Epidemic Leadership E-Book

Larry McEvoy

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 369

Veröffentlichungsjahr: 2021

Beschreibung

A science-based leadership framework for building capacity and overcoming exhaustion in today's complex world Epidemic Leadership introduces an adaptive leadership approach designed to help you (and your followers) thrive and influence in today's complex age. This book provides a how-to methodology for simply and practically putting the principles of epidemic phenomena into successful practice. By understanding their function in adaptive systems and applying their organizing principles to daily work, you can lead more effectively for greater results, more agile responsiveness, and deeper vitality. Epidemic Leadership synthesizes science, stories of leadership experience, and practical technique to shape the challenge of "leading in complex environments" into a compelling field guide for leaders who seek to improve results and contribute to a healthier world. You will be inspired, challenged, and practically equipped to begin a journey toward exponential positive impact in this pivotal era. * Discover a novel leadership approach that's particularly applicable to tackling the big problems in your workplace and world * Realize better performance and enhance your ability to create results sooner and more sustainably, across a wider array of processes and topics * Restore vitality in yourself and those you lead, for renewed hope, enthusiasm and engagement Companies and institutions will benefit from the deep capacities Epidemic Leadership builds. For leaders who struggle to find enough time and energy to create the impact they seek, this book offers a unique path for our challenging times.

Leseprobe

How to LeadInfectiouslyin the Era of Big Problems

Epidemic Leadership

LARRY McEVOY, MD

Copyright © 2021 by John Wiley & Sons, Inc. All rights reserved.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey.Published simultaneously in Canada.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, [phone], fax [phone], or on the Web at www.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, [phone], fax [phone], or online at http://www.wiley.com/go/permissions.

Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor author shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

For general information on our other products and services or for technical support, please contact our Customer Care Department within the United States at [phone], outside the United States at [phone] or fax [phone].

Wiley publishes in a variety of print and electronic formats and by print-on-demand. Some material included with standard print versions of this book may not be included in e-books or in print-on-demand. If this book refers to media such as a CD or DVD that is not included in the version you purchased, you may download this material at http://booksupport.wiley.com. For more information about Wiley products, visit www.wiley.com.

Library of Congress Cataloging-in-Publication Data is Available:

ISBN 9781119787457 (Hardcover)ISBN 9781119787471 (ePDF)ISBN 9781119787464 (ePub)

Cover Design: WileyCover Image: Courtesy of LCI Group, LLC

For the joyous crowds, the great herds, the endless flocks, the teeming schools (of fish and children), and all whose goodness incubates in obscurity ahead of coming abundance

Introduction

When I started writing this book, epidemics didn't hold the attention of many people beyond epidemiologists and risk-policy wonks. Then, COVID-19 hit. By a freak of timing, I found myself writing as the pandemic ended hundreds of thousands of lives, closed our schools and workplaces, crashed the global economy, monopolized the daily news cycle, and drove us out of the open and into hiding, from our parks and streets and deeper into our screens and phones. Like all of us, I watched as the spread of a brainless virus exploited our societal divisions and inequalities, exposed the inadequacy of leadership and supply lines, and tilted a presidential election. A microscopic clump of genetic material enveloped in proteins made the reality of epidemics a palpable threat and an urgent teacher. It challenged our notions of command and control over our environment and opened the possibilities around what leading must become in a changed and changing world.

I write from my perspective as a doctor and particularly as an emergency physician. My clinical career began as a medical student at Stanford University and took root in the garden of pathology we call the emergency department during my residency at Hennepin County Medical Center in Minneapolis. I learned the highly specialized skills that allowed me to diagnose, treat, and resuscitate patients whose unpredictable palette of disease, distress, and destruction flowed into my workplace every day, night, and weekend. Over the course of my clinical career, I learned to find a sense of ease amid the chaos of lives abruptly unhinged from the illusion of “normal.” I learned that high-trust team intelligence outpaced disconnected expertise. I learned that all the algorithms and protocols in the world don't equip us to match the way disease and illness multiply in our populations, a reality our health care personnel recognized only too well from the strain on them during this most recent pandemic.

I also write from the perspective of an executive who has worked with hundreds of leaders and teams over the course of my career. I had the opportunity to help an emergency department and two health care organizations work their way through duress and subpar performance to results both objectively demonstrated and subjectively immeasurable. As the CEO of my state's largest trauma center, I watched several thousand people turn an entire organization around when it was listing badly during the national financial meltdown of 2008 (and when cynics predicted our inevitable collapse). Perhaps befitting an emergency physician and others who find themselves facing the braver work of leadership, I have always worked and learned in places where what used to work doesn't anymore, where people are trying hard and wearing out, and where hope is essential and hard to find.

We live in such times and places today. We have too much to do and not enough time to do it. Our technology ambiguously speeds things along and rushes us so fast we can't think straight. Our models of organization, leadership, and governance are breaking down, or at least groaning and cracking, under the weight of problems that are large, complex, and interconnected. Our world, whether we measure it in divisiveness, environmental degradation, or the vitality of our workplaces and communities, grows unhealthier and more stressed. The future arrives and beckons our response, yet we resist. Leaders have to grapple with all these things in a way that enables people to deliver better results, to learn relentlessly, and to re-energize and reconnect. Somehow those things have to happen not once, not in a few places, but repetitively, everywhere.

Along came coronavirus, specifically SARS-CoV-2, an obscure idea of a germ morphed into a worldwide infectious, political, social disruption with catastrophic and fracturing consequences. No more hiding. It's in our face, here and real. It has threatened our bodies, rattled our minds, split our towns and neighborhoods, and shocked our systems. More quietly, it has asked us if we're ready, really ready, to accept a present reality that invites a powerful shift to a better future.

Epidemics represent and expose the scientific principles underlying networks, complex systems, biology, and, in the case of humans, neurobiology. Such disciplines are rife with research, complex mathematical and statistical formulations, and underlying concepts of physics and biology that can be bewildering. This book is not meant to be an in-depth scientific exegesis. Instead, it is intended as an invitation to think about leading with a new framework, a framework that unfolds into simple, accessible concepts and techniques that leaders can put to work wherever they are to create both individual participation and collective wisdom in a world where scaling both stability and adaptability has become non-negotiable.

The unsettling reality is that epidemics are here to stay; they're going to keep coming, and not just because of wet markets in China and close-clustered human populations and degraded habitats where long-locked pathogens can get loose, leap to us, and multiply across the globe. We have invited and designed a world of networks and swarms, and now we will have to adapt. Our computing power lives in clouds and networks; our social momentum rides on platforms and movements of easily accessible information and even more accessible—and influential—disinformation. Our small local worlds are linked, and the uptake and spread of ideas and actions—healthy and unhealthy—defines leading and following today.

These realities of the modern world—call it “high-velocity, high-volatility,” VUCA, Industry 4.0, or just the twenty-first century—raise compelling questions for leaders.

How do we deal with phenomena that come from nowhere and end up everywhere?

How do we respond and act with agility without rushing ourselves into regressive patterns? How do we match the speed of what is coming at us while slowing down enough to create wide patterns of insight and intention?

What do we keep, discard, and learn anew from a leadership perspective? What works and what doesn't anymore? How do we know?

What do we need to understand to shape a positive future in our lives, teams, companies, and world?

The powerful possibilities are perhaps most compelling. We think, sensibly enough, about stopping epidemics, limiting their damage, returning to normal. At first glance—and second and third—the coronavirus is simply badness, destruction, hindrance. It exposes our operational bottlenecks, our leadership division, our social inequities. Look deeper, and it carries a leadership blueprint for effective action in a connected world.

If I have learned one thing in my lifetime of work as a doctor and a leader, it is that the world is abundant with good ideas and good people. I am only a single searcher of the billions of people who seek better ideas and ways, and I find them every day and everywhere—in the ER in the middle of the night, in slums in Africa, in schools and basketball teams, in start-ups and bureaucracies. Too often those ideas and people stay hidden and “uninfectious.” We need them to rise now, to go epidemic and flood into every nook and cranny where their humble origins can metastasize into florid impact.

I have learned a great deal from the patients I have cared for and from the people who taught me and mentored me (which would include those conventionally labeled “followers”). I learned a great deal also from decades of long days out in bad weather and good in my Montana homeland, where the ubiquitous surging of living things defined my experience and shaped my subsequent thoughts. The science of my profession and the land of my upbringing have helped me understand the beauty and wisdom in biology. Amid a world that has ignored the lessons of biology for too long, my hope now is to share a bit of what biology knows to participate in an epidemic of good.

This book is about our changing concept of leadership in a century when things move faster and overwhelm sooner, where anything can become very big very quickly, and each of us can feel very small. This book is about how leaders can shape and scale both stability and adaptation far beyond their individual contact points; as such, it is also a book about the design and ethic of social power. The epidemics we face, whether Ebola or COVID-19, whether QAnon or racism or opioids, are not going away. Indeed, conditions are set that will invite them to flourish and erupt.

This book has two sections. The first section builds from the universal experience of well-intentioned individuals who find themselves overwhelmed, starting with my sobering encounter with that reality as an emergency physician. Chapter 2 explores the potential advantages of how epidemics arise and grow for those who are encountering the “math problem” of personal effort in the face of diffuse and powerful obstacles. Chapter 3 delves into the implications of complex environments on what leadership does and how it will need to operate in our era of immense challenges. Chapter 4 explores the secret sauce of epidemics for leaders, the idea of self-organization that offers a flywheel to scaling the deliverables of leadership: performance, learning, and vitality.

The second section focuses on the practice of epidemic leadership and how leaders can design and sustain positive epidemics as systemic leverage in human systems. Chapter 5 emphasizes the identification of a positive pathogen as the basis of a constructive epidemic. Chapters 6 through 9 explore the elements of self-organization with respect to epidemics—conditions, interactions, and multipliers—with a special focus on networks and their unique capability to accelerate or obstruct leadership efforts. Chapter 10 explores the paradox of technology in supporting and complicating epidemic leadership. Finally, the type of thinking and the foundational sorts of social pathogens we need moving in today's world comprise Chapter 11, the final chapter.

The reason I write this book intertwines with the impact the pandemic meted out: the realities of our world are unsettling. I write this book because, as a doctor, anything that threatens the vitality of individuals, populations, and communities rouses my concern, and there are far more causes for concern than I could ever address as one lone healer. There is no single bedside I can rush to, no drug I can prescribe, no diagnostic algorithm I can wield. An ethic of healthy twenty-first-century community has to swarm everywhere—through our schools, our economies, our neighborhoods, our corporations, our conflicts, and our institutions. Many people would say such permeation is not possible. But somewhere, in or near Wuhan, China, in late 2019, arose a virus that was nameless, without money or power, with no business plan or Twitter following, with no passport and no cognition—and now it's everywhere, because we passed it among ourselves.

The good news about our current reality is that we have the knowledge and access to exploit these same conditions to create innumerable positive epidemics. It is not just time to lead in the middle of an epidemic, to prevent the next one, or to arrest bad ones. It is time to lead like an epidemic, launch multiple epidemics, and have an epidemic of leaders who know how to “epidemic.”

IUnderstanding Epidemics

1My No Good, Very Bad Night in the Emergency Department

You're gonna need a bigger boat.

—Amity Island Police Chief Martin Brody in Jaws

Friday Night in the Emergency Department

August 15, 2003, Billings, Montana

We begin in illness and injury. On this hot Friday evening, patients swamp the emergency department in the regional trauma center where I work. In the late summer heat, the night is just starting and has already flooded us with a raft of patients, and it promises to keep building. The waiting room overflows with more people. I have worked hundreds of nights like these in the previous decade plus, and I know the pattern. The quiet heat and the coming sunset belie the more ominous certainty of my shift ahead. People would get sick, some dramatically so. People would die. No one had gone about their day thinking these things would happen, but we know. In the emergency department, we check our equipment and ready ourselves with certainty.

As I cross the threshold of the automatic double doors into the department to begin my shift, I know it's busy even without scanning the electronic register we call “the board,” a remnant of the days when we used to list each patient and their chief complaints in bright dry erase marker on a big whiteboard before privacy concerns made it obsolete. I can hear the beeping of monitors, the shift in cadence of nurses' feet, and a low kind of ER buzz. The source is hard to pinpoint, like the low but incessant sound of unseen insect wings. To a casual observer, the department seems quiet, orderly, bright with fluorescent light. We like it that way—who wants to work in, let alone be sick in, a chaos of noise and motion?

The full cornucopia of unexpected disaster and discomfort bubbles out of the streets and homes and open spaces of life in America and flows into every room in our emergency department: automobile trauma, diabetes, cardiovascular disease, emphysema, diverticulitis, stroke, assault, cervical cancer, migraines, lacerations, domestic abuse, and opioids. The terms are medical and numbingly antiseptic, but the reality is stark: as the people of my town enjoy the warm summer evening, they are also crashing, dying, bleeding, fighting, and writhing in droves. While they go about their daily lives, they are part of a large, oddly silent tsunami of ill health that washes over the entire population.

No one is catastrophically ill at the moment, so I ease into my shift, getting labs and X-rays started on a few patients while I mentally accept that we will be working behind for a few hours. No one on the team likes working from behind. We prefer to stay ahead of the wave, seeing people as they come in. It is safer that way, and psychically easier for us. When the wave breaks over us, when we get behind, delays pile up and surprises happen, and surprises mean a higher chance of bad things for patients. Some nights, despite our best efforts, especially hot ones on summer weekends, the wave breaks, and we are playing catch-up. Tonight is one of those nights. The department has been behind since the afternoon, and it will be several more hours before we can get on top of the wave again.

The patients are varied, which is normal for us. The ER is the funnel for anything that can go wrong anywhere, at any time, for anybody. I see an obese patient whose knees hurt, a woman with vaginal bleeding, a middle-aged man with chest pain, a mom with back pain who can't lie down comfortably, an 80-year-old man with bad lungs. Nothing out of the ordinary, except I see all those people in the first 15 minutes, because twice that many wait unseen after that. I use my “30 seconds to meaningful rapport” to inspect and connect with each person I see. My trained eye scans breathing dynamics, skin color, tone of voice. I see eyes and facial expressions, plumb for fear or hidden motivations, search for the best way to settle every person who meets me for the first time in this place that is their bad detour and my daily work. My hands find theirs, and I rest them on shoulders and knees.

I step out of an older man's room into the low hum and look right, then left. I am impressed and grateful for what I see in the team of nurses, techs, registration clerks, and my emergency physician colleague seeing patients alongside me. Several years before, we weren't so much a seamless round-the-clock clinical team as a collection of technically proficient individuals. We couldn't elevate our game in the face of unrelenting pace. We didn't work that well together, and we weren't able to mesh the technical craft of our job with the human presence of connecting to each and every person who was ill, whatever their circumstances.

Eight years later, almost everything is different. More people come to us for care, and the metrics that define “good department” are positive: patient satisfaction and staff engagement have rebounded to high numbers from low ones, safety and quality metrics are strong, and the department sustains itself financially. Nurses are on a waiting list to get a position in the ED from other places in the hospital. Patients come by foot and ambulance, airplane and helicopter. Thank you notes dot the bulletin board in our break room, some with pictures of healed patients on vacations or hikes in the nearby Beartooth Mountains. Nurses, techs, and physicians work hard to help each other across the shift: quiet high-fives, thank-yous, and smiles pepper our interactions.

This night, we are at the top of our game. The patients are getting attentive and skilled care, and the team works fluidly without stress under the pressure of pace and pathology, moving fast without hurrying. We flex and bend to the needs of each patient and the staccato flow of the pace. As an emergency physician, I am at the peak of my craft. Well-trained and supported by capable nurses and skilled physicians alike, taught by thousands of patients, I am in the sweet-spot overlap of state-of-the-art training and sufficient experience, eight years out of a leading residency in my specialty of emergency medicine. I am comfortable on such weekend nights, at ease with the people I work with, the maladies and mishaps I would see, my own strengths and gaps as a clinician.

Despite the team's skill and my experience, a creeping dread wells within me as I scan up and down the hallway. It is my birthday, and while I am used to working holidays of all kinds and at all hours, this particular moment collides jarringly with all my years of effort, learning, triumphs, mistakes, hopes, and deaths in an unsettling pang in my gut and chest. In every room in our emergency department that night, while the ill and injured are getting what they need and we are chewing steadily at the backlog of patients piling into the waiting room, a bigger problem waits—no, grows—outside and beyond, unhurried, unstoppable, and inevitable. Nowhere does this unsettling gloom stick more than in my nose. The smell of blood, alcohol, feces, urine, antiseptic wipes, plastic tubing, vomit, and air freshener mix in my nasal cavity and settle like fine dust into my brain. Years before, when I was thinking of medicine and not yet doing it, I might have gagged. Now I just take a deep breath. It is not the smell of living.

“What you thinking, Scary Larry?” Dana, the charge nurse, appears at my elbow with a slight tug. “Big things or right-now things?”

She and I have worked together long enough to have earned our mutual nicknames for each other: Super Nurse and Scary Larry. I have worked with her while she handled two critically ill patients as the primary nurse while she held the charge nurse helm at the same time in the middle of the night. She can meet the wave. She knows my tendency to arc from micro-focus on the things at hand to macro meanderings on the source and end of what we see. She's more practical and fixes her mental gaze on getting through the shift.

“Big things,” I say.

She smiles, and the tug turns into a nudge. “Keep moving. We can hear about it later when it quiets down.” She gives me a wink before she moves past me: Shifts don't run us, Scary Larry. You and me—we run them.

As I suspected it would, the night swells into repeated waves of patients. They are unique and different individuals, but the patterns are familiar: strokes, heart attacks, overdoses, self-mutilation, asthma, domestic violence, rodeo mishaps, farm trauma, bar fights. I keep moving, patient to patient, through late Friday into early Saturday morning. Until then, I don't eat, and I don't go to the bathroom. Neither does anyone else on the team.

The shift eventually ebbs like all waves do, falling back quietly into the night. By 4:30 in the morning, only two patients are left in the department. Both are resting, with no surprises lurking. One of them snores under a morphine blanket covering the pain of a broken leg, and the slow sound keeps the tempo of the deep night.

Five nurses and I sit at a round table a few feet behind the high counter of the nurses' station. I'm sifting through some blood and urine culture results from the lab, and they are getting ready to “count narcs,” the frequent process of ensuring that all the potentially addictive drugs we use are all accounted for. I am reminded of being in a duck blind as a young boy with my dad, waiting out of the wind for ducks to sail in and disturb the quiet water around us.

“Good work, everyone. We cleaned up that board nicely,” Dana says. She pulls out her auburn ponytail and redoes it. “And now, Scary Larry, what were those big thoughts bouncing around in your head while we were all moving so fast last night?”

“I was just thinking we're getting killed. What's outside that door is growing faster than we can keep up.” I saw them looking at me. One of them rolled her eyes. “And it's getting bigger, not better.”

“What are you talking about?” Mavis had been in the department a long time. She grew up on a wheat farm in eastern Montana and had worked hard her whole life. “Five years ago it would have taken us a whole day to get through what we just did in eight hours. We were rolling.”

I smiled even as my bones felt heavy with fatigue. “It's not that. We run a shift just fine. Better and better every day, really. But society creates more disease, manufactures it actually, faster than we can keep up. The harder and better we work, the farther behind we are against a disease burden that's getting bigger, not smaller. Not in the shift, not in the department, but in the big picture. You ever have that feeling?”

“All the time … and then I stop thinking about it,” said Kim. “It's too much for me. Too big. I just think about my kids and my family and try to be a good nurse.”

“What did you expect? It's an emergency department,” Judy said. “People get sick and injured in more ways than anyone could imagine, and we pick up the pieces.” Judy had worked in the department for 15 years. In her view, humans were fallen and flawed creatures, and we suffered the consequences.

“I think of it as job security,” said Shelly. A couple years later, she would be a nurse practitioner and would leave us for the cardiology department. “No illness, no disaster, no job.”

The Problem That Won't Go Away

They were right and sane and rational, of course, those exquisitely capable nurses in the middle of the night at the tail end of a busy shift. Living and working at the back end of a massive bloom of unhealth and disease tends to make us feel very small. Think about it too much, and you go nuts. You can only go without food and bathroom breaks for so long. You have a job and a family and a life. The shift ends and you have to get some sleep.

Yet the question remains: What will we do about these “too big things”?

As good as we were that shift in August 2003, we were falling behind then, and we are falling behind now. The prevalence of illness we were dealing with that night was—and still is—ominous and exponential: we have epidemics of obesity, high blood pressure, domestic violence, opioids, anxiety, cervical cancer, smoking, meth, HIV, teenage suicide, disinformation.

We have created fancy, distancing words for these things—disease burden, pathology, psychosocial determinants of health—but up close, staring at you with sweaty foreheads and bluish lips, gushing out of wounds, groaning from half-opened mouths, these words cannot sterilize the sensory experience: sickness is on the move.

We spend hundreds of millions of dollars creating a vaccine for influenza every year, educating people, holding flu shot clinics, and influenza still erupts every single year. Worse, when you look at what causes illness and death, lost wages and jobs, lost productivity and the high societal cost of health care, you find a sobering truth: we are creating the epidemics we are trying to stop. They are not mere accidents.

As a doctor intent on creating the reversal of injury, the return to health, some sort of positive impact for and with the patients I cared for, the scale of it drowned me that night in 2003. I had been trained to treat disease and injury, to pull alongside ailing people and, with my hard-earned priestly wisdom and science and human compassion, help them restore themselves. Sometimes it worked, sometimes it didn't, but I had not anticipated that the exponential surge of these things would overwhelm not just me, but all of us. I had been taught that the combination of technical knowledge, well-designed and well-practiced process, and collaborative teamwork was the answer. If not, then sleep deprivation, skipping meals, and not going to the bathroom until the shift was over would surely do the trick.

Was I being foolish to believe the unspoken promise of my training and mentors? Had I been sold a naïve myth unsuited for a cynical world?

That birthday night when the overwhelming reality of what was flowing through the ER doors crystallized in my awareness, I was neither a novice doctor nor an entry-level leader. I had chaired our department as we rose on the efforts and ideas of a hundred people from an apathetic culture and subpar quality to a place patients flocked to when they got sick. I was a senior executive in our larger organization as it was on its way to becoming Consumer Reports' number-one safety organization in 2012.

I had been “leadership developed” since high school and would be throughout my entire executive career. I had been tested, tooled, evaluated, lectured, boot camped, accredited, certified, promoted, fed-back, coached, videotaped, and fish-bowled. In response to the question, “What do you want to focus on?” at a leadership institute, I replied that I wanted to understand how to go from linear to logarithmic, to understand how to move entire systems so they could respond without relying on running people ragged as a workaround. I saw eyes widen—just barely, but I saw it—and then heard a hastily formed reply uttered in a soothing voice: “We start with ourselves, the only thing we really can control, and you can only do what you can do.” Perfectly sensible.

Yet the flu rolls on, and so does Ebola, Zika, H1N1, MERS, SARS, and now COVID-19. And so does the exhaustion and the pace. In my native sector of health care, over 50 percent of physicians are burned out,1 and the literature clearly shows how that physician epidemic impacts quality and cost, not to mention patients' lives, limbs, families, and peace of mind.2 Over half of executives in health care would quit if they could.3 If you lost 40 percent of your blood volume in short order, you would be experiencing what we call class IV hemorrhagic shock. We would consider that class of shock a collapse of the 300-trillion cell system known as you, defined by death unless a trauma team resuscitated you. We can see lots of “collapse” numbers like these—honeybees, cancer, environmental data, employee disengagement. The people I talk with—executives, small business owners, consultants, associates, partners, young, old—all note the same trend: things are moving so fast, there's not enough time in the day, and one little person cannot move these big rafts of inertia. Even if we could, we're all exhausted. According to a recent Gallup study, two out of three employees experience burnout at some point in their jobs, with secondary effects on their health and ability to function at home.4

Sleep-Deprived Insight

After the conversation with the nurses, patients began to trickle in as morning arrived. I finished the shift and drove home to where I lived west of town. I opened the ranch gate to our place and paused to take in the land where I lived. It was a quiet ritual of mine that created space between the sights and sounds of my job and the world of my family. Depending on which shift I had just worked, I took a few minutes under the stars or the bright sun to let the insights of the work settle in and to let the sometimes assaulting nature of it wash out onto the ground.

The bright morning air, still cool, held the hint of another hot day, and the slanting sun cast dark shadows on the sun-washed ponderosa coulees and grassy ridges. There is nothing better to wash the olfactory memory of alcohol, blood, urine, and pus from one's brain than the morning smell of sage and Ponderosa pine, nothing better to replace the beeping of monitors and moans of the sick than the breeze wandering in the grassy air. Surrounded by healthier sounds and sights in my sleep-deprived, almost-to-sleep ease, it struck me that the epidemics that cause such ill consequence among us—obesity, cardiovascular disease, HIV, gun violence—were playing by a different set of rules than the ones underlying how I had been taught to respond to them.

I stopped at the corral to feed our two horses. Randomly, my dad's offhand observation about why horses are beautiful wafted across my mind: They've retained their wild shape. We had bought our place six years before, and like so many of the patients I encountered in the emergency department, it was in a degraded state when we found it: overgrazed, eroded, barren of its original biodiversity, its history largely erased. Our hope was to help it heal, and if the ER was an exercise in meeting people in an arc of health that I might never see again, the land was an arc that stayed with me and under my feet, beginning long before me and extending far after. Although the grass crunched yellow in the high summer of a 10-year drought, the ecosystem was surging back to health, not falling behind. Life was recovering here: grasses and shrubs were rebounding, insects and birds were returning, water and soil were recharging. If the ER shift had exhausted me with its physical pace and psychic implications, the sights and smells of the land in the sunny morning inspired and soothed.

I had grown up here in this place of big land and teeming life, raised and surrounded by people who had me in it early and often. I had long wondered how the elegance of biology, so essential to the enduring vitality of every person and every living thing on this planet, did not seem to translate to how we designed organizations, leadership approaches, team dynamics, or even our internal mindsets. The exponential trends that bedeviled me as a doctor and inspired me as a landowner were playing by biological rules; our responses seemed to be so much more mechanical and rigid. And slower. And ineffective. And falling behind.

In the fuzzy haze of near-sleep consciousness I would endure for another 30 minutes before I crashed onto my pillow, a meandering thought surfaced for the first time: if epidemics organize and spread by different, biological rules, what if we could harness the rules and link them to positive realities—to cures, to answers, to ideas, to swarms of positive impact? If I was serious about health, if I was serious about understanding how to multiply adaptive capacity in the face of too much to do and not enough time to do it, I was going to have to answer—positively—the question posed by the epidemics that flowed across the threshold of the ED in that unstoppable wave. How could we create positive phenomena that spread just as powerfully, exponentially, into every nook and cranny, the way epidemics overwhelm our defenses against them?

I wasn't thinking of epidemics as leadership that morning. I only knew at that time that I was on the right side of wanting to be helpful and the wrong side of the way things launched, grew, spread, and moved. From the patients I attended to the land I lived on, I understood biology held vitalizing, relentless capacity. Beyond that, I was out of ideas, and I was too long without sleep.

I went down into the darkest room in my house and fell into the motionless, dreamless sleep of the night worker.

Notes

1

   Tait D. Shanafelt, MD, et al., “Changes in Burnout and Satisfaction with Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014,”

Mayo Clinic Proceedings

90, no. 12 (December 1, 2015): 1600–1613,

https://doi.org/10.1016/j.mayocp.2015.08.023

.

2

   Maria Panagioti et al., “Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction: A Systematic Review and Meta-analysis,”

JAMA Internal Medicine

178, no. 10 (October 1, 2018): 1317–1331,

https://doi.org/10.1001/jamainternmed.2018.3713

.

3

   “The Impact of Burnout on Healthcare Executives: A WittKieffer Study,”

WittKieffer.com

, online survey conducted summer 2018,

https://www.wittkieffer.com/thought-leadership/impact-of-burnout-on-healthcare-executives-witt-kieffer-study/

.

4

   Ben Wigert and Sangeeta Agrawal, “Employee Burnout, Part 1: The 5 Main Causes,”

Gallup Workplace,

July 12, 2018

,

https://www.gallup.com/workplace/237059/employee-burnout-part-main-causes.aspx

.

2The Good Epidemic—Really?

Nature does not hurry, yet everything is accomplished.

—Lao Tzu

Good People, Bad Disease

In 2008, several years removed from my discouraging night in the ER, I took a role as the CEO of what was then Colorado's largest trauma center. I entered an organization rife with internal strife and external pressures. I had to familiarize myself quickly with a new organization, five thousand new colleagues, teammates, and opinions, and a city-owned health system in a national financial meltdown. Three days' worth of cash on hand stood between us and our debt holders' right to come in and run the place, and we had $320 million of bond debt tied up in the auction-rate bond market, which collapsed midyear, leaving us with worthless and burdensome debt and no bank willing to help us restructure it. Our compliance with federal guidelines was suspect at best, and the penalties for compliance violations were high and included incarceration of the “designated jailable officer”—me. Our finances were sagging after five years of investing in a new hospital with gorgeous brick and glass without replacing the numerous pieces of expensive technology that were reaching the end of their life cycles.

Nationally, we were entering a recession, which always decreases traffic to hospitals and clinics, and our city, strapped for cash as a sales-tax municipality, was hoping we would fund the city's budget, either by funneling cash flow or by selling the organization. All over the country, cities, states, and the nation itself puzzled constantly over how to fund health care, and I had landed in a town that wanted health care to fund the city.