Reviews and Commentary n Historical
Perspectives
Note: This copy is for your personal non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights.
Bill Cook1
Richard B. Gunderman, MD, PhD
W
illiam A. “Bill” Cook (January 27, 1931–April 15, 2011) started Cook Incorporated in 1963 with an investment of $1500. Today, the value of the fortune he left behind is estimated to be $6.1 billion (1). He built his fortune by creating the largest family-owned medical device manufacturer in the world. But the most notable aspect of the story of Bill Cook and Cook Incorporated is not commercial success or wealth creation. Instead, it is a story of shared vision and dedication. At this time of great flux in radiology and throughout health care, it is especially important that we pause from time to time to reacquaint ourselves with the lives of the most visionary people in the history of our field, whose core principles should serve as a source of enduring illumination. And one of the most illuminating of all is Bill Cook, who, with his close friend Charles Dotter, MD, helped create the field of interventional medicine.
Dotter
1
From the Department of Radiology, Indiana University Medical Center, 702 Barnhill Dr, Room 1053, Indianapolis, IN 46202-5200. Received July 21, 2014; revision requested August 7; revision received August 20; final version accepted September 6. Address correspondence to the author (e-mail: [email protected]). RSNA, 2015
q
636
Cook and Dotter first encountered one another in 1963 at the annual meeting of the Radiological Society of North America (RSNA), which took place between November 17 and November 22 (2). It was held at the Palmer House hotel in Chicago, Illinois, and included 61 refresher courses presented by 76 speakers. On the final day of the meeting, participants learned of the assassination of President John Kennedy. One of the 102 technical exhibitors at the meeting was Bill Cook, then the sole proprietor of Cook Incorporated, a nascent medical device company in Bloomington, Indiana. Visitors to the technical exhibits saw Cook standing at a table in coat and tie, with signs displaying wire guides, catheter tubing, and catheterization sets behind him
(Fig 1). On the table was a blowtorch that Cook used to form catheters. One day Cook noticed a “short, bald, muscular man with darting eyes” hovering around the booth. Cook asked the man if he could help him, but the man declined (3). At closing time the man returned, this time approaching and asking if he could borrow Cook’s blowtorch and some Teflon tubing so he could experiment with them in his hotel room that night. Cook had his doubts, in part because he had no spare equipment, but he agreed. Before the man walked out, Cook asked him his name. “Charles Dotter,” he replied. Early the next morning, Cook returned to his exhibit and found 10 beautifully formed catheters that he sold for $10 apiece, producing a sum that nearly paid for the exhibit. Cook saw his first spike in orders immediately following the meeting. This was the beginning of one of radiology’s most fruitful academic-industrial partnerships. For the rest of the meeting, Cook and Dotter spent their evenings engaged in spirited discussions about the future of catheter technology. Dotter invited Cook to visit Portland, Oregon, where he was the chair of radiology, a role he had assumed at the precocious age of 32. Cook said that he would like to accept, but could not afford to make the trip. So Dotter, who had made a fortune as a young man speculating in the precious metals markets, offered to cover Cook’s expenses. When Cook arrived, he found a laboratory “second to none in the United States” (4). Dotter was blazing a path in what would become known as interventional medicine. He began sending novel product concepts to Cook, who quickly custom fabricated the devices to Dotter’s specifications. The integrity and physical properties of the products were carefully tested before shipment, and the products were
radiology.rsna.org n Radiology: Volume 274: Number 3—March 2015
HISTORICAL PERSPECTIVES: Bill Cook
Gunderman
Figure 1
Figure 1: Bill Cook at his technical exhibit booth at the 1963 RSNA annual meeting. (Reprinted, with permission, from Cook Medical.)
often used clinically the same week they were produced. In January of 1964, Dotter was consulted about an 82-year-old woman with diabetes whose feet had developed ulcers. Her surgeon recommended amputation, but she refused. So the surgeon turned to Dotter, whom he asked to perform diagnostic angiography. On performing the study, Dotter found a short-segment tight stenosis in the femoral artery. Dotter had been experimenting with animals to develop a technique he called “transluminal dilatation,” and he decided to attempt it on this patient (5). He passed progressively larger catheters through the stenosis, gradually opening it up. Almost immediately, the patient’s foot became pinker and warmer, and, over the succeeding weeks, her ulcers healed. The stenosis remained open until the patient died of pneumonia 2½ years later. This was the first time that a human patient’s circulation had been restored by using nonsurgical means. Word of Dotter’s new techniques spread rapidly. In August 1964, he was featured in LIFE magazine, which then had the largest weekly circulation of any periodical in the United States (Fig 2). The issue featured ads
for Viceroy filter-tipped cigarettes, the “100,000 mile durability champion” Ford Comet, and photographs of fashion models sporting clothing made of DuPont’s Dacron (“America Lives in Dacron”), which several years earlier was the material used for the first artificial vascular grafts. The Dotter article is titled “Clearing an Artery” and subtitled “Plumbing-style ‘Snake’ Restores Blocked Circulation” (6). It includes a sequence of photographs of Dotter performing a 1-hour angioplasty procedure, including one in which he is “beaming with a look of impending triumph.” Dotter is one of those rare physicians in the past 100 years whose contributions might literally be said to have saved the lives of countless people. He is usually regarded as the single most important figure in the development of interventional radiology. Both angioplasty and the catheter-delivered stent were also his innovations. And he taught and collaborated with many pioneers in radiology, including Melvin Judkins, MD, who developed the transfemoral technique for coronary arteriography using specially shaped catheters. Another colleague was Josef Roesch, MD, who developed the technique for
Radiology: Volume 274: Number 3—March 2015 n radiology.rsna.org
transjugular intrahepatic portosystemic shunt placement. Dotter served as chair of the Department of Radiology of the Oregon Health and Science University in Portland for 33 years, until he died in 1985. After his death, Cook donated $2 million to help establish the Dotter Institute at the Oregon Health and Science University. The innovations spawned by Dotter and Cook’s collaboration would not have been possible without the contributions of a Swedish radiologist named Sven Seldinger (1921–1998). Prior to Seldinger, the only way to get a catheter into a blood vessel was to perform a cutdown procedure, directly exposing the vessel. Seldinger, whose family ran a mechanical workshop, attended the Karolinska Institute, Stockholm, Sweden, where he developed the nowfamiliar percutaneous technique of vascular catheterization involving the use of a hollow needle, a wire, and a catheter. His article describing the new technique was published in Acta Radiologica in 1953 (7). The technique is now routinely used for central venous access, angiography, angioplasty, vascular stent placement, and gastrostomy, among many other applications.
Cook Bill Cook was a serial entrepreneur (8). A graduate of Northwestern University, Evanston, Illinois, who had also served a 2-year stint in the U.S. Army as an anesthesia technician, Cook worked briefly for American Hospital Supply Corp. Before starting the company that would bear his name, he and a partner had founded two other businesses in Chicago. The first made novelty products, including a shot glass that, when drained, revealed the image of a nude woman. Although the product sold well, repeated exposure to alcohol eventually caused the
Published online 10.1148/radiol.15141243 Content code: Radiology 2015; 274:636–640 Conflicts of interest are listed at the end of this article.
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HISTORICAL PERSPECTIVES: Bill Cook
Gunderman
Figure 2
Figure 2: Photograph from the August 1964 LIFE magazine story on Charles Dotter shows Dotter in the angiography suite.
images to peel away from the bottom of the glasses. Cook and his partner then started a business manufacturing disposable hypodermic needles, and this firm eventually grew into the thirdlargest supplier of hypodermic needles in the United States. Soon, however, Cook grew restless and decided to start another company. Weary of Chicago’s harsh winters, Cook and his wife Gayle decided to take their infant son Carl and drive south through Illinois and Indiana in search of a warmer place to live. Packing up their 1960 Corvair and with limited savings, they settled in Bloomington, Indiana, home of Indiana University, which was also Gayle’s alma mater. Cook had a radiologist cousin in California, Ivan Fucilla, MD, who had recently learned of the Seldinger technique and suggested that Cook look into manufacturing the wires and catheters required to perform it, an essentially unoccupied niche at the time. Borrowing $1500, Cook turned one of the bedrooms of their modest two-bedroom apartment into the company’s first production facility, from which he also made its first sales calls. Cook recalled that in the early days he conducted all of the company’s business from the apartment. He had used some of his initial capital to purchase a blowtorch, soldering iron, wire, and plastic tubing. When he was making sales calls, he would don a coat and tie. When it was time to manufacture more product, he would remove his coat and 638
tie, role up his sleeves, and sit down at the workbench. Gayle did the company’s bookkeeping and, unbeknownst to her husband, served as its first quality control officer, removing and hiding product that she regarded as poor in quality. Cook only learned of this part of his wife’s work 4 years later when the Cooks cleared out their apartment to move into the three-bedroom house they occupied for the remainder of his life. The date of the firm’s first sale was September 9, 1963, just 2 months before the meeting with Dotter at the RSNA. On August 29, 1963, Cook sold two wire guides to the Illinois Masonic Hospital, with a sales price of $3.50 each (9). The day the check arrived, the Cooks went out to eat at McDonalds, establishing a tradition repeated with each of the fledgling company’s early sales. In the firm’s 2nd year, Cook hired a young high school graduate, Tom Osborne, the son of a local jeweler, as his first production specialist. Osborne soon proved to be a master innovator and developed a new wire coiling machine that proved crucial to the company’s success. Later, Cook hired as the firm’s first dedicated salesperson Miles Kanne from Chicago, who bunked nights on the Cooks’ couch for much of his 1st year of employment.
Cook’s Philosophy In the 1970s, Cook noticed that, as the firm was growing, the employees were
becoming increasingly disenchanted (10). So one day he gathered each of his 300 or so employees around the loading dock and told them something had to change. Productivity was declining, problems with quality were beginning to arise, and employees were beginning to exhibit a high rate of absenteeism. “If we continue on our present course, we will be losing money within 2 years,” he said. Cook told his employees that he would make them a deal. If they would commit to rectifying these problems, he would “work my tail off to make things right” (4). He discovered that some managers were seen as dictatorial and too rigid. Employees felt that they were not being given an opportunity to perform at their best. Cook began rearranging management because, as he put it, “Managers are not what is necessary for success” (4). Reflecting on what made employees successful, he determined that good production personnel were not always good managers, and vice versa. So he hit upon what became the most important criterion for hiring and promoting leaders in the organization. This was simply that he knew them well and liked them. This was not an arbitrary concession to Cook’s tastes. If after getting to know them well he liked them, he could be confident that they would be reliable, not sow the seeds of dissension, live up to their word, be self-starters, and get along well with others. Simply put, the key to building a good organization is to populate it with good people. So Cook recognized that the best leaders for the organization would be people like him, who enjoyed their work, were goal-driven, and would do what it took to make sure that the job got done properly and on time. His goal was to ensure that he could operate on a friendly basis with all his managers, and they in turn would operate on the same basis with each of the employees. And though there was a lot of work to be done, he would not hire too many people to do it. For example, eight of the firm’s senior executives all shared one secretary. Why? In large part because their work was
radiology.rsna.org n Radiology: Volume 274: Number 3—March 2015
HISTORICAL PERSPECTIVES: Bill Cook
done best when they interacted directly with customers, employees, and suppliers—not through an administrative intermediary. Several additional features of the Cook culture deserve to be highlighted. First, Cook did everything he could to foster a team environment in which he functioned much more like a coach than commander. He realized that if he liked the people he was working with, he and everyone else could get more things done. So he invested a great deal of time and energy in getting the right people on the team, and he continued this investment by talking frequently with employees about what was preventing them from doing their jobs well. He managed by walking around, and he encouraged others to do the same. For example, he was a regular fixture on the production floor, invariably stopping to talk with many employees. He enjoyed their respect in part because they knew he had once been in production himself. Cook took the same approach with his customers. He loved to talk with physicians about the work they did, the challenges they faced, and how his company could help them solve clinical problems and take better care of their patients. He hired people who felt likewise. Cook’s field team was not a salesforce and, in fact, Cook’s sales people were paid not on commission but on a straight salary. In fact, Cook often said that his field representatives would not know how to ask for an order. If a customer wanted to place an order, they could phone Cook’s 1-800 number, the first in the industry, and talk directly with a customer service representative. The field team’s mission was not to move merchandise but to listen to customers and develop collaborative relationships with them. He would often say, “We don’t sell, we educate and learn from the customer,” meaning that physicians’ clinical knowledge and his employees’ know-how were both crucial factors in the equation for innovation (4). Flow rate, tensile strength, radiopacity, and biocompatibility were among the
Gunderman
many characteristics that needed to be mastered by Cook employees and shared with customers to achieve a match between specific patient needs and products. Cook also often said of his company, “We do not practice medicine” (4). Cook was so committed to customer service that he operated a fleet of airplanes. If a product failed in some way, the company would often fly out a representative the very same day. The representative would meet with the physician, investigate the problem, and bring the defective device back to the plant for further study. Cook also flew physicians to the company so that they could see where the devices were developed and manufactured, thereby helping build better collaborative relationships. Cook unfailingly dealt with physicians in a very respectful manner, believing that they were the experts who ultimately saved lives. The job of Cook Incorporated was to meet their needs as effectively as possible. In later years, he was disturbed when he saw physicians becoming subservient to hospitals, insurance companies, and regulators. Cook led by example. No one was more committed on a daily basis to the success of the company, and no one worked harder. He wanted people to take satisfaction and pride in the work they were doing, so he had very few rules. He gave everyone an opportunity to innovate and enhance the quality of their work. In other words, he was an inveterate delegator who believed that by giving people freedom and trust, you tended to bring out their best. Educational and professional credentials mattered less to him than what people actually showed they could do, and in some cases, unexpected people rose to senior positions in the company. For example, one company president, Phyllis McCullough, was a former secretary in the firm and another, Kem Hawkins, had been a high school band teacher (10). Cook emphasized that the company was making not just money but products that were restoring patients’ health and, in many cases, saving
Radiology: Volume 274: Number 3—March 2015 n radiology.rsna.org
their lives. He said, “Make sure you do your best, because someday the device you are making may be used on you” (9). True to his word, as a heart disease patient he always insisted that his physicians use Cook devices. However, he never had them made especially for himself, instead pulling them off the rack at the plant. He happily told employees and customers, “Every needle, wire, and catheter that has been used on me has been made by the company” (9). Charles Dotter was the first radiologist to share his vision with Bill Cook, but he was far from the last. Other pioneers built similar deeply collaborative and enduring relationships. Today the Cook companies manufacture more than 17 000 unique devices, virtually every one of which was created in collaboration with physicians (10). Cook knew that such relationships must be nourished over time if physicians are to move medicine forward. He also knew that excellence is not primarily about money, and he felt strongly that material success brings with it responsibility to put resources to work for communities. One of the many forms Cook’s philanthropy took was historic preservation, and he and his wife are credited with saving 57 historic structures in Indiana alone (1). Finally, and perhaps most important, Cook believed that radiology and radiologists need to remain focused on improving the care of patients, without worrying too much about payments, competition, or politics. Ideas that genuinely improve the quality of life will be rewarded, but rewards always follow performance, not the other way around. For these and many other reasons too numerous to detail here, Bill Cook serves as a shining exemplar of excellence in leadership, and many tenets of his leadership philosophy are urgently needed in health care today. Especially in times of rapid change, it is all too easy to become distracted by little things and lose sight of the ones that really matter. As radiologists navigate the uncertain health care waters ahead, we would do well to bear in 639
HISTORICAL PERSPECTIVES: Bill Cook
mind Cook’s curiosity, entrepreneurial spirit, relationship building, integrity, deep commitment to bringing out the best in others, and overriding dedication to the good of the patient. Disclosures of Conflicts of Interest: disclosed no relevant relationships.
References 1. Forbes. The world’s billionaires. http://www. forbes.com/profile/gayle-cook/. Accessed August 20, 2014.
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Gunderman
2. Geddis LA, Geddes LE. The catheter introducers. Chicago, Ill: Mobium, 1993. 3. Monagan D, Williams DO. Journey into the heart. New York, NY: Penguin, 2007. 4. Indiana Public Media. Bill Cook: one heck of a ride. Bloomington, Ind: WTIU Television, Indiana University, 2014.
7. Seldinger SI. Catheter placement of the needle in percutaneous angiography. Acta Radiol 1953;39(5):368–376. 8. Smith JH. Snowing in Chicago: the story of a fortuitous detour and the founding of Cook Inc. Old Saybrook, Conn: Greenwich, 2009.
5. Payne MM. Charles Theodore Dotter: the father of intervention. Tex Heart Inst J 2001;28(1):28–38.
9. Hammel B. The Bill Cook story: ready, fire, aim. Bloomington, Ind: Indiana University Press, 2008.
6. Life Magazine. Clearing an artery. August 14, 1964; 43–46.
10. McCullough P. 40 years, the story of Cook. Bloomington, Ind: Cook Inc, 2003.
radiology.rsna.org n Radiology: Volume 274: Number 3—March 2015
Perspectives
Note: This copy is for your personal non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights.
Bill Cook1
Richard B. Gunderman, MD, PhD
W
illiam A. “Bill” Cook (January 27, 1931–April 15, 2011) started Cook Incorporated in 1963 with an investment of $1500. Today, the value of the fortune he left behind is estimated to be $6.1 billion (1). He built his fortune by creating the largest family-owned medical device manufacturer in the world. But the most notable aspect of the story of Bill Cook and Cook Incorporated is not commercial success or wealth creation. Instead, it is a story of shared vision and dedication. At this time of great flux in radiology and throughout health care, it is especially important that we pause from time to time to reacquaint ourselves with the lives of the most visionary people in the history of our field, whose core principles should serve as a source of enduring illumination. And one of the most illuminating of all is Bill Cook, who, with his close friend Charles Dotter, MD, helped create the field of interventional medicine.
Dotter
1
From the Department of Radiology, Indiana University Medical Center, 702 Barnhill Dr, Room 1053, Indianapolis, IN 46202-5200. Received July 21, 2014; revision requested August 7; revision received August 20; final version accepted September 6. Address correspondence to the author (e-mail: [email protected]). RSNA, 2015
q
636
Cook and Dotter first encountered one another in 1963 at the annual meeting of the Radiological Society of North America (RSNA), which took place between November 17 and November 22 (2). It was held at the Palmer House hotel in Chicago, Illinois, and included 61 refresher courses presented by 76 speakers. On the final day of the meeting, participants learned of the assassination of President John Kennedy. One of the 102 technical exhibitors at the meeting was Bill Cook, then the sole proprietor of Cook Incorporated, a nascent medical device company in Bloomington, Indiana. Visitors to the technical exhibits saw Cook standing at a table in coat and tie, with signs displaying wire guides, catheter tubing, and catheterization sets behind him
(Fig 1). On the table was a blowtorch that Cook used to form catheters. One day Cook noticed a “short, bald, muscular man with darting eyes” hovering around the booth. Cook asked the man if he could help him, but the man declined (3). At closing time the man returned, this time approaching and asking if he could borrow Cook’s blowtorch and some Teflon tubing so he could experiment with them in his hotel room that night. Cook had his doubts, in part because he had no spare equipment, but he agreed. Before the man walked out, Cook asked him his name. “Charles Dotter,” he replied. Early the next morning, Cook returned to his exhibit and found 10 beautifully formed catheters that he sold for $10 apiece, producing a sum that nearly paid for the exhibit. Cook saw his first spike in orders immediately following the meeting. This was the beginning of one of radiology’s most fruitful academic-industrial partnerships. For the rest of the meeting, Cook and Dotter spent their evenings engaged in spirited discussions about the future of catheter technology. Dotter invited Cook to visit Portland, Oregon, where he was the chair of radiology, a role he had assumed at the precocious age of 32. Cook said that he would like to accept, but could not afford to make the trip. So Dotter, who had made a fortune as a young man speculating in the precious metals markets, offered to cover Cook’s expenses. When Cook arrived, he found a laboratory “second to none in the United States” (4). Dotter was blazing a path in what would become known as interventional medicine. He began sending novel product concepts to Cook, who quickly custom fabricated the devices to Dotter’s specifications. The integrity and physical properties of the products were carefully tested before shipment, and the products were
radiology.rsna.org n Radiology: Volume 274: Number 3—March 2015
HISTORICAL PERSPECTIVES: Bill Cook
Gunderman
Figure 1
Figure 1: Bill Cook at his technical exhibit booth at the 1963 RSNA annual meeting. (Reprinted, with permission, from Cook Medical.)
often used clinically the same week they were produced. In January of 1964, Dotter was consulted about an 82-year-old woman with diabetes whose feet had developed ulcers. Her surgeon recommended amputation, but she refused. So the surgeon turned to Dotter, whom he asked to perform diagnostic angiography. On performing the study, Dotter found a short-segment tight stenosis in the femoral artery. Dotter had been experimenting with animals to develop a technique he called “transluminal dilatation,” and he decided to attempt it on this patient (5). He passed progressively larger catheters through the stenosis, gradually opening it up. Almost immediately, the patient’s foot became pinker and warmer, and, over the succeeding weeks, her ulcers healed. The stenosis remained open until the patient died of pneumonia 2½ years later. This was the first time that a human patient’s circulation had been restored by using nonsurgical means. Word of Dotter’s new techniques spread rapidly. In August 1964, he was featured in LIFE magazine, which then had the largest weekly circulation of any periodical in the United States (Fig 2). The issue featured ads
for Viceroy filter-tipped cigarettes, the “100,000 mile durability champion” Ford Comet, and photographs of fashion models sporting clothing made of DuPont’s Dacron (“America Lives in Dacron”), which several years earlier was the material used for the first artificial vascular grafts. The Dotter article is titled “Clearing an Artery” and subtitled “Plumbing-style ‘Snake’ Restores Blocked Circulation” (6). It includes a sequence of photographs of Dotter performing a 1-hour angioplasty procedure, including one in which he is “beaming with a look of impending triumph.” Dotter is one of those rare physicians in the past 100 years whose contributions might literally be said to have saved the lives of countless people. He is usually regarded as the single most important figure in the development of interventional radiology. Both angioplasty and the catheter-delivered stent were also his innovations. And he taught and collaborated with many pioneers in radiology, including Melvin Judkins, MD, who developed the transfemoral technique for coronary arteriography using specially shaped catheters. Another colleague was Josef Roesch, MD, who developed the technique for
Radiology: Volume 274: Number 3—March 2015 n radiology.rsna.org
transjugular intrahepatic portosystemic shunt placement. Dotter served as chair of the Department of Radiology of the Oregon Health and Science University in Portland for 33 years, until he died in 1985. After his death, Cook donated $2 million to help establish the Dotter Institute at the Oregon Health and Science University. The innovations spawned by Dotter and Cook’s collaboration would not have been possible without the contributions of a Swedish radiologist named Sven Seldinger (1921–1998). Prior to Seldinger, the only way to get a catheter into a blood vessel was to perform a cutdown procedure, directly exposing the vessel. Seldinger, whose family ran a mechanical workshop, attended the Karolinska Institute, Stockholm, Sweden, where he developed the nowfamiliar percutaneous technique of vascular catheterization involving the use of a hollow needle, a wire, and a catheter. His article describing the new technique was published in Acta Radiologica in 1953 (7). The technique is now routinely used for central venous access, angiography, angioplasty, vascular stent placement, and gastrostomy, among many other applications.
Cook Bill Cook was a serial entrepreneur (8). A graduate of Northwestern University, Evanston, Illinois, who had also served a 2-year stint in the U.S. Army as an anesthesia technician, Cook worked briefly for American Hospital Supply Corp. Before starting the company that would bear his name, he and a partner had founded two other businesses in Chicago. The first made novelty products, including a shot glass that, when drained, revealed the image of a nude woman. Although the product sold well, repeated exposure to alcohol eventually caused the
Published online 10.1148/radiol.15141243 Content code: Radiology 2015; 274:636–640 Conflicts of interest are listed at the end of this article.
637
HISTORICAL PERSPECTIVES: Bill Cook
Gunderman
Figure 2
Figure 2: Photograph from the August 1964 LIFE magazine story on Charles Dotter shows Dotter in the angiography suite.
images to peel away from the bottom of the glasses. Cook and his partner then started a business manufacturing disposable hypodermic needles, and this firm eventually grew into the thirdlargest supplier of hypodermic needles in the United States. Soon, however, Cook grew restless and decided to start another company. Weary of Chicago’s harsh winters, Cook and his wife Gayle decided to take their infant son Carl and drive south through Illinois and Indiana in search of a warmer place to live. Packing up their 1960 Corvair and with limited savings, they settled in Bloomington, Indiana, home of Indiana University, which was also Gayle’s alma mater. Cook had a radiologist cousin in California, Ivan Fucilla, MD, who had recently learned of the Seldinger technique and suggested that Cook look into manufacturing the wires and catheters required to perform it, an essentially unoccupied niche at the time. Borrowing $1500, Cook turned one of the bedrooms of their modest two-bedroom apartment into the company’s first production facility, from which he also made its first sales calls. Cook recalled that in the early days he conducted all of the company’s business from the apartment. He had used some of his initial capital to purchase a blowtorch, soldering iron, wire, and plastic tubing. When he was making sales calls, he would don a coat and tie. When it was time to manufacture more product, he would remove his coat and 638
tie, role up his sleeves, and sit down at the workbench. Gayle did the company’s bookkeeping and, unbeknownst to her husband, served as its first quality control officer, removing and hiding product that she regarded as poor in quality. Cook only learned of this part of his wife’s work 4 years later when the Cooks cleared out their apartment to move into the three-bedroom house they occupied for the remainder of his life. The date of the firm’s first sale was September 9, 1963, just 2 months before the meeting with Dotter at the RSNA. On August 29, 1963, Cook sold two wire guides to the Illinois Masonic Hospital, with a sales price of $3.50 each (9). The day the check arrived, the Cooks went out to eat at McDonalds, establishing a tradition repeated with each of the fledgling company’s early sales. In the firm’s 2nd year, Cook hired a young high school graduate, Tom Osborne, the son of a local jeweler, as his first production specialist. Osborne soon proved to be a master innovator and developed a new wire coiling machine that proved crucial to the company’s success. Later, Cook hired as the firm’s first dedicated salesperson Miles Kanne from Chicago, who bunked nights on the Cooks’ couch for much of his 1st year of employment.
Cook’s Philosophy In the 1970s, Cook noticed that, as the firm was growing, the employees were
becoming increasingly disenchanted (10). So one day he gathered each of his 300 or so employees around the loading dock and told them something had to change. Productivity was declining, problems with quality were beginning to arise, and employees were beginning to exhibit a high rate of absenteeism. “If we continue on our present course, we will be losing money within 2 years,” he said. Cook told his employees that he would make them a deal. If they would commit to rectifying these problems, he would “work my tail off to make things right” (4). He discovered that some managers were seen as dictatorial and too rigid. Employees felt that they were not being given an opportunity to perform at their best. Cook began rearranging management because, as he put it, “Managers are not what is necessary for success” (4). Reflecting on what made employees successful, he determined that good production personnel were not always good managers, and vice versa. So he hit upon what became the most important criterion for hiring and promoting leaders in the organization. This was simply that he knew them well and liked them. This was not an arbitrary concession to Cook’s tastes. If after getting to know them well he liked them, he could be confident that they would be reliable, not sow the seeds of dissension, live up to their word, be self-starters, and get along well with others. Simply put, the key to building a good organization is to populate it with good people. So Cook recognized that the best leaders for the organization would be people like him, who enjoyed their work, were goal-driven, and would do what it took to make sure that the job got done properly and on time. His goal was to ensure that he could operate on a friendly basis with all his managers, and they in turn would operate on the same basis with each of the employees. And though there was a lot of work to be done, he would not hire too many people to do it. For example, eight of the firm’s senior executives all shared one secretary. Why? In large part because their work was
radiology.rsna.org n Radiology: Volume 274: Number 3—March 2015
HISTORICAL PERSPECTIVES: Bill Cook
done best when they interacted directly with customers, employees, and suppliers—not through an administrative intermediary. Several additional features of the Cook culture deserve to be highlighted. First, Cook did everything he could to foster a team environment in which he functioned much more like a coach than commander. He realized that if he liked the people he was working with, he and everyone else could get more things done. So he invested a great deal of time and energy in getting the right people on the team, and he continued this investment by talking frequently with employees about what was preventing them from doing their jobs well. He managed by walking around, and he encouraged others to do the same. For example, he was a regular fixture on the production floor, invariably stopping to talk with many employees. He enjoyed their respect in part because they knew he had once been in production himself. Cook took the same approach with his customers. He loved to talk with physicians about the work they did, the challenges they faced, and how his company could help them solve clinical problems and take better care of their patients. He hired people who felt likewise. Cook’s field team was not a salesforce and, in fact, Cook’s sales people were paid not on commission but on a straight salary. In fact, Cook often said that his field representatives would not know how to ask for an order. If a customer wanted to place an order, they could phone Cook’s 1-800 number, the first in the industry, and talk directly with a customer service representative. The field team’s mission was not to move merchandise but to listen to customers and develop collaborative relationships with them. He would often say, “We don’t sell, we educate and learn from the customer,” meaning that physicians’ clinical knowledge and his employees’ know-how were both crucial factors in the equation for innovation (4). Flow rate, tensile strength, radiopacity, and biocompatibility were among the
Gunderman
many characteristics that needed to be mastered by Cook employees and shared with customers to achieve a match between specific patient needs and products. Cook also often said of his company, “We do not practice medicine” (4). Cook was so committed to customer service that he operated a fleet of airplanes. If a product failed in some way, the company would often fly out a representative the very same day. The representative would meet with the physician, investigate the problem, and bring the defective device back to the plant for further study. Cook also flew physicians to the company so that they could see where the devices were developed and manufactured, thereby helping build better collaborative relationships. Cook unfailingly dealt with physicians in a very respectful manner, believing that they were the experts who ultimately saved lives. The job of Cook Incorporated was to meet their needs as effectively as possible. In later years, he was disturbed when he saw physicians becoming subservient to hospitals, insurance companies, and regulators. Cook led by example. No one was more committed on a daily basis to the success of the company, and no one worked harder. He wanted people to take satisfaction and pride in the work they were doing, so he had very few rules. He gave everyone an opportunity to innovate and enhance the quality of their work. In other words, he was an inveterate delegator who believed that by giving people freedom and trust, you tended to bring out their best. Educational and professional credentials mattered less to him than what people actually showed they could do, and in some cases, unexpected people rose to senior positions in the company. For example, one company president, Phyllis McCullough, was a former secretary in the firm and another, Kem Hawkins, had been a high school band teacher (10). Cook emphasized that the company was making not just money but products that were restoring patients’ health and, in many cases, saving
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their lives. He said, “Make sure you do your best, because someday the device you are making may be used on you” (9). True to his word, as a heart disease patient he always insisted that his physicians use Cook devices. However, he never had them made especially for himself, instead pulling them off the rack at the plant. He happily told employees and customers, “Every needle, wire, and catheter that has been used on me has been made by the company” (9). Charles Dotter was the first radiologist to share his vision with Bill Cook, but he was far from the last. Other pioneers built similar deeply collaborative and enduring relationships. Today the Cook companies manufacture more than 17 000 unique devices, virtually every one of which was created in collaboration with physicians (10). Cook knew that such relationships must be nourished over time if physicians are to move medicine forward. He also knew that excellence is not primarily about money, and he felt strongly that material success brings with it responsibility to put resources to work for communities. One of the many forms Cook’s philanthropy took was historic preservation, and he and his wife are credited with saving 57 historic structures in Indiana alone (1). Finally, and perhaps most important, Cook believed that radiology and radiologists need to remain focused on improving the care of patients, without worrying too much about payments, competition, or politics. Ideas that genuinely improve the quality of life will be rewarded, but rewards always follow performance, not the other way around. For these and many other reasons too numerous to detail here, Bill Cook serves as a shining exemplar of excellence in leadership, and many tenets of his leadership philosophy are urgently needed in health care today. Especially in times of rapid change, it is all too easy to become distracted by little things and lose sight of the ones that really matter. As radiologists navigate the uncertain health care waters ahead, we would do well to bear in 639
HISTORICAL PERSPECTIVES: Bill Cook
mind Cook’s curiosity, entrepreneurial spirit, relationship building, integrity, deep commitment to bringing out the best in others, and overriding dedication to the good of the patient. Disclosures of Conflicts of Interest: disclosed no relevant relationships.
References 1. Forbes. The world’s billionaires. http://www. forbes.com/profile/gayle-cook/. Accessed August 20, 2014.
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2. Geddis LA, Geddes LE. The catheter introducers. Chicago, Ill: Mobium, 1993. 3. Monagan D, Williams DO. Journey into the heart. New York, NY: Penguin, 2007. 4. Indiana Public Media. Bill Cook: one heck of a ride. Bloomington, Ind: WTIU Television, Indiana University, 2014.
7. Seldinger SI. Catheter placement of the needle in percutaneous angiography. Acta Radiol 1953;39(5):368–376. 8. Smith JH. Snowing in Chicago: the story of a fortuitous detour and the founding of Cook Inc. Old Saybrook, Conn: Greenwich, 2009.
5. Payne MM. Charles Theodore Dotter: the father of intervention. Tex Heart Inst J 2001;28(1):28–38.
9. Hammel B. The Bill Cook story: ready, fire, aim. Bloomington, Ind: Indiana University Press, 2008.
6. Life Magazine. Clearing an artery. August 14, 1964; 43–46.
10. McCullough P. 40 years, the story of Cook. Bloomington, Ind: Cook Inc, 2003.
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