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Hello and welcome to the Two Piers Podcast. I'm your host Erica D'Eramo, and today we have Dr. Ron Martin joining us. Dr. Martin is a professor emeritus of surgery, a former associate dean of medical of a medical school, former chief physician executive of two large healthcare clinic systems, and a retired colonel in the U.S. Army and senior combat surgeon, he's here to talk to us today about decision making. Dr.
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Martin, thank you for joining us.
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Thank you very much for having me.
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Yeah, I'm really excited to talk about this. It's a topic that I think about a lot in a lot of different contexts.
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So the fact that I get to speak with someone who has really had to understand decision making in a variety of different environments with different types of stakes, different types of organizations is really a treat. So thank you.
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You're welcome.
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So before we jump into the subject of the day, I would love to hear a little bit about kind of your journey, how you came to be in all of these varied and elite positions through your career, but yeah, what was your story?
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Well, I grew up in the Boston area, and for various reasons, decided early that I was interested in medicine when I grew up, and and I followed that path and went to college and medical school, like most people do. And when I get into residency, I had an opportunity to join the U.S.
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Army Reserves as part of their training program, which I did.
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And from there, I finished my fellowship, and I went back. And shortly after I joined the reserves, I got mobilized for the first Gulf War, but that was fairly short-lived, as people remember. And then I spent a lot of my time in the reserves in the army doing regular training until the next set of Gulf Wars.
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But in the meanwhile, I developed my career as a pancreatical biliary surgeon, and I was predominantly focused on high stakes clinical operations, and then service line management and hospital management, and I was more or less convinced by one of my former chairmen that I had to get involved in administration and leadership. And it's one of those stories that I was asked to join a committee when I was first back on faculty, and I turned them down. And I got a call from my chairman about I don't know 30 minutes later, insisting that I come see him in his office, which I did. And I got a kind of a talking to about how it wasn't really an option to turn him down. So he told me that you know I was trying to build a program. He goes, if you're in a meeting like this, if you're not at the table, you're on the menu. So if you want to develop your program, then you need to get on the menu, or at least get at the table to make the decisions. So I did that, and it turned out that worked out well for me, and I wound up being rewarded by having to be put on a lot more committees and lose a lot more free time. And then in 2003, I was pretty far up the academic food chain when we decided to go to Iraq collectively as a country, and I got invited to go along with that, and so that was about a year over there, and met a lot of people, and were involved in a lot of things that got the attention of military leadership. So then I got put in charge of running a bunch of things for them over the years, and like so many things, you just wind up in a position where you get an opportunity, and you do the best with it you can at the moment, not really thinking about what its implications are.
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But when I got done with that, I wound up spending more time training people, both in the army and in the civilian sector, and then more time in education, and then more time trying to keep systems solvent so that they had enough money to meet their mission needs, and you just you you spend the beginning part of your career hopefully saying yes to everything. The middle part of your career, you try to just do what you've agreed to do, and then as you get to the latter part of your career, you have to learn how to say no and focus on what you can really make an impact at, and be a little more selective. And I don't think it's a particularly original arc to have followed. I think a lot of people I know have sort of been in the same position where you get to a fork in the road and you take it, and one day you wind up someplace.
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Yeah, I mean, looking back to maybe a younger version, was this arc expected at all? Like, do you look back and think like I, oh, I, I thought I would be in on this trajectory, or was this kind of the unexpected trajectory?
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No, it wasn't expected at all. I mean, everybody in my family who'd ever served in the military was in the Navy, and when I joined the Army, that was a source of great woe. But I tried to join the Navy first, and they weren't interested in having any surgeons at the time, and they turned me down. Later, they wanted to hire me, but it was too late by then. And still, that might have been a good job to have. And I grew up in a not a super poor neighborhood, but certainly on the upper end of poor and the lower end of not quite as poor. And there was those days they just said people like us don't get to be doctors, so I don't know why you're wasting your time for. And I was never good at taking no for an answer, so I don't know. God, it's pure stubbornness. I just decided to do this. None of it was expected at all, really.
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Yeah. Well, I'm sure there are a lot of people that are grateful that you ended up on that track because it sounds like throughout the surgeon portion of your career, you-I think you have you published. I mean, the number of publications you've written, the number of like thought leadership realms that you've kind of paved the way on. It sounds like you've had quite an impact in your field as well.
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Yeah, I mean, along with other people, I mean, I ran a series called the Surgical Clinics, which used to be called the Surgical Clinics North America. That series has been around for about 100 years, but I was the first actual single person to run it as a consulting editor, and I did that for a little over 20 years.
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So we publish six hardcover books a year on all sorts of different topics. That was good fun because I got to meet a ton of people and and deal with a lot of people who were super smart and in a lot of ways it was like you know like having NASA around to help you do your math homework. I had access to pretty much every expert in the country for a long time, and and I enjoyed that part of it, you know. But there are some people who write because they're predominantly academics and they want to write. I was predominantly a clinical surgeon and a manager who said, "Here's a topic we need to get out there. So I approached the writing world a little differently. But but we found enough stuff. So I've written several 100 papers along with other people, but I didn't really keep track enough that it's writing. I came to enjoy it. I hated it at the beginning, but I will say for people who are starting out, especially in the day where people communicate digitally and don't talk to one another so much anymore. If you really want to, like, if you really want to know something, force yourself to write about it. Because it's one thing to read about it; it's another thing to talk about it. It's another thing to get up and give a presentation about it. But when you have to set it down to writing, where somebody can literally tear your work apart word by word-that's when you know you've you've developed your mastery and and having kids that are trying to go to college now and they're terrified of essays and you see this example all the time. So I'd say for anybody who wants to be a leader or wants to be impactful, no matter what your thoughts about writing are, force yourself to learn how to write, and force yourself to listen with a truly open mind when somebody criticizes what you've just written, because those are some of the hardest skills to develop, but if you get them, you're ahead of so many other people. In my opinion,
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it's interesting too. I mean, just hearing that arc, I think you made me remember why I love doing podcasts. Actually, because I get to just talk to people who are exceptional in their fields, and just I love the term nerd. I mean, I call myself a nerd, but you know, like really, just passionate about their field is how I'll say it. And have lived really interesting experiences.
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So that piece of the being able to work with like people at the top of their field is resonating. But the part about the writing is interesting too, because even people's own thoughts when they're not when they're not even clear on how they think or feel about something, having to put pen to paper and actually put stuff down and be able to look at it and self-criticize it, have it criticized by others, can be a very illuminating and distilling experience.
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Yeah, and it's hard. I mean, emotionally. I can remember some of the first papers I wrote with my bosses, you know, for a really serious audience, and they just eviscerated them. And the thing is, I had like five different co-writers on one paper, and each one would write out the changes the last guy made. It was just a series of circular red pen. Eventually, I had to stop them all and just write down something and say this is the collective version of what we've all discussed, and it got accepted for publication without revision. So I was pretty happy about that. But you have to find your voice. Everybody's got a different way of doing it. But I think one of the things I found about writing and having the passion, particularly with the nerdy bit, is you have to find a way to make it interesting to somebody who's not nerdy about it. Getting the people who believe in your or have a passion that's similar to yours on board, it takes a skill and it's good, but it's not as hard as getting people who don't even know if they give a care in the world about what you're saying to say, "Well, wait a second, that is interesting. I probably should know that. Building the building the ground of fertility for somebody to plant the seeds of thought. That that's where the like the the real educational component, and thinking about how to how to educate people, how to communicate to people, that's where that comes in. And to me, that was probably of all the skills I had to develop, that was the hardest, but the most rewarding of the lot was finding out by just talking with people for a short period of time, where do I need to meet these people to make it work? Because you get a patient who comes in sick, for example, they've never met you. You're about to tell them they're about to go to sleep, and you're going to start removing some organs or something. You've got to build trust in a quick hurry. I mean, you know, sometimes you got more time to think about that.
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Sometimes the clock's kind of ticking, and and you have to explain to them, you know, talk about the decision making part of it. The reason I'm telling you to go to sleep and lose an organ is X. You're sick. You're not at your best. Your your significant other is here.
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They're worried, and I'm going to convince you of this within about the six minutes is going to take anesthesia to get the OR room set up because otherwise you won't be around, and and I think it it can be done. You can convince people of a lot in like 30 seconds, given a little opportunity. But you got to learn how to meet them where they are, not try to get them to meet you where you you think they should be.
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This is like the.
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I think this is one of the keystones of leadership. Is just that element of understanding the landscape, the people. What do they need? What's what will be most effective here, and adapt that adaptiveness of also crafting the messaging to be most effective, based on because you might, I'm sure you could list all the reasons up and down that would be compelling to someone like you making the decision. But what you need to hear, and what somebody who maybe doesn't even know what organs are what, it might be a very different decision, like or a very different set of information that they need.
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No, and and that's I mean a lot of the jobs.
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Like I was pretty broke growing up, so I did a lot of odd jobs along the way. And I worked construction for a while, and you know I I worked with a crew hanging steel. I've done concrete work. I've done I never did any of the things that were super useful around my own house, which I regret a little bit. Plumbing, I'm not so bad at, but I wish I'd done some finished carpentry and things like that. But I found that talking with people from the framework of that I used to work construction or did manual labor to a lot of people was more important to them than whether or not I could explain the ancestry's of you know colon cancer versus large anthonyonos polyps. They they were much more interested that I knew what it took to like repave a street or build a building, and I think to that extent, one thing particularly in medicine that I find challenging for a lot of doctors is they don't spend enough time listening to their patients, and it's not just about what's wrong with them.
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It's like just you can learn from every single patient about what their life is like, and after you've met several 100 or 1000s or whatever, you start to get a pretty good understanding of what other people who have similar circumstances to them what their life is like, and so you can put their problem in the context of how it matters to that person, and that takes time and compassion. But in the end, it's actually way more efficient because you don't get the phone calls. Your staff doesn't get the phone calls. The people aren't anxious, which I think you should do it just out of being a decent human. But whether you're trying to convince people to whether you're a state house or the capital or or talking to you know a guy at the supermarket who's like looks like he's having a rough day. If you learn how to meet them where they are, everybody's the better off for it. And and it takes we grow up in so many isolated bubbles now.
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Worse so with the advent of the internet and sadly podcast, but you know, but it isn't like we have three channels anymore. So people have fewer and fewer common frames of reference. So I think that that's part of it.
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And if you want to be an effective leader, you got to be clear about who it is you're serving and what you need to do to meet the needs of those who you serve. It's way easier to say I'm here to make this hospital money or make these doctors rich or you know or whatever you're going to do.
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I've never actually done that for people. I mean, I made plenty of money and people got rich enough, never as much as they wanted, never as rich as they thought they should be. But it's the boss is the community.
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You know, we're we're there to serve the people, and the same thing with the military. We're we're not always there to practice democracy, but we're certainly there to keep people alive long enough to have democratic debate. We're there to secure the Constitution and all those things that go with it that seem a little old timey sometimes now. But I think that's you. You get a lot more out of just really figuring out where you fit into the community as a leader, rather than trying to form the community to support what you want as a leader, at least in my opinion,
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I mean, I think that that's a really interesting tee up then to the the concept of like what makes for quality decisions. Because I so often encounter clients that will say like, "Well, what if I get it wrong, or what if I, you know, I need to make a good decision here? And to me, the question
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Well, what makes it? What would make for a good decision? And what would right? What would wrong be? But for you, like, what makes for quality decision making? How do you conceptualize the concept?
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Conceptualize good decision making.
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Well, on one level, all decisions are good decisions. On one level, but that's not true across the board. There really are some bad decisions. You can do the a bad decision is one that has a negative outcome you can no longer mitigate. So it's easier to define what's bad. All the rest of them, you either got to a better place more quickly or more slowly, but you'll get there. So, for example, in the world of you know surgery and for that matter combat and things like that, you know that in this case the military metaphors sometimes are more helpful. Like no battle plan survives contact with the enemy, or that the enemy has a vote.
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Those things are all true, and so you've got to have a plan and a backup plan and a backup plan and a backup plan. And the more you understand the system in which you're engaging, and in the military we call it the the center of gravity of the battle sphere in medicine, we look at alternative diagnoses or you know different operative options. You know we've got choices to make. The more you understand about where they are, so that you've eliminated as many of the bad choices before you engage, and then you pick the good choices as the opportunities allow you to, because not everybody is the same on the inside. Like unless you're transplanting, you got to work with the organs you got. Or if you're putting in artificial knees or something, you can get stuff off the shelf. If you're working with regular parts, you got to work with the cards you're dealt, and that's just the way it works out. So, I think good decision making comes from generally being prepared, and being prepared is generally something you don't want to do at the time you have to make a good decision. Now, I think understanding the sense of time is mission critical to any good leader. Knowing when this is the time to make this decision, or this is the time to pause, do some more homework, get some more intel, whatever you want to call it, and. Make sure that we have considered all the options that are available to us. There are other times when it's like you don't make this decision today. This opportunity is gone and gone for good, for whatever reason, and that's the same in business as anything else. And but the more you think about it, the more you understand what you and and the better you understand your long term strategic objectives, because I think most bad decisions or suboptimal decisions they come from the group of people that predominate well are decision makers at the moment, and that they have strategic myopia. They they can't see past the next poll, the next election, the next revenue raising cycle, the next. They want to get the news out on Friday night so that nobody hears about it until Monday morning, if if at all.
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Good leaders are thinking things in terms of a few minutes to a few hours, but out to a few decades. If you start getting too far out in front, you know, 500 years from now, probably don't have very good visibility on those kind of horizons. But certainly, 30 to 50 years out from now, depending on the organization you're working for, you should be testing your short-term decision making against your long-term objectives always.
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Yeah, it's it's funny. A lot of people talk about Simon Sinek and it start with why stuff, but my introduction to Simon Sinek was actually this book Infinite Game, which talks about the this fascinating shift that's happened because we are driven by these short-term deliverables, and it's detached from that longer-term kind of goal wavelength vision. But you bring up a really interesting point, which is that there your concept of like what makes a bad decision? You're only choosing from the options you have at the time, and I think a lot of times people think, "Well, if I make this decision, what if this goes? What if I make this decision and it goes wrong?
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Okay, that's one option. And if you don't make any decision, that is also a distinction, right?
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Yeah, I mean, whether it's Getty Lee saying you know not to decide is to decide, or Dyson saying that you learn 1000 ways not to make a vacuum, or Edison 1000 ways not to make a light bulb, I think if you're an R and D, failure is the most helpful thing ever. So like if you're engineering, building things, or testing out things, or math-I mean, you know-you disprove a theorem; it's hard to prove one. It's easier to disprove one. You only need one example; it crushes it, which is what kind of like math.
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But, but in other things, it's not quite so straightforward.
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So, and that's where you kind of have to hedge your bet. You know, it's I think like for myself, there were points in my career where I had a handful of options to choose from, and I eliminated some just because they were crazy high reward, but crazy high risk, and I didn't have the wherewithal to fail because I didn't have money. I didn't have anybody. There was nobody going to pick me up if I screwed this up. It was going to be serious game over level moment. But but I knew other people that I was sort of in a position where, and they took some of those forward opportunities. Some of them went down in flames, and some of them did remarkably well, and also did good. Some of them did well and didn't do good. I'd rather see them do the good part. But you know, those are things that you have to take into account, so a good decision or a bad decision is really consequence value based, and as long as you have a way to recover from it, you know, then it doesn't really matter. I mean, a detour is a detour, but crashing into a brick wall or going off a cliff, not so much. And I think people think, not to interrupt, but too many people think that every bad decision is a catastrophe. We do have a catastrophization problem in society at the moment.
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I mean, I it it's it's interesting to conceptualize that because I think when we actually play out what are the scenarios here, and you look at like okay, worst case credible, right? Like, can you recover from a worst case credible scenario? If yes. Then we we have a path back. The irony, though, is that you can only. This is maybe where the timing comes in, and and one element of quality decision making, I think, is that you're touching on here is the access to information. So people will often beat themselves up for making a poor decision when, in reality, it was probably the wisest decision at the time, based on the information you had, and either waiting or making another decision would not necessarily have been a quality decision. It simply might have turned out lucky in hindsight, but that's different than a quality decision, perhaps.
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I think so, and I think also people, especially in the age of social media, they fantasize that some other decision would have led to some magically better world that somebody else appears to live in. That's just a bunch of curated nonsense.
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Yeah,
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Surgery and the military have some things in common, and in surgery we have a process called M and M conference, which is morbidity and mortality, which is where we go back in with the most blazingly white light retrospectoscope, look at our decisions and try to tear them to pieces, and we do this in front of each other as almost ritualistic, and a lot of people in medicine don't go into surgery because of it, because nobody wants to be scrutinized at that level. But surgeons, especially good ones, find it necessary. It's sort of a cross between confessional and you know quality improvement, but you want to go back and figure out how to and and in the military we have after action reports. You know when there's a plane crash, the NTSB has their their inspection mechanisms and their schedules, but people who are serious about finding out what went wrong and how to make it better. Do not shy away from looking at their bad decisions.
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And when you go back in that process, at the very beginning of it, the first thing you have to ask yourself is: Let's just use her medicine for the moment for the lingo. Did you have the right diagnosis, and did you have the right information to support that diagnosis, because if it turns out you weren't treating the right thing, the likelihood you were going to get to the right answers low. Might get there by accident. I mean, may just work out, but but and and then you systematically start working through. If you didn't have the right diagnosis, was there something else you could reasonably have done that would have got you to a better point. So a good example would be, like from before a lot of people were born. Now before we had CAT scanners, if you got into a car crack, you might somebody might just perform a laparotomy on you, which means go inside your belly and look around see if you're bleeding, because we didn't know, we didn't have good ways to test for it. You know, we had a few things, and then we didn't have laparoscopes and stuff. But over time, CAT scans and stuff came along where we could image you, and if we could image you quickly, we could tell if there was significant blood in your belly or not. And we wouldn't go and operate on somebody just because we didn't know because their blood pressure was low, we didn't know why, and so we call that a non-therapeutic or a negative laparotomy. So that non-therapeutic laparotomy rate became really, really small when we get to have better imaging.
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So you identify the need is if we'd had more information, we'd have made a better decision. It wasn't that the decisions those people made were bad because if somebody is bleeding in their belly and you don't go to the OR, they're going to die.
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Right,
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That's kind of it. So, but to to your point, and we have those things come up, so it's hard. You have to be really, I won't say rigid of thought, but you've you've got to have a very conformal process so that when you analyze these things, you're being accurate about how you're measuring things, and not adding information about the decision that was made that wasn't available by reasonable means until after the time.
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That part.
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That's the part, and That's to learn. That is a challenge, and you gotta you have to really come to terms.
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Like in the world of surgery, particularly military surgery, I
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you have to be able to divorce the criticism of your action from a criticism of you as a human being, you know somebody can tell you you did an absolutely dumb thing. That doesn't mean you're a dumb person or a bad person, unless of course you did it intentionally, in which case you're kind of an assailant or something. But you can work around that. We have laws.
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Stuff, but that's very very hard for people to grow into because people don't like to be told they screwed up, and they don't like to be told that they were dope, and they don't like any of that. Nobody does, and the idea like, well, I won't have anybody criticize me because they just won't do anything. Well, that's a separate problem than non-functional. You're not criticizable, but you're of no use to anyone.
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Yeah.
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So those are, but those are the things. It's how do you build that into your culture? How do you like take for example Boeing? Now I'm not an expert on Boeing in full disclaimers, but it's pretty clear from looking back that Boeing lost their culture of actively wanting to find something that wasn't working in favor of other objectives.
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Yep,
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and that wasn't good for Boeing or for some passengers or for the industry writ large, you know, and we may find that with other industries too. But willful blindness is not a solution.
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Yeah, I mean, what was it, Upton Sinclair?
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With the like, it's hard to get a man to believe something that his kind of his livelihood depends on him not believing.
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I'm, I'm paraphrasing here, but incentive alignment is wild. But also the other element that you mention here, which it goes beyond just the the extrinsic incentives around maybe cash bonus or whatever, is also that identity threat of like, oh, am I? Do I make bad decisions? Am I a person who makes bad decisions? If this data, if I am disincentivized from believing this inconvenient data, then and I don't see the act of updating my understanding as valuable to my identity, then there's a huge piece there that really kind of creates a barrier to people.
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Well, and as you develop, I mean, because the only capital that's really mission critical to develop is human capital. Everything else is sort of what it is. You know, you can buy it, you can get it, you can borrow it. You just you get your business types to come up with a proposal. You'll you'll find that wherever you need it. But human capital is not that way, and you know your your point brings me to like one of the struggles that I thought we had in medicine, particularly earlier medical education, was that these people would fall into these traps of this imposter syndrome business because they think as soon as somebody criticisms that they're really dumb and they're not smart, and because we definitely the educational system for a long time got a little, a little too in favor of telling everybody that everything was always just fine. Now I'm not trying to make a social case one way or the next, but if the first time you're hearing that that's a bad answer is when you're in college or medical school, people have waited too long. That's that's something you should have heard at least from your parents, if not from somebody else earlier in your life. Nobody makes right answers consistently all the time, and and and being comfortable with I don't know or I was wrong is absolutely essential to improving. But you have to be able to hear hard things. But as if like if you take my senior leadership job, I'm going to be able to tell people some things they really, really don't want to hear, and then make sure that they've got the support and the wherewithal that I don't lose them altogether. You know, I I don't want that. There's no point in trying to improve somebody such that they leave.
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Right.
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If they're going to leave, I don't need to worry about improving them. It's I mean maybe in a more moral level, but on a short-term level, not so much. I need to improve people I want to keep, and if I spend time investing in improving people, I definitely don't want to lose them. Not until it's the right time for them to go for, you know, some better reason. I don't know that all leadership feels that strongly about that, but I think they should.
00:34:23.119 --> 00:35:06.659
I mean, that maybe even ties back to this building capable capability in terms of decision making, though, because that feedback loop is one of the best to me, and I'm biased here, but I feel like that feedback loop, establishing healthy feedback loops, is one of the best ways to build capability and decision making, and even as the leader who needs as much information as you can get in that period of time, in that window that you've got it, to make sure that the information is making its way to you, even if it's inconvenient information or negative information, and that's something that I think a lot of leaders struggle to foster. Like celebrating the bad news-not that we want to celebrate the bad news, but like not punishing the messenger, et cetera, et cetera.
00:35:07.800 --> 00:35:39.079
My greatest fear when I was still practicing was that I would be doing something actively stupid, and that all my junior people who thought that I was a wizard would just not tell me. They go. I thought you knew what you were talking about. I am like, no. If you see me like walking in front of a bus, you let me know. I mean, you know, everybody can get blinders on for any reason, you know. And we obviously work with that with the flight world through Flight Safety International and Cruise Lines. You know that we have similar agencies that do this.
00:35:39.230 --> 00:35:51.969
You know, crew resource management business, and it's all good stuff to foster. But you do have to have a culture where people know they can come to you and say, "I don't think we're making the right decision.
00:35:48.940 --> 00:36:02.429
And you don't just chew their head off. You say, "Okay, because if I can't explain to them why they're wrong, there's only two possible explanations: one, I don't know why they're wrong, or they're right, or two.
00:36:02.610 --> 00:36:21.769
I'm not willing to take the time, neither, which is really acceptable. So you want people to be able, and and to that line of thinking, the biggest mistake I see leaders make writ large is they don't want anybody around who could take over their job in a heartbeat.
00:36:22.818 --> 00:36:22.969
Yep,
00:36:24.289 --> 00:37:24.679
and you got to have trust in your people. But I always wanted-I never wanted anything where we were one deep on the bench, because once that breaks, you're vulnerable. You know, whether it's I don't want one pediatric surgeon because if I lose one, I got a problem with an entire community of young people. You know, I and I, you know, and and you know, to some, when you're in leadership, it's easier to replace you, even though leaders to convince you otherwise. It's not true, you know. the The world, the the cemeteries are filled with indispensable people. Yeah. So, but it's but you do you want to you want to foster succession not for the sake of succession's sake, but you want to foster it for the sake of resilience that you're training people to be able to move up and recognize the problems And and a lot of people find that threatening.
00:37:26.268 --> 00:37:36.978
Oh, that's so interesting that you mention that because I hear when I when I'm working with leaders who are really focused on succession, when they're like, "Man, I'm retiring in the next five years.
00:37:33.139 --> 00:37:58.478
I want to know that these folks have got it. I'm trying to delegate more, but they struggle with the delegation because they'll hand something off and it'll come back to them, and they're like, "But they didn't make the same decision I would have made. I would have done this differently. And like, well, first of all, as long as we're clear on the outcome that needed to happen, this is actually what you're teaching people is how to decide, right?
00:37:58.478 --> 00:38:06.329
Like how to think the way you would do, not to just replicate the outcomes that you would replicate, but actually like the process you use to get there.
00:38:07.710 --> 00:38:25.070
You cannot clone yourself, nor should you. And I think that if you're if you're in leadership, and I was, and you get to the point where it's like I'm going to turn over this decision making to these people, and they start making a bunch of decisions you really don't like.
00:38:21.920 --> 00:38:41.949
That's your cue that it's your time to leave, not to stick around and say you're not doing what I wanted you to do. Because they got to live with the consequences of that. And if you're not ready to, if you're not ready to leave now, then don't delegate that stuff now.
00:38:43.119 --> 00:38:50.260
It's you. You have to be really clear about whose responsibilities are what.
00:38:51.250 --> 00:38:51.309
Yeah,
00:38:52.750 --> 00:38:59.619
and I think when there are blurred responsibility lines, particularly at the admin level, it can be problematic.
00:38:59.679 --> 00:39:47.079
People, you need to put people in the right lanes, however you define them. You know, in sports, you know, is it zone? Is it man to man? Whatever, I don't care. Whatever analogy people like to use, but you know, you've got to put people in the right spot to talk about what they're going to to to have that responsibility. Just like hopefully, we all were at an earlier stage in our career, and but you have to listen to yourself and knowing when to retire, when to really retire-not just to say I want to get paid as much as I get paid, but I want to hand over this responsibility, and I'll take more calls when I'm out doing whatever I like to do, you know, golfing or I don't know, riding bicycles, or I don't know, playing video games. I don't whatever people do these days.
00:39:48.909 --> 00:40:42.519
No, no, no, no. If you're boss, you need to like do the boss work, and if you're not boss, you should have a very short handoff. We. In aviation and in the military, they call it left seat, right seat. I'm sure a lot of other industries do too. But there's nothing worse than doing the right seat ride with some unit that's about to leave, and they're telling you the way you need to do it, and you're like,"I'm not going to do any of the stuff you're doing. As soon as I get you off my footprint, we're going to do this right. Get lost, and I'm sure they feel just the opposite way. You know, like you guys are idiots if you do it. It's like, nah, you guys have been dopes about this. Just looking around for like one day, I can see everything you're doing wrong. But or you guys have got it nailed down. We'll just keep doing this. But either way, beat it. You know, you know, go home, go do what you're gonna do, and we've got it, you know. Nice talking to you.
00:40:43.210 --> 00:41:35.360
Owning that clarity of decision rights. I mean, like one of the questions that I wanted to discuss is actually around like what are the what are the environments or system factors that help enable the people. It's one thing to develop the skills around it, but then there's the context that kind of can enable or disable quality decision making, and in the energy industry, one of the biggest disasters that drove a lot of the regulation and a lot of health and safety improvements was Piper Alpha in the North Sea. And the whole piece around that was decision rights, because no one felt that they were empowered to make the decision to shut off the pumps, right? Like so many people died from that, and that clarity of like where does the decision lie? I think is so critical for ensuring a decision can even happen, and like who owns it?
00:41:35.389 --> 00:41:44.559
Who, in when we talk about like rapid charts, I don't know McKinsey or somebody came up with the rapid chart. Like who owns the D? Who in this room actually has the decision?
00:41:45.340 --> 00:41:45.400
Yeah,
00:41:46.030 --> 00:41:50.170
and they have to have it. So, like, what have you seen in the organizations that get this right?
00:41:52.570 --> 00:42:18.565
Well, certainly, the Department of Defense has a structure that should work very well for it, but like every other structure, from the lowest enlisted guy, rank E1, up into commander in chief, every one of those positions on that organizational chart has a human in it.
00:42:18.420 --> 00:42:20.849
Ah, yes. Humans.
00:42:20.849 --> 00:43:27.030
So, you can have failures in any chain of command. You know, and for example, there are a lot of checks and balances, particularly in war. A sad example, a recent one. Again, this is not to be political necessarily, but the inadvertent targeting, or what appears to be the inadvertent targeting of the girls' school in the early parts of the attack in Iran, we didn't have the right checks in place to prevent that. And from what I gather, and I've got no more insight than anybody else who reads a newspaper, we had some some of the intelligence was based on faulty data that got past everybody. I'm just going to leave it at that, but the outcome is inexplicably bad and inexplicably inexcusable. Other than in war, bad things happen, and they do. But things like that. But the so having clear lines of command are important.
00:43:28.275 --> 00:44:47.280
But I I think the other thing is on a smaller scale, having a leadership group that understands what the common goals are and understands how to shift who's at the helm based on the problem of the day. Pandemic was a good example of that. As it turns out, one of my tasks in one of my trips overseas with another guy was to work out our entire plan for bird flu, when that was a big thing back in like oh 607, we never really had to implement it because we didn't have a bunch of like, you know, bird flu come region through all the various camps where the soldiers and marines and airmen were. But I had all the plans in pocket, and when the pandemic hit and I was out west, just literally pulled it out of a folder and changed the name of this facility to that facility, and we had a plan for pandemic response up and running in a matter of you know 3040 minutes, and we did fine, and that plan became the blueprint for a bunch of other facilities that we worked with, but that's just you. You take the people.
00:44:42.929 --> 00:44:47.280
It's like okay, so here it is.
00:44:47.280 --> 00:45:01.844
So on this blueprint, we changed who's going to be making these decisions about this and this, and the rest of us are in the support mode. And a lot of it, as people probably recall, the ID guy suddenly became famous.
00:44:57.719 --> 00:45:32.340
They'd been vaulted from obscurity, except for maybe the early AIDS epidemic. Suddenly, they were like they're on the news all the time, no matter where they were, whether it was in Maine where you and I live, or you pick the place. The infectious disease gurus at that moment were like local and national celebrities, And then when the pandemic died down, they went back to their regular jobs. So you have to kind of move things up and down depending upon what's going on.
00:45:32.340 --> 00:45:41.219
So I'm hearing two pieces here, though. One is that adaptability piece of having the pieces and players kind of. It almost makes me think of a chessboard, right?
00:45:41.219 --> 00:46:16.590
Like understanding which which piece you are going to move, but the other piece that you are speaking to, which I think is maybe important here, is all of the pre work that went into taking that knowledge and systematizing decision making, so that in the fog of war, in the heat of the moment, the extent to which you are relying on like cognitive heuristics is reduced to the extent you can, so that that those that cognitive load can be dedicated to what it needs to be. But it's sort of like if this, then this.
00:46:12.539 --> 00:46:43.485
If you know enough to be able to do some of that, like okay, the point of no return, right? That Mount Everest hike where everybody died, right? Because they they kept going after that point of no return. So some of these like hard and fast decisions that you've learned the hard way, you've learned from the Piper Alphas, you've learned from the pandemics before. That I that's coming through to me as well, like in how we can support people beforehand before we get to the alarms, and
00:46:43.485 --> 00:49:38.324
I mean, in in the grand scheme, that's where what to do with AI becomes the most controversial to me, because you know, before we called it AI and we were dealing with large language models and other things, and some friends of mine from when I was at Madigan Army Medical Center, we wrote a book on surgical decision making and artificial intelligence before, long before was a thing, and we just thought we were really nerdy about it and kind of trendy. But it turned out by the time it got published, it had become a big fat hairy deal, you know. But it was before there was a Chat GPT and that that stuff, but that's where like there's so much stuff that we've already worked out that nobody knows about. You know the old expression like what you don't know would fill libraries. I mean it's all out there, but somebody's got to read it and put it back in context. And one thing that AI does remarkably well compared to humans is it combs through insane amounts of volumes of information, and is able to retrieve all of it flawlessly in in incredibly short periods of time. It doesn't have any doesn't have the wherewithal to think it through in the sense that you and I would, I would consider thinking, but that's where, like, if you ask AI find me a plan for such and such a thing, it can search places and where information is stored that I don't even know about, and find me some plan, and then I can do with it what I want. If I tell I find a plan and implement it, that might be a terrible idea because it doesn't know if the plan, like maybe the plan killed everyone or something bad, you know, for example, or it had some other reason why it shouldn't be done today. I don't know what it would be, but that's so how you use these parallel computing models, these quantum computing models that handle large amounts of data to make up for your own lack of encyclopedic knowledge of something-that's going to something to be sorted out. I don't know how we get there. I, I think everybody wants to do it quickly. My own bias would be like, just take your time. You know, if you're going to walk into a wall, you'd rather walk into it slowly than quickly. But you never know. I mean, most people will do what people will do, but I think you're right. I mean, yeah. I mean, so sometimes you're lucky enough that a problem comes up and you go,"Oh, wait a minute! I just happened to have the guidebook for that, you know, sitting over there on the floor. Oh, happy day! That doesn't. That's happened once in my career, and I had a long career.
00:49:38.655 --> 00:49:45.585
Yeah. Well, you say that, and also, I mean, every emergency response plan has been developed because
00:49:47.054 --> 00:50:00.539
they do, but they they fall apart. You know, they they, and I'm not saying that in a bad way. I'm saying, matter of fact, I think if everybody understood that, no matter how many times you drill X.
00:50:00.539 --> 00:50:01.409
Yep. Yeah.
00:50:01.409 --> 00:51:25.934
When the airplane crashes, when the boat sinks, when a couple of guys blow up some, you know, pressure cookers at the Boston Marathon, you know, it's everybody's got to respond, and it's not the same in real life. Now, the Boston Marathon bombing is a good example. There were six major teaching hospitals within a short distance, and it was a bad day and a horrible thing, and a child died, and nothing good can be said about it, other than the Boston community responded quickly and in single-minded of purpose. So that that one good thing that came out of it, but that level of like trauma being inflicted on a crowd is like a Tuesday in Afghanistan. But the systems that are there, the people that are handling those problems in these war environments, Ukraine, they do this every day. They've worked it out. It's their new norm, so they're not they're not going from a tabletop exercise to actually find because you go okay. Where's the blood? I don't know. The paper says I have blood. It's like there's no actual blood with the paper. You got to bring the blood in the bag, or we can't give it to the human. Yeah, those are the things that you don't figure out that they're broken until you really try to do it.
00:51:27.139 --> 00:51:39.289
Yeah, I agree with that, and I I think that that is one of the risks of systematizing too much. So like having some frameworks, but like ensuring so somebody's not like, when should I let load the lifeboats? When should I like?
00:51:39.409 --> 00:51:59.860
Okay, well we're T minus whatever till impact, so we're loading lifeboats, right? Like we don't need to calculate that on the fly, but the but the element of being able to make the decision, and when people are too reliant on the flow chart and they are deprived of it, that's when when sometimes we get with the decision paralysis, and I think that that's
00:52:00.670 --> 00:52:00.730
yeah,
00:52:00.969 --> 00:52:09.030
that's the piece I see people struggle with over and over. Is I want more information. It's like you're not going to get more information, so now you have to make a decision with what you've got.
00:52:09.690 --> 00:53:01.260
I mean, one of the great examples of ignoring the flowchart to a degree was when I forget the airline that Sullenberger and the other guy flew for. Oh yeah, even the Hudson, but he turned on the APU, sort of reflexively, which was they had not got to that part on the checklist. Had he not had it, he wouldn't have had enough power to control the surfaces to land the plane at the right angles. So this is just a guy who understood the problem that he was facing, and even though they were going through the checklist as you're supposed to, fortunately he'd made a decision that was outside the checklist that didn't throw him. It didn't, from my understanding. I mean, from reading about it, but there are times when you run into that and you say, "Yeah, I know the book says X, but somebody in charge is going to say we're going to modify X,
00:53:02.099 --> 00:53:02.159
yeah.
00:53:03.300 --> 00:53:20.760
And as a leader, when you make a decision like that, you know that if it doesn't go well, it isn't going to look good. So, and I think if you're going to be a good leader, you got to be prepared to like call an audible and suffer the consequences.
00:53:21.900 --> 00:53:36.019
Yeah. So that concept of preparation, in a way, like I'm hearing the theme of kind of almost preparing for the case without the information, preparing to make the decision that will be questioned later, like mentally preparing for that.
00:53:37.010 --> 00:53:46.599
Yeah. Yeah. You can rely on gut instincts, like if you they'll read you some Malcolm Gladwell and Blink and so forth, but gut instinct only works well if you actually know what you're talking about.
00:53:48.340 --> 00:54:14.340
Yeah, yes, I'm reading a book called Range right now, which a lot of it's been in the ecosystem for a while, but it talk it does talk a lot about this, like seeing all the different contexts, how much your brain can extrapolate or interpolate just from that, and to the point we don't even know. Which I guess Malcolm Gladwell talked about a lot in blank, but you got to put in the hours, right? You have to do the reps to be able to build that.
00:54:15.358 --> 00:54:31.849
That's what they say, but you got to put in the hours. The original paper from I think it was Andreessen or Anderson. I can't remember the guy's name, but the 10,000 hour paper was qualified that it was 10,000 hours deliberately trying to get better, not just 10,000 hours of doing it the wrong way.
00:54:32.719 --> 00:54:32.780
Yeah.
00:54:33.289 --> 00:54:36.860
So if you're not practicing with the intent of improving, you're just killing time.
00:54:37.519 --> 00:54:44.619
Right. The wash up is like the key piece. The actual inspection of where you went wrong and how you would do it differently. Ugh.
00:54:45.250 --> 00:54:45.309
Yeah.
00:54:45.570 --> 00:54:48.599
Goodness. Okay.
00:54:45.570 --> 00:54:54.869
All right. What is? I mean, like, I'm so grateful to get all of this. Um. This. This could be like four podcast episodes.
00:54:54.929 --> 00:54:55.440
Oh my goodness.
00:54:55.440 --> 00:55:07.980
But what would you say? Like the headline. Is for you for listeners to take away in terms of decision making. What's your what's your key message here?
00:55:08.864 --> 00:55:38.369
Be prepared, understand the problem, understand your own limitations and your organization's limitations, and if you need help, get help if you can, if you cannot, do the best you can with what you've got, and trust your resources and your instinct and your personnel. And if you don't feel that you can do that, you need to fix that problem before you're in a disaster.
00:55:34.110 --> 00:55:43.110
That would-I mean-that's a bit long take home, but that's where I would go with that.
00:55:43.110 --> 00:55:52.980
Yeah, I mean, people have written like many, many books on decision making, so I feel like you know one, one or two sentences is really pretty distilled.
00:55:52.980 --> 00:55:59.054
I think the big problem is is you should never make a decision too early if you can get better help.
00:55:59.054 --> 00:56:04.605
Yes. Oh, that's a good one. Never make a decision too early if you can get better help.
00:56:04.605 --> 00:56:24.119
Yeah, and to know when it's you have time to get more help and not that's that's that's the you know the as they say amateurs talk tactics and professionals talk logistics. So know your logistics, and if you're cut off from logistic support. Know what that means too.
00:56:24.119 --> 00:56:34.559
Yeah, yeah. The knowing of the limitations, and sometimes the limitation is information, right? Like we will not the cost of information. It information is not free, right?
00:56:34.559 --> 00:56:43.034
Additional data, additional information. Sometimes it gets increasingly expensive as you're going Further, so that limitation,
00:56:43.179 --> 00:56:55.929
and more information is only useful to you if it actually expands or contracts your option base. If it simply reinforces your option set, it's no use at all.
00:56:56.679 --> 00:57:01.090
I haven't actually thought about it that way, but that's a really helpful distinction that I think.
00:57:02.309 --> 00:57:36.079
Well, in surgery, there's an expression, or at least I think I might have. I don't know that I made it up. It's possible, but I just tell people the beauty of surgery is you don't need to know what's going on; you just need to know what to do. Because there's a lot of things that once you get down to the fact that somebody's bleeding here and you need to stop it, and there's only one operative approach to stop it. It doesn't matter if they're bleeding from their spleen or their liver or some other organ. It's like you've got to get in their belly and stop it. That's it. And trying to figure out, well, I don't want to go to the orange until I know whether they're bleeding from this or that.
00:57:36.559 --> 00:57:39.889
Nope, doesn't matter. You'll find out when you get there. You know.
00:57:40.699 --> 00:57:47.739
Yep. I mean, if it doesn't change, yeah, if it doesn't change your decision set, like it's just additional.
00:57:48.639 --> 00:57:50.530
But I mean, it applies to the grocery store.
00:57:51.190 --> 00:58:01.949
You know, I'm going to go get some groceries. What if they don't have chicken stock or they don't have this thing? Well, I don't know. I get something else. But I got to go to the grocery store because we're out of food. I mean, that's just oh, whatever you're going to do with it, but
00:58:02.219 --> 00:58:02.280
yeah,
00:58:04.710 --> 00:58:13.829
unless and unless you can add or subtract from the choices you have, the value of more information is not much.
00:58:15.780 --> 00:58:28.789
In fact, I'm sure there's probably times where just adding more information just creates more noise when you probably still have the same decision set or the same options that available to you and more clarity. So
00:58:29.239 --> 00:58:48.489
you may introduce confounding variables you weren't prepared to deal with, and I think to your point about noise, people, good leaders can get the signal out of the noise. They know when the one word that comes up in the conversation just changed everything,
00:58:52.030 --> 00:59:05.039
which probably similarly has to do with spending time understanding what makes for valuable information and what is noise. Yeah, yeah, cool. Oh my goodness! Well, I'm.
00:59:05.789 --> 00:59:31.849
I really, really appreciate you coming on and sharing from such a varied perspective. I know that you mentioned like when you talk to folks about doing some manual labor, like it instills trust. I think a lot of the experiences that you've shared and a lot of the pathways that you've traveled probably resonate with a lot of our listeners, and will be very, very applicable. So, thank you.
00:59:32.659 --> 00:59:34.489
You're most welcome. I hope hope it's helpful.
00:59:35.150 --> 00:59:38.840
Yeah, absolutely.
00:59:35.150 --> 00:59:50.139
And for any of our listeners that want to read a summary of this episode. You can find it on the website along with along with the transcript. So, thank you again, Dr. Martin. Really appreciate you, and yeah, wish you well.
00:59:50.889 --> 00:59:51.938
My pleasure. You as well.
00:00:05.099 --> 00:00:43.875
Hello and welcome to the Two Piers Podcast. I'm your host Erica D'Eramo, and today we have Dr. Ron Martin joining us. Dr. Martin is a professor emeritus of surgery, a former associate dean of medical of a medical school, former chief physician executive of two large healthcare clinic systems, and a retired colonel in the U.S. Army and senior combat surgeon, he's here to talk to us today about decision making. Dr.
00:00:43.875 --> 00:00:46.005
Martin, thank you for joining us.
00:00:46.420 --> 00:00:47.619
Thank you very much for having me.
00:00:48.460 --> 00:00:54.549
Yeah, I'm really excited to talk about this. It's a topic that I think about a lot in a lot of different contexts.
00:00:55.450 --> 00:01:10.200
So the fact that I get to speak with someone who has really had to understand decision making in a variety of different environments with different types of stakes, different types of organizations is really a treat. So thank you.
00:01:10.980 --> 00:01:11.459
You're welcome.
00:01:12.719 --> 00:01:28.819
So before we jump into the subject of the day, I would love to hear a little bit about kind of your journey, how you came to be in all of these varied and elite positions through your career, but yeah, what was your story?
00:01:30.019 --> 00:01:50.230
Well, I grew up in the Boston area, and for various reasons, decided early that I was interested in medicine when I grew up, and and I followed that path and went to college and medical school, like most people do. And when I get into residency, I had an opportunity to join the U.S.
00:01:50.349 --> 00:01:53.859
Army Reserves as part of their training program, which I did.
00:01:55.269 --> 00:02:13.770
And from there, I finished my fellowship, and I went back. And shortly after I joined the reserves, I got mobilized for the first Gulf War, but that was fairly short-lived, as people remember. And then I spent a lot of my time in the reserves in the army doing regular training until the next set of Gulf Wars.
00:02:13.919 --> 00:04:05.789
But in the meanwhile, I developed my career as a pancreatical biliary surgeon, and I was predominantly focused on high stakes clinical operations, and then service line management and hospital management, and I was more or less convinced by one of my former chairmen that I had to get involved in administration and leadership. And it's one of those stories that I was asked to join a committee when I was first back on faculty, and I turned them down. And I got a call from my chairman about I don't know 30 minutes later, insisting that I come see him in his office, which I did. And I got a kind of a talking to about how it wasn't really an option to turn him down. So he told me that you know I was trying to build a program. He goes, if you're in a meeting like this, if you're not at the table, you're on the menu. So if you want to develop your program, then you need to get on the menu, or at least get at the table to make the decisions. So I did that, and it turned out that worked out well for me, and I wound up being rewarded by having to be put on a lot more committees and lose a lot more free time. And then in 2003, I was pretty far up the academic food chain when we decided to go to Iraq collectively as a country, and I got invited to go along with that, and so that was about a year over there, and met a lot of people, and were involved in a lot of things that got the attention of military leadership. So then I got put in charge of running a bunch of things for them over the years, and like so many things, you just wind up in a position where you get an opportunity, and you do the best with it you can at the moment, not really thinking about what its implications are.
00:04:05.969 --> 00:04:59.649
But when I got done with that, I wound up spending more time training people, both in the army and in the civilian sector, and then more time in education, and then more time trying to keep systems solvent so that they had enough money to meet their mission needs, and you just you you spend the beginning part of your career hopefully saying yes to everything. The middle part of your career, you try to just do what you've agreed to do, and then as you get to the latter part of your career, you have to learn how to say no and focus on what you can really make an impact at, and be a little more selective. And I don't think it's a particularly original arc to have followed. I think a lot of people I know have sort of been in the same position where you get to a fork in the road and you take it, and one day you wind up someplace.
00:05:01.709 --> 00:05:17.790
Yeah, I mean, looking back to maybe a younger version, was this arc expected at all? Like, do you look back and think like I, oh, I, I thought I would be in on this trajectory, or was this kind of the unexpected trajectory?
00:05:18.689 --> 00:06:10.410
No, it wasn't expected at all. I mean, everybody in my family who'd ever served in the military was in the Navy, and when I joined the Army, that was a source of great woe. But I tried to join the Navy first, and they weren't interested in having any surgeons at the time, and they turned me down. Later, they wanted to hire me, but it was too late by then. And still, that might have been a good job to have. And I grew up in a not a super poor neighborhood, but certainly on the upper end of poor and the lower end of not quite as poor. And there was those days they just said people like us don't get to be doctors, so I don't know why you're wasting your time for. And I was never good at taking no for an answer, so I don't know. God, it's pure stubbornness. I just decided to do this. None of it was expected at all, really.
00:06:11.699 --> 00:06:35.689
Yeah. Well, I'm sure there are a lot of people that are grateful that you ended up on that track because it sounds like throughout the surgeon portion of your career, you-I think you have you published. I mean, the number of publications you've written, the number of like thought leadership realms that you've kind of paved the way on. It sounds like you've had quite an impact in your field as well.
00:06:37.069 --> 00:06:57.370
Yeah, I mean, along with other people, I mean, I ran a series called the Surgical Clinics, which used to be called the Surgical Clinics North America. That series has been around for about 100 years, but I was the first actual single person to run it as a consulting editor, and I did that for a little over 20 years.
00:06:52.870 --> 00:09:05.370
So we publish six hardcover books a year on all sorts of different topics. That was good fun because I got to meet a ton of people and and deal with a lot of people who were super smart and in a lot of ways it was like you know like having NASA around to help you do your math homework. I had access to pretty much every expert in the country for a long time, and and I enjoyed that part of it, you know. But there are some people who write because they're predominantly academics and they want to write. I was predominantly a clinical surgeon and a manager who said, "Here's a topic we need to get out there. So I approached the writing world a little differently. But but we found enough stuff. So I've written several 100 papers along with other people, but I didn't really keep track enough that it's writing. I came to enjoy it. I hated it at the beginning, but I will say for people who are starting out, especially in the day where people communicate digitally and don't talk to one another so much anymore. If you really want to, like, if you really want to know something, force yourself to write about it. Because it's one thing to read about it; it's another thing to talk about it. It's another thing to get up and give a presentation about it. But when you have to set it down to writing, where somebody can literally tear your work apart word by word-that's when you know you've you've developed your mastery and and having kids that are trying to go to college now and they're terrified of essays and you see this example all the time. So I'd say for anybody who wants to be a leader or wants to be impactful, no matter what your thoughts about writing are, force yourself to learn how to write, and force yourself to listen with a truly open mind when somebody criticizes what you've just written, because those are some of the hardest skills to develop, but if you get them, you're ahead of so many other people. In my opinion,
00:09:08.038 --> 00:09:34.009
it's interesting too. I mean, just hearing that arc, I think you made me remember why I love doing podcasts. Actually, because I get to just talk to people who are exceptional in their fields, and just I love the term nerd. I mean, I call myself a nerd, but you know, like really, just passionate about their field is how I'll say it. And have lived really interesting experiences.
00:09:30.499 --> 00:09:56.889
So that piece of the being able to work with like people at the top of their field is resonating. But the part about the writing is interesting too, because even people's own thoughts when they're not when they're not even clear on how they think or feel about something, having to put pen to paper and actually put stuff down and be able to look at it and self-criticize it, have it criticized by others, can be a very illuminating and distilling experience.
00:09:57.240 --> 00:12:01.455
Yeah, and it's hard. I mean, emotionally. I can remember some of the first papers I wrote with my bosses, you know, for a really serious audience, and they just eviscerated them. And the thing is, I had like five different co-writers on one paper, and each one would write out the changes the last guy made. It was just a series of circular red pen. Eventually, I had to stop them all and just write down something and say this is the collective version of what we've all discussed, and it got accepted for publication without revision. So I was pretty happy about that. But you have to find your voice. Everybody's got a different way of doing it. But I think one of the things I found about writing and having the passion, particularly with the nerdy bit, is you have to find a way to make it interesting to somebody who's not nerdy about it. Getting the people who believe in your or have a passion that's similar to yours on board, it takes a skill and it's good, but it's not as hard as getting people who don't even know if they give a care in the world about what you're saying to say, "Well, wait a second, that is interesting. I probably should know that. Building the building the ground of fertility for somebody to plant the seeds of thought. That that's where the like the the real educational component, and thinking about how to how to educate people, how to communicate to people, that's where that comes in. And to me, that was probably of all the skills I had to develop, that was the hardest, but the most rewarding of the lot was finding out by just talking with people for a short period of time, where do I need to meet these people to make it work? Because you get a patient who comes in sick, for example, they've never met you. You're about to tell them they're about to go to sleep, and you're going to start removing some organs or something. You've got to build trust in a quick hurry. I mean, you know, sometimes you got more time to think about that.
00:12:01.455 --> 00:12:19.590
Sometimes the clock's kind of ticking, and and you have to explain to them, you know, talk about the decision making part of it. The reason I'm telling you to go to sleep and lose an organ is X. You're sick. You're not at your best. Your your significant other is here.
00:12:15.705 --> 00:12:41.924
They're worried, and I'm going to convince you of this within about the six minutes is going to take anesthesia to get the OR room set up because otherwise you won't be around, and and I think it it can be done. You can convince people of a lot in like 30 seconds, given a little opportunity. But you got to learn how to meet them where they are, not try to get them to meet you where you you think they should be.
00:12:41.924 --> 00:12:44.745
This is like the.
00:12:41.924 --> 00:13:22.919
I think this is one of the keystones of leadership. Is just that element of understanding the landscape, the people. What do they need? What's what will be most effective here, and adapt that adaptiveness of also crafting the messaging to be most effective, based on because you might, I'm sure you could list all the reasons up and down that would be compelling to someone like you making the decision. But what you need to hear, and what somebody who maybe doesn't even know what organs are what, it might be a very different decision, like or a very different set of information that they need.
00:13:23.120 --> 00:13:25.340
No, and and that's I mean a lot of the jobs.
00:13:25.370 --> 00:14:32.240
Like I was pretty broke growing up, so I did a lot of odd jobs along the way. And I worked construction for a while, and you know I I worked with a crew hanging steel. I've done concrete work. I've done I never did any of the things that were super useful around my own house, which I regret a little bit. Plumbing, I'm not so bad at, but I wish I'd done some finished carpentry and things like that. But I found that talking with people from the framework of that I used to work construction or did manual labor to a lot of people was more important to them than whether or not I could explain the ancestry's of you know colon cancer versus large anthonyonos polyps. They they were much more interested that I knew what it took to like repave a street or build a building, and I think to that extent, one thing particularly in medicine that I find challenging for a lot of doctors is they don't spend enough time listening to their patients, and it's not just about what's wrong with them.
00:14:29.000 --> 00:15:36.740
It's like just you can learn from every single patient about what their life is like, and after you've met several 100 or 1000s or whatever, you start to get a pretty good understanding of what other people who have similar circumstances to them what their life is like, and so you can put their problem in the context of how it matters to that person, and that takes time and compassion. But in the end, it's actually way more efficient because you don't get the phone calls. Your staff doesn't get the phone calls. The people aren't anxious, which I think you should do it just out of being a decent human. But whether you're trying to convince people to whether you're a state house or the capital or or talking to you know a guy at the supermarket who's like looks like he's having a rough day. If you learn how to meet them where they are, everybody's the better off for it. And and it takes we grow up in so many isolated bubbles now.
00:15:37.519 --> 00:15:55.299
Worse so with the advent of the internet and sadly podcast, but you know, but it isn't like we have three channels anymore. So people have fewer and fewer common frames of reference. So I think that that's part of it.
00:15:52.600 --> 00:16:18.120
And if you want to be an effective leader, you got to be clear about who it is you're serving and what you need to do to meet the needs of those who you serve. It's way easier to say I'm here to make this hospital money or make these doctors rich or you know or whatever you're going to do.
00:16:15.899 --> 00:16:26.899
I've never actually done that for people. I mean, I made plenty of money and people got rich enough, never as much as they wanted, never as rich as they thought they should be. But it's the boss is the community.
00:16:28.220 --> 00:17:05.309
You know, we're we're there to serve the people, and the same thing with the military. We're we're not always there to practice democracy, but we're certainly there to keep people alive long enough to have democratic debate. We're there to secure the Constitution and all those things that go with it that seem a little old timey sometimes now. But I think that's you. You get a lot more out of just really figuring out where you fit into the community as a leader, rather than trying to form the community to support what you want as a leader, at least in my opinion,
00:17:06.750 --> 00:17:25.250
I mean, I think that that's a really interesting tee up then to the the concept of like what makes for quality decisions. Because I so often encounter clients that will say like, "Well, what if I get it wrong, or what if I, you know, I need to make a good decision here? And to me, the question
00:17:25.250 --> 00:17:39.140
Well, what makes it? What would make for a good decision? And what would right? What would wrong be? But for you, like, what makes for quality decision making? How do you conceptualize the concept?
00:17:35.990 --> 00:17:39.410
Conceptualize good decision making.
00:17:41.599 --> 00:18:23.900
Well, on one level, all decisions are good decisions. On one level, but that's not true across the board. There really are some bad decisions. You can do the a bad decision is one that has a negative outcome you can no longer mitigate. So it's easier to define what's bad. All the rest of them, you either got to a better place more quickly or more slowly, but you'll get there. So, for example, in the world of you know surgery and for that matter combat and things like that, you know that in this case the military metaphors sometimes are more helpful. Like no battle plan survives contact with the enemy, or that the enemy has a vote.
00:18:26.119 --> 00:20:54.910
Those things are all true, and so you've got to have a plan and a backup plan and a backup plan and a backup plan. And the more you understand the system in which you're engaging, and in the military we call it the the center of gravity of the battle sphere in medicine, we look at alternative diagnoses or you know different operative options. You know we've got choices to make. The more you understand about where they are, so that you've eliminated as many of the bad choices before you engage, and then you pick the good choices as the opportunities allow you to, because not everybody is the same on the inside. Like unless you're transplanting, you got to work with the organs you got. Or if you're putting in artificial knees or something, you can get stuff off the shelf. If you're working with regular parts, you got to work with the cards you're dealt, and that's just the way it works out. So, I think good decision making comes from generally being prepared, and being prepared is generally something you don't want to do at the time you have to make a good decision. Now, I think understanding the sense of time is mission critical to any good leader. Knowing when this is the time to make this decision, or this is the time to pause, do some more homework, get some more intel, whatever you want to call it, and. Make sure that we have considered all the options that are available to us. There are other times when it's like you don't make this decision today. This opportunity is gone and gone for good, for whatever reason, and that's the same in business as anything else. And but the more you think about it, the more you understand what you and and the better you understand your long term strategic objectives, because I think most bad decisions or suboptimal decisions they come from the group of people that predominate well are decision makers at the moment, and that they have strategic myopia. They they can't see past the next poll, the next election, the next revenue raising cycle, the next. They want to get the news out on Friday night so that nobody hears about it until Monday morning, if if at all.
00:20:56.470 --> 00:21:25.970
Good leaders are thinking things in terms of a few minutes to a few hours, but out to a few decades. If you start getting too far out in front, you know, 500 years from now, probably don't have very good visibility on those kind of horizons. But certainly, 30 to 50 years out from now, depending on the organization you're working for, you should be testing your short-term decision making against your long-term objectives always.
00:21:27.589 --> 00:22:14.250
Yeah, it's it's funny. A lot of people talk about Simon Sinek and it start with why stuff, but my introduction to Simon Sinek was actually this book Infinite Game, which talks about the this fascinating shift that's happened because we are driven by these short-term deliverables, and it's detached from that longer-term kind of goal wavelength vision. But you bring up a really interesting point, which is that there your concept of like what makes a bad decision? You're only choosing from the options you have at the time, and I think a lot of times people think, "Well, if I make this decision, what if this goes? What if I make this decision and it goes wrong?
00:22:09.480 --> 00:22:18.660
Okay, that's one option. And if you don't make any decision, that is also a distinction, right?
00:22:19.000 --> 00:22:57.414
Yeah, I mean, whether it's Getty Lee saying you know not to decide is to decide, or Dyson saying that you learn 1000 ways not to make a vacuum, or Edison 1000 ways not to make a light bulb, I think if you're an R and D, failure is the most helpful thing ever. So like if you're engineering, building things, or testing out things, or math-I mean, you know-you disprove a theorem; it's hard to prove one. It's easier to disprove one. You only need one example; it crushes it, which is what kind of like math.
00:22:53.605 --> 00:23:03.805
But, but in other things, it's not quite so straightforward.
00:22:57.414 --> 00:24:41.380
So, and that's where you kind of have to hedge your bet. You know, it's I think like for myself, there were points in my career where I had a handful of options to choose from, and I eliminated some just because they were crazy high reward, but crazy high risk, and I didn't have the wherewithal to fail because I didn't have money. I didn't have anybody. There was nobody going to pick me up if I screwed this up. It was going to be serious game over level moment. But but I knew other people that I was sort of in a position where, and they took some of those forward opportunities. Some of them went down in flames, and some of them did remarkably well, and also did good. Some of them did well and didn't do good. I'd rather see them do the good part. But you know, those are things that you have to take into account, so a good decision or a bad decision is really consequence value based, and as long as you have a way to recover from it, you know, then it doesn't really matter. I mean, a detour is a detour, but crashing into a brick wall or going off a cliff, not so much. And I think people think, not to interrupt, but too many people think that every bad decision is a catastrophe. We do have a catastrophization problem in society at the moment.
00:24:41.380 --> 00:25:41.710
I mean, I it it's it's interesting to conceptualize that because I think when we actually play out what are the scenarios here, and you look at like okay, worst case credible, right? Like, can you recover from a worst case credible scenario? If yes. Then we we have a path back. The irony, though, is that you can only. This is maybe where the timing comes in, and and one element of quality decision making, I think, is that you're touching on here is the access to information. So people will often beat themselves up for making a poor decision when, in reality, it was probably the wisest decision at the time, based on the information you had, and either waiting or making another decision would not necessarily have been a quality decision. It simply might have turned out lucky in hindsight, but that's different than a quality decision, perhaps.
00:25:41.769 --> 00:25:58.509
I think so, and I think also people, especially in the age of social media, they fantasize that some other decision would have led to some magically better world that somebody else appears to live in. That's just a bunch of curated nonsense.
00:25:59.289 --> 00:25:59.349
Yeah,
00:25:59.960 --> 00:27:07.400
Surgery and the military have some things in common, and in surgery we have a process called M and M conference, which is morbidity and mortality, which is where we go back in with the most blazingly white light retrospectoscope, look at our decisions and try to tear them to pieces, and we do this in front of each other as almost ritualistic, and a lot of people in medicine don't go into surgery because of it, because nobody wants to be scrutinized at that level. But surgeons, especially good ones, find it necessary. It's sort of a cross between confessional and you know quality improvement, but you want to go back and figure out how to and and in the military we have after action reports. You know when there's a plane crash, the NTSB has their their inspection mechanisms and their schedules, but people who are serious about finding out what went wrong and how to make it better. Do not shy away from looking at their bad decisions.
00:27:07.400 --> 00:28:33.170
And when you go back in that process, at the very beginning of it, the first thing you have to ask yourself is: Let's just use her medicine for the moment for the lingo. Did you have the right diagnosis, and did you have the right information to support that diagnosis, because if it turns out you weren't treating the right thing, the likelihood you were going to get to the right answers low. Might get there by accident. I mean, may just work out, but but and and then you systematically start working through. If you didn't have the right diagnosis, was there something else you could reasonably have done that would have got you to a better point. So a good example would be, like from before a lot of people were born. Now before we had CAT scanners, if you got into a car crack, you might somebody might just perform a laparotomy on you, which means go inside your belly and look around see if you're bleeding, because we didn't know, we didn't have good ways to test for it. You know, we had a few things, and then we didn't have laparoscopes and stuff. But over time, CAT scans and stuff came along where we could image you, and if we could image you quickly, we could tell if there was significant blood in your belly or not. And we wouldn't go and operate on somebody just because we didn't know because their blood pressure was low, we didn't know why, and so we call that a non-therapeutic or a negative laparotomy. So that non-therapeutic laparotomy rate became really, really small when we get to have better imaging.
00:28:33.740 --> 00:28:45.154
So you identify the need is if we'd had more information, we'd have made a better decision. It wasn't that the decisions those people made were bad because if somebody is bleeding in their belly and you don't go to the OR, they're going to die.
00:28:45.720 --> 00:28:45.960
Right,
00:28:45.960 --> 00:29:15.914
That's kind of it. So, but to to your point, and we have those things come up, so it's hard. You have to be really, I won't say rigid of thought, but you've you've got to have a very conformal process so that when you analyze these things, you're being accurate about how you're measuring things, and not adding information about the decision that was made that wasn't available by reasonable means until after the time.
00:29:16.650 --> 00:29:17.160
That part.
00:29:18.119 --> 00:29:29.900
That's the part, and That's to learn. That is a challenge, and you gotta you have to really come to terms.
00:29:30.559 --> 00:29:35.089
Like in the world of surgery, particularly military surgery, I
00:29:35.180 --> 00:30:02.880
you have to be able to divorce the criticism of your action from a criticism of you as a human being, you know somebody can tell you you did an absolutely dumb thing. That doesn't mean you're a dumb person or a bad person, unless of course you did it intentionally, in which case you're kind of an assailant or something. But you can work around that. We have laws.
00:29:57.789 --> 00:30:26.569
Stuff, but that's very very hard for people to grow into because people don't like to be told they screwed up, and they don't like to be told that they were dope, and they don't like any of that. Nobody does, and the idea like, well, I won't have anybody criticize me because they just won't do anything. Well, that's a separate problem than non-functional. You're not criticizable, but you're of no use to anyone.
00:30:27.289 --> 00:30:27.349
Yeah.
00:30:27.709 --> 00:30:53.888
So those are, but those are the things. It's how do you build that into your culture? How do you like take for example Boeing? Now I'm not an expert on Boeing in full disclaimers, but it's pretty clear from looking back that Boeing lost their culture of actively wanting to find something that wasn't working in favor of other objectives.
00:30:54.730 --> 00:30:54.849
Yep,
00:30:55.869 --> 00:31:11.250
and that wasn't good for Boeing or for some passengers or for the industry writ large, you know, and we may find that with other industries too. But willful blindness is not a solution.
00:31:12.569 --> 00:31:15.180
Yeah, I mean, what was it, Upton Sinclair?
00:31:15.180 --> 00:31:22.019
With the like, it's hard to get a man to believe something that his kind of his livelihood depends on him not believing.
00:31:22.019 --> 00:32:05.579
I'm, I'm paraphrasing here, but incentive alignment is wild. But also the other element that you mention here, which it goes beyond just the the extrinsic incentives around maybe cash bonus or whatever, is also that identity threat of like, oh, am I? Do I make bad decisions? Am I a person who makes bad decisions? If this data, if I am disincentivized from believing this inconvenient data, then and I don't see the act of updating my understanding as valuable to my identity, then there's a huge piece there that really kind of creates a barrier to people.
00:32:06.299 --> 00:33:55.359
Well, and as you develop, I mean, because the only capital that's really mission critical to develop is human capital. Everything else is sort of what it is. You know, you can buy it, you can get it, you can borrow it. You just you get your business types to come up with a proposal. You'll you'll find that wherever you need it. But human capital is not that way, and you know your your point brings me to like one of the struggles that I thought we had in medicine, particularly earlier medical education, was that these people would fall into these traps of this imposter syndrome business because they think as soon as somebody criticisms that they're really dumb and they're not smart, and because we definitely the educational system for a long time got a little, a little too in favor of telling everybody that everything was always just fine. Now I'm not trying to make a social case one way or the next, but if the first time you're hearing that that's a bad answer is when you're in college or medical school, people have waited too long. That's that's something you should have heard at least from your parents, if not from somebody else earlier in your life. Nobody makes right answers consistently all the time, and and and being comfortable with I don't know or I was wrong is absolutely essential to improving. But you have to be able to hear hard things. But as if like if you take my senior leadership job, I'm going to be able to tell people some things they really, really don't want to hear, and then make sure that they've got the support and the wherewithal that I don't lose them altogether. You know, I I don't want that. There's no point in trying to improve somebody such that they leave.
00:33:56.259 --> 00:33:56.470
Right.
00:33:57.099 --> 00:34:21.769
If they're going to leave, I don't need to worry about improving them. It's I mean maybe in a more moral level, but on a short-term level, not so much. I need to improve people I want to keep, and if I spend time investing in improving people, I definitely don't want to lose them. Not until it's the right time for them to go for, you know, some better reason. I don't know that all leadership feels that strongly about that, but I think they should.
00:34:23.119 --> 00:35:06.659
I mean, that maybe even ties back to this building capable capability in terms of decision making, though, because that feedback loop is one of the best to me, and I'm biased here, but I feel like that feedback loop, establishing healthy feedback loops, is one of the best ways to build capability and decision making, and even as the leader who needs as much information as you can get in that period of time, in that window that you've got it, to make sure that the information is making its way to you, even if it's inconvenient information or negative information, and that's something that I think a lot of leaders struggle to foster. Like celebrating the bad news-not that we want to celebrate the bad news, but like not punishing the messenger, et cetera, et cetera.
00:35:07.800 --> 00:35:39.079
My greatest fear when I was still practicing was that I would be doing something actively stupid, and that all my junior people who thought that I was a wizard would just not tell me. They go. I thought you knew what you were talking about. I am like, no. If you see me like walking in front of a bus, you let me know. I mean, you know, everybody can get blinders on for any reason, you know. And we obviously work with that with the flight world through Flight Safety International and Cruise Lines. You know that we have similar agencies that do this.
00:35:39.230 --> 00:35:51.969
You know, crew resource management business, and it's all good stuff to foster. But you do have to have a culture where people know they can come to you and say, "I don't think we're making the right decision.
00:35:48.940 --> 00:36:02.429
And you don't just chew their head off. You say, "Okay, because if I can't explain to them why they're wrong, there's only two possible explanations: one, I don't know why they're wrong, or they're right, or two.
00:36:02.610 --> 00:36:21.769
I'm not willing to take the time, neither, which is really acceptable. So you want people to be able, and and to that line of thinking, the biggest mistake I see leaders make writ large is they don't want anybody around who could take over their job in a heartbeat.
00:36:22.818 --> 00:36:22.969
Yep,
00:36:24.289 --> 00:37:24.679
and you got to have trust in your people. But I always wanted-I never wanted anything where we were one deep on the bench, because once that breaks, you're vulnerable. You know, whether it's I don't want one pediatric surgeon because if I lose one, I got a problem with an entire community of young people. You know, I and I, you know, and and you know, to some, when you're in leadership, it's easier to replace you, even though leaders to convince you otherwise. It's not true, you know. the The world, the the cemeteries are filled with indispensable people. Yeah. So, but it's but you do you want to you want to foster succession not for the sake of succession's sake, but you want to foster it for the sake of resilience that you're training people to be able to move up and recognize the problems And and a lot of people find that threatening.
00:37:26.268 --> 00:37:36.978
Oh, that's so interesting that you mention that because I hear when I when I'm working with leaders who are really focused on succession, when they're like, "Man, I'm retiring in the next five years.
00:37:33.139 --> 00:37:58.478
I want to know that these folks have got it. I'm trying to delegate more, but they struggle with the delegation because they'll hand something off and it'll come back to them, and they're like, "But they didn't make the same decision I would have made. I would have done this differently. And like, well, first of all, as long as we're clear on the outcome that needed to happen, this is actually what you're teaching people is how to decide, right?
00:37:58.478 --> 00:38:06.329
Like how to think the way you would do, not to just replicate the outcomes that you would replicate, but actually like the process you use to get there.
00:38:07.710 --> 00:38:25.070
You cannot clone yourself, nor should you. And I think that if you're if you're in leadership, and I was, and you get to the point where it's like I'm going to turn over this decision making to these people, and they start making a bunch of decisions you really don't like.
00:38:21.920 --> 00:38:41.949
That's your cue that it's your time to leave, not to stick around and say you're not doing what I wanted you to do. Because they got to live with the consequences of that. And if you're not ready to, if you're not ready to leave now, then don't delegate that stuff now.
00:38:43.119 --> 00:38:50.260
It's you. You have to be really clear about whose responsibilities are what.
00:38:51.250 --> 00:38:51.309
Yeah,
00:38:52.750 --> 00:38:59.619
and I think when there are blurred responsibility lines, particularly at the admin level, it can be problematic.
00:38:59.679 --> 00:39:47.079
People, you need to put people in the right lanes, however you define them. You know, in sports, you know, is it zone? Is it man to man? Whatever, I don't care. Whatever analogy people like to use, but you know, you've got to put people in the right spot to talk about what they're going to to to have that responsibility. Just like hopefully, we all were at an earlier stage in our career, and but you have to listen to yourself and knowing when to retire, when to really retire-not just to say I want to get paid as much as I get paid, but I want to hand over this responsibility, and I'll take more calls when I'm out doing whatever I like to do, you know, golfing or I don't know, riding bicycles, or I don't know, playing video games. I don't whatever people do these days.
00:39:48.909 --> 00:40:42.519
No, no, no, no. If you're boss, you need to like do the boss work, and if you're not boss, you should have a very short handoff. We. In aviation and in the military, they call it left seat, right seat. I'm sure a lot of other industries do too. But there's nothing worse than doing the right seat ride with some unit that's about to leave, and they're telling you the way you need to do it, and you're like,"I'm not going to do any of the stuff you're doing. As soon as I get you off my footprint, we're going to do this right. Get lost, and I'm sure they feel just the opposite way. You know, like you guys are idiots if you do it. It's like, nah, you guys have been dopes about this. Just looking around for like one day, I can see everything you're doing wrong. But or you guys have got it nailed down. We'll just keep doing this. But either way, beat it. You know, you know, go home, go do what you're gonna do, and we've got it, you know. Nice talking to you.
00:40:43.210 --> 00:41:35.360
Owning that clarity of decision rights. I mean, like one of the questions that I wanted to discuss is actually around like what are the what are the environments or system factors that help enable the people. It's one thing to develop the skills around it, but then there's the context that kind of can enable or disable quality decision making, and in the energy industry, one of the biggest disasters that drove a lot of the regulation and a lot of health and safety improvements was Piper Alpha in the North Sea. And the whole piece around that was decision rights, because no one felt that they were empowered to make the decision to shut off the pumps, right? Like so many people died from that, and that clarity of like where does the decision lie? I think is so critical for ensuring a decision can even happen, and like who owns it?
00:41:35.389 --> 00:41:44.559
Who, in when we talk about like rapid charts, I don't know McKinsey or somebody came up with the rapid chart. Like who owns the D? Who in this room actually has the decision?
00:41:45.340 --> 00:41:45.400
Yeah,
00:41:46.030 --> 00:41:50.170
and they have to have it. So, like, what have you seen in the organizations that get this right?
00:41:52.570 --> 00:42:18.565
Well, certainly, the Department of Defense has a structure that should work very well for it, but like every other structure, from the lowest enlisted guy, rank E1, up into commander in chief, every one of those positions on that organizational chart has a human in it.
00:42:18.420 --> 00:42:20.849
Ah, yes. Humans.
00:42:20.849 --> 00:43:27.030
So, you can have failures in any chain of command. You know, and for example, there are a lot of checks and balances, particularly in war. A sad example, a recent one. Again, this is not to be political necessarily, but the inadvertent targeting, or what appears to be the inadvertent targeting of the girls' school in the early parts of the attack in Iran, we didn't have the right checks in place to prevent that. And from what I gather, and I've got no more insight than anybody else who reads a newspaper, we had some some of the intelligence was based on faulty data that got past everybody. I'm just going to leave it at that, but the outcome is inexplicably bad and inexplicably inexcusable. Other than in war, bad things happen, and they do. But things like that. But the so having clear lines of command are important.
00:43:28.275 --> 00:44:47.280
But I I think the other thing is on a smaller scale, having a leadership group that understands what the common goals are and understands how to shift who's at the helm based on the problem of the day. Pandemic was a good example of that. As it turns out, one of my tasks in one of my trips overseas with another guy was to work out our entire plan for bird flu, when that was a big thing back in like oh 607, we never really had to implement it because we didn't have a bunch of like, you know, bird flu come region through all the various camps where the soldiers and marines and airmen were. But I had all the plans in pocket, and when the pandemic hit and I was out west, just literally pulled it out of a folder and changed the name of this facility to that facility, and we had a plan for pandemic response up and running in a matter of you know 3040 minutes, and we did fine, and that plan became the blueprint for a bunch of other facilities that we worked with, but that's just you. You take the people.
00:44:42.929 --> 00:44:47.280
It's like okay, so here it is.
00:44:47.280 --> 00:45:01.844
So on this blueprint, we changed who's going to be making these decisions about this and this, and the rest of us are in the support mode. And a lot of it, as people probably recall, the ID guy suddenly became famous.
00:44:57.719 --> 00:45:32.340
They'd been vaulted from obscurity, except for maybe the early AIDS epidemic. Suddenly, they were like they're on the news all the time, no matter where they were, whether it was in Maine where you and I live, or you pick the place. The infectious disease gurus at that moment were like local and national celebrities, And then when the pandemic died down, they went back to their regular jobs. So you have to kind of move things up and down depending upon what's going on.
00:45:32.340 --> 00:45:41.219
So I'm hearing two pieces here, though. One is that adaptability piece of having the pieces and players kind of. It almost makes me think of a chessboard, right?
00:45:41.219 --> 00:46:16.590
Like understanding which which piece you are going to move, but the other piece that you are speaking to, which I think is maybe important here, is all of the pre work that went into taking that knowledge and systematizing decision making, so that in the fog of war, in the heat of the moment, the extent to which you are relying on like cognitive heuristics is reduced to the extent you can, so that that those that cognitive load can be dedicated to what it needs to be. But it's sort of like if this, then this.
00:46:12.539 --> 00:46:43.485
If you know enough to be able to do some of that, like okay, the point of no return, right? That Mount Everest hike where everybody died, right? Because they they kept going after that point of no return. So some of these like hard and fast decisions that you've learned the hard way, you've learned from the Piper Alphas, you've learned from the pandemics before. That I that's coming through to me as well, like in how we can support people beforehand before we get to the alarms, and
00:46:43.485 --> 00:49:38.324
I mean, in in the grand scheme, that's where what to do with AI becomes the most controversial to me, because you know, before we called it AI and we were dealing with large language models and other things, and some friends of mine from when I was at Madigan Army Medical Center, we wrote a book on surgical decision making and artificial intelligence before, long before was a thing, and we just thought we were really nerdy about it and kind of trendy. But it turned out by the time it got published, it had become a big fat hairy deal, you know. But it was before there was a Chat GPT and that that stuff, but that's where like there's so much stuff that we've already worked out that nobody knows about. You know the old expression like what you don't know would fill libraries. I mean it's all out there, but somebody's got to read it and put it back in context. And one thing that AI does remarkably well compared to humans is it combs through insane amounts of volumes of information, and is able to retrieve all of it flawlessly in in incredibly short periods of time. It doesn't have any doesn't have the wherewithal to think it through in the sense that you and I would, I would consider thinking, but that's where, like, if you ask AI find me a plan for such and such a thing, it can search places and where information is stored that I don't even know about, and find me some plan, and then I can do with it what I want. If I tell I find a plan and implement it, that might be a terrible idea because it doesn't know if the plan, like maybe the plan killed everyone or something bad, you know, for example, or it had some other reason why it shouldn't be done today. I don't know what it would be, but that's so how you use these parallel computing models, these quantum computing models that handle large amounts of data to make up for your own lack of encyclopedic knowledge of something-that's going to something to be sorted out. I don't know how we get there. I, I think everybody wants to do it quickly. My own bias would be like, just take your time. You know, if you're going to walk into a wall, you'd rather walk into it slowly than quickly. But you never know. I mean, most people will do what people will do, but I think you're right. I mean, yeah. I mean, so sometimes you're lucky enough that a problem comes up and you go,"Oh, wait a minute! I just happened to have the guidebook for that, you know, sitting over there on the floor. Oh, happy day! That doesn't. That's happened once in my career, and I had a long career.
00:49:38.655 --> 00:49:45.585
Yeah. Well, you say that, and also, I mean, every emergency response plan has been developed because
00:49:47.054 --> 00:50:00.539
they do, but they they fall apart. You know, they they, and I'm not saying that in a bad way. I'm saying, matter of fact, I think if everybody understood that, no matter how many times you drill X.
00:50:00.539 --> 00:50:01.409
Yep. Yeah.
00:50:01.409 --> 00:51:25.934
When the airplane crashes, when the boat sinks, when a couple of guys blow up some, you know, pressure cookers at the Boston Marathon, you know, it's everybody's got to respond, and it's not the same in real life. Now, the Boston Marathon bombing is a good example. There were six major teaching hospitals within a short distance, and it was a bad day and a horrible thing, and a child died, and nothing good can be said about it, other than the Boston community responded quickly and in single-minded of purpose. So that that one good thing that came out of it, but that level of like trauma being inflicted on a crowd is like a Tuesday in Afghanistan. But the systems that are there, the people that are handling those problems in these war environments, Ukraine, they do this every day. They've worked it out. It's their new norm, so they're not they're not going from a tabletop exercise to actually find because you go okay. Where's the blood? I don't know. The paper says I have blood. It's like there's no actual blood with the paper. You got to bring the blood in the bag, or we can't give it to the human. Yeah, those are the things that you don't figure out that they're broken until you really try to do it.
00:51:27.139 --> 00:51:39.289
Yeah, I agree with that, and I I think that that is one of the risks of systematizing too much. So like having some frameworks, but like ensuring so somebody's not like, when should I let load the lifeboats? When should I like?
00:51:39.409 --> 00:51:59.860
Okay, well we're T minus whatever till impact, so we're loading lifeboats, right? Like we don't need to calculate that on the fly, but the but the element of being able to make the decision, and when people are too reliant on the flow chart and they are deprived of it, that's when when sometimes we get with the decision paralysis, and I think that that's
00:52:00.670 --> 00:52:00.730
yeah,
00:52:00.969 --> 00:52:09.030
that's the piece I see people struggle with over and over. Is I want more information. It's like you're not going to get more information, so now you have to make a decision with what you've got.
00:52:09.690 --> 00:53:01.260
I mean, one of the great examples of ignoring the flowchart to a degree was when I forget the airline that Sullenberger and the other guy flew for. Oh yeah, even the Hudson, but he turned on the APU, sort of reflexively, which was they had not got to that part on the checklist. Had he not had it, he wouldn't have had enough power to control the surfaces to land the plane at the right angles. So this is just a guy who understood the problem that he was facing, and even though they were going through the checklist as you're supposed to, fortunately he'd made a decision that was outside the checklist that didn't throw him. It didn't, from my understanding. I mean, from reading about it, but there are times when you run into that and you say, "Yeah, I know the book says X, but somebody in charge is going to say we're going to modify X,
00:53:02.099 --> 00:53:02.159
yeah.
00:53:03.300 --> 00:53:20.760
And as a leader, when you make a decision like that, you know that if it doesn't go well, it isn't going to look good. So, and I think if you're going to be a good leader, you got to be prepared to like call an audible and suffer the consequences.
00:53:21.900 --> 00:53:36.019
Yeah. So that concept of preparation, in a way, like I'm hearing the theme of kind of almost preparing for the case without the information, preparing to make the decision that will be questioned later, like mentally preparing for that.
00:53:37.010 --> 00:53:46.599
Yeah. Yeah. You can rely on gut instincts, like if you they'll read you some Malcolm Gladwell and Blink and so forth, but gut instinct only works well if you actually know what you're talking about.
00:53:48.340 --> 00:54:14.340
Yeah, yes, I'm reading a book called Range right now, which a lot of it's been in the ecosystem for a while, but it talk it does talk a lot about this, like seeing all the different contexts, how much your brain can extrapolate or interpolate just from that, and to the point we don't even know. Which I guess Malcolm Gladwell talked about a lot in blank, but you got to put in the hours, right? You have to do the reps to be able to build that.
00:54:15.358 --> 00:54:31.849
That's what they say, but you got to put in the hours. The original paper from I think it was Andreessen or Anderson. I can't remember the guy's name, but the 10,000 hour paper was qualified that it was 10,000 hours deliberately trying to get better, not just 10,000 hours of doing it the wrong way.
00:54:32.719 --> 00:54:32.780
Yeah.
00:54:33.289 --> 00:54:36.860
So if you're not practicing with the intent of improving, you're just killing time.
00:54:37.519 --> 00:54:44.619
Right. The wash up is like the key piece. The actual inspection of where you went wrong and how you would do it differently. Ugh.
00:54:45.250 --> 00:54:45.309
Yeah.
00:54:45.570 --> 00:54:48.599
Goodness. Okay.
00:54:45.570 --> 00:54:54.869
All right. What is? I mean, like, I'm so grateful to get all of this. Um. This. This could be like four podcast episodes.
00:54:54.929 --> 00:54:55.440
Oh my goodness.
00:54:55.440 --> 00:55:07.980
But what would you say? Like the headline. Is for you for listeners to take away in terms of decision making. What's your what's your key message here?
00:55:08.864 --> 00:55:38.369
Be prepared, understand the problem, understand your own limitations and your organization's limitations, and if you need help, get help if you can, if you cannot, do the best you can with what you've got, and trust your resources and your instinct and your personnel. And if you don't feel that you can do that, you need to fix that problem before you're in a disaster.
00:55:34.110 --> 00:55:43.110
That would-I mean-that's a bit long take home, but that's where I would go with that.
00:55:43.110 --> 00:55:52.980
Yeah, I mean, people have written like many, many books on decision making, so I feel like you know one, one or two sentences is really pretty distilled.
00:55:52.980 --> 00:55:59.054
I think the big problem is is you should never make a decision too early if you can get better help.
00:55:59.054 --> 00:56:04.605
Yes. Oh, that's a good one. Never make a decision too early if you can get better help.
00:56:04.605 --> 00:56:24.119
Yeah, and to know when it's you have time to get more help and not that's that's that's the you know the as they say amateurs talk tactics and professionals talk logistics. So know your logistics, and if you're cut off from logistic support. Know what that means too.
00:56:24.119 --> 00:56:34.559
Yeah, yeah. The knowing of the limitations, and sometimes the limitation is information, right? Like we will not the cost of information. It information is not free, right?
00:56:34.559 --> 00:56:43.034
Additional data, additional information. Sometimes it gets increasingly expensive as you're going Further, so that limitation,
00:56:43.179 --> 00:56:55.929
and more information is only useful to you if it actually expands or contracts your option base. If it simply reinforces your option set, it's no use at all.
00:56:56.679 --> 00:57:01.090
I haven't actually thought about it that way, but that's a really helpful distinction that I think.
00:57:02.309 --> 00:57:36.079
Well, in surgery, there's an expression, or at least I think I might have. I don't know that I made it up. It's possible, but I just tell people the beauty of surgery is you don't need to know what's going on; you just need to know what to do. Because there's a lot of things that once you get down to the fact that somebody's bleeding here and you need to stop it, and there's only one operative approach to stop it. It doesn't matter if they're bleeding from their spleen or their liver or some other organ. It's like you've got to get in their belly and stop it. That's it. And trying to figure out, well, I don't want to go to the orange until I know whether they're bleeding from this or that.
00:57:36.559 --> 00:57:39.889
Nope, doesn't matter. You'll find out when you get there. You know.
00:57:40.699 --> 00:57:47.739
Yep. I mean, if it doesn't change, yeah, if it doesn't change your decision set, like it's just additional.
00:57:48.639 --> 00:57:50.530
But I mean, it applies to the grocery store.
00:57:51.190 --> 00:58:01.949
You know, I'm going to go get some groceries. What if they don't have chicken stock or they don't have this thing? Well, I don't know. I get something else. But I got to go to the grocery store because we're out of food. I mean, that's just oh, whatever you're going to do with it, but
00:58:02.219 --> 00:58:02.280
yeah,
00:58:04.710 --> 00:58:13.829
unless and unless you can add or subtract from the choices you have, the value of more information is not much.
00:58:15.780 --> 00:58:28.789
In fact, I'm sure there's probably times where just adding more information just creates more noise when you probably still have the same decision set or the same options that available to you and more clarity. So
00:58:29.239 --> 00:58:48.489
you may introduce confounding variables you weren't prepared to deal with, and I think to your point about noise, people, good leaders can get the signal out of the noise. They know when the one word that comes up in the conversation just changed everything,
00:58:52.030 --> 00:59:05.039
which probably similarly has to do with spending time understanding what makes for valuable information and what is noise. Yeah, yeah, cool. Oh my goodness! Well, I'm.
00:59:05.789 --> 00:59:31.849
I really, really appreciate you coming on and sharing from such a varied perspective. I know that you mentioned like when you talk to folks about doing some manual labor, like it instills trust. I think a lot of the experiences that you've shared and a lot of the pathways that you've traveled probably resonate with a lot of our listeners, and will be very, very applicable. So, thank you.
00:59:32.659 --> 00:59:34.489
You're most welcome. I hope hope it's helpful.
00:59:35.150 --> 00:59:38.840
Yeah, absolutely.
00:59:35.150 --> 00:59:50.139
And for any of our listeners that want to read a summary of this episode. You can find it on the website along with along with the transcript. So, thank you again, Dr. Martin. Really appreciate you, and yeah, wish you well.
00:59:50.889 --> 00:59:51.938
My pleasure. You as well.
