Machiavelli, “The Spare” and Medical Informatics? A reflection

What does “The Prince”, Prince Harry’s new book, and Medical Informatics have in common?

It is a joy to have a son in college who is still interested in speaking to me, the old fuddy-duddy born in the Last Century. He is attending St. John’s College in Santa Fe, where they study the Great Books curriculum, or as his sister says, “Oh, so you read about ideas from old dead white men?”


It so happens that his class, which started with Aristotle, has worked their way up past Copernicus (my recent post on changing world-views), and now in the sophomore year, is now reading Machiavelli, perhaps my favorite of the classics, since it so much to say about the challenges of leadership.

Over dinner last week, my son and I discussed what I remembered from reading the Machiavelli’s “The Prince” in our Physician/APP Informatics Book Club (yes, we did), and the quotes that I use almost every week at work.

Why Change is Difficult to Lead

The reason that change in an organization is so difficult, is because at best, your proponents are lukewarm, and your detractors have ALL THE PASSION IN THE WORLD –CT’s recollection of quote

And it should be considered that nothing is more difficult to handle, more doubtful of success, nor more dangerous to manage, than to put oneself at the head of introducing new orders. For the introducer has all those who benefit from the old orders as enemies, and he has lukewarm defenders in all those who might benefit from the new orders… The lukewarmness comes from the incredulity of men, who do not truly believe in new things…  –Original text from Machiavelli

How to Manage Bad or Good News

If you have to manage change that people will like, be sure to do it a little at at time and take credit for every improvement, to sustain the atmosphere of good will. If you have to manage a change that people will NOT LIKE, do it all at once. In fact, hire someone to make that change, and, at the end, when they are very unpopular, BEHEAD THEM. Problem solved.
–CT’s recollection.

For injuries must be done all together, so that, being tasted less, they offend less; and benefits should be done little by little so that they may be tasted better.
–Original Text from Machiavelli

Application: we have a new committee, EMO (electronic medication optimization) where we are learning to remove low value medication warnings (eg: multiple stimulants in one med list – many patients have more than one Adderall pill strength needed for the right dose). Suppressing such alerts that are 90% overridden, is a benefit. Every time we reduce clicks, we Broadcast it. Take credit for every reduction, every improvement.

On the other hand, when there is something ‘bad’ we must change, we do it all at once. We have to wipe out physicians’ old radiology order preferences in order to install new radiology orders that incorporate secure chat buttons and more effective routing. DON’T get rid of them piecemeal (they will hate you every time you make a change) rip off the bandaid all at once and remove ALL the preference lists and start fresh instead. ONE painful change. But, the ONE event fades faster in memory than many smaller changes. (Yes, I know that CT Lin ruined healthcare, regardless of what he chooses).

Close readers of the blog will remember that our book club also read Leading Change and also Buy-In by John Kotter. Really practical advice on tackling the sticky issue of how to set up important changes for success.

How to Build Consensus

Back in 2009 when I invented APSO notes (a future post) I had difficulty convincing colleagues to switch to a different format of document. In brief, SOAP notes are how docs have written standard notes for 70 years. APSO puts the assessment and plan, the most important part, at the top for increased speed and readability.

However, I had failed. In our EHR (Allscripts Touchworks at that time) I made APSO a selectable option next to standard SOAP notes. Result? 16% adoption rate, even among my close friends and colleagues.

I had an opportunity in 2011 for a platform change (we were adopting Epic) and I had a committee meeting to see if I could get APSO as the default standard.

Machiavelli teaches us that, if you don’t already know how everyone will vote at an important meeting, you have not done your work.

In brief, I made 30 minute appointments with EVERY influential medical director in that 30-member meeting to discuss APSO, answer their questions and in some cases do some horse trading (this for that) to gain support. Took a couple weeks to do this ground work, for this crucial decision.

Result? I achieved consensus at the meeting. APSO notes were the default (and for a time the ONLY) format available in our new Epic EHR. Thanks, big M.


This brings us to Prince Harry. I recently listened to his book “Spare”. I had not followed the royal drama closely, and did not know that Spare was a disparaging name for himself, in contrast to “The Heir” Prince William, as in “there’s the Heir, and there is the Spare.” How awful. See last week’s blog post (below).

One presumes that the Royal education includes the reading of The Prince, for modern princes.

One also presumes that palace intrigue, public scrutiny, the fickleness of public opinion, all weigh heavily, magnified to searing intensity by social media and paparazzi (what would Machiavelli say about paparazzi?).

Similarly, those leading projects in large health systems must contend with large populations, difficulty communicating effectively, rumor, innuendo, opposing viewpoints, resistance to change (but perhaps, not paparazzi).

Medical Informatics

To bring these threads together, one sees ancient and modern examples of leadership, managing communication, remembering that smart humans lived many years ago and wrote down their ideas. It is up to us to learn history or be doomed to repeat it. Remembering my personal failures, my 16-year journey to Open Notes, my nearly-failed plan to implement APSO notes, and now our struggles to deploy, maintain, study and improve Open Results, these innovations have all been guided, in some way by Machiavelli.

CMIO’s take? Who is the historian in your leadership group? Who reads the literature, learns from the past, and gives your teams perspective? How do you ensure a diversity of opinion, of thought? How do you challenge and disrupt yourselves to avoid complacency? I worry about this all the time.

Prince Harry’s Spare (book review) and a CMIO’s reflection

Prince Harry’s autobiography is an enjoyable listen. For all the swirl about the Royal family, I almost never follow the Royal Family in the news. I was curious about Harry and Megan’s leaving the Royals and moving to Los Angeles, and so I was intrigued. And, I saw him on Late Night with Stephen Colbert. Here are the bare bones of salient facts:

  • William and Harry are sons of Princess Diana and Prince (now King) Charles
  • Diana died in a car crash after divorcing Charles, pursued by paparazzi
  • Paparazzi behavior, driven by newspaper and tabloid money in England, ultimately funded by the British public’s insatiable interest in the Royal family, is nearly unbelievable, and replete with examples of criminal behavior, as recounted by Harry and others.
  • Being in a Royal fishbowl can be intolerable and could and does prompt members to turn on each other.
  • Under the spotlight, everything is magnified: simple individual actions (or even inaction) can be interpreted as super popular or super villainous. Whatever sells papers.
  • Human behavior and relationships are difficult in any family. Under the public microscope it can be unimaginably difficult

The narrative on its own is an enjoyable listen. Harry narrates his own story from childhood growing up in the castle, losing his mom, being the Queen’s favorite, through a rebellious adolescence, into the military, training and flying missions as an Apache pilot, serving in Iraq and Afghanistan, meeting Megan, courting her, and ultimately leaving the Royal family.

I will not judge him for his actions or his writing. We all have limited skills in our relationships, coping skills for our pressures, joys in our pleasurable moments, grief in our catastrophes. It is too easy to ‘look over there’ and critique someone else’s life, not knowing the back story.

Too, it is easy to read an autobiography, adopt the authors views, and sense that everyone else must be evil.

CMIO’s take? I have lots of conflicting emotions about this, and find lots of parallels working with and leading humans in a large organization. I notice that my reactions are a litany of emotions, and less an intellectual response. And yet…

  • Most everything said is a viewpoint. Take them with a grain of salt
  • It is too easy to judge. Turn the judgement back on yourself when you feel it. Do you really know, for example, what it is like to live in a castle pursued by drone-wielding and motorbike-riding paparazzi, and loved ones suicidal from the aggressive hounding, having lost your mother, whose death was directly related to being pursued by those same individuals? What traumas are we each seeking to leave behind, ourselves?
  • The range of human experience is astounding. Sometimes just appreciating that is enough
  • What lessons on egotism can I learn from this? What lessons on brotherliness? On parenting? On collegiality? On grit? On grief? On anxiety? On empathy? What blind spots does this bring up?
  • Prince Harry is the Spare, the denigrating term for the second son who is not ‘The Heir’. This microcosm of an extreme situation, even if written as a grievance, an explanation, can tell us so much about ourselves, about myself.
  • For this, Prince Harry, Duke of Sussex, I am grateful.

The Tartar Steppe (Buzzati), book review

Is it like “Waiting for Godot?” Is it Triste? It’s great, but what is it?


In a past life, I have vague memories of learning French. And I learned there is a word in French that does not translate to English. Triste: the idea of sadness with an indefinable quality (I think).

I feel this, having finished this book. How I found this book, is now lost in my past history, some other book referenced this, and I thought at one point: “I must read.” now, having spend time on/off for 10 years (I first shelved this TO READ in 2012), I have come to the end of the book.

How do I feel? After a decade of pursuing the completion of reading?

Having binged my share of Netflix, HBO, Prime TV shows and movies, I can say that It is not an action flick. It is not a military triumph. So what is it?

I don’t really know.

It feels a little like “Waiting for Godot”: we are sitting, waiting for something, just around the corner, it peeks, and then disappears. Tantalizing.

I’m reading/listening to a different book: Mythos right now by Stephen Fry (hilarious), and Tantalus, one of the old gods, was punished by having tremendous thirst, and water, right THERE, just out of reach. Yes, it feels like that.

It feels a little like Ambivalence, with a capital A, for someone, indecisive, torn between two ideas, two worlds, two things one MUST do, and yet. Just hold, just one more day. Perhaps tomorrow. Like a person staring at their cigarettes, despising them, desiring them, not quite ready to quit smoking.

It feels a little like wanting, desiring, deserving.

How does he do it? Evoking these emotions, without speaking them. The words, the images, beautiful.

The action: a man joins the military. He is sent to the Fort, a desert frontier, facing the North, from where no one expects an attack to come. One hopes for glory, for action. Day after day, year after year, unexpected drama, tragedies, but the expected / not expected attack? Nothing. And when Something Looms, through the telescope, one believes: “it is too much to hope for.”

And the end? Realization, surprise, mostly at oneself.


Writing about it really doesn’t do it justice. Will this review be oblique enough to evoke the mood, the triste, the indirection of the narrative? You must decide.

The Classics: what Copernicus teaches us about dogma vs revolution

I am a collection of contradictions. I alternate between hedonistic Netflix binges and an occasional classic book (Ptolemy, Copernicus, Kepler). What contradictions do you embody, and what has it taught you?

Son brought this book home from his sophomore year at St. John’s College in Santa Fe. You know the school has its bona fide’s when their faculty have written, edited and published the definitive modern editions of these classic books.

This was a fun read. I started with Ptolemy, and the geocentric worldview he championed about 40 CE, and followed some of the geometry proofs (having studied Euclid too many years ago). I watched him build his ‘epicycles’ (circles upon circles) to explain the progression and retrograde motions of the 5 visible planets.

Retrograde: here’s a bonus term for those of us no longer into astrology: it is the apparent reversal of the motion of planets gradually migrating across the sky. From the newspaper, I recall reading statements like ‘Mars is retrograde in Capricorn’ and thinking ‘what hocus pocus is this?!’ Now I know that it means Mars is migrating in reverse direction and it is positioned inside the constellation of Capricorn in the sky. It makes a little more sense descriptively, but I still don’t buy that astrology foretells my future as a result.

Clearly, says Ptolemy, the only rational view of the heavens are that they are concentric spheres. The proof is that with his excellent math, he can predict the positions of the stars into the future.

1400 years later, Copernicus thinks deeply and has an insight (how, though, did he have that insight?). I love books, like Lavoisier’s on Chemistry, where the author lays out his stepwise experiments and failures, and gradual reasoning toward the invention of the concepts of oxygen and hydrogen…

Nevertheless, Copernicus lays out the groundbreaking and heretical thought that the Earth is not the center, and that the sun is the ‘center of the world.’ Heliocentrism. He has to tread gently, as he is shattering what has been accepted by scholars (and the Church) for over one thousand years. (What do WE accept that has been true for 1000 years?)

In his introduction Copernicus gingerly states that both he and Ptolemy have explanatory systems that predict planetary motion successfully. But, the heliocentric model is SO MUCH SIMPLER.

So, how to explain why Mercury and Venus have a much smaller range as they move across the sky night after night, and Mars, Jupiter and Saturn seem instead to span the entire sky? Ptolemy has to jump thru hoops and invent weird epicycles to make sense of this, and yet Copernicus sweeps away all that complexity by saying Earth is itself a planet with an orbit BETWEEN Venus and Mars. Thus the ‘inner planets’ behave differently from the ‘outer planets’ based on Earths own orbit and ‘overtaking’ the orbits of those outer planets. And all the epicycles fall away. It is one of the most ‘ohhh’ beautiful moments in the history of science.

Devastatingly, he draws out what Ptolemy’s epicycles requires planets to do (spirographic pirouettes through space, ridiculous when you look at it that way).

Cool read, even if this aging person is too lazy to revisit Euclid and plow through the math. The thinking, the paradigm shifting, the worldview challenging. That’s fun. Next up, Kepler and Galileo.

CMIO’s take? The world makes sense until someone comes along to up-end it. The instigator proposing the change often is faced with the sharp end of sticks and pitchforks. As Machiavelli told us, change is so difficult because proponents of any change are, at best, lukewarm, while detractors have ALL THE PASSION IN THE WORLD. Copernicus faced this. I have faced this as well, by developing APSO notes, and advocating for Open Notes and Open Results. Whatever change you’re working on, take heart. We tread this road together.

Is listening to an audiobook really reading? (NYtimes)

I take this critique very personally, as about 2/3 of the books I consume are via listening. How about you?


Readers: where do you fall on the reading-with-eyes vs listening-to-audiobooks spectrum? I’m not even going to tackle the eReader vs paper book divide.

Can’t book readers just get along?

TL;DR? Do what you like; reading a book can be about enjoyment, or learning something, or developing empathy. If it meets your goals, do it!

Where do you keep the (informatics) pixie dust? (borrowed from NYTimes)

This is hilarious: angsty flowcharts to help guide readers. Must-read article.

Fawzy Taylor, social media and marketing manager of the bookstore: A Room of One’s Own, Madison, WI, via NYtimes “These Memes Make Books More Fun”

Thank you to Fawzy Taylor, whose brainchild this is. Fantastic in so many ways.

Why can’t we build our informatics and our internal education this way? For example, for newbie informaticists, how about my book-recs graphic above, based on the same idea?

CMIO’s take? What do you think of the graphic? of the style? of the content? Guess what? It doesn’t matter, if it gets us talking!

Steven Pinker Thinks Your Sense of Imminent Doom Is Wrong – The New York Times

Steven Pinker image from

“It is irrational to interpret a number of crises occurring at the same time as signs that we’re doomed.”
— Read on

The Xenobot Future Is Coming—Start Planning Now (

“…the ability to recode cells, de-extinct species, and create new life forms will come with ethical, philosophical, and political challenges”

With CRISPR, the molecular scissors technology ,we are gaining not only read, but WRITE access to our genetic data. Writing code will no longer be limited to computers (and electronic health records), but into living organisms. Are we ready? The technology is racing ahead of our ability to think about and deploy it for the good of all.

Can Learning Machines Unlearn? (

How much data?

I’ve been thinking about this a lot. In our recent work designing predictive algorithms using linear regressions and neural networks, and similar approaches, we’ve discussed the use of EHR (electronic health record) data, and have had some success using such algorithms to reduce deaths from sepsis (blog post from 10/6/2021).

One of many problems, is “how much data?” And it has been interesting to work with our data science colleagues on creating a model, and then carefully slimming it down so that our models can run on smaller data sets, more efficiently, more quickly, with less computing power.


A related problem is “when do we need to forget?” EHR data ages, the way clinicians record findings can change. Our understanding of diseases change. The diseases themselves change. (Delta variant, anyone?)

Will our models perform worse if we use data that is too old? Will they perform better because we gave them more history? Do our models have an “expiration date?”

The article above talks about having to remove data that was perhaps illegally acquired, or perhaps after a lawsuit, MUST be removed from a database that powers an algorithm.

Humans need to forget. What about algorithms?

Isn’t human memory about selective attention, selective use of memory? Wouldn’t a human’s perfect memory be the enemy of efficient and effective thinking? I’ve read that recalling a memory slightly changes the memory. Why do we work this way? Is that better for us?

Is there a lesson here for what we are building in silico?

CMIO’s take? As we build predictive analytics, working toward a “thinking machine”, consider: what DON’T we know about memory and forgetting? Are we missing something fundamental in how our minds work as we build silicon images of ourselves? What are you doing in this area? Let me know.