Evolving Mindset Series: Innovation is Critical to Improving Our World - Part II

The idea of linear innovation is that brilliant scientists make important discoveries, and then brilliant entrepreneurs commercialize these discoveries to benefit all of us. The problem is that innovation doesn’t usually work that way. The idea of planned discovery by primary investigators using a hypothesis-driven scientific method is a lower-brain understanding of innovation. Higher-brain thinking and understanding by government and organizational leaders will be necessary for value-based innovation to flourish.

Innovations that are transformative and truly improve our world have not typically come from planned investment by governments or organizational leaders. In fact, leaders who exhibit lower-brain thinking and competitive or risk-averse behavior can actually inhibit transformative, value-based innovation. 

I was a small part of a value-based innovation that has benefitted our world in my field of surgery. As I started my residency in 1989, all surgical procedures were done through an open incision. Well, that isn’t completely true – some basic gynecologic procedures, mainly diagnostic, were done using a laparoscope, a long skinny tube that allowed the surgeon to see into the abdomen with only a small incision. The gynecologic surgeon had to put their eye at the end of the scope, like looking into a telescope. It was not very practical to do a surgical procedure this way; it was mainly for looking. 

Like many transformative innovations though, the minimally invasive surgical evolution happened through a combination of technologies and collaborations. Technologic advances included putting a camera at the end of the scope so a high quality, magnified image could be displayed on a screen, and insufflation technologies allowed a gas (carbon dioxide) to be pumped into the abdominal cavity that was safe and would create room to do procedures. New types of long, skinny instruments had to be developed by innovative companies that would allow for grasping, dissecting, cutting, stapling, and suturing. 

There was also a need for surgeons to collaborate and help each other through their learning curves, because there were no textbooks to follow and YouTube didn’t exist. The first procedure where this new innovation was applied was gallbladder removal, a fairly common procedure that typically required a painful incision in the right upper quadrant of the abdomen, a several-day hospital stay, and many weeks to recover. General surgeons, who remove gallbladders, had to collaborate with Gynecologists, who were experienced using a laparoscope, to attempt to learn this technique as safely as possible. These surgery pioneers weren’t doing this for fame or fortune, in fact, none were in academic positions or were funded by grants. They were community surgeons who saw the potential value of this less invasive approach for patients. 

Despite the benefit for patients, these pioneers were met with criticism, anger, obstruction, and other harmful behaviors from many healthcare leaders. This resistance to the minimally invasive surgery evolution lasted for about a decade. During this time, the surgeons attempting to advance this valuable innovation (for patients) were threatened with criminal charges, losing their hospital privileges, and I even know of at least one who had to deal with death threats. They were regularly belittled and attacked at surgical meetings, often being accused of “killing patients.”

Why were these healthcare leaders so vehemently opposed to this surgical innovation that is so obviously beneficial for patients? Again, it comes back to lower-brain thinking and behavior. These hospital leaders were afraid that the learning curve might include complications and longer procedures which could lead to a negative impact on the hospital reputation and lower profit margins. The surgeon leaders, typically at academic institutions and other community surgeons who had not adopted laparoscopic surgery were afraid. The academic surgeons were afraid of looking bad because they were supposed to be the leaders of medical innovation and be teachers to the community surgeons. The community surgeons were afraid of losing business if they couldn’t offer a laparoscopic operation and patients wanted to have a minimally invasive approach.

This kind of lower-brain leadership contributed to much harm during this evolution. Instead of giving these pioneers the authority, resources, and support they needed to minimize risks and quickly move through learning curves to achieve better value for patients, many actively tried to obstruct progress and humiliate these pioneers. This led to a higher rate of bile duct injury, the most common major complication during a gallbladder removal. Needless to say, it didn’t have to be that way.

I was very fortunate to be in a hospital during my residency where the leaders were different. They came together to support the implementation of laparoscopic surgery. All of the attending surgeons, including those in competitive practices, agreed to embrace this new technology and learn together. They also recognized that the residents might have faster learning curves because our brains weren’t so used to doing surgery through an open incision with our hands. So, our model was that the fourth-year resident would learn the new laparoscopic procedure at a course or from shadowing the inventor of the new technique, and then they would teach all of the attending surgeons during their fifth (final) year of residency. 

During my fourth year, one of the new laparoscopic procedures was a type of groin hernia repair. I was able to spend the day with the surgeon-inventor of this new technique, Barry McKernan, and he kindly taught me the technique as he performed several procedures throughout the day. During my last year of residency, I scrubbed in on almost every groin hernia repair to help teach the procedure to my attendings and other residents. 

Because of this higher-brain leadership, our group became known as one of the leading hospitals for minimally invasive surgery. In 1990, we did more laparoscopic procedures than any hospital in the world according to the sales representative for the company that made much of the equipment we used. And because we were so supportive of each other, we had no common bile duct injuries during our first nearly 2,000 gallbladder removals. 

We successfully and safely went through our learning curves by having three surgeons scrubbed in on each case. We included the scrub tech and circulating nurse as part of the OR team and allowed them to speak up with any concerns and ideas to improve the operation. Often, especially for more difficult procedures, there would even be more surgeons in the room looking at the monitor to help figure out difficult anatomy or suggest solutions to problems encountered during the procedure. We were all very comfortable stopping and asking for help. If we were called to come help in a case, we did that without question, even though the only surgeon who was paid for the procedure was the primary surgeon. We all knew it was the right thing to do for our patients and each other. But this was not typical. In most other hospitals, the surgeon (or sometimes two surgeon partners) attempting the learn this new way of doing surgery were sometimes ostracized. 

Lower-brain leaders are common in large organizations due to fear of failure and losing status or being fired. That is predominantly why small, start-up companies often replace the established giants in the industry – it’s predictable. One example is how Netflix disrupted Blockbuster. As a start-up, Netflix struggled financially, as with other challenges of growing a business. In one famous failure, before their service was online, they mailed thousands of packages that contained DVDs labeled as President Bill Clinton’s testimony about the Monika Lewinsky scandal, but hundreds of them actually contained a pornographic video. Apparently, the video duplicator that Netflix used also worked for the porn industry. 

The leaders of Netflix took the embarrassing error in stride and no one was fired. They learned from it and adapted, eventually growing to a multi-billion-dollar business. In a recent interview, Netflix co-founder and CEO, Reed Hastings, described a lesson he learned from his marriage counselor. The lesson was that you always have to be honest to gain people’s trust and that it’s vital to admit mistakes in real time. He noted in another interview that he encourages employees to think of “making mistakes as normal,” which in turn, “encourages employees to take risks when success is uncertain… which leads to greater innovation across the company.”

Another example was shared by my friend Bob Williams; we met when he worked at Daytona State College in Daytona Beach, FL. Earlier in his career, he worked at IBM and was one of the early employees at the new (at the time) effort to develop the personal computer. This was a challenge because IBM was a mainframe computer company. They made millions of dollars doing computing projects for large companies by feeding stacks of punch cards into their computers (the size of large rooms) to generate reports for their clients. How could they conceive of making small portable computers and selling them for thousands of dollars, which would cannibalize their multi-billion-dollar business? The reality is they didn’t think the personal computer effort would be very successful, they thought it might become more like a toy home computer.

But the leadership at IBM used higher-brain thinking and behavior to give the personal computer development effort a chance to be successful. They knew that developing a personal computer within the parent IBM company was not a good idea. So, they formed a satellite organization, Entry Systems, located in Boca Raton, FL where the Series 1 minicomputer was developed – and about as far away from the IBM mainframe development labs as possible, without leaving the country. Higher-brain principles in a large organization include the need to separate the new concept from the primary business. Then, the new organization must be given autonomy, authority, and the human and financial resources to succeed. They also must be given the time and ability to develop external collaborations to achieve successful, value-based innovation. 

But in addition to higher-brain leadership, this also requires higher-brain thinking for the innovators. Bob described the innovative and humble small teams that he worked with, much like being in a true start-up company. He told me one story about how challenging it was in the early going. The original 12 members of the IBM PC development team had the hardware to build a personal computer, but they needed an operating system and a coding language to make it functional. They searched around the country and thought they had found solutions for both problems, a company in California that had an operating system and a college dropout in Washington state who had developed a programming language. The small IBM team scheduled a meeting in California one day and then in Washington the next. 

When they arrived in California, a representative of the company said that the company CEO was on a plane and that he could not meet with them that day. This didn’t go well with the IBM team. They were extremely disappointed as they had an appointment, so they traveled on to Washington without an operating system. (Sometimes serendipity is better than a concrete plan.) The young man they met with in Washington, Bill Gates, told the IBM team that his coding language would work well for their needs and he could provide an operating system as well. The rest is history; IBM developed their personal computer and Bill Gates held the rights to the operating system that became Microsoft Windows. 

There are many books written about the need for higher-brain leadership in our world. Unfortunately, there are still far too few leaders that demonstrate this type of thinking and behavior that is critical to bringing more value-based innovation into our world. Some of the principles of this type of leadership include:

• Develop small, diverse teams to lead the innovation efforts

• Give these teams autonomy, authority, and resources to be successful

• Agree upon shared values and long-term goals and hold the teams accountable to demonstrate improved value for customers and for our world in general (including social and environmental value)

• Expect mistakes, failures, and pivots in how to achieve the value-based innovations

• Teach humility, empathy, collaboration, transparency, and vulnerability

• Don’t accept arrogance, divisiveness, siloed information, or competitive and self-serving behavior

I believe there is an opportunity for leaders in healthcare to develop higher-brain thinking and behavior. The status quo in healthcare should not be acceptable. Through my company, CQInsights, I’m looking for these types of healthcare leaders to work with to implement a data and analytics infrastructure that will allow the front-line clinical teams and industry partners to innovate and improve value-based outcomes for all patients, leading to a sustainable healthcare system.

Note: Some of the books that describe the need and principles of leadership that fosters higher-brain innovation include:

• Collective Genius by Linda A. Hill, Greg Brandeau, Emily Truelove and Kent Lineback

• Mindset by Carol Dweck

• Smartcuts by Shane Snow

• Humankind by Rutger Bregman

• How Innovation Works by Matt Ridley

• Now You See It by Carol N. Davidson

• The Medici Effect by Frans Johansson and Teresa Amabile

• Loonshots by Safi Bahcall

• Serial Innovators by Abbie Griffin, Raymond L. Price and Bruce Vojak

• Imagine It Forward by Beth Com stock

• No Rules Rules by Reed Hastings