Category Archives: leadership and management

What product managers can learn from hospice nurses

I wasn’t expecting to learn anything related to product management and software development in a book about how we age and care for aging family, but I did. I have just finished reading Being Mortal by Atul Gawande, who also wrote and conducted the research and transformational changes in The Checklist Manifesto. (Image credit: Public domain: https://commons.wikimedia.org/wiki/File:Stethoscope-2.png)

From doctor-knows-best to patient-knows-best. Gawande talks about the changing role of doctors over time. In our grandparent’s era, ‘doctors knew best’. That was the age of the authoritarian doctor who made the decisions and was trusted to do so. Now, in contrast, for the most part, doctors are considered technical experts who can share information, but decisions ultimately rest with the patient. The idea is that the patient knows best, when given all the facts. However, when patients face important crossroads in their treatment and there are many uncertainties, neither approach works well and both lead to escalating interventions and, often, miserable people.

Both lead to suffering. The authoritarian path didn’t work well for patients because it didn’t take the patient’s fears and hopes into account at all. Without the patient’s preferences, doctors recommend actions within their own sphere of expertise.  Surgeons recommend surgery rather than hospice because surgery is what they know best. But Gawande, who was trained in the current technical-expert-sharing-information model of doctoring, illustrates how information sharing goes just as wrong when it comes to delivering the experience that patients would want. He tells several stories from his own practice, where patients clearly said, I don’t want to suffer, and I don’t want pointless heroics, but then choose to proceed through many, many rounds of painful procedures with very low probability of success. Why is that? 

Software development has the same duality. In software development, we also have this same duality. The authoritarian model:  Which employee is the ‘owner’ of this product? They should make all the decisions about what to develop, and be responsible for the consequences.  Or, alternatively, the ‘Information’ model; let’s have the expert (product manager) gather the facts and present choices to leaders and other stakeholders; or lets develop objective metrics to guide us. And similarly, it can feel like we see-saw between decisions made with too little information and decisions that feel like the information was there, but it was never pulled together into the right decision. So I was very interested in why neither approach is working for doctors and patients, and what might be a better approach. 

Why the informed patient model still fails. Gawande’s analysis of the informed patient that still makes the wrong decisions is that they don’t have the experience or the medical model to make the decision, even when they have all the facts. So, assuming you aren’t an astronaut or experienced physicist, think about it this way. If I put you in a space capsule, ask you where you want to go (which is what the doctors-know-best doctors forgot to do), and I tell you a bunch of readouts and their percentage likelihood of being correct, and then ask you whether to launch, you still aren’t going to be able to make a good decision, because you don’t have a model in your head about how all those measurements add up. Gawande specifically talks about how a patient might be imagining that a particular procedure with a high likelihood of success could extend their life by years, when in reality it is likely to be weeks, not years. The patient doesn’t have the experience to put all the information together into a coherent model and make a good choice. 

So now what? So, is there a middle ground? Gawande describes a model where doctors gather even MORE information about what a patient WANTS by using four questions that come from the world of hospice. Then, the doctor combines the patient’s answers with their professional experience to guide patients in making decisions that are consistent with the patient’s own desires. 

Learning from hospice nurses. The four questions are also interesting. 1. What do you understand about your situation? 2. What do you fear? 3. What do you hope for? 4. What trade offs are you willing and not willing to make?

Ask, tell, or guide? A middle path to product development.  In the world of software development, many organizations (including the one I work for) hire Product Managers to lead product development. In specific, Product Managers are responsible for deciding what features should be added to a product and with what priority. So the question is “Are Product Managers owners (the authoritarian model), expert consultants (the information sharing model), or expert guides (the new model Gawande proposes)?”

I would posit that the same insight Gawande has about doctoring is the right insight for product development. Product Managers don’t own their product. The product isn’t FOR them and there are too many critical stakeholders for them to be owners. But they also can’t present information and expect decisions from business leadership, precisely because the business leaders don’t have the full context and understanding of the detailed workings of the product and market. The product managers DO have that context. 

My key insight from Being Mortal is those four questions that hospice nurses taught doctor’s to use to help them guide their patients. I am curious about whether those questions can be adapted to gather the right information, especially from business leadership and organizational stakeholders that don’t directly interact with the product, to allow Product Managers to wisely incorporate their requirements into good decisions.

So here are the four questions again

  1. What do you understand about your situation? 
  2. What do you fear? 
  3. What do you hope for? 
  4. What trade offs are you willing and not willing to make?

Frankly, they almost work as is. I would only change the phrase ‘your situation’ in the first one to match the context. It could be ‘what do you understand about our goals’, ‘what do you understand about our revenue position’, ‘what do you understand about our strategy for …’

I am going to give these a try. Let me know if you do too!

Key meetings and the power of “What’s up with that?”

One of the biggest privileges of leadership is building on the brilliance and creativity of others. What I can do on my own is small compared to what I can do as part of a team. And, hopefully, what I have learned over the years helps the ambitious, creative, brilliant people that work with me achieve meaningful goals. It is definitely a messy business because people are messy, precisely because of the unique talents and perspectives we all bring. The following are not exclusively my ideas, but I have tested and tested and tested them over again, and they have proven their value. Where possible, I will tell you what sources I based these strategies on.

  1. Some meetings are key. You have to meet with people one on one every week for at least 30 minutes. 
    1. Why one on one? Because when something is uncomfortable or going wrong it either won’t come out in a group meeting or will come out sideways and create the additional need for understanding and repair with a lot more people. 
    2. Why once a week? Because if the frequency is less than that, the vacations, travel, and illness that occasionally derail these meetings create breaks that can span three to four weeks and a month is definitely too long for a problem to fester. 
    3. Why 30 minutes? It takes 30 minutes to talk about a complicated subject. I actually have found that if I meet with someone about projects AND people (including themself), I schedule 45 minutes minimum because the complicated subject often comes up after some simpler things get discussed.

  2. The power of “What is up with that?” I learned this respectful strategy for recovering from failures from The 7 Habits of Highly Effective People by Steven Covey and the wonderful parenting book how-to-talk-so-kids-will-listen-and-listen-so-kids-will-talk by Adele Faber. The basic idea is that, when you think something has gone wrong, the most important factor in resolving the problem is understanding it.

    The first step is to describe the problem non-judgementally. So, for example, the non-judgemental description part might be I noticed that we aren’t going to deliver feature-x by time-y or “I noticed that we had an outage yesterday,” or “People looked tense in meeting z,” or “We collected this data, and I thought it was pointing us toward doing x, but then we did y.”

    Then you ask “What is up with that?” to the person most likely to be responsible and/or have critical information. (For non American English speakers, you can try “What happened with that”? Or “What is going on with that?”)

    As a leader or manager (or team mate) it is your responsibility to discuss any setbacks your team faces, but no one is perfect at handling these conversations. This technique works for anyone, but it is particularly useful for both under and over-reactors. For those of you who might prefer to avoid conflicts, it gives you a way to discuss something in a simple, factual, non-confrontational way. It also works for those who tend to jump to conclusions and overreact, which could intimidate the receiver of the message, by instead giving the receiver space and respect to respond.

    The key to this technique is not to overload either question with whatever stories you might be telling yourself about why or who is to blame. Leaving those stories out preserves trust, maintains a team atmosphere, and keeps the person you are asking on your side and un-defensive. The form of the question is important because it is neutral and open to the information the person you are asking has. You will be surprised what you learn. From a heart-felt “I screwed up and here is how I am fixing it” to “Oh, because we got an opportunity for even better feature la-di-da” to “We didn’t have this important thing we need. Can we work together to figure out how to get that?” It takes a ton of practice, but the good part of this is that the more you do it, the more you trust that you really do have colleagues working with you and not against you.