50/100 - What I Have Learned
The Teaching Hospital
This is post 50. I am halfway through the rule of 100.
Last week I went back and read the fourth thing I started posting regularly online. I had forgotten what I wrote in it.
The line that stopped me was one I had left for my future self. “I’m genuinely excited to see what I’ll have learned, what new connections I’ll have made, and how my own thinking will have evolved by the time I hit post #100.”
Past me had a plan I had quietly been keeping. Twelve months in, I went looking for the right name for what I had been building, and Stanford Health gave me one.
If you have lived in the Bay Area for any length of time, you have heard somebody describe Stanford Health as a teaching hospital. It is how the place introduces itself.
Buried in the Stanford Medicine principles document is a sentence that recasts the phrase. “Without that academic component, there is no reason for us to have a clinical enterprise.”
The teaching is the reason the hospital exists. The medicine is the byproduct. Fifty posts in, I see now I have been quietly running one of these on myself.
What a teaching hospital actually is
A teaching hospital has a triple mission: clinical care, education, research, all interdependent. A patient at one with the same diagnosis on the same day has measurably better odds than a patient at a hospital down the street. A 2017 JAMA analysis of twenty-one million Medicare admissions found adjusted thirty-day mortality at 8.3% at major teaching hospitals against 9.5% at nonteaching ones. The gap is structural.
The structure is a specific list. Bedside teaching, going back to William Osler at Johns Hopkins in 1889. Grand Rounds, weekly, in every department. Graduated supervision, with autonomy granted on demonstrated abilities, not seniority. And programs like Stanford Medicine 25 that exist for the sole purpose of keeping the teaching at the center of the practice.
The teaching is what produces the better outcomes. Not despite the trainees. Because of them.
That sentence changes what you are looking at when you walk into Stanford Health. It also changes what you are looking at when you scroll through fifty LinkedIn posts in a row.
Don’t get me wrong. I am not the attending in this metaphor. I am the resident, fifty cases in. The lessons are partly mine and partly yours. But the parallel was too clean to keep to myself.
1. The bedside is the desk.
Bedside teaching is the founding act of the modern teaching hospital. At Stanford Health, every department still practices it the same way. The attending and the residents walk into the patient’s room together. They take the history together. The diagnosis happens out loud, with everyone hearing the reasoning, including the patient. Osler’s line was “medicine is learned by the bedside and not in the classroom.”
That has been the architecture for over a century. I have been running it at my desk for twelve months without realizing it had a name.
I cannot write a post called “be a better leader.” I have to say which mistake I saw on Tuesday and what I would do differently. The reader gets the case notes. I get a diagnosis I had not made out loud yet. And sometimes the reader sees something I missed and tells me so in the comments. Half the lessons in fifty posts arrived at the moment of writing them down. The other half arrived after, from someone pointing out what I had not.
The case is the unit of work. Frameworks index the case archive. The actual learning lives one bedside at a time.
At a teaching hospital, no case stays at one bedside for long.
2. The teaching is the practice.
Stanford Health runs Grand Rounds every week, in every department. The format goes back to Osler too. A clinician presents a real case in front of the residents, fellows, and faculty. The reasoning happens out loud. Residents ask questions. The teacher answers them in real time. The audience learns from the case. The presenter learns more, because the act of presenting in public is what forces the reasoning to be sound.
Stanford Medicine has its own modern version of this, called Stanford Medicine 25, run by Dr. Abraham Verghese. He is a Stanford physician who is also a novelist. Cutting for Stone. The Covenant of Water. The program teaches twenty-five physical-exam techniques to residents, week after week, in front of an audience. One of the courses is named “Body as Text.” Verghese has spent his career arguing that the act of teaching the exam IS the medicine. The same person at the bedside on Tuesday is the same person writing novels on Sunday. His own life is the proof.
Verghese named what I had been doing without knowing the name for it. The same play, run on a keyboard with a publish button, comes out the same shape.
Every weekly post is a case at rounds. The audience is the residents and faculty in the room. Comments are the questions the audience asks. A colleague messaging me on the side. A senior leader replying with one line. A friend re-sending the post a week later with a sharper framing of what I had written. All of it is rounds. All of it forces the reasoning to be sound.
If I cannot explain why the case turned out the way it did, I did not actually understand it. The teaching is the test. Publishing is how a desk gets a supervising attending.
3. The institution is the byproduct.
A teaching hospital is structurally a learning organism. Every case generates institutional artifacts: the case archive, the curriculum revised every year, the standing protocols. Stanford School of Medicine generates research output that outlives any single resident who walks through it. Graduated supervision (the ACGME’s three-tier model: direct, indirect, oversight) is the institutional rule that turns experience into expertise instead of just hours into seniority.
Stanford Health has had over a century to build its institutional artifacts. I have had twelve months. The shape is the same. The scale is not.
Fifty cases later, the system around me is bigger than any post. There is a topics tracker. A voice fingerprint document calibrated against my own writing. A four-pass polish loop. An AI editor that catches my basic mistakes while the ideas and the point of view stay mine. A workflow that has versioned itself twice. I did not plan these. They emerged from the practice the same way Stanford Health’s institutional artifacts emerged from a hundred years of cases.
The institution is what compounds, not the individual cases. Paul Graham wrote about this.
“Whenever how well you do depends on how well you’ve done, you’ll get exponential growth.”
The writing got easier somewhere around post thirty. The thinking did not get faster. The institution did.
What fifty cases looked like up close
Some of these posts I wrote three weeks ahead of publish day, with a clean outline and a calendar that smiled back. Most of them I did not.
Some I wrote on Friday afternoons with the 8 AM Pacific publish slot closing in fast. Last-minute pushes where the post and the week were getting written at the same time. Some I wrote during weeks I would not write about openly. When something at work was breaking and I could not name it. When something at home needed more of me than I had. When I was tired in the way that twelve months of any commitment makes you tired. The posts you read in those weeks did not say so.
Reading them now, I can see the seam underneath. What is on the page is what I had to work out about leadership while the rest of life was happening at the same time. The thinking ran on a parallel track to the living, and writing it down was how I kept the two from drifting apart.
It’s hard - yet it’s so easy!
A few of the posts mattered more than the others. I cannot always tell which ones from my side of the screen. The ones I thought would land sometimes did not. The ones I almost did not publish turned into the most meaningful conversations I had on the platform last year. The audience is rarely where I expected them to be. The lessons I am most sure of now are the ones the comments forced me to be more honest about than I had been with myself.
The plan past me wrote down is real. The thing I built is not what I thought I was building.
Twelve months in, the institution has a name. Fifty cases on the board. Halfway to a hundred.
If you have been writing online, what is the institution you did not realize you were quietly building? And if you have not started, what is the first case you would put on the board?
#Leadership #WriteToThink #LearningInPublic #TeachingHospital #RuleOf100