Wednesday, June 27, 2018

The rule of five

I read a really good book last year by Douglas W. Hubbard, called "How to Measure Anything."  I can't remember why exactly I selected the book - in fact, I apparently bought the book via Amazon.  Someone could have recommended it, or maybe I saw it while searching for some other book.  Why I read the book is probably not important.  What's important is the fact that it is a really interesting book that is well worth the time, energy, and effort.  And, since process improvement is an important aspect of leadership (particularly in the health care industry), and measurement is crucial to understanding process improvement, I thought I would talk about a couple of the book's take-home points.

Hubbard talks about something he calls the rule of five.  The rule states that "there is a 93.75% chance that the median of a population is between the smallest and largest values in any random sample of five from that population."  It doesn't matter whether the population is 100 or 1,000 or even 10,000, the median of a sample of a five will contain the median of the entire population.  When I first read Hubbard's statement, I didn't believe it.  I have taken a number of statistics classes over the years, and I have been involved with a number of clinical trials over the years as a clinical investigator.  I was always taught that the number of study subjects in a clinical trial was critically important, especially when extrapolating the results from the study to that of the general population.  I can assure you that I was never taught that 5 study subjects was anything close to being sufficient for a clinical trial!

So, what is going on here?  I think the important point to remember is that in many cases, a reasonable approximation of the population's median (of whatever is being measured) is probably close enough for making decisions about process improvement.  Say, for example (and I will use Hubbard's example here) that a company wants to determine whether it makes sense to consider more telecommuting options for its employees.  An important thing to know would be the time required for the company's employees to commute (i.e., how long does it take the employees to drive to work?).  A survey of all the employees (in this case, there are 10,000 employees in the company) could determine the median commute time, but such a survey could be costly and time-consuming.  Conversely, selecting a sample of five employees and measuring the commute time for each employee in the sample could provide a reasonable approximation of the median commute time for the entire company.  According to the rule of five, there is a 93.75% chance that the median commute time of the company is between the smallest and largest values of the sample of five employees.

Still not convinced?  I wasn't either.  Here is the mathematical proof.  Recall that the median is the value (in this case, commute time) that is exactly in the middle of all of the values (i.e., commute times for every employee in the company).  Half of the values are above the median, while half of the values are below the median.  Therefore, if we randomly selected five values, what is the likelihood that the median value for the entire population is within the range of the five values in our smaller sample?  Given that there is a 50% chance (by definition) for each value in the sample to either be above or below the population median, we can calculate the chance that the population median is within the range of the sample.  There is a 0.5 x 0.5 x 0.5 x 0.5 x 0.5 probability that all of the values in the sample are above the median, or 3.125%.  There is also a 0.5 x 0.5 x 0.5 x 0.5 x 0.5 probability that all of the values in the sample are below the median, or 3.125%.  It should be intuitive, then, that there is a 3.125% + 3.125% chance the five values are either not above or not below the population median.  In other words, the chance of at least one value out of the sample of five being above the population median and at least one being below is 93.75%. 

Make sense now?  I had to think about this for a little bit too.  It reminds me a lot of the famous "birthday problem" or "birthday paradox".  Check it out.

Monday, June 25, 2018

"I made a difference to that one."

I served in the U.S. Navy as a pediatrician on the island of Guam, just after residency training.  Our family really enjoyed (and still enjoys) the beach, so living on an island was almost perfect for us.  All of our children especially liked picking up shells and looking at all the sea life that washed up on the shore (starfish, sea cucumbers, and spiny sea urchins were the most common).  I remember my oldest being really fascinated with how blue the starfish were there - the color remains one of the prettiest shades of blue we have ever seen.

With that memory, I recently came across a beautiful, poignant story called, simply, "The Star Thrower."  As it turns out, the story is paraphrased from a 16-page essay by the philosopher and writer, Loren Eiseley.  The story has become quite popular (apparently) on the motivational speaker's circuit and can be readily found on the Internet (see the most popular version, here).  It really has a great message:

One day a man was walking along the beach, when he noticed a boy hurriedly picking up and gently throwing things into the ocean.

Approaching the boy, he asked, "Young man, what are you doing?"

The boy replied, "Throwing starfish back into the ocean.  The surf is up and the tide is going out.  If I don't throw them back, they'll die."

The man laughed to himself and said, "Don't you realize there are miles and miles of beach and hundreds of starfish?  You can't make any difference."

After listening politely, the boy bent down, picked up another starfish, and threw it into the surf.  Then, smiling at the man, he said,

"I made a difference to that one."

Incidentally, the longer, essay version of the story is more philosophical and symbolic, so I like this version better.  Regardless, it is a great story.  We all can make a difference.  Even if it's just one starfish at a time.

Wednesday, June 20, 2018

Gone fishin'

Professional burnout is a serious problem.  Burnout is often designed as a form of job-related stress that results in physical, mental, or emotional exhaustion combined with lingering doubts about an individual's (self-reported) competence and (again, self-perceived) value of personal contributions.  Most studies suggest that professional burnout impacts approximately half of the U.S. workforce.  The percentage of burnout in some professions (notably, physicians, nurses, and other health care professionals) is considerably higher.  Physician burnout can lead to worse outcomes, higher costs, and decreased patient satisfaction with the care they receive.  More importantly, physician burnout can lead, if unrecognized, underappreciated, or untreated, to depression, anxiety, substance abuse, and suicide.


The most frequently cited causes of physician burnout are excessive workloads, loss of autonomy, and the burdens of regulatory compliance and documentation, particularly with respect to the electronic medical record.  While there are a number of important drivers of burnout, work-life balance and the feeling of always being connected to work plays a major role in most studies across a wide range of industries, even in health care.  There is no question that technology has made our lives easier in a number of ways.  However, having a cell phone that allows us to always be available for either a quick telephone call, a text message, or an e-mail can be intrusive.


With this in mind, I recently came across a great suggestion in the magazine, The Atlantic.  The article starts with the writer's own experience of e-mailing a professor to request an interview for another upcoming article.  The writer received (almost immediately) an out-of-office response.  While many of utilize this feature to alert co-workers or colleagues that we are away from the office, this particular message was slightly different.  It read as follows:


 Thank you for your message.  Email received between [these dates] will be deleted from this server eight hours from now.  Please send your message again after [this date].


Wow!  That's perfect!  I was just having a conversation with a colleague the other day who had returned from vacation, only to find "a bazillion" unread e-mails in her Inbox.  Most of the e-mails were actually spam or what I would call "FYI" e-mails (announcing an upcoming lecture presentation or the impending release of the results from a clinical study).  Most of the e-mails did not require action on her part - she simply perused through the long list of e-mails with her finger on the delete button.  She then made a statement that I thought was profound (and one that I have made on a number of similar occasions).  "It would have been easier just to check my e-mail once a day while on vacation."


Is that what we have come to?  Is there truly no escape?  The Atlantic writer goes on to talk about a 2012 study by researchers at the University of California at Irvine that found that individuals who were prohibited from using e-mail for one week experienced significant reductions in their stress levels (as shown by their resting heart rates).  These results remind me of the time when my cell phone died on the drive down to the beach.  I had no way to check e-mail and no one at work could reach me.  It was one of the most relaxing vacations that I have ever had!


So the one counterargument to using an out-of-office message that automatically deletes your e-mails is that it will annoy the individuals that will have to e-mail you a second time.  Fair enough.  But when you realize that more than two-thirds of the e-mail you receive is "spam and noise", maybe that's not so bad.  Or better yet, just think if there was a way to see if someone was actually at work BEFORE sending an e-mail.  If we combined that feature with the automatic deletion out-of-office message above, I think we would have a winner!


We've come a long way from the days when people used to hang a sign on their office doorknob that read, Gone Fishin'.  Perhaps we should revisit that method again...







Sunday, June 17, 2018

Fatherly leadership

Well, my day started with breakfast in bed - it's probably the last time, as all the little birds are leaving the nest.  It was a great breakfast.  We drove over to Indianapolis to celebrate Father's Day with the first man I met and the greatest man I have ever known.  We just got back home about an hour ago and celebrated with a special dinner of homemade banana cream pie (boy, was it good).  I decided to go "Classic Dad" and wear my dress socks with my flip flops.  Really it is a good look!

In all seriousness, today is a day that we celebrate Fathers everywhere.  I was lucky to have one of the best.  I've talked about a few of the lessons he taught me over the years in previous posts.  There is something really special and unique about fatherly advice, and in many ways, I am who I am today as a result of it.  I will leave you with a few of my favorites - those timeless lessons about leadership learned from my Dad:

1. Never stop learning.  Dad was an organic chemist and retired over 10 years ago from a large pharmaceutical company.  He worked there for over 30 years, and I can truly say that he loved his job.  Actually, for him it wasn't a job, it was his passion.  Yet even though he has retired, and he probably doesn't have to, he continues to read about organic chemistry (much to all of his grandkids' amazement).  He never stopped learning.  He taught me to always work hard at learning.  It's a worthwhile investment of time and energy.  The day you stop learning is the day you stop improving yourself, and the day you stop improving is the day you should stop being a leader.  Leaders never stop learning.

2.  Always take care of those you love.  Dad loved being an organic chemist, but he never let it interfere with being a husband and father.  He always put the needs of his family above everything else.  Being a leader is sort of like that too - you should always put the needs of your team above your own personal goals and aspirations.  Leaders take care of their teams.

3.  Never give up.  The Boy Scouts of America played an important role in my father's development, in my development, and my son's development.  Both my son and I are proud Eagle Scouts.  Dad never got the chance, because he didn't know how to swim, and his family couldn't afford swimming lessons.  I was still fairly young, but I remember when Dad went to the local high school to take swim lessons.  He learned how to swim.  He never gave up.  He stood there proudly when I earned my Eagle Scout and when my son earned his.  We shared it with him.  It was his as much as it was ours.  Leaders never give up.

4.  If you do your best and learn what you can, the grades don't matter.  I remember bringing home my first bad report card (it was really bad) following the Spring semester of my second year in college.  Dad's first question - "Did you do your best?"  I had to be honest.  I didn't give it my best, and I knew I could do better.  But what he said next was even more important, "If you learned something, that's all that matters."  Dad felt that as long as I was doing my best, I would learn what I needed to learn to be the best person that I could be.  That's all that mattered to him.  Leaders always give it their best effort and take every opportunity to learn.

5.  Making homemade ice cream requires patience, but it's worth it.  I don't know how many times we made homemade ice cream when I was a kid, but it seemed like we did it a lot.  I used to sit outside with my Dad and watch him patiently add ice and salt to the ice cream machine.  It used to spin and spin and spin.  It went on forever.  Spin and spin.  Add more salt and ice.  Spin and spin.  Add more salt and ice.  He told me to be patient.  All good things come to those who wait.  And when the machine finally stopped spinning, he would give me a taste.  "See, what did I tell you?"  It was definitely worth it.  Leaders know the wait is worth it.

Happy Father's Day to all the Dad's out there.  But most of all, Happy Father's Day to my Dad, who taught me to be a father.  He also taught me to be a leader.  I guess Fathers are like that.

Monday, June 11, 2018

"There's no place like home..."

"Country Mouse" and his wife and youngest daughter made it back home from the "Big City" last night!  There's no place quite like home.  The trip to New York was incredible, and we were able to see most of what we were hoping to see - the Empire State Building, the 9/11 Memorial, Rockefeller Center, Central Park (including Tavern on the Green and the Balto statue), Times Square, Broadway, the Metropolitan Museum of Art (the "Met"), the Natural History Museum, the Dakota (where John Lennon was shot and killed), the Love Statue, the Charging Bull statue (and the Fearless Girl statute too), Wall Street, Battery Park, Ellis Island, the Statute of Liberty, and yes, the no longer infamous (at least in our mind) NYC subway system!  We tasted perhaps the best Banana Cream Pudding that I have ever tasted at Magnolia Bakery.  We paid $4 for a Diet Coke (and argued with the street vendor who tried to jip us by giving us a can instead of the bottle that we paid for).  We ate some great food.  We saw a great musical (Wicked).  Manhattan, Queens, Brooklyn, Staten Island, and the Bronx.  New York City is an amazing place.  But there is still no place like home. 

The trip to New York reminded me yet again of one of the themes that I have come back to a number of times in this blog - expand your boundaries and test your horizon.  I have never been a big fan of art.  Just ask any one of our children about the time we visited an art gallery on a trip to Bern, Switzerland, more or less because it happened to be a rainy day and we had nothing else better to do.  I saw a sign on the wall next to a painting that said "Picasso" and recognized that he was a famous artist (okay, I am not that big of a blockhead).  I commented that the painting was kind of strange and had a lot of blue color in it.  Our youngest daughter told me, "Duh, Dad.  It's from his blue period."  Wait, Picasso had a blue period?  The next Picasso was mostly yellow, so I quickly stated, "This must be from his yellow period."  Nope.  I guess he didn't have a yellow period (but in my defense, apparently he did have a "rose period").  Anyway, I decided to take a visit to New York's Metropolitan Museum of Art (the Met) and really tried to enjoy it (and not make too many dumb comments).

For the most part, I thought the Met was pretty great.  We ended up in the "Modern Art" section, and some of the paintings were a little bizarre, but some of the paintings were really incredible.  I tried my hardest, but I just couldn't refrain from making a comment on one painting, which was called "Photo is the color of my dreams" by an artist named Joan Miro.  I just don't get it.  The entire painting is the word "Photo" painted in one corner of a large square canvas, with the phrase "This is the color of my dreams" in French (I think).  That's it.  The accompanying description made a rather big deal about the fact that the artist also painted nearly invisible lines, "like a primary school student would use to write straight".  Wow.  I wish I would have saved some of our children's kindergarten paintings, we probably could have made a fortune!  All kidding aside, for the most part, I really enjoyed our visit to the Met.  And I am sure that some people - perhaps true art aficionados - really understand and appreciate Miro's painting too.  It's just not quite for me, at least for the present time.

So it's good to broaden your horizon.  It helps change your perspective.  I know our visit to New York and "Photo is the color of my dreams" changed mine.  But, I will say it again.  There's just no place like home...

Thursday, June 7, 2018

"Country Mouse, City Mouse"

There was a book that my wife and I used to read to our kids when they were young about two mice.  One mouse lived in the country ("Country Mouse") and one mouse lived in the city ("City Mouse").  As it turns out, the story was based upon one of Aesop's Fables ("The Town Mouse and the Country Mouse").  All I remember from the story was that the Country Mouse visited the city and decided that she would rather live in the country. 

I know what you are thinking ("Where is he going with this?").  Well, my wife and I recently made a trip to New York City.  It was the second visit here for both of us (other than a number of stops at one of New York's airports to connect with other flights).  Neither one of us had actually seen much of the city though.  We both wanted to go visit the National September 11 Memorial and Museum, which was actually farther from our hotel than either one of us cared to walk.  The easiest (and most comfortable) thing to do would have been to grab a quick taxi ride, but we chose to push beyond our comfort zones and take the infamous New York City subway system.  It happened to be "rush hour," which made it even worse for us.  Just to be clear, both my wife and I grew up in reasonably large cities in the Midwest, we have lived in some fairly large cities on both coasts, and we currently live in a decent-sized city.  New York City, however, is just on an entirely different level.  So, we both felt like the Country Mouse going to the city.

The important thing is that we pushed outside of our comfort zones and challenged ourselves.  We took a risk, albeit a fairly safe risk, but a risk nonetheless.  The reward was well worth it though.  The 9/11 Memorial and Museum is absolutely a must-see for everyone.  It's an amazing place, sad and depressing, yet inspirational and uplifting at the same time.

Leadership is like that some times.  You have to take risks.  You have to push past your comfort zone.  You have to test your boundaries, and when you do, the reward will be worth it.  And you may even learn that the “infamous” NYC subway system isn’t so bad (and is actually kind of fun).

Sunday, June 3, 2018

"The Ancient and Honery Order of Wood Chucks, Inc."

When I was growing up, there was an old television series (I think my parents watched it when they were growing up) that used to play after school on one of our local TV stations in Indianapolis.  I am almost certain that you have heard of it - it was called the "Our Gang" or "Little Rascals" and was a series of short movies produced from (believe it or not) 1922 through 1944.  There was a movie based upon the series that came out in the 1990's, but it wasn't quite the same.  The show was based upon a group of kids from the same neighborhood.  Most of them were poor, but they all seemed to come up with a lot of things to do to have fun anyway.  I used to watch the show almost religiously every day after school.

There was an episode called "Anniversary Trouble" that was particularly famous - it was made in 1935 and included cast members from the older years (Stymie and Jerry) as well as some of the most famous characters (Spanky, Buckwheat, and Scotty).  In this particular episode, the neighborhood gang decided to collectively pool all of their resources (i.e. money) so that they could purchase things that they wouldn't be able to buy individually.  They form a club, called the "Ancient and Honery Order of Wood Chucks, Inc." complete with a President (Stymie), a Treasurer (Spanky),and a secret "high sign" (see image below):
Image result for woodchucks and lil rascals

Sounds like fun, right?  As Treasurer, Spanky is given the responsibility to hold all of the club's money.  Here's the thing, though.  Nobody else in the club trusts Spanky with the money.  As the club meeting adjourns, one of the club members asks Stymie who is going to watch Spanky to make sure he "doesn't take all of our dough."  Scotty is tasked with watching Spanky.  Another club member is tasked with watching Scotty watch Spanky.  Yet another club member is tasked with watching the other club member watching Scotty watching Spanky, and so on, and so on.  In other words, no one in the "Ancient and Honery Order of Wood Chucks, Inc." trusts anyone else!

All teams, no matter the context or setting, are built on mutual accountability and mutual trust.  Without trust, there is no team.  If you watch the rest of the "Anniversary Troubles" episode, you will learn that the "Ancient and Honery Order of Wood Chucks, Inc." lasts for exactly one day.  The club disbands shortly after its founding.  The reason?  Lack of trust.  Everything works out in the end, and the neighborhood kids remain friends.  But the club (or at least the organization that was started to pool their collective monetary resources together) does not last.

Trust is absolutely critical to the success of any team, whether it is a neighborhood club, a sports team, or a group of health care providers.  If you don't trust each and every other member on the team, you don't have a team. 

At times, trust requires a leap of faith.  As the author Ernest Hemingway once said, "The best way to find out if you can trust somebody is to trust them."  And in most cases, the trust that you give is repaid in kind.  That's how groups of individuals become teams.