When Emotional Intelligence Means Higher Performance

Dr. James Stoller is the Chairman of the Education Institute at Cleveland Clinic, a pulmonary critical care physician, and author of Exception to the Rule. Daniel and James sat down to discuss deficit-based thinking, medicine being a team sport, and the simple fact that "doctors, like everyone else that join organizations, expect to grow over the course of their career."

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Dr. James Stoller:
Emotional intelligence is that aha moment that recognizes that we need to pivot from that mindset into one in which we're mindful of our interactions with others and our ability to engage with others in service of the patient's wellbeing.

Dr. Daniel Kraft:
Welcome to Healthy Conversations. I'm Dr. Daniel Kraft and today we're in healthy conversations with Dr. James Stoller. He's the chairman of the Education Institute at Cleveland Clinic and a pulmonary critical care physician. Welcome Dr. Stoller. Not too long ago, I [inaudible 00:00:33] one of your colleagues from Cleveland Clinic, Dr. Mark Hyman, who heads up strategy innovation at the Center for Functional Medicine and you have a different but very interesting niche at Cleveland Clinic. That's the realm of emotional intelligence. So I thought we'd start off by asking you what is emotional intelligence and why does emotional intelligence matter?

Dr. James Stoller:
Emotional intelligence is a bedrock competency for humans as well as obviously in healthcare. And this is really the work of Peter Salvia at Yale, a fellow named Baron, and then the work of Dan Goldman, Richard [inaudible 00:01:08] and others who thought deeply about competencies to lead. Emotional intelligence consists of four quadrants, the ability to understand oneself. Secondly, the ability to manage oneself. Thirdly, the ability to understand one's relationships with others. And lastly, the ability to modify your relationships with others in surface of enhanced organizational performance. It was on the cover of Time Magazine some years ago. By the time things find their way to Time Magazine, they clearly are in the popular mindset. So this is not by any means an original idea, although it's relevance to health care is quite poignant.

Dr. Daniel Kraft:
And I love the way you summarized it in a paper you recently published. "Emotional intelligence is the capacity to understand your own and others' emotions and to motivate and develop yourself and others in service of improved work performance and enhance organizational effectiveness, particularly in health care." I guess the key thing is kind of get what you measure. We're all familiar with maybe IQ as a measurable element.

Dr. James Stoller:
Yeah, we call this EQ, emotional quotient, as opposed to intelligence quotient. And so you can go online and respond to various queries, what is commonly called a multi-rater feedback or 360 feedback. I would evaluate myself and then anonymously others would be asked to evaluate me, people to whom I report, my peers, and people who at least organizationally report to me, against which my self-perception is compared. And so in the analysis of those data one sees the way others see you, the way you see yourself and where there's a gap is often the opportunity for self-improvement. I keep my feedback reports in my top drawer of my desk and pull them out to keep myself grounded. They can be hugely impactful if you have a growth mindset about this.

Dr. Daniel Kraft:
Yeah, it seems like how you set that up, how you let someone understand if you're doing a 360 on them, that it's to help them and their colleagues. Do we really select people more for their IQ or their EQ and are there ways that beyond an MCAT score to help select people maybe have better emotional intelligence that will help improve their patient interactions and outcomes?

Dr. James Stoller:
Now it's a great question that many of us, your listeners have engaged in for their whole lives are selected on the usual competencies you do well on your in college and MCAT so you can get into medical school. You know the drill. It's also clear that that sort of emphasis has within a hidden curriculum, and I certainly experienced this in my training, that people were selected on the force of their cognitive abilities. And we understand today that medicine is a team sport. I'm a critical care doc, a pulmonary doc really do take care of patients in isolation. My colleague Tom Lee, with whom I was an intern, wrote an article in the Harvard Business Review in which he described doctors as heroic lone wolves. And I often think of my own training, there was a dimension of the heroic lone healer and emotional intelligence is that aha moment that recognizes that we need to pivot from that mindset into one in which we're mindful of our interactions with others and our ability to engage with others in service of the patient's wellbeing.

Dr. Daniel Kraft:
And sometimes that reflects on even the clinician wellbeing. We both spent some of our training at Mass General Hospital, which is a little bit more of a... Used to be more old school, but now we have 80 hour work week restrictions. There's a little more attention to the health of the clinician and certainly exacerbated the pandemic burnout and other issues.

Dr. James Stoller:
Being inoculated against burnout is largely feeling like you're supported and can reciprocate help with others. I liken it to an emotional bank account. You deposit into it, you contribute, and all of us are the beneficiaries of being able to withdraw from it.

Dr. Daniel Kraft:
I think a lot of it comes back to knowing your colleagues, mutual support. We hear a lot about precision medicine, telehealth, all the technologies like AI. We don't hear that much about, let's say leadership change, leadership training, change management, team building. Can you share a bit about your experience at Cleveland Clinic over your career and how you've been developing that into some of your leadership training programs?

Dr. James Stoller:
We've placed a large focus on this for doctors and allied health providers and nurses. This is not a physician specific skill. This is applicable to all caregivers at all levels of training. Since doctors are trained in this lone mindset, we have to unfreeze those behaviors by repopulating our cortex with a different set of skills. I have to say in my own journey for a variety of complicated reasons, I went offline and did a master's degree in organizational development, which is heavily imbued with feedback and that was a pivotal moment for me in realizing that these are other skills that are really important to my professional success and contentment. I have the privilege of developing curricula and cascading curricula throughout the Cleveland Clinic, and I'm delighted to say it's not unique to the Cleveland Clinic. They're also, I should say a couple of clinical reflexes that we have as doctors that serve our clinical interests really well, but conspire against our leadership.
One is that doctors are ultimately the deficit-based thinkers, right? Patients come to us because they can't breathe, in my case, and you know what I naturally do as you do is generate a differential diagnosis of the etiology of breathlessness in service, of coming up with a reason in service of providing an answer that will alleviate the problem, right? And that works and has works in Hippocrates, but there's a school of thought that recognizes that if we are thinking organizationally, we have to think appreciatively not in a deficit-based way. In other words, what do we do well and how do we do more of it? And if we were successful beyond our wildest dreams, what would happen? And the authors of this would tell you that words create worlds. That the way you frame a question informs the answer. So that when you frame a question appreciatively, you get a very different answer than when you frame the question through a deficit based lens.
To be brief, medicine is the translation of continuous biologic variables into yes no decisions, right? You see a patient, their diastolic is 89, you say, okay, let's watch that. Their diastolic is consistently 91, you might intervene. If we see a pulmonary nodule that's five millimeters by the Fleischner criteria, we may not follow. If it's seven millimeters, we may repeat a CAT scan. And yet again, organizational thinkers would remind us about the tyranny of the "or" as they call it, and the genius of the "and". And what doctors do clinically is we do "or" and when we lead we must do "and". We must be able to embrace ambiguity and still function. So part of leadership development, back to your question, is bringing these issues to doctor's attention in service of addressing them.

Dr. Daniel Kraft:
I love that answer, but also the idea that we [inaudible 00:08:14] deficit-based therapy, but often it's still very siloed. You're taking care of the lungs, but that might end up in a conflict with the cardiologist or the nephrologist because they're managing other systems. We don't want to just think about one organ system, but holistically the patient.

Dr. James Stoller:
What the whole mindset about working as a team and anchored by the patient's wellbeing is that it sort of levels the playing field. Kidneys are important, lungs are important, hearts are important. It's really not about which is more important, it's about which is more important in the moment in the specific context then who cares anyway. There are no Guinness World Records for the most important organ.

Dr. Daniel Kraft:
This may leverage into a little bit about your educational institute. How do you see success and how have you sort of learned to evolve to get to that better success?

Dr. James Stoller:
We're lucky enough to have what we call our Mandel Global Leadership and Learning Institute that cascades this awareness broadly through the organization to every caregiver. I believe that training like this for doctors is both a recruitment asset as well as a retention asset, that doctors like everyone else, that join organizations expect to grow over the course of their career. That stasis in medicine is never good. That's certainly been my own journey.
So we published a paper a few years ago in which we looked at a cohort of about 272 of my colleagues that engaged in early iterations of our leading in healthcare course and followed their careers at the Cleveland Clinic 10 years later with [inaudible 00:09:44] criteria for what leadership invitations mean. How many of them were invited to serve as department chairs, as institute chairs, as members of our medical executive committee. And the answer was that number was 43%. So that this is a very high yield sort of weigh station, if you will. We're late to the game in healthcare. We've been doing this at my institution at the Cleveland Clinic for 20 years, but organizations like General Electric, Boeing, Toyota, Motorola have been doing this for 50 or 60 years because they've all recognized the primacy of these skills, again, in service of organizational effectiveness.

Dr. Daniel Kraft:
You mentioned other fields. One of my favorites is aviation. I've been a pilot, I've been a flight surgeon and fighter squadrons, we teach crew resource management. Planes crash and many medical errors happen not because of the, let's say the airplane or the surgeon, but how the teams might interact.

Dr. James Stoller:
Team building is a critical part of the curriculum in these leadership development courses. One that I really like is called subarctic survival. The scenario is you're in a plane in the subarctic region of Canada, the plane crashes and you're asked to pick 15 items associated with your survival that are part of the flotsam and jetsam of the crash. And then you rate those items yourself and then you meet as a team and rate those items collectively. And then someone who's actually experienced this scenario will tell you the items and why. And I've done this with well more than a thousand healthcare providers, almost without exception, the teams do better than the individuals, even when there's nobody in the team that is a pilot or a survivalist. And yet even when there's skill in the room, the collective efforts are better than the individual efforts.

Dr. Daniel Kraft:
Well, it's one thing to get something easy to measure, did you survive, did the plane crash or not crash, but in healthcare there's a lot more gray areas. Are you seeing new ways to on the fly or continuously improve learnings through some of these modalities? Because in many cases, particularly in the intensive care unit, maybe a patient had an unfortunate demise and often that's never debriefed and including how the team may have responded to that.

Dr. James Stoller:
Increasingly, we are practicing after action reviews, which is critical to the Navy SEALS, for example, is one could argue there's no higher performing group in the world on the planet. It's free from hierarchy and that's how they get better. And we are increasingly doing that, not just among doctors, but in the ICU respiratory therapists, nurses, fellows, attendings altogether. Sometimes even with patients, believe it or not.

Dr. Daniel Kraft:
I think what they call it in the military is taking off the rank. The youngest lieutenant in the formation gets to sort of debrief and tell the general or colonel what they might have done wrong. And that often doesn't always happen, as easily in healthcare. It's good to hear that that can be encouraged. Do you think this could be, or is it already being imbued into the future of nursing school, medical schools, et cetera?

Dr. James Stoller:
No, it is. In our curriculum at the Cleveland Clinic, Lerner College of Medicine. It's all team-based learning. It's all problem-based learning. There are no exams, no grades, no class rank, no AOA. These are students working in small groups together.

Dr. Daniel Kraft:
That's often an adjustment for those folks who are "gunners" of the straight A folks to get into medical school. It's a different modality, and I was lucky to go to a med school that was pass/fail and much more team oriented. It makes a difference in your experience as a student and then later as a clinician. You have a book, Exception to The Rule, where you open with an appeal for virtue based culture and being intentional about culture in order to assure high performance in an organization. Can you tell more about how culture matters and how that affects organizational performance?

Dr. James Stoller:
Peter Drucker, one of the gurus of organizational development, was quoted as saying, "Culture eats strategy for breakfast." And that's true, right? And there's ample evidence for this. Going back to Aristotle, these are the seven classic virtues. Trust, compassion, hope, wisdom, temperance, courage... Who for example, would not want to work in an organization where trust and compassion were the predominant values? Do you want to work in an organization that says we have no compassion and we don't trust anyone? How do you interact with a patient, right, a difficult patient?
I can tell you personally, this whole journey through organizational development has changed the way I practice medicine. For example, to be concrete, I saw a patient yesterday who came from the state of Washington, a long trip, right? To come to Cleveland, Ohio with a boatload of clinical issues. And so I characteristically begin my visits now taking a page out of appreciative inquiry and say, "Mrs. Jones, what a success. If this visit were successful beyond your wildest dreams, what would happen?" Getting some framing so I know where to take the conversation. I wasn't taught that in medical school, I can tell you. It's usually, "What brings you to see me today, Mrs. Jones?" Right? It's a different framing and it's made a huge difference I believe in patient's experience and in my own ability to navigate the complexity of the clinical problem.

Dr. Daniel Kraft:
And that seems to go beyond individual clinical unit. I've been fortunate to meet several times, Toby Cosgrove, who is your former president, CEO of Cleveland Clinic, and he seemed to imbue this culture, whether it was around no smoking on campus or not having unhealthy meals, no fast food restaurants in your hospital. And one thing that's I think impacted culture, our ability to do things differently, certainly it's been this covid pandemic of which as we're speaking almost two and a half plus years into, certainly in your field of critical care, it's been a big stressor.

Dr. James Stoller:
What is said, crisis is a terrible thing to waste, right? We turned an entire 477,000 square foot education building into a hospital in three and a half weeks to accommodate an early surge that thankfully never materialized. But the activity of doing that and the stress and the urgency of that created teamwork and relationships that have born fruit well beyond those activities. And you see it every day, how we engage with one another, not only within a single institution, but across institutions. Hospitals in Cleveland and leadership came together in extraordinary ways to share personnel, to share PPE, to share ventilators. We sent caregivers to New York ICU teams. If you think about it, this was a world problem and we fixed it. We haven't fixed it, but the progress we've made has been done as a world, right? Sharing information in an open, transparent way. That's been a wonderful takeaway from the pandemic. I think that you, and I'm sure every one of our listeners appreciates.

Dr. Daniel Kraft:
Yeah, it sort of sparked this new health age. We've all been to war in a sense. There's a bit of a [inaudible 00:16:30], and hopefully those relationships, ideas, the things to do in that crisis situation will continue to catalyze better outcomes. The key part of it's unlocking just the mindfulness of the opportunity to have a lens around emotional intelligence or leadership or team management. And briefly that's listening to one of your prior little interviews, you mentioned one of your zen mindfulness things is fly-fishing. How do you tie fly-fishing maybe to your success as a clinician, academic leader?

Dr. James Stoller:
There's a lot of medicine in fly-fishing. Presenting the fly requires technical accuracy, but equally importantly, that there's a tremendous cognitive dimension. When you're sitting on a stream trying to catch a trout, you have to think like a trout. Where would he or she be? What is he or she eating? And the clues that inform that decision, which have a yes no outcome, a dichotomous outcome, you catch the fish or you don't, are predicated on getting it right. It's sort of like clinical trials taken to a very zen sort of level in beautiful places.

Dr. Daniel Kraft:
Well, thanks for having this healthy conversation. I'm sure our listeners really appreciated your inputs and keep doing what you're doing and as we all hope to grow together to build a better future for health and medicine in Cleveland and beyond.