Happy Doctor's Day!

National Doctor’s Day is celebrated every year on March 30th.  The first Doctor’s Day was observed more than 90 years ago, on March 30, 1933 by the Alliance to the Barrow County Medical Society in Winder, Georgia (a small town located just east of Atlanta).  Members of the Alliance selected the date to honor all physicians on the anniversary of Dr. Crawford W. Long’s first administration of anesthesia in 1842.  Of note, Dr. Long used ether during surgery to remove a tumor from the neck of James Venable.  The first Doctor’s Day was observed by sending cards to all the physicians and their spouses, and a red carnation flower was placed on the graves of deceased doctors.  Through a series of resolutions in the years that followed, Doctor’s Day was widely celebrated throughout the southern United States, with sponsorship by the Southern Medical Association.  Eventually, a resolution was adopted and approved by both the U.S. House of Representatives and the U.S. Senate on October 30, 1990 and signed by President George H.W. Bush, designating March 30 as “National Doctor’s Day."  The red carnation remains as the symbol of Doctor’s Day.

I have never been more proud to be a member of this great profession.  We've all had a difficult past few years with everything that has been going on in our world.  Regardless, physicians have been at the forefront leading societal change during one of the most difficult periods in our history.  Importantly, our influence is due in large measure to the trust and respect that society has for our profession.  Physicians are still one of the most trusted of all professions.  As a matter of fact, we are second only to nurses, who have ranked as the most trusted of all professions for more than a decade.

I can honestly say that if I had the chance to do it all over again, I would still choose medicine as my life's work.  Medicine has been my passion and my calling.  Being a physician has made me a better person, and I am incredibly proud to be a member of this esteemed profession.

To all Doctor's - thank you for what you do, each and every day!

Mandatory Education

"Mandatory" and "education" are probably two words in the English language that, when used together, incite strongly negative emotions in hospital employees everywhere.  What perhaps is less appreciated by those same hospital employees is that virtually every organization in just about every industry requires some kind of annual or semi-annual required training.  Let's be honest, most of us, often begrudgingly (and often while multi-tasking) skim through the required slide-decks or online videos hoping to gather enough information to be able to correctly answer the quiz that invariably comes at the end.  And I won't even begin to argue about whether mandatory training as currently implemented is actually effective or not.  I'd be willing to bet that very little of the information in these modules stays with us for much longer than a few minutes after we receive the certificate of completion.

It is with these thoughts in mind that I read an incredibly thought-provoking article in the most recent issue of Harvard Business Review (see "Does Gamified Training Get Results?" in the March/April 2023 issue).  I've learned through the years that I can be easily manipulated through the technique known as gamification (just see my post "All Things Must Pass"  as an example).  Gamification is defined as the addition of the elements of a game to what are typically non-game activities.  These elements include points, badges, and leaderboards.  So, can gamification make "mandatory education" more fun?  More importantly, does gamification make "mandatory education" more effective?  A new study performed at the global professional services firm KPMG suggests that it can (see the working paper "Learning or Playing?  The Effect of Gamified Training on Performance").

The Harvard Business School investigators, Ryan Buell, Wei Cai, and Tatiana Sandino conducted a natural field experiment (which is an experiment conducted in the field where the subjects are not aware that an experiment is taking place) on the implementation of a gamified training tool for the employees at a professional services firm (de-identified in the working paper but revealed to be KPMG in the HBR article).  KPMG wanted to increase their employees' awareness and understanding of the firm's value proposition in order to attract more customers.  The study was conducted in 24 offices participating in the training, which was rolled out at various times in a randomized fashion to create a natural experimental group and control group.  

The gamified training tool was called "KPMG Globerunner" in which employees designed their own avatars who would "race around the world" and answer questions about the firm's service offerings.  Each correct answer would earn travel points, which would open up new travel opportunities for the avatar.  Wrong answers would be corrected with a brief explanation, but no points were awarded.  Employees could also complete mini-game challenges to earn additional points or unlock new levels.  The tool included a leaderboard that showed each avatar and the number of points earned according to rank.

Participation in the training was optional, and employees could engage in the platform as often or as long as they liked.  The HBS investigators analyzed five performance measures on a monthly basis for over 29 months - fees collected, number of clients served, total business opportunities generated, opportunities generated from existing clients, and opportunities generated for new clients.  They also evaluated how much time employees spent on the platform, as well as the number of questions that each employee answered in the training module.  Finally, the investigators analyzed staff engagement, based upon the percentage of employees in each office who logged on to the tool at least once, as well as leader engagement, which was based on how much the leaders in each office played the game.

Analysis showed that the gamified training tool increased the fees collected by participating offices by more than 25% above baseline, while the number of clients increased by 16%.  The investigators also demonstrated that the more employees played the gamified training tool, the more likely the office was to significantly improve performance.  Similarly, offices with engaged leaders also were more likely to improve performance.  Finally, and perhaps most importantly, the impact of the gamified training was sustained for up to 18 months!

These are incredibly promising results!  The study didn't measure the employees' satisfaction with the gamified training platform, but the fact that higher staff engagement with the tool led to greater success at least suggests that they either enjoyed "playing the game" or enjoyed competing with their fellow employees.  KPMG executives were interviewed in an accompanying article in Harvard Business Review, in which it was revealed that 83% of the employees say that they enjoy playing KPMG Globerunner.  As Christian Gossan, a director at KPMG Australia said, "Rote training is boring - but games are the opposite of boring."  Gossan was asked if any employees played the game so much that their productivity decreased.  He responded, "You do need to monitor for that.  Each year a small number of employees - about 1 in 10,000 - become compulsive users, and for their sake as well as the firm's, we need to intervene."

It would be really interesting to see if gamified "mandatory education" could achieve the same level of results (remember that participation in KPMG Globerunner was optional).  Regardless, there appears to be an opportunity here to make mandatory training and education a lot more fun!  

On Top

 I read a book called The Leadership Moment by the author and Wharton professor, Michael Useem several years ago that I really enjoyed.  The book tells nine true stories of both triumph and disaster, which is right up my alley!  I knew some of the stories, including the tragic story of Wagner Dodge and the Mann Gulch Fire (also told in the book, Young Men and Fire by Norman Maclean) and the famous stand by Colonel Joshua Chamberlain and the 20th Maine on Little Round Top during the Battle of Gettysburg (also told in the Civil War novel The Killer Angels and the movie Gettysburg based on the novel).  However, I also learned some new stories, including the story of Arlene Blum, who led the first successful American ascent of the mountain Annapurna I.  I've been intrigued by that story ever since, and I've been wanting to learn more about it.

Annapurna I has been called "The Deadliest Mountain in the World" due to its highest fatality-to-summit rate among the world's 8,000 meter peaks.  Until 2012, the fatality rate (as a percentage of successful summit attempts) was 32%, but that rate has now fallen to under 20% due to a number of successful attempts in the last few years.  The mountain is still quite dangerous due to the number of avalanches, unpredictable weather, and the technical difficulty of its climbing routes.  It is the 10th highest mountain in the world at just 8,091 meters (26,545 feet) above sea level.  The mountaineer Maurice Herzog led a successful summit by an all-French team in 1950, making Annapurna I the first of the 8,000 meter peaks to be successfully climbed.  The mountain is named after the Hindu goddess of the harvest.

A British team successfully reached the summit in 1970, and the first expedition from the United States to reach the summit was the American Women's Himalayan Expedition, an all female expedition team led by Arlene Blum, in 1978.  Blum was an accomplished mountaineer, but expedition mountaineering at that time was largely a male-dominated sport.  Blum had tried to join an expedition to Afghanistan in 1969 and was told that the presence of a female would undercut the "masculine companionship which is so vital a part of the joy of an expedition."  One year later, she had applied to join an expedition of Alaska's Denali (previously known as Mount McKinley, the highest peak in North America) and was told that if she joined, her duties would be restricted to cooking at base camp.  One of her close male friends told her, "You should not sacrifice life on the same altar of egotism that causes men to join the Marines, shoot buffalo, and drive fast cars."  Blum responded by leading her own, all female team that successfully reached the 20,300 foot summit of Denali in 1970.

Blum's early success opened up new opportunities for her, and she was the first American woman to attempt climbing Mount Everest as part of the American Bicentennial Expedition in 1976.  A chance encounter with legendary Polish climber Wanda Rutkiewicz and British climber Alison Chadwick-Onyszkiewicz on an earlier expedition had led to the concept of an all female attempt at Annapurna I, and after her failed summit attempt of Everest, Blum stopped at the Ministry of Tourism in Kathmandu on the way home for a 1978 permit to climb Annapurna I.

Blum recruited a number of experienced mountaineers for her team.  In order to raise the $80,000 required to finance the expedition, the team sold 15,000 T-shirts with the expedition's slogan, "A Woman's Place Is on Top".  The team encountered a number of issues throughout the expedition (including a temporary strike by their team of Sherpas), all of which demonstrated Blum's exceptional leadership skills, as told in Michael Useem's book as well as Blum's own memoir of the expedition, Annapurna: A Women's Place.  Importantly, as of August 1978, only eight climbers had ever successfully reached the summit, and nine other climbers had died during various attempts.  There were only three "established" routes to climb, and Blum decided to use the route known as "The Dutch Rib", as it seemed to have less avalanches, which were a daily occurrence on the other two routes.  

Blum herself decided not to make an attempt at the summit, as she was not feelin well.  However, she knew that as a the team leader, her ultimate success was for the fellow climbers on her team to reach the summit.  She defined the expedition's success by the team's ultimate success, and not by her own personal success.  The first team composed of two climbers (Irene Beardsley and Vera Komarkova - a third climber, Piro Kramer, an eye surgeon, decided to stop after developing frostbite on her right index finger) and two Sherpas (Mingma Tshering Sherpa and Chewang Rinjing Sherpa) of reached the summit on October 15, 1978.  Unfortunately, a second team, consisting of climbers Alison Chadwick-Onyszkiewicz and Vera Watson was not successful, both of whom died on the mountain. 

While the expedition was still viewed as a success (it was even hailed by The New York Times as an "inspiration to women" everywhere), Blum was still criticized for some of the decisions that she had made.  Moreover, the team continued to encounter male chauvinism.  One letter to National Geographic, which had partially financed the expedition, written by mountaineer Galen Rowell said, "Had the men on Annapurna been Americans instead of Nepalese, no one would have gotten away with a claim that this was an achievement by and for American women."  Regardless, in hindsight (we have that luxury), the American Women's Himalayan Expedition broke down significant barriers and opened up opportunities for women in both the sport of mountaineering and in general.  The successful summit attempt by these Americans was an incredible achievement, and I would highly recommend Blum's book and the account written in The Leadership Moment.

 

"Have you been infected yet?"

Once again, the American author, Stoic philosopher, and bookstore owner Ryan Holiday wrote an excellent post today for his "Daily Stoic" blog, entitled appropriately enough, "Have You Been Infected Yet?"  It's not what you think - he wasn't asking if you've been infected with COVID-19 yet.  What he was doing, I think, was comparing the experiences of the ancient Roman emperor and Stoic philosopher Marcus Aurelius during another pandemic called the Antonine Plague.  The Antonine Plague started around 165 CE and lasted for approximately 15 years.  This ancient pandemic was also caused by a virus, believed by most scholars to be either smallpox or measles, and it is believed to have killed anywhere between 1.5 million to 25 million people in the ancient world.  

Holiday suggests that Meditations, which was written by Marcus Aurelius, was a "pandemic book" since it was at least partially written during the Antonine Plague.  He writes, "Marcus Aurelius wrote that there are two types of pestilence in the midst of an epidemic, or indeed any crisis - there is the one that can destroy your life and there is the one that can destroy your character."

Holiday goes on, "Selfishness. Cruelty. Indifference to the fate of your fellow humans. Cowardice. Desperate panic buying. Paranoia. Crippling anxiety. These were things seen in Marcus’s time just as they were seen the last few years. Same goes for scapegoating, demagoguery, misinformation, and all the other things that crisis can bring out of leaders and populations alike. Perhaps you were infected like this. Or perhaps there was something more personal you caught during the pandemic–bad habits, a relapse, screwed up priorities, skewed values."

I have been fortunate during the COVID-19 pandemic, but others have not been as lucky as me.  As we nudge ever so closer to the end of the COVID-19 pandemic, let's all work together to put an end to the other one that seems to have occured with it.  These last three plus years have been incredibly stressful on everyone, but that doesn't give us the excuse to forget how to be kind and respectful.  As Fred Rogers said, "There are three ways to ultimate success: The first way is to be kind.  The second way is to be kind.  The third way is to be kind."

Scale

Did you know that all animals (from the smallest shrew to the largest blue whale) have about 1.5 billion total heartbeats over the course of their lifetime?  We know that rabbits live approximately 3 years, while elephants whose average lifespan is around 80 years.  How can a rabbit and an elephant have the same number of heartbeats during their vastly different lifespans?  The answer is that rabbits have a much higher resting heart rate compared to elephants.  The same is true for most animals (the smaller the animal, the faster the resting heart rate), and there is almost a fairly predictable decrease in heart rate as the body size of an animal increases.  

As it turns out, this mathematical relationship between heart rate and body mass is not unique.  For example, the Swiss biologist Max Kleiber found in the 1930's that an animal's basal metabolic rate is also mathematically related to body mass.  Specifically, metabolic rate scales to the 3/4 power of an animal's body mass, which is now known as Kleiber's Law.  For example, a cat has 100 times the body mass of a mouse, but uses only 31.6 times the same energy as a mouse (the figure below is from an review of the book Scale by Geoffrey West that appeared in the Wall Street Journal).  

 

If you are mathematically savvy, you will note that the scale for both the x-axis (body mass, in kg) and y-axis (metabolic rate, in watts) are logarithmic!  What is remarkable is that all of these different animals fall almost exactly on this line!  The slope of the line is 3/4, which is the exponent in the equation describing the relationship between body mass and metabolic rate.

These relationships between body size and various physiologic variables are known as allometric laws.  More broadly, these relationships have been observed throughout nature and even in disciplines outside of biology.  Geoffrey West (mentioned above) is a theoretical physicist who is now studying complexity theory at the Santa Fe Institute.  West and his team have described a number of what are now called nonlinear scaling relationships (or scaling laws) when studying the characteristics of cities and even organizations!  

Certain characteristics of modern cities, supply chain networks, and transportation can be described by these scaling laws.  So, for example, the number of gas stations per capita, the number of water pipes, or even the average income can all be described by these nonlinear scaling relationships.  Similarly, the average lifespan of a corporation, as well as its market share, number of policies and regulations, and profits are also related to its size.  West gave a TED talk called "The Surprising Mathematics of Cities and Corporations" that is very interesting.

My argument here is that even though our world is incredibly complex, there is a surprisingly vast amount of order in our world too.  As leaders, we should take some time to understand the relatively new fields of complexity theory, chaos, and network science.  As one of my favorite leaders, Winston Churchill, once said, "Out of intense complexities, intense simplicities emerge."

Herzberg's Two Factor Model

Frederick Herzberg was an American psychologist who is perhaps best known for his theories on job enrichment and motivation in the workforce.  His 1968  article, "One more time: How do you motivate employees?" is a classic in management theory and one of the most frequently requested and downloaded articles from the Harvard Business Review.  The article provides a high-level overview of his Motivator-Hygiene Theory , also known as the Two-factor theory.

Herzberg developed his theory after interviewing over 200 engineers and accountants , primarily in the Pittsburgh area, asking them specifically to describe times in their professional lives when they were happy and unhappy with their work.  He and his colleagues both verified and further corroborated their findings in a number of subsequent studies published in the late 1950's and early 1960's.  The fundamental concept (and I believe the most important one) is that job satisfaction and job dissatisfaction are not opposites of each other.  The opposite of job satisfaction is not job dissatisfaction, but rather no job satisfaction.  Similarly, the opposite of job dissatisfaction is not job satisfaction but no job dissatisfaction (all of this reminds me of the Kano model of customer satisfaction, but that is a topic for another day).

The "two-factor theory" comes from Herzberg's findings that there are two broad categories of job characteristics that are important for job satisfaction.  The first category was associated with "the need for growth or self-actualization" and included achievement, recognition, the work itself, level of responsibility, advancement, and the potential for professional growth and development.  Herzberg called these "motivators" and felt that they were intrinsic to the job itself.  The second category involved "the need to avoid unpleasantness" and included company policies and administration, relationship with supervisors, interpersonal relationships, working conditions, and salary.  Herzberg called this second category "hygiene factors" and felt that they were extrinsic to the job.  

Importantly, "motivators" work to increase job satisfaction, while "hygiene factors" work to reduce job dissatisfaction.  Herzberg described these two factors as follows (see also the diagram below):

"The factors on the right that led to satisfaction (achievement, intrinsic interest in the work, responsibility, and advancement) are mostly unipolar; that is, they contribute very little to job dissatisfaction. Conversely, the dis-satisfiers (company policy and administrative practices, supervision, interpersonal relationships, working conditions, and salary) contribute very little to job satisfaction."

Importantly, the presence of "motivators" can produce job satisfaction, but their absence leads to no job satisfaction and not necessarily job dissatisfaction per se.  Similarly, the presence of "hygiene factors" can reduce job dissatisfaction but cannot cause job satisfaction.  

Herzberg's Two Factor Model certainly builds upon and incorporates some aspects of Maslow's Hierarchy of Needs, which is perhaps better known.  One of the main arguments against the Herzberg model is that it has more to do with job satisfaction (and job dissatisfaction), which is related but not equivalent to motivation.  The word motivation comes from the Latin word movere, which means "to move."  Motivation is thus defined as how to stimulate or drive someone to action, i.e. to move.  Someone can be satisfied with their work and still not be motivated (think of someone who is just "going through the motions" or even "quiet quitting").  Conversely, someone can be quite motivated to do the work, even if it doesn't make them feel happy.  I have previously discussed the differences between intrinsic and extrinsic motivation (see, for example, my post "Holes").  Regardless, I do find that the Herzberg Model is a valuable and important contribution.  Job satisfaction and motivation are both incredibly important and complex topics, which I hope to return to in some future posts.

An Irish Blessing

Sometimes, you just have to get into the spirit!  Here are two of my all-time favorite Irish blessings for you:

"May the road rise up to meet you.  May the wind be always at your back.  May the sun shine warm upon your face.  May the rains fall soft upon your fields.  And, until we meet again, May God hold you in the palm of his hand."

"May there always be work for your hands to do.  May your purse always hold a coin or two.  May the sun always shine on your windowpane.  May a rainbow be certain to follow each rain.  May the hand of a friend always be near you.  May God fill your heart with gladness to cheer you."

Happy St. Patrick's Day!