Monday, December 15, 2014

Remote Exercise Partners

The most recent article that I found in the Wall Street Journal focusing on exericse talks about two individuals in Tennessee and New York City who take a spin class together.  Why do I find this interesting?

First, it is another example of the value of having someone with whom to undertake an activity.   The old expression is "two heads are better than one."  This is not so much a matter of two heads in the classic sense in which the expression was originally used.  This has nothing to do with getting ideas from two people.  This is almost "two hearts are better than one".  Not in the sense of love as we would use for Valentine's Day.  But rather love of something.  Almost anything.  Having two people together who love to do something can make it much easier to do.  Each can hold the other accountable.  Each can help to encourage the other.  The process of checking on each other can be one of peer mentoring.  Or it could simple be peer pressure.  But the key is that to have someone to engage in an activity and to engage in checking up on progress with the other person can be very helpful to sticking to an activity and working to continue to improve performing an activity.

Second, it is a great way to re-imagine a use of a technology.  Live streaming can be used for so many things.  So, why not use it for doing workouts together.  So far, it seems like it would work best for activities that don't require a person to get up and move around very much.  But it would be very interesting to imagine some type of "visor-cam" that could help individuals to run together whether they are in the same place or not.

So, in exercise, it is wonderful to re-imagine a use of technology to increase interpersonal accountability.  There are many other parts of life in which re-imaginging technologies to help individuals to connect and to grow better in their performance of activities could also arise.  Leadership skills.  Really any skill at work.  Parenting.  Musical instruments.  And any type of concentrated effort will support concentration in general and have spillover into other parts of life as a person chooses to direct efforts that start in one area of life to other areas that need improvement.  People are likely to find useful the opportunity to connect.  Those can find ways to help individuals connect are likely to be the economic and thought leaders of the future.  

Tuesday, December 9, 2014

Prescriptions for Exercise

Yesterday, I came upon an article in the Wall Street Journal that talked about prescriptions for exercise.  This article fascinated me for several reasons.

  1. I have not been to a medical care provider for anything other than an acute GI issue or subsequent to a fall while running since November 2010.
  2. For many years I did not exercise (August 1999-January 2006), but since January 2006, I have gotten myself into shape, taken off approximately 25 pounds and kept them off, and run xix marathons including a 3:09:49.
  3. I recognize that to go from no exercise to a marathon did not occur overnight.  Even from the time I began being physically active again to being comfortable running a half marathon distance (which I had not done since 1986), took me 20 months until Labor Day weekend 2007.
  4. Despite my success I recognize clearly that what has led to my success has largely been driven by accountability.  Accountability to a coach who designed a training program for me to follow from mid-July through the weekend before Thanksgiving and accountability to a friend with whom I trained who challenged me not to let me dream of running a marathon faster than 3:10 slip away in the last four miles.
So,  what are the parallels I see between physicians writing prescriptions for exercise, my own experience, and some basic habit changing (and habit forming) approaches that can lead to success in multiple types of business and career situations?

First, there needs to be a trigger to change a habit.  For me, it was seeing the scale hit 185 pounds, looking at myself in the mirror, and just feeling not good.  For some, it will take someone in authority, like a physician, telling them they need to make a change.

Second, the change needs to start small.  I didn't even run for the first several months.  I just took my dog at the time on longer and longer walks.  That was a level of effort that I could reasonable make.

Third, the change needs to be accompanied by a longer term goal.  Why set the short term goals?  To reach the even longer ones.  but having only long term goals does not usually work.  It is necessary to to find something rewarding long before the long-term goals completely materialize.

Fourth, there needs to be accountability.  In the case of the patients getting prescriptions for physical activity they are accountable to their physicians.  In my case, I was accountable to my coach and fellow runner.

So--a trigger, short and long term goals, and a sense of accountability can be brought together for an incredible outcome.  The challenge is that medical care providers feel so overburdened that sometimes even taking the couple of minutes to discuss physical activity and write a prescription can seem daunting.  And for those who have not been performing any physical activity, when they look at their counterparts who are running 5 to 7 days a week and getting in 30-40 miles per week, they may think, "I could never do that."  But as I tell my less active friends--you don't need to do that.

This type of approach--finding something to trigger a change that is associated with short and long term goals and someone to whom a person is accountable--can generalize to almost any habit a person would want to start (or break).  This could improve personal outlook, job performance, or many other things and make a person happier, healthier, and perhaps even wealthier over time (spending less on health care and perhaps even health insurance premiums in the example here).  Guarantees?  None--as with much else in life.  The only thing even close to guaranteed is that change is more likely to continue with the combination of things discussed above than without.  Ultimately, sticking to the change and making the best of it is left to the individual. 

Friday, December 5, 2014

TUBA

The other day, I, along with two student leaders from an organization called Net Impact, met with Amy Klosterman.  Amy is involved with an organization she calls TUBA, the acronym for The Uganda-Baltimore Alliance.  Why does she call it TUBA?  Because it revolves around a brass band in Uganda and her US base is Baltimore.  And, in true “Smaltimore” (i.e., Baltimore is really a small town) style, just a couple days after I’d spoken with Amy and the students, I chose a seat at random in a faculty luncheon and ended up next to someone who teaches business communication in our program and who is Amy’s neighbor.  We took some time to continue to discuss the business issues around TUBA.  And that wasn’t the first “Smaltimore” story related to TUBA.  I first found out about the organization when my son, who is now a freshman at the conservatory at Johns Hopkins, played as part of a benefit concert for the organization. 

What is the purpose of TUBA?  First, to promote improved performance by the band members.  They are outside Kampala.  Amy has made numerous trips to work with the group by herself and has taken students from Peabody (the conservatory at the Johns Hopkins University) on one occasion, one student from Peabody on a second occasion, and a high school student from Baltimore City College on one occasion to work with the musicians in Uganda. 

Second, to become self-sustaining.  There are two young men who were part of her earliest group in Uganda who are now leading the organization in East Africa.  They need income to support themselves so that they can lead the other musicians and the organization.

Third, to provide opportunities for a flow of US musicians (whether from Peabody or elsewhere) to Uganda to work with, help train, and make music with the musicians in Uganda.

We spent some time talking about the interest that business students could take in this project.  Amy’s background is a musical one, and the business skills are something she has had to develop and looks to continue to improve or to find others to help her.

We discussed seven challenges that the organization will face.  These are fundamentally business challenges.  If Amy and the team she develops can work through these challenges, she will be able to promote business with humanity in mind in some really exciting ways.  If not, there is a risk to the enterprise that she has developed.  So, it is worth considering what the challenges are and whether they are unique.

First, the goal is to make the Ugandan part of the organization self-supporting.  A key question is “what is actually meant by self-supporting?”  Does that mean no need for donations of any sort?  Does it mean that the two leaders can support themselves but them might still need instruments donated?  What about paying the musicians?  And what fraction of the musicians’ income would this be expected to account for?  The answer to what it will take to make the organization on the Ugandan side self-supporting will vary quite a bit depending on the answer to the first question. 

Second, and still along the lines of needing to define things, what are the set of measures of success?  In particular, are there non-financial measures of success?  Are the non-financial measures going to be on both the US and the Ugandan sides fo the equation?  Or only on the Ugandan side?  Will the measures of success be tangible or intangible?  How will the measures reflect the notion of doing business with humanity in mind?  And how can the criteria be optimized under different financial sustainability levels? 

Third, and following on the discussion of non-financial goals in two places, it is important to consider the resources that need to be managed in two places.  On the US side, at present, the main source of revenue will be donations.  On the Ugandan side the organization has diversified into a new area to try to provide the revenue.  There are both ongoing needs for revenue (salaries) and one-time needs for investment (e.g., building a dwelling to house visitors).  The management of different sources of revenue with different flows of costs in different settings is a non-trivial challenge.  Particularly for an organization that is not a 501(c)(3) organization in the United States yet. 

The diversification question has been answered in part.  They are building a facility to house 400 fryer chickens.  Raising the chickens will have a rhythm because it takes six weeks for them to grow and then the sanitization process before the next group of chickens can come in is 2 weeks.  During that time, the two men whose livelihood will be supported by the chickens can catch up on musical and other pursuits.  The key question with the diversification is whether this was the right one, what are the risks to this potential stream of revenue, and what will happen if it fails.  All standard questions.

To grow the revenue will require more musical activity—and more chickens.  A key question is the appropriate rate of growth.  What can musicians be convinced to do in terms of more activity?  How quickly can expertise in chicken raising by learned?  How much land is available and how much more would be required to grow?  What are the risks of failing to grow?

Sixth, with the potential for growth in musical activities, this raises an interesting question.  Does this mean more practice time and better individual skills for existing musicians?  Does this mean more practice time as a band and better playing as a band?  Does this mean more live events?  And will the band ever be ready for recording?

Finally, when is it time to tell the story?  Of course, Amy and her partners would like to have success and be able to tell a story about success.  As I have learned in many aspects of my life there is actually quite a bit to discuss even before the outcome of success or not is known.  Many people will be interested in the process.  What has worked and what has not?  What are lessons learned?  What would Amy and her partners do again?  What would they make absolutely sure NOT to do again?  What are some tough lessons that have been learned?  And what have been the small and big “victories” along the way to the hoped for final measure of success?  The process can be as important as the outcome when sharing information with other social entrepreneurs who are trying to do well by doing good. 

My blog is just one way of sharing that will be read (on average) by 50-100 people.  However, if you are ready this, I would encourage you to share it.  Then, it will be read by, and hopefully inspire, others.  Inspire them to contribute, should the opportunity ever arise.  But more importantly, inspire them to dream big about making a difference for stakeholders in whatever organization they are a part of.


Hopefully, the business school will also provide Amy with an opportunity to address an audience of students, faculty, and staff with her story.  And perhaps some of them will have other ideas or other connects to help Amy and TUBA to share their amazing story, albeit still a work in progress, so that through the connections that are made, the organization can maximize its chances of success. 

Tuesday, November 18, 2014

Ebola Tests: Sensitivity and Specificity

Yesterday's headlines on USA Today included one that stated "Nebraska Patient Cases Raises Questions about Ebola Test."  The reason for this is the fact that the Nebraska patient was a physician treating Ebola patients who came down with symptoms and was tested and found not to be Ebola positive before other clinicians eventually realized (and found in a later test) that the man in question did have Ebola.  If the physician had been treated earlier, it is possible that his outcome--being brought back to the US and treated--may have been different from the unfortunate death he suffered.

I'd like to comment on this because it raises some really important issues about diagnostic tests.  I would have expected to find some previous writing on this, but I do not.  So here it goes.

People either have a condition or do not.  We refer to those who have the condition as positive and those who dont' as negative.  Sometimes it is good to be "positive."  With the Ebola virus, it is obvious that being positive is a very bad thing.

Test results are also positive or negative.  (Some tests are uncertain, but for the time being we will ignore that.)  So, the result at the end of a diagnostic test suggests that a person either has or does not have a condition.

What makes this most interesting is the fact that there are some people who are truly positive and for which the test identifies the person as positive.  Similarly, there are some people who are negative and whom the test identifies as negative.  These are both desirable outcomes.

However, there are also two other groups.  There are some people who are positive whom the test incorrectly identifies as negative.  And there are some people who are negative whom the test incorrectly identifies as positive.  

A test's ability to correctly identify those who are positive as positive is called sensitivity.  A test's ability to correctly identify those who are negative as negative is called specificity.

In different situations, clinicians and policy makes focus on either sensitivity or specificity.  Sometimes it is important not to over identify cases.  If the consequences of being positive are fairly small, there will be future attempts to diagnose, and further identification and treatment is costly, we can focus on making sure to identify negatives properly--specificity.  Or if there are strong negative connotations and stigmas associated with being positive it can be important to correctly identify negatives.

However there are other cases in which failing to identify a positive case can be deadly.  This is true with Ebola.  This is why in other cases sensitivity is critical.  This does not mean that there should not be concerns about specificity.  If we had a lot of people mis-identified as positive this would require an enormous amount of resources and there may be side effects of the treatment.

The main "question" I think we should asking about the Ebola test is whether there is a way to develop a test that is more sensitive.  And quickly.  And if the government can support that and someone can find it, there may be a profit to be made from an innovation for humanity.  

Sunday, November 16, 2014

Introversion, Analytics, Storytelling

As part of my position as Vice Dean of Education I get to meet a lot of students who have a lot of issues.  This year, I made it a point to also meet students who don't have big issues but who are, in fact, doing great things for the School at which I work.  So, I arranged a series of lunches with leaders of student organizations.  There were many interesting and fun outcomes of the series of four lunches I had a couple weeks back.

One lunch was notable for discussions of introversion, analytics, and storytelling.  You may wonder how those fit together.  Here is how that came about.

First, introversion.  At this particular lunch there were four students.  Some of the lunches I had were largely student driven around issues that applied either to the specific student organizations or around generic student issues.  Two of the lunches were more driven by discussing issues about research or career interests or personal stories.  In this particular lunch, the fourth of the week, the students all knew that I am a runner.  At some point the discussion transitioned to be about management style and personality types.  As I had been leading the conversation, I started with, "Many people don't believe this, but I tested strongly as an introvert on the Myers-Briggs test.  One of the students looked at me quizzically as I said this--body language that said, "Why would people not believe you?"  This student has a keen understanding of what the MBTI really gets at.  I've heard it described as not whether you like crowds but where you go for "recharging" or where you draw your strength.  Many long distance runners--particularly those who are willing to do the longest workouts on their own-are great candidates to guess they would be pretty strong introverts.  Using that time away to think and recharge.  So, that was interesting point number one.

The other two came when the same student, inquisitive about my change from a faculty member at the School of Public Health to a largely administrative role at the business school asked, "Do you still use any of the skills?  And how do they help?"

I gave two answers.

First, I talked about analytics.  While it is certainly the case that I am interested in different data as an administrator and the types of analyses are different, I still need to be analytic.  That is a skill that dates back to my days as a faculty member.  In fact, I would suggest that it is a pretty fundamental part of my personality and dates at least as far back as the future problem solving exercises that I was asked to participate in as part of the academic enrichment program provided by my school district when I was growing up.

Second, I talked about storytelling.  As someone who writes a blog, I'm sure that readers are not surprised to hear that I would focus on storytelling.  The key is how to link that to both research and administration.  While my research reports were never as gripping as a best selling Tom Clancy novel, good research reports tell stories.  Non-fiction, of course.  But stories nonetheless.  And, as a leader, I have to get other people to move in a direction I want them to.  How best to do that?  By telling stories that illustrate the vision of what I want to achieve.  So, maybe I could have called it communication rather than story telling, but the idea is clearly there.

So, that is how I managed to talk about introversion, analytics, and storytelling all as part of an hour long conversation with four students at the Business School.  And I look forward to continuing to have opportunities to share wonderful and interesting stories about my view of the world with as well as about learning from the students who come to the Carey Business School.  

Friday, November 14, 2014

Affordable Care Act and Strains on the System

This has been an interesting week for issues surrounding health insurance for me.  I was surprised by the amount of the increase in my out-of-pocket premium each pay period for health insurance for 2015.  The explanation was not that all of my employer's health insurance premiums were going up so substantially.  Rather, the main issue was that with my raise, I passed a threshold that led to a higher out-of-pocket premium expectation.  Not completely unreasonable.  Just there.

Then, today, I saw an article in the Wall Street Journal.  The article talks about the link between the Affordable Care Act, expansion of Medicaid, and strains on the health care system.

This is not a completely unexpected result.  There may be other data that I have not seen that counter what I read in the article.  If so, I'd like to see them.

However, the key here is that the Affordable Care Act was designed primarily to do one thing--get more people insured.  At least that was my read of the act.  But I did not read every word, and apparently, at least some involved in designing it thought that the lack of transparency was a distinct political advantage.  (You can see a quote from a fellow health economist here.  The fact that anyone in my profession would make such a statement makes me sad.)

When more people get insured, it takes care of only one part of access--the affordability of care.  And the article in the WSJ even points out that in one state to make sure that new enrollees could be covered by Medicaid, it was necessary to tighten up the management of care for existing enrollees.  That leads to an interesting question about sustainability and the "social utility function."  Is it better to give excellent coverage to a smaller number or moderate coverage with lots of controls to a smaller number.

Additionally, the fact that only affordability changed is showing up in how long it takes people to get care sometimes.  And the waiting list is growing for others to get care as more people who were previously not using anything other than the ER engage in the system.  Predictable--totally.

What does this mean?  Was the Affordable Care Act bad?  That, I believe, still remains to be seen.  Was the law put in place without a holistic view of how to solve the problem of access to health care under budget constraints?  Yes.  Could the United States ever implement a holistic reform?  Not likely given the political environment.

So, while the Affordable Care Act may have solved some problems it has created others.  Does that mean it was worse than no legislation at all?  Hard to say.  Does it suggest there is room for improvement?  Yes.  Where will that improvement come from?  Likely from private sector innovation that finds a way to provide affordable access to care to keep a population healthier while making a profit.  The best way to have a healthy bottom line is to run a business in a healthy community.  This wraps all the incentives together nicely if someone or some organization can figure it out.    

Tuesday, November 4, 2014

New Technology in Prostate Biopsies

On the professinal side, I am often looking at new opportunities to screen, diagnose, or treat and asking the economic question--what makes this a good buy?  Some, of course, migth simply say, "It is more effective so why would we not want to use resources for it?"  And given the value that is assigned to life, that is often a reasonable supposition.  However, given the limited resources that are available for medical care and public health efforts, it is also often worth while to ask a few deeper questions and determine whether a use of resources is the best use of resources or not.  

On the personal side, my blogging began with a memorial service for a fellow parent at my kids' elementary/middle school who lost a battle with prostate cancer.  So, when there are new ways to guide screening, biopsies, and making a progosis, they almost always catch my interest.

An article in today's Wall Street Journal focused on the potential use of MRI's to guide biopsies to determine whether prostate cancer is agressive and should be treated agressively or whether it is more likely that the tumor, despite its presence, is clinically insignificant.

The article does a good job of describing everything that would go into an economic, cost-effectiveness evaluation without doing one and without, it appears, one having been completed so far.  Specifically, there is a higher cost to have the MRI prior to the biopsy--but from the patient's point of view some of that is paid by the insurer.  There are some aggressive cancers that are detected by the MRI technique and, as importantly, some cases that are rules as "not signficant" after which a patient can avoid being over treated.  Then, to make matters more complicated, there are also a fair number of cases missed despite the MRI.

Thus, an economic evaluation would have to compare the clear and readily identified cost of the procedure (potentially from different perspectives) with the value of more appropriate identification of aggressive cancers and the value of avoiding over-treatment (not just lower costs but potentially better quality of life that results from avoiding the side effects of surger to remove the prostate like incontinence and sexual dysfunction, and then account for the costs associated with still missed cases.

This would not be a simple analysis.  And while we may have quality of life and life expectancy measures for each of the resulting outcomes, this is a complicated situation in which the fear of a missed case or the disappointment with finding out that the cancer was not as bad as expected should be taken into account.  These types of quality of life issues are dynamic and complex.  

How should a decision be made?  The technology has some distinct advantages.  These should be presented to patients.  However, this does seem to call for shared decision making between the patient and urologist with as much information as possible shared in a way that is comprehensible until there is clear data to suggest whether the MRI is truly economically preferred.