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.
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.
At Farnam Street we believe in the idea that a multidisciplinary approach to big ideas is the best way to form a deeper understanding. Some concepts will intuitively lend themselves to this type of thinking. Something like evolution is an easy one. But there are also times when this cross-pollination is far less intuitive, yet can produce some amazing results.
In Messy: The Power of Disorder to Transform Our Lives, author Tim Hartford walks us through some amazing examples of cross-fertilization and how purposefully adding a measured dose of chaos to your work can benefit you greatly.
In the 1920s a gentleman by the name of Dick Drew worked as a sandpaper salesman at the Minnesota Mining and Manufacturing Company.
One day Drew was thinking about the challenge of painting a car — it wasn’t a specialty of his but he could appreciate the problem. What he did know inside and out was sandpaper, and he intuitively realized that sandpaper could help solve the problem. What he needed was a roll of sandpaper without the sand.
This became known as masking tape and it transformed more than just how we paint cars.
Presently we call the Minnesota Mining and Manufacturing Company 3M, and Dick Drew’s insight in the early 1920’s wasn’t an anomaly, it is the type of innovation that has defined 3M as a company. What made them so consistently creative and innovative?
…3M has a “flexible attention” policy. In most companies, flexible attention means goofing off on the company dime. In 3M it means playing a game, taking a nap, or going for a walk across an extensive campus to admire the deer. 3M knows that creative ideas don’t always surrender to a frontal assault. Sometimes they sneak up on us while we are paying attention to something else.
3M also rotates its engineers from one department to another every few years. This policy is one that many companies—not to mention some employees—resist. Why make someone with years of expertise in soundproofing or flat-screen displays work on a vaccine or an air conditioner? For the company it seems wasteful and for the employee it can be stressful. But for a company that makes masking materials out of sandpaper… the real waste would be to let ideas sit in their tidy silos, never to be released.
The key term here that Harford hits on is reducing silos.
Many companies, whether by design or by accident, tend to be very compartmentalized. In essence, you are given a tiny box within which to work on your project but you often won’t have a good idea of what’s going on in other areas of the company; the opportunities for cross pollination are limited unless you commit to moving positions/projects.
By adding just a little disorder, a company can give its employees the freedom to think differently and maybe even help them out of a rut that is often caused by looking at something with too narrow a focus. Sometimes we just can’t “see the forest through the trees” — we're stuck in our little box.
A company doesn’t have to rotate it’s personnel into wildly varying positions to achieve this goal; it can be as simple as providing an environment which allows employees to easily work on various/differing projects.
Creativity researchers Howard Gruber and Sara Davis see a strong link between the most creative people and their tendency to work on multiple projects. Gruber notes that Charles Darwin is a good example of this.
… throughout his life [Darwin] alternated between research in geology, zoology, psychology, and botany, always with some projects in the foreground and others in the background, competing for his attention. He undertook his celebrated voyage with the Beagle with “an ample and unprofessional vagueness in his goals.”
And then there are the earthworms. Darwin could not get enough of earthworms. This great scientist, who traveled the world, studied the finches of the Galápagos, developed a compelling account of the formation of coral reefs, and—of course—crafted the brilliant, controversial, meticulously argued theory of evolution, studied earthworms from every possible angle for more than forty years. The earthworms were a touchstone, a foundation, almost a security blanket. Whenever Darwin was anxious, puzzled, or at a loss, he could always turn to the study of the humble earthworm.
Gruber and Davis have coined a term for this melting pot of different projects at different stages of completion, they call it a ‘network of enterprises'. They argue that the parallel project approach has four benefits:
Gruber and Davis argue that with the right network of enterprises, an impasse in one project can end up feeling somewhat liberating. If you fall down the wrong rabbit hole you have the ability to pivot to something fresh.
The writer can pull out some old jottings, the scientist can turn to an anomaly she had long wanted to investigate. What would have been a depressing waste of time for a single-minded person can become a creative lease of life for someone with several projects on the go. That’s the theory, but in practice it can be a source of anxiety. Having many projects on the go is a stressful experience that can quickly degenerate into wheel-spinning. (Rather than turning to the study of earthworms for a break, we turn to Facebook instead.)
We have written before about the negative aspects of multitasking and dividing your attention and focus. The goal here would be to find out the number and type of projects which give you the benefits outlined by Gruber and Davis but still keep that number manageable enough to not create an undue amount of stress. This will likely take a bit of trial and error.
Harford himself has a strategy that seems to work. It’s a wonderful mix of messy and organized.
I have a related solution myself, a steel sheet on the wall of my office full of magnets and three-by-five-inch cards. Each card has a single project on it—something chunky that will take me at least a day to complete. As I write this, there are more than fifteen projects up there, including my next weekly column, an imminent house move, a standup comedy routine I’ve promised to try to write, two separate ideas for a series of podcasts, a television proposal, a long magazine article, and this chapter. That would potentially be overwhelming, but the solution is simple: I’ve chosen three projects and placed them at the top. They’re active projects and I allow myself to work on any of the three. All the others are on the back burner. I don’t fret that I will forget them, because they’re captured on the board. But neither do I feel compelled to start working on any of them. They won’t distract me, but if the right idea comes along they may well snag some creative thread in my subconscious.
You can organize your projects like Harford, or come up with your own technique that suits your network of enterprises. The key is to create an environment that allows you to cross pollinate and, ideally, to rotate your crops when you stop liking what the harvest looks like.
Few books have ever struck us as much as Will Durant's 100-page masterpiece The Lessons of History, a collection of essays which sum up the lifelong thoughts of a brilliant historian.
We recently dug up an interview with Durant and his wife Ariel — co-authors of the 11-volume masterpiece The Story of Civilization — and sent it to the members of the Farnam Street Learning Community. While the interview is full of wisdom in its entirety, we picked one interesting excerpt to share with you: Durant's thoughts on the “Great Man” (and certainly, Great Woman) theory of history.
Has history been Theirs to dictate? Durant has a very interesting answer, one that's hard to ignore once you think about it:
Interviewer: Haven’t certain individuals, the genius, great man, or hero, as Carlisle believed, been the prime determinants of human history?
Will Durant: There are many cases, I think, in which individual characters have had very significant results upon history. But basically, I think Carlisle was wrong. That the hero is a product of a situation rather than the result being a product of the hero. It is demand that brings out the exceptional qualities of man. What would Lenin have been if he had remained in, what was it, Geneva? He would have a little…. But he faced tremendous demands upon him, and something in him responded. I think those given us would have brought out capacity in many different types of people. They wouldn’t have to be geniuses to begin with.
Interviewer: Then what is the function or role of heroes?
Will Durant: They form the function of meeting a situation whose demands are always all his potential abilities.
Interviewer: What do you think is the important thing for us, in studying the course of history, to know about character? What is the role of character in history?
Will Durant: I suppose the role of character is for the individual to rise to a situation. If it were not for the situation, we would never have heard of him. So that you might say that character is the product of an exceptional demand by the situation upon human ability. I think the ability of the average man could be doubled if it were demanded, if the situation demanded. So, I think Lenin was made by the situation. Of course he brought ideas, and he had to abandon almost all those ideas. For example, he went back to private enterprise for a while.
One way we might corroborate Durant's thoughts on Lenin is to ask another simple question: Which U.S. Presidents are considered the most admired?
Students of history have three easy answers pop in (and polls corroborate): George Washington – the first U.S. President and a Founding Father; Abraham Lincoln – the man who held the Union together; and finally Franklin Delano Roosevelt – unless the U.S. amends its Constitution, the longest serving U.S. President now and forever.
All great men, certainly. All three of which rose to the occasion. But what do they share?
They were the ones holding office at the time of (or in the case of Washington, immediately upon winning) the three major wars impacting American history: The American Revolution, the American Civil War, and World War II.
It raises an interesting question: Would these men be remembered and held in the same esteem if they hadn't been handed such situations? The answer pops in pretty quickly: Probably not. Their heroism was partly a product of their character and partly a product of their situation.
And thus Durant gives us a very interesting model to bring to reality: Greatness is in many of us, but only if we rise, with practical expediency, to the demands of life. Greatness arises only when tested.
For the rest of Durant's interview, and a lot of other cool stuff, check out the Learning Community.
Few people know the details about one of the greatest stories in sports history. A classic David versus Goliath story that happened at the 1980 Olympics in Lake Placid when the U.S. Olympic Hockey team played the Soviets.
While the U.S. team had won the gold at the Squaw Valley Olympics in 1960, they hadn't done much since then. The only notable showing was 5th place at the 1976 games. The Soviets, on the other hand, came into the 1980 Olympics having won 12 of the previous 15 world championships and 4 Olympic gold medals in a row. The Soviet record since Squaw Valley was 27-1-1.
In fact, the Soviets were so good, that in 1979 there was no NHL all-star game. Instead they just invited the Soviets to play a three-game series called the Challenge Cup. The U.S.S.R crushed the best players in the NHL 6-0 in the deciding game.
The Soviets beating the U.S. hockey team at the 1980 Olympics was as close to a sure thing as you could imagine, or so it seemed. Only things didn't play out the way either team expected.
In his book, 99: Stories of the Game, the legendary Wayne Gretzky tells the incredible story of what transpired.
“In the United States,” Gretzky writes, “the goal was to build a team that, while not having much chance of winning, would at least not embarrass the country.”
Herb Brooks was hired as coach. If there was one guy in the program who wasn't playing to avoid embarrassment, it was Brooks.
Eighty of the best college players were invited to Colorado Springs in July of 1979 to compete for a roster spot (remember at the time the Olympic games were for amateurs). Although it wasn't so much a competition as formality. Brooks had won three NCAA championships coaching Minnesota, so he pretty much knew the 23 man roster he wanted.
A bit of leadership …
Brooks took one of the assistant coaches aside and said “A lot of these guys hate each other, and the only way I can think to make them a team is for all of them to hate me. You're going to have to keep all the pieces together and be the guy they can lean on, because they're not going to be able to lean on me. I'm going to be the same to all of them. I'm going to be tough on all of them.”
In a warm up game before the Olympics at Madison Square Garden, team USA lost to the Russians 10-3. The players were in awe of the opponent.
Brooks has spent a lot of time in Russia learning some of their systems. Herb discovered that when the Russians played hockey, they didn't shoot the puck unless they thought they could score, and so although it might look as if they had fewer than ten shots on goal, they were shots that counted. …
[I]t was all about puck possession. The Russian team didn't have to work as hard in defense because they had the puck so often. When a lot of people watch hockey, they don't seem to focus on that. A big part of my game (Gretzky) was the forecheck—chasing a defenseman down, lifting his stick, and taking the puck. If you take the puck off a defenseman or player in his own end, you don't have as many players to beat in order to score or to make a play.
An unexpected bit of ego and overconfidence …
The first medal-round game featured the Soviets and Americans. The game was played at 5 p.m. but didn't air on ABC until 8 p.m. “One of the most memorable moments in American sports history would be watched by most Americans three hours after it happened,” Gretzky tells us.
In the locker room just ahead of the game, Herb Brooks gave the most inspirational speech of his life. He told the guys, “You were born to be a player. You were meant to be here. The moment is yours.”
The players skated onto the ice and looked up. The arena was packed. People were waving American flags everywhere. In the first minutes, the Americans surprised the Soviets with how fast and emotionally they played. Still the Soviets scored first. Then the unexpected happened.
Buzz Schneider took a slapshot and beat the legendary Soviet goaltender Vladislav Tretiak, tying the game. The Soviets quickly scored again and it looked like the first period would end that way when Dave Christian picked up the puck in his own zone with only five seconds left. Rather than play till the whistle, a lesson we all learn at one point or another and one that was drilled into me by my high-school football coach, the Soviets had let up thinking the period was over. Christian shot the puck up ice, Mark Johnson chased it down, deked Tretiak, and scored with only one second left. Tie game.
In the second period, Soviet coach Viktor Tikhonov pulled a surprise move. He replaced Tretiak—a guy known as one of the best goalies of all time—with his backup, Vladimir Myshkin. I've (Gretzky) had the opportunity to sit down with Tretiak and hear his opinion about it. Tretiak was the biggest star in Russia—and maybe still is, thanks to what he did in '72 as a twenty-year-old goalie—and I think it used to drive Tikhonov crazy. He wanted to show everyone that his coaching was the reason they were winning the Olympics, not Tretiak's goaltending. And to this day, Tretiak thinks that's why he was pulled.
“Don't change a thing. Don't change a thing because they've changed goalies. Don't change a thing. Play the same way,” Brooks was heard telling his team.
A lucky bounce …
In the third period, the Soviets looked dominant again. Then, on a rush, a shot from Dave Silk slipped through a Soviet defenceman's skate right onto Mark Johnson's stick. Before Myshkin could move, it was in the net and the score was tied (3-3). A minute later, the American captain, Mike Eruzione, scored.
Now the Americans were leading, just ten minutes away from a shot at a gold medal. Brooks kept walking up and down the bench saying, “Play your game. Play your game.” He repeated it a thousand times at least.
Jimmy Craig (the American goaltender) was in the zone. He wasn't going to get scored on. When a goalie is in that kind of zone, especially in the playoffs, his ability to anticipate the shot is as good as the rest of his skill set. And Craig wasn't alone—the whole team was flying out there. When you go into a series without the sense of entitlement the Russians had, it gives you the intensity you need to get to that extra level.
The gamed ended 4-3 for the U.S. The Americans swarmed the ice. They could hardly believe it—they had to keep telling themselves, “We beat them. We. Beat. Them.”
It was the first game the Soviets had lost at the Olympics in 12 years.
There are several lessons one can take away from this story—Brooks' leadership to make the team hate him more than each other; Tikhonov's ego pulling the legendary Tretiak to show the world how amazing he was; and the importance of playing to the whistle come to mind. Perhaps the most important lesson of all is that when the conditions are right, a group of “average people” can come together and get non-average results.
99: Stories of the Game goes on to tell 98 other stories about the game of hockey.
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.
If you liked this post, you might like these as well:
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.
Consider this situation: You email a colleague with a question expecting a prompt response, but hours or days later you’ve yet to hear from them. Perhaps you can’t move forward on your project without their input so you find yourself blocked. How do you imagine you feel in this situation?
For many of us, situations like this result in feelings of anger, frustration, or annoyance. Maybe we take it personally and conclude that our colleague is lazy or that they don’t value our time or our work. Perhaps we send off a terse reminder asking for an update.
If we’re feeling particularly revengeful, we alert the person’s manager or mention our grievance to another colleague looking for validation that the offending colleague is in fact lazy and disrespectful – a form of confirmation bias.
Perhaps this colleague has been slow to respond to communications in the past, thus we extrapolate that to all of their communications, a case of the fundamental attribution error.
Of course, it's natural to feel anger and frustration when faced with these situations. But is anger the appropriate response?
In the Nicomachean Ethics Aristotle wrote about The Virtue Concerned with Anger. He begins Book IV with a description of good temper:
The man who is angry at the right things and with the right people, and, further, as he ought, when he ought, and as long as he ought, is praised. This will be the good-tempered man, then, since good temper is praised.
Aristotle tells us that anger has a time and place and that when applied to the right people and for the right reason, is justified and even praiseworthy. But we have to use anger judiciously:
For the good-tempered man tends to be unperturbed and not to be led by passion, but to be angry in the manner, at the things, and for the length of time, that reason dictates; but he is thought to err rather in the direction of deficiency; for the good-tempered man is not revengeful, but rather tends to make allowances.
In Aristotle’s description of good temper, he encourages us to err in the direction of “making allowances”. But how can we do this in practice?
Let’s return to our example.
We take our colleague's lack of response personally and assume they are lazy or disrespectful, but it is important for us to recognize that we are assuming. We often instinctively chose to assume the worst of people, because it slips easily into mind. But what if instead we chose to assume the best?
In her book Rising Strong, Brené Brown describes how she learned to assume that people are doing the best they can and shares a concept introduced to her by Dr. Jean Kantambu Latting, a professor at University of Houston. Brown writes:
Whenever someone would bring up a conflict with a colleague, she would ask, ‘What is the hypothesis of generosity? What is the most generous assumption you can make about this person’s intentions or what this person said?’
By pausing to reflect on our anger we can recognize that we are making a negative assumption and challenge ourselves to invert the situation and consider the opposite: “What is the most generous assumption I can make?”
Perhaps our colleague has been given a higher priority project, or they don’t understand that we’re blocked without their input. Maybe they are dealing with some personal challenges outside of the office, or they need input from somebody else to reply to our message and thus they’re blocked as well. Perhaps they've decided to reduce their email frequency in order to focus on important work.
When we pause to look at the situation from another angle, not only do we entertain some explanations that frame our colleagues in a more positive light, but we put ourselves into their shoes; the very definition of empathy.
We’ve all had competing priorities, distractions from personal issues outside of work, miscommunications regarding the urgent need of our response, etc. Do we think others judged us fairly or unfairly in those moments?
The point is not to make excuses or avoid addressing problems with our colleagues, but that if we recognize we are making negative assumptions by default, we might need to challenge ourselves to consider more generous alternatives. This may alter the way we approach our colleague to address the situation. It takes effort and a commitment to think about people differently.
Someone who knew this best was the late, great author David Foster Wallace.
In his beautiful commencement speech to the Kenyon graduating class of 2005, Wallace reminds the students that the old cliché of liberal arts education teaching you to think is truer than they might want to believe. He warns that one of the biggest challenges the graduates will face in life is to challenge their self-centered view of the world – a view that we all have by default.
Using some of life’s more mundane and annoying activities like shopping and commuting, Wallace writes:
The point here is that I think this is one part of what teaching me how to think is really supposed to mean. To be just a little less arrogant. To have just a little critical awareness about myself and my certainties. Because a huge percentage of the stuff that I tend to be automatically certain of is, it turns out, totally wrong and deluded. I have learned this the hard way, as I predict you graduates will, too.
Here is just one example of the total wrongness of something I tend to be automatically sure of: everything in my own immediate experience supports my deep belief that I am the absolute centre of the universe; the realest, most vivid and important person in existence. We rarely think about this sort of natural, basic self-centeredness because it’s so socially repulsive. But it’s pretty much the same for all of us. It is our default setting, hard-wired into our boards at birth. Think about it: there is no experience you have had that you are not the absolute centre of. The world as you experience it is there in front of YOU or behind YOU, to the left or right of YOU, on YOUR TV or YOUR monitor. And so on. Other people’s thoughts and feelings have to be communicated to you somehow, but your own are so immediate, urgent, real.
Please don’t worry that I’m getting ready to lecture you about compassion or other-directedness or all the so-called virtues. This is not a matter of virtue. It’s a matter of my choosing to do the work of somehow altering or getting free of my natural, hard-wired default setting which is to be deeply and literally self-centered and to see and interpret everything through this lens of self. People who can adjust their natural default setting this way are often described as being “well-adjusted”, which I suggest to you is not an accidental term.
The recognition that we are inherently self-centered and that this affects the way in which we interpret the world seems so obvious when pointed out, but how often do we stop to consider it? This is our hard-wired default setting, so it's quite a challenge to become willing to think differently.
As an example, Wallace describes a situation where he is disgusted by the gas guzzling Hummer in front of him in traffic. The idea of these cars offends him and he starts making assumptions about the drivers: they're wasteful, inconsiderate of the planet, and inconsiderate of future generations.
Look, if I choose to think this way in a store and on the freeway, fine. Lots of us do. Except thinking this way tends to be so easy and automatic that it doesn’t have to be a choice. It is my natural default setting. It’s the automatic way that I experience the boring, frustrating, crowded parts of adult life when I’m operating on the automatic, unconscious belief that I am the centre of the world, and that my immediate needs and feelings are what should determine the world’s priorities.
But then he challenges himself to consider alternative interpretations, something often described as making the Most Respectful Interpretation (MRI). Wallace decides to consider more respectful interpretations of the other drivers – maybe they have a legitimate need to be driving a large SUV or to be rushing through traffic.
In this traffic, all these vehicles stopped and idling in my way, it’s not impossible that some of these people in SUV’s have been in horrible auto accidents in the past, and now find driving so terrifying that their therapist has all but ordered them to get a huge, heavy SUV so they can feel safe enough to drive. Or that the Hummer that just cut me off is maybe being driven by a father whose little child is hurt or sick in the seat next to him, and he’s trying to get this kid to the hospital, and he’s in a bigger, more legitimate hurry than I am: it is actually I who am in HIS way.
Again, please don't think that I'm giving you moral advice, or that I'm saying you're “supposed to” think this way, or that anyone expects you to just automatically do it, because it's hard, it takes will and mental effort, and if you're like me, some days you won't be able to do it, or you just flat out won't want to. But most days, if you’re aware enough to give yourself a choice, you can choose to look differently at this fat, dead-eyed, over-made-up lady who just screamed at her kid in the checkout line. Maybe she’s not usually like this. Maybe she’s been up three straight nights holding the hand of a husband who is dying of bone cancer. Or maybe this very lady is the low-wage clerk at the motor vehicle department, who just yesterday helped your spouse resolve a horrific, infuriating, red-tape problem through some small act of bureaucratic kindness. Of course, none of this is likely, but it’s also not impossible. It just depends what you want to consider. If you’re automatically sure that you know what reality is, and you are operating on your default setting, then you, like me, probably won’t consider possibilities that aren’t annoying and miserable. But if you really learn how to pay attention, then you will know there are other options.
A big part of learning to think is recognizing our default reactions and responses to situations — the so-called “System 1” thinking espoused by Daniel Kahneman. Learning to be “good-tempered” and “well-adjusted” requires us to try to be more self-aware, situationally aware, and to acknowledge our self-centered nature; to put the brakes on and use System 2 instead.
So the next time you find yourself annoyed with your colleagues, angry at other drivers on the road, or judgmental about people standing in line at the store, use it as an opportunity to challenge your negative assumptions and try to interpret the situation in a more respectful and generous way. You might eventually realize that the broccoli tastes good.