By Robert Pearl, MD | Forbes.com | January 5, 2017
Dr. Donald Laub, the chairman of Stanford’s Division of Plastic and Reconstructive Surgery, believed that anything was possible—and that’s what he taught me to believe, too. He was the father of Interplast, the largest volunteer global surgery program of its time. It began in the back of a pickup truck that he bought in Central America, and ultimately evolved into a sophisticated operation providing thousands of surgeries in dozens of locations on five continents. Don also began the Stanford transgender program decades ago, recognizing, as a man of great insight, the pain that gender dysphoria created for individuals born anatomically at odds with their true gender identity.
When I became the CEO of The Permanente Medical Group, the Permanente half of Kaiser Permanente (KP), a decade and a half ago, the organization was delivering high-quality medical care, but the brand was not as strong as it is today. Don’s example of thinking big provided the necessary courage to make the operational improvements required and to implement the 21st century cutting-edge technology needed to establish KP as a national healthcare leader and model for others. Convincing all physicians to offer their patients the ability to send them a secure message, schedule an appointment through an online application and obtain medical care through video seemed daunting but possible.
Don had taught me to embrace a vision bigger than ourselves, and to commit to the hard work essential to make those dreams a reality. His inspiration drove me forward.
For me, the holidays and start of the New Year are always a time for reflection and gratitude. And so over the last month, I’ve looked back on some of my early teachers to glean what I learned from each during my residency at Stanford University. Since I graduated, I’ve applied the lessons they taught me and the powerful insights they provided in ways I could never have imagined years ago. In the same way that our genetic makeup is a combination of our parents, who I am today results from the DNA I inherited from four surgeons early in my career. I will forever be grateful for all the lessons they taught me, the values they transmitted and the role models they were and remain years later.
When I finished medical school, I chose Stanford, wanting to become a cardiac surgeon. I really enjoyed the technical aspects of heart surgery but was drawn to plastic surgery for the opportunity to volunteer to help children with cleft lips and palates around the globe.
Learning an entire surgical discipline requires exposure to many teachers, and over those six years, I was fortunate to work with many dedicated and skilled mentors. The four I write about today stand out, not just for the technical training they provided, but also for the leadership foundation they instilled in me. Through their teaching and example, I have been inspired to push the boundaries of healthcare and help others fulfill their potential.
Dr. Ernie Kaplan, the assistant chief at the time, had a genius for understanding and explaining surgery through pattern recognition. Medicine in general, and surgery specifically, can be mastered in one of two ways—by rote or by pattern. Doctors can memorize a long differential diagnosis or the 30 steps for a particular procedure, or they can extract the key overarching principles and thereby elucidate all of the items and steps on the list. Whether lecturing at an academic conference, performing surgery in the operating room or analyzing data from the research laboratory, Dr. Kaplan always began by identifying the underlying pattern, often before anyone else could recognize it.
This pattern recognition skill is particularly applicable to plastic surgery. The specialty includes hundreds of operations performed from the top of the head to the bottom of the feet. And the underlying principles of one procedure, such as a tendon repair, can be applied to others, such as for children whose eyelids fail to open completely. Similarly, surgeons who master the underlying patterns leading to superior outcomes for children with a cleft lip can then transfer the insights gained to closing a large wound of the lower leg or releasing a burn scar that’s limiting movement of the elbow or hand.
From Ernie, I learned not only much of my clinical skill but also many of the leadership approaches I’ve used over the past two decades. Over time, these ideas have helped move operations in The Permanente Medical Group from “art” to “science.” Ernie taught me that great medical care, whether in the form of superior quality or superior service, can be translated into mathematical principles. Today, we apply this concept to ensure that the supply of both appointments and operating rooms always match the expected demand for each. Using mathematical models, we predict—based on the day of the week and the season of the year—how many people will want to be seen or need a general anesthetic. And we use analogous models to maximize prevention, minimize medical errors and develop high-volume centers of excellence for the most complex medical problems.
Ernie taught me always to look for and identify patterns in nature and life. Since then, I have done so, always asking questions and looking deeper, until the patterns emerge.
Dr. Vincent Rodney Hentz possessed vast experience and a consummate knowledge of anatomy, even though he was the youngest of the faculty members during my residency. Judging the skill of surgeons is difficult, particularly if they operate in a different specialty from your own. One way to do so is to ask the residents with which attendings they prefer to work. The universal answer at Stanford for many years has been Dr. Hentz, or Rod, as he preferred to be called. Anatomical structures just seemed to part for him more easily and precisely than for anyone else.
He and I were microsurgery partners for years after I completed my training, and we alternated weeks working together at Stanford and Kaiser Santa Clara. These surgeries require two teams, and never once did I have any doubt that his half of the procedure would be completed perfectly at the exact moment it was needed. And each time we operated together, I realized that we had improved the outcomes from the previous procedure.
From Rod I learned the value of technical excellence, and that some approaches are better than others, even though some might disagree. Rod taught me never to be satisfied merely performing well, but, rather, always to innovate and improve, ever in search of an even better solution. And so whether I’m in the operating room or the administrative suite, I’ve never accepted that what existed was as good as it could be, and I continually searched for the better way. Rod would caution that even when you’re the best in the nation at something, look for the next set of opportunities to become even better. I continue to value and follow his advice.
In many ways, Dr. Lars Vistnes, a fourth member of the Stanford faculty, was strikingly different from his peers. He had a gentle voice and easygoing demeanor that belied his laser-like focus on results. He never yearned for the spotlight, but instead consistently achieved success, publishing extensively and serving as editor of a plastic surgery journal and as the chairman at Stanford after Dr. Laub. He worked mainly in the Palo Alto Veterans Hospital, a facility affiliated with Stanford. For most leaders, the bureaucracy and paperwork of this type of government-funded facility would exact a toll, but he took it all in stride. Through his efforts, the hospital became one of the best in the nation at rehabilitating patients after spinal cord injury.
Lars brings to mind what Malcolm Gladwell has written about—the two paths to success. One, represented by Picasso, reflects early brilliance and accomplishment. The other he identifies with Cézanne, and includes individuals whose success and best work happen decades later, after years of honing their craft. Lars was more like Cézanne, constantly working to improve, even if only one tiny step after another.
Without realizing what he was doing at the time, Lars was instrumental in supporting my career advancement. He helped me obtain the research grants I needed, appointed me to lead the plastic surgery residency and encouraged me to pursue leadership opportunities. When the time came for me to decide whether to be a candidate for the role of CEO of The Permanente Medical Group, I was ambivalent. I had enjoyed my local leadership role and clinical practice and didn’t know how much I would enjoy a much larger role. He was the one I sought out, and his advice was simple and pragmatic.
“Windows open and windows close,” he said, “and when they open you need to be ready to jump.” Although, in his personal style, he never told me what to do, after talking with him it was clear to me that failing to take the risk would be a decision I would regret forever.
Lars taught me that the evolutionary can be as valuable and powerful as the revolutionary, and the importance of balancing the two. Maybe others could make change happen faster, but none more effectively. He demonstrated the universal truth that thousands of small steps can take you miles.
This article originally appeared on Dr. Pearl’s column in Forbes.