Saturday, November 28, 2015

Don't get angry . . . and don't get even.

Watching the recent angry back-and-forth between Russian President Putin and Turkish President Erdogan has caused many of my friends in the medical world to wonder: Why do high ranking national officials stoop to apparently immature approaches in their disputes, approaches that might lead to an expansion of a conflict to something that neither party wants?

And then I remind them of behavior they have witnessed between senior doctors in their hospitals' operating rooms, intensive care units, and treatment floors. Sheepish looks quickly follow.

There is a school of thought that suggests that your effectiveness as a negotiator is enhanced when you display anger. Professor Alison Wood Brooks at Harvard Business School presents the alternative view in a recent HBR article:

[T]here’s a body of research . . . that documents the consequences of feeling angry while negotiating. This research shows that anger often harms the process by escalating conflict, biasing perceptions, and making impasses more likely. It also reduces joint gains, decreases cooperation, intensifies competitive behavior, and increases the rate at which offers are rejected. Angry negotiators are less accurate than neutral negotiators both in recalling their own interests and in judging other parties’ interests. And angry negotiators may seek to harm or retaliate against their counterparts, even though a more cooperative approach might increase the value that both sides can claim from the negotiation.

Or, as Lucius Annaeus Seneca put it:

Anger: an acid that can do more harm to the vessel in which it is stored than to anything on which it is poured.

In her article, Brooks offers some strategies that can be employed to help people tamp down unproductive anger, both in themselves and in their negotiation counterparties.  Most of her advice relies on a party's emotional intelligence.

Coincidentally, Dr. Gene Lindsey devotes a portion of his most recent weekly newsletter to this issue of emotional intelligence in the health professions. His focus is on the importance of this attribute in enhancing the value proposition for health care delivery, but the topic is also relevant in simple face-to-face clinical relationships.

Many of the points seem self-evident.  For example:

Emotional intelligence — plays a significant role in determining how effectively physicians communicate and establish relationships with patients, as well as with their colleagues.

Effectively leveraging emotional intelligence requires an understanding of how emotional intelligence manifests itself, as well as tools to help understand an individual's emotional intelligence in a healthcare context.

Emotional intelligence has four components: self-awareness, social awareness, self-management and relationship management. EQ is the ability to perceive, evaluate, understand, respond to and influence emotions. 

Having spent many hours in offering negotiation training to residents and medical students over the past four years, I have seen first hand how often these latter four components are missing. Even in classroom simulation exercises, I've seen anger and its close ego-driven relatives--stubbornness, aggressiveness, and passive aggressiveness--employed as negotiation strategies.

More sadly, while working in the medical field, I found myself mediating and moderating such behavior among highly experienced attending physicians.

Linda Pololi, in Changing the Culture of Academic Medicine, explores the environment in medical schools and finds precursor behavior among the faculty that likely influences medical students, to wit, "feelings of dehumanization [and] erosion of trust . . . within an environment where competitive individualism was rewarded and collaboration undervalued."  If their teachers present such an example, is there any wonder why young doctors carry it along through residency and beyond?

But there is hope. As educators we can create a safe learning environment to help young professionals develop aspects of self-awareness, social awareness, self-management and relationship management.

Here's a story from two students who learned some key lessons during a simple negotiation game in one of my classes at Telluride. Derek summarizes what he learned: "The frantic pace of a situation [can] overwhelm you into making irrational decisions.  Once we’ve jumped to a diagnosis, and confidently shared it with others, we are too prone to cling to it beyond rationality. Our ego gets in the way of us re-evaluating, asking what we may have missed, and being open to different opinions."

Note, too, Sam's comment: "I’m not going to lie – my ego still stings a little bit, but what a great lesson, and what a good way to learn it. I hope that stings stays with me so that I don’t make the same mistake again when it matters, when it can affect a patient."

A home for orphan wearables

How many people do you know who've bought a Fitbit or similar device to track their exercise patterns--who have then let the whole venture lapse? The Fitbit now resides comfortably and peacefully in their drawer!

Well, there's a useful way to recycle them, offered by Tufts University professor Lisa Gulatieri. As noted in this article:

Gualtieri started RecycleHealth in April with the goal of giving unused activity trackers — mostly Fitbits so far, but RecycleHealth accepts all devices — a second life. The company has collected about 20 devices so far and has plans to donate them to the Montachusett YMCA in Fitchburg, Massachusetts, where they will be used to help older and lower income individuals have access to devices, as well as to learn about how those populations interact with activity trackers.

Check out the Facebook page for stories on how the idea is spreading, plus more information, including how to get free mailing labels.

Monday, November 23, 2015

Ancient grains are not just old plants!

Just in time for Thanksgiving preparation, I ran into Maria Speck the other day, and we started talking about ancient grains.  She published her second cookbook on the topic a few months ago, and I've now had a chance to look through it.

Beyond some really beautiful pictures by Erin Kunkel, there's lots to view in this compendium.  Of course there's background information from amaranth to wild rice, with stops along the way for freekeh, millet, sorghum, and more.  We learn, too about the absorption method of cooking, contrasted with the pasta method and others.  Should we rinse?  Soak? Toast?  How do we know when it's done?  There are handy charts with cooking times, so we can be more secure about planning ahead.

And then, of course, the recipes. By the dozen, in all kinds of categories.

This encyclopedia is a joy to read.  I'm looking forward to sampling its contents.

"They really need to know"

In her day job, Susan Hackley is chief administrative and financial officer for the Harvard Program on Negotiation, but her prior experience in a variety of public policy and other positions offers her a crisp view on many issues facing the country and the world.  She decided to devote her observational skills to a new project, "A Child's Guide to War," when she realized that for American children aged 13 and younger, we have been at war their entire lives.

As noted:

A Child’s Guide to War is a documentary film project that is helping to bridge the civilian–military divide in the United States.

A wide gulf exists in America between those who have served in the military and their families and those who haven’t. While respect for the military is high, real knowledge is not.

Through the film, a public television program, teaching materials and public meetings we are hosting, we will help Americans better understand the role of the military in our democracy and the role of civilians in understanding, respecting and appreciating the service of those who solemnly swear to protect our country.

This is a work in progress, but you can see some tidbits in this short video produced in Indiana, where Susan and crew interviewed children whose mom or dad has been to war and asked: "What is it like?"  "What do you worry about?"  "What makes you proud?"

There's something compelling about the straightforward answers given by these children.

"My dad's not a killer."

"I just put my thoughts aside."

"They really need to know."

 Take a look and, if you feel moved, please support this effort.

Sunday, November 22, 2015

Serendipity is allowed

How's this for a lesson plan?

Serendipity is allowed . . . and even encouraged.

It is a philosophy set forth by Ed Moriarty, an instructor at MIT's Edgerton Center.  Opening the doors of the strobe lab for "that Saturday thing," as it is called by the students, Ed provides mentorship and asks challenging questions of children and adults of all ages who drop by to play and experiment.

Here is learning at its most creative, combining physical manipulation of electrical components with thoughtful observation.  There is no syllabus, just the joy of learning.

We were giving some friends a tour of MIT and we had explained that the philosophy of play is an important component of life at MIT.  We walked by the strobe lab at an opportune moment and were immediately hijacked by Ed. He said, "Hey, come in here. I want to show you some stuff."

He borrowed a circuit that eight-year-old Amelia had constructed and asked us, "What kind of shadow is created when you have three small diodes shining red, blue, and green and put a finger in front of one of them?"

"What if you hold up several fingers and the shadow falls on someone's face?"

Or as above, "What happens when water comes out of a sixty cycle-per-second pump and is illuminated by a sixty flash-per-second strobe?"  This little boy learned that the stream of water is actually composed of droplets, not a continuous stream.

As noted on the Edgerton Center website:

Always willing to follow students’ lead and to let them discover their own voice, Moriarty offers the intellectual and emotional support that enables students of all ages to learn to engineer by doing.

What do we do in classrooms?  Well, for the most part, we throw away spontaneity and and shoehorn students into tightly constrained curricula.  They learn the facts, but they often lose the creativity and joy of learning that comes from impulse and experimentation.  They soon forget the surprises that serendipity can bring.

Saturday, November 21, 2015

A leadership lesson learned?

As turmoil continues around the world, back here in Massachusetts there's been a kerfuffle surrounding Governor Charlie Baker's remarks about limiting Syrian refugees' access to the state. Several of us, including me, we appalled by what he said. Among those was US Representative Seth Moulton.  Moulton's criticism was, in turn, deemed partisan by the Governor, an accusation Moulton roundly denied. The Governor, too, said that his remarks had been taken out of context, and he appeared upset that he had been accused of a lack of compassion. Indeed, he declined to sign a letter from other Republican governors asking President Barack Obama to suspend efforts to resettle Syrian refugees in the U.S.

A friend on Facebook noted, with regard to this last item:

At least our governor is intelligent enough to listen to his constituency. And it shows we can push him on things, which is a good thing. Bravo Baker for listening and learning from your people.

The question that I ask today is what lesson was learned and how might other leaders also learn from this episode.  If the only lesson Charlie learned from the events was that he had gotten out too far in front of an issue relative to public sentiment and that therefore he had to backtrack, that's just a lesson in politics.

If, however, he learned another leadership lesson, then there is a better result for him personally and for the state.  You see, what Charlie did in his initial comments was to fan a spark of fear, resentment, and xenophobia among at least some people in the state. It does not matter whether Charlie's words were taken out of context. He grabbed the moment and became a lightning rod.

For example, here's one comment from Michele that I received on my blog post:

So if I don't like what this government is doing or the people that are running this country, I should pack up a couple tiny things, my very small children and move to another country? I joined the Navy. I was honored to work beside the Marine Corps. So instead of trying to fix my country I should move and expect everyone else to take care of me? My Grandfather remembers the government coming to his father's house to offer aid to farmers hit by the depression. He proudly refused. Where is the working through adversity attitude? Why is everything "give me help"?

I replied:

Michele, please take a look at some of the pictures and read the stories from these folks. This is not about working through adversity. This is about having your community destroyed, losing your housing and possessions, with threats of bombs every day.

She answered:

I know. I sobbed when their stories started coming through. My concern is my children, Paul. As is their concern I am sure. I am not willing to sacrifice my children's safety as they are not either. We are making decisions based on the same priorities. 

We should in no way discount people's fears when bad things happen in the world. But acknowledging that fear is not the same as fanning it.

Charlie doth protest too much when he claims his words were taken out of context.  The overall context was that a slew of mainly Republican governors were saying approximately the same thing at the same time.  The Governor needs to understand that the moral stature of an elected official is such that his job during times of stress is to bring people together, to appeal to their better instincts and values, and not to their fears.

When he says that "my job is protect the people of Massachusetts," he is both saying too much and too little.  Too much because no one person can protect six million.  Too much because, on this issue, he has no jurisdiction in any event.  Too little because his job is to help maintain a sense of community during a period of unrest.  Too little because his job is to remind us of our underlying values and shared history.

The question for Governor Baker is whether he learned that leadership lesson, not just a passing lesson in politics.

Thursday, November 19, 2015

How to secure more block time

While I hate to promulgate stereotypes about any particular group of medical specialists, this short video is too good to leave without broader dissemination.

Blog roll revisions

I've just finished editing the blog roll on the right hand side of my blog's home page.  I've deleted sites that have been inactive for six months or more.  If yours is no longer listed and you think it should be, please let me know.  Likewise, if you have a new (or old) blog to which I've not linked, please let me know.

Wednesday, November 18, 2015

Blind science

Thanks to Brian Klepper for alerting me to this:

Here's a poignant personal story about modern medicine from my friend Michael Millenson. Michael is a journalist who has played a significant role in ushering in the quality and safety movements in American health care.

The lede:

When I was a newborn — a preemie struggling to survive in a hospital nursery’s incubator — an article deep inside The Washington Post saved me from becoming blind.

The article — on Page A22 — discussed research showing that too much oxygen in an incubator could cause babies to lose their sight. When my worried parents phoned the hospital, they were told doctors had also seen the piece and promptly adjusted the incubator’s air mixture. What none of them knew was that the sight in my right eye had already been destroyed by what is now called retinopathy of prematurity, or ROP. Fortunately, the vision in my left eye remained intact, saving me from a lifetime in the dark.

That was way back in 1953. Yet just a few months ago, a federal judge dismissed a lawsuit involving premature babies enrolled in a study of what incubator oxygen level was best. The infants’ parents said they hadn’t been fully informed of all the risks to their infants. I was stunned. In 2015, how can the oxygen level in incubators still be endangering babies?

Tuesday, November 17, 2015

A gift from Monique

As we approach the Thanksgiving holiday here in the US, I'm reminded that it is almost the anniversary of Monique Doyle Spencer's death.   Here's a repeat of a post from 2013.  I just found a few more copies of the book.  If you'd like one, free, just leave a comment with your full name and snail mail address.

When Monique Doyle Spencer wrote The Courage Muscle, A Chicken's Guide to Living with Breast Cancer, she couldn't find a publisher willing to take the book on.  It was funny, you see, and all the publishers thought it was inappropriate to have a funny book about cancer.  She showed me a draft, and I said that our hospital would publish the book, and we did.  Since then, it has brought good-humored hope and advice to patients and families around the world.  As one reviewer said:  "It should become a textbook for the medical professions and a guidebook for all who must confront, or support those who do, breast cancer. It is a beautiful book, beautifully written, that sweetly balances gravitas, zaniness and one person's truth. The author's humanity is in full, accessible display for all to see, share and learn from."

Monique died on Thanksgiving weekend in 2011, and along with our fond memories of her, the book remains.  I happen to have several dozen copies, as does her husband Michael.  We have decided to offer them at no cost to the readers of this blog.  First come, first served, until we run out.  Just submit a comment with your name and snail mail address, and we will send one off to you in a few days.

To whet your appetite, here is a story about Monique's humor.  It occurred a few months before in 2011.  Michael tells it:

Bobby McFerrin gave a marvelous concert, showing his voice as an instrument, to a packed house at Symphony Hall.  Afterwards he came to the front of the stage and sat, legs dangling, to answer questions. After a bit, Monique plunged in, without being acknowledged, and asked about whether he was asked to do "Don't Worry Be Happy."  I could feel the audience cringe.  McFerrin gracefully answered the question and said he does not perform the song and was sorry to disappoint.  Monique shot back, "I did not say I liked it."  The audience broke out laughing and McFerrin fell to the floor and lay down on the stage, doing the same.

Monday, November 16, 2015

Why, Governor Baker?

I've worked for a lot of governors and have known a lot of governors, and I have always appreciated their need to balance what they might want to say about an issue with the political realities of their job.  But the best of our leaders are the ones who rise above the exigencies of local politics and manage to display a sense of commitment to human needs and values during periods of political stress--and in so doing remind us that compassion is often the best antidote for fear and unrest.

So it was with a tremendous sense of loss that I heard of Governor Charlie Baker's comments about Syrian refugees. Loss as in a lost opportunity to bring people together rather than being divisive. And lost admiration on my part as the Governor stooped to a level that I could never have imagined coming from his mouth.

According to the Boston Globe, here's what he said:

In the wake of the deadly terrorist attacks in Paris, Massachusetts Governor Charlie Baker has joined a group of nearly two dozen American governors who announced Monday they would not allow any Syrian refugees to move to their states.

“I would say no as of right now,” Baker told reporters at the State House Monday. “No, I’m not interested in accepting refugees from Syria.”

“My view on this is the safety and security of the people of the Commonwealth of Mass. is my highest priority,” he added. “So I would set the bar very high on this.”

“I think at this point in time we’d have to be very cautious about accepting folks without knowing a lot more about what the federal government’s plan looks like and how it’s going to be actually implemented and executed,” he said.

"As a general rule, I don’t like, completely without any knowledge at all, to just say yes or no to anything. I mean, I’m a data guy I always have been and always will be,” he said.

He also said, “I’m always going to be willing to at least hear what the federal government has to say.” But he added, “Hearing what they have to say does not mean saying yes.”

Mr. Baker is smart enough to know that, as Governor, he has no jurisdiction on such matters. Immigration policy is solely in the hands of the US government.

So, is he making his remarks to try to influence federal policy or simply to grandstand on the issue?

But what would it mean to stop the flow of refugees from a country that is literally being destroyed before our eyes?  I recently met one such refugee.  She and her husband and baby boy lived in Damascus.  Their home was taken over by the rebels.  It was then bombed by the Government.  They were homeless and were left with no possessions.  They managed to escape through Lebanon and thence to the US, where she is now enrolled in a graduate program at one of the state's great universities. Their local religious community has welcomed them with open arms and has helped them adjust to their new lives. The family is eternally grateful to the US and people here for giving them a chance to live a normal and productive and peaceful life.

Taking the Governor at his word, this family would have been stopped at the border.

Is he really so insensitive and uncaring about people in distress that he means what he says?  Or, does he not really mean what he says but just feels it expedient to say it? I'm not sure which is worse.

I forget right now, but it was either historian Theodore H. White or Arthur M. Schlesinger who, in summarizing his years of studying American history, said, "Never underestimate the tendency of the US public to become xenophobic." True leaders recognize that danger and work against irrational fear of foreigners: They do not stimulate it by dipping into the mire of anger and fear.

Sunday, November 15, 2015

I told you so

There are a lot of terrible lessons that come from the sad case of Amy Reed and other women who have developed more widespread cancer as a result of morcellation of uterine growths.

Here's a comment from a pathologist friend:

I remember, when these morcellators first came out, saying to the gyn's that if a woman had an unexpected endometrial cancer, I would not be able to stage it because you can't tell how deep it went into the uterine wall when the uterus is in pieces. And yes, we were puzzled about the leiomyomas, too. We used to have a rule that you took so many microscopic sections per centimeter of leiomyoma (i.e. larger ones are more likely to be sarcoma) to look for sarcoma. But how could you tell how big it was or which one was which from pieces?

We were ignored of course. It all goes back to how new things are introduced - there is no vetting process at all.

Let's consider this deeply. Pathologists are highly trained MDs who specialize in the identification of anatomical and cellular abnormalities. They are the doctors upon whom other doctors rely for diagnosis of and phasing of cancer. In this case, they made it clear to the doctors who take care of women with potentially cancerous conditions that a piece of equipment and a technique employed by those gynecologists could eliminate diagnostic clarity. And yet, the technology was adopted.

This story represents an institutional failure of the highest order. Underlying that failure, I would assert, is the ongoing medical arms race. Manufacturers design a product that makes life easier for one segment of the medical world.  FDA approval with regard to safety is limited in scope. Because data emanating from usage of the device is inherently inaccurate or incomplete (i.e., a needle in a haystack level of precision), it remains in use notwithstanding harm that has been caused.

But doctors also need to consider the story and reflect on how their own behavior can be destructive.

The pattern. Stories start:

About ten years ago, reports started surfacing in the medical literature of women with severe pelvic pain or unexplained bleeding who all had something in common: they had undergone morcellation years prior. Doctors reported finding growths in the abdominal cavities that could be traced back to the fibroids and uteruses that had been removed. This was troubling enough in itself—it had been assumed that missed particles, without a blood supply, would simply be reabsorbed—but it also raised the possibility that cancer could be spread too.

Serious concerns emerge:

Between 2008 and 2010, case reports of disseminated leiomyosarcoma by researchers in New Delhi, Montreal, Boston and Osaka were published. In at least one instance, the new tumour growth was definitively linked to the original specimen. Other papers compared outcomes for women whose undetected LMS had been morcellated versus not morcellated, and they found that morcellating an LMS tumour made it more likely the cancer would spread, and, according to at least one paper, more likely that the woman would be dead within five years.

By 2011—two years before Reed’s surgery—morcellation had become a full-on conversation among cancer doctors. Jeong-Yeol Park, a gynecological oncologist at the Asan Medical Center in Seoul, Korea and the lead author on one of the morcellation comparison papers, presented his findings at the Annual Meeting on Women’s Cancer. In an Oncology Times article about the talk, Bobbie Gostout, chair of gynecology at the Mayo Clinic in Minnesota, commented: “I don’t think there’s an acceptable, safe morcellator out there ... We are exposing our patients to a risk that to me seems out of bounds.”

Nonetheless, inertia rules, as per what happened after a review of Amy's case and an impassioned plea from her surgeon husband Hooman Noorchashm:

By the end of the meeting, little had been achieved. The Brigham would not lead the world in banning morcellators or even curtail their use in its own operating rooms. A few days earlier, the hospital had circulated an internal memo acknowledging that the risk of accidentally morcellating a sarcoma might be much higher than previously thought. It suggested that all surgeons get informed consent from patients before using the device. With that, the hospital felt that the matter had been dealt with.

Likewise, across town:

Isaac Schiff, head of obstetrics and gynecology at Massachusetts General Hospital (MGH), another Harvard affiliate . . . recalled being alarmed by the case of a morcellated fibroid turning out to be a sarcoma and he brought it up at a faculty meeting on December 12, 2013. There, he and his colleagues changed the hospital’s informed consent procedures.

Meanwhile, the person trying to be the agent of change is himself attacked, as incumbents in the system started to eat their young:

Now, though, the Brigham moved to isolate Noorchashm. The day after the December meeting with CMO Ashley, senior hospital staff circulated an internal email instructing Noorchashm’s colleagues to not communicate with him directly but instead to go through official channels. His job also became a sticking point. 

His descent was steep and lonely. In a matter of weeks, Noorchashm had gone from being a Harvard-affiliated surgeon, a golden boy with a shining future, whose life and identity revolved around the operating room, who got up at 4:30 every morning and seldom made it home in time to kiss the kids goodnight, to someone whose major scheduled activities involved dropping his children off at school in the morning and listening for their buses in the afternoon.

Tragedy upon tragedy upon tragedy. And totally avoidable, if from the start, the thoughtful voices from the pathology profession had been taken into account. Rosemary Gibson (in The Wall of Silence) has written elegantly about the underlying problem, a problem the profession steadfastly refuses to address:

The people who provide health care to patients are organized in different tribes. . . . Virtually no training exists to help them learn how to work together, so instead of learning to understand and respect one another's role, there are chasms among the tribes.

Measuring . . . nothing

At his talk at Harvard last week, the Aga Khan reflected on the state of things in the world and spent a moment on the role of technology.  He noted one adverse result:

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. 

We were treated to a prime example of this during Saturday night's debate among the Democratic candidates for president.  As we watched the debate, we were presented with a visual hodgepodge.  The candidates were in the middle of the screen.  To the right was a semblance of a Twitter feed, showing real-time reactions to the debate from . . . .  Wait, from whom?  Who knows.  The chosen tweets were the ones some CBS functionary had decided were noteworthy enough to share with the millions of people viewing the debate.  Who were these chosen gods and goddesses of political observation, the ones whose 140-character notes were deemed thoughtful, entertaining, or controversial enough to warrant national exposure? Why were their opinions relevant, helpful, or important in any way?  How did their comments help us as citizens reach our own conclusions about the effectiveness of the candidates?

As if that weren't enough, CBS presented the following chart directly underneath the debating candidates:

When we consider all of the possible metrics about the political world, could we come up with something less meaningful that the "relative number of tweets per minute about three candidates during a debate?" What possible probative value about anything does such a metric offer? Simple answer: Not a damn thing.

A superb reporter, Carey Beth Goldberg, in a note to me, said:  "This is one more example of how the ability to measure something online doesn't mean you should."

She then said:

"There was a really good piece on On The Media about how just measuring clicks is misguided too  -- based on a story about spooning (?!?)"

That article is worth a click! 

Friday, November 13, 2015

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!

Thursday, November 12, 2015

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:

Wednesday, November 11, 2015

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.

Monday, November 09, 2015

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!


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.

Sunday, November 08, 2015

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!

Thursday, November 05, 2015

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.

Tuesday, November 03, 2015

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.

Sunday, November 01, 2015

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.