Joe’s Career Blog
Career development observations and advice for medical professionals from Dr. Joseph V. Simone.
Wednesday, July 27, 2016
Like many of you, early in my career I began to face the difficult issues inherent in end-of-life care. I accumulated a library on the issue but found it difficult to find clarifying insights instead of superficial banter or a misplaced spiritual focus. I learned to go to the Russian writers for in-depth, humane descriptions of suffering and death. I have written a bit in the past about the writing skills of these authors relevant to medicine.
Alexander Solzhenitsyn's Cancer Ward is a masterpiece that provides insight into the fears, strengths, and weaknesses of people under enormous stress because of cancer. Fyodor Dostoyevsky is a master at describing how people like us deal with their sins and challenges, and especially the value of lives, especially in The Brothers Karamazov.
However, for the purpose of this column, the best source is the shortest— Leo Tolstoy's masterpiece, The Death of Ivan Ilyich, published in 1886. This novella in my little yellowed-page Bantam Classic pocket book edition (that I got for $1.35 in a used bookstore long ago) is only 99 pages long. It is a tour de force of artistic compression—the impact of a novel from what is essentially a long short story.
Tolstoy Describes the Patient
Tolstoy describes a 40-something man, Ivan Ilyich Golovin, an accomplished attorney who rose to the position of high court judge. Ivan Ilyich (I use this name format as Tolstoy did) develops a slowly progressive, ultimately fatal disease. Despite the radical changes in medicine since his time, Tolstoy would need to change none of the human essentials if he were writing it today; his description of this "worldly careerist" describes features of many of us professionals today. Ivan Ilyich is successful by societal standards. He has married "correctly," has two attractive children, and has achieved substantial professional stature.
One day, shortly after being appointed to the high court, he fell and banged his side. It was sore for a couple of days, then subsided. Later, he noticed a small lump in the area that was mostly painless, but it remained tender to the touch. He had a good life, took pride in his work, moved in the best social circles, and derived great pleasure from playing whist, a card game similar to bridge, with his friends.
But the discomfort gradually became annoying to him and his disposition worsened, leading to frequent arguments with his wife. Finally, his wife insisted he see a doctor. Here is Tolstoy's acidic description of the visit to the doctor:
"The whole procedure was just what he expected, just what one always encounters. There was the waiting, the doctor's exaggerated air of importance (so familiar to him since it was the very air he assumed in court), the tapping, the listening requiring answers that were clearly superfluous since they were foregone conclusions, and the significant look that implied: 'Just put yourself in our hands and we will take care of everything…' [Then] the doctor said: such and such indicates that you have such and such, but if an analysis of such and such does not confirm this, then we have to assume you have such and such…and so on. To Ivan Ilyich only one question mattered: was this condition serious or not? But the doctor ignored this inappropriate question…one simply had to weigh the alternatives: a floating kidney, chronic catarrh, or disease of the caecum…and in Ivan Ilyich's presence the doctor resolved that conflict brilliantly in favor of the caecum, with the reservation that if an analysis of the urine revealed new evidence, the case would be reconsidered."
Over several months, the aches changed to pain that became progressively worse. He began to lose weight and developed a bad taste in his mouth, bad breath, and a poor appetite. Despite repeated visits to doctors and multiple medications, he was on a downhill path.
If Ivan Ilyich had ever thought about death, it was never his own, it was always removed from serious concern. Death happened to others and required expressions of sorrow and condolences that caused brief and unwelcome interruptions in the comforting routines of a busy life. In fact, Ivan Ilyich never deeply examined his life, his only focus being on the physical aspects. He was an opportunist, a "man on the make," in society and his profession; metaphysical issues were of no interest. His professional authority led him to believe he was special.
Even though he sometime acts like a pompous boor, in some ways Ivan Ilyich becomes a sympathetic character because we can glimpse a bit, or more, of ourselves in him, because Tolstoy uses him to express his own fear of death and because of Tolstoy's graphic and heartbreaking description of Ivan Ilyich's suffering.
What sets this narrative apart from most treatments of death in the artistic and medical literature is that everything is described as seen and experienced by the dying patient. The viewpoint is personal and specific instead of generic, making it more poignant, and Tolstoy's artistic genius creates the mood, intensity and relentless clarity of a dying man…it is hard to watch, but hard to look away.
A Story of Medicine
There are several circumstances illustrated by Tolstoy's story that will be familiar to most doctors and nurses.
Ivan Ilyich says this can't be happening to him…it was only a little bump, after all. We are familiar with denial and the attempt to apply reason to what doesn't lend itself to reason. He also points to his living an exemplary, if unexamined, life and the injustice of this happening to him. The application of justice is, of course, also fruitless. He is tormented by the lack of an answer to, Why me? He simply cannot grasp the reality of dying.
He dreams of cures though he eventually comes to acknowledge the fact that he is dying. He thinks about "the big lie." All around him—doctors, family, and friends—talk about his recovery and that the next medicine may do the trick. But it is all a big lie. He knows he is dying but nobody is honest with him. He is "trapped in a mesh of lies." This leads to his isolation, his sense that no one understands and he is all alone facing "It," which is what he calls death. Everyone around him is thinking beyond his death: the funeral, how they will get along without his income, will they get promoted when his job is filled, and so forth. He realizes that is what people do, that is what he did, because they are not dying. He comes to understand that ultimately, everyone faces "It" alone. Near the end he asks everyone to leave him alone.
Everyone lies to him except Gerasim, a farm boy who is brought in to care for him. He alone understands and accepts what was happening. When Ivan Ilyich thanks Gerasim for his kindness and help, the boy says, "We all have to die someday, so why shouldn't I help you?" By this he meant, Tolstoy tells us, that he did not find his work a burden because he was doing it for a dying man, and he hoped that someone would do the same for him when his time came.
Ivan Ilyich's last few days were horrible. He dreamed he was being stuffed into a black bag and he screamed in pain for 3 days before he died. An epiphany and relief came in the last moments before his death. He finally could admit to himself that perhaps he did not live a "good" life. All those honors and high stations and high society now seemed so pitifully irrelevant at this moment. He comes to admit that he could have done better, an admission of his smallness and an understanding of what is really important in life. Thus, his physical crisis ends at the same time as his moral crisis.
We are fortunate to have a contemporary writer with some of the writing skills of Tolstoy and the same uninterrupted gaze at death. Atul Gawande, MD, MPH, a physician and gifted writer has written many books and he writes regularly for The New Yorker magazine. His article on the topic of end-of-life care is, Letting Go, published May 26, 2010, in The New Yorker. What should medicine do when it cannot save your life?"
He tells stories familiar to any oncologist and most physicians about patients who are going to die because therapy is no longer effective, and how patients, families and caregivers deal with it. He includes himself among doctors who on occasion recommend treatments that they know will neither cure nor extend life with even a modicum of quality. He graphically describes the wrenching challenges for families and caregivers facing death and helplessness.
Gawande's article is excellent and I urge you to read his article as well as Tolstoy's novella.
Friday, July 8, 2016
I began writing this column when I was approaching my 80th birthday and finished it when approaching 81. It is a time of recollection, assessment, and reverie. Getting to one's 80s means one has lived through a lot of history. And I now can no longer say only that I am aging, though that is true, but more honestly that I am actually old. "You don't look a day over 76," the guy at the gym cracked. Others try to be kinder and say, "You don't look that old." But I am, which is underscored when I recall the notable events—societal, medical, and personal—that I have lived through in over three-quarters of a century. Describing some of these events and changes may make my lifespan more tangible, since we all are influenced by the environment, events, and culture we have livedin.
- I was born in Chicago in the middle of the Great Depression, which had an indelible effect on my family and me; our values concerning the unreliability of financial security and material things never left us.
- My father was an uneducated immigrant who drove a taxi and earned $15-$20 a week. I never realized we were on the poor side of the social spectrum (with many, many others), but we had enough to eat and a loving home.
- I was married in May and graduated from medical school in June; I was 24.
- I started a rotating internship at Presbyterian-St. Luke's Hospital (PSLH) in Chicago (now Rush) a few years before that training category disappeared, to the detriment of subsequent post-graduate clinical experience.
- We did simple lab tests in the inpatient unit (urinalysis, stool guaiac, stomach acid, and hematocrit) at night and during the day when a quick answer was needed.
- The first contraceptive pill went on the market.
- John F. Kennedy was elected president.
- I was in the midst of a residency in internal medicine at PSLH and was on call every other night, the same as during my internship.
- I started writing a journal, which I have continued to this day, because a faculty member said that would help me learn how to write; it turned out to be an excellent way to think about problems, patients, work, life, and family and occasionally a way to vent my spleen (The journal is now well over a million words).
- James Meredith, the first black student, registered at the University of Mississippi escorted by federal marshals.
- St. Jude Children's Research Hospital opened its doors and accepted its first patient, a boy with acute lymphoblastic leukemia (ALL).
- I and most of the house staff at PSLH were drafted into the military due to the Cuban missile crisis; many of the drafts were rescinded (mine included) after hospitals around the country complained that they would be forced to shut down. Many of us then joined the military reserves staffing a virtual military hospital.
- After 4 years as a pediatric hematology-oncology fellow at the University of Illinois Department of Pediatrics, Dr. Donald Pinkel recruited me to St. Jude in Memphis. My wife and I had never lived outside of Chicago and we had three daughters 6 years old and under.
- We bought a four-bedroom house for $27,500 with an FHA loan and a $2,200 down payment that included closing costs. We had only $200 to our name (credit cards didn't exist). We drove all night in our 1963 VW Beetle with the girls sleeping in the back. After a week at work I asked Dr. Pinkel when we would get paid.
- I passed the written and oral certification exams for pediatrics and internal medicine. Oral exams were later abolished.
- This was a historic and tumultuous year for the whole country and beyond. The Vietnam war was at its peak, causing President Johnson to decline to run for a second term.
- In February, my father died.
- Robert Kennedy was assassinated.
- Civil rights and student protests popped up everywhere, and not just in America. The air was filled with tension, polarization, demonstrations, rioting, civil disobedience, and a deep sense of unease and anger. In this medium, acts of violence and lawlessness were selectively condemned or justified depending on one's viewpoint.
- Dr. Martin Luther King, Jr. came to Memphis to support the striking city sanitation workers, who were all black. On March 28 three St. Jude colleagues and I decided to march with him because of the injustice of the city's leaders. In the middle of the march, windows were shattered and riots broke out and everyone scattered. The four of us started to run back to the hospital, but I reflexively picked up two of the posters that the sanitation workers had carried and dropped when the chaos started. The posters hanged in my office until recently when I passed them to my daughter.
- A week later, April 4, Dr. King was assassinated.
- Dr. Pinkel appointed me to Head of Hematology-Oncology at St. Jude.
- Neil Armstrong landed on the moon.
- Gasoline cost 35 cents a gallon.
- Woodstock attracted more than 350,000 fans.
- The St. Jude group published the first paper projecting the possibility for the cure of ALL. I received nasty phone calls (e-mail did not exist) from colleagues criticizing me for giving patients and families false hope. I responded that if they didn't believe a cure was even a remote possibility, maybe they should send their patients to us (I did have some chutzpah).
- Terrorists at the Munich Olympic Games murdered 11 Israeli athletes.
- G. Gordon Liddy, general counsel of the committee for re-election of President Nixon proposed burglarizing and wiretapping the headquarters of the Democratic National Committee in the Watergate complex in Washington, D.C. A few months later a security guard called the police, which started the Watergate affair.
- The Senate passed the Equal Rights Amendment to the Constitution giving equal legal rights to men and women.
- The St. Jude group published a seminal paper demonstrating long-term survival for half of patients with ALL in Total Therapy Study V, even after cessation of therapy.
- President Nixon was inaugurated in January, but was forced to resign later in the year due to the Watergate scandal.
- The U.S. Supreme Court voted 7-2 in Roe v. Wade making abortion a right based on their interpretation of the Constitution concerning personal privacy and rights.
- Leisure suits became the fashion. I have photos of me wearing one and I assure you they will never see the light of day.
- I was appointed to succeed Dr. Alvin Mauer as Director of St. Jude.
- President Reagan signed legislation making the third Monday in January a national holiday honoring Dr. Martin Luther King, Jr.
- Motorola introduced the first mobile phones to the public.
- ARPANET, founded in 1969 by the U.S. Department of Defense to test models for electronic communication, officially changed the structure to the Internet Protocol, thus creating the Internet.
- Leaders of Washington University asked St. Jude leaders to consider moving the institution to St. Louis; after months of discussion and deliberation, St. Jude stayed in Memphis.
- The AIDS virus was identified and within a year the disease became widespread.
- After 24 years I left St. Jude to become Physician-in-Chief at Memorial Sloan-Kettering Cancer Center.
- Four years later, I was recruited to Utah to help further develop the Huntsman Cancer Institute. I retired from academia 5 years later, in 2001.
- On Sept. 11, 2001, my wife and I moved to Atlanta to be near our two grandchildren and did not hear of the morning attack on the World Trade Center until late afternoon. Our youngest daughter was only blocks away from the attack and we could not communicate with her until late in the day; she was OK physically, but not OK emotionally.
When pulled together, my experiences (and that of many others my age or older) describe a long arc, making my age more tangible in the midst of so many events. And I know how it ends because Shakespeare has told us with the "Seven Ages of Man" speech in "As You Like It" that ends thus:
The sixth age shifts
Into the lean and slipper'd pantaloon,
With spectacles on nose, and pouch on side,
His youthful hose well sav'd, a world too wide,
For his shrunk shank, and his big manly voice,
Turning again towards childish treble, pipes
And whistles in his sound. Last scene of all,
That ends this strange eventful history,
Is second childishness and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything.
Although Shakespeare was right, in general, I am blessed with good health, a fairly good intellect (short-term memory not as sharp, but OK), financial security, and a wonderful family with all members also in good health and happily bonded to each other.
What a blessing to have lived in an exciting age when: good health is more common; medicine is more effective; and opportunities to do good are more readily available. I can say that 80 is just a number and mean it, and I will enjoy whatever time I have left with gusto.
Wednesday, June 22, 2016
We each have personal views on the health of clinical oncology practice and we often hear from prominent members of the cancer community on the issue. But we seldom see in print the views of those in the trenches.
I have asked some oncologists in private practice whom I know and judge to be thoughtful and open-minded to provide their personal views for this column. They represent practices of all types and sizes and from all regions of the country. I asked them to use the SWOT analysis format (Strengths, Weaknesses, Opportunities, and Threats). I suggested no particular topics, but only to give their personal views of the current state of clinical oncology practice in the U.S. today. I did not include duplicates and to fit in the space I could not include every comment or very similar opinions; the texts were lightly edited to fit the format.
This is an update of a similar request I made in 2004, the results of which were published in my column in the September 10, 2004 issue. Most of the original responders agreed to provide new opinions for this column, which represents a rough approximation of the evolution of concerns and improvements in oncology practice over the last 14 years.
Strengths of Clinical Oncology Practice:
- Opportunities for personal growth and service to the community;
- Doctors' general good will and willingness to collaborate and learn;
- The most robust medical scientific community in the world;
- Explosion of knowledge and technology, promising new drugs;
- The shift to targeted, relatively non-toxic therapy;
- The silent revolution of the introduction of effective adjunctive therapies to improve quality of life, like anti-emetics, potent bisphosphonates, growth factors, and pain therapy regimens;
- Strong national organizations and networks, such as ASCO, ASH, and NCCN.
- Excellent patient care and strong reputation of oncologists;
- Excellent payer contracts in our area;
- Greater integration of end-of-life care into clinical practice;
- Enhanced utilization of Advance Practice Providers;
- Treatment value-assessment efforts by ICER, ASCO, NCCN, MSKCC, et al;
- Opportunities for personal growth and service to the community;
- Tremendous increase in understanding the pathogenesis of cancer and new chemical biology to develop new highly active therapeutics;
- Development and deployment of good oncology EHRs and chemotherapy order-entry systems;
- Patients, as always, are compelling and deserving of our efforts
- The science is amazing—and the improvement in outcomes, at least for a minority of patients, is heartwarming;
- Acceptance of evidence-based medicine in medical oncology;
- Exponential growth of computing capacity.
Weaknesses of Clinical Oncology Practice
- Too much money in the system leads to physician excesses and unreasonable expectations of patients, often avoiding or postponing difficult decisions;
- The rising costs of cancer therapy are not sustainable, no matter how much they squeeze the docs;
- Technological advances have increased the cost of care, further straining the system;
- Failure to come to grips with rationing health care (e.g., millions of dollars for separating conjoined twins while American children go without routine health care);
- Pharma--and the public--conspire to use the flashy new drug with the greatest financial impact, rather than that with the greatest medical impact;
- Politicians have explicitly protected big Pharma (in the Medicare Modernization Act!) from competitive pricing, so they and CMS put the oncologist in charge of rationing care as prices skyrocket (it is unclear who the MMA benefits, besides politicians in an election year and big Pharma);
- Failure to take responsibility for the rising cost of treating patients with metastatic disease; embracing very expensive agents that provide statistically significant, but clinically marginal benefit and little, if any, survival benefit;
- Lack of any system of care (read the IOM report on the "Quality Chasm…");
- Treatments known to be ineffective are given far too often;
- Public dissatisfaction with the process of care;
- Complex data presented by hurried physicians is difficult to understand and retain;
- We oncologists too often think we are entitled to special treatment (compensation) just because [of our station in life]--if someone starts looking at what we get paid, it won't stand up to the light of day—this just isn't right;
- Our hospital has a poor reputation, so some patients go elsewhere;
- Our hospital is trying very hard to buy our practice and, we believe, put us out of business since they cannot control us;
- Provider burnout is a growing problem;
- Conflicts of interest, with researchers exaggerating the efficacy of drugs for career and financial benefits;
- Lack of software interoperability, which stifles patient care and research efforts;
- Many physicians order all possible tests and treatments, whether indicated or not, whether useful or effective or not, thus raising costs dramatically;
- EHRs built for general use (e.g., EPIC) are poorly equipped to manage cancer care, thus adding more safety risks and inefficiencies;
- Oncology is a quintessential multidisciplinary specialty--far too few patients are seen in multidisciplinary clinics where shared decision-making occurs most naturally;
- The information overload is backbreaking, communication without filters is overwhelming, current systems are overpriced for the lack of smooth usefulness;
- No link of health care spending to overall spending for a just distribution of goods;
- Mountains of insurance company paperwork;
- Care in silos—only beginning to manage total disease trajectory;
- Economic burden for patients ("financial toxicity") is real.
Opportunities for Clinical Oncology Practice
- There are enormous opportunities because the "system" is so broken, dysfunctional, and non-existent--e.g., a single electronic medical record that can communicate across all systems and platforms; this is one of many opportunities for the federal government;
- Use current technology to see how well we are doing and improve care (e.g., the Quality Oncology Practice Initiative);
- Better systems of collaboration between community and academic oncologists--many academic centers are creating more community oncologists but neglect development of focused experts to whom one can refer rare or difficult problems;
- A huge opportunity for improving the quality of care not only in medical oncology, but also in surgical and radiation oncology, diagnostic imaging, and pathology--each has a major influence on quality of care;
- Improved methods of doctor-patient communication, decision support, and awareness;
- Better models for management of patients with advanced cancer;
- Move more toward skeptical, evidence-based oncology to take the high road in the quality, science. and delivery of care.
- Affiliation with academic cancer centers;
- Greater computer interoperability;
- Liquid biopsy techniques to facilitate research and the patient experience;
- Expanded availability of embedded decision-support tools within the EMR system;
- Oncologists need to be the leaders of care teams. The old model of independent physicians who may or may not call for other opinions is no longer viable--Patients need to know that their doctor is working with other specialists, which is a source of comfort for most;
- Leverage technology to improve the quality, efficiency, and safety of cancer care, including the incorporation of patient-reported information to inform practices;
- We can and should figure out how to better include "mid-level" providers, nurse practitioners, and others--we often waste valuable talent by failing to do so;
- A culture of evidence and cost-effectiveness is taking hold;
- Drug approval and marketing will be tied to value as well as evidence.
Threats to Clinical Oncology Practice
- The piece-meal approach to fixing systemic problems--e.g., MMA--results in serious unintended (but foreseeable) consequences for patients;
- Growing expectations for unreasonably positive outcomes due to hyper-optimism and marketing;
- Potential for an adversarial breakdown of relations between hospitals and doctors--with money exiting the system, physician purchases of CT and PET scanners, and radiation therapy equipment directly competing with hospitals;
- Drug costs will price medical oncology therapy out of reach;
- Ignoring rapidly rising drug costs for all, the inevitable increase in the numbers of those who cannot afford care, and the widening gap between those who can and cannot afford to pay for therapy;
- Everyone else will police us and oncologists will no longer be the leaders of cancer care; there is a risk that "big brother" will have a greater interest in the bottom line than in the quality of care--oncologists must create and maintain standards of care;
- Continuously falling compensation may cause early retirements or curtailment of practices, leaving fewer, overly burdened practices-- the public and Congress don't understand that at this rate we will end up with too few resources and providers to give the care expected.
- Competition from academic centers and large multispecialty groups;
- Our hospital may receive bundled ACO payments and short-change the physicians;
- Move to oral drugs with management by specialty pharmacies;
- Outrageous costs of new drugs;
- Hyperbole of yet another "Moon Shot" boondoggle, raising smoke-and-mirror promises that will lead to disappointed patients;
- "Personalized medicine" prescribing before demonstration of significantly improved outcomes;
- Internet knowledge mixed in with "internet garbage";
- The piece-meal approach to fixing systemic problems--e.g. MMA, MACRA, CMS Part B Demonstration project results in serious unintended (but foreseeable) consequences for patients;
- The rapid growth of hospitalists coupled with the reduced need for patients to be hospitalized for chemotherapy has led to a loss of oncology expertise in hospitals--hospitals have become dangerous places for cancer patients!
- Failure to control drug prices will force many patients to skip the recommended therapy, with unfortunate and unethical consequences;
- The middle class will be crippled by health care costs;
- CMS/government will continue to be barred from negotiating drug prices, while Canada, France, England, and others get big discounts.
So there you have it--a snapshot of the changing status of the practice of Clinical Oncology Practice, with opinions of hope as well as despair. Many thanks to the contributors for generously sharing their opinions. I welcome your thoughts--please let us know by adding your comment in the online version of this column, or by emailing me at firstname.lastname@example.org.
Tuesday, June 14, 2016
I have wrestled with the concept of what makes a great leader many times over the years and have written about it before, but I never grasped the essence satisfactorily. Changes in leadership are common in academic medical centers, hospital systems, and government agencies. Having observed such changes many times in my career, a recent experience once again has made me ask myself what makes a good leader of these organizations and, better yet, what makes a great leader.
Leadership matters and it matters a lot. This statement would seem to be a no-brainer; however, it is common to see leaders chosen irrationally. This is true of business, a medical practice, a hospital, an academic institution, or a government agency. Books on business success, including leadership, seem to be everywhere. While books on leadership of non-profit organizations, particularly those in health sciences and health care, are almost non-existent, leadership qualities are shared in all industries. There are many faulty reasons for choosing a leader. Here are three.
- Longevity: A dean may choose a faculty member to chair a department mainly because he has been with the organization for a long time. He is a nice guy, easy to get along with, and works hard. However, he freezes when having to make an important decision. That slows progress and healthy development of the program. This is especially damaging when he is extremely reluctant to fire or transfer anyone, so he puts the brakes on progress, which can endanger the morale of the team.
- Scientific Excellence & Fame: It is a common, in my experience, to see a very good scientist with a huge bibliography appointed to a departmental chair when she has no leadership skills. She has no vision for developing and improving the department, she is not a good recruiter, and she has an imperial attitude toward those in lower rank. This situation often causes long-term problems among the faculty.
- Lack of Leadership Experience: A candidate is hired despite his lack of experience in successfully leading a group of colleagues. Leadership is a talent that is partly or mostly in the person from childhood. That talent can be improved with experience. It is my own bias that most leaders have a history of leadership in families, school, church, Boy Scouts, or other such community or social organizations; absent that beginning, becoming a great leader is possible, but very difficult.
Models of Good Leadership
There are several gurus of management that have addressed this subject. One of my favorite sources of business management wisdom is Peter Drucker. This legendary sage understood and clearly described the features of running successful businesses. He is famous for believing integrity and high ethical standards are central to good business practice because it is the right thing to do, but also because it is good for the long-term health of an organization. Here is an excerpt from his work.
"What would I look for in picking a leader of an institution? First, I would look at what the candidates have done, what their strengths are—you can only perform with strength—and what have they done with it? Second, I would look at the institution doing the hiring and ask: 'What is the one immediate key challenge?' I would try to match the strength with the needs. Then I would look for integrity. A leader sets an example, especially a strong leader."
Drucker then quotes a famous and successful business leader and asked what he looked for in a leader. The man responded, "I always ask myself, would I want one of my sons to work under that person? If [the leader] is successful…would I want my son to look like that?" Drucker then concludes, "This, I think, is the ultimate question." And my favorite comment by Drucker, "Effective leaders delegate, but they do not delegate the one thing that will set the standard. They do it." Another well-known management expert, W. Edwards Deming, also held this last principle.
Deming is best known for being the American consultant who revitalized Japanese industry after World War II. "It is the responsibility of management to discover the barriers that prevent workers from taking pride in what they do. Rather than helping workers do their job correctly, most supervisors don't know the work they supervise. They have never done the job." Deming goes on to say that such supervisors often use numbers or quotas as the only basis for judgment, without understanding the nature of the work.
The greatest leader in American history was, in my view, Abraham Lincoln. A book that focused on his leadership and political skills cemented this view and, of course, on aspects of his personal character that shaped him (Lincoln: A Life of Purpose and Power). Lincoln's integrity, vision and bedrock principles were combined with uncommon political skills, which enabled him to navigate skillfully the most difficult and treacherous times of our country. He devoured information from all sources and sent aides into the field to obtain first-hand information that helped him make astute strategic decisions. He was an uncommon leader who brought political enemies into his administration because he believed they were the best people for the jobs. This book is the best I have ever read on the subject of leadership.
Leaders With Vision
In my experience, it has been clear the ill effects of poor leadership, at any level from CEO to department head to housekeeping, insidiously permeate an entire institution. This invariably leads to inefficiency at best, and at worst leads to falling dominoes of lost opportunity or catastrophe. Effective leadership is often subtle but direct, nuanced but clearly understood.
What makes great leaders is not a secret. They have grace under pressure, which means both courage and character, while they remain focused on the important aspects of an issue in the midst of chaos. Great leaders repeatedly articulate a consistent, simple public vision by example, conviction, and actions. If the troops don't know what is expected of them, what direction is set or what the leader values most, that is the leader's fault.
However, this vision must be backed by public acts, not just words. There are many opportunities to demonstrate one's vision, both subtle and overt. Whom the leader hires, fires, and promotes sends the most effective signal, but smaller acts can indirectly express his or her values. Great leaders take satisfaction in the success of team members and try to hire people who are better than they are.
I end with two qualities that help distinguish a great leader from a good leader, especially in the not-for-profit world. First, though the great leader remains confident in her final decisions, she must have humility in sufficient measure to mitigate arrogance and promote active listening to those holding other views. Second, she knows that at some time she will be asked to compromise her basic principles. If her values cannot be sustained because of the environment or trustees, the great leader may choose to lose favor, be fired, or quit over a key principle. If the position or stature or pay means so much that the leader will not put her job on the line for a core value, she is no longer free and has taken a step onto a slippery slope. Great leaders start with the mindset of holding core values and principles dear, no matter what the cost.
Friday, May 27, 2016
I am at an advanced age (80) and, though there are disadvantages (I can no longer throw a good forward pass to my grandsons), one of the things I enjoy about my age is that young and old physicians often ask me for advice on career issues. I enjoy that opportunity, which brings me back to my own questions and challenges.
When I was in medical school and for a couple of decades afterward, I and many other physicians before and during their formal medical training, were avid readers of non-technical books about medicine in various formats like biography, essays, and fiction. I wrote about this in a very early column and came across it by accident recently. Although some students and physicians still read about the best values of being a doctor, that practice does not seem commonplace. So here is my small effort to help revive such reading.
A few of these books had a profound and lasting impact on my thinking and values so that even today, decades later, I have vivid memories of the issues, triumphs, and difficulties they addressed. My top three such books: Microbe Hunters by Paul de Kruif (initially published in 1926); Arrowsmith by Sinclair Lewis (1925); and Aequanimitas by Sir William Osler (1904). Don't let the age of these books spook you…truth and passion about our profession never dies.
Of course, the impact of books depends not only on the topic and skill of the author, but also the frame of mind of the reader at that specific time. All three fed my burning idealism, an unformed mixture of saving mankind, practicing medicine with utmost skill, and satisfying my scientific curiosity. These and other books helped move me gradually from seeing medicine as the fantasy depicted by Hollywood in the Dr. Kildare movies to seeing medicine as a vocation, a noble calling.
Microbe Hunters describes the work and the environment of scientists and physicians who explored, opened, and illuminated the world of microbiology. Written for the general public with flair and suspense, a bit like the Western paperbacks of its day, it also has scientific heft and accuracy. I first read it as a teenager when my favorite sections were those describing the work of Louis Pasteur, Robert Koch, and Paul Ehrlich; they still are my favorites. I was and am inspired by the struggles and perseverance of Pasteur and Koch, who laid the foundations of microbiology and its application to curing human disease. Ehrlich strikes a special cord in me for his pioneering search for antibiotics and for essentially establishing the field of chemotherapy. This was dramatized effectively in the 1940 movie, Dr. Ehrlich's Magic Bullet, starring Edward G. Robinson.
Sinclair Lewis's Arrowsmith was dedicated thus: "To Dr. Paul H. De Kruif I am indebted not only for most of the bacteriological and medical material in this tale but equally for his help in planning the tale itself…" I first read this novel during my pre-med years. It traces the career and struggles of Martin Arrowsmith, a physician-scientist in the fast moving, fermenting world of microbiology in the early 20th century. The academic locale is based at the Rockefeller Institute (now Rockefeller University) in New York City, then a world leader in the study of microorganisms and their diseases. I wanted to be Arrowsmith, preventing and curing horrible diseases like plague, fighting the ignorance of peers and the wiles of academic politicians, risking my life to save lives, and tragically and heroically losing my devoted wife to the diseases we fought together in the tropics (the latter no longer seems attractive). It was an inspiring and, yes, heroic way of life.
I was in medical school when I first read Aequinimitas by Sir William Osler and I was immediately captivated. Here was a renowned physician, the first professor of medicine of the Johns Hopkins School of Medicine and one of the founders of the modern era of medicine, speaking directly to me about being a physician, a good physician. The book consists of a collection of Osler's addresses given over the years, many to incoming or graduating medical classes. They were inspiring and made me proud to be a budding member of the profession. But they also were practical, providing advice about how one should behave and what one should value. And most of all, his words rang true, refreshing and clarifying feelings and beliefs that were deeply, if vaguely, held.
The book was an immediate international hit. A section of Osler's preface to the 2nd edition describes the book's reception and intent, as well as his bedrock view of medicine as a calling akin to a religious vocation.
"I have to thank my friends, lay and medical, for their kind criticisms of the volume; but above all, I have been deeply touched that many young men on both sides of the Atlantic should have written stating that the addresses have been helpful in forming their ideals. Loyalty to the best interests of the noblest of callings, and a profound belief in the gospel of the day's work are the texts…from which I have preached. I have enduring faith in the men who do the routine work of our profession. Hard though the conditions may be, approached in the right spirit—the spirit which has animated us from the days of Hippocrates—the practice of medicine affords scope for the exercise of the best faculties of mind and heart."
But Osler's head was not in the clouds. He continues, "That the yoke of the general practitioner is often galling cannot be denied, but he has not a monopoly of the worries and trials in the meeting and conquering of which he fights his life battle; and it is a source of inexpressible gratification to me to feel that I may perhaps have helped to make his yoke easier and his burden lighter."
The title address, Aequanimitas, was given to the medical graduates of the University of Pennsylvania on May 1, 1889, his last day at Penn before leaving for Johns Hopkins.
"…my tender mercy constrains me to consider but two of the score of elements which may make or mar your lives—which may contribute to your success or help you in the days of failure. In the first place, in the physician and surgeon no quality takes rank with imperturbability… [meaning] coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of great peril…It is the quality which is most appreciated by the laity though often misunderstood by them; and the physician who has the misfortune to be without it, who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients." He describes this quality in more detail and expresses regret that "some among you…may never be able to acquire it. Education, however, will do much; and with practice and experience the majority of you may expect to attain to a fair measure."
He goes on to describe the second and similar desirable element. "…the mental equivalent to this bodily endowment [imperturbability is] a calm equanimity. How difficult to obtain, yet how necessary, in success and failure! One of the first essentials in securing a good-natured equanimity is not to expect too much from the people amongst whom you dwell." He continues that colleagues and patients are full of fads and eccentricities, whims and fancies and weaknesses, "which are not unlike our own."
Another passage also demonstrates the timelessness of his words despite the passing of a century. "I would warn you against the trials of the day soon to come to some of you—the day of large and successful practice. Engrossed late and soon in professional cares, getting and spending, you may so lay waste your powers that you may find, too late, with hearts given away, that there is no place in your habit-stricken souls for those gentler influences which make life worth living."
Among the 22 addresses are these titles, "Doctor and Nurse," "Teaching and Thinking," "Internal Medicine as a Vocation," "Nurse and Patient," "The Hospital as a College," and "Chauvinism in Medicine." In the latter, he lists the four great features of the profession of medicine—its noble ancestry, remarkable solidarity, progressive character, and singular beneficence.
I will end this quick survey of Osler with several of his well-known quotes and biographical information. "One of the first duties of a physician is to educate the masses not to take medicine." "Look wise, say nothing, and grunt. Speech was given to conceal thought." "Live neither in the past nor in the future, but let each day's work absorb your entire energies, and satisfy your wildest ambitions."
A brief, but excellent biography of Osler can be found at www.whonamedit.com/doctor.cfm/1627.html. The site also has quotes, a list of his writings, and a bibliography of literature written about him. The best major biography of Osler is the Pulitzer Prize-winning, A Life of Sir William Osler, by Harvey Cushing, MD.\
I believe there is no better inspiration and influence for medical students, residents and fellows than reading Aequinimitas. But reading Osler—and de Kruif and Lewis—still excites and inspires an old duffer like me as well.
A modern day equivalent of these authors is Atul Gawande, MD, MPH, who has written some wonderful articles on being a better physician: "Cowboys and Pit Crews" was published in the May 2011 The New Yorker, which publishes many of his articles. Several excellent books are "Being Mortal," one of my favorites, and "The Checklist Manifesto," Complications," and "Better."