From Cockpit to OR: Surgical Precision and Team Performance With Dr. Matt Cooper

Dr. Cooper drops jaw-dropping tales: defying an anesthesia chief with "he’s not dead till I say he’s dead" to save a bleeding patient (still alive years later), or dodging disaster at 500 feet with quick thinking and trim. From the cockpit to the operating room, he reveals how orientation—our mental map—shapes everything, with top cardiac teams catching four errors per surgery through shared awareness, not flawless execution.  

The conversation soars beyond, tackling healthcare’s fragmentation crisis and reimagining patients as complex adaptive systems, not fixable machines. With AI’s rise and lessons from aviation’s threat management, this episode is your guide to mastering uncertainty—whether you’re leading a team, coding software, or navigating life’s turbulence. Tune in and discover why the OODA Loop isn’t just for pilots—it’s your edge in a world with No Way Out of complexity! 

Matthew M. Cooper, MD MBA FACS FAsMA FCAMA

To Be or To Do: John Boyd and Effective Action – Relevance Persists

John R. Boyd's Conceptual Spiral was originally titled No Way Out. In his own words: 

“There is no way out unless we can eliminate the features just cited. Since we don’t know how to do this, we must continue the whirl of reorientation…”

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Transcript

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Mark McGrath 0:20

So it's 3M , only it's not Minnesota Manufacturing and Mining . Okay , now , I used to work with the derivative of IDS , which turned into Ameriprise , and the headquarters was there in Minneapolis . And that was one of the jokes . I was an East Coaster , I didn't think it was so funny , but whatever .

Dr. Cooper 0:38

There are a lot of jokes coming from that place , but that's another story .

Mark McGrath 0:41

Yeah , offline , but that's another story , yeah offline .

Brian "Ponch" Rivera 0:45

Dr Cooper , I want to get in your background about how you came across one the OODA loop . I know that you're familiar with Scrum , you're very familiar with Lean , you understand team science , you've looked at crew resource management and team steps . But just give us some background on how you came across John Boyd's OODA loop and how you apply it .

Dr. Cooper 1:02

Sure . So in addition to my medical background ,

Introduction to Dr. Cooper's Background

Dr. Cooper 1:10

I have a fairly extensive flying background . It's all civilian but it's everything from aerobatic to doing BFM and ACM with active military folks at Enelis and such , and actually went to work consulting with a company called LifeWings that was a spinoff of CTI Steve Harden and Al Mullins group and we were teaching CRM and aviation-based safety to healthcare . And so I wrote about the similarities between my flying the operating room and was doing , and have continued to do , a very in-depth study of leadership , of decision-making , of how you optimize performance , and continue to do so , and came across John Boyd , first quorum's book , and then read everything I could and then read most of the commentary I could find , and so you know , for me it resonated immediately and continues to do so , and sometimes , you know , it's surprising and a little frustrating . Sometimes you have to communicate to people when for me it was intuitive and resonant . And so I see daily , probably like you gents do , opportunities where this makes sense , where this has value opportunities , where this makes sense , where this has value .

Brian "Ponch" Rivera 2:27

Shockingly , you've done some work with 3M . When I started work with Jeff Sutherland , they were doing a lot of work with 3M at that time and that's kind of how I met Nigel Thurlow . Lean is connected to John Boyd's OODA Loop through the Toyota production system , and then you get into Scrum and Jeff Sutherland's interpretation of the OODA loop , which is built around excuse me how he developed Scrum or co-developed Scrum through the OODA loop . He also claims that it's connected to the Toyota production system , which we now say that they're one and the same . So I want to get your thoughts when you started applying these concepts to you know , from the cockpit to the healthcare industry , maybe into surgical teams . What didn't work for you ? What wasn't working for you when you brought that information over ?

Dr. Cooper 3:13

So , first of all , you have to take the time to develop the culture , and by that I mean there's a maturity that allows you to be objective and constructively critical , to be objective and constructively critical . And unless you take the time to develop the maturity in the system , then it's not going to be successful , it's not going to go over well . And I can give you an example . I mean , early on , I implemented performance debriefs in the operating room . You know , in the traditional way , you let the most junior people , you tell everybody what they did well and then you let the most junior people speak first , so that you don't inhibit or shut down the conversations . But when it got to being constructively what I thought was constructively critical , so that we got better for the next iteration , I had people

OODA Loop Implementation Challenges

Dr. Cooper 3:58

crying leaving the room and so I had to take a step back and say okay , you know , I need to do more behind the scenes work so that they understand .

Dr. Cooper 4:08

And I think one of the things and maybe we'll get into is the difference between civilian life and the military . And I think you know civilian leadership is just catching up with this business of humility and credibility in order to establish trust . Yeah , and I think this civilian side is way behind , where the military has institutionalized that much earlier . And I think trust is the foundation of almost anything . You want to do so however you can , to establish the trust , the openness , that you're as liable to error and need the input as the rest of the team . Then that allows you to then iterate and become better , and so that was certainly the case , and I found that .

Brian "Ponch" Rivera 4:55

We've had some doctors on the show who implemented aviation crew resource management into their surgical teams . We've also had Dr Eduardo Salas , who was one of the creators of the crew resource management , who went on to develop team steps . But I want to unpack your point about making people cry in a debrief , because I've done that not on purpose , but by really following a structured debrief process and without taking people through what we call team development intervention , like actually taking them through a simulation or taking them out of their world and to show them how to communicate , show them how to do these basic things . The problem I ran into about 10 years ago is when I led with debriefing . They didn't know a lot of things underneath it . Right , the humility that you know how to be accountable . We give them a nice structure . We take them through that , have them reconstruct the past , what happened , which most people can't do . They can't even do in a 10-minute simulation . They do with us . Sometimes it actually gets better when we help them out and build that situational awareness .

Brian "Ponch" Rivera 5:54

But I want to go back to that time when you were applying what I'll call effective debriefing and what lessons did you take out of that ? What did you get right about it ? What did you get wrong about it ? How and what are your you know ? What lessons do you take out of that ? What would you get right about it ? Would you get wrong about it ? How would you do it again in the future ?

Dr. Cooper 6:08

Well , if I had to do it again , I'd go slower and I'd start with maybe you know the the . The algorithm was you start with the junior folks , but maybe it's better to start with yourself and say , hey , I screwed up or I need to be better , and open yourself up and show your own vulnerability but also openness to improvement as a start . And you just have to do , you just have to keep trying , and there's some folks who are going to grasp it right away . There are others who aren't . But I think the other important point is and I think most people see new things like this as oh , this is something we're doing today , or this is the new flavor of the month .

Dr. Cooper 6:51

But the difference is , how do you integrate that into the culture of how we do things on a daily basis and throughout ? And so it's not just doing it in the operating room , we're not just doing it in the ICU . I mean , when you think about it , we should be doing that in almost every endeavor , every action . We should be doing an after action report , whatever you want to call it . And so how do you change culture ? Well , that involves not just the rank and file . Leadership has to be out there actively showing that that's a priority , all right .

Brian "Ponch" Rivera 7:25

So you've worked with a lot of leaders in the past and you brought up the point about humility , and that's actually you know . When we create psychological safety in an environment , it's a local construct . It's not something that can be gifted throughout the organization . It's something that leaders have to set the tone on , and that's one thing that we show folks how to do with effective debriefing . And , in your experience , can you kind of walk us through why leaders push back on this ? We'll call it the woo of teams , right , the woo of leadership , which is fundamental to things like TeamSTEPPS and crew resource management and what we teach within the Flow Learning Lab . But why do leaders push back on implementing these things ?

Dr. Cooper 8:01

Well , I think it starts with their own insecurity , their own lack of maturity , their own amnesia about where they once were , and I think those things get together . They forget when they were in a similar position and they think that they're now in some cases . You know , not all cultures are the same . There are some great cultures out there , but when it doesn't work , the leadership forgets where they've come from . They think they're invulnerable . They manifest their insecurities . You know , for a surgeon , for example , you know you say that

Leadership Humility and Trust Building

Dr. Cooper 9:36

surgeons do things the way they were trained in residency . But the side of a mature surgeon , like in other enterprises , is to know when to evolve , when to do things differently . That's a sign of maturity , right ? And I think it's the same thing with leadership as well .

Brian "Ponch" Rivera 9:58

You talk a little bit about ego and maybe there's actually some interesting research I don't have in front of me right now , but it's like having a lobotomy . When you become a leader you forget that , going back to your point who you were , where you came from that you sometimes just do not take information from the outside If it's somebody junior in your organization or what have you . In fact , many people go out and get external coaches and they want to be one-on-one with them . They treat them differently than they would their , their own peers . But can you talk a little bit about ego in the in an operating room and maybe even the cockpit , the similarities and dangers of of both ?

Dr. Cooper 10:33

Yeah , so we all have egos , you know , and , and like fighter pilots who think that they're all handsome but not all tall , I think you said . But you know , we all want to be , I think , at some level , the captain of the ship , and years ago it was true that in the cardiac operating room the cardiac surgeon was the captain of the ship . But the reality is that culture has evolved . I think we've learned that it's better to bring in the shared awareness of what's going on as well as what might go wrong or what might go awry , and so I think we've developed more of a balance .

Dr. Cooper 11:12

So sometimes you do have to put your ego in check . However , sometimes you do have to be assertive . It's not always the time for debate or discussion . Sometimes there are decisions in time-critical situations that are black and white . You don't always get them right because you don't always and frequently you don't have optimal information , and so part of the learning , the long apprenticeship maybe it's lifelong is to know when to assert that a decision has to be made , and sometimes you have to do that against other opinion , against adversity , and that is perhaps a manifestation of ego , but you got to balance it .

Brian "Ponch" Rivera 11:51

I'm curious , as you came across John Boyd's work . I'm sure you came across Mission Command and you just brought up the point that sometimes a leader in an organization has to make a decision , have 51% of the vote . But can you kind of make a ? Is there a connection in your mind between what you see one in the cockpit too , in operating rooms , and then any connection to what you see through a mission command ?

Dr. Cooper 12:13

Yeah , a couple of things . I think the similarities exist in terms of being so well-trained that the commonplace doesn't take your full attention . If it's in the operating room , it means you're trained , but the team is trained also so that when something different happens , you can concentrate on what's different . You know , in the cockpit they teach pilots that when things are quiet you should be thinking about the what ifs right , because things will go on . And in the operating room , you know , for example , I did pediatric cardiac surgery as well and the average pediatric cardiac operation had four errors that occurred and the successful completion of the operation wasn't due to the skill of the surgeon , it was due to the awareness , the willingness to communicate of the team that pointed those out and they were remedied and that's among the best teams . So again , that's the human value of team , the optimal performance value of team .

Brian "Ponch" Rivera 13:14

So I think there's something in there with threat and error management and I wasn't expecting to go there , but since you brought up this , you're trapping something inside of a surgical or an operating room . What we mean by that is you trap the error , so errors come from you , threats come to you . I think that's how it works . So I want to rephrase this again In the cockpit , I think in commercial airlines right now , there's like I believe I'm going to throw a number out there , I may be wrong Seven errors that happen every time a crew goes flying , meaning these things can get outside , they can create a bigger problem , but they trap them , and they trap them because of their teaming skills . The same thing sounds to be true in the operating room and I'm certain the same thing is true on a software team or on a leadership team . Did you come across threat in their management from CRM , and is that where you you get this idea from ?

Dr. Cooper 14:04

Yeah , Okay , absolutely , and I certainly saw it in the cockpit , but certainly in the operating room is more so , a lot of us flying aerobatic planes it's single person CRM , but certainly in a multi-person cockpit or a team or certainly the operating room , there are multiple people involved .

Brian "Ponch" Rivera 14:26

Okay , no , this is great . So when we started our company years ago , we actually built it off of three things it was aviation crew resource management , high reliability theory and John Boyd's OODA loop , and that was before we really understood complex adaptive systems . And fortunately , john Boyd looked at complex adaptive systems and pointed us to things like the Kenevan framework and wicked problems and things like that . Then high reliability theory connects to resilience engineering . It also connects to what is known today as human and organizational performance . So what we're suggesting , not only through this podcast , but what we deliver is , when you look at these natural I'm going to call them natural science approaches to how complex adaptive systems work , which we get through the mass observation of things like flight decks of aircraft , carriers and submarines and even operating rooms . You watch how these high performing teams operate . You can learn a lot from them .

Brian "Ponch" Rivera 15:22

That , compared to what I saw in the agile industry , was a lot of pseudoscience , right , and we've had Alistair Coburn on the show to talk about . Hey , years ago , the agile community went down the wrong path . They went down the pseudoscience path when they should have gone down the Carl Veidt path , which is the high reliability theory , which is what we were kind of talking about here . So what we saw , or what I saw in the years of coaching Agile and maybe a little bit in the lean , is there's a lot of pseudoscience involved in that space and what you're talking about is you basically borrow from what other high performing teams are doing and adapt those practices to your domain or your industry and move forward . So I want to get your thoughts on what you've seen . I know you worked in the . You know a little bit in the agile space as well , but I want to get your perspective on what you saw there .

Dr. Cooper 16:14

Well , that's Boyd's agility right , the willingness to look outside , to change the processes that got you here because they may no longer be the ones that you need today or for the future . And that's a different agility from the agile scrum . But obviously , as you know from working with Jeff and I was at 3M , by the way , when scrumming came in and that was their second exposure to scrum because the first one didn't take , but that's again another tangent . But I think that what you see is that's where most organizations struggle in the face of things which certainly have happened with the pandemic or economic challenges , and for big companies that was certainly the case that prompted spinoffs . It was a necessity to deal with that change in a different way than you have for the last hundred years , and the fact that they didn't do it , weren't willing to do that , were weaknesses , vulnerabilities in their culture that needed to change if they were smart .

Brian "Ponch" Rivera 17:30

Hey , Mark , I want you to unpack some of the things you're hearing from this conversation thus far .

Mark McGrath 17:36

I think what I really take away and I got this out of your paper

Ego Management in High-Stakes Environments

Mark McGrath 17:40

and you know I rated a 10 out of 10 is the importance of orientation . That orientation shapes and that orientation is also fractal and it's also a . You know , the OODA loop sketch is is a an abstraction of how orientation functions . It shows how it shapes and it's fractal at the individual and the team level .

Mark McGrath 18:04

We just had a great conversation with chet richards about that and I think you affirm that and you also talk about distributed decision making and other things and it's how orientation across a team can actually , as you're saying , enhance what it is . And I think that what I would ask you for the leaders that are listening , really narrow and drill down on that hard so that they understand , because even things like ego , I mean that's part of our orientation and we have the humility and the self-reflective powers to account for that . Our orientation gets stronger and stronger . And the other thing I would just add is that you have to constantly break and revise and update that orientation . And I think that that's kind of ties into what Panch was asking about how , when these leaders , why do they push back ? Because they're incapable of breaking their models and revising them and updating them .

Dr. Cooper 19:00

Right , and I think the other thing about orientation , because I absolutely agree , no-transcript . So how do you bring up the average level of performance to a safe level or better level and ultimately to an elite level ? You got to share that , and so that becomes then a shared consciousness , a shared orientation .

Mark McGrath 19:43

I was trying to think of the movie with Alec Baldwin and Nicole Kidman where he's a surgeon and he says I am God .

Dr. Cooper 19:50

Malice , yeah , malice .

Mark McGrath 19:55

That's an example of an orientation that couldn't revise and update .

Dr. Cooper 20:00

I'll give you a real example . I'm pretty modest about having been a surgeon , but it's not uncommon sometimes to have to go back to the operating room after a cardiac operation because of instability bleeding . So there was a fellow I operated on years ago and he was unstable , he was bleeding . We had to take him back to the operating room at night and we were doing CPR on the way to the operating room . We get the operating and the chief of anesthesia is doing the case and he says you know , the patient's dead . And I said he's not dead until I say he's dead and he walked out of the operating room and I saw him annually for years after .

Mark McGrath 20:37

But that's some of the cases where you have to make a decision and maybe that's ego , maybe it's training , maybe it's experience , but sometimes it's not up for discussion yeah , well , I think it goes back to like any anybody and boyd knew this because he did it to his death you constantly have to revise and update your models because everything is in a in a constant state of flux . You can't , you can't statically know um from your medical school days , because things have changed significantly since then . I witnessed an argument the other day with someone on our substack that was , I say , witness , I guess I was a participant pointed out 17 different logical fallacies , 17 different logical fallacies . But what it was saying was like it was pinning something that Friedrich Hayek said in 1938 . He died in 1992 . He had a 54-year career after that one time in 1938 .

Mark McGrath 21:33

But all I had to do was pinpoint on that and then flexibly focus on that . And I think that what you're alluding to is what leaders do , or doctors do , or whatever . They pinpoint on something that they knew to be true or they thought to be true and they don't allow their orientation to be open and they let the entropy settle in because they don't know , they don't realize that they have to constantly update and reorient their models . And that's the title of the Substack is the world of reorientation . That's the title of the podcast . There's no way out of that if you want to thrive .

Dr. Cooper 22:04

Right , but I think you've also discussed on the podcast where AI fits in , and I think that's where , in my mind , that's where augmented performance comes in , and that is , as human beings , we're limited . As the information that we need to evaluate becomes larger and larger , we're less well equipped , because of our own limitations , to do that , particularly incorporating new information and changing the direction of decision vectors . So AI can help . The question , you know it's the same thing in the military right the right information to the right person at the right time . So how do you know when the person's needing that information ? Darpa has been doing a lot of studies on physiologic measurements . And then what information is it ? How do you get it to them ?

Dr. Cooper 22:50

We have analog brains , not digital , and there is some work going on converting information back to the analog to get it better to the brain .

Mark McGrath 22:59

So it seems like AI , well used , is an orientation enhancement for the , for the human in the system and for the for the , for the team in the system . I think that the orientation on AI people think it's going to replace my job and I think that really the orientation that incorporates AI is going to replace the orientation that that doesn't . I mean I I find the more that I interact with AI , the more I've I feel like I've known more about John Boyd than I ever did . Um of 30 years of manual study , um with with the ability to recall things quickly and to apply them fast , but also is going to ask , or I mean , what do you think of this comment ? And I've said it before on the show I think now , maybe because of AI , maybe we could catch up to John Boyd .

Brian "Ponch" Rivera 23:45

Yeah , well , I want to interject something there , moose , and this is something that I just thought of over the weekend , and that is , many pursuits for

Decision Speed and Organizational Identity

Brian "Ponch" Rivera 23:53

AI are to improve the linear , observer-oriented side act cycle , the linear cycle . What I'm saying is we need to use the real OODA loop to improve artificial intelligence , to help us improve human performance , and I think what's happening now with large language models is they're I'm going to use the language of the Kenevan framework here they're targeting the ordered side of the framework , so the clear and complicated domains , whereas humans being complex , adaptive systems , and I think John Boyd's OODA Loop does a great job . His real OODA Loop does a very good job of explaining how those complex systems interact with the external world . The problem is we're using engineering approaches to try to enhance complex adapted systems when we should take a complex adapted system approach to maybe improve overall human performance , which includes that in the operating room .

Brian "Ponch" Rivera 24:44

So I think you've got to be cautious .

Mark McGrath 24:46

Would it be fair to say , doctor , the example that you painted of he's dead ? No , he's not dead until I say he's dead , and you've been treating this guy now for years . It seems to me , as Paunch has just illuminated , that's the difference between a circular , linear OODA loop with flowchart type thinking versus the actual OODA loop sketch , where orientation shapes it , guides and controls what we see in something that's always unfolding and always evolving .

Dr. Cooper 25:14

Right , and that's where AI is challenged . Right , it's easy for AI in most cases to do structured data , but the unstructured data that we deal with all the time is what we really need to make the nuanced decisions . And I think then AI again , as you've stated , beyond the linear . How does it bring in things beyond our ken so that we improve our decision-making ?

Brian "Ponch" Rivera 25:42

So the application of AI into this operational room or operating room is happening now , but I also want to get your thoughts on how doctors are evolving to a change in reality . That maybe the assumptions about how we're treated in my view let me just kind of reframe this In my experience with doctors is they generally do not treat us as a complex adaptive system , that they look at us and try to break us down into a systems view , if you will , and try to target the root cause , which we know . There's no root cause in a complex adaptive system . There's causal factors . So this is kind of leading me to do we have our assumptions wrong about how we should be treating humans , or does that need to evolve ? Or some thoughts on that ?

Dr. Cooper 26:29

Well , it's interesting because it makes me think about whether we all should have digital twins and predict failure modes and things like that in timing , and I think we will in the future . But I think there are a couple of things that have changed in medicine so that those questions may not be asked . They should be , but they're not being asked . And what has changed is and you've probably all experienced it , hopefully minimally with your families is medicine is very fragmented now and it's hard to see who's the person who's steering the ship , who's the person who's got an overall situational awareness of all the aspects and is truly coordinating that . You know it used to be that docs and nurses and their families would get great care in the system . Nowadays everybody needs a navigator to get through so that you're getting coherent , integrated , common sense care . It's very fragmented , things fall through the cracks and I think if they start getting back to the basics then that question can be easily asked .

Mark McGrath 27:39

But I think we're far away from that unfortunately . It seems to go to the institutional , mechanical nature versus the flowing , complex , adaptive system nature where care providers , insurance companies or whatever they're going to operate off of flow charts , they're not going to operate on the complexities , they're not going to allow for change , because we know that orientation is fractal . That's a fractal orientation that's grown and it's become a bureaucratic morass that's actually impeding progress or impeding effective treatment , impeding the complex adaptive systems within it to flourish .

Dr. Cooper 28:47

Right , I mean you see it at all levels . You see it at the average primary care doc whose first concern is I have 20 minutes or 10 minutes per patient and I've got to do the documentation , so half the time I'm with you . I they look at the incremental cost when if they were smarter and looked at a broader , integrated , more understanding of the complexity , as you've said , then in fact they could do better upfront to decrease their total cost of care , which frankly their stockholders would like . But that's not how they think .

Mark McGrath 29:07

Yeah , and that's where the entropy it's like an entropy trap , I mean , it's like an entropy magnet , like bring us more entropy , because that's what's just going to happen , right .

Dr. Cooper 29:16

Well , it's entropy , but it's got a financial incentive to them , right ? Because ? The most complex patients fall off along the way .

Mark McGrath 29:23

Well , that runs out though that's what I'm saying so that energy , of capital or whatever , is getting infused , at some point , that runs out too , and everything crumbles apart and the system breaks down .

Dr. Cooper 29:33

Right . But frankly , to make it clear , a patient who dies early in the hospitalization costs less than complex care .

Brian "Ponch" Rivera 29:46

That's one way to look at it . I mean , it's true though right . Wake up everyone , but you're not saying doctors want you to die in a hospital , right ? No , no , no .

Dr. Cooper 29:57

Quite the opposite . But what I'm saying is we , and very often the payers , have the wrong perspective .

Mark McGrath 30:03

Yeah On the big picture .

Dr. Cooper 30:05

That's the orientation misalignment yeah , yeah , yeah , because you know , we would all say that we want somebody to be as healthy and productive as long as they can can be in their life .

Mark McGrath 30:17

Well , it's like we say all the time , like linear OODA will kill you literally , like it'll actually kill you yeah .

Brian "Ponch" Rivera 30:27

So I want to unpack . I wasn't again . I wasn't expecting to go here either today on on , uh , uh , healthcare . However , if you , if you treat , if you look at us as complex adaptive systems again , um , what needs to change in healthcare ? Uh , and , and how can the OODA loop and the you know , the team , science and situational awareness help change that for the better and your thoughts ?

Dr. Cooper 30:46

So I think the orientation toward precision of what we deliver is important . So I think we can augment . So first of all , take a step back . You know about 70% of a diagnosis when a patient comes to see you is based on the history . It's not based on testing or physical examination . But if you start to augment history with point of care testing , with the ability to say , okay , how do I compare the person sitting in front of me to the last 600 patients , propensity matched in a virtual cohort , then I get a step up in my ability to pinpoint their diagnosis . Once I have an enhanced diagnosis , then I can do the same thing with a virtual cohort of how best to treat them , with what best expected response rate , and so I can be precise for this individual . And so that takes into account an understanding of the complexity that's then manifested but allows me to precisely apply the general base of knowledge to this particular individual . So I think that's where we're going to go . We're just scratching the surface

Healthcare as Complex Adaptive Systems

Dr. Cooper 32:00

of that right now .

Brian "Ponch" Rivera 32:03

So going through the cycle of destruction and creation is absolutely critical to improve .

Dr. Cooper 32:07

Well , I think we've already been destroyed . Now we're putting it together .

Brian "Ponch" Rivera 32:12

Good point . So other aspects of applying you know , not just John Boyd's observer-oriented side-act loop . You read a little bit about EM theory . But where else have you applied this type of thinking and found success or failure ?

Dr. Cooper 32:29

Well , I think the other thing , one of the things that I take out of Boyd , is speed and the need for speed to maintain a , as he would say , decisive advantage . Right , and I think you see that all the time . Sometimes you are in a time critical situation whether it's a patient , an airplane battle where you have to make a time critical decision . Very often you don't have complete information . However , I think you see the same thing in big companies who have to make strategic decisions whether it's analysis , paralysis or some other trait , saying you see that all the time and they lose opportunity .

Dr. Cooper 33:11

And I've thought , well , why the hesitation ? And I think part of the reason why sometimes individuals hesitate or bigger enterprises hesitate is they haven't defined who they are and where they're going . And I think part of it is again a little bit of the maybe it's the fingertip feel of understanding who you are , what your capabilities are , what they're not , but also defining to the agile what does done look like , what's your goal at this . And if that's clear , then I think it's easier to make a decision , a timely decision , if you haven't figured that out and you're just being responsive rather than proactive . I think you see that and you see big companies fail because they're not able to make timely decisions .

Mark McGrath 34:03

I'm emphatically going to agree with everything that you just said , and I always say no essay , no essay , right ? If you don't have the because , as you just said , you know if they don't know who they are ? So , no essay , no essay . If you don't have self-awareness , there's no way you can have situational awareness . Absolutely impossible . Your situational awareness is always going to suck if you have no self-awareness as an individual or as a team .

Dr. Cooper 34:29

Yeah , you know , I think that's one issue . The other thing that resonates for me out of Boyd's work is commander's intent Again something that's common to the military not common in the civilian world civilian world but I always think that if you're going to have distributed decision making , you have to share the information by which you make decisions . Well , that's antithetical to the hierarchies at some big organizations .

Mark McGrath 34:58

They don't want to share . We didn't think you needed to know that . Why would you need to know that Right ?

Dr. Cooper 35:03

right . Yeah , that's a vulnerability right and it comes around full circle . Well , how do you expect people to buy in to what you're asking them to do and help in the decision making , unless you give them the substrate ?

Mark McGrath 35:19

yeah , like that's the shared , the shared consciousness , the , the , the shared orientation . That's again the fractal nature , nature of when , when , why . It's imperative to understand OODA loop sketch versus the , the linear engineered , you know OODA loop .

Dr. Cooper 35:39

I mean it gets back to yeah , go ahead . I'm sorry .

Mark McGrath 35:43

Go ahead when it gets back to doc yeah , well .

Dr. Cooper 35:46

Well , you know it gets back to sort of where we started about culture . You know how do you get the individual to trust . You know a lot of the things we see is we attract talent and then what do we do with talent ? Do we micromanage it to death , to quiet quitting , yeah . Do we micromanage it to death , to quiet quitting ? Or do we optimize and develop it so we get the most back from those individuals , even if they outgrow us ?

Mark McGrath 36:14

That's the multiplier model really Like consciously attracting and nurture as you say attract , nurture and value and retain Right .

Dr. Cooper 36:24

So I'm a big fan of Liz Weissman's multipliers .

Brian "Ponch" Rivera 36:26

Yeah , yeah .

Dr. Cooper 36:27

Yeah .

Mark McGrath 36:30

I also . I love so the paragraph where it starts off with the line Wyatt Earp . You know , saying fast is fine , but accuracy is final . That goes back to the . That's the Schwerpunkt right , that's the orientation .

Dr. Cooper 36:44

Now it's hard to know whether he actually said that , but it's a pretty good quote yeah it's a great , even apocryphal .

Mark McGrath 36:50

But I think the point is is like when people think of speed , they often confuse with haste . You know you're talking about speed . You're talking about something deliberate , with an orientation , where the leader has an intent and it's distributed across the team and there's a shared understanding , because you're showing the fractal nature of orientation . And then , as you go on , in that exact paragraph , it's not how much you know or what you know that gives you the edge . It's how fast you can figure out what's going on and how you can respond to that and adapt to that .

Dr. Cooper 37:23

Right , and it's reasonably intuitive that you need to be fast and precise or accurate , right .

Brian "Ponch" Rivera 37:32

So are you still flying , doc ?

Mark McGrath 37:33

Are you doing any more flying ? I am , I am .

Brian "Ponch" Rivera 37:36

Are you doing any aerobatics anymore ?

Dr. Cooper 37:39

Yeah , so I'm in between aerobatic planes . But I've got a Thorpe T-18 , a two-seat experimental , which is still aerobatic , doing some stuff with that . But at some point , hopefully , I'll get back to air shows .

Brian "Ponch" Rivera 37:53

Which air shows do you like ? Where do you usually fly ? Like , what have you done ?

Dr. Cooper 37:57

Well , so I had an extra 300 for years , and I think the biggest show I flew in . I flew at the Nellis Air Show years ago .

Brian "Ponch" Rivera 38:04

Wow , I flew with the Nellis Air Show years ago . Wow , I was part of the F-14 demo team , so I was the last instructor in the F-14 demo and my body is paying for that . Now I'll tell you that this 230-pound body got crushed around by pulling a lot of Gs all day long . We do back-to-back demonstrations . When I was training the new crew , fly down to Dare County , do an 18-minute show , fly back , hot pit , do it again and no thanks . This body is . There's a cost associated with doing their shows and I'm finding out now . So how's your body holding up to the Gs ?

Mark McGrath 38:43

I'm okay , but I haven't done it as consistently as you know an active duty , no control crashes in the ships .

Dr. Cooper 38:51

I still love it . No , I've had a near miss . I had a bit of fad in my elevator coming out of a tumble and I couldn't get the stick back at about 500 feet and so long story short . I used trim to get the nose up and power for altitude .

Brian "Ponch" Rivera 39:06

Well , let's build on that . How did you know to do that ? Did you ever train to that ?

Dr. Cooper 39:10

So I did Okay .

Dr. Cooper 39:12

So , that's the hangar flying , yeah , and that's the what ifs , yeah . And now thinking , you know a couple of things . I knew I had FOD that I hadn't found before the flight . So the first mistake I made was I shouldn't have done the flight . But having done that in the flight , yeah , I knew the trim authority and an extra was pretty significant Couldn't get the stick back . I didn't think I had the altitude to roll inverted at that point and so I used trim . But time does maybe you've experienced it probably . Time does slow down , yeah , and that's use trim . So , but time maybe you've experienced it Probably time does slow down , yeah

Precision in Healthcare Delivery

Dr. Cooper 39:49

, and that's what happened .

Brian "Ponch" Rivera 39:52

Yeah Well , you're in a flow state there for sure , trying to find some novelty to help you out there . So let's talk a little bit more about that . And you know we talk about flow quite a bit . We actually look at John Boyd's . When you put a boundary around it , it represents a flow system . So we're trying to optimize the currency that's flowing throughout . It could be blood , it could be water , it could be information , energy , whatever the currency may be . But let's take that type of thinking , that flow thinking , back into that intuitive fingerspritzing of fuel approach inside of a team or organizations that's dealing with increased risk or uncertainty or even novelty in the environment . But I want to hear your thoughts on how organizations can leverage the power of flow . And again , it could be any constructive flow from the lean side of the house to the Mihaly Csikszentmihalyi side of the house . But I want to hear your thoughts on how to apply this type of flow thinking to performance .

Dr. Cooper 40:49

You know , I think there's a step before that and that , how do you get the folks you work with to be willing to listen , and who do they listen to ? And you know and maybe it's off the subject a little bit and maybe I'll come back full circle , maybe when I have a better answer but you know , companies and enterprises use consultants left or right , and a lot of the big consultants in particular take stuff off the shelf and it doesn't really apply and it's not really good , and yet companies go back to that . And then sometimes companies , when you've worked with an organization for a while , you lose credibility just by virtue of being in that organization , and so they lose the resource of good ideas .

Mark McGrath 41:33

So I think .

Dr. Cooper 41:33

First , you have to be persistent to get an ear , and sometimes you have to socialize that within an organization so that you can get a sufficient ear of people who are making decisions higher up the chain , and I think you just have to . It's not a precise science and if you got a better way , I'm open to learn that , but you got to be banging on the door , showing people that there's value . There's something else to learn that they haven't conceived of , and the result is very imprecise .

Brian "Ponch" Rivera 42:08

So unfortunately , I'm going to agree with you on this , or fortunately , however you want to look at it . Let me bring up some . You know we've done a lot of work with large organizations . We've done a lot of work with large organizations and what we found is that middle managers that pick up on this , that pick up on these ideas and they really become champions it's insufficient for change in an organization , unfortunately . One thing that Moose and I talk about now is hey look , if you're not an executive , I'm sorry . If you're an executive , you don't understand the OODA loop or you don't understand what we're saying . We don't want to work with you . If we have to spend a lot of time trying to explain this stuff , we're just going to go somewhere else , right ? So we want a low energy approach to building capabilities within an organization .

Brian "Ponch" Rivera 42:51

So , going back to your point , you can't be a profit in your own land . If you're in an organization for a long period of time , the impact that you bring kind of dwindles away over time . People are like , yeah , this may or may not be working and off the shelf approaches let's do Scrum , let's do Kanban , let's do these things . Yeah , those kind of have utility in the right context , but what really matters is building teams , team development , intervention , teaming skills , but nobody wants to put time into this . So bringing it all back together .

Brian "Ponch" Rivera 43:24

The way you build a high-performing organization is your leaders have to buy into this type of thinking and it's a challenge to them , because this is not what you're learning in an MBA . It's not what you learn in course . You actually have to go out and do things like fly an aircraft . You get to learn things from team steps , crew resource management , things that are outside of your domain and you bring them in . That's how this works . You get to bring in consultants that are going to tell you the same thing about SWOT analysis and Scrum and all that other stuff over and over again . So you actually have to step out of your comfort zone and listen to somebody and go wait a minute . That thing works at Southwest Airlines in the 80s , but it doesn't work now . Why is that ? Well , because they stopped doing that , to be honest with you . So you got to find those people that are willing to step outside of their comfort zone and that's , in my view , how you kind of get the organizations to start moving in a new direction Right .

Dr. Cooper 44:18

So a couple of things . I mentioned that when I was at 3M and this isn't any proprietary knowledge we went through two Scrum introductions . The first one , without naming companies , didn't take . And it didn't take because the managers didn't play . They wanted the rank and file to do that but the managers remained managers . They didn't become scrum masters or product owners and they didn't want to have bring in experienced people to serve those roles . So they thought they could do it themselves . Didn't work .

Dr. Cooper 44:52

When we brought Scrum Inc in , everybody had to play and we brought in people who were experienced running it and it took to some degree but frankly it stayed within software . It didn't really go to hardware anywhere else because there was enough resistance . But I think the other thing you bring up Pancho , two other things is that one you have to want to change , but how much do you prioritize the willingness to change and where does that priority fall in terms of available resources , dollars and people to devote to it ? And most enterprises I've seen , whether on the healthcare side or on the medical device industry side , position that fairly low Up near the top we're keeping the lights on and some of the other standard things , but not the more difficult change .

Brian "Ponch" Rivera 45:46

I see the same One thing we do with Scrum Inc . So everybody knows Jeff Sutherland , co-creator of Scrum , runs Scrum Inc Today . He's talking a lot about the things that we're talking about on the show free energy principle , connected to performance , and things like that . So , again , we're not doing any work with them , but in parallel we're seeing very similar activities , which is pretty interesting by itself . So what I ended up doing with Scrum was injecting the human factors side of the house , the team science stuff , and start leading with that . So , rather , starting with the framework , you start with the team development , intervention work where you can , and you focus on the 20% that leads to 80% of your problems the Pareto principle , the Zipf's law . So if you look at how and I think you've looked at aircraft accidents and I don't know if the data are still correct but if you look at why accidents happen in aviation , it's not because of a system failure on the aircraft .

Brian "Ponch" Rivera 46:46

It's generally because of the human factors thing , the same thing in an operating room and I think years ago that may have changed where I think we're losing a 747 every day due to quote unquote due to human performance inside of operating rooms and performance the side of operating rooms and healthcare , or the equivalent of a 747 a day . So the idea is , if you target those things that matter in this case the leadership , the teaming side , the debriefing , the planning , the communication , creating situational awareness , all those things that we believe Boyd Zutelup can tell us how to do , if you understand it correctly , you lead with that and that's

Building Effective Teams in Medicine

Brian "Ponch" Rivera 47:21

what we did successfully and where we are today and , by the way , the research and science backs it up . You start with the human factors and you start to build real teams . One question to you about coming from the medical community are doctors trained on how to work together as teams early on ?

Dr. Cooper 47:45

Okay , yeah , great point and actually it was among my notes about the difference between the military and civilian . You're not trained formally about background , history , how to work with teams and leadership and leadership development is not part of the usual civilian development , even for people like surgeons you know , cardiac surgeon right ? Captain of the ship . You'd think somewhere along the way there might be some value in developing skills about leadership . Not so , again , can the civilian world learn from the military ? Absolutely , there are huge gaps and there's another side to that and maybe you too have seen that , or maybe not , because you're on the good side . But the people I know who've had military backgrounds have a sense of self-validation that allows them to do almost anything in a positive way . But it takes a lot and it's a much more individual , idiosyncratic journey for civilians to do that and they're not all successful .

Mark McGrath 48:53

It's interesting , I wonder , if , where were the first medical school that teaches OODA loop sketch , where were the first medical school that teaches OODA loop sketch , how you know how would they accelerate ? Or or even an established medical school bringing in , say us , to teach and understand the OODA loop sketch , to enhance and enrich what it is that they already , you know , are learning , for something that they're going to have to , they're going to have to do .

Dr. Cooper 49:21

Yeah Well , it changes the foundation of learning in medicine . So , for example , what you're starting to see now in surgical training programs , that it's not numerically based to graduate from year to year , as it once was , because cases are fewer and fewer available . So how do you develop an objective evaluation of performance to advance people to the next level and how do you accelerate that ? And maybe it's the same sort of thing when you start to realize that in fact , it's not just individuals but teams . So if you inject OODA in the bigger sense and you inject team skills in the bigger sense , and how do you objectively evaluate that as a performance assessment that allows you to go on to the next stage ? But but there have to be profound changes in how we , how we teach people in order to make that .

Brian "Ponch" Rivera 50:13

So All right , hey , I want to leave . Uh , you know , turn it over to you to see if you have any questions or anything that you want to talk about . Anything you've read on the show , anything you saw , anything we can help you with .

Dr. Cooper 50:26

Well , I think what you're doing is absolutely terrific and again , as where we started , Boyd's work and all of the connections are amazingly resonant for me and have been for a long time .

Mark McGrath 50:41

And .

Dr. Cooper 50:41

I think that speaks to the fact that this is the reality of the cosmos and this is a way of helping to understand and deal with the complexity and the changing challenges . We see the dynamics and I think that the more we understand it , the more we apply it , the more we continue to expand . It is only a great thing . So how do we get the word out , even to a larger audience ? Because I think there's , as I wrote , but as I believe that there is tremendous value here .

Brian "Ponch" Rivera 51:12

Yeah , your paper . It came out in October 2024 , is that right ?

Dr. Cooper 51:18

Something like that .

Brian "Ponch" Rivera 51:18

yeah , yeah so what kind of reception did that ? Yeah , yeah , so , and what kind of uh reception did you get ? Okay , what kind of feedback ? I mean any comments concerns yeah , not much no , why is that ?

Dr. Cooper 51:28

and maybe , maybe that was the journal wasn't , wasn't the biggest circulation journal , it was on linkedin . I'd given a talk , talk at an international aerospace meeting on Boyd , and even there in an audience which is significantly military space aerospace . You'd think that people would be interested and it was more like oh , I've heard of that , been there , done that , of that , been there , done that , and I think that's I would put that in the case of that's the superficial understanding of the linear OODA rather than the bigger context and the bigger potential .

Brian "Ponch" Rivera 52:08

Well , let's do this . The three of us here we know OODA loop quite well , so let's come up with a game plan on how you could do a 15 minute TEDx or an hour long presentation to really have high impact using John Boyd's OODA loop . So , moose , I want you to go first .

Mark McGrath 52:24

Yeah , I think the power of the article that we've been discussing is the universal applicability of it , so I could give it to any one of my clients and regardless of their you know , irrespective of domain , I always try to drive that point home that the concepts that Boyd was basically tapping into and harnessing these are not synthetic things that are manmade and mechanistic . These are trying to tap into the rhythms of the cosmos for lack of a better term and I think that that's a lot of things why people push back or they rub on it , because they think , well , I can do it better , I can do it better . No , you can't do it better than the laws of gravity and the laws of physics and all the other things that he's harnessing . So I think there's that number one . And number two is the point that I think we've talked about this a lot .

Mark McGrath 53:14

Everything that Boyd is talking about is happening , whether you like it or not , and everything that Boyd is talking about is happening whether you like it or not , and everything that that's going on in OODA Loop Sketch is happening to you right now and you're actually doing this and and your lack of awareness creates the vulnerabilities of why , eventually , your place in that system is going to crash because you can't adapt , you can't revise your models , you can't update and it can apply literally . Your models . You can't update and it can apply literally to anything . There's no limit of what it can apply to . The only requirement is humans that make decisions .

Dr. Cooper 53:48

And put another complexion on it . We worry about optimizing things today , but no matter how we get it for today , it may not be good enough for the future . We should be spending a significant amount of time on preparing , and these constructs are certainly . I know you've talked about heuristics , but they're part of the way to get there .

Brian "Ponch" Rivera 54:10

I think two things for me to really have an impact and I haven't done this yet , we've played around with a little bit is maybe start with the mental health aspect of understanding how genetics , culture and experience can lead to post-traumatic stress right , and it can be positive or negative stress . Those three components of the orientation drive everything for the most part , and they mix with new information . So you could potentially start a talk with starting with mental health , the impact on us , and don't even bring up the OODA loop at all until maybe the very end , right . Another aspect is maybe start with how we perceive reality . The latest and greatest out of neuroscience suggests that our internal map of the external world drives everything . So reality is constructed top down , inside out . It's generated by some world . Go back to your AI example there of a what do you call it ? Not a 3D , but a Help me out there Digital , twin , digital twin , so you have a digital twin .

Brian "Ponch" Rivera 55:13

Yeah , so you have an internal digital twin of the external environment and the map is not the terrain . Yeah , so you have an internal digital twin of the external environment and the map is not the terrain . So that new information coming in is only coming in because what you predicted is not what your sensory organs are actually receiving . So , again , we could potentially create a whole TED talk or a conversation about how you perceive reality , how mental health impacts us , and then reveal John Boyd's OODA loop later on through aviation and go . This was never created around a fighter pilot . Oh , by the way , from a fighter pilot perspective , you can use it and it's pretty powerful and you can apply it for , you know , a cell to a neuron , to an organization .

Dr. Cooper 55:50

I wonder the pair . Actually , Gary Klein has written a little bit about that . You know , 20 years later , looking at recognition prime decision-making and he sees it as two parts , one of which is the experience you've gained that allows you to recognize something the same or similar to apply . But the second stage is that internal simulation .

Brian "Ponch" Rivera 56:13

Yeah , yeah . So this is interesting , that's orientation .

Mark McGrath 56:17

That's going on in your orientation Right . So when we sat , down .

Brian "Ponch" Rivera 56:21

I sat down with Gary Klein four years ago to talk about RPD and the OODA loop , and this is before I learned about the free energy principle and something very important which goes back to that what-if scenario you were talking about . When aviators are flying right , when there's nothing going on , what are you doing ? Well , what they're doing is they're running a constant simulation , you , you doing ? Well , what they're doing is they're running a constant simulation . You're constantly planning , you're building a course of action and for those of you who are not familiar , let's go back to flight training in the mid-90s . For me it is when you're flying across country , you're always looking for divert fields . Where's next ? What can I do next ? What if I have to go over there ? You're always running a simulation that you hope you never have to actually execute .

Brian "Ponch" Rivera 56:58

That is already represented within the John Boyd Zooto Loop and we discovered that and I won't say we discovered it , but we helped make it more known that that pathway that moves from act back to observe , which is internal to the system , is that simulation , the course of action , the policy , and that lines up well with recognition , prime decision making . But at that point , when I was talking to Gary Klein , we were sitting down and drawing this out . I did not know those connections existed and I'd love to go back and talk to him about this , because today my view is RPD is already reflected inside of John Boyd's OODA loop and we brought this up before with not just Gary but a lot of other folks . John Schmidt , who wrote Warfighting for the Marine Corps , worked for Gary Klein , and we're not saying RPD is null and void . It's very , very useful .

Brian "Ponch" Rivera 57:51

What I'm saying now is when you look at John Boyd's OODA loop from the lens of the latest and greatest out of neuroscience active inference , predictive process and Bayesian inference it crushes everything that's out there and it's a simple way to understand how living systems interact with the external environment , and that's what I believe would lead to a great talk about . How do you understand this simple thing that could be applied to understanding psychedelic assisted therapy , to mental health , to how we perceive reality , to creating high performing teams , to developing strategy , which is really dependent on your internal map of the external world , which most organizations don't have . And I want to ask you this when you're going through your training as a doctor to do surgery , don't you have to have a good map of a heart . I mean , yeah right , I don't know what the heart looks like .

Dr. Cooper 58:48

Sure , you obviously Looks like this right .

Brian "Ponch" Rivera 58:52

Yeah , there you are .

Dr. Cooper 58:57

You know , but there's also a learning curve , right , and you know , and , and people learn most from their mistakes or their errors or their omissions or commissions , and that's certainly true of surgeons , um but ?

Brian "Ponch" Rivera 59:11

but you don't want to . You don't want a surgeon doing agile surgery on you , do you ?

Dr. Cooper 59:15

Well , so it was like that years ago . You know the great Denton Cooley's of the world were inventing the operations at the time of the operation . You know things have become a little bit more predictive , yeah , but you do want the recognition of what's different . You do want the novelty sometimes to recognize the novelty and understand when you have to do something a little bit different Because what you're faced with is a little different .

Brian "Ponch" Rivera 59:43

Great point .

Mark McGrath 59:43

Do you find I was curious ? You know before , yeah , I had a

The Universal Applicability of OODA Loop

Mark McGrath 59:49

Wall Street background and I found that every time you bring in Boyd or talk about Boyd , or you try to teach portfolio managers , investment advisory teams , even economists I mean we know this to be very valuable , effective stuff that helps you thrive in all forms of chaos and adversity and there's a lot of pushback because , well , guess what ? He didn't go . John Boyd didn't go to Harvard , he wasn't prepared at Exeter or whatever . He didn't have a PhD , he didn't have a tenured professorial position . All the institutional animosity against John Boyd . Do you ever run into anything like that in medicine ?

Dr. Cooper 1:00:30

Oh sure , but by the way I'm a bit of a Hawkeye , so he was okay . So Boyd went to Iowa , right ?

Mark McGrath 1:00:37

That's right .

Dr. Cooper 1:00:39

So , oh sure , there's a bunch of that . You know , not everybody can go to Harvard . Not everybody who comes out of Harvard is any better than anybody else . Yeah , and I think you know if you have kids we both have kids you know , when you're looking at colleges and things like that , you look at among the things well , what's the network ? What doors does a particular school open up in addition to what their offerings are ? And that's a consideration , at the end of the day , it's the individual that determines . But sometimes it can be a little harder route because you don't have the same network , same exposure . So , yeah , there's the same thing in medicine and you know certain people out of when you come out of certain schools , you get certain residencies and things like that . I think the government's investigating that now .

Mark McGrath 1:01:26

Actually , yeah Well , I think you know it's what's interesting to point out that that was actually his starting point of of of what incited him to write Destruction and Creation , because I think a lot of his questioning how is it that me , a major in the Air Force with no doctorate , with no master's degree , with a full-time fighter pilot teaching lifestyle , with a family with five children , one with severe special needs , how did I do all this in my free time ? How did I come up with EM theory in my free time without all that ? And I think that that was really his starting point .

Dr. Cooper 1:02:09

Well , that's to be , or to do , right . Yeah , so he was the one who was doing it . Yeah , and that's not the way the entire world works obviously , otherwise we wouldn't be here talking about it .

Mark McGrath 1:02:21

Yeah Well cool Doc .

Brian "Ponch" Rivera 1:02:25

What a fantastic opportunity to kind of connect with you for the first time . I know we've been trying to do this for a while . I want to thank you for coming on no Way Out to share your insights on not just Boyd but on how to be an effective leader and some thoughts on the healthcare industry as well . Any last thoughts or questions for us or anything you want to lay in part with our audience ?

Dr. Cooper 1:02:47

Just to say thanks and that keep up the battle , because I think , again , there is tremendous , tremendous use and applicability of Boyd's theories and the connectivity that it leads us to , that we will only be better for it and again , thank you .

Brian "Ponch" Rivera 1:03:06

Thank you . Thanks for coming on .