Book Review-Quiet: The Power of Introverts in a World That Can’t Stop Talking

Terri and I give a talk on conflict de-escalation and resolution with great regularity. One part of that talk is about the Myers-Briggs Type Indicator (MBTI) and specifically the introversion-extroversion scale. I – from the front of the room – ask the audience to predict whether I’m an introvert or an extrovert. Rarely do I hear introvert. In this context, it makes sense; but in the context of reading a book and writing a review each week, it doesn’t. As an introvert who lives in an extroverted world, I felt like I needed to read Quiet: The Power of Introverts in a World That Can’t Stop Talking. In part, I needed to understand the world and how extroversion was valued, but I also needed to understand myself and how I could maintain this disconnect between a speaking personality and a reflective one.

Being Sensitive

Being a sensitive person isn’t said as if it were a strength or virtue. It’s said with an air of disdain for the fact that you can’t adapt to the world more easily. It’s said as an accusation of a character flaw rather than the positive capability that it can be. This is at the root of the conversation between introverts and extroverts, because our degree of sensitivity has a high correlation to our introversion – or lack of it.

It seems the answer to why we’re introverted vs. extroverted may lie in our desires to regulate the amount of stimulation that we’re getting. Introverted folks tend to be more sensitive and therefore use quiet, isolation, and reflection to regulate their stimulation to a comfortable level. Extroverts, conversely, tend to be less sensitive and therefore need more excitement and interaction to reach their ideal levels of stimulation.

Culture of Character

My family connections run back to Chautauqua, New York, where a religious training center was started that eventually radiated out speakers to lecture on literature, science, and, of course, religion. It was the late 1800s, and it was a time when there was a “culture of character.” What you did in private was more important than the impression you made in public.

The character of a person was the very fabric of the nation, as people didn’t aspire to be famous but instead devoted themselves to being defined by their actions. It was a time of rural ruggedness and of hearty work to keep the hearth warm. There wasn’t time for such luxuries as caring what other people thought of you. You spent your time fighting off the wilderness and providing for your family.

Culture of Personality

At the heart of the transition from culture to personality was a young man named Dale Carnegie, or at least that is what he changed his name to. His parents expected him to become a teacher or a preacher. They didn’t anticipate that he would descend into the role of a salesperson. They thought this was beneath the moral fiber of the child they raised. But the times had changed. By the early 1900s, more people were living in cities, the threat of death was further from people’s minds, and there was a need for people who could sell.

The transformation had started, and Carnegie was at the center of it. Instead of honor and reputation, people were valuing charisma and enthusiasm. We had transitioned from interested in how we behaved in private to how we behaved – or at least were perceived – in public.

Take Me to Church

The evangelical movement may be losing steam. John Dickerson’s book, The Great Evangelical Recession, cites data that indicates that fewer people are going to church. More people are describing themselves as spiritual but not religious. However, the rise of evangelical churches transformed the church experience. Churches today are becoming more show and involvement with fewer opportunities for contemplation and reflection. We’re entertained by feature soloists and engaged in group community through singing.

For me, it barely registers. I recognize that it’s a show – perhaps the right show and a necessary one, but a show nonetheless. For someone who has already learned how to adapt to the needs of a world that is more extroverted, this seems like a little thing; but to those who are desperately seeking refuge from the storm that we call life, it can be easy to see how one more adaptation may be too many.


One thing that I’ve learned not to pray for is patience – because God doesn’t give it to you, he teaches you patience. Patience is an underrated virtue that somehow got lost in our rush to the velocity of our new world. Einstein was patient and persistent. So was Edison and his thousand attempts to make a lightbulb. However, in today’s world, we rarely reward those who toil in obscurity. The culture of personality doesn’t value patience like the culture of character did.

Introverts are, on average, more patient. They’ll stick with it a little longer. They’ll have a bit more grit (see Grit). Their internal interests drive them towards figuring out how things work, and once they’ve figured out how things work, they can create unique solutions to problems that others can’t find.

Stretch Our Strengths

Introverts can often adapt to the world around them, finding ways to fit in, but it has a cost. It’s possible to be in a situation more suited for an extrovert as an introvert. It’s not that it’s not possible – as the introduction to this review indicated. The tricky part is that introverts can only do this for so long. They’re putting on a show, and the show has a cost.

First, when the introvert’s internal resources are depleted (see Willpower), they won’t be up for an extroverted experience. Second, they’ll need recovery time. Terri and I, though rarely lacking in a conversation, will find that, post-presentation, we often sit in near silence so that we can both recover. (She’s an introvert, too – just not as strongly as I am.)

We know that, in many ways, we have a natural “set point” that we seek. We can, with conscious effort, reach to heights of extroversion – but not when we’re exhausted. Fitting into an extroverted world requires willpower – and that isn’t always available. Experts believe that we can stretch into uncomfortable areas – but only so far. Like a rubber band, we’ll keep coming back to the place that is more natural to us.

Introversion Is Not a Disease

Ultimately, introverts need to learn to accept the values of their nature. It’s introverts that allow us as a civilization to accomplish great things. Our extrovert friends and relatives need to accept us for who we are and recognize our values. That isn’t to say that there isn’t value in the gregarious. Rather, it’s valuable, just not essential. Love is essential. Gregariousness is optional.

If you’re an introvert, get some Quiet – and take your power.

Book Review-Eight Dates: Essential Conversations for a Lifetime of Love

Hollywood makes it look easy, whether it’s jumping from a building to a rope ladder hanging from a helicopter or it’s building and sustaining a lifelong love – at least as much of the love as you can fit into a two-hour movie. Just because they make it look easy doesn’t mean it is. Having a high-quality and deeply intimate relationship takes work. That’s something that the Gottmans know about – not only personally but in their work as well. Eight Dates: Essential Conversations for a Lifetime of Love is a roadmap for building and maintaining a lifetime of love.

At its heart, the book shows a way to prioritize each other and hold the eight conversations every couple should have at least once – if not on a regular basis.

Requiring Vulnerability

Identifying what keeps people together and what drives them apart is what John Gottman has been doing for decades. As I mentioned in my review of The Science of Trust, Gottman is distinguished by his capacity to predict divorce after a short few minutes of argument. His criteria for the way couples manage their conflicts are very predictive of how likely it is they’ll be able to stay together. So, when he says that vulnerability is required for a lifelong relationship, it’s worth perking up your ears.

To get to vulnerability, we’ve got to make two stops first. The first step is trust. I’ve written about trust and its relationship to vulnerability extensively. The most recent coverage is in Trust=>Vulnerability=> Intimacy, Revisited. The short version, for our context, is that trust is the belief that we can predict someone’s behavior enough that the chances of betrayal are low. When we predict that the other person will have our best interests at heart, we develop a perception of safety. This perception of safety allows us to become vulnerable. So, the stops on our way to vulnerability are trust and safety.

Requiring Effort

John Gottman calls the moments when you can make the choice to lean into your love or be selfish “sliding door” moments. In the response for a bid for affection, you have the choice to make to do what you want – or respond to the bid and pour into your relationship. Sliding door moments are the choice between what we want in the moment and the long-term health of the relationship. That isn’t to say that we should, or even could, make the decision for love every time. It’s always possible that we’re too tired, too sore, or too distracted. However, it’s the effort it takes to make these choices routinely that builds relationships up.

Making the decision to turn into your relationship isn’t always natural. It’s not the easiest choice. It’s a decision to put your relationship first, because you know that good relationships nurture and sustain you when things get difficult.

Whenever you’re putting effort into anything, there’s a background accounting happening. Is the effort I’m putting in worth the results I’m seeing? While we can defer seeing results, ultimately, the calculus that happens is deciding whether the results are worth the effort. (See Relationship Calculus for more.)

ualities and Characteristics

The Gottmans share six characteristics that seem to be found more often when successful couples are speaking of their marriage:

  • Fondness
  • Affection
  • Admiration
  • We-ness (vs. separateness)
  • Expansiveness (vs. withdraw)
  • Glorifying the struggle

I know plenty of couples whose marriages work for them but in which there is very little “we” and a lot of “I” space. They enjoy their time together, but that time is small and secondary to their individual lives. While it seems to work for them, it doesn’t work well for Terri and me – and the Gottmans seem to believe it’s not the best approach.

For the record, Terri and I get to work together, both literally and figuratively. Her desk is right next to mine. We speak together. We write together. We dream together. It seems like that is important.

Expansiveness is an interesting aspect – it’s “Yes, and…” It’s amplifying each other’s perspectives rather than negating them. It’s an attempt to build the other person up rather than tear them down. Our jobs are to help the other person become the best person they can be, and that means supporting them. (See my review of Group Genius for more on improvisation and “Yes, and…”)

Finally, I can say, personally, that Terri and I feel like we’re on a mission together. We’re struggling – to have a great marriage, to raise children, to build a business, to eliminate healthcare-associated infections. Through all of it, we’re in it together.

The Dates

The eight dates are:

  1. Lean on Me: Trust and Commitment
  2. Agree to Disagree: Addressing Conflict
  3. Let’s Get It On: Sex and Intimacy
  4. The Cost of Love: Work and Money
  5. Room to Grow: Family
  6. Play with Me: Fun and Adventure
  7. Something to Believe In: Growth and Spirituality
  8. A Lifetime of Love: Dreams

Each date is laid out with a guide to how to be successful. Everything from where you should be and what to bring are included in the guide to give you the best chances of success. There’s no guarantee that you’ll be able to successfully navigate the sometimes difficult conversations, but at least with the guide, you’ll handle some of the big things that trip people up and create barriers.

For Love of Money

While I have great respect for Gottman and agree with most of what he shares, there’s one area where I’ll disagree about the root cause. The research says that money is one of the top five reasons couples fight. I’ll agree that it shows up this way, it feels this way, and it may even be the content of the conversation. However, I believe that couples disagree about money because of a difference in values.

It’s not that they’re in a conflict about money. They both want more income for the family, less expenses, more play time, a more stable nest egg for rainy days or retirement, and so on. They’re quite aligned on all these things. Where they’re not aligned is in their values about each of these in relation to one another. Should we save more money or have more vacations? Should we take stressful jobs with higher salaries – or live simpler lives with a less stressful job?

Those are the real questions at the heart of the fights. The husband wants to buy a new car, because he thinks he deserves it. The wife is concerned about the kid’s college fund, or the fact that they can barely meet their current commitments, or whatever. Similarly, the husband may not understand the new dress that helps the wife feel more attractive.

So, while money is the surface level-issue that’s seen, in my experience, it’s rarely the root cause.

Conflict Apathy

I’ve developed conflict apathy. I don’t go looking for fights. However, I’m no longer afraid of them, either. I don’t worry that there will be hurt feelings or permanent damage. I speak my truth in love and expect that Terri will do the same. That’s not to say we don’t hurt each other – we do. However, we don’t run away from the conflicts because we’re afraid of getting hurt.

We walk through the conflicts, because the view on the other side is better. We walk through the conflicts, because we know if we’re willing to do that, we’ll stay on the same side and work together.

I don’t know if you can build what Terri and I have, but Eight Dates might be a good start.

Book Review-Words Can Change Your Brain: 12 Conversation Strategies to Build Trust, Resolve Conflict, and Increase Intimacy

On the one hand, there’s plenty of research that our memories aren’t stored in words, they’re stored in concepts. There’s the awareness that most of communication – particularly emotional communication – is done with body language. On the other hand, there’s Words Can Change Your Brain: 12 Conversation Strategies to Build Trust, Resolve Conflict, and Increase Intimacy. We know that words do matter. That’s why there are marketing copywriters and political speech writers who spend their entire careers trying to get into our head and shape our thoughts.

We know that our emotions can change the expression of our genes (turning them on or off). We know that our words can trigger our emotions. As a result, we can unleash the power of our genes through our words and how we interact with others. It’s powerful stuff that most people have never been trained on nor even considered. However, considering how we can communicate with others is perhaps the greatest power we can wield.

The History

The compassionate communication approach that Andrew Newberg and Mark Robert Waldman explain in the book grew out of work helping couples build intimacy and resolve conflicts, but it has become a tool that has been used by business and environments far from the bedroom.

The good news about this history is that it means the strategy was designed with the awareness of the most highly charged conflicts that exist. The bad news is that the parties in these types of relationships are highly motivated to resolve their conflicts. As a result, the strategies that are proposed sometimes are overly prescriptive and aren’t practical in business situations. While they may be effective at limiting bad behaviors in intimate relationships where the conflicts are already well known, requirements like limiting all talking to 30 seconds or less may not work well in the general context of a business conflict, where there is a higher intellectual and lower emotional component.

In the interests of full disclosure, we teach conflict de-escalation and resolution. (Visit for more.) As a result, I’ve developed some strong opinions of what can – and can’t – work in the real world. We teach that conflict isn’t good or bad – it’s both. We can get good conflict when we learn and work through the disagreement and bad conflict when we build resentment and fail to take others into account.

That being said, there’s a lot of good material here that can add value to resolving any conflict.

The Twelve Strategies

The twelve strategies recommended by Newberg and Waldman are:

  1. Relax
  2. Stay present
  3. Cultivate inner silence
  4. Increase positivity
  5. Reflect on your deepest values
  6. Access a pleasant memory
  7. Observe nonverbal cues
  8. Express appreciation
  9. Speak warmly
  10. Speak slowly
  11. Speak briefly
  12. Listen deeply

Let’s walk into each of these and provide additional supporting references.

1. Relax

Stress changes the way we react. Drive shares how stress focuses us and prevents us from considering all our options – and considering all our options is exactly what we need when we’re in a conflict. More than considering our options, stress changes our responses. When we’re afraid (stressed), our brain is actively looking for attacks and that can cause us to perceive the other person’s words as attacks. (See Thinking, Fast and Slow for cognitive biases and how they shape our thoughts.)

2. Stay Present

As Sherry Turkle explains in Alone Together, we’re more technologically connected and more personally disconnected. The suggestion for difficult conversations is to stay present in the moment. (Alternatively, Vital Smarts calls difficult conversations “Crucial Conversations.”) Perhaps my favorite way of expressing this is the way John Gottman describes it as “emotional attunement” (see The Science of Trust for more). If you find that your mind is starting to wander because the other person isn’t communicating fast enough for you, you may find that matching your breathing to the other person’s provides enough stimulation to keep you focused and at the same time cultivates that emotional attunement.

3. Cultivate Inner Silence

If you’re looking for outer peace, you’re likely to need inner peace. You can’t give what you don’t have, and without inner peace, you don’t have peace to offer. Perhaps the best expression of how to create inner peace comes from the Dalai Lama in his book, An Appeal to the World: The Way to Peace in a Time of Division. You may also find that Mark Epstein’s The Trauma of Everyday Life provides great advice for using meditation to create a sense of inner peace.

4. Increase Positivity

Whether it’s John Gottman’s recommendation of five positive comments for every one negative (see The Science of Trust) or you prefer Barbara Fredrickson’s three-to-one ratio (see Positivity), being positive helps in a conflict. It encourages the other person to be positive, too, and that may be all the lubrication necessary to resolve the conflict. Positive people are just more likeable.

5. Reflect on Your Deepest Values

Steven Reiss, from his research, came up with 16 basic motivators. (See Who Am I? and The Normal Personality.) Jonathan Haidt came up with six foundations of morality. (See The Righteous Mind.) Strength Finder has its aspects (see Strengths Finder 2.0). These and many more tools are designed to give you an opportunity to learn more about yourself and what matters most to you. While this is important to knowing who you are and becoming emotionally stable, it does little to serve you in the moment. (You may want to see Emotional Intelligence or Emotional Intelligence 2.0 for more).

We find a better exercise is to work through the means and ends. That is, in a conflict, you want something. It’s important to understand whether that is the end that you really want or only a means for you to reach the end you want. For instance, you may want freedom and see a car as a way of getting it. If you don’t realize that the car is just a means to the ends, you may get hung up on getting a car when any solution that leads to freedom is acceptable.

6. Access a Pleasant Memory

Paul Eckman spent a lifetime studying the face and how we convey our inner states to one another, both intentionally and unintentionally. (See Nonverbal Messages and Telling Lies for more on his work.) It turns out we convey quite a range of emotion with our faces, and, through the magic of mind-reading, others pick up on this. (See Mindreading.)

Positive or pleasant memories signal to our face that we’re happy, and that is conveyed to others – and ideally puts them in a similar state. The result of this can be a greatly reduced sense of friction in a conflict. Rick Hanson explains how to rewire our thinking and to be more positive, happy, and pleasant in his book, Hardwiring Happiness.

7. Observe Nonverbal Cues

While mirror neurons operate at an unconscious level, it’s important to actively observe non-verbal cues to surface our awareness of what the other person is thinking or feeling. John Bowlby and Mary Ainsworth studied attachment styles of children and their mothers. They found that parents who were more appropriately attentive to their children produced children who were more secure and able to function in the world. (See Daring to Trust.) This is consistent with the research with rats and the mothers who licked and groomed them more, creating rat cubs which were more likely to explore. (See How Children Succeed.)

Motivational Interviewing, a technique that is commonly used to help people make difficult changes, is built on the foundation of careful attention to what is going on with the other person – something that we could all focus on when we are navigating a conflict.

8. Express Appreciation

Primal Leadership shares Zig Ziglar’s quote, “Your attitude, not your aptitude, will determine your altitude.” How To be An Adult in Relationships calls it an “attitude of gratitude.” It’s a desire to appreciate the other person and to communicate that. Focusing on the things you like or appreciate in the other person can help you both find common ground in your respect for one another.

9. Speak Warmly

Working with recovery groups taught me the difference that tone can make. Twelve-step meetings start with “Hello my name is…” and are totally shaped not by the words that are said but the tone and tenor they’re said with. (You can see more context in Why and How 12-Step Groups Work.) The tone and tenor of the words spoken during a conflict can convey more than the words themselves, so speaking warmly can be a powerful message to the other person that you want to find a way through the conflict. (See Trust Me for more.)

10. Speak Slowly

It was a pre-conference session years ago with my friend Eric Shupps that helped me to understand the value of speaking slowly. I’m from the Midwest, so my typical speaking speed is laid back. Eric is from Texas, and he sports a slightly more relaxed and slower speech with only the slightest hint of a southern drawl. During a break at the session, a young woman came up and said that she couldn’t understand me. Eric and I were slightly confused, as we’re both used to getting the occasional comment about his speech. As we dug deeper, we found out that we were (and particularly I was) speaking too fast.

The truth of the matter is that we (I) crammed way too much content into the day, and we were speaking fast to get through all of it. Some of the students were grateful for the compressed experience – but others couldn’t keep up.

In our conflicts, we want to speak slowly to create space for the other party to process what we’re saying carefully. It doesn’t do us any good to communicate everything quickly if the other person doesn’t understand.

11. Speak Briefly

There’s an old saying (associated with Mark Twain) that gets compressed to “I would have written a shorter letter, if I had more time.” That seems to make no sense. Longer would give more time to write. However, it’s more accurate to say that we can refine our thoughts and write less if we’re given time. In a conflict, it’s paradoxical that you can get to a resolution sooner by pausing to consider your reply after the other person is done speaking. If you’re willing to allow some pause before speaking, you may find you speak less, the other person understands more, and the conflict is resolved sooner.

The “protocol” for compassionate communication calls for 30 seconds of communication at most – which I find more restrictive than necessary. 30 seconds is approximately 75 words – not much can be conveyed in that. The good news is that it prevents issues from stacking and makes it easier for the parties to align. The bad news is that it takes a lot of cycles.

12. Listen Deeply

Focusing on what the other person is saying and trying to deeply understand is key to resolving the issue. That means not working on your response until they’re done – and the opportunity to create a delay in the conflict. Delays are okay on multiple levels, because the slower the conversation, the less likely it is to be perceived as a threat.

Dispassionate Observation

The master-level trick for managing conflict is to find a way to be a dispassionate observer. Instead of reacting to what the other person is saying with fear and concern, you watch as if you’re an observer who is watching the conversation unfold. This level of detachment is difficult to accomplish but powerful. Because you’re not in the middle of the conflict, you don’t have to worry about whether the other person wishes you harm or not.

This frees your mental capacity to focus on creating solutions that may accomplish what both you and the other party really want.

Perceived Safety

The dispassionate observation works because the observer is safe. As explained in Trust=>Vulnerability=>Intimacy, Revisited, our need for the perception of safety drives our ability to connect with others. The greater degree of safety we feel, the greater trust we generate and, in return, the greater degree of feelings of safety we get back. It’s a cycle that starts with getting off our heels and into a more relaxed stance (both figuratively and literally), so that we can be open to feeling safe and helping the other party feel safe as well.

Rescripting Memories

One of the things that trips most folks up in a conflict that goes sideways is that you’re not really discussing the situation of the current moment. The responses from the other person (and your own) don’t make sense when measured by the item of dispute. Instead, we’re tripping on emotional landmines left by the process of growing up. (See Step, Step, Click for more on emotional landmines.)

Another master-level trick is to work on your memories, to change them into memories that don’t create emotional triggers. Our memories are much more malleable than we believe. (See Science and Pseudoscience in Clinical Psychology for more.) And we have the capacity to change the way we perceive threats. Albert Bandura was famous for helping those with snake phobias overcome them by providing progressively higher perceptions of self-efficacy. (You can learn more about Bandura’s work in Moral Disengagement.)

Maybe you can use the words in Words Can Change Your Brain to rescript the way you approach conflicts.

Book Review-Reversing Burnout: How to Immediately Engage Top Talent and Grow!

It’s surprising how many books there are on burnout. It seems like every day I get introduced to someone else who has a book either directly on burnout or with a subtitle including the word burnout. When a friend introduced me to Peter Atherton, I hadn’t heard of his book, Reversing Burnout: How to Immediately Engage Top Talent and Grow! However, I’m glad that I did learn about the book, both because of its ability to share Peter’s story as well as the insights it can offer folks who are struggling.


Like many of his peers, Atherton connects burnout to stress. While I disagree with this framing, I understand the perspective, because stress does, in an indirect way, contribute to burnout. When Terri and I did the research for Extinguish Burnout, we discovered that the key was that feeling of inefficacy, what Martin Seligman and Steve Maier would have called “learned helplessness” decades ago and more recently recognize is the lack of learned control. (See The Hope Circuit for more.) For us, it’s about whether our expectations of ourselves and our perceived results are aligned when we are triggered into evaluating them. When they’re not aligned, we feel like we’re ineffective, we have no control, and burnout sets in with its exhaustion and cynicism.

Stress is a contributor in that it triggers a set of reactions that are like a payday loan. The person feels like they need their entire capacity to fight today’s fight and the result is shutting down the immune response, digestion, and anything else the body feels it can defer to another time. The problem is that restarting these processes and getting them back into homeostasis takes more energy than just leaving them running. The result is less long-term efficacy for a bit of short-term efficacy. Living in a constant state of stress has been linked to numerous health issues, but its role on burnout is simply the reduced overall efficacy. (See Why Zebras Don’t Get Ulcers for much more on the impacts of stress.)

Overloaded Becomes Overwhelmed

At some level, the kind of biological stress that triggers the literal stress response in humans isn’t the kind of stress that Atherton is speaking about. Instead, he’s talking about the kind of gap between expectations and results. When you’re unable to answer all your emails, address every customer concern, take care of all the employees, etc., you feel the weight of the gap between your expectations that you can do it all and the reality that you can’t. The perception that we should be able to do it all keeps us in a perpetual state of being overloaded. Instead of prioritizing or delegating, we continue to believe that we can do it all, even when we can’t.

We all get overloaded at times. It’s a part of the normal ebb and flow of life. It’s not the idea that we’re overloaded that’s interesting, it’s the idea of what we do when we’re overloaded that’s interesting. Atherton’s point is that when we remain overloaded, we become overwhelmed – which leads to the inefficacy that we believe is at the core of burnout.

The solution, we believe, to managing the fact that you are overloaded is to ground yourself in reality. It’s unreasonable to believe that you’ll always be able to keep up. It’s unreasonable to believe that you’ll handle every complaint. You can resolve the problem of being overloaded by letting go of things you don’t need to do – or simply can’t do. You recognize these things by connecting yourself with what is reasonable for a human to be capable of.

Detachment and Disengagement

Atherton spends some time connecting burnout to disengagement and explaining what he calls the “burnout-disengagement cycle.” Here, too, the underlying message seems to harken back to learned helplessness. Of course, disengagement, like burnout, is bad, but one of the things that can prevent burnout, detachment, is strangely close to disengagement linguistically, and because of that they seem to be often confused.

Disengagement is giving up or shutting down. Detachment is accepting the limitations you have in controlling outcomes. While we have influence over the outcomes, the reality is we’re rarely in true control. There are always external circumstances that can interfere with our ability to do something. (See Resilient for more on detachment.)

The truth is that our world is probabilistic. We like to think A leads to B, but, in reality, A only leads to B in 90% of the cases. In this situation, it’s denying reality to say that anything we could do could truly cause an outcome we desire. (See The Halo Effect for more on the probabilistic nature of life.)

The best place to land is concerned for the outcomes, committed to our own behaviors, and, in the end, letting go of the poor outcomes we couldn’t prevent. We continue to care for the hurting, while not blaming or shaming ourselves because we couldn’t prevent it. (See our video post Kin-to-Kid Connection: Understanding Shame and Guilt for a video on shame and guilt, Dare to Lead for a collection of Brené Brown’s work on shame and guilt, or my review of I Thought It Was Just Me (But It Isn’t) for a shame map.)

Shifting From “Me” To “We”

At the beginning of our careers (and our lives), we’re naturally concerned with “me.” We’re looking for the best job for us. We’re focused on us. Gradually, as we mature, we broaden our scope from “me” to “we,” initially defining “we” as our significant other and expanding it gradually as children are born. However, at some point, we make an even bigger leap from “me” to “we” when we expand our considerations beyond our immediate or extended family and instead focus our interests on our ultra-extended family in the form of the entire human race. Perhaps, you may say, that most folks never get to a concern for the entire human race. However, this is the path we’re on. (See The Evolution of Cooperation for more on the thinking about why this is true.)

Many of us built careers around some technical skill, and some of us became successful because of it. That success reduced the degree of challenge in our career, and our success plus the passage of time makes it possible for us to see that we can do more for our world than just deliver the technical skills. We get restless and want to do something more. Decades ago, it would have been called a midlife crisis, and it would have led to a divorce and remarriage – and a sports car. However, today it can mean finding a path to help others.

Fear of the Same or Fear of Missing Out

We’re afraid that nothing will ever change. We’re afraid that what we have today is all there is. Fear rules our lives. On the one hand, we’re afraid we’ll be stuck or we’re missing out on something. Our friends’ Facebooks are littered with vacations, parties, and accolades. We wonder why we can’t have what they have.

We forget that, from their point of view, our feeds on Facebook are glamorous too. We post our trips to conferences and the customer success stories. We don’t post the red-eye back from Seattle leading directly into preparation for the wedding of a child and the pain caused by a lack of sleep. No one wants to hear that, it’s not happy. So, we don’t post it, and they see only the trips and the weddings. They see the highlight reel we post, not reality.

We see the same thing from them, just the highlight reel. All good, no bad. The result is we feel like they’re doing things that are better than or more interesting than we’re doing, but the truth may be very different.

Making the transition from a successful career to one of uncertainty for the good of “we” at great personal risk to “me” isn’t for the faint of heart. It’s challenging on nearly every level – but it can be equally rewarding.

Golden Handcuffs are Still Handcuffs

Too many people become trapped in their success. They are being paid “too much.” They enjoy the symphony tickets, the new cars, and the mansion they call home. The result is the fear of letting it all go to respond to the calling of our heart and help others can speak too loudly, and we can turn away from that calling we all have to help our fellow men and women.

The good news is that golden handcuffs often create a margin – the ability to work on your own projects. That margin is fertile ground for rediscovery and regrowth that may imbibe us with the courage to conquer those fears. Maybe you’ve got enough margin to consider Reversing Burnout and finding your new mission.

Book Review-The Secret Lives of Adults: Your Seven Key Relationships – and how to make them work

Who are we really? Are we the person we are when we’re with friends? Or is it that we’re the person we are with family? Or perhaps we’re really expressing our true nature when we’re by ourselves. In The Secret Lives of Adults: Your Seven Key Relationships – and how to make them work, Allison Keating explores the different aspects of our identity.

Seven Relationships

Keating believes we have seven key relationships:

  1. Me, Myself, and I
  2. Mum (Mom) & Dad
  3. Siblings
  4. Romance
  5. Parenthood
  6. Friends
  7. Work

These relationships are how we express ourselves. Fundamental to this is an understanding of how to bring our whole selves to each of these relationships and how to fit these images of ourselves together. I’ve spoken a few times about the need for and power of an integrated self-image. (For just some examples, see Braving the Wilderness, Happiness, The Trauma of Everyday Life, Schools without Failure, Compelled to Control, and Beyond Boundaries.)

Being an Adult

Whatever image we see for ourselves, it should be an adult. Richo speaks in How to Be an Adult in Relationships about what it’s like for us to be the most authentic human that we can be. Keating takes a different approach: instead of focusing on the things we need to give ourselves and others, she seeks to help us better understand ourselves.

We’ve this unconscious assumption that adults must have life all figured out. After all, as a child, we thought our parents were all-knowing and really had it sorted. At least, we felt like this until we became teenagers and suddenly decided we knew more about life than they did – only to return to our beliefs that our parents knew everything when we hit our twenties.

The problem is that this is a false belief. Being an adult means you’re willing to confront the places you don’t have figured out, but few adults I know feel like they’ve got it all figured out. Instead, most of the folks I know, who are brave enough to be honest, know that we’re all struggling to do our best in a world that keeps changing. We hope that our awareness of the world continues to grow.

Relationships Today

As Sherry Turkle explains in Alone Together, we’ve got technology that connects us nearly every moment of every day, but at the same time we’re more alone than we have ever been. We have fewer confidants and fewer real friends, even as the number of our Facebook friends blossoms. Friends are an emotional buffer that allow us to weather the storms of life. Without them, we feel buffeted by the minor challenges of day-to-day life and poorly equipped for all that being an adult means.

Our friends today are less likely to know about the deep, emotional scars we carry with us since childhood and the embarrassment of our past. As a result, the friends we do have are poorly equipped to know when they need to step up and support us.


The pace of progress continues to increase. We’re producing more food than ever before. We can meet our own needs with fewer hours of work than ever in the history of humanity, but we’re also working more hours and harder than even a few years ago. The competition bug has caught us. Social media has turned up the volume on the age-old problem of “keeping up with the Jones’.” We get caught on the hamster wheel of work and keeping up, and we barely realize we’re doing it.

Gone are the days “on Walden Pond,” where a deep thinker could sit and stare at the water and peer into their own souls. It’s easier for us to login and find out what someone else is thinking (or saying they’re thinking) than it is to connect with ourselves and what we truly think, feel, believe, and fear.

The tyranny of this is that it binds us to the hurts of our past. No one seems to know about the hurts. Not our friends. And, buried under layers of denial, not even us. We react to others based on events that we no longer remember.

Knowing and Not Knowing

A Johari window is a simple, two-by-two grid of knowing and not knowing both ourselves and others. It creates spaces where we know things about ourselves that others don’t know, things that both we and others know, what others know but we don’t, and, finally, things that neither others nor we know about ourselves. It seems that, instead of peering into the space where no one knows, we’re more interested in staring at the spot where others know things about us that we don’t know.

We’ve become obsessed with “what do they really think about me?” In an age of political correctness and ethical and moral weakness, we must wonder: is what someone telling me what they really feel? Too often the answer is no, and we know it. But we also know that getting to the real answer may not be possible because of the fears they carry inside of themselves. (See The Fearless Organization for more about fear and its impacts.)


Sometimes, the knowledge that you gain about yourself addresses the limitation – and sometimes it doesn’t. Knowing you have the flu doesn’t stop you from having it. It can, however, inform what you do and how you change your behaviors so that you can get better. With the flu, you may choose to get more rest, but you’ll still have a few days before your body has a chance to recover.

On the other hand, knowing that you are sabotaging your success by a simple behavior, you can stop the behavior and get more success. The amount of action (or inaction) required is trivial compared to the challenge of awareness.

The journey to understand ourselves is filled with both kinds of awareness. There’s the kind that makes the problem evaporate – and the kind that exposes the long path that we have to recovery.


Much of the hurt we experience and react to is said to come from our attachment style. John Bowlby and Mary Ainsworth described the attachment styles as: secure, ambivalent, avoidant, and disorganized. (For more see Daring to Trust.) Of these, only secure attachment was considered to be non-afflictive. That is, people with secure attachment styles have fewer places of harm and are therefore supposed to be less reactive to environmental stressors.

In practical terms, your attachment style isn’t fixed. (See Mindset.) You can heal old wounds by recognizing them and working through them. In effect, we walk towards the pain that we felt, and we resolve it rather than ignoring it. Ignoring the pains we feel leaves us vulnerable to someone else triggering the emotional landmines that we’ve buried. (See Step, Step, Click for more.)

Unconscious Time Travel

It seems that our unconscious doesn’t notice the passing of time. This was hinted at in the movie A Beautiful Mind. (See Incognito for more context.) The point the movie made was that Nash’s friend and the little child that he saw never aged. They never changed as he aged. It’s almost like they were frozen in time. This is an interesting curiosity that could be relegated to a value for dream interpretation until you consider how we respond to hurts.

Our response to hurts is quick and automatic (see Thinking, Fast and Slow for more on how this happens). In that response is no sense of the time that has gone by – or even, to some extent, how the situation has changed. We’re still that frightened little boy or girl on the inside. It’s that frightened boy or girl that’s lashing out. Until and unless we can quiet the pain of that spot inside ourselves and learn to be okay, we’ll never be able to stop the outbursts. Whether we were injured ten minutes ago or ten years, we’ll still respond to similar situations – until we address the core.


Perhaps our greatest fear lies beneath the surface. The fear is that we’ll be or become unlovable. Some memory back before our brains were fully formed warns us that we’re dependent upon others. We hear every criticism as a hint that this fear of being unlovable may be true. Deep inside, we can’t stop the nagging feeling that we may be unlovable and therefore ultimately vulnerable again.

The nagging feeling can be pushed back. It can be kept from surfacing too frequently, though everyone seems to have it surface now and again.

Constructive Arguing

Some people are taught by their environment that they must always be agreeable. Perhaps their family system is predicated on the need for tranquility at all costs. Instead of having healthy disagreements and constructive arguments, hurt feelings are buried until the day that they boil over. Everyone else is surprised, half at the content of the explosion and half that the family member couldn’t keep it together.

In a system where conflict is bad – rather than constructive – it’s hard to make it ok. In other environments, healthy means sharing feelings without being hurtful and arguing about the perspectives and the values but not about the worthiness of the people. As we learn to be better adults, we learn that, to be ourselves, we must be willing to engage in constructive arguing – and we need to learn how to do that well. (Here, John Gottman’s The Science of Trust is great.)

The Cult of Easy

While the need for tranquility may be isolated to some families and some environments, it seems like there is the perspective that things should always be easy. We shouldn’t have to pour our hearts and souls into things, it should just come naturally, like the YouTube star who seems to effortlessly makes millions.

The truth is “Tenacity, hard work and persistence, especially in the face of adversity, are how you succeed.” As we learn to be adults, we learn that adulting isn’t easy. It’s not easy to face the fifth or fiftieth rejection – or the five-hundredth. It’s not easy to slave over something for years or decades in obscurity believing that something will turn any day now. However, it is how success is won, at least for most of us. (See Grit for more.)

Accepting Your Feelings and Frustrations

In the end, being an adult means accepting your feelings – good and bad. That includes the joy and the frustrations. You can’t side-step or ignore your feelings, because they will eventually come out whether you want them to or not.

Feelings are a part of The Secret Life of Adults – and just like the book, they’re worth discovering.

Book Review-Transformational Security Awareness: What Neuroscientists, Storytellers, and Marketers can Teach Us About Driving Secure Behaviors

The first highlight I have for the book is “Just because I’m aware doesn’t mean that I care.” It’s a truth that we first get exposed to around the age of three, when our theory of mind begins to accept that others think differently than we do – or at least they have different information. However, it’s a key challenge to remember when it comes to how to create a security awareness program that works, as Perry Carpenter explains in Transformational Security Awareness: What Neuroscientists, Storytellers, and Marketers can Teach Us About Driving Secure Behaviors.

One of the things that I do from time to time is help some of my friends who work in information security. I’ll spend a few months helping them with some aspect of their systems or their programs, and then I’ll go do other things again. I’ve found that it’s hard for me to personally stay in information security for long, because I don’t want to remain vigilant for threats all the time.

Social Engineering

What’s the most vulnerable part of any security program? The answer is always humans. We can plan the best systems, implement the best hardware and the best software, only to find that a human is responsible for letting people through the back door. How many physical security plans have been thwarted by someone propping open a door, letting someone “official-looking” into the building, or failing to make sure the door is latched behind them? I can say that I’ve walked into buildings that I should have been escorted through simply by grabbing a door before it latched.

I learned about social engineering years ago through Social Engineering. Most of what people would consider social engineering, I’d put in the consultant’s essential toolkit for getting things done without authority. It’s about ways of getting folks to break – or ignore – the rules, and it works.

The Gaps

There are two critical gaps in security awareness that we’re always trying to solve. The first is the gap between knowledge and intention. We all know that we should exercise, get proper sleep, hydrate, and eat healthy. That’s our knowledge. However, few of us would say that it is our intention to do all these things. That is the first gap between what we know and what we intend. It’s further than the distance between knowing and caring – it’s more than caring, it’s deciding that we want to take action.

They say the road to hell is paved with good intentions. Note that it’s not good actions – it’s good intentions. Even if we’ve decided we want to take action towards something, will we actually do it? Many have had great intentions and set their New Year’s resolutions only to decide that their resolution was too much work – some before they even start.

With the two gaps, there’s often a huge gulf between what you’ve taught people and how they actually behave. Some of that may be due to the forgetting curve (that they’ve forgotten since they were taught), but this doesn’t account for the wide discrepancies.

Speaking of Security

When we’re speaking about security, we need to make sure that the messages are personal, emotional, and relevant. I often explain that everyone listens to one radio station – WIII-FM or “What is in it for me?” The result is that if the message isn’t tuned to them and their personal circumstances, it may not be heard.

One of the common challenges when working with messaging in business is that people assume the messages must be dry and devoid of any emotion. Organizations are starting to realize that you have to accept emotions in the workplace if you want a high-performance and high-functioning team. However, the idea that emotions are a useful tool hasn’t made its way to the folks who teach communications at most organization.

Finally, messages about security must be relevant. There’s a signal to noise ratio that people use for determining how much they’re going to pay attention to. The more irrelevant things they experience from you and your team, the less that they’ll pay attention to your messages. For the sustainability of the program, they must perceive things to be relevant to them when you communicate.

Events vs. Environment

Carpenter speaks about security awareness needing to be more than an event. Instead of the annual security awareness training, effective security awareness is continuous. It is, perhaps, punctuated by big events, but, overall, it’s an environment where everyone is reminded about the relevance of their need to be vigilant against threats. When Carpenter describes the difference between what most people do and what is effective, he uses the word “campaign.” However, even campaigns have ends. I prefer to think about how it’s a part of the continuous addition of information into the environment to reinforce the learning.

Lazy Brains

Carpenter points out that we use lots and lots of mental shortcuts for the work we do on a daily basis. Our brains are calorie hogs. They consume 20-30% of the glucose (or sugar, our bodies’ fuel) but represent only about 2-3% of our body mass. (See The Tell-Tale Brain for more.) Because our brains are lazy, we use lots of heuristics (shortcuts) that hackers exploit to get us to do things that we wouldn’t do if we fully considered them.


Carpenter uses the Fogg Behavior Model – which basically states that you need enough motivation and ability to respond to a prompt. The greater the ability, the less motivation is required for a prompt to be effective. We all prompt people to do something. We ask them to do something, and they decide whether they will do it based on their motivation and their ability. This reminds me about how The Psychology of Hope speaks about hope being composed of two pieces – willpower (motivation) and waypower (ability). Kurt Lewin said that our behavior is a function of both person and environment – what we bring with us and the pressures or motivators of the environment. (See Leading Successful Change, Moral Disengagement, and many more for Lewin’s equation.)

The Fogg model does have the benefit of clarity around a triggering event. A latent ability and a motivation will not activate without some sort of triggering event – that could be an internal thought or an external prompt, but something has to start the reaction. Think of it this way: gasoline has a great deal of potential – but that potential is only activated with some sort of a spark.

Facts and Frames

Carpenter aptly points out that one of the biases we all suffer from is that we’ll tend to ignore those facts that don’t fit our frame of thinking. When facts and frames meet, frames will almost always win. Our brains love consistency and abhor inconsistency. When something comes across our awareness, and it doesn’t fit our frame, we seek to find a consistent answer. Given the investment in our frame, the fact is often quickly jettisoned.

The frame further shapes the way we process our environment and how we’re motivated. It’s like walking around with rose-colored – or green-tinted – glasses. We see the world through those glasses – whether we want to or not.

Working with Users

Users may feel like a frustration from time to time, but the reality is that, without them, there would be no need for security or security awareness. We can think that they should know better, that they should keep separate passwords for separate sites and systems, but the reality is we’ve exceeded the reasonable capacity for our users to do the behaviors we think they should do. A typical user might have 100 sites they use in varying degrees of frequency. There’s no practical way to remember that many passwords without the aid of a system.

I don’t know any corporate infrastructure team that doesn’t have some sort of password management system to manage their passwords. Why would we deny users the same tools if we know, as professionals, we can’t manage passwords without a tool?

In our work with our users – I like to call them business clients – we must work with their limitations, or we’ll be constantly disappointed in them and in the success of our security awareness programs.


It’s not supposed to be about emotions. It’s black and white, on and off, true or false. Or at least that’s what we want to believe. As Daniel Kahneman aptly points out in Thinking, Fast and Slow, our emotional, automatic, first response can lie to our thoughtful, rational brain – without us even realizing it. It’s this lying that we do to ourselves that malicious individuals can take advantage of, and it all comes down to emotions.

So, don’t get angry when users let the next malware into the organization; read Transformational Security Awareness so it doesn’t happen again.

Book Review-Burnout to Breakthrough: Motivating Employees with Leadership Tools That Work

Everyone has a backstory. You do. I do. Every author I meet does. Everyone I read has some sort of a backstory that has led them to where they are today. That’s certainly true of Ina Catrinescu. She relates part of her childhood from the former Soviet Union in Burnout to Breakthrough: Motivating Employees with Leadership Tools That Work. She has a unique perspective on the “chains” that bind us. Having moved from the socialist world to the capitalist world, she’s seen firsthand how both worlds have the capacity to demoralize and demotivate people. One was enslaved to an immutable dogma, and the other is tethered to a rat race.


Around my house, the family is quite fond of saying that, if anything can be done, I’ll overdo it. I believe in excellence and have been known to take on some crazy projects. (Like the solar powered mini-barn.) However, I’ve got absolutely nothing on the Japanese, who created a whole word that means “overwork to death:” karōshi. It’s more than a high suicide rate. It’s literally being so encompassed in their work that they’ll keel over at their desks. They’ll work until they simply can’t work any longer.

Not to be outdone, the former Soviet Union taught kids songs that basically translated to, “Your only purpose in life is to work your fingers to the bone, and you better do so thoroughly because the whole country is watching!” While this may not rise to the death toll of karōshi, it’s still a powerful push towards overwork.

In America, we’re subject to our own factors. Our protestant work ethic has us believing that we need to work not to live but rather work to achieve. Achievement, for many, is measured in the cars you drive, the neighborhood you’re in, and the clothes you wear. We work so we can get more things that prove to others that we’re working. As more people work and can afford these things, we must find ways to differentiate ourselves and demonstrate that we work hard.

Productivity has improved 97.5% since 1960, but that hasn’t meant that we work fewer hours. In truth, we’re working as many or more hours today than we ever have. Greater productivity isn’t reducing the number of hours we’re working.

Minimum Income

Communism was a grand experiment. At least in the case of the Soviet Union, it didn’t work out. Another experiment was done in Canada that did work out – until it was stopped. What would happen if you offered people money every month with no strings attached? Would the recipients become lazy and do-nothing, or would they use the money to get back up on their feet? The experiment in Dauphin, Manitoba, Canada did just that. Money was provided to low-income residents with no strings attached. They could continue to receive it for as long as they needed it.

The results seemed positive even though the program was stopped. It seemed like the results were better health, but as of now, the program hasn’t been tried on a broader scale.

Prosperity not Profit

Most organizations measure their results with a balance sheet. It’s net income that matters. However, much like gross domestic product doesn’t capture the full picture of the good we’re doing, profit isn’t the full measure of the organization. (See The Hope Circuit for Gross Domestic Happiness.) Red Goldfish explains how looking at the good you do in the world may be good for your bottom line. Reinventing Organizations focuses on how increasing the level of consciousness in the organization can be an important part of bringing more joy to the individual, the organization, and the world.

More people are trying to figure out how to run their lives with the new bottom line. Instead of it being all about money, it’s about impact. While not everyone is trying to find a way to make the world better, more people are considering it. Given that the roots of burnout exist in the world of caring professions, in which professionals try to “change the world,” it’s no surprise that this idealism, while beneficial to the world, can cause challenges to the psyche of the individual.

Finding Meaning

Finding your “why” is a challenging – and evolving – thing for everyone. (See Simon Sinek’s Start with Why for more.) Despite the challenge, without a sense of purpose, you’re likely to find yourself adrift without a clear sense of what you expect to get done and what you need to be focused on.

Privilege of the Platform

Years ago at an NSA annual event, I heard a comment that has stuck with me. “The privilege of the platform” resonated, because, despite the fact that so many people fear public speaking, it’s still an honor to be asked to share what you know with so many people. The platform isn’t a right, an obligation, a duty, or a task to be done. It’s a privilege. Similarly, management can be seen as a burden or a great opportunity. Robert Greenleaf in Servant Leadership speaks about how leaders serve those that they lead.

When we speak about burnout, we find that we speak about the difference between “having to” and “getting to” do something. It’s obviously a mindset shift, but it’s one that makes a big difference.

Values are not Virtues

Everyone has values. Whether we can articulate them or not, everyone has values that they hold. However, not all these values are virtues. Just because you value something doesn’t make it virtuous. It seems that too many people believe their values are universal values that everyone holds rather than recognizing that we each have our own values and motivators. (See The Righteous Mind and Who Am I? for different ways of learning what values we hold and what motivates us.)

We must accept the reality that others hold different values than we do.

What About Burnout?

There is a lot of good information in Burnout to Breakthrough, but, in the end, I found that I struggled to find the tie-in to burnout. While you may get a lot of good information, I’m not sure how it will help you avoid or prevent burnout.

Book Review-The Burnout Solution: 12 weeks to a calmer you

The recognition that burnout is more than a “job thing” and can impact any area of your life was one of the reasons why the book The Burnout Solution: 12 weeks to a calmer you was interesting. As with most burnout books I’ve read, there’s a lot to agree with – and enough to disagree with.

The Role of Stress

Many people – particularly those who have been led astray by some of the academic literature – like to say that burnout is caused by stress. The problem is that’s an oversimplification of what’s really going on. To understand, we must understand the basics of stress, how we appraise stressors, and, ultimately, the root cause of burnout.

When it comes to stress, I always start with Why Zebras Don’t get Ulcers. I start there because it’s the most complete coverage of stress that I’ve found. It took me three blog posts to do a review of it because the information was that powerful. The short version of stress is that it’s a “payday” loan. It’s a high interest loan against the future, so that you can survive today. When we feel stressed, our body makes choices that work for the short term at the expense of our long-term productivity, energy, and efficacy. One of the things in Why Zebras Don’t Get Ulcers that contradicts The Burnout Solution is that the impact of stress is a reduction in immune system response – not an increase. Research consistently shows that the introduction of steroids (including the cortisol released during stress) makes people more susceptible to infection, not less.

The tricky part about stress is that it’s almost always generated internally. Certainly, there are objective stressors in the environment, but they don’t convert to stress unless our appraisal of the stressor is that we’ll be overly harmed or overwhelmed by it. (See Emotion and Adaptation for more on how we appraise our emotions – including fear, which causes stress.) When we believe that we have all the resources and support necessary to overcome the stressor without any real risk, a stressor doesn’t convert to a stress. Thus, stress is something we generate internally.

The root of burnout is our belief that we can’t be effective. If we can’t manage our stressors, we can’t make progress towards our goals, and we’ll perceive ourselves to be in burnout. Secondarily, the impact of stress is short-term gain at the expense of long-term efficacy, which further deepens the perception that you’re not effective. At some level, stress is coincident with burnout, because the belief that you can’t navigate or overcome the stressors exists in both. However, at another level, stress is just a sidekick, not a cause.

Self-Imposed Demands

When Terri and I talk about the bathtub model in Extinguish Burnout, we explain that demands have a valve, and we can control the degree to which we accept them – even the degree to which we generate them ourselves. It’s one thing to learn to say no to others. It’s another thing to say no to the “shoulds” and “aughts” that happen inside your head.

More than anything, understanding how we view our demands and learning to change our perspective can allow us to hold onto our personal agency.

Impatience is a Reaction, Patience is a Response

When it comes to finding more calm, learning to respond and not react is important. We’re wired with two systems (to use Kahneman’s language from Thinking, Fast and Slow). The first system is quick and instinctual but often devoid of consideration of the long-term consequences of actions. The second system is more contemplative and is a response instead of a reaction.

When we tune our ability to change our appraisal of events, and we can consider them in a larger context, we’re able to be calmer – and, in the perspective of The Burnout Solution, we’re able to prevent burnout. I believe finding calm is an important goal. I even believe that reducing stress will reduce the degree of burnout you’re feeling, but I’m not convinced that solving stress alone will do it. However, read The Burnout Solution and make your own decision.

Book Review-Better: A Surgeon’s Notes on Performance

I’m sometimes a hard guy to impress. Sometimes, I strive for excellence and look for ways to get better, and I forget to appreciate that good is good enough. Maybe that is why I appreciated Better: A Surgeon’s Notes on Performance so much. It certainly doesn’t hurt that I’d previously read and reviewed Atul Gawande’s Checklist Manifesto and Being Mortal. However, in the end, I think what I recognize in Gawande is that passion for making things better, because better is possible.

Medical Advances

From the dawn of medicine until relatively recently, doctors largely did their patients more harm than good. Techniques like bloodletting weakened patients when they needed their strength the most. Sometimes, even when advances were possible to move medicine forward, they were resisted. Ignac Semmelweis discovered the basis for germ theory in 1847 and the need to wash hands after working on cadavers or before helping mothers deliver their babies. Today, it’s positively obvious, but back then, it was unique and different.

There are numerous accounts for why Semmelweis was so ineffective at convincing his peers that germs existed, and that handwashing was sufficient to stop (or at least hinder) their spread. Most of them involve what are described as “personality defects.” Gawande reports that Semmelweis refused to defend or support his germ theory and instead resorted to personal attacks – which didn’t win him friends. (See Mastering Logical Fallacies for some of the techniques that may have made it difficult to take Semmelweis seriously.)

Handwashing and Antibiotic Resistance

Over 150 years after Semmelweis’ discovery, we still struggle to wash our hands effectively. Depending upon whose numbers you want to believe, handwashing compliance in acute care settings (mostly hospitals) is somewhere between 20% globally and between 50-80% in the United States. And we’ve tried everything to get those rates up. We’ve put alcohol stations at every door. The WHO has spent countless millions on campaigns like the “The 5 Moments” to teach providers when to wash their hands, and we’ve barely moved the needle. More importantly, we’ve not managed to improve patient outcomes – not one iota.

The consequences are terrifying. We’ve become so reliant on antibiotics that when antibiotic resistant strains of bacteria emerge, we’re caught flat-footed. In 1988, a Vancomycin-resistant enterococci (VRE) strain infested a renal dialysis unit in England, and by 1997, 23 percent of ICU patients were infected. Vancomycin is a go-to drug for infections, and when VRE adapted, we didn’t know what to do. In healthcare, we assume our antibiotics will save us – but when the bacteria adapt, we don’t know what to do. SARS (severe acute respiratory syndrome) was primarily spread through healthcare workers.

We fail to realize that the scary things that we must combat today aren’t fixable by an antibiotic. Take MRSA (Methicillin-resistant Staphylococcus aureus). Methicillin is another go-to drug that a bacterium found a way to resist. What’s scarier is that the newer strains – the ones that haven’t made the news yet – are resistant to not just one of our antibiotics but multiple of our wonder drugs.

When It Doesn’t Work

Medicine has changed war. Medicine has dramatically reduced the death toll in war. It’s reduced the mortality of both mother and child during childbirth. It’s made conditions that would have been fatal into outpatient surgery, yet it’s not enough. “The paradox at the heart of medical care is that it works so well, and yet never well enough,” writes Gawande.

It’s hard to have conversations in a group of people and not have someone tell a story of a loved one who died of a health issue. Too many of these stories involve complications that happened as a part of the medical care itself, whether it was an infection they didn’t have when they came in, a medical error, or just something that wasn’t an expected outcome.

As much as we have made progress, we’ve not been able to deliver the best care consistently.

It’s a Business

While it’s nostalgic to think of the doctor who serves a community, accepting livestock and services in trade for the healing he can offer, that’s not the world of today. Healthcare is a business – a big business (as is pointed out by Mistreated). As a business, doctors need to do what is necessary to keep the business going, and that may mean they stop helping people when doing so means you can’t afford to be in business.

The reality is that the skill of a surgeon in the operating suite has almost nothing to do with how much money they’ll make. Their ability to make a business run will drive their revenue and their professional survival as a doctor.

Follow the Rules and Innovate

It’s a double bind. On the one hand, we know there’s not enough application of the best practices that have been demonstrated through research. On the other hand, there’s no way to innovate if we don’t break some of the rules – in a controlled way – to see if we can make things better. This is the central concern at the heart of making medicine better.

On the one hand, we want doctors who read the latest journals and follow all the latest advice. On the other hand, we’ve seen research be reversed as new information is gained – and that information is only gained when we stray from the rules.

Clearly, the difference is that, in the one case, doctors fall upon the norms of their groups and just do what they’ve always been doing, even when there is research saying it’s ineffective or there are better approaches. It’s just too hard to override your experience. You’ve done sometimes hundreds of these procedures with only a few complications. Why should you have to learn something new? How many injuries would it really save? We don’t believe the research; we believe our personal experience.

So, we have to encourage consistency and simultaneously find ways to carefully try new ideas to see if we can get even better.

The Ego and the Average

At the end of the day, being better is about elevating yourself above the average. The only way to know if you’re making progress is to measure your performance, and that comes with a great risk. You may discover, much to your dismay, that you are only average, despite your striving and struggle. Despite the trials and the conquests, your performance is only average. While this may be, on the surface, bad news, it does at least let you know where you are. If you want to become better – as a surgeon or just in life – perhaps you should read Better.

Book Review-Mistreated: Why We Think We’re Getting Good Health Care—and Why We’re Usually Wrong

It’s no secret that the American healthcare system is broken. While there have been great advances in healthcare that saves lives and improves the quality of lives for so many people, it is still broken. The problem is that we can’t take a step back and fix it because it’s still saving lives every day. Mistreated: Why We Think We’re Getting Good Health Care—and Why We’re Usually Wrong walks through the details of our healthcare system from blind spots and misperception to motivations that are out of alignment with what’s best for the public.

Confronting the Truth

It’s a convenient belief that we have the best healthcare system in the world. It’s convenient, because it fits the facts that we have the most expensive healthcare system in the world. More expensive means better, right? It’s convenient to believe we have the best healthcare system in the world, because we send our loved ones to get healed here, and we want the best for them. We ourselves get our care here, and why wouldn’t we want the best?

The problem is, while it’s convenient to think we have the best healthcare system in the world, that’s far from true. We have “the highest infant mortality rate, the lowest life expectancy, and most preventable deaths per capita” of the modern world. While we spend the most on healthcare, our results are far from the top of the pack. Instead, our system invites waste, greed, and poor outcomes, all the while believing the care we receive is good. At some level, we know that this is lunacy, but it’s a convenient thought that keeps us from confronting the truth. Seventy-six percent of people describe the quality of their care as good or excellent. This statistically can’t be true.

Affordable Care Act

The Affordable Care Act (ACA) is the most sweeping set of healthcare reform that has been done in decades. While focused on making it easier for every American to have access to healthcare, it was able to address some other issues as well. No longer would people be denied insurance because of a preexisting condition. Preventative care was made nearly or completely without cost to the consumer.

While this was important legislation, it didn’t strike at the heart of the structural problems healthcare faces. We pay for services instead of paying for health. We’ve not been able – yet – to transform the relationship to one where the consumer only pays for results. This change can make all the difference.

Unnecessary Surgery

If pain is the symptom, surgery rarely has better outcomes than alternative treatments. Yet we perform surgery to repair a torn meniscus and place stents in people’s arteries at great cost with little or no actual health benefit. The results are in – and they say we shouldn’t do them. Like dozens of other treatments that are ineffective, we still do them because it’s standard practice or because they’re marketed aggressively.


There’s a bit of news now about how opioid manufacturers, particularly Purdue Pharmaceuticals, engaged in aggressive marketing of Oxycontin, which had a high potential for abuse but which the company routinely led physicians to believe was safe. Dreamland covers this aspect of our healthcare woes in detail. The short version is that we began treating pain as a vital sign, and physicians began getting more directly measured by their intentionality about treating pain. In most cases, this meant prescribing them a pill.

Pharmaceutical companies learned that, when marketed to them directly, consumers would ask their doctors for the medication. Often, they’d get what they ask for. Doctors are reluctant to deny their patients the medications they’re asking for – even when it’s not effective. Consider the over-prescription of antibiotics. A patient doesn’t feel well, and they make the decision to go to the doctor. They expect the physician will do something to make them better. They expect they’ll get a pill that will make them better. The physician, tired of explaining that an antibiotic won’t help, prescribes it anyway, knowing it won’t make them better. In the next week, the patient feels better and attributes their wellness to the drug – instead of to the virus running its course.

We see this desire of the public to just get a pill and fix it show up in every aspect of healthcare, including mental health, where it’s easier to take an anti-depressant than to deal with the underlying problem. (See Warning: Psychiatry Can Be Hazardous to Your Mental Health for more.)

Generalists and Specialists

The frequency with which you deal with a problem makes a big difference in your outcomes. The truth of the matter is that in medicine – like many other disciplines – you can’t get good at something if you’re never given enough time to practice and learn. Intuitively, it makes sense. If you do one gall bladder surgery a month, you’re not going to be as skilled at it as someone who does 100 a month. However, in most cases, the market doesn’t allow physicians to become hyper-specialized into a single kind of surgical procedure. Even our specialists cover a wide range of procedures and patient problems – too wide to drive the kind of volume in the procedure that would make them truly good at their craft.

What tends to happen is that a generalist treats a few patients a month and gets, at best, middling results from them. Even the specialist can’t afford to be hyper-specialized, because all the generalists are taking the cases they need to stay fully busy and get very good at what they do.

That’s not to say that generalists, like your primary care physician, are bad or not needed. It is believed (based on successes in other nations) that the best solution to the healthcare performance problem in America is to get primary care physicians better at preventative medicine – true health care – instead of trying to triage and route patients who are truly sick.

There’s a very old saying that “a stitch in time saves nine.” Meaning if we catch things early – like before they start – it takes very little to maintain or repair the situation. The later we catch a problem, the more challenging the recovery becomes – but that’s what we reward in our current system. Specialists (such as they are) are paid roughly three times what primary care physicians are paid. We undervalue the preventative measures that can have the greatest impact, and we elevate the heroic, last-minute attempts to help someone survive.


There’s a real soft spot in my heart for the understanding that we undervalue simple interventions that save lives and instead invest our money into technological marvels that have little or no real impact on outcomes. Another big marketing tool that healthcare systems are using is robotic surgery. Again, it makes sense. Doctors’ hands can be shaky, but robotic hands are not. However, the efficacy for robotic surgery isn’t any better than regular surgery – oh, and it takes longer. However, organizations are spending millions of dollars on these robotic surgery devices, which sit idle most of the time. Physicians want to have them but don’t see any need to make their jobs harder without better outcomes.

The soft spot for me comes because of our IV dressing patent. It’s simple. It’s straightforward. And we’re still trying to get the market to accept a change that may impact materials cost by $1 and may substantially reduce healthcare-associated infections (HAIs). It’s not sexy, but it seems to work. That may be why it’s not being used. Because, in the upside-down system of American healthcare, if it doesn’t seem like it’s cool, then it’s not worth doing.

Dr. Pearl shares his appreciation for information technologies and the ability for these simple technologies to improve outcomes.

Diabetes Advantage Program

It seems like a lifetime ago to me now. The study was being done in 1999, and the journal article was about the program titled “A Systematic Approach to Risk Stratification and Intervention Within a Managed Care Environment Improves Diabetes Outcomes and Patient Satisfaction” in Diabetes Care (Volume 24, Number 6, June 2001). The short version is we took patients with diabetes who were being treated by primary care providers, and we gave the primary care providers suggestions for the actions they should take to help their patient better manage the disease. We basically made it easy for the physicians to do the right thing.

The recommendations would print out to add another oral medication, the nurse would write a more specific recommendation in based on the physician and the specific drugs the patient was on, and the physician would sign the orders. The physicians quickly learned to trust the system (and the nurse). They realized the system was giving their patients the benefits of the best research on the disease without them having to study it.

The net result was about a 1-point drop in HbA1c values in 12 months. To put that in perspective, back then, the threshold for having diabetes was 6, and the threshold for uncontrolled diabetes was 8. (These values have been adjusted a bit in more recent standards.) So, a 1-point drop in HbA1c values was a substantial change. Most of that change is attributable to the system “reminding” physicians to do what the research suggested was best.

In short, helping caregivers with information technology works – and we’ve known it works for decades now.

Environment of Care

We tend to overestimate our rational rider and underestimate how much of what we do is shaped by the environments that we are in. Kurt Lewin proposed that human behavior is a function of both person and environment. You can’t predict what a person will do without understanding both. More recently, we’ve seen how people can be made to do awful things to other people with relatively little encouragement. The Nazi extermination of Jews was unfathomable. However, as both Albert Bandura (in Moral Disengagement) and Philip Zimbardo (in The Lucifer Effect) explain, it’s relatively easy to disengage our morality and cause people to behave in ways that don’t make rational sense. They both point to the work of Stanley Milgram after World War II, in which subjects were thought to be giving progressively higher voltage shocks to another subject in the next room. Most continued to give shocks that they perceived to be potentially fatal with little more enticement than knowing it was for the experiment.

It’s surprising how little factors can cause us to take different behaviors. Nudge uses numerous examples of how changing the easy or default answer changes the way people eat and save. When you look at the body of literature around change, you’ll find that, much of the time, making change work is about a few well-placed interventions. (See Switch, Redirect, Change or Die, Change Anything, Made to Stick for examples.)

These same factors hold true whether we’re talking about something truly evil or we’re simply talking about practices that aren’t effective. Once the group establishes a social norm, it’s hard for new people to adjust the norm, even when the new target has better demonstrated outcomes. In short, the team becomes fixed in their perspective and don’t accept the valuable input from the outside. (See Diffusion of Innovations and Hackman’s Collaborative Intelligence for more on the receptiveness of a group or team to outside influence.)

Sometimes, the best examples of what to do are sitting right under our noses. The Washington Post Magazine arranged for internationally-acclaimed virtuoso Joshua Bell to play his violin at a subway stop for spare change. The man who played for presidents and sold out concert halls earned a little more than $32 in his time at the subway station. The expectation that he was simply a street player led nearly everyone to treat him as one. The environment we’re in really does dictate how people respond to us.

Healthcare Is a Team Sport

In America, we’re enamored with the idea of a lone hero charging across the western plains to conquer a new land. The wagon trains of families banding together to face the hostile wilderness just doesn’t sell as well. We want to believe the surgeon has better outcomes while ignoring the impact of the hospital, the nurses, and even the janitors. In healthcare, janitors are called environmental services (EVS) workers. The painful fact is that most EVS workers clean somewhere between 30-50% of the things they’re supposed to clean between patients.

There’s a growing body of research that shows pathogens are being passed from one patient to the next because of improper or incomplete cleaning. Moving the needle from 50% to 80% of the objects cleaned can have a reduction in HAIs of about 20%. To put that in perspective, that’s more than one infection saved per EVS worker per year.

Nursing, too, has been shown to have a critical role in the outcomes for the patient. “Better” nursing care is associated with better outcomes. Subtle things like the degree of burnout nurses experience has an impact on the patient outcomes.

Everywhere we look, there is evidence that it’s more than the gifted surgeon that makes the difference in the outcomes. Now more than ever, healthcare is a team sport – and one that is sure to continue. The silent member of the team – but the one that is always present – is the patient.

Patient Non-compliance

One frustrating aspect of healthcare is that frequently the patient is non-compliant with the protocols they’ve been given by the healthcare staff. Whether that’s failing to take medications or it’s not doing the prescribed exercises, getting the patient to behave in their best interests is often a frustratingly difficult challenge. To be fair, most of the challenges here are ones that educational folks have learned to address but healthcare hasn’t picked up on.

Healthcare workers aren’t careful about educating patients and asking questions for which the correct answer is no. By default, humans will answer yes if we don’t understand. So, asking questions that have no as answers can help ensure the patient understands. (See Incognito, Predictably Irrational, and The Hidden Brain for more.) For instance, instead of asking “Do you understand that you should take this with a meal?” you might ask “So, do you believe you should you take this on an empty stomach?” Healthcare workers suffer from the curse of knowledge, which means they fail to explain in a way that patients can understand. (See The Art of Explanation for more.)

What’s more, healthcare workers haven’t been taught to give patients productivity aids to help make them more successful. (See Job Aids and Performance Support for more.) The handouts they give patients are largely unintelligible even by healthcare workers, and they aren’t inviting to someone who’s unfamiliar with healthcare and what’s happening to them. Beyond the paper they’re given, they’re rarely pointed towards tools that can help them be more compliant – like an application for their smart phone that will remind them when it’s time to take medications.

If we’re going to make healthcare better, we’ve got a long way to go. We’ve got to address the motivators that cause people to take advantage of others. We’ve got to move towards higher specialization and more preventative medicine. And we need to get everyone on the team – including the patient – so we can prevent more people from being Mistreated.