Marina Gorbis's Blog, page 1517

Today, Just Be Average

Do you ever “back door brag” about being a perfectionist?

Unlike other obsessions and addictions, perfectionism is something a lot of people celebrate, believing it’s an asset. But true perfectionism can actually get in the way of productivity and happiness.

I recently interviewed David Burns, author of “Feeling Good” has made this exact connection. In his more than 35,000 therapy sessions he has learned that the pursuit of perfection is arguably the surest way to undermine happiness and productivity. There is a difference between the healthy pursuit of excellence and neurotic perfectionism, but in the name of the first have you ever fallen into elements of the second?

Taken to the extreme, perfectionism becomes a disorder. Burns shares the wild example of an attorney who became obsessed with getting his hair “just right.” He spent hours in front of the mirror with his scissors and comb making adjustments until his hair was just an eighth of an inch long. Then he became obsessed with getting his hairline exactly right and he shaved it a little more every day until his hair receded back so far he was bald. He would then wait for his hair to grow back and the pattern continued again. Eventually his desire to have the perfect hair led him to cut back on his legal practice in order to continue his obsession.

This is an extreme example to be sure, but there are less severe ways in which our own perfectionism leads us to major in minor activities? Have you ever obsessed over a report when your boss said it was already plenty good enough? Have you ever lost an object of little importance but just had to keep looking for it? Do colleagues often tell you, “Just let it go”?

Aiming for “perfect” instead of “good enough” can seriously backfire. This happened to me recently when I was asked to teach a workshop to the leaders of a prominent technology company. I took the time to understand their needs and personalize the materials to their specifications. And I already had materials I had taught scores of times with great results to pull from. But my obsession for making it perfect led me to scrap all of that the night before, and as a result I was unprepared and exhausted. I felt jumbled and my slides distracted from the main message. If I had shot for average instead of perfect, I would have been able to focus more on the client in the moment and things would have turned out very differently.

This left me wondering: what if trying to be average could actually accelerate your success?

Overachievers have such high expectations of themselves that their “average” might be another person’s “really good.” So instead of pushing yourself to give 100% (or 110%, whatever that means) you can go for giving 75% or 50% of what you usually might offer. This idea is captured succinctly by the mantra, “Done is better than perfect” — which Facebook has plastered all over the walls of their Menlo Park headquarters. That’s not to excuse shoddy work. Rather, the idea is to give engineers permission to complete cycles of work and learn quickly instead of being held hostage by an unattainable sense of perfection.

The word “perfect” has a Latin root; literally, it means “made well” or “done thoroughly.” Another translation would be “complete.” And yet today, we use it to mean flawless. If you must pursue perfection, at least use the former definition rather than the (unattainable) latter.

If you are a perfectionist, overachiever or workaholic you are probably used to taking on big challenges. The  nature of the obsession makes it easy to do what is hard. Paradoxically, it may be harder at first to try to be average.

To understand why, we need to understand the role of fear in perfectionism: “If I don’t perfectly [fill in the blank] something terrible will happen.” Often perfectionists are so used to this anxiety that they no longer even consciously recognize it; it’s just the fuel that keeps them working, working, working and honing, honing, honing.

While the logic may be totally false, the emotion is absolutely real. As a result, it takes greater courage for a perfectionist to try to be average than to tackle almost any other challenge. Being average scares them, so they haven’t experienced the benefits of being average.

Here’s how Burns put it: “There are two doors to enlightenment. One is marked, ‘Perfection’ and the other is marked, ‘Average.’ The ‘Perfection’ door is ornate, fancy, and seductive… So you try to go through the ‘Perfection’ door and always discover a brick wall on the other side… On the other side of the ‘Average’ door, in contrast, there’s a magic garden. But it may have never occurred to you to open the door to take a look.” As he wrote in a recent entry on his blog, “Much of our suffering derives from our perfectionism, and our belief that we should be ‘special.’ But…[w]hen you don’t have to be special, life becomes special. This may be what the Buddha was referring to when he talked about ‘the Great Death,’ or the death of the ego.”

If you think you are the type of person who takes on hard assignments with ease, you might try to do something really hard: try being average for one day. What you find might surprise you.

Chatting with the Cashier Will Improve Your Mood

If you buy your coffee quickly at Starbucks without saying much of anything, you’ll probably arrive at the office sooner, but if you stop to chat with the cashier, you might get to work in a better mood. Research participants who smiled, made eye contact, and briefly conversed with the cashier subsequently reported greater satisfaction with the visit and were in better moods (4.31 versus 3.80 and 4.22 versus 3.60, respectively, on 1-to-5 scales) than those who avoided unnecessary conversation, say Gillian M. Sandstrom and Elizabeth W. Dunn of the University of British Columbia. Seemingly trivial interactions can confer a sense of belonging, an effect that people tend to overlook in their quest for efficiency, the researchers say.

What Corporations Can Learn From a 4,000-Person Parade Extravaganza (Seriously)

The samba schools that compete in São Paulo’s annual Carnival parade are big, complex organizations. Mocidade Alegre, which danced away with first place in the parade this year and in 2012, brings almost 4,000 people to the parade. They show up on time, dressed in exuberant costumes and arranged in 25 wings, singing and dancing in a tightly choreographed display that they’ve been practicing for nine months. There’s also a 250-man percussion orchestra (known as a bateria) and five floats interspersed among the wings.

Winning or losing the carnival parade contest is decided by a cohort of referees who assess each samba school on 10 criteria that resemble key performance indicators (KPIs) in the corporate world. Over the next year, all the samba schools seek to improve their performance on those KPIs. The result is spectacular, and Brazil’s carnival parades have become a world-class show transmitted by TV to over 100 countries.

It is also, for the great majority of the participants, a volunteer show. Less than 5% of samba-school members (mostly those such as seamstresses and float builders whose duties coincide with normal working hours) receive any pecuniary reward. This last must be especially aggravating to managers of multinationals in Brazil who pay people to work only to have them arrive late, leave early, and ask for sick leave when they are not sick.

What is that the samba schools have that corporate organizations in Brazil don’t?

In search of answers, I studied Mocidade Alegre, interviewing people of all ranks in the organization, from dancers with no managerial authority, to the wing chiefs who cajole the dancers into compliance, to the many directors, to the school’s president. The metaphor for samba school that came up most frequently in these interviews was “family,” which fits the group-orientation of Brazilians. Members identify with the samba school, feel they belong, that the school is theirs. They cry when they lose out and they cry when they win.

“Winning or losing the Carnival Parade is part of the game,” says Daniel Sena, 31, Mocidade’s Director General of Harmony. “But treating people nicely is the core of our business; that is what makes them come back for the renewed challenge, even after losing a parade.” Sena, a supervisor in a company that sells credit to the upcoming Brazilian middle class, thinks corporations underplay this element and rely too much on the motivational power of financial incentives.

Many Mocidade members see big contrasts between their corporate day jobs and the atmosphere at the samba school. Fifty-year-old Márcia Uzam is a wing coordinator with Mocidade and a mediator in a large corporation with 400 lawyers. Márcia says she has seen “corporations discarding people as if they were garbage when they are past their prime,” while at a samba school, “the oldies are recycled.” Indeed, despite tight time limits in the Carnival competition, the samba schools take pride in parading with their older members, who have helped build the schools’ standing. That sends a powerful positive signal to the younger ones, who will not feel “used” and liable to be discarded; it also contributes to the sense of community which Rob Goffee and Gareth Jones argue is what corporate workers desire the most.

Not only does Mocidade nurture the relational dimension of the organization, it also handsomely recognizes contributions with titles.  I have never been in a business organization with so many “directors.” Ariane Camilla, 27, a journalist by day who is Mocidade’s Director of Carnival, believes there are more than 30 directors at Mocidade. Titles at Mocidade carry no financial weight, because people are not paid. But the people bestowed with such titles and ranks carry them with pride, wearing shirts with their rank and name embroidered on them. Rank is matched with empowerment. Leaders have a large degree of autonomy and consequently develop the sense of ownership crucial to success. Ineffectual wing leaders may lose their dancers to another wing leader at the samba school in the next Carnival parade.

It’s a bit like 19th century Latin American independence armies, which had so many colonels one might think they were top-heavy. But no, everybody knew then who the real boss was, as they know today that the boss at Mocidade is Solange Cruz Bichara Rezende, the 43-year-old president, seen weeping in this video clip after learning that her samba school had won the 2013 parade.

Mocidade Alegre, then, is a 4,000-strong organization led by a 43-year-old woman, with a 27-year-old woman as a sort of second-in-command, and a Director General of Harmony, Daniel Sena, who is black (or Afro-Brazilian, as Americans would have it). All this in Brazil, a country where women are known to have much slower and shorter corporate careers than men, and where black directors are vanishingly rare in larger corporations. Mocidade is a community, and family, but not one built along standard ethnic or hierarchical lines.

What can large corporations operating in Brazil learn from all this? Mainly that building and maintaining community is crucial to success. This is especially true in emerging-market countries where the workforce has experienced great change and dislocation. In Brazil, the rural share of the population dropped from 50% to 15% over the past 40 years. China and India are in the midst of similar transformations; Africa will follow soon after.

Recent rural migrants end up in the slums of Rio, São Paulo, Mumbai, or Nairobi. Their houses are not only poor but also unsafe, subject to landslides, floods, or forced eviction. With each onslaught, migrants may see their affective bonds severed. Samba schools are a place to find a lost sense of community. Newcomers are easily accepted because they are recruited along affective networks rather than by education or experience. At corporations, on the other hand, recruiting emphasizes competence over affinity, and leaders are appointed from above, frequently without considering the views of those to be led. Workers also usually cannot drift away from a poor leader unless they leave the organization.

A successful samba school such as Mocidade Alegre is a closely knit organization with a strong focus and great teamwork. The corporate workforce in Brazil tends to become a collection of individuals with a low level of engagement. The corporation responds to this low engagement with controls, which further removes the autonomy of individuals, undermining their sense of belonging and forcing them to work under unfamiliar rhythms. It is no wonder that corporations in Brazil suffer from high absenteeism and turnover. They need to learn from the samba schools, whose members parade even in the pouring rain, for no pay at all.

Foreign multinationals in Brazil and other emerging markets should consider recruiting at places like the samba schools that concentrate large numbers of people desirous to belong and engage. I would also recommend that corporations recruit by affinity where possible, particularly where teamwork is important. These workers might require more training, but the cost could be offset by lower wages, stronger teamwork, and, eventually, higher productivity. Besides, by recruiting in this way corporations may also contribute more to social cohesion in emerging markets, becoming an agent of modernization in societies where discrimination is still rampant — except at the samba schools.

Anxiety Is A Double-Edged Sword

When we’re feeling anxious about making a decision — and this is especially true if it’s a high-stakes decision — we tend to seek the counsel of our friends or colleagues. But this isn’t always a good move to make, and it can lead us astray. Why? When we’re anxious, our ability to tell the difference between “good” advice and “bad” advice is diminished. It’s almost unfair: anxiety makes us run to others for help but it also makes us more susceptible to bad advice. So be careful, keep calm, and carry on.

The Dangers of Denial

Great leaders tell it like it is. In other words, they focus on reality, no matter how painful or unpleasant it might be, and then figure out what to do about it. In contrast, less effective leaders sometimes avoid hard truths, argue with the data, and delay tough decisions.

While it’s easy to be critical of leaders who can’t face the facts, the truth is that most of us engage in denial at one time or another, usually without even knowing it. As human beings, it’s one of the most common defense mechanisms that we use to cope with difficult situations. It’s the first of Swiss psychiatrist Elisabeth Kübler-Ross’ now-famous five stages of grief, in which she observed that many people react to news of their terminal illness by denying anything is wrong with them. This is an extreme case, of course, but lots of business situations trigger denial as well. Here are two quick examples:

A large natural resources company acquired a smaller competitor and announced that it would be closing a number of low-producing mines within a year. Six months later the corporate HR manager visited these mines to help with the transition and was surprised to learn that the planning hadn’t even begun. When he questioned the mine leadership team he was told, “We’ve heard this story before but we produce too much ore for the company to really shut us down.”

The executive team of a pharmaceutical company knew well in advance that it was facing the loss of patent exclusivity for a particular drug, which would significantly reduce sales revenue in the coming year. Despite not having sufficient new products to replace these losses, the team delayed making commensurate cost reductions, with each manager saying that their people were indispensable.

There are many stories like these at all levels of organizations. Just the other day, I was talking with a twenty-five year old financial analyst who told me that she is looking for another job because the products in her division are becoming commoditized and will probably be sold off or eliminated. When I asked her how her colleagues were reacting to this she said, “They don’t believe it can happen to them so most of them aren’t doing anything.”

This brings up an important point about denial: It’s easier to see in others than in yourself. This means that coping with it usually needs to be a team effort. Even the most open and honest of managers sometimes engage in “wishful hearing” and interpret things the way they want them to be, instead of how they really are. That’s why really good managers value subordinates and colleagues who are not afraid to bring them bad news, tell them the truth, and help them peel away their own unconscious avoidance mechanisms.

Given these subtle psychological dynamics, here are two principles to keep in mind for dealing with denial in your own career and your work with colleagues:

Don’t assume that everyone sees the world through the same lens as you. Facts and data are usually open to interpretation, and people have different underlying criteria for how they analyze them. We all emphasize some things and discount others, based on past experiences, personality, and tolerance for discomfort. That’s why the financial analyst saw what she thought was the “writing on the wall” about her division’s future, while others in the group saw a different story.

Get tough subjects out in the open. Because of these different interpretations, find ways to facilitate and encourage dialogue, particularly when complex issues are on the table. While denial can still occur, it is less likely when teams are able to look at the situation from multiple angles, challenge underlying assumptions, and eventually get a better picture of what’s really going on. So while it’s true that great leaders usually don’t get trapped in the denial of hard realities, it’s often because they get a lot of help from their teams.

So yes, denial is alive and well in most organizations, which leads to delayed or inappropriate decisions, inaccurate or misleading communications, and a host of other dysfunctional outcomes. But it’s important to remember that it’s a natural human reaction to anxiety-provoking situations, which is why it’s important for teams to help each other see the truth.

Don’t Move to Silicon Valley Without Preparation

We hear a lot about technology and globalization these days, especially how they are hollowing out the American middle class. But there has been an immense positive impact from the globalization of entrepreneurship, making Silicon Valley’s formula of technology-based start-ups an international instrument for economic development.

I live amid this trend, living and breathing it daily. As someone who mentors entrepreneurs, I constantly hear the question from founders located across the United States or around the world: Should we move to Silicon Valley?

This is no idle question. Steve Case, for one, argues that it’s possible to build world-class tech companies outside the Valley. In a recent post on HBR.org, Maxwell Wessel draws on data to argue that companies raise money more quickly, have better prospects to be acquired, and face better long-term survival rates if they locate in Northern California.

My take on the subject is that if you’re going to move to Silicon Valley, be prepared. It’s horribly expensive, which impacts your burn rate. The talent war for start-ups that lack major VC backing can be brutal, and too many entrepreneurs underestimate this factor. And it’s not easy to survive the early stages of such a move.

Let’s imagine these conceptual arguments in more concrete terms. You’re the founder of a start-up that’s too nascent to allow you to draw a salary–but to live in the Valley, you’re now paying $3,000 a month to rent an apartment. You have no funding, but you have to convince some engineer who’s already juggling 15 job offers (including offers from Facebook, LinkedIn, and Google) to join you to help finish your product. Rehearse the pitch in your head, and please come share it with me at one of my Thursday morning free mentoring sessions. I’d like to see how it sounds. I’d like to see if you could convince me.

Remember, you have no funding, so you have limited ability to pay this person. Beyond equity, you have two things to rely on: vision and personal charisma. Since the company has not much to show for it yet, the equity probably isn’t much of a draw, either.

Is this engineer going to accept your job offer? The answer, in most cases, is no.

Companies that move to Silicon Valley after gaining traction end up having a better success rate. Traction means running experiments to suggest you’ve found a validated business model, some actual revenue, some early wins. If you’re going to move to Silicon Valley, waiting until you’re beyond the very early days can make sense.

For one thing, having achieved traction may allow you to raise funds. There’s a misconception that VCs and angel investors fund ideas, but generally speaking, that’s not true. That may happen if you are a serial entrepreneur on your third venture and have made money for investors before–but even in that case, you would be able to invest in your own bootstrapping stage. In any case, you don’t need outside investors till your experiments are somewhat mature.

If you really can’t start your company where you are, consider moving to a U.S. city that’s less competitive than Silicon Valley. Here are a couple of interesting case studies:

The Israeli company Perfecto Mobile is thriving in Boston. They moved to America, but not to the Valley. Among the advantages: less competition for talent.

The Indian cloud-backup company Druva did move to the Valley, but it waited until it had achieve traction enough to receive funding from Sequoia.

Now, when they hire, the first question–who is your backer?–meets with a satisfactory answer.

We also have examples of companies thriving in Arizona and Chennai … and many other places. Arizona-based InfusionSoft raised funding from Silicon Valley’s Mohr-Davidow Ventures, but by the time they did so, they already had millions of dollars in revenues.

Freshdesk, based in Chennai, India, raised money from Accel Partners in India, and even though they are selling to a global customer base, they have stayed in Chennai, keeping cost-structures down. Not only do they enjoy less competition for talent, they also enjoy less competition for funding. The company has 10,000 customers for their helpdesk software-as-a-service product, and thus far, $6 million in financing.

Greg Gianforte, the founder of RightNow, told me years ago that one of the best decisions he made was to build his engineering operation in Montana. Costs are low. Quality of life is high. Attrition is non-existent. Greg did raise money in Silicon Valley, but by then, his company had significant revenue. He eventually took the company public, and later sold RightNow to Oracle for $1.3 billion. I have called him the Montana Mogul.

More recently, Utah is seeing significant startup activity, and is able to draw capital as well, including from the Valley. Companies like Omniture, Pluralsight, Steals.com, and others are making excellent progress. Omniture has been acquired by Adobe, and was venture-funded by Silicon Valley firms such as Hummer Winblad.

Finally, if you do come to the Valley with the right ammunition – a solid investment thesis, proven model, traction, and execution track record–no matter where you come from, investors will shower you with financing.

In fact, if you have a solid operation elsewhere that costs less, faces less competition for talent, and offers a sustainable competitive advantage, the investors here like it very much. Large operations in Arizona, Utah, or India would work in your favor, not against. A small Silicon Valley operation with a large off-Valley base may be the ideal model for many entrepreneurs.

Of course, people come to Silicon Valley from all over the world, and many of them become successful. That is the myth of our golden Valley. That is what draws global talent to us.

But do not do not make a blind decision based on media hype or a cursory understanding of what’s involved.

If you come to the Valley, come prepared.

And know this, that, you can ALSO succeed elsewhere just fine.

Update Your Job Search

Month by month, the job market keeps easing upward. Although we haven’t fully made up the number of jobs that were lost in this recession, almost every industry has grown jobs since the economy hit rock bottom in February 2010. And there are plenty of new kinds of jobs that have been created since then, too.

Now this optimism is starting to spread. People who stayed glued to their jobs during the downturn are starting to dip their toes in the water to see if there is a new position out there for them. But while they have been hunkered down waiting for the recession to pass, the job market has been changing. If you have been at the same organization for five or more years, you are in danger of making some big mistakes that can completely derail your job search. Here’s a handful of those pitfalls and how to avoid them.

You have an inflated expectation of what you’re worth. If you have worked for the last five years with little or no increase in pay, you may feel angry or resentful. Zero to one percent was pretty standard for many workers during the recession, and there was actually wage deflation during this period. The PayScale Index for Q3 notes that in real terms wages in the United States have gone down 7%.

However harsh the reality is, take a long, cold look at what kind of salary you can realistically command. It may well be less than you expect. To research that, you can use online sources like PayScale or Glassdoor, and sometimes an organization’s website. But if you want to be sure, ask a headhunter, talk to people in your professional association, or find friends who have just landed similar jobs. Real people will be straight with you.

You use old-fashioned search techniques. In the last five years, job boards have been going the way of newspaper ads. Now, recruiters proactively use social media to identify potential candidates instead of waiting for resumes to come in. If you don’t have a social media presence – on LinkedIn, Twitter, or your own website – you aren’t likely to get noticed.

For example, when Andy started his job search as a senior manager in marketing for a major nonprofit, he hadn’t taken the time to create a compelling online presence for himself – he didn’t think he needed to. However, when he ran into obstacles in his job search, he chose to beef up his LinkedIn presence. He added as many contacts and colleagues as he could – including vendors – posted some samples of his work, and solicited some endorsements. Snatching the opportunity to update his skills in his field, he took a seminar in SEO analytics and put that on his LinkedIn profile, which LinkedIn immediately sent out to all his contacts. That produced some email congratulations and ultimately the contacts that won him his next job.

You present yourself as more junior than you really are. You have more skills and experience since the last time you were on the job market. Conveying all that is more than adding another job to the top of your old resume: Think through how you frame yourself. Junior people present themselves as hard-working, energetic, and quick to learn. They are looking for a way into a career and will say yes to most offers. People who are more senior present themselves as experienced, thoughtful, strategic, accountable, and targeted. They know what they want and will have the common sense to say no when a position or company doesn’t feel right.

If you are a mid-career or senior professional, make sure your resume and interview techniques don’t make you look junior. In Beverley’s case, her job itself caused her to understate her accomplishments. As a hospital administrator, she had to facilitate strong medical personalities. She would never have been as successful if she boasted to them about her accomplishments. But on the job market, she had to present herself more as senior and effective, and less as friendly and eager to help. Fortunately she was active in amateur theatricals, and was told to “answer their questions as if you were playing a queen.” She got the change immediately.

You waste time blaming the gate-keepers. Where there used to be human resources reps filtering an applicant’s access to jobs, there are now software programs that make the first cut at the resumes and screen for the hiring manager’s wish list of specifications. While it used to be tough getting a job by responding to an ad, it’s now close to impossible. There is no one to call, no way to follow up, and worst of all, no one to blame. So don’t waste your time on negative feelings. Get creative.  Write a letter directly to the CEO. Walk in and apply in person. I have one client who went through her doctor to get in contact with a hiring manager at a hospital, another who solicited donations to a college that he and the hiring manager both went to. Just don’t send presents. That’s a real red flag.

When you think about it, there is not much difference between someone who has not taken a look at the job market in five years and someone who has returned to work after a five-year assignment in another country, or someone who is returning to work after staying home with children for five years. The key to success is to assume things have changed, do some careful data gathering about what those changes are, and be patient and creative about fitting yourself back in.

Why Can’t U.S. Health Care Costs Be Cut in Half?

Technological improvements in health care have given us the quality of life we enjoy today. But chronic conditions, end-of-life care, and an aging society will bankrupt the United States if it doesn’t make dramatic changes to its health care system. America — and many other countries — need an audacious goal to get off the unsustainable path.

What if the United States set itself the goal of cutting healthcare costs in half — without sacrificing quality, and in about a decade?

Sound undoable? In “Delivering World-Class Health Care, Affordably,” we argued that some Indian hospitals are delivering high-quality care at 5% to 10% of U.S. prices. Of course, the United States is not India, so its costs will always be higher. But even with all the constraints, cutting U.S. healthcare costs in half is not preposterous. After all, it’s been done in other industries, sometimes in less time (think computers or consumer electronics).

Or take the example of autos. When Karl Benz introduced the Mercedes Benz in 1876, each car was handmade from start to finish. Every customer was assumed to be unique and so was every car. Making autos was a craft, and very few people were skilled enough to put one together. Buyers visited the Benz factory and stayed for a week to test drive the car and fix any bugs before taking delivery. The net result: The craft approach produced only a few automobiles at extremely high cost for the very rich.

Enter Henry Ford, who revolutionized the industry with his manufacturing innovations, lowering the price of cars from $2,000 in 1908 to just $260 by 1925 — an 87% reduction! He didn’t do it by making cars shoddier or offshoring production to low-wage countries. His secret was mass production in a “focused factory,” using interchangeable parts, specialization, and the assembly line. (See this HBR article on attempts to apply the focused factory concept to health care.) By making only one type of car (Model T) in volume, he cut unit costs dramatically. Ford shifted the auto industry from craft to mass production, and the Japanese later took it a step further to lean production. At each step, costs fell sharply yet quality improved.

If we go back a hundred years, medicine had to be practiced in a craft mode since each patient was unique and our ability to diagnose diseases and treat them was rather limited. Knowledge and technology have advanced at a such a rapid pace that today that quite a number of medical conditions can be treated using a “process” approach. Yet, too much of U.S. health care is stuck in the craft mode. It is producing a Rolls Royce for each patient! Why can’t U.S. health care go vastly farther in streamlining operations, standardizing protocols, and rationalizing facilities to create focused hospitals for heart surgery, hernia repairs, cataract surgery, hip and knee replacements, organ transplants, or even cancer treatment — anything that’s not an emergency procedure and can be scheduled in advance?

Many U.S. health care providers are going down this road (see “Fixing Health Care on the Frontlines”). But the most innovative Indian hospitals are doing much more. Narayana Health in Bangalore, India, uses the focused-factory approach to perform open-heart surgeries for $3,000, versus $75,000 to $150,000 in the United States. The total number of open-heart surgeries performed in the United States is about 550,000 — six times India’s — but this volume is spread across too many hospitals. The same can be said of other procedures that might lend themselves to mass or lean production.

Aravind Eye Care in Madurai, India, performs cataract surgery in assembly-line fashion. Doctors focus their time on diagnosis and the most intricate aspects of surgery, while less-skilled paramedics take care of everything else. Care Hospitals in Hyderabad performs angioplasties with remarkable efficiency and efficacy. Lifespring focuses on uncomplicated maternity care for the urban poor. HCG Oncology performs advanced diagnoses and procedures in its Bangalore “center of excellence,” while its spoke facilities provide radiation and chemotherapy treatments. Onco-pathologists and medical physicists, who are scarce in India, sit in Bangalore and provide services remotely, using telecommunication links to patients at spoke hospitals. (See this HBR article on how to redesign knowledge work, including health care.)

Changing U.S. health care to achieve a 50% cost reduction will require patients, providers, insurers, and others to make major adjustments. But such changes happen routinely in other industries. With costs spiraling out of control, the day has come when the same must happen in health care.

Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us at healtheditors@hbr.org, and sign up to receive updates here.

Leading Health Care Innovation

From the Editors of Harvard Business Review and the New England Journal of Medicine




Bringing Outside Innovations into Health Care
How to Rehabilitate Medicare’s “Post-Acute” Services
The Sequestration Cuts that Are Harming Health Care
Negotiation Strategies for Doctors — and Hospitals

Are Your Most Compliant Customers Those Who Are Emotionally Disorganized?

People who were momentarily alarmed at what they believed were parking tickets on their windshields were subsequently 1.65 times more likely to comply with a street vendor’s request to purchase aromatic Indian sticks. Similarly, people were more likely to answer a questionnaire if the surveyor first asked, “Haven’t you lost your wallet?” (nothing had happened to the wallets). These experiments, by Dariusz Dolinski and Katarzyna Szczucka of Warsaw School of Social Services and Humanities in Poland, demonstrate that the “emotional disorganization” following apprehension and relief makes people more likely to comply with a request.

How Anxiety Can Lead Your Decisions Astray

High-stakes decisions — which can range from starting a business to consummating a joint venture to hiring or firing someone — have something in common: they involve high levels of uncertainty. When so much is unknown or unknowable, trying to decide what the right course of action might be triggers anxiety. In response, many of us seek the counsel of others to help us make these weighty decisions.

Consulting experts and trusted friends may seem like a wise choice, but it comes with unexpected costs. Recently, my colleagues and I undertook research to understand how anxiety impacts people’s willingness to accept advice from others and their likelihood of following poor guidance (PDF).  The upshot? Our natural instincts can get us into a lot of trouble.

In one of our studies, we asked college students to look at a photo of a stranger and estimate that person’s weight. We told them that they would receive a $1 bonus per photo if they came within 10 pounds of the right answer. After completing the initial task, some participants were shown an anxiety-inducing clip from the movie Vertical Limit; the rest watched a “neutral” clip from a National Geographic documentary about fish in the Great Barrier Reef. Next, students rated their self-confidence and then completed another round of weight estimates. But before being shown the photographs again, the students indicated whether they wanted to receive advice from someone else before making their guesses. Those put in an anxious state by the movie clip felt less confident than those who watched the nature documentary. Ninety percent of those in the anxiety condition opted to seek advice; only 72% of those in the neutral state did. Those in the anxious state were also more likely to take the advice they were given.

This might not be a problem — except that anxiety also impairs our ability to accurately judge the quality of the advice we received. In a follow-up to the above experiment, my colleagues and I had another group of participants write about an experience from the past that made them anxious or about their last visit to the grocery store (typically a neutral experience) and then estimate the number of coins in a jar. This time, some participants were given bad advice; others were given good advice (i.e., they received accurate estimates of the number of coins). Those who were in a neutral state were more likely to take advice when it was good rather than bad. But anxious participants tended to make no such distinction. Anxiety reduced their ability to discern between good and bad advice.

These two tendencies — being more receptive to advice and less discriminating — can combine in a way that can be harmful. In fact, in a similar study, we found that people who were made to feel anxious were more open to, and more likely to rely on, advice even when they knew that the person offering it had a conflict of interest — that is, when he or she would benefit financially from the participant taking the advice.

The anxiety we triggered in our experiments was relatively mild. By contrast, the anxiety prompted by high-stake decisions can be so great that it can overwhelm our careful plans and analysis.

Eliminating the emotional turmoil of high-stakes decisions may not be always possible, but there are ways to minimize your likelihood of falling prey to bad advice.

Refrain from making major decisions until you are in a relaxed state and can clearly reflect on the matter at hand.
Avoid making a quick decision or obsessing over details. Using a metaphor from golfing, rather than focusing on the endless details of the perfect shot — such as the correct club, proper grip, turning your shoulders just so, and so on — it may be more helpful to focus on the more important outcome: where you want the shot to land.


High Stakes Decision Making An HBR Insight Center




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