Blog Posts

We’ve seen sports teams full of All-Stars who don’t win games. These All-Stars score the most points and block the most shots. And yet their teams lose, repeatedly.

Medicine has its All-Stars; with scorecards to prove it. But, who elevates the care delivered by the entire team? This is hard to measure.

The Scorecard

Who is the best physician?

The answer: You cannot tell from this data.

Look at any health care scorecard and you might think you can identify the best. However, the data is incomplete. We have an opportunity before we make decisions to step back and consider what the data shows, and what it does not.

The Lost Physician All-Stars

We have colleagues who elevate our game. These individuals may get lost in the statistical dashboards that compare us. Conversely, scorecard leaders may bring us down.

• Physician A picks and chooses the easiest patients. They are cynical and difficult to work with—and they monopolize resources.
• Physician B cares for the most complex patients and is the first physician the nurses go to during times of difficulty. They educate staff, students, and patients. They elevate care the moment they step on to the floor.

Some of the statistical laggards are our most valuable players.

Plus-Minus

Plus-Minus is a sports statistic. It measures a player’s impact on the game by measuring the difference between their team’s total scoring vs. the opponent’s total scoring when they are in the game. When a high plus-minus player is in the game, the team scores more points than opponents and the team is more likely to win. On the other hand, a low plus-minus player may score the most individual points but sink the team.

Data is Incomplete.

It’s hard to calculate plus-minus. But, we must consider it.

There is bias in the measured and nuance in the unmeasured. We need to challenge data—to step back and think about what is not being measured; what is missing. This exploration improves the care we provide. As we seek what is missing, we gain a broader perspective. We make better decisions.

Look for the unmeasured All-Stars. Whenever, we present comparative data we need to ask: “What is the plus-minus?”

What do you say when a colleague asks, “Can we debrief? What do you think I could have done better?”

Whether it be a difficult case, a challenging meeting, or an uncomfortable interpersonal interaction, it’s good to have a strategy to assist.

But this can be thorny, because sometimes we were there too—we’re entwined. It’s easy to get lost in the details of our own experience of what occurred and what we could have done better—but this is not about us.

We have an opportunity to help our colleague step up onto the balcony to consider what happened during their experience on the dance floor? The following mnemonic will help you get out of your own brain to prompt an even approach to post-event debriefing.

MERDE

The mnemonic for post-event debriefing is MERDE. Merde is a naughty word in French. However, it’s also a word that ballet dancer’s utter to each other before performing on the dance floor—similar to “break a leg.” It is the “break a leg” connotation that I prefer—but sometimes, the former fits perfectly.

A Coaching Approach

I prefer to approach debriefing discussions as a coach and a teacher, rather than as a mentor. As a coach, we ask questions to help our colleague reflect upon their experience, behaviors, and decision-making. And when we teach we provide new information to encourage learning. Whereas when we mentor, we share what we, the mentor, saw and what we would have done differently given our subject-matter expertise. Each of these “hats” is helpful—but, coaching is the best strategy to prompt internal reflection and a chance for growth. Coaching also allows us to stay out of our own head.

M: State of Mind.

So much of how we experience our day depends upon our state of mind. At the same time, as our day progresses our state of mind changes. We may start the day on a high note and somewhere in the middle get knocked down.

We can ask our colleague a simple question, “what are your thoughts about what happened?” perhaps followed by “how was your state of mind?” Questions give our colleague an opportunity to step up onto the balcony to think about how they make sense of the situation.

We may add our observation of the event. For example, “I noticed your level of energy changed…” or “you seemed upset…” This invites discussion of how emotions and behaviors affect experience.

Sometimes we bring a disturbed mindset into situations. We are hungry or tired. We need to pause. Things happen at home, we receive an email, or someone messages us. So, let’s ask about other experiences leading up to and surrounding the event.

As they debrief, we witness their sensemaking, we reflect it back to them, and we help them connect with their state of mind.

E: Education.

Throughout our lives we encounter gaps in knowledge and skills. These gaps are a normal part of uncomfortable situations. We can address this with our colleague.

We ask, “As you think about what happened, what would you like to have understood better?” Or, “what gaps in your own knowledge might have played a part?” These gaps may be related to familiarity and expertise with a process, skill, and/or understanding of facts and information.

On the other hand, there are things we know that others do not. We can ask, “what gaps did you sense others had in their knowledge of what occurred?”

It may turn out that the gaps are not in education, but rather a misunderstanding of different perspectives.

R: Relationships.

How we get along with others affects our own well-being and effectiveness, and that of our teams. What does our colleague notice in their relationship with others around the event?

“I noticed [the following tone, facial impression, gesture]:

• during your phone call with [this person], or
• when you were approached [in this manner], or
• as you gave orders during [this situation]

What are your thoughts about what happened?”

In what ways did interpersonal dynamics affecting their experience? Do they feel safe? How will it change relationships in the future?

D: Documentation.

Documentation such as letters, memos, voicemails, charting, and emails play a part in how we communicate. Each is a prime opportunity for reflection.

Probe for an understanding by asking: “What do you think about your documentation of the event?”

On the other hand, our colleague’s instinct may be to respond to the event through documentation. So, we could ask: “What do you think would be the best way to follow-up on this?”

E: Efficiency.

Multitasking and inefficient process set us up to fail. It is helpful to reflect on how barriers to efficiency impact experience.

• “I noticed that [these people] were repeatedly having to ask you for [next steps].”
• “What was your sense of how that meeting was run?”
• “How might you improve efficiency the next time this occurs?”

Conclusion

MERDE gives a roadmap to guide post-event debriefing. It provides a grounded way to help a colleague reflect on what occurred and how they make sense of the experience to move forward.

Here is my post “Coaching Physicians to Become Leaders” for the Harvard Business Review blog.

Physicians are being called upon to lead large health care organizations. Many physician leaders partner with executive coaches to help them strategize, identify key alliances, and build their teams as they establish leadership presence in their role.

Read the full post here: “Coaching Physicians to Become Leaders“

As I sit on this old wooden pew, I rock side-to-side to ensure that blood flows to each part of my bottom. We’ve been at this rented church for 75 minutes listening to the sounds of my daughter’s violin class recital and now it’s time for the last piece.

A high school student with a large tattoo of a stanza on her left bicep stands up and begins to play. A beautiful and tenderly nuanced sound fills the hall. Siblings, who have been leaning against parents, drop their handheld games and listen. The crowds sits with hushed hunger as she lifts us with her musicianship.

The performance ends and we compliment the young virtuoso about her masterful display of advanced technique. The young virtuoso responds with a smile, “Thanks! And there are so many parts that I look forward to improving.”

The Mind of an Expert

This young violinist thinks like an expert. She loves what she does and yet she is even more excited about the possibilities of what she might accomplish.

Similarly, we as physicians are experts. We completed residencies and fellowships and yet there is so much to learn. There are so many things we can do to advance our expertise not only in medicine, but also in business, leadership, relationships, and anything else we set our minds to master.

We’ve seen some colleagues excel in one facet, but struggle with many others; and at the same time we work with colleagues who excel in virtually every aspect of their lives. This raises some questions: How do we stay experts? And how do we become an expert?

Here are Three Steps to Become an Expert:

1. Think like a beginner.

The beginner’s mind sees potential. It hungers to learn and to grow.

Expert physicians maintain the mind of a beginner. They think that their most basic abilities can be further developed through dedication and hard work.

This procedure that we have done for years, perhaps we can identify and eliminate wasted steps. These thoughts that we have when this occurs, perhaps we can change our cognitive approach. That reaction we have with a precious individual, perhaps we can nurture a deeper relationship.

Expertise is cultivated through learning. This is harvested from books, journals, Twitter feeds and blog posts, and the inspiration we gain at conferences. Experts think like a beginner. And then they practice.

2. Deliberate practice.

Experts work their butts off. However, it is not just the amount of effort or the time spent. The effort needs to be smart and focused. The practice needs to be deliberate.

A guitar player who plays “Stairway to Heaven” for three hours each day is probably doomed to play in an awkward cover band; whereas, the guitarist who practices a solo that is just out of reach of current skills for one hour each day is more precisely on a path to expertise.

We are each part virtuoso and part cover band. Repeating a mediocre approach to a patient problem may be familiar and may get the job done, but it is not expertise.

Experts engage in deliberate practice. They dissect skills down into smaller and smaller chunks and work to fine-tune each skill one chunk at a time. They practice in a focused manner. And then they reflect.

3. Reflect.

In between practice, experts reflect on their performance and elicit the feedback of others. This important step is a key driver towards expertise.

It is increasingly common for élite athletes, Fortune 500 CEOs, and physicians to work with a coach or a mentor to help them reflect upon what is working and what can be better.

Novak Djokovic is the top ranked men’s tennis player in the world. He strives to consider every detail, looks at every angle as being crucial, and seizes moments where he can gain an incremental edge to beat the best when his competition is already the best it has ever been.

Djokovic is the best in the world and yet he and virtually every other élite athlete travel with a coach. His coach helps him identify skill chunks to develop, create goals for practice, and most importantly to reflect upon results. Together they create strategies for future deliberate practice.

Eric Schmidt, Chairman of Google, recently remarked during an interview with Fortune Magazine that he works with an executive coach. This is a very common practice for Fortune 500 CEOs. His coach helps him see himself as others see him. His coach helps him identify his blind spots as he runs a multi-billion dollar business.

Atul Gawande, an endocrine surgeon, recently wrote in The New Yorker about his use of a mentor coach. He found that after residency he was getting better and better, until he didn’t. He worked with a retired surgeon who observed his surgical skills for wasted moves, made observations about operative positioning, and discussed strategies to reduce complications.

Look around to the mentors, colleagues, and coaches who can help you. Look for an outside observer to be an aligned confidant who can help you reflect and develop further brilliance and ability. Identify areas of your professional and personal life where you can develop and extend expertise.

Moving forward

We know that expertise is not innate and it is not luck. Instead, expertise is gained through hard work, it takes time to achieve, and it expires if not nurtured.

The old idea of “see one, teach one, and do one” is outdated. Physician experts prefer to “see one, practice one, reflect and improve on one.” They enjoy this process and they repeat it as part of their daily ritual.

The moment the expert physicians become comfortable with their current skills is the exact moment that they begin their path towards mediocrity. Experts approach life with a beginner’s mind. They deliberately practice. And they reflect.