This book is reminiscent of The Sixth Extinction, and somewhat of The Singularity is Near, and also of Guns Germs and Steel.
I particularly like how the author creates the framework of shared belief systems, and collects not just shared rules for games, but also shared beliefs in religion, shared policies in government, and most importantly, shared principles for money, the only universally shared belief system.
The author also goes through the rise of agriculture, the importance of fictions and myths in sustaining shared beliefs. He posits that human cooperation allowed the extinction of competing primates, and that humans are in the process of upgrading to gods.
The more I reflect, the more I get out of Tom Friedman’s recent book. Here are a collection of some of my favorite quotes from his book. There are lessons on blogging, adaptability, governance, and the acceleration of Moore’s Law, globalization, and climate change. Also see Goodreads.com, a great place where I’ve collected my own book reviews and shared important quotes from this, and other authors.
“This ain’t no cloud, folks! And so, instead of calling this new creative energy source “the cloud,” this book will henceforth use the term that Craig Mundie, the computer designer from Microsoft, once suggested. I will call it “the supernova”—a computational supernova.”
“The same thing, notes Brynjolfsson, happened 120 years ago, in the Second Industrial Revolution, when electrification—the supernova of its day—was introduced. Old factories did not just have to be electrified to achieve the productivity boosts; they had to be redesigned, along with all business processes. It took thirty years for one generation of managers and workers to retire and for a new generation to emerge to get the full productivity benefits of that new power source. A December 2015 study by the McKinsey Global Institute on American industry found a “considerable gap between the most digitized sectors and the rest of the economy over time and [found] that despite a massive rush of adoption, most sectors have barely closed that gap over the past decade … Because the less digitized sectors are some of the largest in terms of GDP contribution and employment, we [found] that the US economy as a whole is only reaching 18 percent of its digital potential … The United States will need to adapt its institutions and training pathways to help workers acquire relevant skills and navigate this period of transition and churn.” The supernova is a new power source, and it will take some time for society to reconfigure itself to absorb its full potential. As that happens, I believe that Brynjolfsson will be proved right and we will start to see the benefits—a broad range of new discoveries around health, learning, urban planning, transportation, innovation, and commerce—that will drive growth. That debate is for economists, though, and beyond the scope of this book, but I will be eager to see how it plays out. What is absolutely clear right now is that while the supernova may not have made our economies measurably more productive yet, it is clearly making all forms of technology, and therefore individuals, companies, ideas, machines, and groups, more powerful—more able to shape the world around them in unprecedented ways with less effort than ever before. If you want to be a maker, a starter-upper, an inventor, or an innovator, this is your time.”
“Intel engineers did a rough calculation of what would happen had a 1971 Volkswagen Beetle improved at the same rate as microchips did under Moore’s law. These are the numbers: Today, that Beetle would be able to go about three hundred thousand miles per hour. It would get two million miles per gallon of gas, and it would cost four cents! Intel engineers also estimated that if automobile fuel efficiency improved at the same rate as Moore’s law, you could, roughly speaking, drive a car your whole life on one tank of gasoline.”
“All of these are signs “that our societal structures are failing to keep pace with the rate of change,” he said. Everything feels like it’s in constant catch-up mode. What to do? We certainly don’t want to slow down technological progress or abandon regulation. The only adequate response, said Teller, “is that we try to increase our society’s ability to adapt.” That is the only way to release us from the society-wide anxiety around tech. “We can either push back against technological advances,” argued Teller, “or we can acknowledge that humanity has a new challenge: we must rewire our societal tools and institutions so that they will enable us to keep pace.”
“We go to school for twelve or more years during our childhoods and early adulthoods, and then we’re done. But when the pace of change gets this fast, the only way to retain a lifelong working capacity is to engage in lifelong learning.”
“Teller tells his teams: “I don’t care how much progress you make this month; my job is to cause your rate of improvement to increase—how do we make the same mistake in half the time for half the money?” In sum, said Teller, what we are experiencing today, with shorter and shorter innovation cycles, and less and less time to learn to adapt, “is the difference between a constant state of destabilization versus occasional destabilization.”
“Historically, noted James Manyika, one of the authors of the McKinsey report, companies kept their eyes on competitors “who looked like them, were in their sector and in their geography.” Not anymore. Google started as a search engine and is now also becoming a car company and a home energy management system. Apple is a computer manufacturer that is now the biggest music seller and is also going into the car business, but in the meantime, with Apple Pay, it’s also becoming a bank. Amazon, a retailer, came out of nowhere to steal a march on both IBM and HP in cloud computing. Ten years ago neither company would have listed Amazon as a competitor. But Amazon needed more cloud computing power to run its own business and then decided that cloud computing was a business! And now Amazon is also a Hollywood studio.”
“But the ancients believed that there was wisdom in patience and that wisdom comes from patience … Patience wasn’t just the absence of speed. It was space for reflection and thought.”
“Every computing device today has five basic components: (1) the integrated circuits that do the computing; (2) the memory units that store and retrieve information; (3) the networking systems that enable communications within and across computers; (4) the software applications that enable different computers to perform myriad tasks individually and collectively; and (5) the sensors—cameras and other miniature devices that can detect movement, language, light, heat, moisture, and sound and transform any of them into digitized data that can be mined for insights.”
“Looking back on all my interviews for this book, how many times in how many different contexts did I hear about the vital importance of having a caring adult or mentor in every young person’s life? How many times did I hear about the value of having a coach—whether you are applying for a job for the first time at Walmart or running Walmart? How many times did I hear people stressing the importance of self-motivation and practice and taking ownership of your own career or education as the real differentiators for success? How interesting was it to learn that the highest-paying jobs in the future will be stempathy jobs—jobs that combine strong science and technology skills with the ability to empathize with another human being? How ironic was it to learn that something as simple as a chicken coop or the basic planting of trees and gardens could be the most important thing we do to stabilize parts of the World of Disorder? Who ever would have thought it would become a national security and personal security imperative for all of us to scale the Golden Rule further and wider than ever? And who can deny that when individuals get so super-empowered and interdependent at the same time, it becomes more vital than ever to be able to look into the face of your neighbor or the stranger or the refugee or the migrant and see in that person a brother or sister? Who can ignore the fact that the key to Tunisia’s success in the Arab Spring was that it had a little bit more “civil society” than any other Arab country—not cell phones or Facebook friends? How many times and in how many different contexts did people mention to me the word “trust” between two human beings as the true enabler of all good things? And whoever thought that the key to building a healthy community would be a dining room table? That’s why I wasn’t surprised that when I asked Surgeon General Murthy what was the biggest disease in America today, without hesitation he answered: “It’s not cancer. It’s not heart disease. It’s isolation. It is the pronounced isolation that so many people are experiencing that is the great pathology of our lives today.” How ironic. We are the most technologically connected generation in human history—and yet more people feel more isolated than ever. This only reinforces Murthy’s earlier point—that the connections that matter most, and are in most short supply today, are the human-to-human ones.”
“That is why, I explained to Bojia, as a columnist, “I am either in the heating business or the lighting business.” Every column or blog has to either turn on a lightbulb in your reader’s head—illuminate an issue in a way that will inspire them to look at it anew—or stoke an emotion in your reader’s heart that prompts them to feel or act more intensely or differently about an issue. The ideal column does both.”
“column writing is an act of chemistry—precisely because you must conjure it up yourself. A column doesn’t write itself the way a breaking news story does. A column has to be created. This act of chemistry usually involves mixing three basic ingredients: your own values, priorities, and aspirations; how you think the biggest forces, the world’s biggest gears and pulleys, are shaping events; and what you’ve learned about people and culture—how they react or don’t—when the big forces impact them.”
“Social media is great for collective sharing, but not always so great for collective building. Good for collective destruction, but maybe not so good for collective construction.”
“If you want to solve a big problem, you need to go from taking credit, to sharing credit, to multiplying credit. The systems that all work, multiply credit. Multiplying credit is just another way of making everyone in the system feel ownership. And the byproduct is both resilience and propulsion.”
“Social media is great for collective sharing, but not always so great for collective building. Good for collective destruction, but maybe not so good for collective construction.”
“The rabbi stated: When you look into the face of the person who is beside you, and you can see that person is your brother or your sister, then finally the night has ended, and the day has begun. Hastening that heavenly day, is the moral work of our generation.”
“The political scientist Francis Fukuyama: Social capital is a capability that arises from the prevalence of trust in a society or in certain parts of it. It can be embodied in the smallest social group: a family, as well as the largest of all groups, the nation. And in all the other groups in between. Where trust is prevalent, groups and societies can move and adapt quickly through many informal contracts. By contrast, people who do NOT trust one another will end up cooperating only under a formal system of rules and regulations…”
“On local city councils being effective: The job of the council is to get together and debate and discuss. But you do it in a way that preserves the relationships so that we can get together next week and do it again.”
Congratulations to colleague Amber Sieja MD on her first-author publication of our work on improving EHR (electronic health record) usability by reconfiguring traditional SOAP notes into APSO notes, and then deploying it across an entire health system, AND THEN measuring the outcomes.
As always, a pleasure to work with smart people who can turn their daily work (physician informatics and deploying and improving the EHR) into new knowledge (publications, talks, quality improvement). Congrats to Amber!
“In this study, the authors demonstrate widespread adoption and satisfaction with the novel APSO (Assessment, Plan, Subjective, Objective) format for progress notes at a large, integrated health delivery network.”
Our Physician Informatics Group (PIGs) has a book club. We read a book every couple months, and a recent book we read together was Patients Come Second. It is a provocatively titled book, but also timely, in the setting of physician burnout in our country.
There are lots of goals we have in Informatics. We have ASPIRATIONAL GOALS, with lofty thoughts of building or partnering with Deep Mind or IBM’s Watson, and have the Machine learn about healthcare and build predictive models and seek and destroy wasteful non-productive treatments. These are like building the upper floors of a would-be skyscraper.
We have KEEP THE LIGHTS ON goals, squashing software bugs, seeking out reasons for “slow performance,” upgrading to the new software version, fixing various things as they stop working. One wonders, exactly how many lines of code are required to run an enterprise EHR? 2 million? 10 million? Its is a wonder more doesn’t happen day-to-day. This is like keeping the first floor of a building running smoothly.
Our FOUNDATION IS CRUMBLING, however. And this puts the entire structure at risk. I’ve been in Informatics since 1998, seen 3 major and countless minor EHR’s come and go at our institution. I’ve played the cheerleader for years, setting the vision to Modernize Healthcare, one doctor, one clinic, one patient, one organization at a time. We’ve all held our breath, that “the next version of software” will finally reduce the burden on our physicians. I’ve implemented major changes in the system for the benefit of patients (Open Notes, Open Results, Online communication between patients and physicians), and physicians (Dragon speech recognition, remote access to charts, eliminating shadow paper charts, unifying many clinics around a single EHR database, establishing APSO notes as a default standard for improved readability, building EHR Genius Bars, creating EHR Sprint teams (more on this another time)).
Between the burden of increasing federal regulation, the burden of increased documentation to justify the hard work that physicians do (“I certify that I personally updated the past medical, surgical and family histories in this patient’s chart”), the requirements from the Joint Commission, interpreted from Medicare regulation:
The patient’s smoking status is …, the patient’s fall risk is …, the patient’s main concern today is …, the patient’s score on depression screening is …, the patient’s vital signs are …, the patient’s past medical, surgical, family history is …, the patient’s substance abuse history is …, I certify I have reviewed the patient’s State Opiate Registry to ensure no inappropriate opiate use by the patient … the patient’s “exercise minutes per week” are …, the patient’s answers to the 40 Review of Systems symptom questions (not related to current visit) are …
AND THEN after being grilled like this, the patient can finally tell us:
“why I am here today.”
And, on top of that, there are RAC audits: The Recovery Audit Contractor, the wolf-hounds contracted by Medicare to sniff out fraud, with the explicit arrangement that any inappropriately Medicare-billed visits in the past will be labelled fraudulent, and the monies returned to the Feds, often with penalities in the $$ millions, with a substantial fraction “earned” by the obviously highly motivated RAC auditor.
The joy of medicine has a smaller and smaller corner of the office to thrive in. Burnout.
It is a stake through my heart that EHR’s are commonly cited as the reason for burnout, and many of my major decisions of the past decade have been in the service of reducing this burnout, balancing what is best for patients with what is best for doctors.
Maybe it is time to ramp up the care-and-feeding of doctors, and let Patients Come Second, so that patient care can be joyful again, and patients can enjoy better relationships with their docs, and better overall healthcare. Sometimes a shake up in attitude helps us look at the world differently.
I hear that some organizations are giving their docs the gift of time: giving docs certificates for “time” that can be spent asking a “gofer” to shop, to buy groceries, to help with laundry or dry cleaning, to shuttle kids to/from child care, to put gas in the car. Some are flexing their doc’s work hours to match family obligations (school children), others are finding other ways to give back valuable time to harried docs.
How can we help Patients Come Second (so that everyone does better)? What can we all do to think outside the box, and bring joy back to medicine?
I did not attend HIMSS this year. Sounds like the Epic vendor booth handed out copies of a very old book called Truth and the Dragon, about combating propaganda, written in the 1960’s (the days of the Red Scare). (Thanks to Pete Wenzlick for the hot tip.) What is old, is new again. I plan to read this with my kids.
I did not believe the reviews. Three-Body was a terrific book, but reviewers said that book 2 was better, and then book 3 was even better. Well, believe it.
I was enthralled by the Three Body Problem. Celestial mechanics, virtual reality gaming done right, alien interaction over galactic distances, political upheaval, insoluble problems pulled together into a tight narrative.
I boggled at Dark Forest. Description of the principles of Cosmic Sociology (no kidding! I loved this construct and its corollary ideas), the suspicions across light-years. Just so well constructed and told.
And, now Death’s End. The author broadens his view to illustrate his point “The Universe is big, but Life is bigger.” And another point, that older civilizations end up using the laws of physics as weapons. What?!? Suffice it to say, the narratives set up in the previous books are kicked up another notch. Moreover, the author creates 3 compelling fairy-tales that are not only terrific stories in themselves, but completely crucial to the larger story-arc. This is my new favorite trilogy of all time.
I read lots of what I call “popular psychology” books, the way I used to devour “popular science” magazines when younger. I find the intricate and contradictory patterns of the mind even more interesting than the latest scientific or technological breakthroughs. Having numerous habits that I wish I could change, and, as importantly, having numerous colleagues, and perhaps most importantly, patients who have habits I wish I could influence positively, I was eager for the anticipated advice.
Duhigg writes clearly and compellingly. He stocks the chapters with story after dissected story of how habits can change at an individual, small group, or large corporate or even national level.
This main tenet is the sequence of links between CUE-BEHAVIOR-REWARD, and how even our best conscious intentions are overwhelmed with the subtle, insistent, irresistable patterns in this habit-sequence. Want fries and a drink with that burger? That TV remote and barcalounger calling to you at the end of a long day? The gym too far away AGAIN?
He finds fault with those (like me) who believe that IT’S JUST WILLPOWER. No, it’s not. Habit will win every time (in the long run). His idea, at the individual level, is that it’s worth taking stock of the habit you’re interested in changing (say, getting enough sleep at night), and determining, really what the cue (it’s 11pm and quiet in the house) and the reward (now I can finally think, and read!) are. Then, it’s a matter of retaining the reward and figuring out what other behavior can sustainably be substituted: audible books to listen in the car? turning off your screens in the evening and reading for 2 hours? carving out 2 hours some other time in the day?
Furthermore, his insights on strong ties, weak ties, sense of community, obligation, make this more than just a self-help book.
CMIO’s take? This one clearly demands a re-reading. I’m going to use this to analyze my own habits, and see which of my behaviors I can hack. Furthermore, I’m wondering if, as a physician, I can create concrete new habits and rewards for my patients, whether’s there’s a simple formula, or whether that work is so much more self-driven, so much harder, as it seems to be.
It’s no longer adequate to tell patients “just go get some exercise”. Now its time to discuss: what is the cue-behavior-reward of exercise? Cue: get home from work. Behavior: sit down, turn on TV, Reward: relax and enjoy the evening. However, there are those who, once started on an exercise habit, find the behavior: exercise leading to its own reward: feeling better about yourself.
But, how to get over the hump of change? Some other mini-reward for 30 days to establish the new habit and start feeling the new reward? Using a calendar and marker? Perhaps a prescription from the doctor taped to the fridge with checkboxes to complete? A doctors fake-pill bottle of minty tic tacs that you can take daily AFTER exercise, and then we count the pills together at the end of 30 days? There’s something powerful here for all of us.