"The goal of all leaders should be to work themselves out of a job."

Retired Navy SEAL, podcaster, author, and leadership consultant Jocko Willink and his partner (also a former Navy SEAL) Leif Balbin wrote a really good book on leadership principle, called Extreme Ownership: How U.S. Navy SEALs Lead and Win.  The essence of the book boils down to one simple principle, summarized by Willink:

“The book derives its title from the underlying principle — the mind-set — that provides the foundation for all the rest: Extreme Ownership. Leaders must own everything in their world. There is no one else to blame."

The book is structured in such a way that each chapter starts with a story from Willink's and Balbin's experience as Navy SEALs in the Wars in Afghanistan and Iraq.  The story illustrates a key leadership principle, which they explain further in the middle section of each chapter.  The chapter then concludes with an example of their leadership principle in practice in a non-military setting. 

The blogger, Jeffri Sandy provides an excellent summary of the key principles in his blog post "10 Lessons from Extreme Ownership":

1. Admit and own mistakes and develop plan to overcome them, and blame no one else.

2. As a Leader, you must demonstrate Extreme Ownership throughout the chain of command down.  There are no bad teams, only bad leaders.

3. As a Leader, you must explain not just what to do, but WHY.  Find out If You don't know.

4. Control your own Ego.

5. Simplify the plan.

6. Prioritize and execute.

7. Build trust with your members.

8. Leading down the command.

9. Leading UP the command.  Don't ask your leader what you should do, tell them what you are going to do.

10. Discipline yourself.

As an example of the last leadership principle, Jocko Willink starts his day every morning around 4:30 AM or so - and just to prove it, he posts a picture of his watch every morning when he wakes up on his Twitter and Instagram site.  It's a great illustration of the "practice what you preach" principle.

Even if you are not in to military stories, there is a lot to learn in Willink's and Balbin's book.  I also don't want to glorify the U.S. Navy SEALs - they are an elite military force for sure, but they have also had their share of leadership problems over the last few years (see here).  I highly recommend the book.

I enjoyed "Extreme Ownership" so much, that I recently checked out their next book, The Dichotomy of Leadership from the library.  Willink and Balbin once again structure this book in the same way that they did in Extreme Ownership - a military story, a brief discussion of the key leadership principle, and an illustration of the leadership principle in a non-military setting. 

The book starts out with an Introduction by Balbin.  He is sharing a personal experience from the War in Iraq in 2006.  He describes a rather tense firefight that seems to be heading in the wrong direction.  His next line is a powerful one:

"Every bone in my body wanted to step up and take charge, bark a verbal command that could be heard over the sound of intense gunfire.  But I wasn't in charge."

Consider this - Balbin was the Platoon Leader in charge of the SEALs in the firefight.  Actually, he was one of those SEALs in the firefight.  On that particular day, the platoon's operation was being led by the Assistant Platoon Leader, who happened to be one of the least experienced SEAL officers in their unit.  Balbin provided some assistance to his junior officer, but he never took control of the situation.  He didn't have to - with a little encouragement and a gentle push, the junior officer led the team to safety and turned a potentially losing firefight into a victory. 

As Balbin stated, "The goal of all leaders should be to work themselves out of a job."  He recognized that his Assistant Platoon Leader needed to have the experience of commanding a field operation under the tense, emotionally-charged, conditions of combat.  By putting his junior officer in charge, he gave him important leadership experience, which ultimately made the whole unit more effective.  He goes on further:

"Trying to navigate between leadership and followership was an example of the Dichotomy of Leadership, the balance that every leader must find between two opposing forces in leadership.  Ready to lead, but also knowing when to follow.  Taking Extreme Ownership of everything that impacts the mission, but also empowering others to lead with Decentralized Command."

We've heard that before - Balbin is talking about one of the foundational principles of High Reliability Organizations, "Deference to Expertise".  I talk about this one a lot, because it is so incredibly important.  But in order to get there, frontline leaders need to have the experience and training to be able to fulfill the mission, whether it is a special forces operation in a war zone, the sales launch of a new product, or taking charge of a code blue team in a hospital.

The goal of every leader is to train his or her direct reports so that they can take charge.  It's actually kind of strange when you think about it.  The goal of every leader is to become superfluous!  Leaders, regardless of the setting, should yield to their "Assistant Platoon Leaders" as frequently as possible, but always remain available to provide coaching, guidance, and mentorship when necessary.  The direct report benefits.  The team benefits.  The leader benefits.  And ultimately, the organization benefits.

"Lovable Losers" once more...

I knew in the first inning (actually, before the first was even a third of the way through) that the Reds were in deep, deep trouble against the Milwaukee Brewers last night.  The starting pitcher for the Reds was missing the strike zone - A LOT.  The one time (well, okay, there were a few more times) he didn't miss the strike zone, Brewers outfielder Ryan Braun hit a grand slam home run.  By the end of the top of the first inning, the Reds found themselves behind 6-0.  And just like that, the Chicago Cubs' season came to an unceremonious close.

Before the game started last night, the Brewers could have knocked the Cubs out of the play-offs with either a win over the Reds or a loss by the Cubs to the Pittsburgh Pirates.  As it turned out, the Brewers got both the win over the Reds, as well as the Cubs' lo, their eighth loss in a row.  Even the casual baseball fan knows that an end-of-the-season play-off race is absolutely the worst time to go on a losing streak.

Unfortunately, no one was surprised by the Cubs' epic flop.  Well, not really.  The season simply did not go well.  What's sad is that most of the key members of the 2016 World Series Champion Cubs team were still part of the organization.  Fans and pundits alike expected this team to be competitive for many years to come.  Some even used the word "dynasty."  While the Cubs were certainly relevant this year, their collapse at the end of this season, combined with last year's end-of-the-year slump (though not as bad as this year's for sure) followed by a loss in a one-game post-season play-off here, can only be summarized with the phrase "lost opportunities." 

So what happened?  There were injuries to some key players this year, including the fact that the 2016 World Series MVP, Ben Zobrist, missed four months in the middle of the season to deal with a family situation.  It's not a great excuse though, as every team experiences injuries at some point.  Just look at the team that eliminated the Cubs from the play-offs - the Milwaukee Brewers - who lost their reigning MVP and superstar, Christian Yelich, to a season-ending injury less than 3 weeks ago.  The Brewers still managed to pull off a winning streak to clinch at least a Wild Care play-off spot, and they remain just one game behind the St. Louis Cardinals for the NL Central Division championship.

The bottom line is that the Cubs just didn't perform.  The starting pitching rotation was horribly inconsistent.  Look no further than Kyle Hendricks, who pitched six scoreless innings against the Pittsburgh Pirates a couple of nights ago before surrendering six runs in the bottom of the 7th inning.  The Cubs had one of the worst win-loss records on the road this year (31-46, not counting the last 3 games of the year that have yet to be played) - it was almost like they were a completely different team when they played outside of Chicago.  They gave up leads late in the game, and they never could seem to win in a one-run game.  They lost four games in a row to the Cardinals this weekend by one run - in every single game!  They even led the Major League in baserunning errors.  Championship caliber teams simply must, and do, perform better than the Cubs did this past year.

Inevitably, whenever a sports team finishes out the year like this, fingers start to point and ask, "Who is to blame?"  And almost always, the fingers start to point at the individual in charge - the head coach or manager.  There's been speculation all season about whether or not the Cubs will extend an offer to Manager Joe Maddon to come back next year.  Maddon has been a good manager for his entire career, so is it really his fault that the Cubs underperformed this year?

Is it fair to blame the head coach or manager when athletic teams underperform?  Do coaches and managers really have that much impact on the success or failure of a team?  Most of the studies performed to date have tried to answer this question by looking at whether a team's wining percentage improves after a coaching change - generally, it does not.  Studies performed since the late 1960's have shown that baseball teams that change managers rarely, if ever, improve their winning percentage.  A recent study found that managers have very little effect on the performance of hitters and pitchers.  Another study used data from 1970-2011 and found that managers, on average, account for about 8.5% of the variation in team performance in Major League Baseball (MLB).  Not very impressive!  Dave Berri summarized the available literature on coaching and team performance for the blog, Freakonomics ("Is Changing the Coach Really the Answer?"), perhaps stating it best:

"It may be true (and more than likely very true) that you are better off with a professional coach than with a random person grabbed from the stands (or no one at all).  But it doesn't appear that the choice of professional coach matters much."

Not a ringing endorsement, right?  However, University of Chicago researchers, Christopher Berry and Anthony Fowler used a slightly different approach in their analysis of data from MLB, the National Basketball Association, the National Football League, college football, and college basketball.  They used a technique that they called, "Randomization Inference for Leader Effects" (RIFLE) to account for effects that are beyond the control of individual coaches.  They found that baseball managers actually account for about 20-30 percent of the variation in an individual team's success.  MLB managers affect the number of runs scored, the number of runs allowed, point margins, and victories (they actually mattered more for the number of runs allowed than for the number of runs scored).  As it turns out, they used the RIFLE method to analyze political leaders too (see the study here) and found that world leaders have significant effects on a country's Gross Domestic Product, and U.S. state governors had important effects on a state's crime level.  So, maybe we should blame Joe Maddon for the Cubs' lackluster performance this season.

These issues are certainly germane to a discussion of leadership in general.  Is leadership important?  Absolutely.  Do leaders have an impact on the of their teams outside of the world of sports?  It depends on who you ask (see the article Do CEO's Matter?" published a few years ago in The Atlantic).  As it turns out, there are a number of studies that show that a corporate leader doesn't really influence his or her company's performance all that much.  As a result, several management theorists have followed the leads of companies like Zappos (see the Harvard Business Review article, Beyond the Holocracy Hype) and Morning Star (see the HBR article (First, Let's Fire All the Managers) and adopted either a flattened hierarchy or self-managed teams.  Similarly, Sam Walker's book (it's a really awesome book, by the way), The Captain Class suggests that it's not the head coach that matters, as much as it is the team captain (Walton analyzed several different teams from several different sports and found that the team captains for each of these dynastic teams shared a number of similar characteristics). 

The problem here is that someone has to be ultimately accountable for a team's performance.  Fair or not, it's generally almost always the head coach, manager, or corporate executive that is the one that is held responsible for a team's poor performance.  Regardless of what he has done for the Chicago Cubs organization, I just don't see how Joe Maddon will be able to keep his job when the season ends this Sunday.  And, as much as I like and respect Maddon, he probably deserves a share of the blame for the way that the Cubs ended their season this year, even if he deserves at least some credit for winning the first World Series Championship for the Cubs in 108 years! 

For now, as much as I hate to admit it, the Cubs are the "Lovable Losers" once more - at least until next year!  Just wait until next year.  There's always next year.

The illusion of control

A few weeks ago, my wife and I tried using the online grocery service at our local Kroger store.  Overall, we were reasonably satisfied with the service.  We completed our grocery list online, ran a few other errands, pulled into the special parking zone at the store, and waited a few minutes for one of the store's employees to bring our groceries to our car.  We did order some fresh produce, and while the bananas (one of my mainstays) were fine, I felt that I would have picked a different (and better) bunch of bananas than what the store employees picked for us.  I'm clearly more of an expert than some random Kroger employee when it comes to my personal tastes in bananas.  As I thought about our experience some more, I remembered a story that I heard in the not so distant past.

How many times have you stepped into a crowded elevator and waited for the elevator doors to close?  How many times have you hit the button on the control panel that is supposed to close the doors?  If you are like me, I bet you probably hit the "door close" button more than once, right?  Perhaps you would be surprised to learn that these buttons do absolutely nothing!  Pushing the button once, let alone multiple times, doesn't do a thing.  The doors are automatically timed to close when they close, and we don't have any control over when they do close (importantly, the "door open" buttons do actually work).

Did you also know that, at least in New York City, pushing the button at the pedestrian crosswalk is an exercise in futility?  Since the late 1970's, most of these signals at pedestrian crosswalks have been automatically timed by a computer.  Pushing the button does absolutely nothing.  Apparently, these buttons at one time did actually work, but the decision was made to leave them in place even after the change to the computerized timing signals was made.

It's our human nature to feel like we have some semblance of control, whether that control involves picking fresh produce, closing elevator doors, or letting the traffic signals know that we are ready to cross the street safely.  The psychologist Ellen Langer called this the illusion of control based upon a study that she published in 1975.  It's actually a fascinating study.  Langer "sold" lottery tickets to 53 office workers for $1 each (in other words, the overall prize for winning the lottery was $53).  Half of the workers were handed a random ticket, while the other half selected the ticket themselves (just like when you have the option of selecting your numbers or having the computer select them for you when you purchase a lottery ticket).  Here's where things get interesting.  A few days before the scheduled lottery, Langer offered to buy back the lottery tickets for any amount of money.  The results are incredible.  The workers who had selected their lottery ticket sold  their ticket back to Langer for an average of $8, while those who were handed their tickets sold their ticket back for an average of only $2!  Simply stated, the office workers were more reluctant to part with their tickets when they had a hand in choosing the ticket, or when they were in control.

The implication is fairly clear, I hope.  Just check out any of the recent studies on employee engagement or physician burnout. One of the commonly cited factors in most studies on physician burnout is a loss of autonomy or control over direct patient care.  Similarly, giving employees at least some control over their work is one of the most frequently suggested interventions for improving employee engagement.  As it turns out, not only do we feel like we have control over things (even when we don't), we absolutely like to be in control.  Taking away even an illusion of control is probably one of the surefire ways of making employees really angry.

It is incumbent on us, as leaders, to provide as much autonomy and control for our employees as possible.  The more we do so, the more our employees will feel empowered, valued, and engaged with their work, all of which will translate to a happier and a more productive workforce.  And when it comes to making changes that could be perceived as taking away some control?  Langer's "illusion of control" study would suggest that we do so at our peril.  Coming full circle and going back to our recent experience, what was our overall impression with the online grocery ordering service?  We'd rather have control over the quality of produce we purchase and won't be ordering our bananas (or any other fruits and vegetables for that matter) online again anytime soon.
        

“Know when to fold ‘em...”

There's a song by the country singer, Kenny Rogers, called "The Gambler."  The chorus has a line that goes, "You've got to know when to hold 'em.  Know when to fold 'em.  Know when to walk away.  Know when to run."  There's something to be said about knowing when to give up on a hand in poker and count your losses.  What's true for poker is many times true in life.


I recently finished the book, Late Bloomers: The Power of Patience in a World Obsessed with Early Achievement" by Rich Karlgaard.  Karlgaard devotes all of Chapter Six ("Quit! Subversive Advice for Late Bloomers") to knowing when to walk away from something.  There are all kinds of books on perseverance and willpower, and I am certain that many of you have heard the saying, "Winners never quit and quitters never win."  Tenacity.  Perseverance.  Persistence.  These are all great traits, but as Karlgaard emphasizes in his book, "Sometimes quitting is the right decision."  He discusses in convincing detail that the research in this area makes three key points:


1. "Tenacity, or willpower is a limited resource." 
As it turns out, there is a limit to tenacity (defined here as doggedness, determination, persistence, perseverance, and resilience).  Several years ago, the psychologist Roy Baumeister published one of my favorite studies of all time about something that he called "ego depletion" (I have posted about this topic a few times before - see, for example, "What do I know of man's destiny? I could tell you more about radishes" or "You're not you when you're hungry...").  Basically, there's a limit to how much willpower we can take.  If we exhaust our willpower on one thing (say, resisting the temptation for that ice cream sundae), then we have less willpower to keep us from doing something that is beneficial to us (maybe going for a 3 mile run) or to stop us from doing something that is not good for us (maybe sitting on the couch and watching television instead of finishing that homework assignment).  Baumeister wrote that willpower is "a scarce and precious resource" - if we push our willpower to exhaustion, it's just like exercising our muscles to our breaking point - we will no longer have enough to get us through and we eventually break down.  Karlgaard writes, "Perseverance applied in meeting others' expectations - whether family, community, or society - will deplete our reserves of willpower.  And then when we really need determination and resolve, we may not have enough left to pursue a new pathway or genuine passion."  In that case, if we are trying to do something against our will, or if our heart just isn't in to it, maybe it is better to quit and re-direct our efforts towards something that we are either fully engaged with or something to which we are passionately motivated to succeed. 


The economist Steven Levitt, the co-author of the book, Freakonomics, has a similar take.  We should recognize, as soon as possible, if a project or new idea just isn't going to be working out.  Rather than continuing to waste precious resources (time, energy, and willpower) on something that is doomed to fail, we should learn from our mistakes and re-direct our efforts on something that has a higher likelihood of success.  He writes:


If I were to say one of the single most important explanations for how I managed to succeed against all odds in the field of economics, it was by being a quitter.  That ever since the beginning, my mantra has been "fail quickly."  If I started with a hundred ideas, I'm lucky if two or three of those ideas will ever turn into academic papers.  One of my great skills as an economist has been to recognize the need to fail quickly and the willingness to jettison a project as soon as I realize it's likely to fail.


The problem is, due to something called the "sunk cost fallacy", our brains are wired in such a way that if we have already invested resources in a project or idea, we are likely to continue to invest those resources even when it's obvious that the project or idea has very little likelihood of succeeding.  Karlgaard emphasizes that we should recognize this tendency and quit before we waste any more time or deplete our willpower reserves.


2. "Quitting can be healthy."
Karlgaard also mentions several studies that show that subjecting ourselves to either the "sunk cost fallacy" or "ego depletion" can be hazardous to our wellbeing.  For example, a number of studies show that our stress hormone levels decrease, our sleep-wake cycles improve, our moods improve, and our immune system works better when we quit trying to achieve difficult or "unattainable goals" (recall my experience with the famous Incline in Colorado Springs, Colorado).  The psychologist Carsten Wrosch has conducted a number of studies in this area that are of interest (check out a few of these studies here and here or search online using the terms "goal disengagement" or "unattainable goals" for some additional examples).  Here, I think, it is always important to push ourselves by setting what are known as "stretch goals" - however, we should also subscribe to the principle of setting so-called "SMART" goals, where the "A" stands for achievable.  In other words, if we want to run a marathon, we should certainly set that goal.  But our goal shouldn't be to run a marathon tomorrow.  We should train for it, so that it is truly an achievable goal.  Doing otherwise can be hazardous to our physical and mental wellbeing.  As Karlgaard writes, "...misplaced tenacity can actually make us sick."


3. "Quitting, not doggedness, often produces better results."
Lastly, Karlgaard writes that "quitting often works."  He goes on further, "Any experienced tech startup founder will tell you how critical it is to know when to quit."  He talks about the late Andy Grove, who at one time was the CEO of Intel.  Apparently, at one point, during the early 1970's, Intel made most of its money on memory chips.  However, by the end of the decade, Japanese and South Korean companies had entered the memory chip market and were undercutting (and beating) Intel on price.  Intel had developed a microprocessor, but the company continued to focus on memory chips instead.  Grove recommended quitting the memory chip business altogether and focusing solely on microprocessors.  He finally asked one of Intel's other co-founders, Gordon Moore (of Moore's Law fame), "What would happen if somebody took us over?  What would the new guy do?"  To which Moore replied, "The new owner would get rid of us and get out of the memory business."  That is exactly what Intel did.


It turns out, Kenny Rogers was absolutely correct.  You do have to "know when to fold 'em."  Quitting, rather than being "for losers" can actually be the smartest decision to make at times.  Knowing when to quit is incredibly important.  Here are a few final tips:


1. It's okay to quit working on a project or idea if doing so is completely disrupting your life to the detriment of your physical and mental health.


2. It's okay to leave a company if your goals are not aligned with the company's.  If you want to make microprocessors and the company doesn't, maybe it's better to just leave. 


3. It's okay to re-focus or re-direct your efforts on a new project or idea - the important point is to learn from your mistakes.  Maybe trying to run a marathon isn't such a good idea after all, and you should try bicycle riding instead! 


4. We should always get out of relationships (and that goes for personal ones, as well as business ones) if the relationship is causing us harm.

EHaaaRrrggggh!

Our Chief Medical Information Officer (CMIO) and I recently had a conversation around an upcoming roll-out of a new upgrade on our enterprise-wide Electronic Health Record (EHR).  It was a good discussion, and I think our team has done a great job planning for this major system upgrade. After our discussion though, I started thinking a little more about the EHR in general.  In spite of their well-documented benefits (most notably, decreased costs and improved outcomes), EHRs have also been a huge source of frustration among providers. 


Don't get me wrong - I am thrilled that we are no longer using paper records in hospitals.  I have witnessed firsthand how much of an impact that our EHR has had on reducing medication errors, improving communication among the different providers on the health care team (especially now that physicians and other providers on the team can actually read the hospital charts!), and improving the coordination of care by allowing easy access to past medical records, as well as access to a patient's current medical data from anywhere in the hospital.  However, for all of their benefits, EHRs have also complicated care in ways that were possibly unanticipated.  For example, the cost of implementation of an EHR is incredibly high - while most hospitals can afford the upfront and ongoing investment of resources required to implement and maintain an EHR, the cost for many office-based physicians is still way too high.  In addition, there is always a significant learning curve between different systems at different institutions (in the latter case, there is little in the way of interoperability or transferability even when the different institutions are using the same EHR vendor).


The learning curve associated with a new EHR can be difficult for sure.  Even more concerning is the fact that in many cases, the EHR is not adapted to the normal workflows used in the hospital or office settings, leading to costly inefficiency.  For example, one study showed that office-based physicians spent only 27% of their time on direct patient care and 49% of their time on EHR and desk work.  Another study showed that for every hour that a physician spent on direct patient care, he or she spent nearly 2 hours on the EHR - these same physicians spent an additional 1 to 2 hours on EHR work at night while at home!  As a result, several studies (here's one) have suggested that EHRs lead to lower job satisfaction and increased work-related stress for providers, and many of these studies cite EHRs as the single most important cause of professional burnout.  An article by the late Pulitzer Prize-winning journalist Charles Krauthammer in the Washington Post even suggested that the EHR was driving many physicians to leave the practice of medicine!


With all of this in mind, and in the context of my recent conversation with our CMIO, I found an interesting article in the pile of unread articles on my desk (remember one of my older posts, "Today's word is...Tsundoku"?) this morning entitled, "How Does the Implementation of Enterprise Information Systems Affect a Professional’s Mobility? An Empirical Study".  The authors of the study (from the Mendoza College of Business at the University of Notre Dame) conducted an investigation to determine whether the implementation of an EHR result in increased turnover of physicians (i.e. physicians leaving one institution for another).  They utilized data from both the Florida Agency for Health Care Administration and the Healthcare Information and Management Systems Society (HIMSS) Analytics Database, so the study was focused only on hospitals and physicians in Florida.  That being said, the final dataset included almost 13,000 physicians working at just over 300 hospitals between 2000 to 2010, for a total of just over 144,000 physician-hospital-years worth of data.


There were three key findings reported in the subsequent paper:


1. If the newly implemented EHR provided what the authors' termed non-trivial complementarities (basically, if physicians thought that the EHR produced benefits that made care more efficient or easier), physicians were more likely to stay at the institution.  Conversely, if the newly implemented EHR significantly disrupted normal workflows and routines, physicians were more likely to leave and go to a different institution.  No real surprises there.


2. Younger (which the authors' defined as those physicians practicing for 10 years or less) and older (defined as physicians practicing for 30 years or more) were far more likely to leave when the EHR disrupted workflow compared to mid-career physicians (those practicing for 10-30 years).  In addition, general practitioners were more likely to leave compared to specialists. 


3. The level of competition and number of previous EHR or IT implementations significantly influenced whether or not physicians left.  In other words, if there were other hospitals close by or if there had been a number of previous EHR or IT implementations at the same hospital, physicians were more likely to leave.


So what is the take-home message here?  First, health care leaders need to recognize that the execution of any EHR implementation or upgrade must go well - therefore, plan ahead!  While the implementation team may get a free pass the first time around, subsequent implementations or upgrades that don't go well will likely increase physician turnover.  Second, involving key stakeholders in the EHR implementation is critical.  Here, physicians, as key constituents, should participate during the initial design and build phase of the implementation.  I was just shadowing one of our ambulatory physicians the other day and noticed that she had to go through a number of steps to document her patient's clinic visit.  There are a number of short-cuts (smart phrases, drop-downs, etc) that could have significantly improved the efficiency of her documentation.  Having end-users be a part of the design and build goes a long way towards aligning the EHR with the normal workflows and routines. 


The study's dataset only went through 2010 - I suspect that more health care systems have already made the change to an EHR.  So, I do wonder if physicians are less likely to leave one institution for another, now that both likely have an EHR.  Regardless, I do think that this particular study sheds light on an important topic.  The EHR has clearly improved documentation for revenue capture (here's one of many available studies on the impact of EHRs on revenue capture), now we need to make sure that the EHR works just as well to make documentation better for providers.

"Lest we forget..."

Today, September 11th, marks 18 years to the day when the world changed forever.  It seems strange that there is now an entire generation alive today that was yet to be born on that fateful day, September 11, 2001.  I remember that day like it was yesterday

I really have no words that can adequately convey what I am feeling today.  So many people died that day.  So many people have died in the wars that followed it.  Many of us - perhaps most of us - either personally knows or knows someone who personally knows, someone who was directly impacted by the events of that autumn day.  Our lives changed in one instant.  It's hard to convey that message to those among us who don't remember or cannot remember because the events happened before they were born.

Country music singer Alan Jackson wrote a song about September 11, 2001.  Like many of us, he first heard of the attacks on the morning news.  Like many songwriters I suppose, he immediately felt the need to write a song about how he felt, but he simply was unable to find the words that could somehow convey his thoughts and emotions.  "I didn't want to write a patriotic song.  And I didn't want it to be vengeful either.  But I didn't want to forget about how I felt and how I knew other people felt that day."

A few weeks later, on October 28, 2001, he suddenly woke up at around 4 AM and the words just came to him.  He got out of bed and wrote his song.  And he first played it to a live audience at the Country Music Association's annual awards show on national television on November 7, 2001.  It is a beautiful song.  Pure poetry.  I can't thing of a better way to remember September 11, 2001. 

Where were you when the world stopped turnin'
That September day?
Were you in the yard with your wife and children
Or workin' on some stage in L.A.?
Did you stand there in shock at the sight of that black smoke
Risin' against that blue sky?
Did you shout out in anger, in fear for your neighbor
Or did you just sit down and cry?

Did you weep for the children, they lost their dear loved ones
Pray for the ones who don't know?
Did you rejoice for the people who walked from the rubble
And sob for the ones left below?
Did you burst out with pride for the red, white, and blue
And the heroes who died just doin' what they do?
Did you look up to heaven for some kind of answer
And look at yourself and what really matters?

I'm just a singer of simple songs
I'm not a real political man
I watch CNN, but I'm not sure I can tell you
The diff'rence in Iraq and Iran
But I know Jesus and I talk to God
And I remember this from when I was young
Faith, hope, and love are some good things He gave us
And the greatest is love

Where were you when the world stopped turnin'
That September day?
Teachin' a class full of innocent children
Or drivin' down some cold interstate?
Did you feel guilty 'cause you're a survivor?
In a crowded room did you feel alone?
Did you call up your mother and tell her you love her?
Did you dust off that Bible at home?

Did you open your eyes and hope it never happened
Close your eyes and not go to sleep?
Did you notice the sunset for the first time in ages
And speak to some stranger on the street?
Did you lay down at night and think of tomorrow
Go out and buy you a gun?
Did you turn off that violent old movie you're watchin'
And turn on I Love Lucy reruns?
Did you go to a church and hold hands with some strangers
Stand in line to give your own blood?
Did you just stay home and cling tight to your family
Thank God you had somebody to love?

I'm just a singer of simple songs
I'm not a real political man
I watch CNN, but I'm not sure I can tell you
The diff'rence in Iraq and Iran
But I know Jesus and I talk to God
And I remember this from when I was young
Faith, hope, and love are some good things He gave us
And the greatest is love
I'm just a singer of simple songs
I'm not a real political man
I watch CNN, but I'm not sure I can tell you
The diff'rence in Iraq and Iran
But I know Jesus and I talk to God
And I remember this from when I was young
Faith, hope, and love are some good things He gave us
And the greatest is love

And the greatest is love
And the greatest is love

Where were you when the world stopped turnin'
On that September day?

So today, of all days, please remember.  Light a candle.  Listen to a song.  Raise a flag.  Say a prayer for peace.  Do whatever you do.  Just remember.  Lest we forget.

Gray-haired wisdom

The ancient Chinese philosopher, Confucius, once said, "By three methods we may learn wisdom: First, by reflection, which is noblest; Second, by imitation, which is easiest; and third, by experience, which is the bitterest."  Wisdom, then, comes with experience.  Here, I using the word experience to refer to life experiences, everything that we learn and experience as we grow older.  The word wisdom is defined as "the quality of having experience, knowledge, and good judgment" (the emphasis on the word experience is mine). 

There is a reason that the U.S. Constitution mandates that individuals must be at least 35 years of age to be eligible to become President of the United States.  In fact (at least according to Wikipedia), the median age of all of the U.S. Presidents at the time that they were elected is 55 years and 3 months.  Theodore Roosevelt was the youngest person to be elected President at age 42 years and 322 days.  Similarly, at least according to one study I found, the average age of CEO's in Fortune 500 companies has increased from age 45 years in 2012 to 50 years in 2017. 

I am not saying that wisdom only comes through being older - an opinion that I at least share with Confucius (which is pretty good company, after all, don't you think?).  There are certainly a number of examples of individuals who have acquired wisdom through reflection and imitation, as Confucius suggested.  I am sure that many of you have heard the common phrase describing individuals who are "wise beyond their years."  However, I also think that is important that we don't discount the fact that wisdom also comes with age ("gray-haired wisdom").

There seems to be a growing trend for hiring younger individuals in a number of industries and disciplines - some would say that we are experiencing a "youth movement."  For example, several teams in the National Football League (NFL) have recently hired younger head coaches.  According to one recent study, the average age of newly hired NFL head coaches over the last 20 years was 48 years, with more than half of them ranging between 42 and 51 years of age.  However, the majority of the head coaches hired this past off season were younger than the median age over the past 20 years, and in fact, younger than the low end of the 42-51 year age range - Arizona Cardinals head coach Kliff Kingsbury (age 40 years), Cleveland Browns head coach Freddie Kitchens (age 44 years), Green Bay Packers head coach Matt LeFleur (age 39 years), Miami Dolphins head coach Brian Flores (age 37 years), New York Jets head coach Adam Gase (age 41 years), and Cincinnati Bengals head coach Zac Taylor (age 36 years).  Not all of the new NFL coaches were younger (Bruce Arians of the Tampa Bay Buccaneers is 66 years of age  and Vic Fangio of the Denver Broncos is 61 years old). 

Why the sudden trend towards younger head coaches?  One reason - Sean McVay.  Three years ago, the  Los Angeles Rams hired Sean McVay as their new head coach when he was only 30 years old.  The team started winning, and in McVay's second season he became the youngest head coach ever in the Super Bowl (the Rams lost to the New England Patriots).  But still - McVay is 24-8, his quarterback (a former number one overall pick in the NFL draft who many pundits thought was going to be a bust after his first NFL season under a different head coach), Jared Goff signed a huge contract this past off-season, and several NFL teams are now looking for the next Sean McVay to try to replicate the Rams' success.

Rich Karlgaard, the publisher of Forbes magazine, writes about the growing trend to hire young in his newest book entitled Late Bloomers: The Power of Patience in a World Obsessed with Early Achievement.  Karlgaard counters with the argument that society's current obsession with the early achievements of wunderkinds is misguided and potentially harmful.  Karlgaard recently told NPR in an interview, "Some people are naturally gifted, focused prodigies. I have nothing against them — in fact, I applaud them.  The problem arises when we think that's the path that's appropriate for all kids, teens and young adults."  Karlgaard suggests that rather than focusing on identifying the next wunderkind (Bill Gates, Mark Zuckerberg, or Sean McVay), we should be looking at so-called "late bloomers" (individuals who find success relatively later in life). 

Karlgaard, who himself became successful relatively later in life, argues that six key characteristics or strengths make late bloomers "worth the wait":

1. Curiosity - There isn't enough evidence to suggest that late bloomers are more curious than early bloomers (and there probably won't be).  However, while early bloomers tend to focus like a laser on one particular area of interest (e.g. a single sport like baseball, playing a musical instrument, or becoming a master at chess), late bloomers explore a variety of disciplines and areas of interest.  As a result, they tend to pick up the label of "lacking focus" in a world that overvalues early achievement.  Rather than being expert in one particular area, late bloomers tend to acquire knowledge and skills in a number of, at times, seemingly unrelated areas of interest.  They use this broad-based, breadth of knowledge ("a mile wide" instead of "a mile deep") to be innovative thinkers and problem-solvers. 

2. Compassion - Late bloomers tend to show greater self-reflection, less ego-centeredness, and compassion and understanding towards others.  They use these insights to understand and help others.  Late bloomers often meander through childhood and early adulthood from one failure to the next.  Importantly, by failing often, they eventually succeed (failure leads to learning, learning eventually leads to success).

3. Resilience - Late bloomers are resilient.  Resilience, or "grit" tends to be an excellent predictor of success.  Dr. Angela Duckworth's research suggests that individuals who test high on the "grit scale" are more likely to complete Navy SEAL training or graduate from West Point (grit is more predictive than athletic ability or intelligence in this regard). 

4. Equanimity - Here, Karlgaard defines equanimity as a certain "mental calmness, composure, and evenness of temper, especially in a difficult situation."  Think of equanimity as "grace under pressure" - late bloomers do extraordinarily well in highly stressful situations.  Certainly, their resilience helps here as well, but it's more than just grit.  Late bloomers, often due to the summation of their life experiences, remain "calm under fire", and research has long established that calm leaders are more effective leaders.

5. Insight - Insight is more than just that "Eureka moment" or "moment of genius."  Karlgaard claims that research shows "our insights are the result of us drawing on our full mental library of experience, patterns, and context, yielding an idea of extraordinary value."  Late bloomers can draw upon their greater collective life experiences to come up with novel ways of problem-solving.

6. Wisdom - Karlgaard presents evidence that strongly supports the notion that wisdom increases with age and experience, which means that we have come full circle.  There is something to be said about "gray-haired wisdom."  In the end, life's experiences matter greatly.  Perhaps we should be focusing less on depth of knowledge in one particular area and instead try to acquire breadth of knowledge in a variety of areas.  Ironically, it's taken me half of a lifetime to figure that out.  In other words, it is only through the wisdom of age that I have come to the realization that breadth of knowledge is just as important as depth of knowledge.  Wisdom begets wisdom, apparently.

Paging Dr, Kildare...

I will occasionally listen to XM Radio's "Radio Classics" on the drive to and from work - one of my favorite shows is "Doctor Kildare", which aired from 1949 to 1951 and starred Lew Ayres in the title role as Dr. James "Jimmy" Kildare and Lionel Barrymore as his mentor, colleague, and friend, Dr. Gillespie (you will likely recognize Barrymore as the villainous Mr. Potter in the Christmas classic, "It's a Wonderful Life").  The radio show was based upon characters created in the 1930's by the author Max Brand (a pen name).  Over the years, the same characters have been used in a novel, several movies (starring both Lew Ayres and Lionel Barrymore), a comic strip, comic book, a 1960 television series (starring the actor, Richard Chamberlain), and a short-lived and relatively unsuccessful 1970 television series.  One of the recurring themes in all of the stories is the relationship between the physicians and the hospital administrator, Dr. Carew. 


Last night, I listened to an episode "Benjamin Barkley", which originally aired on February 15, 1950.  In this episode, Dr. Gillespie is sick and unable to care for one of his frequent patients, an elderly (presumably) and wealthy patient named Benjamin Barkley.  Barkley presents with abdominal pain, fever, and an elevated white blood cell count, and Dr. Kildare makes the diagnosis of acute appendicitis.  Barkley refuses to undergo surgery, and of course asks to speak to the hospital administrator, Dr. Carew.  The first half of the episode calls to mind the issue of the "VIP patient" (see my previous blog post, "Every one of my patients is a VIP"), as Barkley demands special treatment because of his status as a wealthy patient who personally knows the hospital administrator.  I don't want to focus on "VIP patients" today.  Rather, I was interested in the recurring theme on the relationship between the physicians and the administrators, which was further highlighted in this episode.


The relationship between the medical staff and hospital administration is an important one, but it is not always a good one.  There are countless articles in trade journals and chapters in textbooks on health care administration about how to build better relationships between physicians and hospital administrators.  One would think that administrators and physicians mix like oil and water (i.e., they don't).  One proposed solution is for physicians to assume a greater leadership role in hospitals by becoming administrators.  I have certainly written about this issue in previous blog posts.  However, at least in the case of Dr. Kildare's hospital, having a physician-administrator (in this case, Dr. Carew) doesn't necessarily help.


There are just as many articles and textbook chapters about how physician-administrators can help bridge the divide between the medical staff and hospital administration.  Considering the case of Dr. Kildare and other, real-world examples, this is not always a successful solution to the problem either.  Most physician-administrators will tell you stories about how colleagues told them that they were "going to the other side" or "becoming a suit" when they became physician-administrators.  Personally, I have never been told that, though to be honest I continue to treat patients in the hospital on a relatively frequent basis, and I suspect that helps.  However, if I were to be completely honest, there are times when I feel that I am caught somewhere in the middle - I am not necessarily viewed as an administrator, nor am I considered as one of the physicians.


I raise all of these points in light of an article I recently came across entitled "First and foremost, physicians: the clinical versus leadership identities of physician leaders".  The authors of this article conducted a series of interviews with 25 physicians from 4 different hospitals (though all 4 hospitals were from the same larger health care organization).  Approximately half of the physicians were full-time administrators and were not actively practicing medicine, while the remaining half were part-time administrators.  The latter group held different leadership positions within the hospital - Medical Director, Head of a service line, etc and maintained an active clinical practice as well.  The study's findings were incredibly thought-provoking and highly relevant to the current discussion:


1. All physician-administrators (whether full-time administrators who were not actively practicing medicine or part-time administrators who were) self-identified as physicians first and administrators second. 


2. Physician-administrators in a part-time role (e.g., Medical Directors, Heads of service lines) subjugated their leadership roles and prioritized their roles as physicians to the point that they created a self-fulfilling prophecy.  Typical statements included, "What am I?  Vice-something..." or "It's really not that big of a role" or "I have a nominal title of executive director, but I am not really sure what that means."  These part-time physician-administrators claimed that they were motivated to advance organizational priorities and goals but were reluctant to address issues that were not fully supported by their medical staff colleagues.


3. While full-time physician-administrators felt supported (and respected) for their leadership role, part-time physician-administrators did not.  In most cases, part-time physician-administrators did not receive protected time or additional compensation for their leadership role.  Hence, they often felt that their colleagues were "picking up the slack" when their leadership responsibilities took them away from their clinical duties.


I can think of a couple of potential solutions to some of the issues identified in this particular study.  First, I think it is important that full-time physician administrators spend at least a portion of their time in active clinical practice.  If these physician-administrators are going to bridge the gap between the medical staff and hospital administration, they need to spend time in both worlds.  Maintaining an active clinical practice builds trust, establishes credibility, and will help assure mutual respect for the roles that the different sides of the organization play.  Second, leadership training is critically important, especially for part-time physician-administrators.  Being a good physician does not mean that you will be a good leader and manager (being a successful administrator requires both).  Third, part-time physician administrators need to be provided protected time to devote to their administrative duties and recognized throughout the organization for the important role that they play.  


We can certainly learn a lot from Dr. Kildare.  Oh, and by the way, in the end, things turned out just fine for Mr. Barkley.  Dr. Kildare removed his inflamed appendix, and everyone was happy by the end of the episode!