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The Calm Company

01.06.17 // Medicine, Miscellany

Amidst desires for simultaneous growth, quality, profit, and patient satisfaction, the delivery of healthcare has gotten more…complicated. But the disconnect between the powers that be and the providers who actually work on the ground has turned work for big hospitals and institutions into something increasingly more like working for a big widget factory.

Spurred by rising costs, healthcare in the US has felt the need to “catch up” with the “best” business practices. Have more meetings. Look at more processes. More management. More managers for the managers we just hired.

A few bits from the intro to the forthcoming book, The Calm Company, on Signal v. Noise, the blog from 37Signals (the company behind the team management software Basecamp):

Work claws away at life. Life has become work’s leftovers. The doggy bag. The remnants. The scraps.

You’d think with all the hours people are putting in, and all the promises of tech’s flavor of the month, the load would be lessening. It’s not. It’s getting heavier.

Technology has been used to add capacity, not to improve workflow. As an example, MyChart is a great tool that allows patients to communicate with clinics and providers without calling repeatedly or making an appointment just for a routine refill or to answer a simple question. But you don’t get paid to answer MyChart messages. They’re added on to your workload. The more you’re willing to meet patients where they are and do things on MyChart, the more unpaid work you do and the more time and energy you lose. That’s a system flaw. This is part of why the average physician spends 1-2 hours at home charting daily. More uncompensated time.

Crazy companies all tend to be especially great at one thing: wasting. Wasting time, attention, money, energy.

The answer isn’t more hours, it’s less bullshit. Less waste, not more production. And far fewer things that induce distraction, always-on anxiety, and stress.

I am routinely impressed at how good healthcare systems are at wasting dollars to save cents. Skimping on cheap patient transporters so that highly paid specialists sit around waiting for the next case to start and then run overtime. Understaffing clinic nurses and MAs, leaving the physicians to deal with more phone triage and data entry. The money in some cases comes from different pots, which sometimes allows departments to seem more profitable or efficient than they really are.

Hospitals make changes like real enterprises do but mostly without the critical reflection to see if process improvements are actually improvements. We tokenize quality through small projects to avoid dealing with foundational infrastructural failures—because those are actually hard.

On-demand is for movies, TV shows, and podcasts, not for you. Your time isn’t an episode recalled when someone wants it at 10pm on a Saturday night, or every few minutes in the collection of conveyor belt chat room conversations you’re supposed to be following all day long.

When breath becomes air

12.12.16 // Medicine, Miscellany

I actually posted this excerpt once before, but I just finished Paul Kalanithi’s When Breath Becomes Air and was moved anew by his missive to his infant daughter:

When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing.

Earlier in the book, in conversations with his oncologist about coming to terms with how to spend his life with cancer, this entreaty comes up multiple times:

Find your values.

In his moving memoir (which doesn’t at all belittle fields like radiology), Kalanithi softly and compellingly argues that this is the key to how you live like you were dying.

Obama thinks about the future

12.04.16 // Miscellany

The New Yorker has a fascinating article about Obama dealing with the fact that Trump won. It’s eminently quotable, but I particularly liked his brief discussion on the futility of trying to “bring back” lost industry through protectionism:

The prescription that some offer, which is stop trade, reduce global integration, I don’t think is going to work,” he went on. “If that’s not going to work, then we’re going to have to redesign the social compact in some fairly fundamental ways over the next twenty years. And I know how to build a bridge to that new social compact. It begins with all the things we’ve talked about in the past—early-childhood education, continuous learning, job training, a basic social safety net, expanding the earned-income tax credit, investments in infrastructure—which, by definition, aren’t shipped overseas. All of those things accelerate growth, give you more of a runway. But at some point, when the problem is not just Uber but driverless Uber, when radiologists are losing their jobs to A.I., then we’re going to have to figure out how do we maintain a cohesive society and a cohesive democracy in which productivity and wealth generation are not automatically linked to how many hours you put in, where the links between production and distribution are broken, in some sense. Because I can sit in my office, do a bunch of stuff, send it out over the Internet, and suddenly I just made a couple of million bucks, and the person who’s looking after my kid while I’m doing that has no leverage to get paid more than ten bucks an hour.

I recently read The Wealth of Humans, in which Economist writer Ryan Avent presents an engaging argument about how things have and are likely to change with increasing automation. I think people are generally pretty quick to believe that robots will eventually replace everything but have nonetheless been far less inclined to think about what that will actually mean. For the economy, for humans, for society as a whole.


  1. General Tso was a real general
  2. His chicken was a dish actually created by a Taiwanese chef and isn’t a bastardized American creation.

Chef Peng Chang-kuei, the inventor of General Tso’s chicken, just passed away at the age of 98.

// 12.03.16

Organizational stupidity

09.29.16 // Miscellany

Please read and cherish this incredibly cynical essay in Aeon, “Stupefied: How organisations enshrine collective stupidity and employees are rewarded for checking their brains at the office door.” I’m going to superblockquote a chain of some of my favorite parts. Please tell me this doesn’t describe every hospital you’ve ever worked in:

No matter how hard you search there is little – if any – leadership to be found. What most executives actually spend their days doing is sitting in meetings, filling in forms and communicating information. In other words, they are bureaucrats. But being a bureaucrat is not particularly exciting. It also doesn’t look very good on your business card. To make their roles seem more important and exciting than they actually are, corporate executives become leadership addicts. They read leadership books. They give lengthy talks to yawning subordinates about leadership. But most importantly they attend many courses, seminars and meetings with ‘leadership’ somewhere in the title.

Ha, yes.

But often there are very weak reasons for following ‘industry best practice’. For instance, when the Swedish armed forces decided to start using Total Quality Management techniques, some officers naturally asked: ‘Why?’ The response: ‘This is presumably something we benefit from, since this is what they do in the private sector.’ In other words, we should do it because others are doing it.

Applying methods and policies wholesale because they worked somewhere else without then evaluating those changes is a critical role of most middle managers.

At the outset of our research, we suspected that organisational life would be full of stupidities. But we were genuinely surprised that otherwise smart people would go along with collective stupidity, and be rewarded for doing so. Mindlessly following rules and regulations – even if they were completely counterproductive – meant that professionals would be left alone. Using empty leadership talk would get ambitious people promoted into positions of responsibility. Copying other well-known organisations meant a firm could be seen as ‘world-class’. Launching branding initiatives meant that executives could focus on the easier work of manipulating surface images and avoid the much messier realities of organisational life.

This is just brutal.

Working in a stupefied firm often means blinding others with bullshit. A very effective way to get out of doing anything real is to rely on a flurry of management jargon. Develop strategies, generate business models, engage in thought leadership. This will get you off the hook of doing any actual work. It will also make you seem like you are at the cutting edge.

This is what people are hoping to master when they go back for that MBA.

Literally every business/leadership/whatever book I’ve ever read should have been a few blog posts or a short essay. While a lot of people have been piling on recently and calling BS on the organizational psychology and tedious bureaucracy that compose the contemporary large organization, I’m actually tempted to pull the trigger this time and read the book (if only for the refreshingly direct approach).

[Education Needs] Denied

09.13.16 // Miscellany

Sad, no good, very bad, depressing reality reported by the Houston Chronicle:

Over a decade ago, the officials arbitrarily decided what percentage of students should get special education services — 8.5 percent — and since then they have forced school districts to comply by strictly auditing those serving too many kids.

Their efforts, which started in 2004 but have never been publicly announced or explained, have saved the Texas Education Agency billions of dollars but denied vital supports to children with autism, attention deficit hyperactivity disorder, dyslexia, epilepsy, mental illnesses, speech impediments, traumatic brain injuries, even blindness and deafness.

Special education rates have fallen to the lowest levels in big cities, where the needs are greatest. Houston ISD and Dallas ISD provide special ed services to just 7.4 percent Tweet this link and 6.9 percent of students, respectively. By comparison, about 19 percent of kids in New York City get services. In all, among the 100 largest school districts in the U.S., only 10 serve fewer than 8.5 percent of their students. All 10 are in Texas.

An embarrassing and frankly sadistic cover up.

When asked about the drop at a 2010 state Senate Education Committee hearing, [special education director Eugene] Lenz did not mention the target.

“We fundamentally believe it has a lot to do with improving general education,” he said.

Fundamental beliefs sound a lot of like lies and crazy talk.

Also, I thought everyone actually involved in teaching children agrees that the increased emphasis on teaching toward standardized tests/metrics in young children while simultaneously cutting budgets for anything remotely enjoyable was making “general education” worse.

Prisons and Profit

08.31.16 // Miscellany

Very long but excellent journalism in Mother Jones from Shane Bauer, who spent 4 months working undercover in a Louisiana private prison. Hint: it’s terrible. Here’s one terrible facet from an almost endless number of ways in which this system is failing:

If [an inmate] were sent to the hospital, CCA would be contractually obligated to pay for his stay. For a for-profit company, this presents a dilemma. Even a short hospital stay is a major expense for an inmate who brings the company about $34 per day. And that’s aside from the cost of having two guards keep watch over him. […]

One day, I meet a man with no legs in a wheelchair. His name is Robert Scott. (He consented to having his real name used.) He’s been at Winn 12 years. “I was walking when I got here,” he tells me. “I was walking, had all my fingers.” I notice he is wearing fingerless gloves with nothing poking out of them. “They took my legs off in January and my fingers in June. Gangrene don’t play. I kept going to the infirmary, saying, ‘My feet hurt. My feet hurt.’ They said, ‘Ain’t nothin’ wrong wicha. I don’t see nothin’ wrong wicha.’ They didn’t believe me, or they talk bad to me—’I can’t believe you comin’ up here!'”

His medical records show that in the space of four months he made at least nine requests to see a doctor. He complained of sore spots on his feet, swelling, oozing pus, and pain so severe he couldn’t sleep. When he visited the infirmary, medical staff offered him sole pads, corn removal strips, and Motrin. He says he once showed his swollen foot, dripping with pus, to the warden. On one of these occasions, Scott alleges in a federal lawsuit against CCA, a nurse told him, “Ain’t nothing wrong with you. If you make another medical emergency you will receive a disciplinary write-up for malingering.” He filed a written request to be taken to a hospital for a second opinion, but it was denied.

Eventually, numbness spread to his hands, but the infirmary refused to treat him. His fingertips and toes turned black and wept pus. Inmates began to fear his condition was contagious. When Scott’s sleeplessness kept another inmate awake, the inmate threatened to kill him if he was not moved to another tier. A resulting altercation drew the attention of staff, who finally sent him to the local hospital.

Just gruesome.

Capitalism is pretty great if you want to drive down the price of electronics. It does less well in industries without meaningful competition that traffic in human rights and services. If you can make more money by denying service, then it’s in a company’s best interest to provide the barest minimum possible and stop slashing just before losing business.

Sad thing is, despite how scummy the CCA prisons clearly are, the parallels with the US healthcare system are pretty easy to make.

Survivorship Bias & Other Problems With Science

07.15.16 // Miscellany

Two great longish weekend reads:

Vox’s The 7 biggest problems facing science, according to 270 scientists:

Scientists need more carrots to entice them to pursue replication in the first place. As it stands, researchers are encouraged to publish new and positive results and to allow negative results to linger in their laptops or file drawers.

This has plagued science with a problem called “publication bias” — not all studies that are conducted actually get published in journals, and the ones that do tend to have positive and dramatic conclusions.

And David McRaney’s fun discussion of survivorship bias.

The military looked at the bombers that had returned from enemy territory. They recorded where those planes had taken the most damage. Over and over again, they saw that the bullet holes tended to accumulate along the wings, around the tail gunner, and down the center of the body. Wings. Body. Tail gunner. Considering this information, where would you put the extra armor? Naturally, the commanders wanted to put the thicker protection where they could clearly see the most damage, where the holes clustered. But Wald said no, that would be precisely the wrong decision. Putting the armor there wouldn’t improve their chances at all.

Embedded in both:

You can’t just look at success (or successful people) to achieve meaningful success or become successful (corollary: data is not the plural of anecdote). Arguably more important is looking at the failures to see why they fail. And if both groups do things the same, then it’s not the method.1It’s the madness.

Also, this applies to every self-help/self-improvement personal story you hear (entertaining, potentially inspiring, and scientifically without merit).

The Call for Technological Humility

06.29.16 // Miscellany

Maciej Cegłowski runs pinboard, a fantastic and fantastically simple bookmarking site (it’s what I use to power the interesting links sidebar section of this site). He’s also a level-headed, funny, and cogent writer on software and technology. From the transcript of his recent talk on the moral economy of tech:

But as anyone who’s worked with tech people knows, this intellectual background can also lead to arrogance. People who excel at software design become convinced that they have a unique ability to understand any kind of system at all, from first principles, without prior training, thanks to their superior powers of analysis. Success in the artificially constructed world of software design promotes a dangerous confidence.

This hubris reminds me of many of the physicians, especially those described in Siddhartha Mukherjee’s Emperor of Maladies (which I finally got around to reading and is excellent). William Halstead was a brilliant surgeon who tried and unabashedly failed to treat metastatic cancer with ever more radical surgery, sure, but then you have Ben Carson going from talented surgeon to laughable failed politician.

Intellectual and technical gifts are wonderful, but then it becomes easy for people to not only overstate their own prowess but to mistakenly believe that their competency applies undiminished to disparate fields. (Of course this doesn’t apply to me, only other people).

Great read.

Pepsi learns that nothing is quite like the bittersweet tang of aspartame

06.28.16 // Miscellany

Less than a year after ruining the flavor of diet Pepsi by switching from aspartame to sucralose due to “customer demand,” Pepsi plans to bring back the original formulation.

When PepsiCo removed aspartame from Diet Pepsi in August, it said the change was the No. 1 request by customers. Industry executives have blamed the declining sale of diet sodas on concerns people have about the ingredient.

All the fanfare around the change belied the fact that if you think “health” concerns are the most actionable criteria for soda drinkers over something like taste, then you’re terrible at running a company. I drink a ton of diet soda, but I’m not going to pretend it’s the healthy beverage choice. People are leaving soda predominantly to drink water as an overall healthier choice, not just because aspartame is uniquely abhorrent as an artificial sweetener (even if people loudly say it is), but because artificial sweeteners are not natural/organic/magical/goodforyou. And is water is obviously the best beverage choice (other than coffee in excess and alcohol in moderation, both of which can make you nearly immortal).

The old version is going to be an additional offering in the Pepsi lineup and not a return for the flagship product (which is probably still a mistake). The new formulation is terrible: I noticed the change before I’d even heard the news. In a can (without tons of ice), it’s almost completely unpalatable.

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