Category: Human Nature

Is Vulnerability a Choice?

Being vulnerable is not a choice. It’s a reality of living. What we do with that vulnerability can either open doors to deeper connection, or throw up walls that stifle growth and fulfillment.

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Vulnerability: the quality or state of being exposed to the possibility of being attacked or harmed, either physically or emotionally.

Given the potential consequences, why would anyone ever choose to be vulnerable? Who wants to risk an emotional or physical attack?

At the basic biological level, it seems to make very little sense to be vulnerable. When we are, we can more easily get hurt. We can get physically maimed or killed by a predator. Emotional attacks can make us afraid of rejection. Since the vast majority of us don’t want to die and instead pass on our genes, avoiding vulnerability seems to make perfect sense. Be tough in order to increase your chances of a long life. Don’t give anyone the opportunity to hurt you.

However, humans usually want to do more than just survive. We focus on the quality of our lives as well. Yes, we want our lives to be long. But we also want them to be good.

Part of a good life is having good relationships. We are social creatures and live longer, healthier lives when we have people around us that we trust and love. We want to be around people who can make us laugh and help us through life’s inevitable hard times. Our lives are less stressful when we have people with whom we can relax and be authentic. Without genuine vulnerability, it’s impossible to build the types of relationships that can provide comfort and increase resilience. The risks of vulnerability may be high, but the rewards of positive, strong relationships are even higher.

The reality is, we are vulnerable in some way at all times. We are vulnerable to viruses and accidents, misunderstandings and the pain caused by our fears and anxieties. Vulnerability is a part of life for all of us. Having close relationships where we can be vulnerable is actually a way to reduce our overall weakness. As Dr. Sue Johnson said on The Knowledge Project, “We need connection with others like we need oxygen. We’re way too vulnerable without it.”

The only choice we really have when it comes to vulnerability is the choice to acknowledge it or not. There is no doubt it can be hard to be vulnerable, especially if we didn’t have positive experiences with it as children. But social connections sustain us, and meaningful social connections are hard to build and maintain without mutual vulnerability.

Some people constantly pretend they have no vulnerabilities. Those people are frustrating to be around. Why? Because everyone is vulnerable in some way, so we know that those who say they aren’t are lying. No one likes to spend time around people who can’t be honest. Furthermore, people who refuse to acknowledge their vulnerabilities (at least to themselves) don’t make great friends or partners because we can’t learn much from them to help us process our own vulnerabilities. Even if it’s hard to pinpoint, we sense something is missing in our interactions with them. They don’t trust us enough to risk hurt.

Someone who goes on about how everything in their life is okay can’t offer much insight into how to deal with things that are most definitely not okay. And someone who thinks they are infallible tends to blame others when things don’t work out. They can’t admit to being wrong, which is another drawback to having them as a friend.

In her TED talk on the subject, author Brené Brown says, “The more afraid we are, the more vulnerable we are, the more afraid we are.” We develop these lists of all the things we won’t do and all the ways in which we won’t engage with people in order to protect ourselves. Our vulnerabilities get registered as something that could be exploited to hurt us. So we put up big buffers of denial and anger because it seems that if we admit we are afraid of something, our whole lives are going to come crashing down as people rush in to take advantage of our weaknesses. Except that isn’t true.

When we allow ourselves to be vulnerable (most often to those we are closest to, but also occasionally to others when the situation would benefit from us putting ourselves out there), we can create amazing reciprocal interactions that empower all parties.

When we are able to say the following: “I don’t know,” “I made a mistake,” “I’m sorry for causing you pain,” “I’m scared,” “I cried last night,” or “I’m struggling with this,” we actually free up energy because we no longer have to put effort into maintaining our buffers and our illusions. When we open up and admit to our vulnerabilities, we give people the opportunity to safely admit to theirs as well. We might hear back: “I make mistakes all the time,” “I’m scared as well,” “I cry too,” or “I also struggle with that.” And in that shared space, we can let go of some of the fear and make room for a deeper connection. When we are vulnerable with someone who doesn’t judge us for it, we can grow stronger. We can become less affected by situations that normally cause us stress.

Most importantly, we strengthen our connection with the people we are sharing with.

Although someone may react by ridiculing you when you admit to a fear, a far more common reaction is respect for your bravery and a sigh of relief over a shared circumstance. Someone doesn’t have to share your particular fear to feel a connection. We’re all afraid of something, and by being honest about your fears, you have signaled that others can share their fears with you in return.

We have written before about the social media prism and how it distorts reality, leading most of us to believe we are the only ones whose lives suck sometimes. The endless posts about career successes and fabulous vacations are really a large-scale representation of the fear of vulnerability. Complex, varied lives become little more than a glittering highlight reel. We never get to see the outtakes.

But coming clean about the downs increases the value of sharing the ups. At the very least, it’s more relatable. We learn more through failure than we do through success. And since we can’t try everything, learning from others’ failures is exceptionally valuable. To just hear the story of the person who made it big and sold their company is not useful. To hear about their multiple failures, their trials, their stops and starts and all the times they doubted themselves—now that’s an insight worth sharing.

Being vulnerable starts with being honest with yourself. How can you get better if you can’t admit that you could be better? How are you going to be a better partner or friend if you can’t admit that sometimes you aren’t a great one? How will you learn from your mistakes if you don’t acknowledge making any?

When we share that vulnerability and find people we can be open with, we form valuable connections. After all, to really trust someone, we need to know if they are going to be there when we are vulnerable. As Dr. Sue Johnson explained on The Knowledge Project, “When you can be vulnerable for a moment, and that person tunes in and cares about your vulnerability, that’s the person to go with.” In this way, vulnerability can also serve as a litmus test for your close relationships. If you can’t be vulnerable with someone, why bother? What can you really get from a relationship in which you can never relax and be yourself?

When we have people with whom we can be vulnerable, we actually reduce our exposure to potential harm and improve the quality of our life. By putting ourselves out there and risking hurt, we often find that we create more meaningful interactions with the people in our lives. When we have people we can trust with our deepest vulnerabilities, we increase our ability to be resilient in the face of chance and change.

The Evolutionary Benefit of Friendship

Healthy friendships offer far more than a reliable person to share a beer with. Research shows they can make us healthier, wealthier, happier and overall more successful. Here’s how.

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Is friendship important for our survival?

At first glance, the answer isn’t obvious. Other relationships get more play: romantic partners, parents and kids, families, professional networks. It’s easy to find books on improving your marriage or your relationship with your coworkers. The ability to create and maintain friendships, though, seems a bit taken for granted. Often it appears that either we all do it with relative ease, or we just don’t care. We have a feeling that neither of these is true.

Friendships require sustained effort that can often be just as confusing to navigate as a marriage. Over time they will go through ups and downs, face challenges from time pressures or geographical constraints, and have to resolve misunderstandings. And these are the good ones. We also have to try out many friends to find the ones who stick, and weed out the ones who turn out to be bad for us. And unlike our ancestors, we have to put a lot of effort into considering what is a friend, given the seemingly infinite number of connections we can make on social media.

Our ability to form relationships with people who aren’t related to us, however, is a critical skill that helped turn us into humans. It’s a fundamental part of who we are.

Biologically, our ability to develop and maintain social connections is directly related to the size of our brain. The research of Robin Dunbar (of Dunbar’s Number, one of our mental models), has demonstrated that because we are limited by our brain capacity, the fitness advantage of larger social groups was a driver in the evolution of parts of the brain. Other scientists have corroborated this idea that our larger brains are primarily a social versus ecological adaptation. It wasn’t because we happened to have a bigger brain for say, hunting, that we pursued complex social relationships, but rather that these relationships were critical for the evolutionary development of neocortical capacity. Friends made us smarter and gave us more potential.

Looking at ourselves through a biological lens also suggests that one of the obvious advantages to friendships is the diversity they create. If you are being attacked by a saber-toothed tiger, it would be nice to be able to rely on more than one individual for help. And, perhaps more importantly, your chances of thwarting the tiger are increased if you are part of a tribe that includes people with different skill sets. Someone who understands tiger behavior, someone who can kill it, and someone who can treat any resulting wounds could be helpful. Furthermore, being part of this diverse group means that when the environment changes, someone can likely adapt and lead the way for everyone else.

In a modern context, having diversity in our relationships has multiple applications. For one, it doesn’t make much sense to put all your emotional eggs in one basket. Committed romantic partners are wonderful, but if they die the last thing you want to be is alone. Your survival is quite literally dependent on having close friends who can support you through the hard times. And having friends with different specialties, interests, strengths and weaknesses can help us test out ideas and develop our character by giving us a safe space to experiment.

What about the value of friends who are smarter or better at the things we aspire to do? As in dealing with the tiger, friends with different talents can help us realize our own potential.

In her book The Friendship Cure, Kate Leaver provides a convincing argument for the value of friends. They are worth it for the benefit to cardiovascular health alone! Interestingly, she writes that “social integration and close relationships are the most important predictors of mortality, well above things like alcohol consumption, exercise and diet.” With a network of reliable friends, we live longer and in better health. And good friends make us feel good. There is a reciprocity that Leaver explores in all sorts of manifestations, demonstrating just how amazing friendships can be for the quality of our lives.

The value of friendship has been evident for a long time. Aristotle devoted a good part of the Nicomachean Ethics to contemplating friendship, but took it as self-evident that friends were important. He wrote, “for no one would choose to live without friends even if he had all the other goods.” Defining what makes a good friend, fine, he could spend some time on that, but there was no doubt that friendship itself was “a necessary component of happiness.”

To really see the value of friends, think of your social ecosystem, the web of interpersonal connections that you engage with as you live your life. Leaver asks, “what do we get from friendship that we don’t get from romantic relationships, family or work?” When you answer this question, you’ll see where your friends fit.

The answers are going to be different for everyone. It could be that friends provide you with a place to go to admit your fears and frustrations without being judged, or a history of yourself that you tap into to keep you grounded, or someone to go to axe throwing with on Thursday nights. The point is, we can get profound positives from friends that we cannot get in our other relationships.

We become who we are in great part because of the friends we have. — Alexander Nehamas

Aristotle also said that “though the wish for friendship comes quickly, friendship does not.” Yes, they do take work. But the good news is that if you put some effort into learning what it means to be a good friend, the rest isn’t going to feel like work at all. Why? Alexander Nehamas writes in On Friendship that friendship “provides companionship and a safety net when we are in various kinds of trouble; it offers sympathy for our misfortunes, discretion for our secrets, encouragement for our efforts.”

So why does friendship seem to get relegated to the bottom of our relationship endeavors? Leaver argues that “we’ve built a culture of individuality without knowing how to be alone successfully or how to truly combat loneliness.” If friendship becomes another check box on your daily to-do list, you’re probably not going to feel like you actually have friends. That kind of social interaction is going to feel more stressful than beneficial, and consequently you will likely start to avoid it.

A further consideration is that friendship seems to go by the wayside as we pursue the things we believe we need to consider ourselves successful. Material goods, titles, fame, a large number of social media followers. Whatever.

But Leaver’s point is that friends are actually a key component of success. Without them we become isolated and vulnerable to loneliness, pain, and poor health. With them we live longer, with more laughter and less fear, and a higher quality of life. Doesn’t that sound like something worth some effort?

Edward Deci: On the Relationship Between Need Fulfillment and Motivation

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.

Intrinsic Motivation

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:

  1. The need for autonomy
  2. The need to feel competent
  3. The need for relatedness

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.

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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.

Internalizing & Autonomy

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.

Under One Roof: What Can we Learn from the Mayo Clinic?

The Mayo Clinic is one of the top-rated hospitals in the US and enjoys remarkable success. In this post, we consider the reasons for the Mayo Clinic’s success and what we can learn from it to apply to our own organizations.

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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.

Pulling the Same Oar

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.

An interesting book called Management Lessons from the Mayo Clinic (recommended by the great Sanjay Bakshi) details some of Mayo’s interesting culture:

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.

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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.

Under One Roof

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.

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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.

The Chessboard Fallacy

“In the great chess-board of human society,
every single piece has a principle of motion of its own.”
— Adam Smith

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One of our favorite dictums, much referenced here, is an idea by Joseph Tussman, about getting the world to do the work for you:

“What the pupil must learn, if he learns anything at all, is that the world will do most of the work for you, provided you cooperate with it by identifying how it really works and aligning with those realities. If we do not let the world teach us, it teaches us a lesson.”

By aligning with the world, as it really is and not as we wish it to be, we get it to do the work for us.

Tussman’s idea has at least one predecessor: Adam Smith.

In The Theory of Moral Sentiments, Smith excoriates the “Men of System” who have decided on an inflexible ideology of how the world should work, and try to fit the societies they lead into a Procrustean Bed of their choosing — the Mao Zedong-type leaders who would allow millions to die rather than sacrifice an inch of ideology (although Smith’s book predates Maoism by almost 200 years).

In his great wisdom, Smith perfectly explains the futility of swimming “against the tide” of how the world really works and the benefit of going “with the tide” whenever possible. He recognizes that people are not chess pieces, to be moved around as desired.

Instead, he encourages us to remember that everyone we deal with has their own goals, feelings, aspirations, and motivations, many of them not always immediately obvious. We must construct human systems with human nature in full view, fully harnessed, fully acknowledged.

Any system of human relations that doesn’t accept this truth will always be fighting the world, rather than getting it to work for them.

The man of system, on the contrary, is apt to be very wise in his own conceit; and is often so enamored with the supposed beauty of his own ideal plan of government, that he cannot suffer the smallest deviation from any part of it. He goes on to establish it completely and in all its parts, without any regard either to the great interests, or to the strong prejudices which may oppose it.

He seems to imagine that he can arrange the different members of a great society with as much ease as the hand arranges the different pieces upon a chess-board. He does not consider that the pieces upon the chess-board have no other principle of motion besides that which the hand impresses upon them; but that, in the great chess-board of human society, every single piece has a principle of motion of its own, altogether different from that which the legislature might choose to impress upon it.

If those two principles coincide and act in the same direction, the game of human society will go on easily and harmoniously, and is very likely to be happy and successful. If they are opposite or different, the game will go on miserably, and the society must be at all times in the highest degree of disorder.

Think of how many policies, procedures and systems of organization which forget this basic truth; systems of political control, price control, social control and behavioral control — from bad workplaces to bad governments – which have failed so miserably because they refused to account for the underlying motivations of the people in the system, and failed to do a second-order analysis of the consequences of their policies.

It’s just as true in personal relations: How often do we fail to treat others correctly because we haven’t taken their point of view, motivations, aspirations, and desires properly into account? How often is our own “system of relations” built on faulty assumptions that don’t actually work for us? (The old marriage advice “You can either be right, or be happy” is pure gold wisdom in this sense.)

Smith’s counsel offers us a nice out, though. If our own system for dealing with people and their own “principles of motion” are the same, then we are likely to get a harmonious result! If not? We get misery.

The choice is ours.

Daniel Kahneman on Human Gullibility

“The premise of this book is that it is easier to recognize other people’s mistakes than our own.”

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A simple article connecting two ideas from Daniel Kahneman’s Thinking Fast and Slow on human gullibility and availability bias.

A reliable way to make people believe in falsehoods is frequent repetition, because familiarity is not easily distinguished from truth. Authoritarian institutions and marketers have always known this fact. But it was psychologists who discovered that you do not have to repeat the entire statement of a fact or idea to make it appear true. People who were repeatedly exposed to the phrase “the body temperature of a chicken” were more likely to accept as true the statement that “the body temperature of a chicken is 144°” (or any other arbitrary number). The familiarity of one phrase in the statement sufficed to make the whole statement feel familiar, and therefore true. If you cannot remember the source of a statement, and have no way to relate it to other things you know, you have no option but to go with the sense of cognitive ease.

This is due, in part, to the fact that repetition causes familiarity and familiarity distorts our thinking.

People tend to assess the relative importance of issues by the ease with which they are retrieved from memory—and this is largely determined by the extent of coverage in the media. Frequently mentioned topics populate the mind even as others slip away from awareness. In turn, what the media choose to report corresponds to their view of what is currently on the public’s mind. It is no accident that authoritarian regimes exert substantial pressure on independent media. Because public interest is most easily aroused by dramatic events and by celebrities, media feeding frenzies are common. For several weeks after Michael Jackson’s death, for example, it was virtually impossible to find a television channel reporting on another topic. In contrast, there is little coverage of critical but unexciting issues that provide less drama, such as declining educational standards or overinvestment of medical resources in the last year of life. (As I write this, I notice that my choice of “little-covered” examples was guided by availability. The topics I chose as examples are mentioned often; equally important issues that are less available did not come to my mind.)