Engineers: Heal Thyselves (and Healthcare)

The article I can’t get out of my head is one by Greg Ip in The Wall Street Journal: Crises at Boeing and Intel Area National Emergency.

Boeing and Intel offer healthcare some lessons about the importance of engineers

I’m old enough that I remember when the Boeing 707 took airline passenger travel from the prop age to the jet age. I’m old enough that I remember that we all wanted PCs with Intel chips when companies starting giving office workers their first PCs. I’ve read enough history to know the storied engineering background and achievements of both. I mean, those B-52s that have been the backbone of the U.S. Air Force bomber command for the past 70+ years: those are Boeing planes.

To younger people, though, Being is the company whose doors pop out mid-flight, or which abandons astronauts in space. When they think of Intel – oh, I’m just kidding; when younger people think about chip companies, it’s NVIDIA or TSMC. Intel’s stock is doing so badly it may get kicked out of the Dow Jones Industrial Average.

So, as Mr. Ip says: “A generation ago, any list of America’s most admired manufacturers would have had Intel and Boeing near the top. Today, both are on the ropes.”

He goes on to add:

The U.S. still designs the world’s most innovative products, but is losing the knack for making them.

At the end of 1999, four of the 10 most valuable U.S. companies were manufacturers. Today, none are. The lone rising star: Tesla, which ranked 11th.

Intel and Boeing were once the gold standard in manufacturing groundbreaking products to demanding specifications with consistently high quality. Not any longer. 

What is most frustrating, Mr. Ip points out, is: “Neither fell prey to cheap foreign competition, but to their own mistakes. Their culture evolved to prioritize financial performance over engineering excellence.”

As an example, in a Blockbuster-could-have-bought-Netflix parallel, The New York Times reports that Intel could have bought NVIDIA in 2005, but the reported $20b price was considered too expensive. NVIDIA is now worth $3.5 trillion. Whoops.

Boeing’s new CEO, Kelly Ortberg, admits: “The trust in our company has eroded,” and that Boeing needs “a fundamental change in culture.” It doesn’t help that its machinists have been on strike almost 2 months, with the union rejecting Boeing’s latest offer last week. Boeing is slashing some 17,000 jobs, considering selling off its Starliner business, and trying to raise as much as $25b. 

Intel has also cut jobs, is trying to beef up its manufacturing through a revitalized foundry business (which some believe Intel should spin off), and has seen its stock crater (down 52% YTD), but CEO Pat Gelsinger vows: “We see the finish line in sight.”

Intel is still waiting for some $8.5b in CHIPS Act funding, “There’s been renegotiations on both sides,” Mr. Gelsinger told The New York Times. “My simple message is, ‘Let’s get it finished.’” But, as former Commerce Department official Caitlin Legacki noted: [There is fear that] Intel is going to take chips money, build an empty shell of a factory and then never actually open it, because they don’t have customers.”  Its much-hyped plants in Arizona and Ohio have both faced setbacks.  

Meanwhile, the vultures are circling: there are rumors that Samsung and Apple may want to acquire Intel.

The trouble is, which is Mr. Ip’s point, neither has any real domestic competition; if either would fail, it would throw even more of our economy to the mercy of foreign manufacturers (or, in its space business, make the U.S. even more dependent on Elon Musk’s SpaceX). That’s the national emergence he is warning about.

My point with all this is not so much to add another lament about the decline of U.S. manufacturing as to emphasize the decline of the role of engineers. Earlier this year Jerry Useem, writing in The Atlantic,  argued: “When the wave of Japanese competition finally crashed on corporate America, those best equipped to understand it—the engineers—were no longer in charge. American boardrooms had been handed over to the finance people.”   

 Mr. Useem points out that a revitalized GE “is belatedly yielding to the reality that workers on the gemba [Japanese term for the shop floor, where value is actually created] are far better at figuring out more efficient ways of making things than remote bureaucrats with spreadsheet abstractions.” That sounds a lot like what Mr. Ortberg is saying: “We need to be on the factory floors, in the back shops and in our engineering labs.”

So what, you might ask, does this have to do with healthcare? 

It turns out that there is something called a healthcare engineer. In fact, there is an American Society of Healthcare Engineers, which says is “dedicated to optimizing the health care built environment. ASHE’s 12,000+ members design, build, and operate hospitals, and are involved in improving the health care physical environment from the time hospital blueprints are drawn throughout the lifespan of a facility.”

I rather prefer a definition from much-cited 2015 paper: Healthcare Engineering Defined: A White Paper, which asserted that, despite being in use for decades, “the definition of “Healthcare Engineering” remains ambiguous.” It sought to resolve that.

The authors – and there were 41 of them – didn’t agree with ASHE that it was (just) about building hospitals and other healthcare facilities. The authors believe: “Healthcare Engineering is engineering involved in all aspects of healthcare.”

More specifically:

Healthcare Engineering is engineering involved in all aspects of the prevention, diagnosis, treatment, and management of illness, as well as the preservation and improvement of physical and mental health and well-being, through the services offered to humans by the medical and allied health professions.

The definition covers both engineering interventions (for patients), and engineering for healthcare systems – “the complete network of organizations, agencies, facilities, information systems, management systems, financing mechanisms, logistics, and all trained personnel engaged in delivering healthcare within a geographical area.”  

That’s quite a bigger role than I expect most of us think of engineers in healthcare...to the extent we think about them at all.

Credit: Healthcare Engineering Alliance Society

Many think our healthcare system has become so dysfunctional because businesspeople run it, not clinicians. Others blame the clinicians, such as for focusing more on income than on, say, quality and equity. We can all agree: however we got here and whomever is to blame, our healthcare system is a mess.

I think healthcare should take a lesson from Boeing and Intel: let the engineers take charge. E.g., not just build the building but design the processes of interventions as well as the buildings that house them.   

After all, they could hardly do worse.  

Health Care's Endless Loops

Last week the Federal Trade Commission (FTC) issued its final “click-to-cancel” rule, making it easier for consumers to cancel various kinds of subscriptions, such as gym memberships or streaming services. It will require enrollments to be as easy to cancel as they were to enroll.

Gym membership cancellations aren't the only "endless loop. Credit: FTC

“Too often, businesses make people jump through endless hoops just to cancel a subscription,” said Commission Chair Lina M. Khan. “The FTC’s rule will end these tricks and traps, saving Americans time and money. Nobody should be stuck paying for a service they no longer want.”

Oh, boy, Chairperson Khan: if you want to talk about jumping through endless loops, let’s talk about health care.

The FTC rule was part of its effort to modernize its 1973 Negative Option Rule. It had issued a preliminary rule in March 2023, which drew some 16,000 comments. Laura Brett, vice president of the National Advertising Division of BBB National Programs, explained the need for the rule to CNN: “(Consumers) had to jump through hoops online to find out where to cancel. Other times they might’ve been able to sign up online, but in order to cancel they had to call and talk to a representative. Other kinds of memberships required them to actually show up in person to cancel their subscription,”

Credit: FTC

The new rule is also part of a broader Biden Administration Time Is Money initiative, “a new governmentwide effort to crack down on all the ways that corporations—through excessive paperwork, hold times, and general aggravation—add unnecessary headaches and hassles to people’s days and degrade their quality of life.”

Predictably, not everyone agrees. The U.S. Chamber of Commerce called the whole Time is Money initiative a heavy-handed effort to micromanage business practices and pricing, and warned it would lead to “fewer choices, higher prices, and more headaches.”

But of course they do; I mean, if you asked an AI to create a Chamber of Commerce response to virtually any regulation, it would probably sound much like that.

Critics see politics behind the rule. In her dissent, Melissa Holyoak, one of the FTC’s two Republican commissioners, wrote: “Why the rush? There is a simple explanation. Less than a month from election day, the Chair is hurrying to finish a rule that follows through on a campaign pledge made by the Chair’s favored presidential candidate.” The same could be said of the Biden Administration’s new proposed rules to make over-the-counter birth control to be covered by insurers at no cost to patients.

Be that as it may, we all have more subscriptions than we probably really want, the gym membership scam has been going on so long that there was a Friends episode about it almost 30 years ago, and who among us hasn’t gotten caught in endless loops with supposed customer service representatives – if you can ever reach a live person – about some problem with a company?

Which leads me to health care.

Providing health care has always been complex, as physicians like to remind us, but just trying to receive health care has grown more and more complex over the past several decades (while growing drastically more expensive). Time is Money, the Biden Administration tells us, but in health care, the only people whose time is valued are the people billing us. We are, after all, patients, so we are supposed to be patient.

The FTC, and the Biden Administration more generally, has this right: Time is Money, and that’s our time and our money. The initiative specifically included healthcare – “…the unnecessary complications of dealing with health insurance companies…” – but I don’t think that goes far enough, fast enough.

We've all been there. Credit: Bing Image Creator

I like the precept that things should be as easy to get out of as they were to get into, although I want to use that more as a parameter than a restriction in expanding the discussion to healthcare.

For example, many of us have been complaining for years about lack of health information interoperability. Despite valiant efforts to bring it about, we all fill out too many of the same forms, asking for the same information, in too many different medical offices, and too many of us find that crucial parts of our health information do not make their way to subsequent health care practitioners, unless we make it happen. E.g., ever have to photocopy a medical record or obtain a CD of imaging results so that a new physician can see them?  You shouldn’t have to.

It should be easy – or, at the very least, easier.

Other examples, in no particular order:

• It should be harder for health care organizations to send patients to collections (or to sue them) than it would be to meet with them in person to try to negotiate a settlement.
• Claim denials should be as easy to appeal as the claim was easy to deny.
• Preauthorizations should be as easy to obtain as they are to deny.
• It shouldn’t be any easier to disenroll insurance members as it is to enroll them (I’m thinking of you, Medicaid disenrollments!).
• It should be as easy for patients to find new in-network providers as it is for their existing provider to become out-of-network.  
• It should be as easy for a patient’s appointment to start on time as it was to make the appointment. And late or cancelled appointments should result in financial considerations to the patient.
• It should be as easy for patients to find information on physicians’ actual expertise/experience as it is for them to find their marketing promises.
• It should be as easy for patients to obtain second opinions/referrals as it would be to make appointments with their current physicians.

I’m sure many of you have your own ideas/suggestions – feel free to note them in the comments below, or as responses to posts about this on Twitter or LinkedIn.

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I admit that I don’t think that subscription cancellations is one of the more important things the FTC could be working on, or that the above suggestions are the top things they should focus on in health care. I’d rather, for example, that they expand their work on assuring health care competition or the role of private equity in health care.

Still, our time is money, and sometimes that time is our health too, so anything they can do to help reduce the endless loops, in healthcare and elsewhere, I’m all for.

Make Mine Möbius

As both a long-ago math major and someone with an overdeveloped sense of whimsey, I’ve long been fascinated by Möbius strips. You know Möbius strips: they look like they should be two sided, but they are actually one sided (as you can test by tracing a line all the way around without lifting your pencil). They’re simple to make, but deceptively complex (mathematicians would add that it is a non-orientable surface with no boundaries, but let’s not go there).

The Gboard double-sided keyboard. Credit: Google Japan

You probably never found yourself thinking, hmm, I wish I had a keyboard that was a Möbius strip, but the good folks at Google Japan thought some of us wished we had a keyboard that we could type on both sides of. So, voila: they invented a Möbius strip keyboard.

"'I want to use the back of the keyboard as well as the front!'," Google Japan writes, in one translation, of the problem it aimed to solve. "In response to the voice of such users, I made a keyboard that has no front or back. A unique keyboard with two sides. Gboard double-sided version."

“If you turn the keyboard upside down, you can’t type at all. After racking our brains trying to find a solution to this major problem, we came up with this keyboard,” Google Japan noted in another translation of the blog post.

They call it the Gboard double-sided, aka the “Infinity Keyboard.” (I’m kind of disappointed they call a Möbius strip “double-sided,” but I’ll blame the marketing people, not the product people).

"The endless structure has no front or back," Google Japan claims of its design. "You can type at any angle. If you put the Gboard double-sided version [somewhere], suddenly a circle of people will form there. If we used it together, smooth 'teamringWorkin.' You'll come up with some original ideas.” 

One can certainly hope so.

Now, that's teamwork. Credit: Google Japan

The Infinity Keyboard has some 208 mechanical keys, able to be accessed at any angle and from both “sides.” They are laid out in ortho-linear 26x8 layout, with per key RBG lighting (ergo, using as a Christmas wreath is one application the developers mention). The keys are hot-swappable, allowing users to easily customize the array. With all those keys, users can have keys specifically for typing, gaming, and coding, as well as in other languages. Sadly, it isn’t wireless, using a USB-C connection.  

Google Japan estimates it weighs “20.8 donuts,” which Fast Company figures is about 2.2 pounds (based on the weight of a Krispy Kreme Original Glazed).  

Google Japan shows a number of uses for the keyboard, including simultaneous use by several people but also to wear as a bracelet or as the aforementioned Christmas wreath. And, they point out, it would be great in weightless conditions, since it has no top or bottom.

It turns out that Google Japan has been releasing unique keyboard designs each year on October 1, because – I had never counted -- 10/1 = 101 = number of keys on a typical keyboard.  Previous efforts include the Gboard Bar, which has all the keys laid out horizontally (some 5 feet long!), the Gboard Bending Spoon, which allows users to input by – you guessed it – bending a spoon, and Gboard Caps, a wearable keyboard in the (rough) shape of a cap.

Although each of these keyboards exist and are functional, Google has no plans to commercialize them. They’re intended to engender some smiles, and, perhaps, spur some creative thinking. However, Google has made the schematics and firmware open source on GitHub, with 3D printing STL files. You can make one yourself and see what it can do for your creativity/productivity.

Have at it. Credit: Google Japan

Or, if you’re not that technically oriented, they have a PDF that lets you make a paper version just to get a sense of it.  

Marcus Mears III, reviewing the Infinity Keyboard in TechRadar, says: “I love seeing these bizarre keyboard designs pop up…It's this type of ingenuity and playful creation that we need to keep advancing in the world of computer peripherals - where would we be if we never moved on from trackballs and beige membrane keyboards? Certainly not at the Gboard Double-Sided Version.” 

Jesus Diaz, in Fast Company, goes further in his praise: “If anything, this ongoing keyboard joke shows that there’s nobody in the world like the Japanese to create the quirkiest, most fun designs on the planet.” He adds: “Nobody else can compete with their imagination, but here I humbly submit, Google Japan, two final words for the next Gboard: hula hoop.”

I look forward to seeing what they come up with next October.

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We live in a world that, for the most part, has never advanced from the QWERTY keyboard design, which, as you may recall, was originally intended to slow typists down so they wouldn’t jam the typewriter keys. Obviously, it’s been a long time since that’s been our big problem, yet we’ve gotten so used to that layout that we’re still using it. So if it takes a double sided, Infinity keyboard, Möbius strip keyboard to jar our thinking about keyboards (or anything else), I say: good work, Google Japan!

Much as I love the concept, I have to admit that I’ll probably never use a Gboard double sided keyboard, and I’m certainly not going to attempt to build one. But I love that the design team at Google Japan thought of it, and I hope others are inspired to build their own, to play around with it, and to see what new ideas it might spark.

I’ve written before about people trying to break traditional design paradigms – e.g., umbrellas or even the wheel. We get so used to doing things in a particular way using existing designs that we often don’t remember that, hey, other designs are possible, and some of those designs may open up not only new ways of doing the things we’re doing but also help us identify new things to do. Design should be an enabler, not a constraint.

Their video talks about wanting “a keyboard with a twist, one that turns the problem space outside-in.” That’s what design should be helping us do.

You're Not Going to Automate MY Job

Last week U.S. dockworkers struck, for the first time in decades. Their union, the International Longshoremen’s Association (ILW), was demanding a 77% pay increase, rejecting an offer of a 50% pay increase from the shipping companies. People worried about the impact on the economy, how it might impact the upcoming election, even if Christmas would be ruined. Some panic hoarding ensued.

Then, just three days later, the strike was over, with an agreement for a 60% wage increase over six years. Work resumed. Everyone’s happy right? Well, no. The agreement is only a truce until January 15, 2025. While money was certainly an issue – it always is – the real issue is automation, and the two sides are far apart on that.

Fighting automation isn't going to work

Most of us aren’t dockworkers, of course, but their union’s attitude towards automation has lessons for our jobs nonetheless.

The advent of shipping containers in the 1960’s (if you haven’t read The Box: How the Shipping Container Made the World Smaller and the World Economy Bigger, by Marc Levinson, I highly recommend it) made increased use of automation in the shipping industry not only possible but inevitable. The ports, the shipping companies, and the unions all knew this, and have been fighting about it ever since. Add better robots and, now, AI to the mix, and one wonders when the whole process will be automated.

This is the world of shipping today. Credit: Logistics Management

Curiously, the U.S. is not a leader in this automation. Margaret Kidd, program director and associate professor of supply chain logistics at the University of Houston, told The Hill: “What most Americans don’t realize is that American exceptionalism does not exist in our port system. Our infrastructure is antiquated. Our use of automation and technology is antiquated.”

Eric Boehm of Reason agrees:

The problem is that American ports need more automation just to catch up with what's considered normal in the rest of the world. For example, automated cranes in use at the port of Rotterdam in the Netherlands since the 1990s are 80 percent faster than the human-operated cranes used at the port in Oakland, California, according to an estimate by one trade publication.

The top rated U.S. port in the World Bank’s annual performance index is only 53^rd.  Sixty-two ports worldwide – out of some 1300 – are considered semi- or fully automated. According to Heather Long in WaPo, the U.S. has 3 ports that are considered fully automated and another three that are considered semi-automated.  Loading and unloading times in the U.S. are longer than competing ports. Increased use of automation, in some fashion and to some degree, is necessary to stay competitive.

Yet the dockworkers are unmoved. In a letter to members, the ILW leader vowed: “Let me be clear: we don’t want any form of semi-automation or full automation. We want our jobs—the jobs we have historically done for over 132 years.” He insists the new six-year contract must include “absolute airtight language that there will be no automation or semiautomation” 

“The rest of the world is looking down on us because we’re fighting automation,” said Dennis Daggett, executive vice president of the ILA. “Remember that this industry, this union has always adapted to innovation. But we will never adapt to robots taking our jobs.”

This is what needs to get resolved by January. Wages are important, but only for those who have jobs. It very much reminds me of last year’s Hollywood writer’s strike, which was partly about money, but also about not letting studios use generative AI to do their jobs.

Seem familiar? Credit: Mandalit del Barco/NPR News

It’s worth pointing out that dockworkers may not quite fit the typical blue collar union worker stereotype. The Wall Street Journal reports that the average, full-time dockworkers on the West Coast made $233,000, while more than half of their East Coast counterparts earned over $150,000. Not all dockworkers earn such amounts, nor has full-time work available, but – still.  

Resisting automation is a great rallying cry to union members, but is not realistic. “The argument to stop automation now is slamming the barn door decades after the horse has gotten out. This is not going to work long term. The economic incentives behind it are too strong,” Harley Shaiken, a professor emeritus at the University of California at Berkeley, told The Washington Post.

Mr. Levinson told WaPo: “In the past, the longshore unions have agreed to various types of automation, but there’s always been some kind of price attached in terms of protecting the jobs and protecting the union’s jurisdiction. And I assume that there is some price at which this dispute will be resolved.”

Professor Kidd, in The Hill, urged: “The ILA needs to be looking at a long-term vision. There’s no industry — journalism, academia, manufacturing — that hasn’t been changed by technology,”

Along those lines, Erik Brynjolfsson, the director of Standford University’s Digital Economy Lab, suggested to The Hill:

I find it very short-sighted of the dockworkers, or any workers, to be pushing against automation if you can instead, find a way that the gains get shared. I would hope that there’s an opportunity there to strike an agreement where there is a lot more automation, not less automation and that some of the benefits get shared with the dockworkers and others.

This is not just a dockworker’s issue. As Ms. Long wrote in WaPo, “the bigger reason everyone should pay attention is that this is an early battle of well-paid workers against advanced automation. There will be many more to come.” Or, as Allison Morrow quipped in CNN: “The bots come for all of us, which is why the outcome of the port strike is particularly important to watch.”

Maybe you’re not a longshoreman, or a Hollywood writer. But the future is coming for your job too. I was struck by the title of an NYT op-ed by Jonathan Reisman, M.D.: I’m a Doctor. ChatGPT’s Bedside Manner Is Better Than Mine. As Dr. Reisman concludes:

In the end, it doesn’t actually matter if doctors feel compassion or empathy toward patients; it only matters if they act like it. In much the same way, it doesn’t matter that A.I. has no idea what we, or it, are even talking about.

I think of another quote from Professor Brynjolfsson, from a WSJ article earlier this year: “This recognizes that tasks—not jobs, products, or skills—are the fundamental units of organizations.”  I.e., when it comes to thinking about the future of your job, you really need to be recognizing which tasks in it could be done as well or better by automation/AI. They’re going to be more than you might like.  

The future is here.