Our Dunning-Kruger Healthcare System

Psychologist David Dunning, originator of the eponymous Dunning-Kruger effect, recently gave an interview to Vox's Brian Resnick.  For those of you not familiar with the Dunning-Kruger effect, it refers to the cognitive bias that leads people to overestimate their knowledge or expertise.  More importantly, those with low knowledge/ability are most likely to overestimate it. 

Does this make anyone else think of the U.S. healthcare system?

Credit: drschat

Professor Dunning proposed the effect in 1999, in a paper in Journal of Personality and Social Psychology, along with then-graduate student Justin Kruger.  Since then, it has become widely known and broadly applied (not always accurately, as Dr. Dunning explains in the interview). 

Their paper had a chart that summarized their findings:

Credit: Dunning-Kruger, Journal of Personality and Social Psychology

Dr. Dunning believes that we tend to think that this effect only applies to others, or only to "stupid people," when, in fact, it is something that impacts each of us   As Dr. Dunning told Mr. Resnick, “The first rule of the Dunning-Kruger club is you don’t know you’re a member of the Dunning-Kruger club.  People miss that.” 

Or, as Dr. Dunning characterized it in a 2014 Pacific Standard article, "We are all confident idiots."

So, how does this relate to our healthcare system? 

We brag about our excellent care, our great hospitals and doctors, and all those healthcare jobs powering local economies.  Yet we have by far the most expensive healthcare system in the world, which is expensive not because it delivers better care or to more of its population than health systems in other countries, but because it feels it is justified in charging much higher prices.  Our actual outcomes, quality of care, and equity are all woefully mediocre on a number of measures. 

Credit: Kaiser Health News

How many of you live in an area that has at least one hospital system claiming to be one of the "best" hospitals in the country?  I've lived a lot of places, and each of them had one or more hospitals making that claim.  Your local hospital(s) may as well.  I hate to break it to you, but, in most cases, that claim is not likely to be true. 

Similarly, how many of us like to believe that our doctors are "the best"?  Perhaps they even have "best doctors" plaques in their offices to support this claim.  Again, it's possible that they are, but, in most cases, those beliefs are not likely to be true. 

Statistically speaking, most of us receive average care, and some of us receive sub-standard care.  We don't live in Lake Wobegon.  We can't all be getting the best care, or even above-average care. 

Just look at how few hospitals earn high ratings from The Leapfrog Group.  Look at nationally or even internationally known hospitals like UNC Children's or Houston Methodist, both of which had embarrassing revelations about the quality of some of their programs uncovered by investigative journalism.  Look at how even problem doctors often evade our vaunted medical licensing system. 

They all probably thought they were much more capable than they were. 

In the Vox interview, Dr. Dunning referred to a 2018 paper he co-authored, which found that beginners don't start out displaying the Dunning-Kruger effect, but often soon manifest it:

Although beginners did not start out overconfident in their judgments, they rapidly surged to a "beginner's bubble" of overconfidence."...Hence, when it comes to overconfident judgment, a little learning does appear to be a dangerous thing.  

I think about how uncertain medical school students turn into nervous residents and ultimately become the uber-confident physicians we're used to.  Dr. Dunning discussed how we need to do better distinguish facts and opinions, and be more willing to admit "I don't know."  How often does your physician admit they don't know something -- and would that give you more, or less, confidence in them if they did?  

In The Atlantic, Olga Khazan reported on a new study that suggests that, despite all their supposed superior knowledge, doctors don't really make better patients than the rest of us.  They get C-sections about as often, and about as unnecessarily as we do, they get about the same amount of unnecessary/low value tests, they're not better at taking needed prescriptions.  

As Michael Frakes, one of the authors told Ms. Khazan, the doctors "went through internships, residencies, fellowships. They’re super informed.  And even then, they’re not doing that much better."  Professor Frakes speculated that even physicians tended to be "super deferential" to their own physicians, despite their own training and experience.  

They're underestimating their own knowledge, and their doctors may be overestimating theirs.  A new meta-study found almost 400 "medical reversals" -- common tests or procedures that are not supported by research data.  As one of the co-authors told The New York Times: "You come away with a sense of humility.  Very smart and well-intentioned people came to practice these things for many, many years. But they were wrong."  

It is widely accepted that as much as a third of our healthcare services are unnecessary or inappropriate -- even physicians admit that -- but, of course, it is other physicians doing all that.  No one likes to believe it is their doctor, and few doctors will admit that they are the problem.  

Dunning-Kruger, indeed.

Much as they'd like us to, it is not enough for us to always assume that our healthcare professionals and institutions are qualified, much less "the best."  It is not enough for us to trust that their opinions are enough to base our care recommendations on.  It is not enough to believe that local practice patterns are right for our care, even when they are at variance with national norms or best practices.

"Trust" is seen as essential to the patient-physician relationship, the supposed cornerstone of our healthcare system, but trust needs to be earned.  We need facts.  We need data.  We need empirically-validated care.  We need accountability.  

Otherwise, we just fall victim to healthcare's Dunning-Kruger effect.  

In Defence of Ignorance

You may not realize it, but there is something wrong with your body.  Perhaps you have a mutated gene.  Maybe some cells are misbehaving.  Your body chemistry may be out of whack.  Some of your microbiota could be changing from a mutual benefit, or at least a stalemate, with your body to battling it.  It could be lots of things.

If you had a computer program as sophisticated as your body's code, thrown together over as long a time by as many programmers, you'd expect some bugs.  If you had a piece of machinery as complex, and used as hard as your body, you'd expect a few things to be constantly breaking down.  Yet somehow we seem surprised when we're told something is wrong with us.

Let's face it: past your early/mid-twenties, what we politely call "aging" should more realistically be called "deteriorating."   We just don't always realize it, and that's not necessarily a bad thing. 

Credit: Shutterstock

A few weeks ago I saw a primary care doctor.  Almost as an afterthought, she suggested one more scan.  I suspected I was being upsold, but I didn't want to be difficult and it wasn't particularly expensive, so I agreed.  Much to my surprise, the results indicated I might have a serious condition -- not life-threatening, but certainly life-altering.   There were treatments for it, but they were lengthy, unpleasant, and expensive.  Moreover, they could only slow the progression of the disease, not cure or even halt it.

I was not a happy camper.

She sent me to a specialist.  More tests, more scans, and he confirmed her suspicions.  He sent me to an even more expert specialist, who did more tests and scans, with some surprising conclusions.  There was some damage, he agreed, but nothing too serious, just something to watch.  I didn't yet have the disease in question.  Come back in a year just so we can keep an eye on it.

All this took several weeks, which I'm sure is very short compared to what others have had to endure, but which seemed interminable to me.  I kept thinking about all those treatments, all that money, and how my life would be different as the disease had progressed.  All for naught, as it turned out.

I'm kind of wishing I had turned down that original scan. 

We're detecting problems ever earlier.  CTs, MRIs, PET scans can pick up cancer cells at early stages.  We're already using "liquid biopsies" or fecal samples to find tiny traces of cancers, in minimally invasive ways, and are on the cusp of detecting early stage cancers and other problems through even more refined blood tests. 

The trouble is that not all the findings are important.  For example, many scans pick up abnormalities that should be considered "incidentalomas," researchers found last year.  “We know that the diagnosis of incidentalomas can cause patient anxiety and is likely to lead to further investigations and treatment, some of which will be unnecessary, and some of which will cause harm,” said lead study author Dr. Jack O’Sullivan of the University of Oxford. 

Credit: MedPage Today

As H. Gilbert Welch, MD, a professor at the Dartmouth Institute for Health Policy and Clinical Practice and author of a related study, told MedPage Today: "The human body is full of small anatomical abnormalities.  The more we look, the more we find, and the more we intervene. And that’s generally not in our patients’ interest."

Similarly, those new blood tests may have only a 1% false positive rate, but: "One percent in a patient population of 5,000 is manageable.  With 1 percent in hundreds of thousands or millions, you quickly get into different dynamics,” Joydeep Goswami of Thermo Fischer Scientific said in an interview with MedCity News at the recent annual meeting of the American Society of Clinical Oncology.  

It's cool that the Apple Watch can give us 24/7, real-time monitoring of irregular heart beats, and who knows what kinds of such monitoring we'll be able to do next.  But we're also going to turn up apparent issues that aren't really issues, getting lots of people needlessly worried and subject to subsequent tests/procedures/expenses.  

We can get findings.  Lots of them.  More all the time.  We just don't always know what to make of them.  As Dr. Welch said, "the more we look, the more we find."  Sometimes it might be better not to look. 

I think back to my early days in health policy, when there was much discussion about the supposed rationing in the U.K.'s National Health Service.  For example, it was widely believed in the U.S. that no one over 65 could get dialysis through the NHS.  A study -- and I can't recall the authors -- found that, in fact, there were no explicit prohibitions or even guidelines about it.  It was just that physicians were reluctant to order it for seniors.  As one physician put it, "well, at that age we're all a bit crumbly, aren't we?"

Indeed, we are all bit crumbly, and the trouble is we don't always know which of our many flaws are "normal" and which need action.  

We don't have the right baselines.  We don't know what "normal" should look like, for which people, at which ages.  We don't know which of what Dr.Welch called our "small anatomical abnormalities" will never manifest as real issues, and can be safely ignored.  No, give us a finding, and someone will want to take action on it. 

Should we stop trying to find ways to find and diagnosis potential issues at earlier stages?  No, of course not.  But we need to spend at least as much time and money understanding what they really mean.  Sometimes a flaw is just part of who we are.

Should we stop trying to treat issues once identified?  Well, maybe.  Most of us freak out when given a serious diagnosis, but part of physicians' job is to help us understand when action is necessary and when waiting or even ignoring something is the best course of action.  Part of their job may be not to put us through that at all.

Sometimes ignorance is, in fact, bliss. 

Eating Meat May Soon Be Beyond, Impossible

I have to admit: I like a good burger.  I'm always game for chicken tenders.  And if someone wants to take the pepperoni from my pizza, they're going to have to pry it from my cold, dead hands.  All that being said, if I had to be involved in, or even watch, how any of it was processed, I'd probably never eat meat again. 

All that may change within a generation.  Consulting firm A.T. Kearney, for example, predicts that by 2040 60% of the "meat" most of the world eats will come from meat substitutes. 

Whether this will be good for our health remains to be seen.

Credit: NTL Photography

It was hard to miss the buzz around Beyond Meat's IPO last month.  Beyond Meat sells a variety of plant-based meat alternatives, including in Whole Foods.   It is just rolling out the latest version of its Beyond Burger, making it even closer to a traditional burger.  It is "meatier," tastes better, and even looks more like a real burger. 

Still, Beyond Meats is not satisfied.  CEO Ethan Brown told The Verge: "We are on this mission to build a perfect piece of meat and that product is imperfect. There are things about it that aren’t exactly like meat and that really bothers us."

Meanwhile, fast food chains are having a hard time keeping Impossible Food's meat alternatives in stock.  Their Impossible Burger is on the menu at 9,000 restaurants -- when you can get it. "We are working our hardest to increase production and are making real strides," a spokesperson told CNET.  It's a good problem to have; CNET also reports the company has seen a 50% increase in revenue since Impossible Burger 2.0 launched in January 2019.    

Tyson Foods' new nuggets

Lest anyone think this is only a movement from industry upstarts, Tyson Foods is planning to introduce "chicken" nuggets made out of peas, among other plants.  It is Tyson's first foray into meat alternatives, and executives believe it could be a $1 billion annual business.  In his version of the classic railroad/transportation question, Mr. White rhetorically asked: 

Are we just an animal protein company, or a protein company? Once you expand that definition, where does it allow you to go?"

His conclusion: "There are opportunities for us to produce and supply many of the products produced today in traditional form, in plant-based form."  

Plant-based meat alternatives have been around for many years, particularly soybean-based, but failed to generate much excitement from anyone who was not already a vegetarian/vegan.  Firms like Beyond Meats and Impossible Foods have taken these products to new levels, reaching more mainstream audiences.  And we may just be scratching the surface.

The next wave may be cell-cultured meat, for which regulators are just starting to get a framework.  In this version, cells harvested from an animal are actually cultured in a lab to product the final product.  All the taste, texture, and appearance of "traditional" meat, but without any animals actually being slaughtered, and potentially cheaper.  "If only half of it becomes remotely true, it will be one of the most important advancements of the century," Kristopher Gasteratos of the Cellular Agricultural Society told The Washington Post.

In its report, A.T. Kearney forecast that cultured meats will be the majority of alternative meats by 2040.  

This is not much ado about nothing.  It is not just another food craze.  Americans eat about 200 pounds of meat per year, split about equally between livestock and poultry.  Most people have heard warnings that too much red meat is not good for us (and white meat may not be all that much better), but most of us don't think about the impact of the meat industry on the environment. 

All those cows, pigs, chickens, and turkeys take a lot of effort: crops to feed them, space to raise them, and a godawful about of waste (including plenty of methane).  As Timothy Egan wrote in The New York Times: "Industrial agriculture to produce meat is the coal-mining of food production."

Not a pretty picture.  

There economics of supplying all that meat, especially as people in developing nations start wanting more, are going to force us to meat alternatives.  When we get serious about climate change -- and someday soon we're going to have to -- reducing the impact of the meat industry is going to be high on the list of targets.  It is going to happen.  It will get cheaper, it will fool our taste buds, and younger generations will never even know they've made a trade-off.

That doesn't necessarily mean it is going to be good for us.  We're eating a lot more processed food than we were even a generation ago, and it clearly has not been good for us.  Just look at obesity and diabetes rates, among other measures.  We know how to make food cheap, and how to make it tasty, but we're not as good at making cheap, tasty food healthy.  

As Mr. Egan also said:

The cautionary note is that we don’t have enough experience yet with the “secret sauce” that makes the new line of fake burgers taste so good. Both Beyond Meat, and Impossible Foods, the two darlings of alt-meat, use about 20 different ingredients in their patties. They are highly processed Frankenfoods hatched in a lab, not carrots pulled out of the earth.

And those are plant-based alternatives, not cultured meats that most would more likely think of as "Frankenfoods."  We may be substituting one kind of processed food for another.

My worry is that we're not evolved to eat these meat alternatives.  We evolved to eat meat and plants.  We evolved a complex microbiota to go along with them.  But we've barely scratching the surface of understanding our microbiota and its impact on our health. 

Stanford study on alternative meat & gut microbiome

We know that our diet and our lifestyle have big impacts on our microbiota, and that it has a major influence on many, if not all, aspects of our health.  We know that our increased intake of processed foods is changing our microbiota, in ways we do not yet understand.  Introducing meat alternatives that we're not evolved for, with a limited understanding about how it will impact our microbiota, is only going to raise more concerns.

Synthetic meat is going to happen.  For that matter, synthetic plants are probably going to happen.  The "coal mining" metaphor illustrates why.  I just hope we design them as much for our health as we do for our taste.

An Ounce of Prevention, a Libra of Cure?

Just when you thought Facebook's ambitions couldn't get any broader, just when you thought it might have been chastened by some of its recent embarrassments (Russian bots?  Privacy scandals?), it ups the ante: now it's planning a global currency. 

Technically, it is a cryptocurrency.  It is going to be offered through Calibra, a new Facebook subsidiary, in conjunction with a couple dozen major partners, including Mastercard.  The project will be run by the Libra Association, "an independent, not-for-profit membership organization headquartered in Geneva,Switzerland." 

I don't know much about cryptocurrency, but my first thought was, hmm, maybe healthcare needs one. 

Most people think of bitcoin when they hear "cryptocurrency," which is not always a positive connotation, but Libra promises to be different.  There will not be a fixed amount of it, it will be tied to more conventional currencies such as the dollar and the Euro, and it will not be anonymous.  Facebook is hoping to avoid people using it to buy illegal drugs or to get ransomware payoffs. 

Still, many view this as a big deal:

• The Wall Street Journal called it "among the boldest efforts yet to bring digital currencies into the mainstream."   
• The Washington Post asked: "Is Facebook’s new Libra currency a play to become the world’s banker?"  It added that "Facebook says its ultimate goal is for Libra to become the native currency of the Internet."
• Vox called it "an attempt at the internet-age US dollar...The goal is for libra to become the first truly mainstream cryptocurrency."
• Business Insider thinks it could be as big for Facebook as Amazon Web Services has been for Amazon.
• David Marcus, Facebook's head of blockchain technology research, said:  "It feels like it is time for a better system.  This is something that could be a profound change for the entire world."
• Matt Stoller, a fellow at the Open Markets Institute, tweeted that "it's like a private global International Monetary Fund run by techbros."
• Professor Jennifer Grygiel, writing in The Conversation, speculated that Libra means that Mark Zuckerberg "wants Facebook to become a virtual nation, populated by users, powered by a self-contained economy."
• The Verge's Nick Statt charges that Calibra is a secret weapon behind "Facebook’s ambitions to create a quasi-nation state ruled by mostly corporate interests."

Excited yet...or concerned?

Early look at Calibra app.  Credit: Calibra

Facebook wants to make transferring money and making payments as easy as messaging, and if you think that is farfetched, you haven't been paying attention to China, where WeChat is already doing that.  One of Libra's first targets are the billions of unbanked around the world, who face lack of credit and/or high fees when trying to do transactions. 

Few think Facebook's ambitions end there; many see this as a new revenue source, reducing Facebook's dependence on advertising dollars, especially as privacy restrictions increase.   Mr. Statt says: "Think of it as the Bank of Facebook — an arm of the social network that hopes to do for loans, credit, money transfer, and commerce what its suite of apps has done for online communication."

Of course, whatever concerns one might already have about how Facebook handles privacy aren't going to get any easier when it starts handling financial transactions, although, not surprisingly, Facebook vows there will be absolute firewalls.  “Your financial data will never be used to target ads on Facebook,” said Kevin Weil, vice president of product for Calibra.

Libra isn't expected to go live until at least next year, and it faces a host regulatory challenges, from across the world.  As Governor Philip Lowe of the Reserve Bank of Austria said, “I think there’s a lot of water to flow under the bridge before Facebook’s proposal becomes something that we’re using all the time."

Initial Libra partners.  Credit: Libra

It is important to note that, although Calibra sees Facebook's WhatsApp and Messenger as "great homes for Libra," Libra is not exclusive to Facebook.  Calibra's Kevin Weil told Mr. Statt: "The real goal is to boost adoption to the point where Libra can have a vibrant financial services economy built on top of it, not just by Facebook but by any other company in the world."

Healthcare companies, are you listening?

There are probably others, but the only healthcare company I know trying to, in essence, use its own currency is Citizen Health.  It is using four types of blockchain-based "crypto assets," including Medits that can be earned through health activities and used as payments in health transactions.  Physicians can also "tokenize" their services.  Citizen plans that these crypto assets be used in Medoplex, their soon-to-come health marketplace.  

Facebook identified the issues that the unbanked have with financial transactions, but healthcare has plenty of its own issues with financial transactions.  Tens of millions of Americans lack insurance (many of whom may also fall into the "unbanked" category), and tens of millions more face large deductibles that mean they end up paying for much of their care.  No one -- patients, healthcare professionals, and health plans -- seems very happy with the processes that go from care to payment.  

If this isn't ripe for digital currency disruption, I don't know what is. 

A cryptocurrency won't, in itself, make healthcare more affordable.  Nor will it automatically ensure people have more money to pay for it.  But given the widespread inefficiencies in, and dissatisfaction with, current healthcare payment mechanisms, someone should be seriously exploring its use in healthcare.

Blue Cross Blue Shield Association might be big enough to make a cryptocurrency viable.  So might a United or an Aetna.  The Medicaid/Medicaid-eligible populations might make a natural target.  Or perhaps this could be the killer app Facebook itself uses to make it big in healthcare.

Many people are trying to figure out the role of cryptocurrency, and blockchain generally.  Healthcare is no exception.  Libra is an example that the world is moving forward, and healthcare should be figuring out how it might take advantage of it or similar approaches.

U.S. Healthcare Is a Cadillac...Unfortunately

The good news: the U.S. healthcare is a Cadillac.  The bad news: it's not an Escalade or even an XTS, it's a Cimarron, which is on most experts' list not only of the worst Cadillacs ever but also the worst cars ever -- expensive and poor quality.  It was literally a Chevy Cavalier dressed up and trying to pretend to be a luxury car.

You probably get the metaphor. 

The ill-fated Cadillac Cimarron

There was a time when "Cadillac" was essentially a synonym for quality.  Products aspired to be "the Cadillac of ____."  It was a compliment of the highest order, understood worldwide.  Foreign auto manufacturers tried to match its quality and make a dent into its market share.  There was a time with U.S. healthcare had that kind of status too.

I remember when, as a child, my pediatrician made house calls in his Cadillac, marking the time both when Cadillacs were the car of choice for highly respected professionals and when doctors still made house calls.  That's an era gone by; physician parking lots these days mostly have Audis,  BMWs, Lexus, Mercedes, and maybe a Tesla or two.  House calls have, for the most part, been gone longer than the Cimarron.

Cadillac suffered the fate of U.S. auto manufacturers generally.  It didn't focus enough on quality and innovation, it didn't do enough to control its costs, and it wasn't prepared for the influx of well made, more efficient, more affordable cars from foreign competitors.   Cadillac has certainly fought back, especially spurred by the success of its Escalade SUV in the early part of the century, but it is no longer the market leader in luxury vehicles, and only an optimist would predict that it will ever recover that position. 

No one aspires to be the Cadillac of anything anymore, and saying that the U.S. healthcare system is the Cadillac of health systems is not a compliment. 

As is now well known, we spend way more than other countries -- in absolute dollars, in share of GDP, and per capita -- than other countries.  Yet the health benefit of all that spending is not evident; our mortality is nothing to brag about (and declining), our disease burden is higher, and our rates of death amenable to healthcare indicates we lag other countries in delivering timely and effective care.  And, of course, we are far from universal coverage. 

Whether it is Peterson-Kaiser Health System Tracker, The Commonwealth Fund, the OECD, or any number of other studies, our healthcare system comes across as that Cimarron -- overpriced, clunky, and unloved. 

It is not that there is not excellent care in the U.S.; some of the best care in the world is here.  You just have to be in the right place, at the right time, with the right amount of money/insurance.  If not, too bad.  Performance is wildly uneven -- between states, metro areas, race/ethnicity, gender, and income. 

In some ways, the U.S. healthcare system is much worse than Cadillac, because Cadillac never aspired to be the car for everyone.  GM had its range of divisions, targeted at various socio-economic levels, with Cadillac at the top.  With the exception of say, county hospitals, federally qualified health centers, or the VA (each of which has its own struggles), we like to sell our Cadillac healthcare system to everyone. 

As long as there are patient taxpayers for public programs like Medicare/Medicaid or plenty of healthy members for private health plans, our healthcare system could get away with expecting us to buy Cadillac-priced, Chevy Cavalier-quality healthcare.  But taxpayers are running out of patience, as evidenced by our trillion dollar annual deficits and increasing numbers of (healthy) people opting to not buy health insurance (or buying skimpy versions). 

Cadillac fooled a lot of people for a long time too, just because it was Cadillac. 

We're not as lucky with healthcare as we were with cars, though.  We can't just import other healthcare systems (although we do import about a quarter of our physicians).  In fact, we're exporting aspects of our system, even our widely maligned EHRs.  Yes, Singapore controls its costs pretty well, Switzerland has great outcomes, and Britain taught everyone about universal access, but none of them are setting up shop here.  Our healthcare system thinks it can survive mostly as is despite all the evidence of its shortcomings.

It took Cadillac decades to reach its nadir with the Cimarron, and decades to recover.  It makes, I'm told, some great cars these days, but it hasn't regained either its market share or its place as a symbol of excellence. 

Similarly, the U.S. healthcare system has been bemoaning its cost crisis for fifty years, and has been aware of it quality problems for almost as long (e.g., Wennberg) yet its performance continues to drift further away from that of health systems in other developed countries.

Despite HMOs, DRGs, ACOs, value-based care and other innovations, though, what hasn't happened in U.S. healthcare has been true acceptance that the "product" is deeply flawed, much less a clear strategy for making radical improvements to it. 

It's not going to last.  People found their way to buying foreign luxury cars, and those manufacturers figured out they could set up plants here to build their cars in the U.S. in order to sell even more.  It will happen in healthcare too; probably not in the same way, but in some way.  People will, at some point, seek higher quality and more affordable options, even in healthcare.

Outgoing medical tourism is booming, growing in the U.S. by as much as 25% per year.  The late, great economist Uwe Reinhardt warned that: "medical tourism can do to the US health care system what the Japanese automotive industry did to American carmakers after the Japanese products developed a value for money and reliability reputation."

Perhaps more importantly, in an era of telemedicine, artificial intelligence, robotic procedures, and loads of digital health options, expecting U.S. borders to shield ideas and options from elsewhere in the world is as foolish as expecting car buyers would keep buying Cadillacs just because they were, well, Cadillacs. 

Millennials, Gen X and Gen Y don't remember Cadillac as the symbol of excellence, and they haven't seen much about our healthcare system that they like either.  If it wants to survive, our healthcare system better come up with something they want to pay for. 

You've Been Planning All Wrong

Like many of you, I spend a lot of time thinking about the future, especially the future of healthcare.  There are so many things to consider.  Changing demographics.  New technologies.  New findings about, or approaches to, health problems.  New entrants and new combinations of existing competitors.  Changes loom everywhere.

Jeff Bezos thinks about the future differently.  When it comes to business strategy, he said:

It's interesting, I do get asked quite frequently what's going to change in the next 10 years. One thing I rarely get asked is probably even more important — and I encourage you to think about this — is the question: What's not going to change in the next 10 years.  

Wow.  Mind blown.  Of course that makes sense.  Of course it helps explain Amazon's relentless strategy that, for many years, ignored profits for long-term investments.  Of course it should apply to healthcare as well.

Mr. Bezos elaborated:

The answer to that question can allow you to organize your activities. You can work on those things with the confidence to know that all the energy you put into them today is still going to be paying you dividends 10 years from now.  

Otherwise, he warned, companies constantly have to change their strategy trying to cope with things that change.  He believes that thinking about the things that won't change doesn't require extensive research: "As soon as you think about it that way, these things are so big, so fundamental; you can just write the answers down."

In Amazon's case, it's all about lower prices, fast shipping, and a large selection.  As he explained: "It's impossible to imagine people saying to me, 'Jeff, I love Amazon. I just wish you delivered a little more slowly. Or, I love Amazon, I just wish your prices were a little higher."

He offered some other tidbits that are worth noting:

• "You have to be a missionary, not a mercenary. And, paradoxically, the missionaries end up making more money."
• "If you have a business idea with no risk, it’s probably already being done."
• "We need big failures in order to move the needle. If we don’t, we’re not swinging enough."
• "People who are right a lot listen a lot, and they change their mind a lot."

Not much of that sounds like what's happening in healthcare, does it? 

Healthcare people have a lot on their minds these days.  The future looks like a scary place, or certainly a very different one.  There are lots of people evaluating what's coming, and how it will impact them and their healthcare organization.  Consultants are being hired, projections are being made, reports are being written, plans are being formulated.

Millennials and successor generations are not going to be as patient as prior generations, and will be much more tech-savvy.  White males are not going to be the standard.  "Traditional" families are already not the norm, and the family structure and support systems they used to bring will be different.

Our system is already so expensive that traditional funding sources can't keep up, and it seems like things are only going to get more expensive. Things like artificial intelligence and Big Data are clearly going to be part of the future, but exactly how they will fit it, and what existing approaches and personnel are going to be impacted, are unclear.  Genetic engineering/editing, nanobots, and 3D printing will change the approaches and cost structures our healthcare system has been used to.

Lions and tigers and bears, oh, my!

When it comes to thinking about the things that won't change in healthcare, I worry that too many people think they boil down to:

• there will always be patients;
• they'll pay whatever they have to in order to have even a chance to get better;
• better health requires more health care.

Luke Skywalker would know what to say about that:

Too often, our healthcare system sees itself as the thing for which patients must change.  And that most definitely is going to change.

Thinking about the things that don't change is harder than Mr. Bezos suggests, at least for me.  Nonetheless, here's my list:

• Patients are, first and foremost, people, with lives that matter to them;
• Health care is only a small part of what brings health;
• People want to be healthy, although they're not always sure how to achieve that, nor always willing to make the effort they should;
• When they aren't feeling right, people want to be comforted.

The healthcare system claims to be all about patients, and sometimes it is, but that's not the thing that won't change.  "Patients" is an elusive notion -- when, what, where, how all keep changing.  It has led us wrong in many ways.

The North Star of healthcare should always be treating people like people.

Credit: Getty Images

Do that, and it wouldn't keep them waiting so long or so often.  Do that, and it wouldn't be making some decide between food or treatments.  Do that, and it wouldn't send some of them to collections (especially when they are already facing major crises).  Do that, and we'd hear less about arrogance and/or indifference from healthcare professionals/ organizations.

Healthcare isn't about helping patients feel better, or, at least, less bad.  It is, or should be, about --  as VanderWeele, et. alia recently put it -- helping people "flourish."  That is something that won't change.  Focus on that, and it will still be paying dividends in ten years.

As Mr. Bezos urged, be a missionary, not a mercenary.  Change your mind.  Take risks, swing for the fence, but be prepared to fail.  The changes ahead are things to be used to help address the things that don't change.  Blue Origin aside, this is not rocket science.  This is something that healthcare not only can do, it is something it must do. 

My list might be wrong.  It probably is.  Even if it is right, it may not be as specific as it should be, like Amazon's core goals.  So what's your list?

Salesforce Shows the Way

Another mass shooting, this time in Virginia Beach.  By the time some of you read this, another mass shooting may have driven the events in Virginia Beach out of the news cycle.  As seems to be our pattern, there has been sympathy, sorrow, and some outrage, with offers of "thoughts and prayers" from our elected officials in lieu of action. 

Salesforce.com is taking its own action.  In a move that occurred in April but was just reported on May 30 (the day before the Virginia Beach shooting, by the way), Salesforce has told customers that it will not let their customers use its software to sell a broad range of firearms.  The Washington Post, which first reported the move, had a great headline about the move: Tech giant brings software to a gun fight."

I wish I'd thought of that headline almost as much as I wish I had the nerve, or the ability, to take such a bold action. 

Marc Benioff, Salesforce.com co-CEO.  Credit: Getty Images

The Verge reported the specifics of Salesforce's policy as follows:

Worldwide, customers may not use a Service to transact online sales of any of the following firearms and/or related accessories to private citizens. Firearms: automatic firearms; semi-automatic firearms that have the capacity to accept a detachable magazine and any of the following: thumbhole stock, folding or telescoping stock, grenade launcher or flare launcher, flash or sound suppressor, forward pistol grip, pistol grip (in the case of a rifle) or second pistol grip (in the case of a pistol), barrel shroud; semi-automatic firearms with a fixed magazine that can accept more than 10 rounds; ghost guns; 3D printed guns; firearms without serial numbers; .50 BMG rifles; firearms that use .50 BMG ammunition. Firearm Parts: magazines capable of accepting more than 10 rounds; flash or sound suppressors; multi-burst trigger devices; grenade or rocket launchers; 80% or unfinished lower receivers; blueprints for ghost guns; blueprints for 3D printed guns; barrel shrouds; thumbhole stocks; threaded barrels capable of accepting a flash suppressor or sound suppressor.

They've evidently given this some thought.

It's not entirely surprising that Salesforce might take such action.  It's founder, chairman, and co-CEO, Marc Benioff, called last year for the AR-15 to be banned, immediately following the Parkland shootings.  He's donated money to gun control groups, called for social media companies to be regulated due to their addictive products, and has been vocal about addressing the homeless problem in San Francisco. 

Late last year Salesforce also announced it was hiring Paula Goldman, as its first "chief ethical and humane use" officer, whose role is "to develop a strategic framework for the ethical and humane use of technology across Salesforce."  Ms. Goldman will report to Salesforce's Chief Equality Officer, yet another unique, high level, socially conscious position, which was created in 2016. 

I don't know if this decision was generated by Ms. Goldman or by Mr. Benioff directly, but, either way, but kudos to whomever thought of it and made it happen.  It potentially puts at risk millions of dollars in revenue from impacted customers/potential customers, but Salesforce's products -- especially its CRM suite -- are so integral to so many businesses that moving away from them is not a decision that any of them could make lightly.

Software to a gun fight indeed.

To be fair, Salesforce is not the only large company taking some action.  Retailers like Amazon, Walmart, eBay, and Dick's Sporting Goods have all moved to ban or restrict gun sales. Shopify won't let its platform be used to sell certain firearms.  Citigroup won't do business with clients who don't follow its policies of firearms.  Levi Strauss & Co. and Tom's Shoes are donating significant amounts of money to organizations seeking to end gun violence. 

Levi CEO Chip Bergh told Fast Company:

My daughter goes to school in San Francisco, and they practice lockdown drills more than they do earthquake drills.  That says something about our country. 

I really believe that 20 years from now, we’re going to look back and say this company was again on the right side of an important issue. I think it’s imperative that companies not be afraid to weigh in on the issues that are really impacting the world, whether that’s gun violence or climate change. If we stand on the sidelines, we’re not really fulfilling our full responsibility to the world.

Levi's would have a hard time figuring out how to not sell jeans to people who sell, or buy, guns, but tech companies can have significant impacts on people who do either.  Amazon may be bigger than Salesforce, but until it does something like saying Amazon Web Services (AWS) won't support companies that sell firearms, Salesforce has to take the prize for using software to do something to reduce gun violence. 

Credit: Chief Executive.net

I applaud Salesforce for this initiative, but to me it's not only about guns, or even about leveraging tech.  It's about corporations remembering that they are part of communities, and that the short and long-term health of those communities matter, even at some impact on revenues and profits.  It's about CEOs and other executives using their corporate roles to give back to the community, not just their philanthropic efforts.  Wall Street doesn't usually look kindly on those kinds of actions, but Main Street should.

Who more than healthcare organizations should be taking these kind of bold stands, in their own ways?

For example, I think about the churches buying up medical debt, as Kaiser Health News just reported, wiping out millions of dollars of such debt for thousands of people.  And I wonder about the healthcare organizations that are selling such debt, sending untold numbers of their patients to collections.  Where are the organizations, healthcare or other, who refuse to do business with ones that do? 

Let's do all we can to end gun violence.  Let's use tech to help accomplish that and other social goals.  But let's not stop at guns and let's not stop at tech.  Healthcare organizations and professionals should be not just be about delivering health care but also about using every means in their disposal to improve the lives of people in their communities, even if it means making some people mad. 

I don't know how successful Salesforce will be with their new policy, but I applaud them for it, and I am especially interested to see who will follow in their footsteps, and how.  I hope it's someone in healthcare.