RTCrawford’s Weblog

A couple of years ago, my colleague Jim Porto at UNC Chapel Hill asked me to teach a two-day seminar on performance psychology, and I loved it. My students, on the other hand, initially evidenced a normal distribution, with agnosticism as the mean. In other words, a small number loved it, a small number hated it, and most figured it was a necessary block to check before moving on to more productive things. As I continued to teach it and my skills presenting the materials became better, the response improved, and, because the materials were taken from research rather than the self-help section at Borders, the impact has been rewarding (and the student evaluations would make my mother proud).

Well, I no longer teach the seminar (having handed it to others who are every bit as capable), but I’ve retained interest in the topic. Over the winter holidays, I read Malcolm Gladwell’s Outliers and Geoff Colvin’s Talent is Overrated. While both are interesting (Colvin’s is better, despite Gladwell’s higher standing on the New York Times Best Seller list), I decided to apply Jacobi and invert – looking at the causes of failure.

While Taleb’s Black Swan is the most thought provoking, Ormerod’s Why Most Things Fail, Dorner’s The Logic of Failure, Weick’s Managing the Unexpected, and Chiles’ Inviting Disaster identify the common themes and will play a growing role in my Quality Controls class. Colvin, especially, spends considerable time defining what “focused study” is and isn’t. Add this to the research work of Stanford’s Albert Bandura and more recent research by Robert Fritz (Path of Least Resistance), Peter Senge (Fifth Discipline), Charles Manz and Henry Sims (The New Superleadership) and the visualization techniques of psychiatrist Tad James, and you have the makings of a workable model.

All of this is helpful when investing in equities … and personal healthcare (which is a different form of personal and societal investment). Both Gladwell and Colvin note that 10,000 hours of focused study are necessary to achieve exceptional performance at complex undertakings … like golf, basketball, computer science, bridge, and, well, investing – explaining, Tiger Woods, Michael Jordan, Bill Gate and Steve Jobs, and Warren Buffett (Buffett is an exceptional bridge player, by the way).

10,000 hours translates to around 10 years, which may seem odd, since we tend to work a little more than 2,000 hours at a 40-hour-a-week job. The 10,000-hour goal, if divided by the 2,000-hour-a-year job would imply that excellence can be achieved in as little as five years, but the key constraint arrives with the definition of “focused study.”

Focused study is where the learner never goes into rote-execution mode. Every golf or basketball shot, every played card, each investment decision, etc. is studied carefully before, during, and afterwards. With investments, this includes analyzing which stock screens work best, which ratios matter most, and, of course, which investments worked and which did not. Equally, important, it includes tracking the stocks not chosen. Were they the poor opportunities you imagined? Did they turnout better than expected? Could you have gotten disgustingly wealthy if making a different choice … . And, most annoying and obnoxious of all, why were you wrong? Learning from victories is rare but learning quickly from mistakes is all the more rare.

This avoidance of rote performance is fundamentally different than what we imagine as the ideal. Most employers want their workers to perform at high levels of competence as if it were second nature, not as though the worker were first learning and plodding their way through the task with each attempt. But that is precisely what a Tiger Woods does in practice and during tournaments, and, given his mantra that “the first rule of investing is not to lose money, and the second rule of investing is the first rule of investing” (I’m paraphrasing), it is what Buffett does, as well.

Years ago, when I was a housekeeping supervisor at Athens Regional Medical Center in Athens, GA, one of the best housekeepers working for me was a special case – a severely, learning-challenged young man, bought to us by social services. He was, in short, a charity hire (over which I had no say or right of rejection), and his subsequent excellence came as a great surprise. Now, it should be understood that conventional housekeeping at home or for a hotel is different than housekeeping for a hospital. While the income is not commensurate with the necessary ability, hospital housekeepers are skilled technicians (when the work is done properly), and the consequences of poor quality are significant. Patients have died due to nosocomial infections (the departing gift one patient left for the next in the form of germs not eliminated by housekeeper). Several years ago, before an intensive reform effort, 19,000 medically-preventable adverse events were attributed to nosocomial infections in Pennsylvania, alone. Well, our learning-challenged worker was slow to be trained and slow to clean, and there was not much hope for him, until we realized that his slowness was because he was thorough – painfully thorough. In other words, he never developed the rote execution that would allow him to develop a pat plan of cleaning and perform it consistently.

Ultimately, we realized he would never become a high-volume, production worker. Rather than fire him, we kept giving him a smaller and smaller number of rooms to clean. This started with half of a large Med-Surg ward. It was too much for him (he fell behind and never caught up). Then it was a medium sized ward. Same outcome. A small ward of 10 rooms in labor and delivery. Ditto. Finally, there was nothing smaller except the ICUs … or termination. We gave him four ICU beds, and he thrived … not because he cleaned them quickly but because he didn’t clean them quickly.

I have a good friend who recently discovered a large lump in one breast. The lump was verified by their family-practice nurse-practitioner, and the patient was referred to a large local medical center for a mammogram and ultrasound. Neither exam was able to find the lump (a good thing, since this meant cancer was less likely). Initially, the lump was 2.5 cm, just below the skin surface, but it was growing quickly, and she went to UNC for a second opinion. A new mammogram and ultrasound were ordered. No less than five radiologists worked on her breast to get the image by ultrasound (the mammogram never caught it, even when using the most advanced imaging at high resolution). A core needle biopsy (guided by ultrasound) got tissue for a confirmable diagnosis (stromal sclerosis with cystically dialated ducts, a benign infectious process). The difference between the two facilities? One worked efficiently, while the other worked in the moment (“learning” the patient and her breast until achieving success).

This is not unusual in medicine, even thought we pretend otherwise. It turns out that the same is true of colonoscopies, where cancers are often missed along the interior wall of the gastro-intestinal tract – the inside wall closest to the naval. Endoscopists who work slowly find more tumors before no treatment for cure is possible. The same holds for bronchoscopies (at the other end of the patient). And, yes, 10,000 hours to achieve excellence is important here, as well.

Now, this runs contrary to other studies. First, we have Thomas Kuhn’s Structure of Scientific Revolutions, which indicates that advances are more commonly authored by the young than older, more-experienced researchers. I’ve been co-author on research indicating that more recent medical school graduates know, understand, and employ optimal care practices more consistently than longer-tenured physicians. Does this mean that we have the inconsistency equivalent of “eggs are good for you,” “no, they are bad for you,” “no, the whites are good, the yellows are bad”? Not at all.

It appears to me that recent medical school graduates deliver better care because they do not know any better than to do what is in the best interest of the patient. Their knowledge about optimal care is current. The science has not changed since graduation. They have not fallen behind in their knowledge. And they have not become devoted to their preferred treatment approach. Eventually, however, they will become the very physician against which they compare so favorably – the one with white hair, who finds it difficult to keep up with the current volume of patients much less the current volume of new research.

But there is an exception to this model – the teaching attending (the professor physician). Academic medical center attendings, regardless of age or longevity in the profession, know and deliver optimal care more consistently than even their recently-graduated students. They see and treat one-third fewer patients, and those patients tend to be more sick and present with more complex conditions. The more experienced they are, the better the results. In other words, they have the time necessary to stay abreast of best practices in their areas of expertise, and they have the time necessary to treat patients slowly – not because the patients are slow (some are), the doctors are slow (some are), the medicine is slow (it is not), or the payers are fast (none are). Instead, they have the luxury of staying in the moment, avoiding the problems of rote performance, and have the luxury of 10,000 hours … typically, much more.

And that leads us to the question of how to avoid crises and failure … which will have to wait for another time.