Listen to people you don’t like!

The Aga Khan delivered the Samuel L. and Elizabeth Jodidi Lecture at Harvard University yesterday.  He has been a strong proponent of pluralism in the world and has devoted billions of dollars in resources from the Aga Khan Development Network to enhancing education, health care , culture, and economic development in the world's poorest countries in Asia, Africa, and the Middle East. The full text is here, but I offer a pertinent excerpt, with lessons about an increasingly divisive level of political debate in the US and elsewhere:

In looking back to my Harvard days (in the 1950s), I recall how a powerful sense of technological promise was in the air — a faith that human invention would continue its ever-accelerating conquest of time and space. I recall too, how this confidence was accompanied by what was described as a “revolution of rising expectations” and the fall of colonial empires. And of course, this trend seemed to culminate some years later with the end of the Cold War and the “new world order” that it promised.

But even as old barriers crumbled and new connections expanded, a paradoxical trend set in, one that we see today at every hand. At the same time that the world was becoming more interconnected, it also become more fragmented.

We have been mesmerised on one hand by the explosive pace of what we call “globalisation,” a centripetal force putting us as closely in touch with people who live across the world as we are to those who live next to us. But at the same time, a set of centrifugal forces have been gaining on us, producing a growing sense — between and within societies — of disintegration.

Whether we are looking at a more fragile European Union, a more polarised United States, a more fervid Sunni-Shia conflict, intensified tribal rivalries in much of Africa and Asia, or other splintering threats in every corner of the planet, the word “fragmentation” seems to define our times.

Global promise, it can be said, has been matched by tribal wariness. We have more communication, but we also have more confrontation. Even as we exclaim about growing connectivity we seem to experience greater disconnection.

Perhaps what we did not see so clearly 60 years ago is the fact that technological advance does not necessarily mean human progress. Sometimes it can mean the reverse.

The more we communicate, the harder it can sometimes be to evaluate what we are saying. More information often means less context and more confusion. More than that, the increased pace of human interaction means that we encounter the stranger more often, and more directly. What is different is no longer abstract and distant. Even for the most tolerant among us, difference, more and more, can be up close and in your face.

What all of this means is that the challenge of living well together — a challenge as old as the human-race — can seem more and more complicated. And so we ask ourselves, what are the resources that we might now draw upon to counter this trend? How can we go beyond our bold words and address the mystery of why our ideals still elude us?

--

A pluralist, cosmopolitan society is a society which not only accepts difference, but actively seeks to understand it and to learn from it. In this perspective, diversity is not a burden to be endured, but an opportunity to be welcomed.

A cosmopolitan society regards the distinctive threads of our particular identities as elements that bring beauty to the larger social fabric. A cosmopolitan ethic accepts our ultimate moral responsibility to the whole of humanity, rather than absolutising a presumably exceptional part.

Perhaps it is a natural condition of an insecure human race to seek security in a sense of superiority. But in a world where cultures increasingly interpenetrate one another, a more confident and a more generous outlook is needed.

What this means, perhaps above all else, is a readiness to participate in a true dialog with diversity, not only in our personal relationships, but in institutional and international relationships also. But that takes work, and it takes patience. Above all, it implies a readiness to listen.

What is needed, as the former Governor General of Canada Adrienne Clarkson has said, and I quote, is a readiness “to listen to your neighbour, even when you may not particularly like him.” Is that message clear? You listen to people you don’t like!

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.