The Secret To Happiness

8:00: What's bad about having too many choices
15:06: The Secret to Happiness

The whole thing's worth watching.

Hellooooo Health!

Jay Parkinson to me is the definition of a brazen careerist. Health care is a very conservative sector that's eons behind in technology, rife with political machinations and just filled with complexity on all ends. Dr. Parkinson has single-handedly taken on the industry and changed the paradigm from health care to patient care in less than a year. There's a lot of history behind this, and rather than rehash it in prose, I'll hyperlink to milestones that have led to the launch of Hello Health, Jay's company. Safe to say, this model of care delivery is not going anywhere and may spark a revolution in the years to come.

• Original Website & Philosophy - In a nutshell, doctors making house calls like the old days with an iPhone packing in the patient records instead of a briefcase.
  

• The Video Brief - Think medical Facebook. Why not just add your doctor as a "friend" on a privatized network and message him with a problem?
  

• Summary Article on Hello Health Launch - Scalability is occurring one doctor at a time and I only foresee trailblazing growth in the future.

Bottomline: While most of us are used to email, IM, Facebook, iPhone, Google and overall internet-based communication, health care has only just turned on the computer. Jay Parkinson has skipped decades by providing patients real-time access to primary care services. The progress is exponential considering the industry context. The start-up's in Brooklyn, but at this rate Hello Health might be in your neighborhood sooner than you think.

TALK Patient, LISTEN Doctor, COMMUNICATE Healthcare

Here are some excerpts from a disturbing review of the doctor-patient relationship in the NYTimes Well section. This is important.

...there is a disconnect between the way doctors and patients view medicine. Doctors are trained to diagnose disease and treat it, he said, while “patients are interested in being tended to and being listened to and being well.”

The reasons for all this frustration are complex. Doctors, facing declining reimbursements and higher costs, have only minutes to spend with each patient. News reports about medical errors and drug industry influence have increased patients’ distrust. And the rise of direct-to-consumer drug advertising and medical Web sites have taught patients to research their own medical issues and made them more skeptical and inquisitive.

Keep in mind that EVERYTHING revolves around the communication between a patient and physician; need for lab tests and procedures, need for prescription medication, referral to specialists who then may refer out to more specialists, the odds of the doc getting sued, chances for the copay to get waived, whether the insurer finds reason to deny treatment, what your stress level will be that day (and maybe for a long time afterwards).

Going to the doctor has one of the highest potentials for changing your life (what else is there? job interview, meeting the parents, going to court). It all boils down to interaction, so its worth your while to make sure you find a doc that suits your personality, understands your lifestyle, and listens(!!). The article also gives a few more pointers.

Patients who don’t trust their doctor should look for a new one, but they may be able to improve existing relationships by being more open and communicative.

Go to a doctor’s visit with written questions so you don’t forget to ask what’s important to you. If a doctor starts to rush out of the room, stop him or her by saying, “Doctor, I still have some questions.” Patients who are open with their doctors about their feelings and fears will often get the same level of openness in return.

Is Blogging becoming a crutch?

I’m amazed by bloggers who can post 3 times a day (Tyler Cowen) with relevant content but find it pretty unrealistic unless there's some major incentive involved; money, larger audience, branding, etc. Done pro-bono, blogging still serves a personal purpose but at what point does it take away from spending an hour doing something else? What’s the opportunity cost? When does it start becoming a conversational crutch?

Its happened a lot that I preface what I’ve blogged in conversation, and that’s a huge pro to blogging; it organizes my thoughts around a specific topic really well. Sometimes though, I have a great conversation with someone that provides a similar organizational benefit and I end up taking hours blogging about it.

For the average blogger with a friend/family/coworker audience, it might be more beneficial to just keep sharing the learning points at a company picnic, family get-together, or house party. Blogging may just be getting in the way of something that’s already become clear to the blogger and probably will not reach a larger audience outside their personal scope anyway.

Even if you’re journalizing your thoughts, the cumulative hours spent typing away may not be worth the effort. To avoid letting the process of blogging get in the way of life experience, a friend of mine uses a private twitter account to document momentary occurrences. A quick 140 word text gets the job done 90% of the time. The rest is blogged. Brilliant!

Bottomline: A journal can be a blog, but a blog is not necessarily a journal. Some conversations are just more worthwhile having in real life with people you know. If you have enough of an audience to test out your new ideas before exploring them in conversation, then go for it. I don’t believe this represents the majority of bloggers though. As a litmus test, ask yourself this; “if my computer (and blog server) crashed right now and I lost what I was writing, would it really be worth writing again?”

As the Wordle Churns

If you haven't already, check out Wordle! Basically, you type in a few words in a text box and it generates a cloud image of those words. You can wordle any website or del.icio.us feed as well. My clouds are below.

This blog:

My del.icio.us tags:

Words I used to create a collage for a friend's wedding:

Universal Health Care: Right, Privilege or Commodity?

Must-read intelligent and clear-cut article on the different perspectives behind universal health care. If you've ever wondered why the U.S. is having trouble solving the 47 million uninsured problem, this article gives you a glimpse into why. Here's an excerpt:

We Americans are truly a spoiled lot when it comes to consumerism - the medical industry is not spared. We want to go to the best doctor possible. We want choice, and we will pay for choice. If there is a special procedure, we want it done. What we do not realize is that those choices and tiers of medicine are only availed through a profit-driven capitalist medical industry. Where do we think all of those drug and device discoveries are coming from? From the company that spent billions of dollars researching it and who sells it at a handsome profit and whose stock is listed in the public markets!

Everyone deserves to be in the Credits

Movies are such a grand affair to make: lighting, makeup, production, set design, casting, assistant to the 2nd cameraman, and the list goes on. Why are we familiar with these terms? Because they're in the credits! Mind you, most of us don't watch the credits because we're really there for the big show, but it really really matters to the people involved in the making. They tell it to their family, friends and even acquaintances with a sense of pride and accomplishment. In fact, I was an extra in The Namesake for about seven seconds and its become one of those things that just gets mentioned off-hand in conversation. The notion of credits is very transferable to other arenas, especially in the work world.

No matter how hoaky, being mentioned at a picnic, a newsletter, a party, or conference has a very lasting effect on people. No one's really immune. The very best companies make use of this concept heavily in other ways as well through sophiscated-sounding titles, celebrations, and leadership opportunities (in anything; from taking charge of team projects to managing the company softball team). Whatever work efforts we're involved in, there is a beginning, a middle and an end. Focus is almost always on the first two; start-up and maintenance. Yet companies evolve just the same as TV sitcoms do. The "end" with credits and all is the shifting point to antoher theme, product or customer; think Apple, Google, Microsoft but also Johnson & Johnson, GE and Procter & Gamble.

Bottomline: Acclaim matters. Make it a part of your work and personal life. Commend yourself and others upon meeting deadlines, reaching milestones, achieving goals. Change has to be a part of the system (more on that in another post). Employees and customers continue to stay interested only if you remain interesting. Figure out how to get you and your organization there. Credit opportunistically and you'll only create more opportunities to credit.

You're Not Really As Old As Your Age

Preemies or premature infants are tracked closely during their first few years of their life to see how they develop. Weight, size, and head circumference are some of the growth factors used to adjust their age and calculate what’s called a “real age”. For example, a 6 month old baby who scores low on these metrics may be adjusted to an age of 4 months. It’s in this light that I’ve been thinking of adult age as being adjusted by maturity level. We’ve all seen or taken those “real age” tests that tell us our real age is 21 or 32 even though we might actually be 25. I want to explore the principle behind this a little more, but in the sense of how mature other adults (40+) view us to be.

The idea originates from the fact that we now live much longer lives and our personal and work lives have changed dramatically because of it. We have more time room to maneuver in. We don’t have to be “settled” at 24 anymore (ha!). A career isn’t forever and we explore possibilities related to our hobbies and interests rather than something we picked in our adolescence. This extension in our settlement as adults has a larger effect though on how we are perceived by other adults. Their generation did have to grow up fast (relatively) and we’re largely held to a similar framework. If we don’t meet expectation, then we’re treated, well, like children. Unlike the preemies, who are given the attention and care to catch up to their age, 20 and 30-somethings in a state of maturity flux (in school or changing careers) are pushed further down the “adult” totem pole.

A simple example is a 28-yr old married postgrad (med/law/PhD) with two kids. He/she obviously pays bills and has gone through some major “adult” experiences (marriage, childbirth) but being a student really cramps mature interactions with other adults. Or to turn it around, there’s the 24-yr old single marketing professional without any kids who still starts his/her weekend on a Wednesday night. Comes to work on time, is ambitiously climbing the ladder, but due to lifestyle choices is held to a lower maturity level. Both are well-functioning citizens of society and because they don’t fit the old career paradigm, they’re not afforded the same respect as adults who’ve made more PC choices.

Bottomline: Your boss can boss you around because you’re not working, but can’t parent you because you choose to play world of warcraft in your free time. Your professor can teach you his/her expertise, but can’t make you come to class (you’re paying for it!). Stick to roles and don’t adjust people’s age by your perception of their maturity level. Yes, a boss can be a parent and a professor can guide behavior, but not until they’re asked. Relationships are mutual agreements and too often adults take on added unasked-for responsibilities just because they think they can. If you’re a recipient of this sort of behavior, make your age and maturity clear. There’s no set definition for “adult.”

On the Ground instead of in a Parachute: How to Think when Choosing a Career

Most career books advise imagining a circumstance where you have an infinite or an unbelievably large sum of money and have no need to work. They ask; what would you do then? Where would you want to be? How would your ambition change? The answers to these questions are supposed to guide you to your calling or that daily endeavor that holds true personal value.

Make it more real. The questions are legit, but the hypothetical scenario suggested is just too fantastical. Think about it in terms of what you earn now (which also eliminates that initial desire to go on a superfluous shopping spree). If you could have the salary you have now without having to do the work you do now for it, what then? Say you earn $50,000/year and it was guaranteed no matter what. How would you plan your day to day?

Bottomline: Our imaginations are powerful and may be a little too convincing. Who hasn’t dreamed about possibly earning a million dollars? Planning out career options based on that dream though is a little far-fetched and unrealistic. Work with the numbers you have now because they actually affect your lifestyle. It’s a clearer perspective when you can understand it on today’s rather than tomorrow’s terms.

Prenup Economics: A friendly conversation on losing your shirt and then some

I had a conversation with a friend the other day about who a prenup matters to most. Someone with $80M dollars or someone with $20,000. Assume net worth here, and also assume that without the prenup, each person potentially faces to lose half their net worth.

My friend’s theory was the person with $20,000 has a lot more to lose without a prenup because his purchasing power decreases at a much greater magnitude than the person with $80M. The wealthier party’s lifestyle isn’t too dramatically affected by a 50% loss, whereas the opposing party most likely won’t be able to pay the bills anymore. So the poorer person should care about the prenup more.

I disagree and on the same basis of purchasing power. First of all, $10,000 is a lot easier to recover than $40M. Regardless of the person’s working capabilities, it will certainly take much less time for any given individual to redeem the smaller amount. Second, and the guiding principle behind my argument; the wealthier person can just do that much more with more money. This isn’t about buying cadillacs and islands, its about translating purchasing power to production power.

$10,000 will pay the bills and could possibly be invested/gambled/leveraged to produce more money. Considering the wealthier person’s expenses are proportional to the less wealthy person, the $40M will also be used to pay the bills, but the remaining balance will still produce greater relative purchasing power. So the wealthier person should care about the prenup more.

Bottomline: Prenups have a relative repugnancy cost depending on culture. Net worth may not be as important as other personal costs in determining the need for a prenup. Based on divorce rates upwards of 50% in America, it bodes well for most people to get a prenup. As the argument stands though, the wealthier person should care more about the prenup and not necessarily for the most obvious reasons.

1975-1985: The Liaison Generation

I use the computer for everything now, but I remember waiting in lines to sign up for courses and using library cards to find books and turning my homework in on paper! I’m not as plugged-in as 12 year olds, but I’m not adapting as much as someone 40+. Of course this is a generalization with quite a few outliers (one of my favorite people to work with is a 56-year old grandmother who is also a systems analyst for a 250-member physician group), yet I’ve found that people born between the 1975 and 1985 tend to share similar traits due to similar transitional experiences as they were growing up. They’re liaisons bridging the “old” and the “new” way of doing things.

The biggest disadvantage for this liaison generation is not belonging to either group. Just think of all the buzzwords that have emerged for the identity roadblocks faced earlier than ever before; quarter-life crisis, career angst, job hopping, corporate distrust, etc. The decade’s worth of experience with one mode – the “old” way – is lacking and the innate response to use technology as the first mode for anything – the “new” way – is also lacking.

Out of this though comes the advantage of being translators. Connecting the “old” and the “new”, using what works best depending on the situation, and most of all helping others along the way. For the “new”bies, the liaison generation can provide a sense of origin, where things began and grew from and why. For the “old”ies it’s much more obvious; providing a simple way to adjust to ever-evolving technology and convert from desk to desktop.

Bottomline: What does all this mean and why is it important? It’s about defining a role. Offering one possible reason (out of many) for the confusion faced by an entire generation. There are business opportunities here, jobs to be created, organizations that face to benefit. A unification of perspective can only help this cohort of liaisons pave its path more certainly.

Health Care Undercover or: How to better manage the doctor-patient relationship

Undercover or fake patients seemingly pose ethical and annoying dilemmas for docs. How are doctors and practices rated? Is it fair for a fake patient to take up the time that could be used for a real patient? Is there a long-range view towards improvement or is this just hastily doled-out criticism?

These "mystery patients", similar to the mystery shoppers of retail clothing, come off as lone mercenaries; experienced patient-actors formerly found in med school classrooms looking to make a little more cash. There's no organization, no national quality board, no clear follow-up on the "dirt" they uncover. They're the symptoms of a larger problem of worsening physician-patient communication, lengthy wait times, and poor service by the administrative staff.

Why not just educate patients to be smarter medical shoppers? Teach them to look out for the same things the undercover types are meant to probe; waiting room ambiance, front-desk rapport, total visit time, total time with doctor, total wait time, bedside manner, clarity of medical explanations, the list goes on.

Why not give doctors the checklist of items they'll be evaluated on? Considering that physicians go into the business of patient care because they're humane and conscientious people, you can assume they seek to improve their health care services. If they were made aware of unmet patient expectations, they'd concentrate their efforts to meet them. How many of us go through life thinking we're doing right by our loved ones, friends and colleagues? In order to find out, all we have to do is ask.

Bottomline: Health care is defined by the relationship between a doctor and a patient. Everything else is either contributory or detrimental to that relationship. The problems may be complex, but the equation is simple. Instead of sprouting more and more side industries to correct the health care "problem", lets focus on the two sides that matter most and redirect all our time, money and energy towards their betterment.

Health Insurance Potholes To Watch Out For

Each insurance company is different so first thing figure out coverage restrictions.

• Do they cover routine visits or only sick visits?
• What's your deductible and how much do they cover before and after you meet it?
• How are inpatient hospitalizations covered?
• What about surgeries (major v. minor, inpatient v. outpatient)?

The first two are important to know from the get-go, but for the rest its good to just have the benefits and coverage guidelines printed out or bookmarked somewhere for reference purposes.

Few other things you'll come across after going to the doctor are prescriptions, labs, and image results.

• Does your insurer have a discounted formulary for prescriptions or pharmacies they contract with? (HUGE savings here)
  
• Does your doctor send your labs out to a company that's covered by your insurer? If not, you could owe a lot of money for processing your lab results. Worth checking both with your doctor and insurance company on this one!
• Who reads and interprets your images (MRIs, X-rays, CT scans, etc.)? Same as labs, if the diagnostic imaging company or the doctor interpreting your image results is not covered under your plan, you'll get a separate fee.

Whoa!...I know. I've lost $750 and several brain cells dealing with the issues above. Now I annoy secretaries, nurses and insurance representatives to no end BEFORE and DURING my doctor's visit so I can avoid major money and time headaches AFTER the fact. Its like the law. You don't realize how powerful it is until it impacts you personally. No wonder 59% of doctors support a single-payer national health insurance system!

What makes a company attractive?

Stock value? Growth rate? Philanthropic fundraising?

No. Its always the employees. And why? Because they do things like inject codes into their programs that have no intrinsic value but to entertain or put their dog in the company's founders profile as their mascot.

This makes the company a zany and fun place to work. When work is a life given, you need more than just money as a driver. An organization's social vibe affects its commercial value in the eyes of consumers and potential future employees. Personal happiness comes from interpersonal interactions.

Debt, repugnancy & the primaries

1. Hospitals auctioning debt online: its all about expectations. Not expecting patients to fall through on their credit, hospitals are being crushed under bad debt. Expecting a patient not to pay at least allows hospitals to provide charity care and write it off. In the meanwhile they're giving the highest bidder (mostly debt collectors) a chance to see if they can get the money back themselves.

2. NYC's idea for an organ-recovery ambulance: mile-long waiting lists for kidneys and livers drive this and legalized organ selling would certainly boost more entrepreneurial ventures in this niche. Only if we could get over our repugnancy costs.

3. Incredible interactive graphic breaking down voter demographics for the Democratic Primary: a very revealing data-driven perspective on differences in voting by age, race, gender, income and education. Make your own judgments on what this primary was really all about.

Should a doctor think like a clinician or a businessman?

In the U.S., most physicians often think like both. Oh wait, add accounting to the mix too. Clinical care, administration, and billing make up the 3-part mental framework of a physician in the U.S. The two business components represent all the paperwork doctors do after the patient leaves. Exact details of what the person came in for, documentation of the treatment protocol advised, and the appropriate billing code so doctors can get paid by the insurance company. Multiply this by say 30 patients and you have a typical day at the doctor's office. And that's just for one medical provider.

This is a lot of work. Many practices have an "administrative session/day" set up once a week when physicians can catch up on all this paperwork. A physician's day just seems so fragmented that I wonder how they concentrate on the one thing that matters; patient care. I explored this a bit through an international lens, seeing how other countries did it. Do nationalized health care systems like the ones in UK or Canada take away the business component or add more bureaucracy? What does a market-based system such as the one in the U.S. have to offer that they don't? Regardless of all the politics around which system is "better", I focused on just one thing; what occupies a physician's mind on a daily basis making the rounds and taking care of patients?

It comes down to incentives, in many cases monetary. In the U.S., most physicians get a good portion of their income on a fee-for-service (FFS) basis, whereas nationalized docs primarily tend to be salaried. I reached out to fellow blogger, Jason Shafrin of the Healthcare Economist, on this and he said,

"while salaried doctors may be more "objective" they do not have the incentive to innovate as would be the case in the FFS system. Physicians can invent new technologies to better care for patients if they know they will be reimbursed for their efforts in a FFS system. However, if the physician is salaried, the incentive to innovate is lower."

U.S. physicians certainly work harder. The more they do, the more they make. And that's where all the paperwork comes in. The insurance companies, along with Medicare & Medicaid, want to make sure they're not paying for frivolous tests and procedures. There's a very close watch over what physicians do in the U.S. Fraud litigation and skyrocketing malpractice rates are evidence of this. And ironically, the other major component of malpractice, medical errors, drives physicians to practice medicine more defensively and order more and more tests to cover themselves. Talk about a rock and a hard place.

In salaried systems this is less the case. We have a few major ones in the U.S. such as Kaiser Permanente originating from the West Coast and the government-run Veterans Affairs (VA) department. And countries such as Canada and the UK provide much larger-scale examples. From a basic day-to-day care perspective, these systems do provide freedom from the business side of medicine and allow physicians to focus on patient care. But as mentioned above, the trade off is less innovation and less incentive to work hard. On top of that, Jason mentions,

"while the physicians may be salaried, someone is being paid not on a salaried basis. The organization is usually paid on a per person basis (capitation) or fee-for-service. Even if physicians are paid on a salaried basis, management may compel them to increase or decrease procedure rates. For instance, the NHS may put managerial pressure on physicians to reduce utilization of services in order to reduce costs."

Bottomline: Even mental resources have to be allocated. If a physician isn't business-minded, someone else will be on his/her behalf. The economics don't necessarily favor a national or a market system since you lose drive for growth in the former and create drive to overdo in the latter. Maybe the U.S. could benefit from a nationalized sub-specialty system and a market-based primary care system. The hybrid methodology seems to be more favorable here, but that hasn't been tried and tested. The question of optimal patient benefit still remains within this incentive-based catch-22.

Eye-opening views from around the web

1. Scobleizer on using technology to get what you want out of life.

2. Bob Wachter providing a very detailed excerpt on the development of Google Health.

3. GPhone, or rather Android, demos!

4. A spiritual view of finding & fulfilling need (the business case for demand).

5. How mainstream media covers medical news.

Providing patients the means to monitor their own health

An elderly coworker recently mentioned her participation in a home-based, digital, disease management (DM) program sponsored by Blue Cross Blue Shield. At first I was astounded that an insurer would sponsor this. While there's always been a clear business case for prevention and monitoring to avoid chronic care costs in the long-term, insurance companies haven't been exactly eager to jump on board. They might be starting to see the win-win though:

"Keeping [at-risk] patients stable and quickly getting them care when it's needed can reduce hospitalizations and cut the insurer's medical costs. And since the savings come from improving the patient's health and quality of life, programs such as Blue Cross' "Your Heart Matters" are generally popular with participants."

That's from this article detailing how the above congestive heart failure (CHF) program works remotely from patient's homes.

"Every morning, Sedaris steps on a special digital scale beside the bed in her Raleigh home and answers a series of questions. Is she swollen or short of breath? Has she taken her medicines? The scale, provided by her health insurer, ships her weight and other data to a nurse's computer at Blue Cross and Blue Shield's disease management center in Winston-Salem. Any suspicious results -- an overnight weight gain of just a pound or two is a signal that Sedaris is retaining fluid that may strain her heart -- and the nurse is on the phone. She'll talk with Sedaris and, if necessary, send her to get medical attention.

The technology to remotely monitor patients' pulse, weight, blood pressure, blood-oxygen levels, general mobility and other indicators is already widely available. The declining costs and increasing use of high-speed Internet service should only accelerate acceptance of monitoring devices."

This is incredible! For more, here's another personal example from the Healthcare Economist.

Write It Down!!

I can't be any more clear. Whether you type it up, put it in a notebook, scribble it on a napkin, writing your ideas down has many benefits. I recently discovered this as I went through a spring cleaning of sorts through my computer's old files.

One, keeping a written record allows you to look back and see how you were thinking and articulating at a specific time period in your life. Its a personal benchmark for self-evaluation. For example, a lot of people feel they wrote a lot better in high school or college. Its possible. But many people just stopped writing when they began working. You can only observe patterns if you have something to look at. Whether it be ideas, short stories, poems, free-writing diatribes, it doesn't matter. It all becomes part of a personal portfolio of your work. To determine growth, you need reference points.

Two, as you gain experience and knowledge, the ridiculous can seem all the more plausible. As the saying goes, "one person's trash is another person's treasure". In so many ways, you are a different person year to year. What may not seem feasible at the time may be of great value to you later on. You can never tell in the moment so its worth writing it down!

Bottomline: In order to chart change and growth in your thought process (even after college!), you have to have some form of a written record. Blogging is one of the most efficient, least resource-intensive ways of accomplishing this. No matter how you go about it though, I guarantee you will find the experience rewarding.

Own What You Do

To buy or rent is a decision we all come across some time in our lives, usually in terms of cars or houses. Yet if asked, "Do you own your life?", the concept is a little more elusive. Ask an entrepreneur or independent contractor this question, and you will get a straight response; yes! In fact, its the question. The one that motivated them to produce, create, start something of their own. But that's just one way of looking at it.

We all own something (immaterial, of course!), whether we're aware of it or not. Its the thing we truly feel we have the power to effect, with a response equal to our will to effect it. Whatever it may be - leisure time, work schedule, planning the company picnic or the next major funding initiative - it should be acknowledged. Its an extremely self-empowering exercise!

What you discover through this process is that its all about how you approach it. The attitude you bring to the table. How many times have I heard, "same shit, different day" or "maybe I'll win the lotto this time". These are really defeatist statements. They shape your psyche and send a negative signal to those around you.

Bottomline: When you own what you do, you can take charge of the simplest daily routine with purpose in mind. Whether that purpose is change, growth, or maintenance doesn't matter. You simply believe in it more, because you're not renting your spot. As an employee, a father, a brother a husband. Any cap you wear applies.

Not Interested

At B&N the other day, I order my usual coffee with soy milk, and as soon as I see the barista about to pour what's left of the vitasoy into my coffee, I tell her to stop. I start to go into an explanation of how the really cold foamy dregs of milk at the bottom of the carton coagulate in very hot coffee and that...this is where the barista gives me a look and says, "so you want me to open a new carton...gotcha!"

I know at first it seems like I was trying too hard, but I had good reason since this had occurred before and I wanted to avoid 1) wasting a cup of coffee, 2) wasting mine and everyone else's time in line and 3) avoid having the barista go through the customer conciliation process that could have been avoided in the first place (coagulated milk&coffee is not a pretty sight!). But the barista was not interested in the why of the solution that would avert repeating the problem in the future; she only wanted the solution itself.

Prior education makes no difference. From the bookstore coffee stand to a physician's office to board of trustees of a major corporation, the why of it has become less important. And why I hope you would ask is this so? The primary reason given seems to be lack of time; everyone's too busy to spend time figuring out the why. I contend that its just the opposite: not taking the time to figure out why makes us more busy. And busy doing things that are duplicative and useless. The stop-observe-evaluate and then do mentality is becoming rare. Technology is being treated more as an added burden rather than a tool for efficiency.

Bottomline: Think what a day without cell phones, texting, google, twitter, facebook, and RSS would be like. Then plan the day out in a way that technology actually benefits it. Don't be beholden to your resources, make use of them as you best see fit to accomplish your goals.

Produce what you Consume

"The world brought me to my knees
What have you brung you?
Did you improve on the design?
Did you do something new?"

--Lupe Fiasco, ala "Superstar"

The "you attract what you think" principle has been proving itself quite well in the last few weeks. My recent interest in America's high consumer-to-producer ratio and how the web is contributing to lower it has led me into some very enlightening conversations off-line.

The real-time nature of the web makes you shift your thinking from "What am I contributing?" to "What am I contributing NOW?" (totally Tim Ferriss). The latter used to be too resource-intensive a question for any one individual to ask until the internet came along. Take Yoani Sanchez for example. Her blog helps to make the rest of the world aware of the way the Cuban government controls its citizens. Even though it is only one person speaking out, the validity of the outcry can be judged by the response. And this entire discussion occurs on a market-governed online forum.

Whereas the ability to vote used to be the single source of contributing one's personal voice to the global agenda, now one's online persona, free of anonymity, fuels the underlying free-market democracy developing exponentially online. This is incentive enough to become a member.

Bottomline: Turn off the TV, get off your butt, and do something. You never know who you'll meet, help, or learn from.

Your Future Doctor will see you Now

I wrote a post recently on needing a medical facebook (and medical twitter) to improve communication between patients and physicians. Jay Parkinson not only does this real-time for his patients, but he also sees them in their home, face-to-face for as much time as deemed mutually necessary. I wonder if the time saved from ridding himself of inefficiencies in communication has something to do with it.

"On the doctor side, I have a facebook-like platform that allows me to see and receive client updates and communicate via email, IM, video, and SMS with my clients and colleagues. We don’t do eVisits — we simply communicate normally via a whole range of communication options to help streamline healthcare delivery."

Hello Health!

Second-hand Health Care: Why Health 2.0 is Lagging

AMA is sponsoring a seminar called "Financing electronic health record (EHR/EMR) systems: Should your practice accept a donation?".

Looks like the open market making up for gov't inefficiencies. At first it seems like a salvation army effort to donate something that still works but isn't useful to the hospitals (like donating an old phone system), but look at it long-term and you see that it only slows down the transition from paper to electronic records.

Here's why: using a sub-par, used EMR system in your practice isn't going to help your practice if the doc next door buys a state-of-the-art system. Plus, interfacing not conversion is the more important issue. The EMR has to talk to other EMRs, pharmacies, scheduling systems. Old systems don't have this capability. The main reason I'm against this is because a practice's paper process indicates how well its electronic process will be. So if you make a lot of medical errors on paper, you'll probably do the same (if not worse) on an electronic system.

Bottomline: Bush passes initiative (in 2001) to have every practice/hospital on an EMR by 2014. He doesn't provide ANY financial help whatsoever to make this happen. Hospitals try to convert on the cheap and realize they need to upgrade within the next 5 years. Having an EMR becomes the cost of doing business, like having credit card machines at a department store. Financing (the money it costs to implement) is a NON-ISSUE. Do it well the first time, don't take hand-me downs and upgrade faster than the next guy. Adopting early makes you better off in the long run.

Tim Ferriss - Lessons Learned

After reading the 4HWW, watching Tim Ferriss interviews and reading his blog, these are the action items I've implemented. The goal: a simple focused day with (very) few distractions.

• Stopped all pop-up notifications: those annoying outlook envelopes, gmail notifiers, IM pop-ups, and twitter device updates. The moment these appear you lose focus on what you're doing. No matter how good you are at multi-tasking, when you see that message appear on the bottom right of your screen, its in your head. That takes away from what you're doing in the moment. Check these things on your own time, twice a day or more depending on what your needs are, but don't let them rule your present time.
  

• Started a notebook of ideas: during the day we all have crazy ideas that pop into our head. Time-trending these by writing them down helps to figure out when your thought process is most clear. Also, I haven't written anything in what feels like ages. Writing is the mode of learning I grew up with and my retention is far better when I jot things down.
  

• Practiced being deliberately attentive: its easy to allow yourself to get distracted because there's so many things on your computer, desk, phone that draw you away. Forcing myself to stay on course with the task/project at hand has in fact made it more enjoyable. You can't force flow, but you can make an effort to avoid what leads you away from it.
  

• Began tracking what I eat: it seems like a hassle at first, but is really easy to do. I keep a log of all my meals on Google Calendar. Since you can see the blocks for each day next to each other, its easy to spot patterns in your diet. Its really helps me see when I veer away from the norm (whatever that may be for you personally).
  

• Minimized my taskbar: the amount of time I spend on the computer completely warrants this. As I'm working on one thing, I have a a habit of taking quick glances at the various screens that accumulate on my taskbar as the day goes on; Outlook, Gmail, articles, presentations, videos, etc. Having the taskbar hidden seems like such a small thing, but it has made an enormous difference in my "in the moment" concentration level.
  

We need a Medical Facebook

Deloitte's Health Care Consumerism Survey has some pretty interesting results. I think it attracted a biased sample of consumers though, mainly because of this finding: 1 in 4 consumers maintain a personal health record. I find that very hard to believe, especially when the word, "maintain", is used. "Started", "created but never used" would be more fitting.

PHRs are ubiquitous - hospitals, insurers, popular medical websites all provide them - but people rarely use or update them. You put your information in, register a login and never look at it again. Why? Because its not connected to anyone. Even with all your medical info in one place, you don't have the ability to share that information very easily. Docs have to know about it, support it and use it in order for it to work. Otherwise, its just a Facebook profile without any friends!

Here's another reason why PHRs won't take off any time soon:

"Tethered" means linked only to a provider or a hospital and "standalone" refers to a web-based service like WebMD or Microsoft's HealthVault. Its hard to build a Facebook, let alone a medically-based version with all the privacy/security issues involved. The need is obviously there. PHRs won't take off without it.

EDIT: Doctors don't trust PHRs because they don't link to anything they use on a regular basis. Get connected!

Worker, Interrupted

"Want to get something done? Turn off Twitter. Turn off Facebook. Turn off blog comments. Turn off FriendFeed. Turn off Flickr. Turn off YouTube. Turn off Dave Winer’s blog and Huffington Post. Turn off TechMeme.

Turn off the distractions."

--Robert Scoble

After reading the above from Scobleizer's productivity post, I of course looked up all the references I didn't know and lo and behold I was signing up for another Web2.0 application. Classic.

Yet this also gave me insight into my own assimilation within the grab-and-go, click-through culture that's been rapidly developing over the last decade. Procrastination-induced internet escapism is an easy habit, and at the sake of projects and work. Reading may broaden one's perspective, but it doesn't lend to daily, efficient production. What Csíkszentmihályi describes as flow.

Mastering information, i.e. diligently taking notes to be referenced later and forever committed to our personal knowledge bank, is infrequent in today's look-up-on-wikipedia, web-bite world. Rather, we take snapshots. Into fields, philosophies, lives, ideas, hobbies and even vocations. We don't really know these things, but we feel like we do. Vicarious information gathered and stored in bookmarks on del.icio.us or google notebook make up our reference libraries now. Learning doesn't happen through osmosis though. And the doing must be done (channeling some Yogi Berra here!). Keeping pace with our reading/browsing through personal accomplishments, whatever they may be, is important so that when we look back we see our own contributions among the multitude.

Marc Jacobs on Simplicity

“The thing I love about the gym is not having to make choices,” he notes. “My trainer says, ‘You’re gonna lift this; you’re gonna do that ten times.’ Okay, great—just tell me what to do and I’ll do it. It’s the same thing with my nutritionist. All I have to do is follow instructions. I love that. This is not about ‘Would it be better in red or blue?’ There isn’t a lot of abstract, circular thinking involved. And it’s great. Those times are really nice for me.”

--Marc Jacobs from this GQ article

Bloggers Galore!

I spend a whole bunch of time reading a wide variety of blogs. So much so that (like email) I had to force myself to limit my blog reading to specific times during the day. A quick check of google reader can sometimes lead to a 2 hour wayward session out in the blogosphere. Below are a few bloggers I keep up with and mostly discovered through my random traverses.

1. My friend, Deep, started blogging around the beginning of the year. She offers a unique, personal perspective on (actually living) life as a med student. Her idea of doctors using twitter to keep in regular touch with their patients is just brilliant!

2. Cameron's commented on my blog several times. His blog is filled with pointers on relationships, fitness, and life in general. Here's one of my favorite posts.

3. If you're interested in health care IT, John Halamka's your man. He's professionally involved in an array of things, from being a CIO of a hospital system to ice climbing to playing the Japanese flute. This post gives you a humorous, insider perspective into what he's all about.

4. Jason Shafrin, the healthcare economist, is running a great segment comparing health care systems around the world. If you're interested, here's France, the first in his series.

5. If you can keep up with Tyler Cowen, then subscribe to marginal revolution. His interests are varied, but the common theme is economics. I learn something everyday from his posts!

Monday Afternoon Recap

Here's a few interesting things I came across over the weekend & this morning.

1. Hospital Compare went up late March. See if your hospital is there. The site still has a long way to go though on useful metrics.

2. Study finds link between drinking and breast cancer (for post menopausal women). I'll give this finding about 2 years before its refuted. I have no clinical research experience to speak of, but research news over the past 5 years certainly doesn't boast a great track record.

3. It was hard to miss this article on rising co-payments for drugs if you opened up the NYTimes this morning. The anecdotes are disheartening and the sad fact is that after decades of highly subsidized drug prices, we're only now being faced with the real costs of innovation. Longer life and better health come with a big price tag.

4. On a lighter note, check out Clear, an ezpass for airport security!

5. Also, I saw this on a friend's key chain the other day. What a great way to keep your favorite pictures with you all the time. And its cheaper than those wallet-size shots!

Why not showing up to your doctor's appointment is such a big deal

No show rates for doctor's appointments are frustrating on all counts. Patients who don't show up are most likely not going to get rescheduled for another 4 weeks due to a consistently packed schedule. The doctor could have gotten another patient in and if known ahead of time, another patient waiting to get in would have taken the empty slot.

Solving this problem has always been a slippery slope. Charging patients a fee for not showing up or failing to cancel 24 hours prior to the appointment can seem antagonistic and turn patients off to your practice. Yet letting a few patients continue their lax or tardy behavior at the sake of not providing care for those that are in need can be costly as well.

There are ways to solve this problem that satisfy both patient and doctor. What got me on this topic in fact was an article that described one really innovative solution:

"We added a new doctor - first name "Virtual," last name "Physician" - into our scheduling database. When our habitual no-shows scheduled an appointment, we place them on Dr. Virtual Physician's (or Dr. VP, as we have come to call it) wide-open calendar. The primary care physician's schedule is not affected by the chronic no-show's appointment. If the no-show patient does appear for the appointment, they are placed in the queue behind the on-time patient."

EDIT: Doctor's offices do get walk-ins (GPs, Pediatrics, etc.), but the timings are never predictable. Regardless, keep in mind that doctor's offices keep very static schedules. A lot of practices use the virtual scheduling solution above to block off times daily or on Fridays for catching up on administrative activities. The reason they don't just fit it in when a patient doesn't show up is because the expectation is that there is a real medical reason for the visit and many potential medical reasons for a delay. So time lost due to a no show is all real time.

Why are the Insured Crowding ERs?

Emergency departments (EDs) are almost always overcrowded and a new study sheds some light on the who, the how and the why. The increased number of visits from the mid '90s to now are in fact coming from insured patients who have access to a usual source of care (PCPs)! Visits by the uninsured, who would normally be considered the more likely culprits, have actually stayed stable in the past decade.

This is really important on the policy end, considering universal health care (if enacted) may exacerbate, not reduce the ED overcrowding problem. Also, if the uninsured aren't the main concern behind this issue, safety net funding for bad debt may take a hit.

But back to why the insured might be responsible for more visits in the ED. The authors say the

"increase in ED use may be attributable to lack of ready access to primary care and other structural problems in the health care system."

Structural problems such as long waiting times for appointments, lack of relevant patient info such as medications and prior medical/surgical history, sub-par diagnostic and treatment capabilities, and poor post-visit communication between patient and their PCP. This is really disconcerting since EDs are being filled up with patients who have minor complaints or illnesses, thereby diluting triage meant to prioritize those with urgent needs.

Looks like there's a lot of work cut out for all of us in health care.

EDIT: In regards to Di G.'s comment about clarifying how insured patient's actually wind up in the ED, here's one elaboration. Say you're experiencing horrible stomach pain and your PCP is out of town. You go to another doc to get a referral for a GI specialist. The new doc has no history of your prior history of bulimia or the gall bladder operation you had a couple years back and now neither does the GI guy. The GI doc, unaware of the lack of your medical information, sees you and when you're prompted to provide information about the meds you're on, you have no idea and start listing the colors of the rainbow you see every morning in your pill box. Your prior history is incomplete, you don't know what meds you're really on, and you're pretty high on the pain scale. You're an easy triage to the emergency department regardless of who sees you. But in the ED, the triage nurse will most likely put you towards the bottom of the list after the gun shot wounds and car accident patients. Hence, the 4 hour wait.

Electronic records are just one part of the solution. More importantly the flow of information from one site to another is the key to making this all work. The VA does it well, but most other clinics use different vendors that don't talk to each other.

Real-time Tap

It would be really nice to have some way of knowing the minute details of certain events real-time. I'm thinking along the lines of wait times for gaining entry into a live show or sporting event, travel times and actual timings for airport shuttles, delay alerts for traffic and flights, stadium seating availability due to cancellation or no shows and so on.

With a smartphone, you can access the web and look up the time and location of an event via its related website (if there is one). But that's a static, passive way of communication. We need some way to automate that friend who gets there early and calls you about a long line, a delay, or a saved seat.

Dysfunction junction, what's your function?

What's the deal with Southwest's boarding policy? I just can't find a reason for it. I'd heard about their alphanumeric system of boarding passengers by groups A, B and C in that order with a # attached to indicate your location within the group, but experiencing it was similar to what cattle must feel like when being prodded to pasture. And I was in group A!

I got the seat I wanted, but that would have been the case with any other airline, as long as I booked early. Southwest fills the niche of booking anytime and checking in early (which is why they constantly overbook and have to make concessions). If I hadn't checked in exactly 24 hours prior to my departure time, I wouldn't have gotten the seating group I did. If Southwest doesn't believe in first or business class, then simply get rid of it and let people pick their seat when they book and see if they can grab a better one based on availability at the airport (like JetBlue does). In fact, the system is so dysfunctional that websites started popping up to automate early check-in for a fee. Gaps in efficiency get closed and Southwest has fought well and hard to block these websites from closing them. But why bother when you can just spend the money on creating an efficient process in the first place?

Back to the Past

I booked a cruise to the Bahamas recently, and I can't begin to tell you what a hassle it was to go through the process. I need a vacation from booking my vacation!

I would love to go to someone and say, "this is where I want to go, this is what I'm willing to pay, take care of the rest." Oh wait, it's called a travel agency! And they're all going out of business because we have the convenience of doing everything ourselves through orbitz or priceline or travelocity.

But price shopping is anything but convenient. The initial thrill of beating the big hotels wears off pretty quickly. And then you have to keep a log of all the confirmation #'s, hotel phone #'s, travel regulations and...well, that's another blog post on travel organization.

Looks like there may be a reemerging niche for travel planning. Or maybe just hiring a travel websites expert. Either way, extend your hours AAA!

In Want of Need

“Is there any other industry in this country which seeks to presume so completely to give the customer what he does not want?”
--Rupert Murdoch

Sometimes leftovers just sit in the fridge, not because you don't want them, but because they're in the back of the fridge. If you keep fruit out on the table instead of a cookie jar, you're more likely to eat fruit. And if you make it appealing, say by putting a variety of bright colored fruit on the table, you'll be even more likely to grab something on the way out the door.

Availability is extremely important in changing habits. Marketing is all about spending lots of money to get a product in front of you. Once you see it, you start thinking about price and quality, but whether you need it is lost in the novelty and appeal. Most of our cultural mores and definitions of beauty are shaped this way. I can't help but think that Rupert Murdoch preferred seeing really skinny, attractive women on TV, which left us a culture of eating disorders and a single-minded warped sense of beauty. Its remarkable!

But if big corporations and marketing firms can psych you out to want what you don't need and like what you never cared about, so can you. Put that fruit bowl on the table, maybe along with some oatmeal in your pantry, and sugar-free juices in your fridge. Avoid TV for a week and see how you feel. Go grocery shopping with a list in hand. Work out a personal budget and use cash more. The tips are endless and you've heard them all before. But there is truth in cliché and when you're better off because of it, it doesn't matter what you call it. What matters is that it works.

The Closing Flood Gates

"In any great organization it is far, far safer to be wrong with the majority than to be right alone."
--John Kenneth Galbraith

We all love specialists. Patients know exactly what they go to them for, they've seen the problem hundreds of times in a given month so they have a pretty good idea how to treat you, their offices have 42" plasma TVs not magazines, and they attract the cream of the med school crop so you know they're good. But who gets you to see them?

PCPs! They're the referral centers. The gatekeepers to the rest of health care industry. And soon they'll be in pretty dire straits. Just go to the AAFP policy page, and you get an idea of all the Federal advocacy issues they're involved with. People flock to where the money is, but in this case the monetary incentives set up for the specialty docs and against the primary docs may not actually be beneficial to our health.

Insolvency or plain old not having the money

"Without change, rising costs will drive government spending to unprecedented levels, consume nearly all projected federal revenues and threaten America's future prosperity."
--Treasury Secretary Henry Paulson

The dates in this NPR news article are just scary. 2041 for Social Security. 2019 for Medicare. According to program trustees, those are the forecasted years when the trust funds for each benefit program run out. "Depleted" and "wiped out" were also particular terms chosen by the author of the article.

But I thought Medicare Part D was just approved just a few years ago? How did it get budgeted in? And what about the privatization debate for social security? If the gov't can't support us (or needs to exorbitantly raise tax rates to do so), maybe we should be allowed to invest for ourselves.

The healthcare economist elaborates further on the Medicare end.

Weekend Smörgåsbord

1. Tyler Cowen's link to RateMyCop.com

2. TEDBlog's mirror therapy for phantom limb pain

3. DMX on Obama (Ctrl+F "Obama")

4. Calculating your RealAge

5. Slate on the 25th Amendment loophole: 2 presidents for the price of 1!

A Mortgage-Backed Life

As I'm washing dishes today, I'm constantly thinking of what I have to do next. Go to the bank, get a car wash, go workout, get something to eat. The list continues. I'm on autopilot with my shoulders shrugged and brow creased. Getting to the next thing is more important than what I'm doing now. I'm not enjoying the process.

We always seem to be trying to get to the happy and fun moments without giving much thought to what we're experiencing now. So often I hear "just gotta get through the day", or "same shit different day". Your job or whatever you're trying to get out of the way may be terrible, annoying, or boring, but its the attitude you have towards it that'll make it easier to handle. Unless you have an alternative (which, if you did, you would grab right away and not complain), the task still has to be done.

Owning what you do always helps. When you really personalize something, make it your responsibility, realize your name will be on it, you start paying more attention. Think about owning a car or house versus renting either one. You just take better care of the thing you own because ultimately its you who'll have to fix it if something goes wrong. Even with such a simple thing as washing dishes, if you say to yourself, "if I don't pay attention to this and do it well, I'll be eating out of a dirty plate and might get sick", you'll be that much more focused.

I read about this "ownership perspective" a long time ago when I was perusing books that helped you narrow down your career choice. One of the books kept bringing up the fact that no matter what you choose to do, from engineering to auto sales, own that job and make it yours. Don't go in thinking you're getting paid to work. You're renting yourself (your human capital) out. Go in owning that job! Think like the owner and see what you can do to improve the place, ask questions, make suggestions, get a comment box going, whatever gets you involved.

Applying this point of view to your career is too big of a start. Keep it simple. Now how many things popped in your mind while you were reading this? Start there...

The oh-so-close horizon

Vista (vist-uh) n.

1.	a view or prospect, esp. one seen through a long, narrow avenue or passage, as between rows of trees or houses.

2.	such an avenue or passage, esp. when formally planned.

3.	a far-reaching mental view: vistas of the future.

Have you noticed how the word, "vista" has been popping up everywhere?? Considering definition #3, I understand why and it makes even more sense in the corporate view of things. Strategic planning meets Marketing, right? Here are a few more instances:

• WorldVistA
• AmeriCorps VISTA (Volunteers in Service to America)
• the Rx variety of course...Evista
• and c'mon now...Windows Vista

It's About Time

Time Out of Mind is simply a wonderful article. Author Stefan Klein makes a strong and articulate argument against the notion that "time is money".

"Believing time is money to lose, we perceive our shortage of time as stressful. Thus, our fight-or-flight instinct is engaged, and the regions of the brain we use to calmly and sensibly plan our time get switched off. We become fidgety, erratic and rash.

Tasks take longer. We make mistakes — which take still more time to iron out. Who among us has not been locked out of an apartment or lost a wallet when in a great hurry? The perceived lack of time becomes real: We are not stressed because we have no time, but rather, we have no time because we are stressed."

After taking a couple of economics courses, you invariably come to realize that the "cost" in opportunity cost is in fact stress. Applying the "no free lunch" principle makes perfect sense when you're making a calculated decision on which alternative might be best for the growth of your business. But does it realistically apply when you're calculating your free time in terms of dollars? "My free time is worth _______." Its really not, because its free! It only costs as much as you think it does. Hence the stress.

Quick elaboration. Suppose you get paid $10/hour and all your overtime is pre-approved. Now you have to valuate every extra hour beyond 8 hours as being worth $10, otherwise you lose it. Therefore, any activity you might choose to do outside of your work time has to be worth more than $10 to you. But what if you take a break because you're tired? Or go grab a sandwich? Or just do nothing? Some might say that these activities make you more productive and energetic allowing you to work more hours later. That's one possible rationalization. But is it even necessary?

The moment you choose to pursue an activity outside of work, your acceptance of the cost is intrinsic in your choice. Borrowing from economics once again, that cost is sunk. If you decide to focus on it, you only end up causing yourself stress above and beyond the $10 you already decided are worth losing. So then, would it be appropriate to say that opportunity cost is in the mind of the perceiver?

Trendy Disruptive Marketing

Dove's self-esteem fund sponsors the two videos below. If you haven't seen them yet, they're definitely worth a couple minutes of your time. There's been a lot of debate about whether this is some sort of "altruistic" marketing to fuel sentiment against mass media depictions of women.

Keep in mind this is marketing. Just like any other company selling any other product. But Dove has caught on to all the female angst that's been building up over the past few decades against the fashion, diet, exercise industry to make us all look like twigs. And why not? It does in fact sell:

"According to Information Resources, Inc., sales of Dove soap brands grew 7% to $281.3 million from Jan. 1 to Nov. 5, 2006; Dove hair care products sales grew 13.3% to $102.5 million; and Dove skin care products and lotions grew 16.2% to $117 million in that time period. Unilever posits that one in every three households uses a Dove product."

EVOLUTION


ONSLAUGHT

"The Thing To Do"

"Our leading men are not of much account and never have been, but the average of the people is immense, beyond all history. Sometimes I think in all departments, literature and art included, that will be the way our superiority will exhibit itself. We will not have great individuals or great leaders, but a great average bulk, unprecedentedly great."
--Walt Whitman

Whenever someone says "its the thing to do", I usually cringe and think exactly the opposite. Its not that I don't want to do what everyone else does, or that I'm above it in any way, but I'm instantly mystified and skeptical at how so many people can agree on one thing. Back in the 80's it was the thing to wear bell bottoms, and we all know how badly that went.

But now, its become a great mass marketing scheme. An iPhone, a big-screen tv, facebook, having a USB-drive hanging off your key chain are all considered chic and nouveau. Taco Bell (insert any generic fast food chain here) features a new special and its the thing to do to grab one. Even the coming election suffers from this phenomenon. Obama is the guy to want to vote for. Whether any of the above are sensible or not makes no difference. They're just the things to do.

Then again, making a well thought-out decision backed by unbiased research is very difficult these days. Who has the time for it? We outsource this kind of brain power to the Al Gores and Malcolm Gladwells of the world, hoping they took the time to do it right. I don't have the answer, and going against "the thing to do" just because it is isn't right either. All you can really do is be aware of peer pressure, groupthink, and the bandwagon effect. Once you acknowledge the mass mania, its much harder to get caught up in it. But its just a start. Then comes the hard part; personal justification.

Google Health Teaser

Google recently developed a partnership with the Cleveland Clinic to test its Google Health application.

Today, Google released a few teaser screenshots!

Modigliani-Miller Theorem Explained

"Think of the firm as a gigantic tub of whole milk. The farmer can sell the whole milk as is. Or he can separate out the cream and sell it at a considerably higher price than the whole milk would bring. (That's the analog of a firm selling low-yield and hence high-priced debt securities.) But, of course, what the farmer would have left would be skim milk with low butterfat content and that would sell for much less than whole milk. That corresponds to the levered equity. The M and M proposition says that if there were no costs of separation (and, of course, no government dairy-support programs), the cream plus the skim milk would bring the same price as the whole milk."

- Merton Miller from "Financial Innovations and Market Volatility"

Should your PCP be your Friend?

“The real price of everything, what everything really costs to the man who wants to acquire it, is the toil and trouble of acquiring it.”
--Adam Smith

It depends on if you think your car mechanic should be your friend. You see either professional about as frequently, mainly in times of distress. But the key difference is that your primary care practitioner (PCP) is your gatekeeper to the rest of the medical world, so it is worth your while to develop a strong relationship with one. You'll realize just how important this r'ship is when you move out of town, change your insurance, and oh yeah, get sick.

PCP shopping is essential. I just posted about the website, Vitals, which helps you do just that. There are many other sites that do the same, including the one your insurer most likely provides you (the most important!). You'll get a pretty long list of internists, family practitioners and general practitioners in your area and pretty soon you'll be scratching your head wondering just who to go to. Its pretty hard to compare doctors the way you compare cars and electronics. There's no consumer reports for physicians...at least not one that's agreed upon. But in general, keep in mind the following when making your choice:

1. Call and see how long the wait is before the next appointment. If its longer than 3 weeks, they're either really good or really inefficient. Double check if the doctor is on vacation or on service at a local hospital. That should give you a better idea of how they allocate their time. Then its up to you if you want someone reputed or someone reliable.
   
2. If you do choose the busy doc, ask who will take care of you instead when you absolutely have to come in. It could be another doctor, the head nurse or a resident. Either way, you have that much more information to work with.
   
3. Ask the secretary for a recommendation, then call again the next day and ask a different secretary. See if they'll let you speak briefly to a nurse and get her recommendation. This'll also let you know if they do phone consults either with the physician or the nurse. This way you can get triaged in quicker when you're sick.
4. See if they have an electronic medical record (EMR). This indicates many things about the practice; they're up-to-date, they're willing to spend the money to stay that way, and they want to be organized.
5. What about a website?? Do they partner with your preferred pharmacy? Can you refill your prescriptions online? Make an appointment online? Get test results online? Do they provide a personal health record (PHR) to help you organize your own health record and communicate your problems as they're happening?

Notice how none of the above goes into quality of care or bedside manner. There's very little out there to provide you with such metrics...again, its forthcoming. Who would've thought picking a doctor would be such a chore!? But its like anything else. You get what you put into it. And that all depends on how you answer the question above.

Get your Vitals Taken

George Van Antwerp posted a positive review for this site, Vitals.com, and I have to agree with him. I looked up some of the physicians I had worked with in the past and found out more about them than I ever knew before. It was startling at first to see their age, years of experience, and where they went to college. Then I started thinking about the ever-steady finding that more experienced physicians are simply better practitioners, so why shouldn't patients be aware of these characteristics?

Anyway, overall the site is really user-friendly. You can find a doc, figure out who to see for your problem and even rate the physician after your visit. Now it just needs critical mass.

More Rhetoric, Little Evidence

"When you encounter seemingly good advice that contradicts other seemingly good advice, ignore them both."
--Al Franken

This Valentine's Day NEJM article, "Does Preventive Care Save Money? Health Economics and the Presidential Candidates", speaks for itself.

"Our findings suggest that the broad generalizations made by many presidential candidates can be misleading. These statements convey the message that substantial resources can be saved through prevention. Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not. Careful analysis of the costs and benefits of specific interventions, rather than broad generalizations, is critical. Such analysis could identify not only cost-saving preventive measures but also preventive measures that deliver substantial health benefits relative to their net costs; this analysis could also identify treatments that are cost-saving or highly efficient (i.e., cost-effective)."

A visual always helps too:

Capitalism Entrapment

"The power of vested interests is vastly exaggerated compared with the gradual encroachment of ideas."
--John Maynard Keynes

I don't think there is such a legal term, but there should be. Or even better, it should be in the DSM-IV.

Capitalism's primary tenet is to promote efficiency in the interaction between buyers and sellers in a given market. Nobody really cares who is doing the selling or buying as long as they continue (and never stop) doing it. Its about the product, not the person.

I'm specifically thinking of Britney Spears. Young, talented and pretty, she makes it big on the world scene when she's 17 and now, a failed marriage and two kids later, she's suffering from a major drug problem. And selling. She sings about her problems and sells. She sings about being able to sell even though she has problems...and sells! We don't care about what's going on with her personally, we just love her music. She's enrapturing. She's entrapped.

The right or wrong of it is never clear. You can point to Bill Clinton's infidelity or Robert Downey's Jr.'s addiction or Ken Lay's corruption. But it depends which side you're on, the side that made money or the side that didn't. And money has the tendency to blind people to the hypocrisy in others' actions.

Bottomline is that as mega corporations continue to drive the mom's & pop's out of business, there's a growing disassociation between the seller and the product. To condone the behavior we want, we must ourselves live and breathe it. Eat better and exercise more if you want to curb the obesity epidemic. Become a socially responsible investor to avoid blindly funding oil, cigarettes, and fast food. Take responsibility and make yourself accountable for it, because everyone learns by example!

EDIT: How could I forget Martha Stewart!?

YOU determine the Value of YOUR Health Care

"Men occasionally stumble over the truth, but most of them pick themselves up and hurry off as if nothing ever happened."
--Sir Winston Churchill

Heath Ledger's death was such a tragedy, especially considering the cause of his death; accidental overdose of prescription medication. Its so infuriating! We're always talking about asymmetry of knowledge and medication compliance, yet considering the scope of funding in health care, there's very little procured to make the physician-patient interaction more valuable.

We get very little time with our physicians, an average of about 10 minutes to discuss our problems. Considering a physician sees approximately 20 patients or so a day, you, as a patient, have to be succinct and clear in your relay of information and hope the doctor is a good listener. Beyond that, there's little you can change at the point-of-care.

But think of all the things that happen before you even get to see the doctor.

1. You call to make an appointment - insurance registration
   
2. Fill out forms - reason for visit, current medications, medical history
3. Sign some important looking papers - HIPAA, release of medical records
   
4. Get your vitals taken - base health status
   
5. Meet with the nurse - history of present illness (HPI), review of symptoms (ROS)
   

There's potential for breakdown and success on all these counts.

#1. Very little is more hazardous to your health than getting a huge bill from your doctor. Problem: Most likely the breakdown happened when the billing department forgot to call your insurance company and precertify you for services and procedures during your visit. Providing your insurance info is the first part of this whole process!

Solution: No matter how good your doctor's office is, check with the insurance company yourself! Make sure you know your copay and get your deductible information before you go in. After the visit, if you're prescribed a test or medication, check with the insurance company again to see where you should go. Sometimes the pharmacy or imaging center recommended by the doctor's office isn't covered under your insurance (or might not be the cheapest option!).

#2. This is probably the most important of all. Problem: You've written the same thing over and over again going to different doctors, but still you forget what that medication with the long name is called. Or you forget that you finished the course of your antibiotic treatment a few weeks ago. Or you decide that the headaches you've been having every so often are not important for your dentist to know. And did you fax your records from the previous 5 doctors you saw? Do you even remember the second one's name!? The list continues.

Solution: Get all your medical info in one place. Find a doctor that offers a personal health record (PHR) or web portal. Go online to HealthVault, RevolutionHealth, WebMD and fill in the blanks. These sites have put in a lot of work to make it easy for you. If you prefer paper, get a file folder and drop all your info in there. Take a CD, print out your record or take the file folder with you to the doctor's office so you don't forget anything!

#3. Complicated legal forms are a necessary evil. Problem: You don't really care about what you're reading so you sign and date at the bottom and hand them in. The front desk secretary files it away along with your ins. card and photo ID and when you come in the next time, for some reason you have to repeat this process.

Solution: Fill out your medical forms first and hand them to the secretary. Take the time to read what HIPAA is all about and fill out your PCP's name in the medical release form so he/she is notified of the current visit. If you can, check if the doctor's office has an electronic medical record (EMR). This avoids the practice losing papers (because they get scanned in electronically) and saves you time from filling out everything all over again. Also, request a copy of your medical records so you can enter them online or put them in your file folder. A doctor's office has to comply with your request within 30 days (10 if you're from NY)!!

#4. Don't worry about white coat syndrome. You're here to talk about what's wrong and get a medical opinion. On top of that, you came prepared! So relax and let the nice ladies fuss over you.

#5. This is where the nurse will go over everything you wrote down. Problem: There's a game of telephone being played here where the front desk talks to the MA who talks to the NP who talks to the doctor. To their credit, most of it is documented.

Solution: Your job is to be repetitive and stick to your story. Keep in mind the top 3 things you came in to discuss. Don't go on and on about how tired you felt after the Giants tailgate. Nurses usually ask you about pertinent things you might have overlooked like recent minor illnesses, allergies, or over-the-counter medications you're taking. Pay attention and be detailed about your answers.

By the time you get to see the doctor, both of you will have a clear idea of what your record represents and what you're coming in about. After restating the top 3 issues, the repetition can stop. Let the doctor ask the questions, be concise in your answers and ask for further explanation if you don't understand something. By the time you leave, you should have a general understanding of your treatment plan. Ask a nurse or MA for definitions and medical pamphlets after to make sure you have a full understanding . Remember, you're on the clock, so coming in organized prepares everyone for what's important; your health care!

McMe, Myself, and I

"Caveat emptor; 'Let the buyer beware'"
--Laidlaw v. Organ, John Marshall

Super Size Me is a good movie in presentation. A great movie in fact. I haven't eaten McDonald's in a very long time - at least 6 years - and now I definitely know I'm better off for it.

(Weird thing is, I ended up craving some Mickey D's by the end!)

The Last Bite

"Probably the difference between man and the monkeys is that the monkeys are merely bored, while man has boredom plus imagination."
--Lin Yutang

If you like something, do you want more and more of it? Most people generally believe that to be the case. Money, sex, food, friends, free time; in general, the pleasures of life that bring us happiness. But sometimes actually having more of that thing we like doesn't leave us as satisfied as having one less of that thing and wanting one more.

Think about it. Experiencing that mental and emotional desire of meeting a budgetary goal, enjoying a romantic night with your beloved, and craving that last bite of dessert is much more potent than getting as much of those things as we want. You meet a challenge, distance does make the heart grow fonder and too much dessert is bad for you. Its what whets your appetite for more that's enjoyable, not binging on your favorite dish (which just leaves you feeling bloated and sick).

This can be applied. Next time, get one less scoop of ice cream than you want, have one less drink, stop before you're full, spend five minutes less in the shower, get home a little earlier from the bar, watch one less hour of TV. You'll keep craving that activity to the point when you just have to have all of it. And that's one of the greatest feelings in the world.

What's up with the Food Pyramid?

"If you can't easily trace a food back to its source in nature, don't eat it."

--Gregg Avedon

While tracking the evolution of the food pyramid, I became delighted, confused and shocked all at once. What was once holy 15 years ago has now turned completely on its head. A few pictures will help...



What's going on here!? The red meat is now split at the top with white bread, rice and pasta to be used sparingly when before the steak image was lumped in with nuts and fish at 2-3 servings/day and the bread, rice and pasta were at 6-11 servings/day!! Quite the shift don't you think?

Look towards the bottom for daily exercise and plant-based oils as a major component and also the addition of alcohol in moderation. This is in line with what we've all been hearing over the years, but what strikes me is how long it took to get the message out there. I remember my sister and cousins being taught the old pyramid only 4 years ago in middle school and high school. Even if parents have been keeping up with the latest news and research, how are they supposed to explain to their kids that what they're being taught in school is wrong?

If you visit USDA's food pyramid site now, you'll find the most latest version called, MyPyramid. It basically allows you to customize the pyramid based on your age, sex, weight, height and level of physical activity. After inputting all the relevant values, the site provides detailed recommendations and even lets you pick a plan that will lead to a healthier weight (based on your original values). Definitely worth a look. About time they decided to shy away from a one-size-fits-all model.



If you're interested in the progression of changes in the pyramid and want to learn more about why it was so flawed to begin with, check out this page.

EDIT: Here's even more from the Harvard School of Public Health on USDA's flawed methodology in constructing the original food pyramid and how to determine what really is good for you to eat.