Are smart phones making us dumb?

There was a time several years ago when I subscribed to both the Wall Street Journal and the Financial Times newspapers.  I enjoyed reading both, but it just got to be too much.  I soon found myself just throwing the daily edition of each newspaper unread (or partially read) into the recycle bin.  I have to be 100% honest though, while I thought the writing was slightly better in the WSJ (and more focused on current events in the US), the articles were shorter and easier to digest in the FT.  I've posted in the past about how much I like to read, but more recently I've found myself enjoying shorter books, magazine articles, and newspaper articles.  So, I started wondering if something was going on with my reading habits.  Have they changed?  As it turns out, there may be a very logical answer and explanation.

The American writer and journalist, Nicholas Carr, wrote an article for The Atlantic in 2008 entitled, "Is Google Making Us Stupid?"  He expands on this theme in his excellent book, The Shallows: What the Internet Is Doing to Our Brains. He suggests (and provides convincing evidence) that our online reading habits have changed not only how we read, but also how we think.  Consider this - studies show that when we read online, we skim over information and bounce around the Internet using either the embedded hypertext links or by starting a completely new search.  Just like my preference for the shorter articles of the Financial Times compared to the Wall Street Journal, we've all lost our ability to read lengthy passages of text.  Our brains have become permanently accustomed to the 280 character count of Twitter or the short messages with all the emoji's that we send and receive in a text!  As Maggie Jackson writes in her book Distracted, the Internet, social media, and email are all set up to distract us and keep us distracted.  Carr describes the changes in his reading habits by stating, "Once I was a scuba diver in a sea of words.  Now I zip along the surface like a guy on a Jet Ski."  Case in point, in his book Carr references an article that appeared in New York magazine in 2009 written by Sam Anderson, entitled "In Defense of Distraction."  I took a look, but when I saw how long it was, I quickly skimmed through it!

Even traditional forms of media have been forced to adapt to our new reading habits.  Television programs add text crawls at the bottom of the screen, while magazines and newspapers (if they are even around) have shortened their articles (see my point on the Financial Times above) or provided abstracts or summaries of the longer articles.  I've even heard of e-books that have started to look more like the Internet, complete with hypertext links, pop-up advertisements, and rolling text crawls.  

What if the Internet has changed more than just our reading habits?  What if it has fundamentally changed the way we think?  Carr starts and ends both the Atlantic article and his book with a famous scene from Stanley Kubrick's 1968 movie, 2001: A Space Odyssey.  Astronaut Dave Bowman is slowly turning off the computer HAL-9000, which had tried to kill him earlier in the film (and actually did kill his fellow astronauts).  At first, HAL-9000 admonishes, "Dave, stop. Stop, will you? Stop, Dave. Will you stop?"  As the astronaut continues to shut off HAL's circuits, one at a time, the computer responds with "I can feel it. I can feel it. I'm afraid."  Carr ends the article (and the book) with, "That's the essence of Kubrick's dark prophecy: as we come to rely on computers to mediate our understanding of the world, it is our own intelligence that flattens into artificial intelligence."  It's a haunting prediction, but one that doesn't seem all that far off.  

Carr writes, "The Net grants us instant access to a library of information unprecedented in its size and scope, and it makes it easy for us to sort through that library - to find, if not exactly what we are looking for, at least something sufficient for our immediate purposes.  What the Net diminishes is...the ability to know, in depth, a subject for ourselves, to construct within our own minds the rich and idiosyncratic set of connections that give rise to a singular intelligence."  To be blunt, the Internet is driving our brain into the shadows!

There is evidence to suggest that "how" we read helps to shape the neural circuits inside our brains (called neuroplasticity - for another example of neuroplasticity, see my post "London Hackney" on the neuroplasticity found in London taxi drivers).  For example, experiments have shown that readers of written language that uses symbols (e.g., Chinese characters, called Hanzi, that are among the oldest writing systems in the world) develop different neural circuitry compared to those whose written language uses an alphabet.  Similarly, studies have shown that our online reading habits ("power browsing" to use a term by another author) form different neural circuits in our brain compared to our traditional way of reading, where we become deeply engrossed in an article or book.

As it turns out, people have been worrying about how advances in technology can change us in dramatic ways since the time of the ancient Greeks.  In Plato's Phaedrus, Socrates laments how writing has made people forget how to think.  Socrates argues that the written word is "a recipe not for memory, but for reminder."  And as people use the written word as a substitute for the knowledge that they used to carry around in their heads and recite by memory, they will "cease to exercise their memory and become forgetful."

Maybe Nicholas Carr is right.  Maybe our smart phones have made us less intelligent.  Technological progress has become, to use Socrates' analogy, a crutch that in the long run will only make us less intelligent, less resilient, and less independent.  Carr carries on this theme with his book on the dangers of automation, The Glass Cage: How Computers Are Changing Us, but that is a topic for another post.

Royal Pains Part Two

I ended my last post ("Royal Pains") with a promise to revisit and further explain my statement that the lack of alignment between physicians on a hospital's medical staff and the hospital administration is well known.  Some experts refer to this lack of alignment as "Blue Suits versus White Coats", referencing that administrators frequently wear blue or black suits, while physicians frequently wear white lab coats.  Unfortunately, negative stereotypes only make this lack of alignment worse.  As Deane Waldman and Kenneth H. Cohn write in The Business of Healthcare, "The manager sees a doctor who has no understanding of, or interest in, resource constraints or proper organizational behavior, even if the doctor has an MBA and manages a successful multimillion-dollar division. The doctor sees a heartless bean counter who cares nothing for patients, despite the CEO spending seven hours before a state oversight committee aggressively seeking support for the doctors’ medical programs."

The management expert Henry Mintzberg suggested that there are four different "worlds" or subcultures that exist in hospitals today (see his article, "Toward healthier hospitals"): the hospital trustees (or Board of Directors), the physicians, the managers (i.e. the hospital administrators), and the nurses.  Mintzberg also noted that these four worlds rarely talk to each other, nor do they attempt to solve problems by collaborating together.  Each world has its own language, which makes it even harder for the "citizens" of each of the four worlds to collaborate and communicate with each other.  Mintzberg wrote his article in the late 1990's, and while the communication and collaboration between the four different worlds has certainly improved, I will admit that there are still four distinctly different subcultures in most hospitals today.

The divide (some would call it a chasm) between physicians and administrators is compounded by the fact that the growth in the number of healthcare administrators has far outpaced the growth in the number of physicians.  Between 1975 and 2010, the number of physicians in the U.S. increased by 150%, roughly proportional to the growth of the U.S. population as a whole.  In contrast, the number of healthcare administrators increased by 3,200% (see the graph that is frequently shown on social media below):

Most experts defend the tremendous growth in healthcare administrators by citing the tremendous growth in complexity of the U.S. healthcare system due to advances in technology in general (and in information technology in particular), as well as the greater scrutiny from regulatory agencies and payors.  Unfortunately, the imbalance in growth between physicians and administrators has only further escalated the tensions between the two groups.  As Pooja Chandrashekar and Sachin Jain write (see "Understanding and fixing the growing divide between physicians and healthcare administrators"), "Physicians blame managers for creating administrative hurdles that diminish autonomy and increase workload.  Administrators blame physicians for failing to comply with resource complaints."

Some of the reasons for this growing divide between physicians and administrators is historical.  It was not all that long ago that most physicians were independently employed (rather than being employed by hospitals), working mostly in a private practice setting and rounding occasionally at the hospital whenever one of their patients was admitted.  There was very little regulatory or administrative oversight of physicians, which has largely changed in recent years.  While both physicians and administrators are often following a call to serve, they differ in how they approach that calling.  For example, while physicians focus on improving the health of their individual patient, administrators focus on improving the health of the population.  While an individual physician may feel justified in expending all the available resources for one patient, an administrator often has to balance resource expenditures to serve the needs of all the patients who seek care in their organization.  

One potential solution to this issue is to develop physician executives who can bridge the divide between their colleagues and the hospital management team.  There has been a virtual explosion of physician leadership programs in the last several years, including dual-degree (MD/MBA) programs, postgraduate certificates, and graduate (e.g., MHA, MBA, MMM) programs tailored specifically for physicians. Hospitals and health systems have developed specific executive-level leadership roles for physicians, with a number of different titles (Chief Medical Officer, Physician-in-Chief, Chief Clinical Officer, etc).  These physician executives must balance reading the New England Journal of Medicine with the Wall Street Journal, speaking both the "language" of their physician and administrator colleagues. What frequently happens (based on surveys of physicians in executive positions), however, is that the physician executive is never fully embraced by the administrators ("You're still a physician!") and can find themselves alienated by their physician colleagues ("You've gone to the dark side!").  It can be difficult to balance this reality that they may no longer be viewed as physicians by their colleagues, while at the same time never be fully trusted by the hospital management team.

There are certainly other ways to bridge the divide between physicians and administrators.  There are countless articles and books written on this very subject.  Admittedly, however, despite the growing literature on this subject, the divide between physicians and administrators remains.  What has worked well in one organization may not necessarily translate to another organization, as a lot depends on the history, culture, and leaders of an organization.  Regardless, here are some high-level, general themes (from the Chandrashekar and Jain article, as well as the Institute for Healthcare Improvement's (IHI) white paper, "Engaging Physicians in a Shared Quality Agenda"):

1. Unite around a common, patient-centered vision. What's generally not very controversial, even between physicians and administrators, is that the care that is provided in an organization should be of the highest quality.  I've found that physicians and administrators can and often do unite around the common goal of providing safe, effective, timely, efficient, equitable, and patient-centered care.  

2. Improve mutual understanding of roles.  Administrators need to understand the physician experience, but just as important, physicians can benefit from looking at a problem through the lens of an administrator.  Executive rounding (using Lean/Six Sigma concepts, "going to the gemba", a Japanese term for "the place where value is created") and clinical shadowing programs are two commonly used techniques to help administrators gain a better understanding and appreciation of what physicians do.  Conversely, leadership training and teaching physicians "the business side of medicine" can help physicians better appreciate and understand what administrators do.

3. Increase transparency and provide opportunities to collaborate.  To increase trust between physicians and administrators, organizations should increase transparency around how and why certain decisions are made.  Better yet, having members of the medical staff participate in those decisions helps to increase trust and collaboration.  Importantly, these physicians shouldn't be viewed as the token physician representative, but rather as active participants in the decision-making process.  A number of organizations have adopted so-called leadership dyads (physician/nurse, physician/administrator) or triads (physician/nurse/administrator), whether for service line leadership or leadership of organization-wide change initiatives.  Importantly, make physician involvement in these initiatives clearly visible to the rest of the medical staff.  

4. Remember that respect is as important as autonomy.  Administrators can preserve both autonomy and respect by engaging physicians in "active problem-solving, rather than passive rule-following".  Administrators should take physicians' concerns about administrative burden, workplace culture, and burnout seriously.  Initiatives that are co-led by physicians and administrators (see the "dyad model" above) and that focus on reducing hassles and wasted time can go a long way.  The IHI white paper "Engaging Physicians in a Shared Quality Agenda" recommends changing the narrative by making physicians partners, not customers.  Having administrators treat physicians as partners, collaborators, and colleagues will go a long way towards building trust and collaboration.

The leading healthcare organizations have figured out how to narrow the divide between senior management and physicians.  It's not easy.  But it's important for physicians and administrators to be on the same page when it comes to the goals of the organization.

Royal Pains

My wife and I were looking for a new television show to watch the other night, and we found a show called Royal Pains on Netflix.  Apparently the show first aired on USA Network from 2009 to 2016.  It was billed as a comedy-drama about a physician who unexpectedly finds himself providing concierge medicine to the uber rich in the Hamptons.  The preview looked good, and the fact that the original television show ran for 8 seasons suggested to us that it might be good.  It was not.

Perhaps I'm being overly critical, but the way that medicine was portrayed was just blatantly false.  First, the main character, Dr. Henry "Hank" Lawson (played by the actor, Mark Feuerstein) is an emergency medicine physician.  That's perfectly fine, but apparently he is an emergency medicine physician that does everything, including practicing cardiology, surgery, anesthesiology, emergency medicine, and primary care medicine.  Emergency medicine physicians can do a lot of things, but they can't (and don't) provide comprehensive medical care for every disease, every age, or every situation.  

Second, the opening scene shows Dr. Lawson playing basketball on an outdoor basketball court, somewhere in New York City (presumably Brooklyn, based upon the scenery in the background).  One of the players that he was guarding (not very well) suddenly collapses on the court and becomes unconscious.  Dr. Lawson quickly goes into "doctor mode" and starts to assess his new patient, noting that the patient isn't breathing and doesn't have a pulse.  Rather than performing CPR, Dr. Lawson places bags of ice around the victim's head and body.  At some point, the victim magically starts to breathe again.  In my opinion, it's completely irresponsible for television shows to depict CPR (or the unlikely outcomes from that CPR) that is blatantly wrong.  Unfortunately, it's an all too common problem.  Dr. Lawson is told that an ambulance is at least ten minutes away (also not realistic), so he asks the rest of the players if anyone has a SUV (most of them raise their hand).  He loads the victim (after immobilizing his head, neck, and spine with wadded up gym clothes) in the back of the SUV and drives him to the hospital, which just happens to be the hospital where he works.  

Third, Dr. Lawson, who is supposedly on his day off, continues to provide care for the young basketball player, but of course he is suddenly called away to care for an elderly man with a suspected heart attack.  Apparently Dr. Lawson is the only physician that can provide emergency cardiac care at that particular hospital!  As luck would have it, the elderly man just happens to be the hospital's primary benefactor who donated all of the money that was needed to build the hospital (his large picture is shown hanging on a wall in the hospital lobby).  Of course, the hospital administrator has come down to the emergency department and is telling Dr. Lawson to ignore caring for the young patient and focus all of his attention and efforts on the patient who is the donor.  Dr. Lawson at first tries to provide care for both patients (on a side note, neither patient has been tracheally intubated at this point, despite the fact that both are in the operating room, presumably in critical condition), but sadly, the patient who donated all the money to the hospital dies.  The young patient from the basketball game lives.  Dr. Lawson leaves the hospital, believing that he had at least done well in saving the young man's life, and meets his fiancée at a local restaurant.

Later that day, Dr. Lawson is called before the hospital Board of Directors and learns that his license has been suspended and that he has been fired from his job at the hospital.  I won't delve into how physician peer review is supposed to work in real life, but suffice it to say that a hospital Board of Directors (1) can't take away a physician's license to practice medicine (only the state's medical licensing agency can take away a physician's license and only after due process), (2) would never conduct a peer review (they are not "peers"), and (3) would never fire a physician (the hospital's administrator could do so, but it wouldn't happen just because the physician lost a patient).

There's plenty of false information out there in the real world.  We don't need more false information created by the media.  I understand that television shows may not be 100% accurate, but the depiction of medical practice in this particular show (at least the first episode) was not even close to being accurate.  In addition, the lack of alignment between physicians on a hospital's medical staff and hospital administrators is well known.  However, I've never experienced anything remotely close to what was shown in this particular episode of this television show, either as a physician or as an administrator.  I will discuss this lack of alignment in my next post.  Just to close the loop, we turned the show off and won't be watching any new episodes.

What would you do?

No, this isn't going to be a post about ABC's television show "What Would You Do?" hosted by John Quiñones (although I do like the show).  The title of today's post is an actual question for all of you.  If you had the time, energy, and resources, what problem would you try to solve?  If I told you that you would win $1 million for solving the problem, would that help?

Interestingly enough, several years ago, a group of mathematicians did just that, proposing a contest to see who could solve a short list of well-known mathematical problems that have been around for years.  The Clay Mathematics Institute in Cambridge, Massachusetts selected seven problems in mathematics in 2000 that had yet to be solved (and more importantly, they believed should and could be solved).  Anyone who solves one of the problems will receive a $1 million prize.  They are called the Millennium Prize Problems, and so far, only one of the seven problems has been solved (a problem called the Poincaré , which was originally conjectured in 1904, was solved by the Russian mathematician Grigori Perelman in 2010 (incidentally, Perelman declined the prize because he could not share it with another mathematician on whose work he had developed his proof).  

I suppose it's important to mathematicians that these problems should be solved.  And I suspect that solving these mathematical problems could help advance society in ways beyond just mathematics.  I'm tempted to ask though, if we could provide a monetary prize to solve some of society's more pressing problems, would that encourage people to try to solve them?  And if so, which problems would they choose to solve?  Alternatively, if we had to choose 7 problems that should be solved, which ones would we choose?

"Don't cry because it's over..."

We are well past the Autumnal Equinox, the day when the Sun appears exactly above the Earth's equator as it moves from north to south, thereby ending Summer in the Northern Hemisphere and Winter in the Southern Hemisphere.  The days are growing shorter, and the nights are getting longer.  The leaves are starting to turn.  The Major League Baseball play-offs have started, and both the college and professional football seasons are in full swing.  Summer has always been my favorite season of the year, and it always makes me a little sad to see the seasons finally change.  But as Theodore Geisel, aka Dr. Seuss so wisely said, "Don't cry because it's over, smile because it happened."  There's a lot more meaning in that quote than the simple passing of the seasons.  

Unfortunately, as is so often the case, Dr. Seuss never actually said that quote.  A high school student, Christopher Roche, was delivering his valedictorian speech at graduation and added those words to a quote from Dr. Seuss' book, Oh, The Places You'll Go ("We're off to great places, so let's be on our way").  The quote is rightly attributed to the German poet, Ludwig Jacobowski, who used the line in his poem "Bright Days" from 1899:

Ah, our brilliant days

shine like eternal stars,

They glow past as consolation

for future sorrow.

Don’t cry because it’s over!

Smile because they have been!

And if the days get cloudier,

Our stars redeem!

Regardless of who said it, the sentiment is one that we should all pay heed.  

"Change is the law of life"

I came across a great quote by President John F. Kennedy from a speech that he delivered in Frankfurt, Germany on June 25, 1963.  The context of the speech is important.  During that same trip, President Kennedy would visit the Berlin Wall on June 26th and famously announce, "Ich bin ein Berliner."  But it was his address the day before that to the Assembly Hall at the Paulskirche (St. Paul's Church), site of the first free German Parliament in 1848, where he outlined a vision of transatlantic partnership that continues to define relations between the United States and Germany to this day.  

President Kennedy was both celebrating both American and German liberty, but he was also warning that neither the U.S. nor Germany could rest on the laurels of the past.  Only with a continued commitment to the future could liberty be preserved.  He said, "But Goethe tells us in his greatest poem that Faust lost the liberty of his soul when he said to the passing moment: Stay, thou art so fair. And our liberty, too, is endangered if we pause for the passing moment, if we rest on our achievements, if we resist the pace of progress."

The quote that I found comes right after the passage above.  President Kennedy said, "Time and the world do not stand still. Change is the law of life. And those who look only to the past or the present are certain to miss the future."  It's an incredible quote on a theme that I've written about a lot in a number of previous posts.  While the speech refers to political events of a time long ago, the words and themes in President Kennedy's speech are just as relevant today.  It's well worth a read, if you want to go deeper and beyond his great quote on change!

Lines of Succession

I've been fortunate to hear a number of former and current U.S. Presidents speak in person over the years, which started when I was a junior in high school and had the opportunity to hear then President Ronald Reagan speak in Indianapolis.  I don't remember anything from his speech (and I don't even remember why he was in Indianapolis), but I do remember having to show up a couple of hours early and not being allowed to leave my seat until after he had finished his speech and left the building.  To be 100% honest, I really wasn't in to politics at that point in my life, which is really too bad when I think now about the opportunity that I had then to hear someone who has been called "The Great Communicator" speak.

I bring this memory up for two reasons.  First, this past weekend my wife and I went to the movie theater for the first time in forever to watch the new movie, Reagan, starring Dennis Quaid.  The movie started off with a little too much "America and Apple Pie" but we both ended up liking it by the end.  Second, I just finished reading The Situation Room by George Stephanopoulos, which talks about how U.S. Presidents from Kennedy through Biden dealt with the major crisis (or crises) of their respective administrations.  One particular crisis featured prominently in both the movie and the book - the assassination attempt on President Reagan on March 30, 1981.  While I can't remember any of the details from Reagan's speech in Indianapolis, I can remember where I was and what I was doing when he was shot in Washington, D.C. by John Hinckley, Jr.

I also vividly remember then Secretary of State Alexander Haig telling the White House Press Corps, "As of now I am in control, here in the White House, pending the return of the vice president and in close touch with him."  Vice President George H.W. Bush was on a plane flying back to Washington, D.C. from Texas at the time (remember that communication back then wasn't as simple as it is now).  President Reagan was in surgery under general anesthesia, and with Vice President Bush not immediately available, no one really knew who was technically in charge.  Haig and David Gergen (Director of White House Communications at that time) had the following exchange, as transcribed in Stephanopoulos' book:

Gergen: Al, a quick question.  We need some sense, a better sense of where the president is.  Is he under sedation now?

Haig: He's not on the operating table.

Gergen: He is on the operating table.

Haig: So the helm is right here.  And that means right in this chair for now, constitutionally, 'til the vice president gets here.

Gergen: I understand that. I understand that.

Shortly thereafter, Haig delivered his now famous statement to the White House Press Corps:

Haig: Constitutionally gentlemen, you have the president, the vice president, and the secretary of state, in that order. And should the president decide he wants to transfer the helm to the vice president, he will do so. As of now, I am in control, here in the White House, pending the return of the vice president and in close touch with him.

While it's hard not to admire Haig's "Take Charge" attitude, particularly during a crisis, he made a glaringly obvious mistake.  The U.S. Constitution and the Presidential Succession Act of 1947 actually specifies who has authority after the vice president, and it's not the U.S. Secretary of State.  The individual who is third in line of succession after the Vice President is the U.S. Speaker of the House, followed by the President Pro Tempore of the Senate.  The Secretary of State only comes after that. 

I've mentioned Keith Grint's model of leadership in the past (see most recently "Tame the Chaos?").  Grint suggests that the preferred leadership style during a crisis is "Command", which he defines as a more authoritative, hierarchical, "one person in charge" type of leadership.  In The Situation Room, Stephanopoulos mentions a story told by Anthony Lake, who served as the National Security Advisor to President Bill Clinton during the failed Black Hawk Down Incident during the Battle of Mogadishu in Somalia in October, 1993.  Lake said, "I bought a used sailboat once.  And in the cockpit, someone left up a little brass plate that said, In an emergency, consider doing what the captain suggests."  When viewed from that lens, Haig was clearly using the right leadership style for the situation that he and his team were facing.  The problem was that he just didn't have the constitutional authority to take charge.  If there had truly been a concern about who was "In Charge", authority should have been passed to Speaker of the House Tip O'Neill.

There is enough confusion and chaos in the middle of a crisis.  The last thing that any organization needs (particularly the United States Government) is confusion around who is in charge.  As I reflect on this particular episode, I can't help but wonder how many organizations today have developed a clear line of succession for when the leader is not immediately available?  Admittedly, we live in a different world than 1981 - communication is much better and if someone in the organization needs to get in contact with the leader, it's usually not too difficult.  However, there is no substitute for "boots on the ground" leadership presence, and someone needs to be in charge until the organization's leader can be contacted and ideally until he or she can be physically present.  If your organization doesn't have a defined line of immediate succession, perhaps you need to develop one?