Bad behavior among the youngsters on the pitch

I came across this cartoon on Facebook (with thanks to UK surgeon Isam Osman) and it prompted me to write about a trend I've noticed while refereeing youth soccer games. I've seen a tendency for younger and younger players to imitate the bad behavior that is evident in professional matches.  By younger, I mean nine-year-old boys. 

What kind of behavior?  The first set are comments or complaints about the referee's calls (or non-calls).  "Didn't you see that?" is one comment.

Or, on the other side, when a player is whistled for a foul, the "What me?" reaction is more and more prevalent.

The second set--per the cartoon above--is a tendency to "take a fall" when gently nudged, in the hope the referee will call a foul against the other team and issue a free kick to the "aggrieved" party.

It used to be the case that you didn't see this stuff until the boys were a bit older. Now, the little boys have learned it.

Of course, these tactics work against the interests of the boys who use them, in that they stop playing while they engage in their demonstrations, while the other team just keeps playing--often in possession of the ball.  But that lesson is often missed, especially when the coaches aid and abet the bad behavior in their own comments--or in their silence.

Meanwhile, in contrast, check out this bit of good-hearted sportsmanship from a 2011 Manchester United vs Everton match:

Tea: A public service message

Unclear about whether sex is consensual? The issue is presented in a crystal clear manner in this video, compairing sex to drinking a cup of tea. According to Metro, the advert is part of the #ConsentisEverything campaign being launched by Thames Valley Police.

"If they're unconscious, they don't want tea," is an example of the advice.

Here's the video.

Lo: Finance doesn’t have to be a zero-sum game

I think we're all a bit gun shy of terms like financial engineering because of the degree to which unscrupulous or ill-advised investment bankers and others created financial instruments that almost destroyed the world economy back in 2008. But if we can put aside that prejudice for a while, we can recognize that use of some financial instruments and strategies can permit society to advance on many fronts with an appropriate amount of risk.

It is in that light that I highly recommend that you watch this TEDxCambridge talk by MIT's Andrew Lo. Andrew has a thoughtful concept that might speed the development of cancer treatment drugs. He asks "Can financial engineering cure cancer?" and notes:

This short non-technical exposition highlights the impact that each of us can have on treating cancer and other diseases, no matter who we are or what we do for our day jobs. I’ve been amazed at the connections that have emerged from random conversations with total strangers about cancer, and how useful those connections have been in getting us to this point.

Take a look!



Summary:

We are making breakthroughs almost weekly in our understanding of cancer and other deadly diseases, both in how to treat and – in some cases – how to cure them. So why is funding for early stage biomedical research and development declining just when we need it most? One answer is that the financial risk of drug development has increased, and investors don’t like risk. What if we could reduce the risk and increase the reward through financial engineering? By applying tools like portfolio theory, securitization, and derivative securities to construct “megafunds” that invest in many biomedical projects, we can tap into the power of global financial markets to raise billions of dollars. If structured properly, investors can earn attractive returns with tolerable levels of risk, and many more patients can get the drugs they desperately need. Finance doesn’t have to be a zero-sum game; we can do well by doing good if we have sufficient scale.

Two masters degrees? Using college as a crutch?

My most read blog post is one I published in April 2007, called, "For students: Don't collect degrees." It was prompted by a question I received from a student:

As someone who is in on the business/medical/policy of today's health care system, what do you think about the career prospects of those pursuing a joint JD/MPH? Is it worth it?

Virtually every day--even over eight years later--it tops the list on my blog statistics in terms of viewers, and it has prompted about three dozen comments.  I'm very pleased young people have found it helpful as they consider their career paths.

Here's the latest inquiry that's come across the transom:

Mr. Levy, I would appreciate your thoughts. I have a MPA in H.C.Administration and a MS in Organizational Change Management. I've been a generalist as I enjoy change and have many interests: acute, ambulatory, and long term care as well as work in social services providing services to individuals with I/DD and in behavioural health.

I seem to have gravitated towards social services and have thoughts of State or Federal government though I would probably become overly frustrated with their pace.

I guess I have a couple inquiries: If I persue (sic) a doctorate or JD, what concentrations would round-out my Masters? Also, I would love to work abroad or for an agency where there might be intermittent travel. Would you have any suggestions?

Thanks for your thoughts. 

And my reply:

Whoa, you have two masters degrees and you want to go back to school for more? My first reaction is that you've already spent enough time getting degrees and that it's time to get more experience in the work place and figure out what you really care about doing.

But if you want to get a Ph.D., it should not be to "round out" your masters. You only get a Ph.D. for one of two reasons: (1) To become an academic and be a professor somewhere; or (2) to work in a place like the World Bank, where they seem to value that degree. As to what field you should pursue for a Ph.D., you'll need to pick a field where you can make an original contribution to the field. Based on what you've learned and experienced to date, can you imagine what that might be? If not, don't even think about getting a Ph.D.

As to a JD, you only go to law school to become a lawyer. You don't go to law school to round out your education. It is a trade school. It is not a place to expand your intellectual capital, unless, again, you intend to enter academic law and become a professor. If so, you should, again, have a sense of where you can make an original contribution to the field.

On the professional front, if you fear that the state or federal government would be too slow for you, don't go there. Slowness is the nature of government. It is designed to be slow and deliberative.

Your last point about wanting an agency where there might be travel suggests that you are putting the cart before the horse. First, find an agency that excites your passions and sense of purpose. If it involves travel, then you get a bonus. But, don't pick an agency that involves travel for the sake of the travel.

In short, it sounds like it's time to stop being such a generalist and get your hands dirty actually working in the trenches and doing something interesting and difficult. After a few years of that, you can figure out if more formal education is worth doing. Sorry, but your note suggests that you are using college as a crutch to avoid committing to some job where you will have to test out what you really care about. Take a leap!  

By the way, when it comes time to negotiate that new job offer, check out our book on salary negotiation and more: How to Negotiate Your First Job!

First they throw the flowers. Then they throw the pot.

Please check out this new article I've written for the athenahealth Health Leadership Forum, one in an occasional series.  Comments are welcome there or here.

The network you might not like

This has been my week to discuss networks (Internet and electricity), but I would be remiss if I didn't spend a few moments on the networks that are most likely to rob us of personal choice and increase costs: Health care networks. 

Wait, didn't President Obama promise us that the new health care law would preserve choice for us? Didn't he promise us lower costs?  Well, in spite of much good that the law accomplished in terms of providing access to health insurance, these are two areas that have gone awry. For a variety of reasons--most of which have little to do with providing you with better care--the hospital world has grown more centralized. It's done so to reduce competition and get better rates from insurance companies. It's done so to create larger risk pools of patients under the "rate reform" that incorporates more bundled and capitated payments. It's done so to keep you as a captive customer for your health care needs. It's been aided and abetted by electronic health record companies that find a mutual advantage with their hospital colleagues in minimizing the ability of your EHR to be easily transferable to other health systems. As I've noted, we truly have created "business cost structures in search of revenue streams," rather than a vibrantly competitive system focused on increasing quality and satisfaction and lowering costs.

Many people don't even know they are part of a health care network until they discover its limitations. It might be that the insurance product they bought has different rates for in-network doctors and facilities from out-of-network doctors and facilities. It might be that their primary care physician subtly or not so subtly directs them to specialists in his or her network because they share in the financial reward of eliminating "leakage" to other systems. It might be that they discover that an MRI or other image taken in one health system cannot be transferred electronically to another, perhaps necessitating a second image and its accompanying cost.

From the patient's point of view, the strongest argument for an effective health care network is that your care might be carefully managed throughout your diagnosis and treatment and recovery journey.  But that result is observed in the breach more than found to be true. Indeed, there often seems to be little in the care pathway within a network that is indicative of good communication or a breakdown of silos across the various specialists and facilities in the network.

The country could have gone another way.  When we funded the current expansion of EHRs, we could have made it a requirement that they easily talk with one another.  When we encouraged clinical integration, we could have made it clear that combined corporate ownership across the spectrum of care would be severely limited, allowing for many "Switzerlands"--community practices and community hospitals that could have served multiple systems in a nondiscriminatory manner. Instead, the US government and many state governments have actively encouraged just the opposite.

I'm sorry to say that this horse has left the barn, and it's probably too late to close the door in most parts of the country. Instead of enjoying the positive externalities of a truly interdependent system of health care facilities and doctors, the US has dramatically foreclosed the potential for such societal gains. This is a mistake for which we will all pay for a very long time.

Another network you’ve joined

My post earlier this week about incorporating end users of the Internet into the network to enhance its performance and stability reminded me about a research project I was involved in back in 1979 at MIT.*  A group of us, led by the late MIT professor Fred C. Schweppe (one of the world’s experts in electric power systems control) took a look at how a dynamic electric power system might function.  The term for the project was coined by project member Richard Tabors, who was trained in biology: “Homeostatic utility control.”

As Richard reminded us, a human body responds in real time to changes in the environment and other challenges to moderate heart rate, respiration, and the like to keep us on a steady keel. We eat that Halloween candy, and our pancreas figures out how much insulin we need to convert sugars. We take a run to work off the candy calories, we get hot from the exercise, and we sweat to cool down our bodies.  We face the danger of a territorial dog as we run, our adrenaline flows, and the hormone stimulates all kinds of physiological adjustments, which then relapse to base levels when the threat is gone.

We all wondered whether a regional electric grid could do likewise if signals to and from the periphery were employed.

Specifically, the question we sought to answer was whether an electric power system that incorporated demand side management and disbursed power generation at the site of customers would, with a pricing regime that transmitted the real-time marginal cost of electric power production, be stable.  In other words, would customer responsiveness to actual minute-by-minute prices result in a more efficient system—or would it spin out of control in a fit of instability. (Remember, in a power grid the demand for electricity has to be supplied essentially instantaneously to maintain voltage levels, frequency, and other key parameters.)

Our research question was hypothetical at the time.  There were very few distributed electric power sources in 1979, and what energy conservation and load management programs existed were not premised on customer response to real-time price signals.  But we all envisioned a world when such things would be commonplace.

Well, the analysis showed, as well as could be determined based on lots of assumptions, that a network that integrated customer-level supply and demand price-responsiveness could indeed be stable (as stability would be defined by power systems criteria.)

We fast-forward to today, a world in which distributed generation and load management are rapidly infusing regional power grids.  Think about those solar panels on your roof that supply you and also sell power back into the grid, or appliances that respond to price signals to operate during off-peak periods. With improvements in computer technology and telecommunications infrastructure, it is likely that the conclusions about stability we reached back in 1979 are still true.  Today’s power systems, too, are likely to have more resiliency than the power systems that existed back then.  There is less dependence on a few, very large generating units.  There is more redundancy in electricity transmission capacity.  And locating power generation closer to load centers reduces a portion of transmission system losses that occur when power is sent over long distances.

I’m currently on the board of one of the organizations with some responsibility in this arena, ISO-New England, the supervisor of electric system reliability and the entity that designs and operates the markets for capacity and energy in this six-state area. You can imagine that the many sectors in this regional power exchange (e.g., transmission owners, generation owners, investors in “alternative” resources, end users, power marketers, and others) have divergent financial interests. I’ve been tremendously impressed, during my tenure on this board, at the degree to which the participants work together—notwithstanding their individual financial interests—to help design a system that works for the benefit of the consumers in the region, with due consideration for environmental protection.

But good will and a sense of regional purpose will not necessarily yield consensus in this forum or in similar forums in other regions of the country.  Among other things, participants have different time frames over which they engage in capital formation, cost recovery, and return of capital.  Important public policy questions remain, too, because the electric power system is not only ubiquitous, but because its output has become an essential input to our lives—affecting public safety, education, other utility services, our personal lives, and commerce.  Thus, the manner in which distributed generation and load management are introduced into the electric power system will remain a topic of hot discussion in the body politic and before federal and state regulators.

Contrast this vibrant debate with my earlier post, in which I noted that Akamai’s reach into the distributed network to be present on your home computer occurred without much public discussion or government regulation. I do not argue with the technical merits of the solution employed, but I note that the question of how the resulting enhanced value of the Web is shared among its participants has not reached the public consciousness. Maybe things are going so fast because of the exponential growth in Internet traffic that such questions can only be viewed through a rear-view mirror.

While the stakes for the Internet are high, even the Web requires electricity to run. I urge my readers, whether running hospitals or involved in other industries, to become informed as to the issues facing our electric power system and not only be wise buyers and sellers in that marketplace but also active participants in the public discussions surrounding this sector. Our job, together, is to help ensure that the rules governing the enhanced distributed network do not produce a zero sum result but rather create value for society as a whole—and that the manner in which that value is shared across the sectors is broadly viewed as fair and proper.

--
* Summarized here: "New Electric Utility Management and Control Systems," MIT Energy Laboratory Technical Report, No. MIT-EL-79-024.

A new view of network externalities

For those of us who have been involved in running or regulating network infrastructure, there's been a sea change in the framework for deciding on appropriate policy concerns.  In the old days, all we had to "worry" about were what the economists call network externalities. These externalities could either be positive or negative in nature.

A positive externality occurred every time someone would join up to a network, say, by subscribing to the early telephone system.  While each person received a certain value in subscribing, all other uses also received an enhanced value from that person joining the system.  Why? Well, simply put, everyone could now reach an additional subscriber at minimal extra cost.

A negative externality would occur when the network would become congested.  In such a case, each additional subscriber would slow or degrade the service quality for all the incumbents, causing a need for capital investment to restore service quality, or a time-of-use pricing regime to ration service during congested periods.

In the days of regulated monopolies, a government body would intervene in the design and operational aspects of the network service to decide what level of service quality was appropriate, what level of investment was needed, and what the pricing design should be.

Now, though, we've arrived at the Wild West of network service, the Internet. A 2012 article by J.M. Glachant in the Review of Economics and Institutions summarizes:

How does the inability of public policy makers to keep up with things become evident?  Let me provide an example from a talk I heard by Tom Leighton, the CEO of Akamai.  Akamai's role in the Internet world is to optimize traffic flow for its customers. If you are Facebook or Google or Amazon, you want your users to have an instantaneous response when they click on a link: People are much more likely to buy something if there is no perceived delay when they do so. Akamai, therefore, has set up a worldwide network of thousands of servers to help route traffic and speed up information flows between its large commercial customers and the millions of computer and device users.

But even Akamai can suffer from negative network externalities.  The number of users in the world is growing, the number of apps and sites is growing, and the number of objects on each web page is also growing.  All this suggests an exponential surge in traffic over the coming years.  For Akamai, the cost associated with installing thousands more servers would be large, and even if possible, would not result in the end-to-end quality service that is desired.

So the answer has been to reach out further along the branches of the tree and to enlist individuals' computers to be miniature servers in the Akamai optimization network.  Here's how it works, emphasis added.:

The Akamai NetSession Interface is a secure application that may be installed on your computer to improve the speed, reliability, and efficiency for application, data and media downloads and video streams from the Internet. It is used by many software and media publishers to deliver files or streams to you. 

If the software or media publisher uses the feature and if you enable it, NetSession can also use a small amount of your upload bandwidth to enable other users of the NetSession Interface to download pieces of the publisher's content from your computer. The NetSession Interface runs in the background and uses a negligible amount of your computer resources or upload bandwidth when you are not actively downloading content. 

How is it installed and how do you give permission? It is enabled when you "agree" to the terms and conditions of one of the applications to which you subscribe.

Akamai NetSession Interface downloads or streams content to you only after you have requested it from your software or media publishers. 

And, as the site explains, you can opt out at any time.

But who actually reads those terms and conditions? Well, no one really, so this was news to me and many others when we heard Tom describe it at a recent seminar.  I asked, "Why should I feel good about having this software installed on my computer?" His answer, "It will make your own service faster, and you will have contributed to the Internet ecosystem in lowering costs to everybody."

Putting aside whether I would actually ever be able to detect such cost savings, is there something immoral or manipulative in this process? That question, too, was asked by an audience member at the seminar. Tom's response was, in essence, amoral. He said that this was a required technical fix to the massive growth in traffic on the Internet, and he repeated what's on the company's website:

The NetSession Interface is safe and secure and does not contain spyware, adware, or a virus. It does not gather and transmit your personal information, nor does it harm your computer. Its purpose is to be a tool to improve the speed, reliability, and efficiency for downloads and streams.

I think a number of us were concerned about what we heard. Was Big Brother going to take over our computer for some nefarious purpose? Tom is certainly trustworthy, but what if some nasty person becomes head of Akamai? Or what if some circuit designer deep in the company attaches a nasty bug to our computer?

Well, the truth of the matter is that if you are connected to the Internet, you have bigger things to worry about.  The chance of your computer being corrupted by a bad actor somewhere in the world--a criminal organization or an insidious domestic agency or foreign government--is already remarkably high.  If you are concerned about privacy or malware, you truthfully should be off the Web totally.  So the incremental risk of being part of the Akamai distributed network is small compared to what you are already experiencing.

So, oddly, Tom's amoral reply is actually the right one.  His job is to optimize web traffic for his customers and to design technical fixes to do so. If one of those technical fixes is to enlist your computer in the distributed network, that's what he needs to do. (That kind of fix, by the way, is a nice way to balance the positive and negative externalities associated with network expansion.) The only appropriate public policy response to the plan that we could devise is the one already employed by Akamai, to disclose the existence of this fix and to give you the right to opt out.  Could the company do that in a more outgoing way, so we might be more knowledgeable and make the choice not to play? Perhaps, but truly, how many of us would do so? A negligible number, I'd guess.

If this story is typical of what to expect in the Wild West of Internet externalities, in contrast to earlier network services, public policy makers will find themselves ever more irrelevant.

You can't stay ahead of these errors.

Remember the story about my MD friend's elderly mother, the one who was suffering from falls because she was over-medicated for blood pressure issues? Once the doses were reduced, she did fine: "She has more stamina than ever before. She is happy."

Well, here's the next chapter:

So Mom is back in her original assisted living place, walking with a walker, to everyone's surprise. However, the medical errors are following her.

When she was being discharged, the rehab center sat me down and gave me a discharge summary and medication list, saying they had been faxed to the original nursing home. We went over and discussed every medication.

9 pm the night she went back, my phone rings; it's the nursing office of the original place saying they have her on Tramadol but the pharmacy says there is an allergy. I said, "What?" You see, Tramadol was not on her medication list. They said, "It wasn't on the list YOU gave us but it IS on the list that was faxed to us." So, I said, "There are 2 lists out there!" I said, "Take her off it," and hung up.

Today, two WEEKS later, the nurse practitioner calls and starts discussing clonidine, a BP medicine she was on. I said, "What?" You see, again, that wasn't on her medication list.  She said, "Oh, but the rehab center started her on that and I want to discontinue it." I told her there were at least 2 medication lists out there but she wasn't interested. So I said, "Fine, d/c the clonidine."

So . . . she's been on 2 BP drugs instead of 1 for two weeks, which was the original reason she was falling so much!

 

I'm ready to give up. You can't stay ahead of these errors.

Good news for C. diff patients: The "Poop Pill" arrives.

Way back in December 2013, I introduced my readers to OpenBiome, a start-up formed by a couple of MIT graduate students who had a new concept for Fecal microbiota transplant (FMT), which is now recognized as an effective cure for C. difficile patients.

In March of this year, I reported from one of the founders:

We've experienced rapid growth and are working with over 230 hospitals in 43 states and have provided treatments for over 2800 recurrent C. difficile patients at this point. 

We have also been testing and developing an encapsulated formulation that should reduce procedure related costs and risks for treatment of C. difficile, while enabling long term maintenance therapy for the investigation of chronic conditions where a single dose is unlikely to provide lasting benefit. 

Now it looks like that approach is going well. Gabrielle Emanuel at the Commonhealth blog reports:

Fecal transplants may have just gotten a lot easier to swallow.

OpenBiome, the nation’s first stool bank, is beginning large-scale production of a poop pill. This week marks the first time such a pill will be commercially available to hospitals and clinics.

Early tests suggest the pill is highly effective and comparable to traditional, more invasive delivery methods — for instance via colonoscopy, enema or a plastic tube through the nose and into the stomach or intestines.

Developing a pill that would not dissolve because of what it was delivering was the engineering task faced by the company.

After about a year and a half of work and testing, researchers at OpenBiome came up with something they’re calling the Microbial Emulsion Matrix (MEM).

Basically they’re taking the poop and suspending it in oil. The oil prevents the water from dissolving the capsule. Then, they freeze the capsule. This doesn’t kill the bacteria but it does make them inactive, stopping them from breaking down the capsule. Only once the pill is inside the gut does it break down — this time from bacteria on the outside, instead of on the inside.

I'll be looking forward to future chapters from this innovative group of folks, who are working on a very important health problem

A new concept: Acceptable preventable harm

Blogger Melissa Clarkson offers a wryly humorous take on a goal established by the CMS Partnership for Patients, to reduce preventable harm by 40% between 2010 and 2014.  She asks:

I was not aware that harm comes as a mix of acceptable harm and unacceptable harm and the concern is getting rid of the unacceptable portion.

But if hospitals are striving for such a goal, I simply ask that they fully explain this to patients and families. And to help, I would like to provide some ideas for facilitating this communication.

Here are some of the graphics she proposes for those hospitals who wish to be fully transparent.

For a hospital welcome sign:

For a marketing campaign:

For the front lobby:

More seriously, and perhaps not coincidentally, according to this Modern Healthcare article:

The Leapfrog Group has released the second round of its bi-annual hospital safety scores, which show “sluggish” improvement in patient safety among the nation's hospitals.

An example of superb medical training

I have made a serious commitment on this blog to promulgate the best in medical education, with a strong emphasis on programs that focus on clinical quality and safety improvement. It was with a delighted gasp of approval, therefore, that I read this recent bit of feedback posted on the residents' bulletin board of the anaesthesia department at a major academic medical center. This is truly superb pedagogy, well worth emulating in other training programs.

In case you are not familiar with Wu-Tang Clan, you can enhance your cultural competence by viewing this video.

Riding the Cancer Coaster

Several months ago, through a virtual friendship with her father, I got to know a young lady named Clarissa Schilstra.  She is a lovely and thoughtful person who has been through double doses of cancer in her short life.  She is now a member of the class of 2016 at Duke University. We first met in person (all three of us) in August of 2014.  Clarissa felt that she learned a lot from the passages of her life and wanted to share what she had learned with others, and so she wrote me back in July:

"I am really excited to tell you that I have written a book this summer, to help teens and young adults with cancer through the social and emotional challenges of treatment."

The book is now out, and it is very, very good.  My review is as follows:

Clarissa Schilstra offers knowledge, wisdom, and advice to teenagers and young adults who are facing the travails of a cancer diagnosis. Drawing from her own experience, employing plain talk and empathy, she offers helpful suggestions for the entire family. This is an essential book for anyone you know who is going through this life-changing chapter in his or her life.

If you can't change people, change people.

My friend and colleague Michael Wheeler, in his excellent book The Art of Negotiation, notes:

"Negotiation is never about us alone. What ultimately unfolds is a function of each party's attitudes and decisions, not just our own. Asking ourselves, 'How did I do?' is the wrong question.  It's a one-hand-clapping exercise.  Instead our starting point should be, where did we end up and how did we get there?"

I was reminded of this advice by a New York Times article about Justice Ruth Bader Ginsburg by Irin Carmon. Excerpts:

“My advice is fight for the things that you care about,” Justice Ginsburg said. Fair enough — banal enough, really. Then she added, “But do it in a way that will lead others to join you.”

Justice Ginsburg [has] no patience for confrontation just for the sake of it. “Anger, resentment, envy and self-pity are wasteful reactions,” she has written. “They greatly drain one’s time. They sap energy better devoted to productive endeavors.”

As Ginsburg notes, one way in which the opposite approach is often evidenced is through self-pity and self-victimization.  I've run across this often in the health care world, and, sadly, it is a technique often used by the most prominent in the field.  As CEO of a hospital, I saw it when there were disputes between a particularly assertive chief of one service and two other, more passive, chiefs of service.  Each of the latter would come in to me with an aura of self-victimization, complaining about the colleague and asking me to solve their problems with him. This, even though they were just as senior, experienced, and famous in their fields as he was in his.

Their self-victimization was their way of avoiding responsibility.  Meanwhile, other chiefs figured out how to deal with the bully--through humor, redirection, or otherwise--knowing that pursuing the shared goals of the hospital was the overriding objective.

Look how Ginsburg deals with an angry and bullying member of the Court whose views are often widely at variance with her own:

“I’ve been known on occasion to suggest that Justice Scalia tone down his dissenting opinions … because he’ll be more effective if he is not so polemical.”

Imagine, giving advice to your philosophical adversary so that he will be more effective!  Ginsburg understands that in a court of nine members, today's negotiation is but one of many to come. But her thoughtful approach offers lesson beyond the Court.

Over the last several years, I have been teaching negotiation to corporate executives and advising corporations on complex and interesting business negotiations.  As is evident to many in the business world, the most important part of a negotiation with another party is first achieving an alignment within your own organization.  Indeed, many deals fail to be brought to fruition because of internal failures, rather than substantive business issues with the external counterparty.  As I've analyzed those internal problems, I've seen that a significant percentage of the failures occur because some division chief engages in a kind of self-victimization:

"No one cares about my point of view, so:"

"...I'll just be quiet about flaws I see in the deal;" or
"...I'll withhold important information from my division;"
"...I'll quietly do my part to undo the deal later."

These folks are actually more comfortable with having stopped an initiative that could be of broad corporate value because of the way they perceive their treatment.

It might--or might not--surprise my readers to learn that such things occur, even in highly profit-driven organizations.  What's the remedy?

It's easy to say that we should want to run organizations so that each person feels empowered, entitled, and encouraged to call out problems and state his or her objections.  But, even in those places, there are some people who will tend to engage in self-victimization and act as anchors on joint progress.  In the Supreme Court, where there is lifetime tenure, it comes to a teacher like Ginsburg to try to help her colleagues learn and grow.  In other organizations, things turn to the leaders to recognize the syndrome and deal with it directly.

You as a leader have a responsibility to create a true culture of engagement, substantive support to encourage full participation by all in your organization, and a commitment to your staff's personal and professional growth. In so doing, your key attribute as a leader must be empathy, to understand where the people in your place are in their own learning process.

But, here's where I offer what might seem to be self-contradictory advice--but it is advice informed by years of experience.  If, in the presence of that culture, support, and commitment, you are still facing key staff members who are characterological and persistent self-victimizers, it's time to cauterize the wound.  In such cases, revert to the old adage:  If you can't change people, change people.

Only certain people

A person who has over 3000 friends on Facebook saw no irony in posting the picture above in her status bar.

Being less alone together

Above, seen on a table at the back of a conference room during a staff all-day negotiation, team-building, and communication workshop.  It is a great enforcement mechanism to enhance interactions and the learning process, imposed by the conference organizer. I think Sherry Turkle would be pleased.

She has said:

What I've found is that our little devices, those little devices in our pockets, are so psychologically powerful that they don't only change what we do, they change who we are. Some of the things we do now with our devices are things that, only a few years ago, we would have found odd or disturbing, but they've quickly come to seem familiar, just how we do things.

So just to take some quick examples: People text or do email during corporate board meetings. They text and shop and go on Facebook during classes, during presentations, actually during all meetings. People talk to me about the important new skill of making eye contact while you're texting.

Why does this matter? It matters to me because I think we're setting ourselves up for trouble -- trouble certainly in how we relate to each other, but also trouble in how we relate to ourselves and our capacity for self-reflection.  

So you want to go to that board meeting, but you only want to pay attention to the bits that interest you.

The story from Consorci Sanitari del Garraf

"In 2009, three medical facilities in the comarca del Garraf, near Barcelona, merged into one organization, the Consorci Sanitari del Garraf. Faced with a 17% budget cut, a result of the financial crisis, the newly created hospital had to find a way to improve its processes and become more efficient."

This is a really sweet story from Spain that illustrates how you don't need lots of money and extra resources to apply Lean thinking.  Read the text, but really watch the videos to get a feel for how it happened.

The vestigial newspaper

It isn't often that I take someone's comment on a story and use it as the heart of a post, but someone named Greg Lee nailed it and summarized what I've been watching, too.  The context is this latest story about layoffs and buy-outs at the Boston Globe.  Like Mr. Lee, I read the comments of the editor and said, "Nice try."  Here's what Mr. Lee said:

I understand the financial realities that drive the recent moves by the Boston Globe. It is now, however, a lesser paper than it was, before this current process. 

What was touted to subscribers as redesign and layout changes, has actually been evidence of a slow retreat in journalism, at the Globe. The layout changes feature bigger type sections, more graphics and white space, and much less news coverage and op-ed pieces. 

It's depressing, as a life-long subscriber of over 45 years, to see this current decline in the Boston Globe. The new bottom line is less news coverage and less in-depth journalism, in the daily edition. Economic reality dictates these changes. I understand that point. But please don't call process an improvement or a new birth of possibility. Call it what it is, which is slow, strategic retreat.

How much more so when we watch the paper's owner invest in a new on-line "vertical" called STAT.  Here's the promo:

People at the Globe have told me that 40 people have been recruited for this venture.  That's a hefty annual budget.  Time will tell whether STAT rises to the level of the other big producers in the health care news arena--Pro Publica, Kaiser Health News, and the New York Times.  Time will tell, too, whether--even with great reporting and presentation--STAT will succeed as a business venture.

But I return to Mr. Lee's comment.  For several years, the management has shed as much as possible in costs and journalistic assets, hoping that enough remained to look and feel like the Globe.  Now, it must be difficult to sit in the shrinking Globe newsroom while millions of dollars are allocated to a new enterprise.  The investment in STAT is the strongest indication that the newspaper is now a vestigial organ in the minds of the owners.

In appreciation: Maureen Bisognano and Jim Roosevelt

It's a big day for transitions in health care here in Massachusetts. Maureen Bisognano has announced that she will step down as head of the Institute for Healthcare Improvement, and Jim Roosevelt announced his retirement as CEO of Tufts Health Plan.

Others will surely offer their thoughts on the notable accomplishments of these two folks, and so I prefer to spend a bit of time talking about them as people.  Oddly, I can apply almost the same descriptors and adjectives to the two of them--with one pertinent exception, as you shall see.

First, both are driven by a sense of public purpose.  Guided to do what is right for their community or the broader world, they have never left a doubt as to their underlying dedication to make the place work better--safer, higher quality, and with extreme attention to the dignity of individuals.

Second, both are unfailingly polite, measured, and respectful in their communications and relationships with people of all persuasions and backgrounds.

Third, both are good humored, taking their work seriously but never taking themselves too seriously.

Fourth, both are devoted to their families, and their families are devoted to them.

Fifth, I am hard pressed to think of anyone in the community who doesn't respect them.  They are truly admirable people.

The major difference?  Well, let's just say that Jim doesn't have much of a Boston accent, whereas Mo, well . . . .

I join thousands in wishing them well for the next chapter of their lives.

Madaket is not just a beach on Nantucket

To understand corporate nimbleness and creativity, read this story and then compare it to my previous one about IBM.

As I've noted in the past, there are lots of companies seeking to find one or another Holy Grail in the health care world.  After all, when this sector comprises almost 20% of the US economy, who wouldn't want a piece of it?  But to be successful, you need to offer a product or service that actually enhances the day-to-day lives of clinicians or others in the sector.

This brings us to Madaket, founded by my buddy Jim Dougherty and friends.  (Note: I have no financial interest in the venture.) They noticed a very serious hole in the health care marketplace--the enrollment of doctors with the variety of insurance companies with which they must deal--and have developed an elegant solution to fix it.  Short version:

The average healthcare provider works with 25 payers. Providers must be enrolled with payers to receive payments. Each payer requires a unique set of forms, procedures, and data to be submitted in order to enroll for Electronic Funds Transfer (EFT), Electronic Remittance Advice (ERA), Electronic Data Interchange for Claims (EDI) and other common provider-payer transactions. When providers make minor changes to their enrollment information, they must submit these forms again.

It takes months for payers to fully process provider enrollments – and months before providers start receiving correct payments. Time is wasted dealing with paper forms, correcting manual errors, and tracking down the status of enrollments. Madaket automates the enrollment process.  Providers fill out a simple online form once, and Madaket sends the right information each applicable payer. The result? Less paperwork, faster payment.

Here's the video:

Note the design: All web-based, user friendly, and infinitely scalable. In addition, the existence of Madaket will pull those insurers who currently rely on paper and faxes into the same web-based environment, further enhancing its (Madaket's) deliverablity and efficiency over time.

This is a winner.  Let's go back to that beach on Nantucket and contemplate the good that will come from this!

Big data, big deal

Cousin Dave hamming it up in the 1960s

The joke goes like this:

Sherlock Holmes and Dr. Watson decide to go on a camping trip. After dinner and a bottle of wine, they lay down for the night, and go to sleep.

Some hours later, Holmes awoke and nudged his faithful friend.
"Watson, look up at the sky and tell me what you see."

Watson replied, "I see millions of stars."

"What does that tell you?"

Watson pondered for a minute.
"Astronomically, it tells me that there are millions of galaxies and potentially billions of planets."
"Astrologically, I observe that Saturn is in Leo."
"Horologically, I deduce that the time is approximately a quarter past three."
"Theologically, I can see that God is all powerful and that we are small and insignificant."
"Meteorologically, I suspect that we will have a beautiful day tomorrow."

"What does it tell you, Holmes?"
Holmes was silent for a minute, then spoke: "Watson, you idiot. Someone has stolen our tent!"

Last week, I found this eight page insert in the New York Times, and I was left wondering if this IBM ad was inadvertently another form of the joke.

IBM, you see, is trying (again) to transform itself.  Once the industry leader in whatever it wanted to do, it has now spent years slowly decapitalizing as it tries to find a commercial niche.

Now, it is offering services based on Watson, noting that "Watson is designed to understand, reason and learn.  In a sense, to think."

In a sense?

Here's a quick summary from Wikipedia:

Watson is a question answering (QA) computing system that IBM built to apply advanced natural language processing, information retrieval, knowledge representation, automated reasoning, and machine learning technologies to the field of open domain question answering.

The key difference between QA technology and document search is that document search takes a keyword query and returns a list of documents, ranked in order of relevance to the query (often based on popularity and page ranking), while QA technology takes a question expressed in natural language, seeks to understand it in much greater detail, and returns a precise answer to the question.

According to IBM, "more than 100 different techniques are used to analyze natural language, identify sources, find and generate hypotheses, find and score evidence, and merge and rank hypotheses."

Is that thinking? Stanley Fish offered this view:

Far from being the paradigm of intelligence, therefore, mere matching with no sense of mattering or relevance is barely any kind of intelligence at all. As beings for whom the world already matters, our central human ability is to be able to see what matters when.

So, in short, IBM is offering an expensive tool that might help corporate executives troll through lots of data and try to divine commercially relevant strategies. It suggests that, "When your business thinks, you can outthink" the competition.

IBM five-year stock price summary

I guess the proof of the pudding is whether this approach can be applied to IBM itself.  What I see instead is a behemoth of a corporation, with tens of thousands of employees spread across the world unfocused in purpose and execution, stagnant in the capital markets--with thirteen straight quarters of decline in revenues.  The company is an exemplar of brute force decision-making, being outflanked left and right by more nimble players in the marketplace.  The additional value offered by Watson is unlikely to be attractive to industry leaders in other fields.  The millions of dollars spent on the Times insert is, in my mind, just another example of ineffective corporate thinking.  What's the audience, and how is the ad persuasive?

Back in the 1960's, you could drop by the IBM building in New York City and pick up the iconic blue think desk sign seen above.  I still have mine.  I'm saving it for my daughters to take to Antiques Roadshow someday, where it might have some value as an a piece of industrial archeology.

Shared baselines as a guide to protocols

There have been some interesting and important discussions flying across the web in recent days on the issue of protocols in helping to reduce variation and reduce the incidence of harm to patients.  My mistake in the debate was assuming that medical leaders would be reasonable about how protocols should and should not be used.

A doctor friend, highly committed to patient safety, notes:

My point about the protocols is that I have been chastised for not following them in situations where it was blatantly obvious that they did not apply. ("The protocol is there for a reason.")

The chastisement comes not from hospital administrators, but from clinician leaders in the doctor's own department:

We just got another email scolding us for not following the "colorectal pathway" sufficiently. One of the provisions of that pathway, for example, is strict limitation of iv fluids, sometimes difficult to "comply" when patients are severely dehydrated from their bowel preps, particularly the elderly.

The initial goals were to decrease opiate use and decrease PACU LOS, both worthy goals, but we're all annoyed at being beaten over the head with them and getting our hands slapped if we deviate, even with good reason.

It's ironic that on the one hand we are extolling the virtues of gene-based individualized therapies, but on the other hand we are trying to pigeonhole every patient into a standardized protocol. 

This is disappointing in so many ways, but especially because the solution is in the hands of the profession.  Brent James discussed the sensible application of protocols to clinical process improvement, as employed in the Intermountain Health system, several years ago:

The concept of “shared baselines” came to rule:

1 -- Select a high priority clinical process;
2 -- Create evidence-based best practice guidelines;
3 -- Build the guidelines into the flow of clinical work;
4 -- Use the guidelines as a shared baseline, with doctors free to vary them based on individual patient needs;
5 -- Meanwhile, learn from and (over time) eliminate variation arising from the professionals, while retain variation arising from patients.

Note that this approach demands [my emphasis] that doctors modify shared protocols on the basis of patient needs.  The aim is not to step between doctors and their patients.  This is very different from the free form of patient care that exists generally in medicine.  Notes Brent, “We pay for our personal autonomy with the lives of our patients.  This is indefensible.”  The approach used at Intermountain values variation based on the patient, not the physician.

I guess my friend's experience is one example of the Law of Unintended Consequences.  I think the rigid approach being employed in that doctor's hospital and elsewhere is the result of little or no training in clinical process improvement in medical schools and in graduate medical education. We have often been told by residents, during our Telluride patient safety workshops, that they get more exposure to matters of clinical process improvement and high reliability systems in four days than in their seven previous years of medical training.

Brent expressed hope back in 2011:

Brent is optimistic because he has seen this philosophy of learning how to improve patient care extend to more and more doctors and hospitals around the country.  He views it as providing the answer to the rising cost of care, and he is excited about the potential.  He concludes that this is a “glorious time” to be in medicine because it is the “first time in 100 years” that doctors have a chance to institute fundamental change in the practice of medicine.

Thus far, such change only exists in certain islands of excellence, and it clearly takes energy and thoughtfulness to sustain it even in those places.

An error about mistakes

There are few neurologists I admire more than Martin Samuels, chief of service at Brigham and Women's Hospital in Boston.  So it truly pains me to see him engaging in a convoluted approach to the issue of mistakes.  Read the whole thing and then come back and see what you think about the excerpts I've chosen:

The current medical culture is obsessed with perfect replication and avoidance of error. This stemmed from the 1999 alarmist report of the National Academy of Medicine, entitled “To Err is Human,” in which the absurd conclusion was propagated that more patients died from medical errors than from breast cancer, heart disease and stroke combined; now updated by The National Academy of Medicine’s (formerly the IOM) new white paper on the epidemic of diagnostic error.

No, the obsession, if there is an obsession, is not about perfect replication and avoidance of error.  The focus is on determining the causes of preventable harm and applying the scientific method to design experiments to obviate the causes.  The plan is, to the extent practicable, implement strategies to help avoid such harm.

[T]here is actually no convincing evidence that studying these mistakes and using various contrivances to focus on them, reduces their frequency whatsoever.

Yes, there is convincing evidence (from Peter Pronovost's work on central line protocols, for example) that the frequency of errors that lead to preventable harm can be dramatically, and sustainably, reduced.

For example, there is absolutely no reason to believe that a comprehensive medical record will reduce the frequency of cognitive errors, whereas it is evident that efforts to populate this type of record can remove the doctor’s focus from the patient and place it on the device.  

Well, here's one place we agree! EHRs might actually increase the chance of cognitive errors. But why would you pick that one example, Martin?

We all try to avoid errors but none of us will succeed. This is fortunate as errors are the only road to progress. Focusing on the evil of errors takes our attention away from the real enemy, which is illness. We should relax and enjoy the fact that we are lucky enough to be doctors. 

There are errors that lead to progress and there are errors that lead to death and other harm. The flaw in Martin's article is not so much what he says, as the extrapolation he makes from what he says.  A friend sent me a note summarizing the case nicely:

While I agree that we’ll probably never achieve zero errors in healthcare for a number of valid reasons, there is ample evidence that a systematic approach based on the scientific method can significantly reduce harm to patients.  Yet, there is no reference to the great work done by so many of his colleagues, e.g., Peter Pronovost, Lucian Leape, Donald Berwick, John Toussaint, Robert Wachter and Gary Kaplan, just to name a few.  Nor is there any empathy toward the patient and the impact of avoidable harm on his or her life. 

"Protocols are for nurses."

Every now and then you hear something so dramatically stupid that you have to wonder.

One such example was a couple years back, when someone said: "I only text on the highway."

The latest example comes from a resident who was being "trained" by an attending doctor.  The resident was about to administer a drug using the protocol developed by that hospital's clinical department--one based on evidence produced as a result of systematic clinical evaluations.

The attending doctor interrupted the trainee and said, "Don't do it that way. I've been a doing this for over 20 years, and that way is stupid."

The resident replied, "But I've been told that this is the protocol."

The rejoinder, "Protocols are for nurses. Do it the way I say."

Which is worse, the pedagogy that has been employed or the practice of medicine that is being carried out?

After several years of participating in resident quality and safety workshops, I can report that we hear stories about this kind of thing quite often. Each time, the resident is put in an untenable position. Each time, a patient is put in jeopardy.

Marty teaches about mathematics and learning

My buddy Sam came home from back-to-school night at Wellesley Middle School inspired by his son's math teacher, Marty Wagner.  He related Marty's message to the parents, that mathematics is about taking risks and making mistakes.  He said, "If your kids aren't frustrated when they come home, I'm not doing my job."

In my undergraduate days at MIT, an esteemed mathematician named Gian Carlo Rota taught freshman calculus and put it this way when we were having trouble grasping a new concept: “Learning is overcoming your prejudices.” He understood that people are not really good at getting past their old frameworks of viewing things and in so doing have to work through the discomfort of adopting a new view of a topic.

Afterwards, you experience the joy and satisfaction of having learned the new item and find yourself on a new plane. At that point, as noted by Cynthia Copeland Lewis, "As soon as you understand 2 x 4 you can't believe there was a time when you didn't understand it."

A key attribute of a good teacher is to have sufficient empathy with his or her students to understand where they are in the learning cycle--the initial interest, the distress of overcoming prior conceptions, and the pleasure of success.  In an email Marty sent to parents many years ago, he displayed that empathy and helped the parents understand how he was trying to teach their children.

We did do a lot of cross-country skiing this vacation, but having two pre-adolescent boys means that we also did a lot of downhill skiing. At this point it is clear that my two boys (9 and 11) are definitely better skiers than I. They kept going through the glades on ungroomed and extremely bumpy trails, in and out of trees, and kept pushing me to do the same thing. I would have been perfectly happy to stay on nice, groomed, cruising trails.

 Frankly, it's hard for me to get over the fear of falling. I don't like to put myself in a position where I might fall.

I think that many 7th graders are in a similar position. They are being asked to accomplish more than they think they can. There is more content, more homework, more tests, more new thinking than they feel comfortable with. As a teacher, my job is to push students to go down the hill, support them when they fall, and tell them that they need to go right back and do it again.

After skiing this week, I can really appreciate how scary that is. I have extra respect for the courage of students who do fall-- who can't quite figure out the homework, or maybe even get failing scores on tests, but then come right back, get help when needed, and figure out what they need to know to do well on their next test or quiz. 

We can expand on Marty's construct to the corporate and institutional environment.  If a key job of a leader is to help his or her place become a learning organization, a full understanding of the stages of learning is essential.  The key attribute of the leader, then, is to have sufficient empathy to understand where his charges are in the learning cycle. He or she can then adopt strategies that will help them move to the next stage, both individually and collectively.

Two books

I'm often asked to read books and post reviews here, and I thus find my bookshelf overly full.  I just can't get to them all.  (Indeed, I just donated a few dozen books--some read and some never opened--to one of our local hospital management degree programs!)

I recently received two requests, and frankly, I was hesitant.  For one thing, I am friendly (in the internet virtual kind of way) with the authors, and when friendship is involved little good can come of an honest review. For another, the topics were troublesome and likely to be a bit timeworn--yet another book styled as a guide to personal health and yet another autobiography about the trials and tribulations of being a doctor.

Well, what a relief!  They are both very good, and I am pleased to recommend them to you.

An Illustrated Guide to Personal Health

Tom Emerick and Robert Woods, with some important help from illustrator Madi Schmidt, offer 40 common sense steps to improving your health.  Don't worry.  You don't have to adopt all 40, but you might like to.  As the authors note:

Alas, medical care can really only deal with about 20 to 25 percent of the things that cause you to die before your time.  The remaining 75 to 80 percent [other than genetics] of health risks come from . . . factors . . . you alone can control.

With good humor the authors warn:

As you read this book, you will see a lot of repetitive redundancy, over and over.  Why? We are trying to inculcate you with certain principles.

Much of what we have written here is documented science.

Some of what we wrote here is less science than a merger of philosophy and personal observations.

And then the final disclosure:

Some people do almost everything wrong their entire lives, and we mean everything, and live to be age ninety. 

I'll let some of the chapter headings titillate your interest. To find out more, buy the book. Don't worry.  It's short.

Avoid Hand Dryers in Public Restrooms

Avoid Antibacterial Soaps and Gels

Let Kids Play in Dirt

Don't Take Multivitamins

Envy is a Killer

Brush and Floss Your Teeth Regularly

Retirement Can be Bad for Your Health

Medicine Man, Memoir of a Cancer Physician

As first glance, Peter Kennedy is the stereotypical overly intelligent young man who dives into his medical school textbooks to learn everything so he will never face the possibility of not knowing something important that he might face in the classroom or the clinic.  There not much hint of emotional intelligence as we read that chapter.  Later, too, we see his impatience with colleagues, administrators, and regulations, and we are set on believing that he is overly hard-driving and arrogant.

Why on earth would we consider his life to be interesting? Simply, because we watch him grow as a human being and as a doctor.

It turns out that this fellow is deeply dedicated to his patients. We like to talk about patient-centeredness today, as though it is a new concept.  Decades ago, Peter walked the walk, sometimes literally.  Here are some excerpts from his fellowship period:

The work [of taking care of indigent patient's in the Ben Taub cancer service] was long and rarely exciting.  On those occasions where I couldn't quite understand a patient's difficulty with immediate family or home issues, I ventured into the Fifth Ward (Houston's ghetto district) to visit patients at night in their homes. It was plain stupid to go alone. I had seen hundreds of the wounded from that region, more than enough to make me wary, but I was never approached or threatened on those visits.  It was at those times that the total impact of a patient's journey to improvement or death upon his family became reality to me.

As I talked with patient and family . . . I felt something in the room change. And as I explained a mother's medical status, her husband, her children, and any extended family present would calm down and give me all their attention.  Some of the free-floating anxiety, and the suspicion and wariness about a physician in their home at nine p.m. began to dissipate.

I pushed past my own hesitation a little further.  Patient and family were presented with a gentle reboot of sorts, a statement of data rather than information mixed with hysteria or bias. . . . They became active participants in their own disease and its treatment.

[He'd say:]

"When I am sure you understand all of this, and you must try very hard to do so, we'll talk about what can be done to reverse, stop, or cure this cancer.  I'll tell you about treatment, warts and all.  Nothing will be held back"

"Then we'll use this information to decide what we as a team think is best."

And then Peter offers this confession to the reader:

As I became more deeply involved in it, I began to impart a quality I did not know I had--true empathy.

I had been trained originally to use evasion and misdirection as tools to maintain hope. 

It is unusual for an author to display the vulnerability that Peter offers, not just on these clinical matters, but with regard to his personal life.  (I'll leave those sections to you.)  His story is a compelling one. It is a privilege to be asked to read it. I am pleased to recommend the book to medical students, clinicians, administrators, and patients.