia finds itself in a full-scale retreat.  More importantly, the Army of Northern Virginia gets caught on the wrong side of the Potomac River and is trapped.  The river was overflowing due to heavy rains, and the Union Army, or so it is believed, had a golden opportunity to fight the Army of Northern Virginia and rout them.  The Civil War could have ended there and then.  Instead, General Meade delays his advance, the river subsides, and the Army of Northern Virginia escapes a disaster.


Lincoln was furious with Meade.  He wrote a letter to General Meade that follows:

Executive Mansion,​

Washington, July 14, 1863.​

Major General Meade​

I have just seen your despatch to Gen. Halleck, asking to be relieved of your command, because of a supposed censure of mine. I am very--very--grateful to you for the magnificent success you gave the cause of the country at Gettysburg; and I am sorry now to be the author of the slightest pain to you. But I was in such deep distress myself that I could not restrain some expression of it. I had been oppressed nearly ever since the battles at Gettysburg, by what appeared to be evidences that yourself, and Gen. Couch, and Gen. Smith, were not seeking a collision with the enemy, but were trying to get him across the river without another battle. What these evidences were, if you please, I hope to tell you at some time, when we shall both feel better.

The case, summarily stated is this. You fought and beat the enemy at Gettysburg; and, of course, to say the least, his loss was as great as yours. He retreated; and you did not, as it seemed to me, pressingly pursue him; but a flood in the river detained him, till, by slow degrees, you were again upon him. You had at least twenty thousand veteran troops directly with you, and as many more raw ones within supporting distance, all in addition to those who fought with you at Gettysburg; while it was not possible that he had received a single recruit; and yet you stood and let the flood run down, bridges be built, and the enemy move away at his leisure, without attacking him. And Couch and Smith! The latter left Carlisle in time, upon all ordinary calculation, to have aided you in the last battle at Gettysburg; but he did not arrive. At the end of more than ten days, I believe twelve, under constant urging, he reached Hagerstown from Carlisle, which is not an inch over fifty five miles, if so much. And Couch's movement was very little different.​

Again, my dear general, I do not believe you appreciate the magnitude of the misfortune involved in Lee's escape. He was within your easy grasp, and to have closed upon him would, in connection with our other late successes, have ended the war. As it is, the war will be prolonged indefinitely. If you could not safely attack Lee last Monday, how can you possibly do so South of the river, when you can take with you very few more than two thirds of the force you then had in hand? It would be unreasonable to expect, andI do not expect you can now effect much. Your golden opportunity is gone, and I am distressed immeasurably because of it.​

I beg you will not consider this a prosecution, or persecution of yourself. As you had learned that I was dissatisfied, I have thought it best to kindly tell you why.​

Abraham Lincoln​

Surprisingly, Lincoln never sent the letter!  The letter was not discovered until after the end of the War, shortly after his assassination.  It was found in an envelope in his desk that was endorsed by Lincoln himself, stating "To Gen. Meade, never sent, or signed."  Apparently, Lincoln often wrote letters that he never sent.  It was his way of venting his anger and frustration without offending or attacking the person who had caused his frustration.  In other words, he took "a deep breath and count to ten."

Grace.  Composure.  Poise.  We, as leaders, need these skills, especially in times of difficulty.  So whenever you find your temper starting to flare, whenever someone on your team triggers your frustration, "take a deep breath, count to ten" and re-direct and re-focus. 

The Fable of the Wind and the Sun

I am reading Dale Carnegie's classic self-help, business, leadership book right now - "How to Win Friends and Influence People" (actually, I am reading the version for the "digital age").  So far, the book has been worth the investment in time to read.  A lot of the points that Carnegie makes can be boiled down to a simplified version of the famous Golden Rule ("Treat others as you would like to be treated," or alternatively, "Don't treat others in ways that you would not want to be treated.").  There is certainly more than just that, but it strikes me as interesting that there is a need for a book about how we should treat one another.  Robert Fulghum wrote a poem, entitled "All I really need to know I learned in Kindergarten" - it really is that simple.  But I do think we would all do well to read and heed these words again.

Carnegie tells a story in the book that perked my curiosity just enough that I looked it up online.  It turns out that the story Carnegie used in his book is from a long time ago (he did mention that).  I mean a really long time ago - like ancient Greece.  One of Aesop's Fables is called simply, The Fable of the Wind and the Sun.  The story goes something like this. 

The Wind and the Sun were having an argument one day about who was stronger.  By chance, a weary traveler happened to be walking by at just that moment, and the Wind and the Sun decided to have a contest - a test of strength if you will.  The Sun stated the challenge - "Whoever can cause that traveler to lose his cloak is the winner."  The Wind went first.  He blew as hard as he could, but the harder he blew, the more the traveler pulled his cloak tight around his body.  Finally, after trying for several minutes, the Wind gave up and told the Sun it was her turn.  The Sun was hiding behind the clouds the whole time.  As soon as the Wind told her that it was her turn, she emerged from the clouds and shone brightly on the path that the traveler was walking along.  After a few minutes, the traveler wiped the sweat off his brow and took off his cloak.  The Sun proudly announced, "See, I win."

Every one of Aesop's Fables has a moral.  The moral of this story is that you can get a lot farther with kindness than you can with strength or power.  As another old saying goes, "You can catch more flies with sugar than you can with vinegar."  Kindness is a great and powerful tool for every leader to have in his or her armamentarium.  Imagine how much better the world would be if everyone followed this simple rule.  It all comes down to how we treat everyone else in our lives.  Kindness is contagious.  Kindness works.  Be kind to one another.

Health care's "chicken or egg" problem

There's a graphic that is getting a lot of air time lately in various circles in the back hallways of hospitals and physicians' offices.  It's actually not that new, but I seem to hear one or two of my colleagues talking about it or mentioning it to me personally fairly often these days.  The conversation goes something like this:

"Did you hear that there are 10 administrators for every physician in the United States?" 

"Wow - I just read an article online that said that the number of health care administrators in the U.S. has increased by almost 2300% since the 1970's."

And then someone else pulls up a graphic on their cell phone and just says, "This."

As it turns out, investigators at Harvard reviewed data from both the Bureau of Labor Statistics and the American Medical Association and found that the number of health care workers in the United States increased by 75% from 1990 to 2012.  In other words, if you are talking with one of your kids about careers with a lot of job security, look no further than the U.S. health care industry.  In this study, most (almost 95%) of the growth in health care jobs occurred in non-physicians.  The ratio of physicians to non-physicians changed from 1:14 to 1:16.  Moreover, only six of the 16 non-physicians were actual front-line clinicians (nurses, allied health professionals, pharmacists, medical assistants).  So back to the statement I heard earlier - there are roughly 10 administrators (loosely defined as administrative and management professionals) for every physician in the United States!

Whenever I hear some of my colleagues talk about these statistics, I start asking them questions about what they think is going on - the usual reply is something like, "Well, this only proves my point that health care has gone too corporate." I also hear comments like, "Health care is being run by the suits!"  I don't necessarily disagree with these comments, but I do think there is a clear "Chicken and Egg" problem here ("Which came first, health care became 'Big Business' because of all the glut of health care administrators or alternatively, we had to hire so many health care administrators because health care has gone too corporate?").

Let's be careful here.  There is no question that health care is a big business.  How could you say anything differently about an industry that accounts for nearly 18% of the U.S. gross domestic product (GDP)?  I don't think it is necessarily a bad thing to call health care a business - indeed, there are a lot of things we can learn (and have learned) from the business world to make health care better for our patients.  And it is important to call out that the concept of health care as a business is nothing new.  Socrates, in Plato's Republic, asked, "But tell me, this physician of whom you were just speaking, is he a moneymaker, an earner of fees, or a healer of the sick?"  In its heyday, the American Medical Association (AMA) did everything it could do to protect the business interests of physicians.  The AMA originally attached the stigma of "socialized medicine"" to then President Harry Truman's attempts at health care reform (recall that socialism was a four-letter word during that time of the rapid rise of communism).  Only fairly recently has the AMA been supportive of the kinds of health care reform to move closer towards universal health care (the AMA supported passage of the Affordable Care Act and has been vocal in its opposition to the more recent health care bills before Congress). 

Regardless of how you feel about it, the simple fact is that medicine is a profession (and always will be - a topic for another time) and health care is a business.  Deal with it.  However, I do think that the rapid and unprecedented increase in the number of health care regulations and requirements that touch virtually every aspect of the patient encounter is really the key driver of the increase in the number of health care administrators in the United States.  We have created such a complex system that there is no choice but to shift the burden of documentation (as far as documentation outside the patient-physician encounter, and in many places we have shifted this burden on administrators as well - see the growth in the number of medical scribes), billing and coding, regulatory compliance, and at times complex negotiations around reimbursement to non-clinical professionals.  Our patients are sicker and more complex than ever before - it takes an army of clinical coordinators to work with the number of different providers that care for the modern patient.  And if anything, all we have done with all these additional layers of bureaucracy (though absolutely necessary in the current system) is to increase the cost of care.  None of these non-clinical administrators work for free.  The U.S. has the most expensive health care system in the world, and in large measure, a significant driver of health care expenses stems from administrative costs.

So, what can we do?  First, we can't blame the administrative burden and associated costs that currently exist in the U.S. health care system on the number of administrators.  Just ask the next administrator you see why they joined the health care profession.  The odds are that he or she wanted to make a difference, just like you and me.  Health care administrators are just as dedicated to patients as we are, even though their job is different from ours.  And in many cases, they want to help us do what we do so that together we can make the patient better.  Second, we have to be part of the solution.  Part of the blame lies with us - many of the regulatory requirements were imposed on us, because we weren't doing what we needed to do to cut out waste and make health care delivery more efficient.  We have more control over what we do than we sometimes think.  There are a lot of things that we can do to cut out waste.  Third, we have to continue to advocate for real health care reform - the kind that will make our system simpler and more efficient.  Regardless of what side of the political aisle that you fall on, there are things that we can agree on that will cut out some of the administrative burden and eliminate the hassle factor.  Fourth, we need to encourage leaders in our field to join the fray.  For too long, we left health care administration to the so-called "business types" ("the suits").  We need physician leaders who can cross over "to the other side" and become administrators (while at the same time continuing to practice medicine, if possible).  Rather than poking fun at our colleagues who move into administrative positions, we need to celebrate them and thank them.  They have work to do - for us.  There is no mystery why some of the best hospitals and health care organizations are led by executives with a clinical background.

So which came first, the chicken or the egg?  As it turns out, that's not an easy question to answer.  The reality is that health care has always been a business, at least to some extent.  If we are going to get a handle on the rising costs and growing number of administrators, we are going to have to make health care delivery simpler and more efficient. 

"The only easy day was yesterday"

The U.S. Navy SEALs have a saying (it's used so frequently that I almost would think it is a motto),  "The only easy day was yesterday."  BUD/S ("Basic Underwater Demolition/SEAL training) is a grueling, incredibly intense, 24-week long "school" that both tests and trains sailors to become part of the elite special forces Navy SEALs.  The course emphasizes leadership training, as well as mental and physical stamina.  Approximately five weeks into BUD/S is "Hell Week", where SEAL candidates can look forward to 4 hours of sleep the entire week, 20 hours per day of intense physical activity, and more than 200 miles total of running.  Very few SEAL candidates finish BUD/S, which is one of the reasons the motto, "The only easy day was yesterday" is so appropriate.  Completing BUD/S requires incredible stamina (both physically and mentally), dedication, fortitude, and resilience.

The psychologist Angela Duckworth has studied resilience extensively (some of her test subjects have been Navy SEALs in fact) and wrote a book called "Grit: The Power of Passion and Perseverance".  A number of researchers have studied "resilience" and "grit" - one of the universal findings is that individuals who are faced with and seem to do fine during periods of incredible physical, mental, and emotional stress have one thing in common - a feeling that they and not their circumstances largely determine what happens to them in life.  Resilient individuals are "masters of their fate" (see the poem, Invictus) - they believe that whatever happens to them, they are in control of how they respond and make it through to the end.  Sounds a lot like the Navy SEALs, correct?  In other words, the one thing that we can control, no matter the circumstances, is our attitude.  And the more positive our attitude, the more likely that we will be able to respond successfully to whatever the world throws our way.

I have been thinking about resilience a lot lately.  I recently heard that Chief Justice John Roberts of the United States Supreme Court recently gave the "commencement address" at his son's ninth grade graduation ceremony.  However, instead of the usual platitudes that we hear too frequently at commencement speeches, Chief Justice Roberts used a different approach.  In the middle of the speech, he said the following:

Now the commencement speakers will typically also wish you good luck and extend good wishes to you. I will not do that, and I’ll tell you why. From time to time in the years to come, I hope you will be treated unfairly, so that you will come to know the value of justice. I hope that you will suffer betrayal because that will teach you the importance of loyalty. Sorry to say, but I hope you will be lonely from time to time so that you don’t take friends for granted. I wish you bad luck, again, from time to time so that you will be conscious of the role of chance in life and understand that your success is not completely deserved and that the failure of others is not completely deserved either. And when you lose, as you will from time to time, I hope every now and then, your opponent will gloat over your failure. It is a way for you to understand the importance of sportsmanship. I hope you’ll be ignored so you know the importance of listening to others, and I hope you will have just enough pain to learn compassion. Whether I wish these things or not, they’re going to happen. And whether you benefit from them or not will depend upon your ability to see the message in your misfortunes.

Chief Justice Roberts is giving his son's classmates a very valuable lesson here.  Don't expect that things will always be fine and dandy - at times, you will run into mean, nasty people.  At some point in your life, someone will cheat you or take advantage of you.  And on some occasion in the future, you will fail.  Rather than yielding to the temptation to just crawl into a corner and sulk, instead of focusing on the fact that someone got the best of you, either fairly or unfairly, and rather than seeing the negatives in any one particular situation, (1) embrace the hard times, (2) learn from mistakes and failures, and (3) look at the positives.  In other words, BE RESILIENT.

You could certainly look at the SEALs' motto and say that it means that every day is going to be harder and harder.  However, with Angela Duckworth (among others) and Chief Justice John Roberts in mind, I will interpret the motto in a more positive light.  Yes, there are always going to be tough times ahead.  But you made it through today, and if you can make it through today, you will make it through tomorrow.  "The only easy day was yesterday", but "It matters not how strait the gate, how charged with punishments the scroll.  I am the master of my fate.  I am the captain of my soul."

What can health care learn from Uber?

I just spent the past few days in Boston for my daughter's college orientation (last one for the Wheeler family!).  I decided, with my wife's permission of course, to run my own experiment.  I was interested to know whether Uber was less expensive than a typical taxi cab fare (my hypothesis was that Uber was cheaper, but I really can't say why I believed that to be the case).  The conditions in the two experimental groups (group 1 - Uber, group 2 - taxi) were fairly identical - a one-way trip from our hotel to the college campus, same pick-up and drop-off location and similar time of day (we actually took two separate trips approximately 1 hour apart - don't ask why!).  Contrary to my original hypothesis, the costs were about the same, including the tip.  So based on this experiment, it really doesn't matter whether you take Uber or a taxi.  There is a big "however" here... 

The convenience of using the Uber app far outweighed any advantage to taking a taxi.  I was able to use the app to arrange for our pick-up.  I knew how the Uber driver had been rated by previous users.  I knew my charges in advance, as well as the estimated time that I would reach our destination.  Finally, I didn't have to worry about paying the driver, as my credit card was automatically billed by the app itself.  Contrast that with the typical experience with a taxi.  First, and perhaps most importantly, unless you are in an area where taxi cab drivers frequent, you have to search on the Internet and find a telephone number for a taxi cab company and call to arrange pick-up.  Even if you are at a public venue, you either have to flag down a taxi driver yourself or pay a tip for someone from a hotel or airport to flag one down for you.  Second, you have no ability to see how others have rated the taxi cab driver or know in advance how much the taxi fare is going to cost.  Third, you have to either pay in cash (the method that seems to be preferred by almost every cab driver I have used) or use a credit card (I doubt that most taxi cab companies have the latest and greatest IT security systems, so using your credit card brings the additional risk of credit card fraud). 

In all fairness, there was one incident over the last couple of days when we could not connect with our Uber driver.  The driver cancelled our appointment and charged us a penalty fee of $5.  However, with a quick explanation on the Uber app's "help" button, I was able to avoid the $5 penalty (although we ended up having to go "old school" and have the hotel bell hop call us a cab).  On the other hand, when we needed to be picked up at the college campus to go to the airport, there was not a taxi in sight.  It was raining, which may have been one reason why we could not find a cab (see great article here).  The convenience of Uber proved itself again.

So what is my point?  During our flight home, I pondered to myself and thought that there is a lot that health care can learn from Uber.  First is the issue of convenience - on this point, Uber beats out the taxi cab companies hands down.  We are seeing a similar phenomenon in health care with the increase in so-called retail health care clinics.  These clinics are typically staffed by nurse practitioners or physician's assistants and are located in pharmacies or grocery stores.  As far as convenience goes, it's hard to beat the proximity to patients' home as well as the hours (usually after the normal work day) that these clinics are open.  While one could certainly argue that the care provided at these locations is not as good as the care provided by a patient's own primary care physician (the two biggest complaints from primary care physicians that I have heard are that they overprescribe antibiotics and that there is no continuity of care), most studies suggest otherwise.  Moreover, as far as continuity of care goes, the shift towards team-based care, even in the primary care setting, often means that you don't necessarily always see your primary care physician (you may see one of his or her partners, or even one of the practice's nurse practitioners or physician's assistants). 

Second is the issue of price transparency.  When you use Uber, you know in advance how much it is going to cost you.  Again, in most cases, the retail clinics provide a fairly comprehensive listing of their charges for a number of different visit types.  Unfortunately, most primary care practices and hospitals still do not provide this degree of price transparency (certainly not BEFORE the care is delivered). 

Third is the issue of driver ratings.  How much better would it be if patients were able to rate their providers based on friendliness, courtesy, how well they explained the care that was going to be provided, and how much time they spent with the patient?  Many health care organizations are heading in this direction, including my current organization.  Anecdotally, we and others have found that transparency around individual provider-specific experience ratings typically results in a better patient experience over time (most physicians will use these ratings to improve their delivery of care).

Finally, from a technology perspective, Uber clearly beats out taxi cab companies.  I think health care is heading in that direction, but we still have a long way to go.  I remember watching the cartoon, "The Jetson's" when I was a child.  Whenever Elroy was sick, he would be seen virtually by his pediatrician (see picture below).  It is hard to believe that we are seeing more of these kinds of "virtual visits" through telemedicine in health care today!

Suffice it to say, there is a lot that we, in health care, are learning and can learn from a company like Uber (with the notable exception of how their CEO runs the company, of course).  What does all of this have to do with leadership in health care?  Easy - as I have suggested in a number of previous posts, we as health care leaders can learn a lot by going outside our own industry.  There is a lot for us to learn from other industries.  The parallels are there, if we just simply take a look.

Charlie Golf One

I recently added my own personalized logo to my e-mail signature to go along with my name and contact information, my three values for my team that go along with our mission and vision statements ("Be like Young.  Work as a Team.  Clear the Deck."), and the usual disclaimer (the one that says that the e-mail was intended for only for the individual who it was addressed to, etc., etc., etc.).  I can't take credit for the logo, as it is the same one used by the Medical Corps of the United States Navy.  I learned about the logo and its meaning while I was on active duty as a pediatrician and general medical officer in the Navy.  I have had a few questions about what it means, so I decided to write about it in today's blog.

The logo is fairly straightforward.  If you have any nautical background, you will immediately recognize (even if you don't know their exact meaning) that the logo consists of four signal flags.  In the early history of the Navy, ships would communicate with one another while at sea using signal flags and pennants (remember that this was before the invention of the radio).  The first signal flag in the logo is the international answering pennant, while the next two signal flags are the phonetic alphabet letters for "C" ("Charlie") and "G" ("Golf").  The last signal flag in the sequence is the numeric signal for the number "One."  Collectively, the international answering pennant followed by "Charlie Golf One" means that a ship has received a distress signal from another vessel and is responding with the signal, "I will stand by to assist you."  These four signal flags are proudly flown beneath the American flag at every United States Navy medical command.  "Charlie Golf One" is the motto for the Navy Medical Corps and reflects the proud tradition of rendering aid to our nation's sailors and marines. 

It is simple, and it is elegant.  "I am standing by and ready to assist or help you."  Leadership, when it comes right to it, is about service (Robert Greenleaf has written extensively about a concept that he calls servant leadership).  Almost every great leader talks about putting the needs of his or her team first.  The great football coach, Tony Dungy, once said, "The secret to success is good leadership, and good leadership is all about making the lives of your team members or workers better."  Nelson Mandela said, "It is better to lead from behind and to put others in front, especially when you celebrate victory when nice things occur.  You take the front line when there is danger.  Then people will appreciate your leadership."  In other words, great leaders are "servant leaders" who put the needs of their team members ahead of their own.  They are also the first to take the blame, and the last to take any credit.  They are always there, "standing by, ready to assist" their team.  In other words, CHARLIE GOLF ONE.