One of the most important executive responsibilities is shaping value-creating work. This requires a “feel” for the work. Feel lies at the heart of an organization’s ability to improve quality, reduce cost and build value.
The many demands on health care leaders can sometimes distract them from their feel for the work that generates value. Reconnecting them with that feel can ensure that value-based initiatives remain on track.
It’s a good time to consider what feel is and how it can be enhanced. Executive feel is one kind of feel. It has characteristics that are common to feel in most other human endeavors.
Feeling through the curve
Feel is derived in a wide variety of experiences.
I didn’t own a car until I was almost out of college. Until then, I rode motorcycles. My first motorcycle was an 80 cc Yamaha. Its speedometer didn’t work, but I learned to feel when I was edging past the speed limit. I graduated to a bike that had a voracious tendency to foul spark plugs. I learned to feel when one of its two cylinders began to miss a beat. Then I progressed to larger bikes.
By the time I was 18, I was in sync with my bike. I knew exactly how far I could lean it into a curve. I also learned that loose gravel or wet leaves on that curve could turn into a sprawl of sparks and bloody denim. The motorcycle’s grip on the road resulted from complex physics including momentum and gravitational pull as well as the composition of the tires and the condition of the pavement. But I didn’t bother with any of that. Experience gave me all I needed to get safely through the curve.
By riding every day for years, I developed a feel. But here’s the thing: Thirty years later, when I got back on a motorcycle, the feel was seemingly gone. When I rode into a curve, I was tentative and nervous. What had once been unconscious and fluid required forethought and intention. The feel of a bike and the road had eroded.
Knowing how to feel
Feel is different from intuition. Anyone can have intuition. But feel comes from experiences repeated. It’s what you get when mind and body convert repetition into second nature. It’s what a gymnast has when she’s on the balance beam every day, and what she loses when she no longer practices. Feel comes from doing.
For example, Homer’s Odysseus had what Greeks call “métis.” He knew how to deceive the Cyclops and lead his men safely home. He knew because experience had given him the feel he needed to prevail against the odds. He had sailed a turbulent sea. Outwitted the Trojans. Engaged the gods. And persuaded his followers to stretch beyond what they believed was possible.
In medieval Japan, samurai trained until their swords became extensions of their arms. Their feel for their weapons was developed to the point that they could move almost without conscious thought when confronted.
Red Adair had the only team in the world that could be called on to put out the oil fires ignited during the 1990 Gulf War. Adair had a feel for wellhead fires developed by confronting hundreds of blowups — each one unique due to the chemical makeup of the oil, the wind direction and hundreds of other factors. There was no handbook when it came to extinguishing an oil fire.
In New Zealand, competitive sailors develop a feel for the interaction of wind, water, body and boat when they are very young. They often train alone in small boats from which the rudder has been removed. They learn to steer the boat by shifting their body weight in rhythm with the feel of wind and currents. As they advance, they learn to do this while blindfolded.
Southern writer Rick Bragg conveyed the importance of feel in a recent article in Garden & Gun by recounting his brother’s perspective on why Rick couldn’t catch fish: “‘You just don’t know how to feel,’ my brother said. I thought for a moment he was trying to be sensitive, but he was being technical. ... ‘When you fish, you can’t touch the bottom, what’s under there, so you got to feel through your line, feel it when your bait slides across a rock, or almost gets snagged in sticks and brush and stuff, and feel it, ’specially, when he bumps that bait, and when he takes it. You got to feel all the difference in all of that, or you spend all your time gettin’ hung up, or you let the fish get off, or let him spit out that bait. Rick, you don’t feel it.’”
Developing a sense of feel
You never lose your feel entirely. Some of it hangs around. Even if the gymnast, long since retired from competition, is not as steady as she once was, some of her feel is residual, stored forever as muscle memory.
There is much debate about what intuition is and where it comes from. But one thing is relatively certain: Experience complements, hones and leverages intuition into something more — something that translates into feel. Unlike immeasurable intuition, the experience that gives rise to feel can be quantified and developed. To enhance feel, one needs to increase exposure to relevant experience. This observation is reflected in economic theory where it is referred to as the “experience curve.” Organizations become better at producing something the more they do it. The same dynamic applies to individuals.
In my office, I have two black-and-white photos. One is of Charles Lindbergh, whose Spirit of St. Louis had no windshield. In 1927, Lindbergh felt his way down a muddy runway, felt his way into the air, felt his way across the Atlantic and felt his way back to earth in Paris. He developed his feel by barnstorming and flying airmail.
The other photo is of an elderly Helen Taussig with a stethoscope; she’s listening to the heart of an infant. Taussig, the world’s first pediatric cardiologist, bullied Johns Hopkins’ renowned surgeon Alfred Blalock into performing a path-breaking procedure that saved the lives of thousands of blue babies. The photo is exceptional not only because Taussig’s devotion to the child is so apparent but because it was so obviously staged: Taussig was deaf. A stethoscope was useless to her. She relied on feeling a baby’s heartbeat with her fingertips.
Taussig’s feel, the experience that ran through her fingertips, extended beyond the bedside. It equipped her for other challenges that required a sense of when and where to push and how hard. Those were requisite competencies when Taussig later confronted the dangers of thalidomide, a sedative sold in Europe to counter morning sickness during pregnancy.
Taussig learned of increases in the number of children being born with severely deformed limbs in Europe. She went to Germany and spent six weeks visiting clinics, examining deformed babies and interviewing doctors as well as mothers. She noticed that the abnormalities were not in evidence in U.S. military installations where thalidomide was unavailable. She returned home and shared her findings in testimony to Congress. Her arguments led the U.S. Food and Drug Administration to reject attempts to market the drug in the United States. Investigating, pushing, speculating and experimenting her way to a fix for blue babies had given Taussig the feel she later needed to battle thalidomide.
Several years ago, Toby Cosgrove invited me to watch him perform a minimally invasive heart procedure at the Cleveland Clinic. This was revolutionary work at the time. When Cosgrove entered the room, it got quiet. Informality morphed into disciplined routine. I presumed I would stand somewhere near Cosgrove. Instead, a step stool was placed behind his heels as he positioned himself at the patient’s side. He told me to get on the stool and lean over his shoulder. So I did, and I watched.
What I saw wasn’t anything a machine could do, or will ever be able to do. It was the accumulated experience of thousands of procedures performed over decades and translated into feel. The Germans have a word for it: "fingerspitzengefühl," or “feelings in the fingertips.” Cosgrove’s feel extended to the invention of several medical devices that bear his name and eventually to a role as CEO of one of the world’s leading medical institutions. He had developed a feel not only for what made great heart surgery but also for what made a great heart hospital.
According to Nobel laureate Daniel Kahneman, “The acquisition of expertise in complex tasks such as high‑level chess, professional basketball or firefighting is intricate and slow because expertise in a domain is not a single skill but rather a large collection of mini‑skills. Chess is a good example. An expert player can understand a complex position at a glance, but it takes years to develop that level of ability.”
Becoming an expert on feel
Many people have tried to deconstruct what made the violins and cellos of Antonio Stradivari so marvelous. Richard Sennett, in his book The Craftsman, suggests the answer may be found in Stradivari’s workshop. Like other craftsmen of his time, his house was both a place of work and a home. It was filled with young apprentices who labored from dawn to dusk. Unmarried apprentices slept beneath their workbenches on bags of straw. The youngest did prep work like soaking wood in water, rough molding and rough cutting, while the more experienced did the finer cutting of the instrument’s belly and the assembly of the neck.
Stradivari assembled many of the parts himself, then did the critical work of varnishing. In the workshop, spurred by the master’s constant presence, according to Sennett, was “the absorption into tacit knowledge, unspoken and uncodified in words, that occurred there and became a matter of habit, the thousand little everyday moves that add up in sum to a practice.” For those with demonstrated feel, authority is conferred. It comes, writes Sennett, from “seeing what others don’t see, knowing what they don’t know; their authority is made manifest in their silence.”
Feel is perhaps the most defining characteristic of a craftsman. A craftsman’s experience has a result: It’s called skill. According to Sennett, craftsmanship involves "dimensions of skill, commitment and judgment in a particular way. It focuses on the intimate connection between hand and head. Every good craftsman conducts a dialogue between concrete practices and thinking; this dialogue evolves into sustaining habits, and these habits establish a rhythm between problem solving and problem finding.”
There is, of course, a close connection between thinking and doing. Each shapes the other. Experience begins to erase the boundaries between thinking and doing until they start to merge and mix.
In his book Thinking, Fast and Slow, Kahneman suggests there are two modes of thinking. Fast thinking “operates quickly with little or no effort and no sense of voluntary control.” Slow thinking “allocates attention to the effortful mental activities that demand it.” Experience, I would suggest, transforms slow to fast through exposure and repetition.
For a motorcycle rider, this might be demonstrated in shifting gears, which must be carried out in sequential steps: First, note the RPMs on the tachometer (or the sound of the engine). Second, pull in the clutch with your right hand. Third, upshift or downshift with the toe of your left foot, one gear at a time. Fourth, release the clutch handle. Because an inexperienced rider must think about all this, his efforts are often slow and jerky. The experienced rider completes the process smoothly in a continuous uninterrupted sequence. This has been described by the psychologist Mihaly Csikszentmihalyi as “flow.”
Creating value from feel
It is often suggested that the realm of the executive is thinking and deciding. But for leaders, deciding must always translate to doing even if it is doing through others. Doing through others is another way of defining “management.” In management, the executive may be removed from direct contact with the work of the organization, but she most certainly ought to be shaping the doing of that work. In management, experience and feel count. Perhaps more than anything else, what executives get paid for is shaping work so it yields more value.
Thoughts of craftsmen and workshops bring to mind the making of tangible things like violins and cellos. But intangible things have value, too. Some services are better than others.
The crafting of tangible things and the management of intangibles are at their heart about the same thing: They are intended to bring forth greater value. The quality at the heart of value benefits from feel. The operating room, and the broad, complex organization in which it was embedded, was Cosgrove’s workshop. It wasn’t just the feeling at his fingertips that mattered. It was the feel he had for the people in that workshop.
Feel is informed by closeness to the work that generates value. It was Stradivari’s presence in his workshop. It is also the executive in the workshop that extends from the boardroom to the nursing floor, the operating room and the exam room. When cut off too long or too often from the interface between caregivers and patients, a health care executive’s feel for the work will atrophy.
A feel for things implies a “touch.” Sennett describes how calluses form on the hands of people who use them for work, protecting the nerve endings and sensitizing them to physical contact. To create value, individuals and organizations must “be in touch.” Whether that touch is direct or indirect, they must be in touch enough to develop calluses.
A feel for leading well
For a health care executive, the path to developing feel is straightforward but hard. It requires repeated exposure to the true, value-creating work of the organization.
Some advisers have recommended “rounding” as a way to improve the management of health care. Rounding is a technique borrowed from medical school in which students follow experienced faculty from patient to patient while the faculty member expounds on each case and engages in Socratic dialogue.
Managers who practice rounding are still outside observers. More immersive experience will accelerate their effort to develop feel. This might involve shadowing doctors and nurses, gowning up in the operating room and spending time helping in the emergency department. Authenticity and authority are derived from demonstrated feel. That’s why savvy physician executives continue to stay involved in patient care. It maintains their feel while preserving their credibility and authority among colleagues.
Feel has its own metrics. There are myriad feedback loops that continuously convey how things are going: The sound of the motorcycle engine. The rhythm of a heartbeat. According to Kahneman, anesthesiologists are in a good position to develop intuitive skills because they receive immediate feedback on their actions. He writes, “If an anesthesiologist says, ‘I have a feeling something is wrong,’ everyone in the operating room should be prepared for an emergency.”
What Taussig was doing when she laid her fingertips on the chest of a child was to feel for abnormalities in the rhythm of the heart. The kind of work being done defines the nature of what must be felt. Executives need reliable metrics to manage effectively.
There is much talk in health care about value, as there should be. But value in health care is not generated by medical loss ratios, length of stay or return on investment. When I think of value, I find myself looking past the ratios and measures to the narrow space between Taussig and her infant patient. There, I’m reminded, is the heartbeat of value. All value in health care originates at the interface between a caregiver and a patient — whether well, injured or ill. And key to shaping that value is a feel for its many determinants. A feel made of experience.
Dan Beckham is the president of The Beckham Co., a strategic consulting firm based in Bluffton, S.C. He is also a regular contributor to H&HN’s website.
The opinions expressed by the author do not necessarily reflect the policy of the American Hospital Association.