Bigger isn’t always better

From Company of One: Why Staying Small Is the Next Big Thing for Business by Paul Jarvis:

I like reading things that are not about medicine and seeing what lessons cross domains and apply. The premise of Jarvis’ book is that growth for growth’s sake is a terrible business model for many businesses and especially the many people that run them. It’s okay to be big, but any decision to grow the enterprise should be an active choice considering all factors and not just the default MO taken from the recent start-up culture of silicon valley.

My wife left her employed university position last year to start a solo private practice, and it’s been wonderful. It’s not hard to see how there are so many downsides to being part of large company or expanding your own business too much. On the former, no control. On the latter, so much time managing the machine that it’s easy to completely lose track of why you started the practice and what you liked about it.

But here are four passages that also resonated with me as a physician and educator:

Miles Kington, a British journalist, reportedly said that “knowledge is knowing that a tomato is a fruit. Wisdom is not putting it in a fruit salad.” We should never assume that having an abundance of knowledge is the same as having an abundance of wisdom.

This is the problem with equating performance on a knowledge assessment like a high-stakes multiple-choice examination with real-life competence. Knowledge is important, but it doesn’t mean you can perform in your field.

More isn’t better—better is better. There are advantages to putting in the time and effort to master a skill, but there’s also a great need for balance.

“More isn’t better” is a real truism for so many things in our world. We should question whenever something or someone simply wants more of us: more hours, more years of training, more free labor, more notches on the CV belt. It’s not necessarily that the “more” is inherently bad–it almost never is–but that doesn’t mean it’s worth it.

Sukhvinder Obhi, a neuroscientist at McMaster University, coined the term “power paradox” to describe what happens when we gain power through leadership: we subsequently lose some of the capabilities we needed to gain it in the first place—such as empathy, self-awareness, transparency, and gratitude.

The power paradox explains much of the bullying we see within strict hierarchies: how excrement rolls downhill from the top of a poorly-run organization all the way to the youngest least experienced students who are just doing their impressionable best to insulate themselves from the worst of indoctrination as they grow.

[Cal Newport, author of So Good They Can’t Ignore You] believes that we need to be craftspeople, focused on getting better and better at how we use our skills, in order to be valuable to our company and its customers. The craftsperson mind-set keeps you focused on what you can offer the world; the passion mind-set focuses instead on what the world can offer you.

There are some people who in life (or medical school), are confident they know exactly what they want. They are passionate about dermatology and orthopedic surgery. That’s great.

But I don’t think there’s anything wrong with the rest of the world, those who simply don’t know or seem to be missing that “passion.” I agree with Newport that passion is something you can grow through competence and the craftsmen mentality. There are no perfect jobs or fields. There are good and bad aspects to everything, and suggesting otherwise drives so much anxiety in the specialty and residency-selection process.

Success has more to do with you, your goals, and your perspective than it does with exactly what box you place yourself in.


What Money Buys

From How to Think About Money by Jonathan Clements:

First and foremost, money buys time and autonomy. Secondarily, it buys experiences. Last, and least, it buys stuff, and more often than not, the stuff we buy makes us miserable.

Most people live their lives with these in the opposite order, but Clements is absolutely right.

You don’t have to be a FIRE-fanatic to realize that setting up your professional life, spending, and saving to optimize for number one is the winning strategy.

Simple Sabotage

Simple Sabotage: A Modern Field Manual for Detecting and Rooting Out Everyday Behaviors That Undermine Your Workplace is a book inspired by a real World War II CIA field manual called “Simple Sabotage” that was written to help “guide ordinary citizens, who may not have agreed with their country’s wartime policies towards the US, to destabilize their governments by taking disruptive action.” You can read the declassified original document at that link.

It’s short and fascinating and much of it is timeless. Operationally, it functions as a “how-not-to” for creating an efficient organization. The CIA’s top 3 takeaways:

1. Managers and Supervisors: To lower morale and production, be pleasant to inefficient workers; give them undeserved promotions. Discriminate against efficient workers; complain unjustly about their work.

2. Employees: Work slowly. Think of ways to increase the number of movements needed to do your job: use a light hammer instead of a heavy one; try to make a small wrench do instead of a big one.

3. Organizations and Conferences: When possible, refer all matters to committees, for “further study and consideration.” Attempt to make the committees as large and bureaucratic as possible. Hold conferences when there is more critical work to be done.

These points were once felt to be a great way to sabotage Nazi Germany, but they seem to have been voluntarily taken up by most modern American businesses.

A good example from the book is the “obedient saboteur,” someone who–by doing exactly what he’s told to do–is actually making things worse:

This problem can be particularly acute in organizations with a culture of “continuous improvement.” Continuous improvement is a business philosophy created by W. Edwards Deming in the mid-twentieth century. This philosophy thinks of processes as systems and holds that if each component of the system constantly tries to both increase quality and reduce costs, efficiency and success will follow. But taken to an extreme, even continuous improvement can lead to sabotage.

One company we know had a call center manager driving his team to move from an average pickup speed of 1.4 rings to 1.2 rings. The division head asked, “How often do callers abandon us after only 1.4 rings?” “Almost never,” he was told. “Virtually no callers who actually intended to call us hang up before the third ring.” Yet the call center manager persisted in trying to ensure that all calls were answered more quickly each year. Why? Because getting the phones answered quickly was his job—by definition, quicker was better. He never thought to question whether he had crossed the threshold where process had overridden outcome. He had become one of the Obedient Saboteurs. If you asked him why he was trying to lower pickup times, he would tell you that faster pickup means improved customer experience. That’s true—but the threshold is three rings. Once you get below three rings, faster pickup times don’t continue to improve the customer’s experience anymore.

The problem we see, time after time, is that nobody bothers to go back and tell the call center managers of the world to go continuously improve something else.

To keep this kind of sabotage out of your group, step back and conduct a formal review of any continuous improvement programs you have in place. If they aren’t relevant anymore, pull the plug.

Also see: measure what matters.

To fight back, ask yourself:

What is the stupidest rule or process we have around here?

What are the three biggest obstacles you face in doing your job?

If you could rewrite or change one process or procedure, what would it be and why?

A lot of quality improvement isn’t real:

It’s adding clutter. It’s replacing content with process.

We should be just as ruthless when evaluating quality measures and metrics as we are with the fail points that inspire them.

Studying during residency

Here are some questions I received a long time ago about studying during residency:

  1. Do you have any thoughts on studying to become a better doctor?
  2. What and how do you study when not preparing for some fun standardized test?

The easy answer for the latter is that in our modern system of medical education and board certification, you’re always preparing for a fun standardized test.

But I think the real answer to both of these questions to make it about your patients as much as possible.


You should always consider a broad differential and use real patients as opportunities to consider and learn about alternative diagnoses. If you have the motivation, consider further broadening your differential or treatment considerations unnecessarily just to have a relevant excuse to learn more about given topics. Think “I know it’s not disease X, but what if it was?”

Grounding as much learning as you can with patient care will give you the broad foundation you need in your field to build on when new things come along. But on top of that, linking up the information you learn from resources and articles with real live patient memories gives that information more staying power and helps you fight against the forgetting curve.

In medical school, you are hyper-directed in the content you must master, though in many cases toward low-yield material and wasted energy. In residency, you have more leeway toward becoming an expert in things that will directly impact your practice.


I think for many residents it’s generally difficult to “study” in the medical school sense of systematically sitting down with a book or resource without a test looming in the near future. You’ll have the in-service, which you can use as motivation for dedicated review and MCQ fun, but preparing for your patients/daily activities is something you can do continually and, when done aggressively, can cover a large fraction of the relevant material. You may find relevant book chapters helpful on occasion, but squeezing in UptoDate articles and occasionally reading their references, the infrequent Google Scholar/PubMed search, and reading up on the next day’s procedures/surgeries (or the equivalent for your field), are going to work well in general.

I do think that Anki style flashcards and question banks are still good tools. If you have rotations that contain relatively well-defined material, these may even be straightforward to consider and implement on a schedule. In radiology, for example, it’s pretty easy to (at least plan) to read a book on chest radiography and do the chest RadPrimer MCQs on a dedicated chest rotation.

You may need to give yourself a long-term curriculum to work through, whether that’s guided by a commercial question bank or just following the table of contents of a gold standard textbook.

The Crux

The real limitation here is time and energy. Residency is busy. Call shifts can be brutal, and by the time you recover, you’re on call again. You may have a spouse who needs support and children who deserve a parent. And people keep trying to dump boring research projects on you. Sometimes, something’s gotta give.

But what I would say is that you’ll be more able to learn efficiently if your outside-work-life is harmonious enough that you can be fully present for your daily work. That part is almost non-negotiable. So before you guilt yourself for not studying enough at home, make sure you’re doing the things that you need to in order to recharge your battery to be a thoughtful physician for your patients. The trite lines with all the burnout talk out there is that you need exercise, eat healthily, and spend time nurturing your meaningful relationships. And you know what? That’s probably a good start.

Most of the things that really have an impact will come up as you engage actively with patient care, but some of the other BS will only come when its time to review for that next standardized high-stakes exam.

Ultimately, you caring about your patients as individual human beings and paying attention are the two most important things you can do to provide good care and to learn.