"What kind of leader makes for a great President?"

For the past several years, I've been reading at least one biography (occasionally more than just one) of all the U.S. Presidents in order, starting with George Washington.  It all started with a book club that I joined at the Cincinnati Mercantile Library.  The book club kept on pace with a six biographies every year, but unfortunately now that I am living in Chicago, I haven't been keeping to that same schedule.  I am currently on our 33rd President, Harry S. Truman (though technically, I read David McCullough's excellent biography of Truman several years ago).  I am hoping to finish up in the next year or two.

I've learned a lot of history while reading biographies of the 45 men (unfortunately, no woman has ever served as our nation's chief executive) who have served as U.S. President.  More relevant to this blog, I've learned a lot about leadership in general.  With that in mind, I read an interesting article ("What kind of leader makes for a great President?") in the Wall Street Journal the other day by Colleen Shogan.  Shogan served as the 11th Archivist of the United States from 2023 to 2025, and she currently serves as the CEO of In Pursuit, a new initiative from More Perfect, to look back upon our first 250 years and "distill its most timeless lessons to inspire and inform our future."  

Shogan asked historians, journalists, military leaders, and civic leaders (including former U.S. Presidents and First Ladies) to identify one lesson from our nation's Presidents and First Ladies and write an essay about it.  She found that "the most consequential American leadership has rarely been loud or ideological.  Instead, it has relied on character, restraint, discerning judgement and a capacity to distinguish between compromise and moral surrender."  Shogan felt that four leadership qualities stood out among all of the other lessons:

1. "The importance of character"

Shogan writes, "Character shapes decisions most clearly when stakes are high and outcomes are uncertain.  Character can serve as a mitigating factor in the face of disaster, while the absence of character often has the opposite effect."

2. "The importance of soft power"

We all know U.S. Presidents who have tried to be effective by exercising what is known as hard power, which is best defined as the ability to coerce others to do what you want through threats, force, or financial leverage.  In contrast, soft power is the ability to persuade and attract others to voluntarily align with your goals through shared culture, values, and policies.  The most successful Presidents and First Ladies didn't have to rely upon hard power.

3. "Compromise with principles"

Shogan writes, "The role of compromise is critical in a democracy, but with an important caveat: Compromise untethered from principled leadership corrodes democratic legitimacy rather than preserving it...The lesson isn't that leaders should refuse compromise.  Rather, they must know what is morally nonnegotiable and understand why.  When compromise becomes an end in itself, it weakens both leadership and legitimacy."

4. "Learning from failure"

Failure is an opportunity to learn, and Shogan suggests that "leadership is often honed by failure...Failure clarifies what success obscures.  It exposes weak assumptions, tests cherished institutions, and forces citizens to confront uncomfortable truths."

I've just found my new favorite podcast!  There is a lesson for every President and many of the First Ladies (see the website here).  There is an essay, audio, and video for every single lesson on leadership.

It's déjà vu all over again...

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

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

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

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

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

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

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

1. Respect the Human Element

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

2. Build Strong Organizational Governance

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

3. Adapt Leadership and Culture to Enable Change

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

4. Ready the Workforce for an AI-Enabled Future

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

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

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

"The Science of Talking to Strangers"

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

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

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

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

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

He writes again:

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

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

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

Why do giraffes have long necks?

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

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

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

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

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

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

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

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

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

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

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

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

1. Integrity

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

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

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

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

2. Intent

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

3. Capabilities

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

4. Results

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

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

Is AI going to replace us?

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

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

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

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

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

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

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

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

The power to command or the courage to serve?

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

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

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

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

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

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

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

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

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

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

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

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

It's a wonderful life

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Leadership Lessons from D-Day

Today, June 6th, 2026 is the 82nd Anniversary of D-Day, the first day of the Allied Forces liberation of Europe during World War II.  General Dwight D. Eisenhower is properly credited for planning and leading Operation Overlord, the code name for the opening phase of the operation, which began with the Allied landings at Normandy on D-Day, June 6, 1944.  I've posted a few times in the past to honor the soldiers, sailors, and airmen that participated in the battle that was the "turning point" during the European Theater of World War II (see, in particular, "Ike's Back-up", "...plans are useless, but planning is indispensable", "D-Day", and "Logistics wins wars!").

I've always been very interested in D-Day and the lessons on leadership that studying Operation Overlord can provide, even to those of us who aren't in the military.  I highly recommend the historian Stephen Ambrose's two books, D-Day and Band of Brothers (Tom Hanks and Steven Spielberg produced a HBO mini-series based upon Ambrose's book called "Band of Brothers" - one of my all-time favorites!).  I also highly recommend The Longest Day by Cornelius Ryan.  I am looking forward to reading Normandy '44 by James Holland in the very near future (it's currently at my bedside), as well as Leadership, Management, and Command: Rethinking D-Day by Keith Grint (I've posted on Grint's model of Leadership, Management, and Command for Wicked, Tame, and Critical problems in the past).  Finally, I am really looking forward to seeing the new D-Day movie "Pressure" starring Brendan Fraser and Andrew Scott.

There's a lot to say about General Eisenhower (the same can be said about President Eisenhower, by the way).  No one but a brilliant strategist and tactician with superb organizational and managerial skills could have possibly orchestrated and supervised combat operations that began with an airborne invasion involving over 1,200 paratroopers, followed by a multi-national amphibious assault involving over 5,000 ships and boats and nearly 160,000 soldiers from the United States, Great Britain, Canada, Australia, Poland, France, and other forces from the Allied nations of World War II.  Suffice it to say, however, I think there are three key leadership points to be made:

Planning is indispensable, Plans are not

As the former heavyweight boxer Mike Tyson once said, "Everybody has a plan until they get punched in the face."  Alternatively, the Prussian war general Helmuth von Moltke (the Elder) said, "No plan survives first contact with the enemy."  Adaptability and agility are both key leadership traits here.  The writer Cicely Simpson has called adaptability "the secret sauce of leadership".  Adaptability is defined in this context as "the capacity to recognize when a situation has changed, relinquish what's no longer working, and orient toward what's actually needed now".  Simpson suggests that it is a combination of flexibility and versatility.  Agility is defined as the ability to manage and deal with change.  The recently released movie "Pressure" tells the story of how Eisenhower and his meteorologist James Stagg had to make last second adjustments to their original battle plans due to changing weather conditions at Normandy.  Again, having a plan is absolutely important.  But both the leader and the plan should be adaptable and agile enough to adjust due to unforeseen circumstances.

Unity of command is necessary

The French general Napoleon Bonaparte once said, "Nothing is so important in war as an undivided command.  There should be only one army conducted by one chief...Better one bad general than two good ones."  The D-Day invasions required unprecedented collaboration and cooperation, not only between the different branches of military service, but between different Allied militaries, each having their own leadership hierarchy.  Eisenhower was named the "Supreme Allied Commander" for a reason.  He had the final say in all of the major decisions, but he was also the one who would be held accountable for those same decisions (he famously wrote, "If any blame or fault attaches to the attempt, it is mine alone" in a letter that he would send if the mission had failed).  There was no other way to manage the clash of personalities and differing interests - and there were many - but, everyone knew that Eisenhower was ultimately in charge.  That's important for leading during any crisis (see Grint's "Command" during "Critical" problems), but even when not leading in a crisis, it's important to know and understand the "rules of the road" in terms of the team's roles and responsibilities, authority, and accountability.  I personally like the "Responsibility Assignment matrix", also known as the RACI matrix, which I feel should be generated anytime a group of individuals gets together to accomplish some task or solve a problem as a group.  It always helps to know who is making the decision.

Empower your front-line leaders

"Deference to expertise" is one of the key defining characteristics of a so-called High Reliability Organization (HRO).  Paratroopers in the 82nd and 101st Airborne Divisions landed off-course during the initial hours of D-Day.  They didn't wait for orders - instead, they improvised and adapted in order to complete their missions.  In contrast, the German soldiers defending Normandy were unable to adjust - they had to wait for orders from the top.  Famously, the German Panzer tank divisions couldn't be used without permission from Adolf Hitler himself, who was still in Berlin at the time!  

The bottom line is that General Eisenhower was the absolute best leader for the mission.  Through a combination of planning, adaptability, agility, trust, and empowerment, the operations on D-Day were successful.  Today, we remember General Eisenhower's leadership and take it as a lesson for what we can do as leaders today.  Today, we also honor the sacrifices of the soldiers, sailors, and airmen who sacrificed their lives on that day 82 years ago.  D-Day marked the beginning of the end - the liberation of Europe from Nazi Germany. 

Blind Taste Tests and the Universal Laws of Success

Now that all of our children are adults, we try to do something fun and unique over the Christmas Holidays.  For example, last year, we each randomly drew a dinner course (cocktail, appetizer, soup/salad, main course, side dish, dessert) and country out of a hat and made an international dinner together.  A couple of years ago, we conducted a blind taste test of different wines.  We selected six different wines from different vintners (all the same varietal - Cabernet Sauvignon) at six different price points, ranging from $5 (very, very cheap wine - I think the label on the bottle just simply said "Wine") to about $120.  Let's just say that the one family member who never drinks wine ended up scoring the highest and winning the contest!

Albert Laszlo-Barabasi mentions another more famous blind taste test involving wine in his most recent book, The Formula: The Universal Laws of Success.  Laszlo-Barabasi is a physicist at Northeastern University and author of a number of books on network science, including one of my favorites, Linked: How Everything Is Connected to Everything Else and What It Means for Business, Science, and Everyday Life.  Laszlo-Barabasi argues that success is often less about individual merit alone.  Instead, success often depends upon social dynamics, networks, timing, and cumulative advantage.  He talks extensively about his "five laws of success":

1. Performance ("how good you actually are") drives success ("how much recognition or reward you receive") - but when performance is hard to measure, networks drive success

When results are objectively measured, the best performer usually wins.  For example, think of all the events in track and field.  It's easy to determine who the winner is - it's always the individual who runs the fastest race or jumps the farthest (or highest).  Contrast those events with figure skating, where performance is subjectively measured by a group of judges.  It's not as easy to figure out who really won.  Just look at the controversy around the ice dancing finals at the recent 2026 Winter Olympics.  Similarly, when it comes to business, politics, art, or academia, performance is almost always subjectively measured, and as a result, people rely more on reputation and personal connections.  Laszlo-Barabasi cites a number of examples, including the world of wine!  Professional wine tasters may not always be reliable when it comes to selecting the best wines, particularly in a blind taste test.  Studies have shown that they can be fooled by items on the wine label (such as the reputation of the vintner) or even the fanciness of the bottle itself.

2. Performance is bounded, but success is unbounded

Laszlo-Barabasi suggests that human performance has natural limits.  For example, there is a reason that it took so long to break the 2 hour barrier in a marathon, which was recently accomplished by two runners, Sabastian Sawe of Kenya and Yomif Kejelcha of Ethiopia at the 2026 London Marathon.  Notably, Eliud Kipchoge of Kenya broke the 2 hour barrier in an exhibition in 2019, though his marathon was not an actual race, but rather a highly controlled, optimized environment with rotating pacemakers and laser-guided pacing.  Given human's physiologic constraints, there will never be a day when someone runs a marathon under an hour.  But while performance has limits, recognition of that performance does not.  A good book can become an overnight bestseller if it was written by a bestselling author, while a great book written by a relatively unknown author may never get read by a large audience.  Similarly, a good wine by a well-known vintner may get all of the best ratings, while at the same time, a great wine made by a lesser known vintner does not.

3. Previous success multiples future success

Laszlo-Barabasi talks about the principle of "cumulative advantage" here, where the "rich get richer" (see also my post on the "Matthew Effect").  Success creates more visibility, more opportunities, more trust, and better network connections, all of which make future success easier.  Momentum matters.  Graduates of prestigious universities often get better job offers.  Famous researchers are often cited more, and they are often successful at getting their research published in the best journals (even when the studies are mediocre at best).  A vintner who has made a good wine in the past will likely sell more wine at higher prices in the future.

4. Team success depends on diversity and balance, but credit usually goes to one person

We know that almost everything that is accomplished in today's society requires a team effort.  Unfortunately, society tends to reward a single visible leader, often calling that leader a "genius" or superstar.  CEO's receive the lion's share of credit for corporate profits.  Scientists are awarded the Nobel Prize, even when the discoveries were made by teams of collaborators.

5. With persistence, success can come at any time

Laszlo-Barabasi uses the label "Q factor" to describe an individual's underlying ability to produce high-impact work.  Because the value of any new idea is largely random, an individual's personal Q factor determines whether that idea becomes a mediocre project or a monumental breakthrough.  The key insight here is that even the most brilliant, high-impact idea will fail to make a dent in the world if executed by someone with a low Q factor. Conversely, a high Q factor allows someone to consistently produce high-impact work even if their individual ideas in a given moment are mediocre.

Laszlo-Barabasi would agree that talent and effort are important.  However, performance must be visible, validated, and socially amplified in order to turn it into success.  Laszlo-Barabasi's five laws of success probably have more to do with how performance is subjectively evaluated than the actual quality of the performance itself.  Whether that performance is ice skating, conducting and publishing a research study, or making wine doesn't really matter.  I will return to the topic of blind taste tests again in an upcoming post.

Workslop

When I was a third-year medical student (many years ago), I rotated for a month on the pediatric neurosurgery service.  I rounded every morning with the senior resident (who actually was the only resident that month) on all of the hospitalized patients that were being treated by the neurosurgeons.  My job was to write the daily progress note in the medical chart, which I did while the resident examined the patient.  The resident basically told me what I should write on the first day of the rotation, and after that I knew what the expectations were for what the daily progress note should look like.  Here is a good example:   

AF/VSS.  Doing well, overall stable post-op course.  Continue present plan.

Just to be clear, "AF" is short-hand for "afebrile" (no fevers) and "VSS" is short-hand for "vital signs stable."  I will admit that there's nothing in that note that could be considered helpful!  The note technically fulfilled the documentation requirements, but in reality my note added almost no clinical value for the next provider (or anyone who had to review the medical record in the future).  

As it turns out, there's a term to describe what I wrote - it's called workslop.  Apparently, the growing use of artificial intelligence (AI) has popularized the term.  I am starting to see a lot of articles on workslop, specifically in the context of AI.  For example, the writer Jill Lepore recently wrote an article for The New Yorker magazine on slop (see "The prehistory of A.I. slop").

Interestingly, the editors at Merriam-Webster's online dictionary named slop as their Word of the Year in 2025.  They define slop as digital content of low quality that is produced usually in quantity by means of artificial intelligence.  Journalist Meghan Bobrowsky at the Wall Street Journal perhaps said it best when she said, "AI Slop is Everywhere".  She writes, "Over the past few weeks, my Instagram has been filled with AI-generated cat soap-opera videos" and fully admits that she spends at least "a few mindless minutes" scrolling through the videos at the end of her day.  Given the purported demand for this kind of digital content, she concludes, "But if the early results - and my own scrolling habits - are anything to go by, it's about to get a lot sloppier."

We hear a lot about AI and how AI is going to replace jobs.  Organizations have invested heavily in AI, but according to a recent study from the MIT Media Lab, 95% of organizations have yet to see any measurable return on their investment.  Workslop may help explain why.  

As a team of investigators from BetterUp recently stated in an article published by Harvard Business Review (see "AI-generated 'workslop' is destroying productivity"), "Employees are using AI tools to create low-effort, passable looking work that ends up creating more work for their coworkers."  They surveyed 1,150 employees across several different organizations and found that 41% reported receiving a specific instance of AI-workslop that adversely affected their work.  Using this data, the investigators estimate that employees in organizations today spend on average 2 hours every day dealing with AI-workslop, which equates to about $186 per employee per month in lost productivity.  For an organization of 10,000 workers, this translates to over $9 million per year in lost productivity!

The aforementioned investigators admit that they focused on the impact of workslop on productivity, but they suggest that "what should really worry leaders is the impact workslop can have on human relationships."  They found that over 50% of workers perceive colleagues who send workslop as less capable, less trustworthy, and less intelligent.  In other words, AI-workslop negatively impacts collaboration, trust, and engagement.  

Some CEOs actually are mandating AI use by the employees in their organization, while other CEOs are telling their employees to "embrace AI or become irrelevant".  Unfortunately, these kinds of  mandates and recommendations will likely increase the prevalence of AI-workslop.

In a follow-up article, again published in Harvard Business Review (see "Why people can create AI 'workslop' and how to stop it"), the BetterUp team suggest that the proliferation of AI-workslop is a failure of leadership and results from a combination of unclear AI mandates and overwhelmed teams.  They had a number of suggestions to make organizations more resistant to AI-workslop.  First, leaders should dial back on unclear, blanket mandates to use AI.  Just like any new technology, implementation of AI requires training and education of the employees within the organization.  Building a culture of trust and psychological safety within the organization is equally as important.  Employees should be able to admit openly that they used AI to develop a work product and feel safe asking for feedback on its quality.  

The BetterUp investigators concluded, "The greatest irony of all is that to make AI work at work, we need to get better at being human.  Leaders need to make space for the unpolished, slower-but-more-rewarding work of human collaboration.  Without organizational changes that enable agency and trust, rather than AI mandates for overburdened teams, we'll all drown in the sludge of workslop." 

“Skin in the Game”

I've been sitting on this post for quite some time, as I wasn't sure whether I wanted to write it or not.  It's a long story, as I have very mixed feelings on the topic.  However, a recent report published in the Journal of the American Medical Association (JAMA) prompted me to finish this post.  The report ("Changes in nonprofit hospitals' finances, operations, and quality of care after using management consultants") used several different data sources to quantify non-profit hospitals' spending on management consultants over a nearly 12 year period.  They next evaluated whether the use of these management consultants had any significant impact on finances, operations, or the quality of care delivered.

The investigators compared 306 US nonprofit hospitals that used a management consultant for the first time in 2010-2022 with 513 matched hospitals that didn't use a management consultant during 2009-2023.  More than 20% of nonprofit hospitals hired a management consultant during the study period, paying an average of $15.7 million for these services.  All told, the nonprofit hospitals in the study spent $7.8 billion on management consultants between 2009-2023.  Financial performance (e.g., revenue, expenses, margins, cash reserves), operational performance (e.g., inpatient utilization, staffing, executive and worker compensation), and quality of care measures (e.g., 30-day mortality, readmission rates) did not appreciably change after the consulting engagement.  In other words, nonprofit hospitals spend exorbitant amounts on management consulting fees with very little return on their investment!

I've read a lot about the management consulting industry over the past few years.  A few years ago, I posted a reply to someone else's post on LinkedIn about the 2023 book, The Big Con: How the Consulting Industry Weakens Our Businesses, Infantilizes Our Governments, and Warps Our Economies by Mariana Mazzucato and Rosie Collington and an accompanying review that appeared in the Wall Street Journal by Barton Swaim (see "The Big Con Review: The Conquering Consultants").  The main premise of the book is that management consultants are becoming increasingly influential in both business and government, but rather than adding value, they are instead oftentimes weakening the organizations that they are trying to help.  As these organizations outsource strategy and other operational functions to the consultants, they lose in-house expertise, creating a vicious cycle in which the organization becomes even more dependent on the management consultant.  If you read the 2014 book The Firm: The Story of McKinsey and Its Secret Influence on American Business by Duff McDonald, you will learn that this is the exact business model for these consultant firms.  They essentially work to make organizations dependent on the consultants for key business functions.

If you are interested in reading further, there are two additional books that I've found to be worthwhile on this subject.  The first is the 2023 book When McKinsey Comes to Town: The Hidden Influence of the World's Most Powerful Consulting Firm by Walt Bogdanich and Michael Forsythe, and the second book a older (published in 2005), but still worth a look, Martin Kihn's  House of Lies: How Management Consultants Steal Your Watch and Then Tell You the Time.  Kihn's central argument is that management consultants frequently repackage common sense recommendations as high-priced expertise, offering fancy slide presentations instead of practical solutions.  The title is self-explanatory - these consultant firms often "borrow" information from clients, reframe it in polished language, and then sell it back to them as strategic insight.

Last, but not least is an old video clip from a 1992 talk that Steve Jobs gave at the MIT Sloan School of Management.  Jobs said that one of the biggest issues with the recommendations that management consultants make is that they are never around long enough to see their recommendations put into action.  They never get the opportunity to learn from their mistakes if the recommendations are not the right ones.  He said, "I think that without owning something over an extended period of time, like a few years, where someone has a chance to take responsibility for one’s recommendations, where one has to see one’s recommendations through all action stages and accumulate some scar tissue for the mistakes and pick one’s self up off the ground and dust one’s self off, one learns a fraction of what one can."  Jobs suggested that management consultants just don't have enough "skin in the game."

As you are reading this post, I may have led you to believe that I am against the practice of bringing in management consultants in general.  That's not necessarily the right conclusion.  I have had some great engagements with management consultants.  However, as I reflect, the engagements that have been the most successful are the ones with a specific, focused problem to solve (e.g., "Let's improve efficiency of operations within the call center").  The ones that have fallen short (in some cases, far short) of success are the ones that have tried to take on too much (e.g., "Let's transform the organization's culture").  

Back to the JAMA article - if these management consultants were brought in to transform the organization by driving improvements in financial metrics, operational metrics, and quality of care, I can't imagine that they would be successful.  As a matter of fact, there is a well-known statistic provided by McKinsey that 70% of organizational transformations fail.  What's not clear is whether organizational transformations succeed any better when management consultants are involved.  The data published in JAMA would suggest that is not the case.