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Over 500,000 people visited Farnam Street last month to expand their knowledge and improve their thinking. Work smarter, not harder with our free weekly newsletter that's full of time-tested knowledge you can add to your mental toolbox.
Krista Tippett, whose wonderful book Becoming Wise: An Inquiry Into the Art of Living distills many of her conversations, offers us a window into exploring ourselves and others, through generous listening and asking better questions by moving away from the false refuge of certitude.
On the art of starting new kinds of conversations Tippett offers shining wisdom, countering the notion that we need to win or lose.
I find myself drawn to black holes in common life— painful, complicated, shameful things we can scarcely talk about at all, alongside the arguments we replay ad nauseam, with the same polar opposites defining, winning, or losing depending on which side you’re on, with predictable dead-end results. The art of starting new kinds of conversations, of creating new departure points and new outcomes in our common grappling, is not rocket science. But it does require that we nuance or retire some habits so ingrained that they feel like the only way it can be done. We’ve all been trained to be advocates for what we care about. This has its place and its value in civil society, but it can get in the way of the axial move of deciding to care about each other.
Listening is an everyday act, and perhaps art, that many of us neglect.
Listening is more than being quiet while the other person speaks until you can say what you have to say.
Tippett introduces us to generous listening, language she picked up from a conversation with Rachel Naomi Remen, who uses it to describe what doctors should practice. Tippett explains:
Generous listening is powered by curiosity, a virtue we can invite and nurture in ourselves to render it instinctive. It involves a kind of vulnerability— a willingness to be surprised, to let go of assumptions and take in ambiguity. The listener wants to understand the humanity behind the words of the other, and patiently summons one’s own best self and one’s own best words and questions.
Of the many reasons we would want to engage and renew our listening skills, asking better questions is near the top.
[W]e trade mostly in answers— competing answers— and in questions that corner, incite, or entertain. In journalism we have a love affair with the “tough” question, which is often an assumption masked as an inquiry and looking for a fight. … My only measure of the strength of a question now is in the honesty and eloquence it elicits.
Questions are the means by which we explore ourselves, each other, and the world.
If I’ve learned nothing else, I’ve learned this: a question is a powerful thing, a mighty use of words. Questions elicit answers in their likeness. Answers mirror the questions they rise, or fall, to meet. So while a simple question can be precisely what’s needed to drive to the heart of the matter, it’s hard to meet a simplistic question with anything but a simplistic answer. It’s hard to transcend a combative question. But it’s hard to resist a generous question. We all have it in us to formulate questions that invite honesty, dignity, and revelation. There is something redemptive and life-giving about asking a better question.
Questions themselves can offer no immediate need of answers. Counter to our notion that everything must have an answer, some of the most worthwhile questions are the ones with no immediate answers.
And yet we insist on dividing so much of life into competing certainties.
We want others to acknowledge that our answers are right. We call the debate or get on the same page or take a vote and move on. The alternative involves a different orientation to the point of conversing in the first place: to invite searching— not on who is right and who is wrong and the arguments on every side; not on whether we can agree; but on what is at stake in human terms for us all. There is value in learning to speak together honestly and relate to each other with dignity, without rushing to common ground that would leave all the hard questions hanging.
In a way answers are like the goals that Scott Adams brought to our attention — a false, but comforting, refuge. Yet, for many of us probing ourselves with questions about how we should live and what it means to be a citizen in a global world, it is in the search that we find meaning.
“Trust is the expectation that arises within a community of regular, honest, and cooperative behavior, based on commonly shared norms, on the part of other members of that community.”
— Francis Fukuyama
Our society is largely based on trust. In fact, it is so ubiquitous we suspect you don’t normally notice it’s influence; for most of us, it is largely habitual.
Trust has evolved as our interactions and influence have become more entwined over time, and the complexity of society has increased. It’s not just our social interactions that have adapted over the years; our tools and technology have also changed dramatically.
This backdrop makes for a fascinating discussion by security technologist Bruce Schneier in his book Liars and Outliers: Enabling the Trust That Society Needs to Thrive By. The book outlines how society establishes and maintains trust and tackles some core concepts related to trust from the past, present, and future.
Why is trust such an important aspect of our society? Part of it is because of the sheer complexity of how our species is linked and interacts.
All complex ecosystems, whether they are biological ecosystems like the human body, natural ecosystems like a rainforest, social ecosystems like an open-air market, or socio-technical ecosystems like the global financial system or the Internet are deeply interlinked. Individual units within those ecosystems are interdependent, each doing its part and relying on the other units to do their parts as well.
To get a better idea of the sheer breadth and depth of this, take a moment to think about situations in your day to day where you choose (consciously or unconsciously) to trust. In the act of driving you are trusting: your fellow drivers, your car manufacturer, the gas station, and your mechanic. When eating in a restaurant you are trusting: your waiter/waitress, the cooks preparing the food, and the farmers who provided the raw ingredients.
We have learned through experience that we can trust somewhat implicitly in these situations, it is rare that someone breaks our trust in the above examples but it does happen.
…all complex ecosystems contain parasites. Within every interdependent system, there are individuals who try to subvert the system to their own ends. These could be tapeworms in our digestive tracts, thieves in a bazaar, robbers disguised as plumbers, spammers on the Internet, or companies that move their profits offshore to evade taxes.
Or… a driver that passes you while texting and a restaurateur violating food health and safety codes to save money. These parasites are good examples of failures of trust. And what they all have in common is a conflict between the interests of society as a whole and the interests of specific individuals or a small group.
This conflict is perfectly normal. You will never have a state where absolutely everyone agrees, and this is a good thing. For example, someone might break the trust for what they believe to be moral reasons, not for selfish or petty reasons. History shows us that those who defy the group norm can even become the catalysts for dramatic, and much needed, social change.
Compliance isn’t always good, and defection isn’t always bad. Sometimes the group norm doesn’t deserve to be followed, and certain kinds of progress and innovation require violating trust. In a police state, everybody is compliant but no one trusts anybody. A too-compliant society is a stagnant society, and defection contains the seeds of social change.
On a micro level everyone defects sometimes. We are as complex as the society in which we live. We will agree with some societal norms and therefore cooperate in those moments, but at other times we may not agree and could defect. This is situational as well, we react differently when we are in desperate situations. We would all steal food if we had a starving family at home. (Or maybe worse, in the case of a truly awful situation.) We are far less likely to defect when all our needs are cared for.
Schneier argues it’s the scope of the defection that we should be worried about.
What we’re concerned with is the overall scope of defection. I mean this term to be general, comprising the number of defectors, the rate of their defection, the frequency of their defection, and the intensity (the amount of damage) of their defection.
The scope of defection is important because the level of cooperation/trust in a society is often indicative of health. Sociologist Barbara Misztal identified three critical functions performed by trust:
1. It makes social life more predictable,
2. It creates a sense of community, and
3. It makes it easier for people to work together.
If the rate of defection is too high then these critical functions are not being met. (As Charlie Munger likes to say, the highest form a civilization can reach is a seamless web of deserving trust.)
Since a healthy, thriving society requires a certain level of trust, we can attempt to nudge possible defectors into complying with the societal norms. The dilemma occurs when an individual has to make a choice between the group interest and their personal competing interest. The idea is that we can add societal pressure that can induce cooperation over selfishness in these types of situations.
In the book Schneier outlines four basic categories of societal pressure:
Moral pressure — A lot of societal pressure comes from inside our own heads. Most of us don’t steal, and it’s not because there are armed guards and alarms protecting piles of stuff. We won’t steal because we believe it’s wrong, or we’ll feel guilty if we do, or we want to follow the rules.
Reputation pressure — A wholly different, and much stronger, type of pressure comes from how others respond to our actions. Reputational pressure can be very powerful; both individuals and organizations feel a lot of pressure to follow the group norms because they don’t want a bad reputation.
Institutional pressure — Institutions have rules and laws. These are norms that are codified, and whose enactment and enforcement is generally delegated. Institutional pressure induces people to behave according to the group norm by imposing sanctions on those who don’t, and occasionally by rewarding those who do.
Security systems — Security systems are another form of societal pressure. This includes any security mechanism designed to induce cooperation, prevent defection, induce trust, and compel compliance. It includes things that work to prevent defectors, like door locks and tall fences; things that interdict defectors, like alarm systems and guards; things that only work after the fact, like forensic and audit systems; and mitigation systems that help the victim recover faster and care less that the defection occurred.
The book goes on to explain these concepts in greater detail as well as taking a look back at the evolution of cooperation, trust, and security.
Schneier also tackles issues like the influence of technology and what the future will bring. In all, Liars and Outliers is a fascinating look at how society enforces, evokes and elicits trustworthiness and compliance, as well as an interesting look at the role of the defector as either a catalyst for social change or the creator of risk in a healthy society.
I'll bet you think this article is about you.
“We all know selfishness when we see it,” writes essayist Kristin Dombek opening The Selfishness of Others: An Essay on The Fear of Narcissism. She's right. We see it everywhere from TV to family and lovers. Playing in the tension between pathology and common selfishness, her book offers a thought-provoking look at how narcissism became a cultural phenomenon and repository for our fears.
What is wrong with the narcissist she asks?
This is harder to know. If you see the smile on the face of a murderer, you must run. But if you are unlucky enough to love someone who seems suddenly so into himself that he doesn't care who he hurts, someone who turns from warm to gone when he doesn't need you, so self-adoring or wounded he meets criticism with violence or icy rage, who turns into another person in front of your eyes, or simply turns away when he said he'd be there—if you love someone who seems to have the particular twenty-first-century selfishness in some more subtle, or worse, invisible way, you will likely go to the internet for help.
The internet of course offers answers to even the wrong questions.
You'll read, in that seizable portion of the self-help internet we might call, awkwardly, the narcisphere, a story that can change the way you see everything if you start believing in it, giving you the uncanny but slightly exciting sensation that you're living in a movie. It's familiar, this movie, as if you've seen in before and it's a creepy one, but you have the most important role in the script. You're the hero.
The basic script plays out like this.
At first, the narcissist is extraordinarily charming, even kind and sweet. Then, after a while, he seems full of himself. It could be a “he” or a “she,” but let's stick with “he.” That's what you start to think, when you know someone like this: he's full of himself. But the narcissist is empty.
Normal, healthy people are full of self, a kind of substance like a soul or personhood that, if you have it, emanates warmly from inside of you toward the outside of you. No one knows what it is, but everyone agrees that narcissists do not have it. Disturbingly, however, they are often better than anyone else at seeming to have it. Because what they have inside is empty space, they have had to make a study of the selves of others in order to invent something that looks and sounds like one. Narcissists are imitators par excellence. The murderer plagiarized most of his manifesto, obviously and badly, but often narcissists are so good at imitating that you won't even notice. And they do not copy the small, boring parts of selves. They take what they think are the biggest, most impressive parts of other selves, and devise a hologram of self that seems superpowered. Let's call it “selfiness,” this simulacrum of a superpowered self. Sometimes they seem crazy or are really dull, but often, perhaps because they have had to try harder than most to make it, the selfiness they've come up with is qualitatively better, when you first encounter it, than the ordinary, naturally occurring selves of normal, healthy people.
Because for the narcissist, this appreciation of you is entirely contingent on the idea that you will help him to maintain his selfiness. If you do not, or if you are near him when someone or something does not, then God help you. When that picture shatters, his hurt and his rage will be unmatched in its heat or, more often, its coldness. He will unfriend you, stop following you, stop returning your emails, stop talking to you completely. He will cheat on you without seeming to think it's a big deal, or break up with you, when he has said he'd be with you forever. He will fire you casually and without notice. Whatever hurts most, he will do it. Whatever you need the most, he will withhold it. He cannot feel other people's feelings, but he is uncannily good at figuring out how to demolish yours.
It isn't that the narcissist is just not a good person; she's like a caricature of what we mean by “not a good person.” She's not just bad; she's a living, breathing lesson in what badness is.
Immanuel Kant offered a formulation for how to do the right thing: Asking yourself, if everyone acted this way, would the world be a better place? Good people, we tend to believe, will treat others as the ends themselves, not the means. Narcissists, along with psychopaths, do the opposite. For them, people are the means toward other ends. “If everyone were to follow suit,” Dombek writes, “the world would go straight to hell.”
The realization that the narcissist, not so much selfish as not really having a self, changes everything. Suddenly you can see them for what they are: puppets or clowns. While they may look human, they are not.
So what should you do when you are confronted with a narcissist?
It seems no matter what you answer, you'll be haunted forever. With equal certainty the internet offers two pieces of common advice: love them and expect nothing and hope that they change, or run as fast and as far as you can.
If the prevailing wisdom that narcissism is becoming more and more common is indeed true, today's prevailing advice doesn't scale.
Kant's advice no longer holds. But that is not the worst of it. Running is an act of the very same coldness described by the diagnosis. What if the only way to escape a narcissist is to act like one yourself?
The question of the selfishness of others, though, leads quickly to the very difficult question of how we know things about others at all, and the mind-knotting question of how we know things at all.
Dombek goes on to explore provocative questions of ourselves—most of us can be put in environments where we display situational narcissisms; why is having a boyfriend or boss like having a villain; why do the narcissistic descriptions of others (“in moments you quietly bury deep inside you”) remind you of yourself.
Edward Deci’s work on motivation is so often quoted (Dan Pink's Drive comes to mind) that we decided to go back to the primary text by Deci himself, a book called Why We Do What We Do: Understanding Self-Motivation.
The author is probably best known for his thoughts on the role of autonomy in intrinsic and extrinsic motivation. Deci co-developed the Self-Determination Theory with Richard Ryan.
Deci and Ryan believed that people naturally develop through a process of engagement and interaction with the world and that said interaction tends to be driven by a “movement toward greater consistency and harmony within.”
The urge to develop an integrated sense of self is thus a central feature of who we are as individuals, and the activity — both physical and mental — that is necessary for this natural developmental trajectory is intrinsically motivated.
This intrinsic motivation is both driven by three innate psychological needs:
In Deci's view, when the needs are being fulfilled, we will have plenty of motivation. When there are obstacles between us and these needs, it will be demotivating.
In our day to day lives, we will interact with the environment and we will integrate what we feel and learn from these interactions into our sense of self. Think of this like a continuous feedback loop. This environment is littered with societal influences, which can be motivating or demotivating, depending on how they interact with our innate needs and sense of self.
Deci uses an example of a young “artistic athlete.” This individual, who has talent both in an athletic arena and with artistic expression, will ultimately be tugged at times towards being an artist or athlete. To feel authentic to themselves, they will need to find a way to express themselves in both of these realms. If they don’t then they won’t be able to feel that sense of harmony; the self they are reflecting to the world won’t be consistent with the self they feel within.
Ideally, both aspects of this individual need to be nurtured, which Deci calls “autonomy support” — supporting the development of a whole, integrated person.
To characterize our perspective more formally, we view human behavior and experience in terms of the dialectic between the person and the environment – the interaction (and potential opposition) between the active organism striving for unity and autonomy and the social context that can be either nurturing of or antagonistic toward the person’s organismic tendencies. Synthesis occurs when there is enough support in the social context so that the natural, proactive tendencies are able to flourish. But in the absence of adequate supports, not only will intrinsic motivation be undermined, but so too will the development of a more integrated or coherent sense of self.
Deci and Ryan discovered that there are specific social contexts that can undermine this integration.
First, those social contexts that are excessively inconsistent and chaotic. These situations make it next to impossible for people to know what is expected of them: They can’t understand how to behave as there is no consistent feedback, which tends to leave people with little to no motivation (they can’t tell if they are being effective and will feel less a part of the group/situation – no competence, no relatedness).
Second, those social contexts which are extremely controlling. These environments pressure people into certain types of behavior and removes autonomy. The people who comply with the demands tend to become almost robotic at times. Whether the individual is complying with or actively defying the controls, they are not acting autonomously.
Autonomy is the key; without it, Deci believes people will lose their motivation and worse, it will hinder their development.
To develop in a natural and healthy way people need to perceive that they are in a “psychological state of feeling free.” People tend to know when they are being controlled, even if they can’t name it, they feel it. We can’t even trick ourselves, sometimes we think we truly want something but we are actually doing it out of a sense of obligation or fear.
Some people believe that our need for autonomy and our need for others is inherently contradictory. Not so, says Deci:
People have often portrayed the needs for autonomy and relatedness as being implicitly contradictory. You have to give up your autonomy, they say, to be related to others. But that is simply a misportrayal of the human being. Part of the confusion stems from equating autonomy and independence, which are in fact very different concepts.
Independence means to do for yourself, to not rely on others for personal nourishment and emotional support. Autonomy, in contrast, means to act freely, with a sense of volition and choice.
So how do we nurture those around us to help them become the best, authentic version of themselves? Deci and Ryan talk about this in terms of helping people to internalize values/regulations.
They believe there are two distinct types of internalization: Introjection and Integration. Introjection is akin to swallowing a rule whole without thought, whereas integration is more like chewing and digesting a rule. This the optimal form of internalization.
The behavioral output of introjection—swallowing a rule whole—are things like rigid compliance, halfhearted adherence and sometimes even defiance.
Introjected values and regulations can thus result in a variety of outcomes, but none of these is optimal. Clearly the half-heartedness and the rebellion are good for neither party. And while the rigid compliance may please the socializing agents who prompted it, there are serious costs to be borne by the people who comply.
This introjection manifests mostly in a lack of vitality and enthusiasm. It’s hard to be motivated when you are focused on pleasing others instead of being authentic to yourself.
So how can we focus on helping people integrate the regulations and values that will help them to develop to their full potential?
If you put a rooted avocado pit in a pot of earth it will probably grow into a tree, because it is in the nature of avocados to do that. It happens naturally. But not all pits become trees; some shrivel and decompose. They fail to thrive because the climate is inadequate, or the necessary nutrients are lacking. They need sun; they need water; and they need the right temperatures. Those elements do not make trees grow, but they are the nutriments that the developing avocados need, that are necessary in order for the avocados to do what they do naturally.
The metaphor is simple but poignant. Too often we ask the avocado pit to grow into an apple tree. You can try to nudge that avocado into becoming something else but it will never happen, and you will both be miserable.
It all comes down to autonomy support, according to Deci:
It is particularly interesting that autonomy support, which was a crucial contextual nutriment for individuals’ maintaining intrinsic motivation and as a result being more creative, processing information more deeply, and enjoying their activities more, also turns out to be essential for promoting internalization and integration of the motivation for uninteresting, though important, activities.
At one level of analysis, autonomy support means to relate to others – our children, students, and employees – as human beings, as active agents who are worthy of support, rather than as objects to be manipulated for our own gratification. That means taking their perspective and seeing the world from their point of view as we relate to them. Of course, autonomy support may require more work, but then, as socializing agents, that is our responsibility. For us to expect responsibility from others, we must accept our own responsibility as the agents of their socialization.
Autonomy support is not the same as being overly permissive. Having no limits or regulations will create inconsistent and chaotic environments that are no better to generating feelings of autonomy and full development.
Permissiveness is easy, but autonomy support is hard work. It requires being clear, being consistent, setting limits in an understanding, empathic way.
People will continue to make mistakes; that's human nature (and it’s often a byproduct of trying hard things). Reacting with either heavy-handedness or permissive indifference does not help. Setting the environment for growth and trying to understand the situation from the other person’s point of view is the best course of action.
We all have the need for autonomy, to feel competent, and to relate to others. If you want to learn more about motivation in yourself and others pick up Why We Do What We Do, it’s well worth the read. The other influential book on motivation in recent years is Daniel Pink's Drive.
The biologist Lewis Thomas, who we've written about before, has a wonderful thought on creating great organizations.
For Thomas, creating great science was not about command-and-control. It was about Getting the Air Right.
It cannot be prearranged in any precise way; the minds cannot be lined up in tidy rows and given directions from printed sheets. You cannot get it done by instructing each mind to make this or that piece, for central committees to fit with the pieces made by the other instructed minds. It does not work this way.
What it needs is for the air to be made right. If you want a bee to make honey, you do not issue protocols on solar navigation or carbohydrate chemistry, you put him together with other bees (and you’d better do this quickly, for solitary bees do not stay alive) and you do what you can to arrange the general environment around the hive. If the air is right, the science will come in its own season, like pure honey.
One organization which clearly “gets the air right” is the much lauded Mayo Clinic in Rochester, Minnesota.
The organization has 4,500 physicians and over $10 billion in revenue from three main campuses, and it is regularly rated among the top hospital systems in the United States in a wide variety of specialities, and yet was founded back in the late 20th century by William Worrall Mayo. Its main campus is in Rochester, Minnesota; not exactly a hub of bustling activity, yet its patients are willing to fly or drive hundreds of miles to receive care. (So-called “destination medicine.”)
How does an organization sustain that kind of momentum for more than 150 years, in an industry that's changed as much as medicine? What can the rest of us learn from that?
It's a prime example of where culture eats strategy. Even Warren Buffett admires the system:
A medical partnership led by your area’s premier brain surgeon may enjoy outsized and growing earnings, but that tells little about its future. The partnership’s moat will go when the surgeon goes. You can count, though, on the moat of the Mayo Clinic to endure, even though you can’t name its CEO.
The Mayo Clinic is an integrated, multi-specialty organization — they're known for doing almost every type of medicine at a world class level. And the point of having lots of specialities integrated under one roof is teamwork: Everyone is pulling the same oar. Integrating all specialities under one umbrella and giving them a common set of incentives focuses Mayo's work on the needs of the patient, not the hospital or the doctor.
This extreme focus on patient needs and teamwork creates a unique environment that is not present in most healthcare systems, where one's various care-takers often don't know each other, fail to communicate, and even have trouble accessing past medical records. (Mayo is able to have one united electronic patient record system because of its deep integration.)
Importantly, they don't just say they focus on integrated care, they do it. Everything is aligned in that direction. For example, as with Apple Retail stores (also known for extreme customer focus), there are no bonuses or incentive payments for physicians — only salaries.
The clinic ardently searches for team players in its hiring and then facilitates their collaboration through substantial investment in communications technology and facilities design. Further encouraging collaboration is an all-salary compensation system with no incentive payments based on the number of patients seen or procedures performed. A Mayo physician has no economic reason to hold onto patients rather than referring them to colleagues better suited to meet their needs. Nor does taking the time to assist a colleague result in lost personal income.
The most amazing thing of all about the Mayo clinic is the fact that hundreds of members of the most highly individualistic profession in the world could be induced to live and work together in a small town on the edge of nowhere and like it.
The Clinic was carefully constructed by self-selection over time: It's a culture that attracts teamwork focused physicians and then executes on that promise.
One of the internists in the book is quoting as saying working at Mayo is like “working in an organism; you are not a single cell when you are out there practicing. As a generalists, I have access to the best minds on any topic, any disease or problem I come up with and they're one phone call away.”
In that sense, part of the Mayo's moat is simply a feedback loop of momentum: Give a group of high performers an amazing atmosphere in which to do their work, and eventually they will simply be attracted by each other. This can go on a long time.
The other part of Mayo's success — besides correct incentives, a correct system, and a feedback loop — is simply scale and critical mass. Mayo is like a Ford in its early days: They can do everything under one roof, with all of the specialities and sub-specialities covered. That allows them to deliver a very different experience, accelerating the patient care cycle due to extreme efficiency relative to a “fractured” system.
Craig Smoldt, chair of the department of facilities and support services in Rochester, makes the point that Mayo clinic can offer efficient care–the cornerstone of destination medicine–because it functions as one integrated organization. He notes the fact that everyone works under one roof, so to speak, and is on the payroll of the same organization, makes a huge difference. The critical mass of what we have here is another factor. Few healthcare organizations in the country have as many specialities and sub-specialities working together in one organization.” So Mayo Clinic patients come to one of three locations, and virtually all of their diagnoses and treatment can be delivered by that single organization in a short time.
Contrast that to the way care is delivered elsewhere, the fractured system that represents Mayo's competitors. This is another factor in Mayo's success — they're up against a pretty uncompetitive lot:
Most U.S. healthcare is not delivered in organizations with a comparable degree of integrated operations. Rather than receiving care under one roof, a single patient's doctors commonly work in offices scattered around a city. Clinical laboratories and imaging facilities may be either in the local hospital or at different locations. As a report by the Institute of Medicine and the National Academy of Engineering notes, “The increase in specialization in medicine has reinforced the cottage-industry structure of U.S. healthcare, helping to create a delivery system characterized by disconnected silos of function and specialization.
How does this normally work out in practice, at places that don't work like Mayo? We're probably all familiar with the process. The Institute of Medicine report referenced above continues:
“Suppose the patient has four medical problems. That means she would likely have at least five different doctors.” For instance, this patient could have (1) a primary care doctor providing regular examinations and treatments for general health, (2) an orthopedist who treats a severely arthritic knee, (3) a cardiologist who is monitoring the aortic valve in her heart that may need replacement soon, (4) a psychiatrist who is helping her manage depression, and (5) and endocrinologist who is helping her adjust her diabetes medications. Dr. Cortese then notes,”With the possible exception of the primary care physician, most of these doctors probably do not know that the patient is seeing the others. And even if they do know, it is highly unlikely they know the impressions and recommendations the other doctors have recorded in the medical record, or exactly what medications and dosages are prescribed.” If the patient is hospitalized, it is probably that only the admitting physician and the primary care physician will have that knowledge.
Coordinating all of these doctors takes time and energy on the part of the patient. Repeat, follow-up visits are done days later; often test results, MRI results, or x-ray results are not determined quickly or communicated effectively to the other parts of the chain.
Mayo solves that by doing everything efficiently and under one roof. The patient or his/her family doesn't have to push to get efficient service. Take the case of a woman with fibrocystic breast disease who had recently found a lump. Her experience at Mayo took a few hours; the same experience in the past had taken multiple days elsewhere, and initiative on her end to speed things up.
As a patient in the breast clinic, she began with an internist/breast specialists who took the medical history and performed an exam. The mammogram followed in the nearby breast imaging center. The breast ultrasound, ordered to evaluate a specific area on the breast, was done immediately after the mammogram.
The breast radiologist who performed the ultrasound had all the medical history and impressions of the other doctors available in the electronic medical record (EMR). The ultrasound confirmed that the lump was a simple cyst, not a cancer. The radiologist shared this information with the patient and offered her an aspiration of the cyst that would draw off fluid if the cyst was painful. But comforted with the diagnosis of the simple cyst and with the fact that it was not painful, the veteran patient declined the aspiration. Within an hour of completing the breast imaging, the radiologist communicated to the breast specialist a “verbal report” of the imaging findings. The patient returned to the internist/breast specialist who then had a wrap-up visit with the patient and recommended follow-up care. This patient's care at Mayo was completed in three and one-half hours–before lunch.
So what are some lessons we can pull together from studying Mayo?
The book offers a bunch, but one in particular seemed broadly useful, from a chapter describing Mayo's “systems” approach to consistently improving the speed and level of care. (Industrial engineers are put to work fixing broken systems inside Mayo.)
Mayo wins by solving the totality of the customer's problem, not part of it. This is the essence of an integrated system. While this wouldn't work for all types of businesses; it's probably a useful way for most “service” companies to think.
Why is this lesson particularly important? Because it leads to all the others. Innovation in patient care, efficiency in service delivery, continuous adoption of new technology, “Getting the Air Right” to attract and retain the best possible physicians, and creating a feedback loop are products of the “high level” thought process below: Solve the whole problem.
Lesson 1: Solve the customer's total problem. Mayo Clinic is a “systems seller” competing with a connected, coordinated service. systems sellers market coordinated solutions to the totality of their customers' problems; they offer whole solutions instead of partial solutions. In system selling, the marketer puts together all the services needed by customers to do it themselves. The Clinic uses systems thinking to execute systems selling that pleasantly surprises patients (and families) and exceeds their expectations.
The scheduling and service production systems at Mayo Clinic have created a differentiated product–destination medicine–that few competitors can approach. So even if patients feel that the doctors and hospitals at home are fine, they still place a high value on a service system that can deliver a product in days rather than weeks or months.
Patients not only require competent care but also coordinated and efficient care. Mayo excels in both areas. In a small Midwestern town, it created a medical city offering “systems solutions” that encourage favorable word of mouth and sustained brand strength, and then it exported the model to new campuses in Arizona and Florida.
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Creating Effective Incentive Systems: Ken Iverson on the Principles that Unleash Human Potential — Done poorly, compensation systems foster a culture of individualism and gaming. Done properly, however, they unleash the potential of all employees.
Can Health Care Learn From Restaurant Chains? — Atul Gawande pens a fascinating piece in the New Yorker about what health care can learn from the Cheesecake Factory.
“I am a person who listens for a living. I listen for wisdom, and beauty, and for voices not shouting to be heard.”
Krista Tippett, the host of the compelling podcast On Being, is an incredible conversationalist. From poets and physicists to neuroscientists — her show offers conversations that traverse time and disciplines. At the heart of her inquiry lies space to explore what it means to live a meaningful life.
In Becoming Wise: An Inquiry into the Mystery and Art of Living, Tippett, who listens for a living, offers an illuminating slice of these conversations. As a illuminating guide, her reflections walk us through the work of a lifetime exploring love, compassion, and forgiveness.
The book is organized around virtue and “gentle shifts of mind and habit.” She explores five raw materials for living a meaningful life:
Words — The language we use to tell stories to ourselves and others;
Body — “The body is where every virtue lives or dies”;
Love — More than something we fall into or out of, love is “the only aspiration big enough for the immensity of the human community.”;
Faith — “Literal reality is not all there is.”;
Hope — Hope has nothing to do with optimism or wishing, rather it reflects reality and reveres truth. Hope is a habit.
Tippet resurfaces questions many have explored before us. “What does it mean to be human? What matters in life? What matters in death? How to be of service to each other and the world?”
Each person explores these questions at one point or another in the context of our age and ourselves. The questions are not independent. Who we are to each other is a reflection of what it means to be human.
Wisdom leavens intelligence, and ennobles consciousness, and advances evolution itself.
Life is where we explore the mystery of ourselves and others. Here Tippett offers a voice to “those raw, essential, heartbreaking and life-giving places in us, so that we may know them more consciously, live what they teach us, and mine their wisdom for our life together.”
In the introduction Tippett refuses the false duality and headlines that drive so much of our divide.
[M]any features of national public life are also better suited to adolescence than to adulthood. We don’t do things adults learn to do, like calm ourselves, and become less narcissistic. Much of politics and media sends us in the opposite, infantilizing direction. We reduce great questions of meaning and morality to “issues” and simplify them to two sides, allowing pundits and partisans to frame them in irreconcilable extremes. But most of us don’t see the world this way, and it’s not the way the world actually works. I’m not sure there’s such a thing as the cultural “center,” or that it’s very interesting if it exists. But left of center and right of center, in the expansive middle and heart of our life together, most of us have some questions left alongside our answers, some curiosity alongside our convictions.
Imagination and nuance and the spaces between headlines is where we live. The book is an exploration of these spaces.
I have yet to meet a wise person who doesn’t know how to find some joy even in the midst of what is hard, and to smile and laugh easily, including at oneself. A sense of humor is high on my list of virtues, in interplay with humility and compassion and a capacity to change when that is the right thing to do. It’s one of those virtues that softens us for all the others.
She also offers a sobering reminder of our capacity to control.
We are never really running the show, never really in control, and nothing will go quite as we imagined it. Our highest ambitions will be off, but so will our worst prognostications.
No section of the book is more compelling than exploring words — “I take it as an elemental truth of life,” she writes, “that words matter.”
This is so plain that we can ignore it a thousand times a day. The words we use shape how we understand ourselves, how we interpret the world, how we treat others. From Genesis to the aboriginal songlines of Australia, human beings have forever perceived that naming brings the essence of things into being. The ancient rabbis understood books, texts, the very letters of certain words as living, breathing entities. Words make worlds.
On our affinity for tolerance she challenges us:
We chose too small a word in the decade of my birth— tolerance— to make the world we want to live in now. We opened to the racial difference that had been there all along, separate but equal, and to a new infusion of religions, ethnicities, and values. But tolerance doesn’t welcome. It allows, endures, indulges. In the medical lexicon, it is about the limits of thriving in an unfavorable environment. Tolerance was a baby step to make pluralism possible, and pluralism, like every ism, holds an illusion of control. It doesn’t ask us to care for the stranger. It doesn’t even invite us to know each other, to be curious, to be open to be moved or surprised by each other.
Words are containers.
The connection between words and meanings resembles the symbiosis between religion and spirituality. Words are crafted by human beings, wielded by human beings. They take on all of our flaws and frailties. They diminish or embolden the truths they arose to carry. We drop and break them sometimes. We renew them, again and again.
In one illuminating conversation, Tippett talks with one of her favorite thinkers about the failure of “official language and discourse” the poet Elizabeth Alexander, who read at the first Obama inauguration.
Here’s what we crave. We crave truth tellers. We crave real truth. There is so much baloney all the time. You know, the performance of political speech, of speeches you see on the news, doesn’t it often feel to you like there should be a thought bubble over it that says, “what I really would say if I could say it is . . .”
And how we are drawn to words that shimmer.
I learn so much every day from being a mother. My sons are 11 and 12, and you see the way children know when they’re being bamboozled. And they also are drawn towards language that shimmers, individual words with power. They will stop you and ask you to repeat a shimmering word if they’re hearing it for the first time. You can see it in their faces.
Words are the backbones to stories — the ones we tell others and the ones we tell ourselves.
The art of conversation I’m describing here is related, but it is something subtly and directionally different— sharing our stories in the service of probing together who we are and who we want to be. To me, every great story opens into an equally galvanizing exchange we can have together: So what? How does this change the way you see and live? How might it inform the way I see and live? I believe we can push ourselves further, and use words more powerfully and tell and make the story of our time anew.
“The world,” says physician Rachel Naomi Remen in an interview with Tippett, “is made up stories; it is not made of up facts.”
And yet we tell ourselves facts to piece together stories. Stories are how we make sense of life. Remen continues:
Well, the facts are the bones of the story, if you want to think of it that way. I mean, the facts are, for example, that I have had Crohn’s disease for 52 years. I’ve had eight major surgeries. But that doesn’t tell you about my journey and what’s happened to me because of that, and what it means to live with an illness like this and discover the power of being a human being. And whenever there’s a crisis, like 9/ 11, do you notice how the whole of the United States turned towards the stories? Where I was, what happened, what happened in those buildings, what happened to the people who were connected to the people in those buildings. Because that is the only way we can make sense out of life, through the stories. The facts are a certain number of people died there. The stories are about the greatness of being a human being and the vulnerability of being a human being.
There’s a powerful saying that sometimes we need a story more than food in order to live. They tell us about who we are, what is possible for us, what we might call upon. They also remind us we’re not alone with whatever faces us.
Becoming Wise is for those of us who want to explore the great questions of life with imagination and courage, realizing that much of life is lived in nuance that changes with who we are and, importantly, where we are standing.