ACTN (Advanced Connected Transportation Network)

(ac-tin  /akten/ a family of multifunctional proteins found in contractile elements in muscle that are critical to the mobility of organisms).

This is the supporting document to the grant application I have submitted to the Virginia Department of Rail and Public Transit in the hopes of implementing MoveUP as a digital backbone to a comprehensive, collaborative transportation system for smaller cities and rural communities.

Introduction and Outline

Transportation is a fundamental component of community health, affecting every individual within the community and every component of life including employment, business development and success, education, nutrition, activity, and entertainment.  Transportation has been repeatedly sited as the most important need in community health needs assessments 1,2.  A lack of adequate transportation negatively impacts all aspects of individual health as a major social determinant of need 3.

Buses provide an efficient way to move people when applied in densely populated urban areas.  However, buses continuously demonstrate an inability to meet the needs of small cities and rural areas with a lower population density, where the lack of consistent ridership and a necessity of widely spaced stops negates their advantages.  Furthermore, there are essentially no transportation options in rural areas for people who do not have access to a car for whatever reason.

The automobile has advanced tremendously, and there are many untapped opportunities that could be applied to small cities and rural areas with the combined potential of providing effective personal mobility for all.  Persistence of antiquated models such as buses and taxicabs operating using telephones and taximeters has prevented the implementation and study of a comprehensive model that takes collective advantage of numerous and significant advances in this arena.  Digital platforms with enhanced connectivity; pure electric drivetrains with vastly lower service and use costs; semi-autonomous and impending full-autonomous capabilities for reduced incidence and insurance costs and enhanced fleet capabilities; shared ownership and shared use models; fleet unification for simplicity; assembling these new but currently available components into a cohesive and integrated system has the potential to transform life in more rural settings across the country. 

Application of these advances can be performed in a cost-effective and ultimately financially sustainable manner that will allow data collection on fleet needs such as vehicle number and miles travelled per person, power consumption and costs, insurance models, service requirements, and continued system improvements.  Applied properly, this could bring much needed and viable transportation solutions to unserved rural populations and result in the enhanced efficiency or progressive phase-out of expensive bus systems that only provide inefficient transportation to a small subset of the population that has no other options.

  1.  Enhanced connectivity: MoveUP
    1. Digital solution to connect riders to drivers in any setting.
    1. Accessible by everyone, even those who cannot use a smartphone.
    1. Allow creation of numerous flexible transportation systems that can be interconnected.
    1. Move people and resources (deliveries).
  2. Modernized Fleet
    1. Shift to all electric fleet.
      1. Reduced fuel costs (approximate 1/3).
      1. Reduced service costs (greatly simplified drivetrains)
    1. Semi-autonomous drive.
      1. Markedly reduced adverse incidents.
        1. Reduced insurance costs.
        1. Reduced repair costs.
    1. Development of autonomous drive.
      1. Achieving full-autonomous drive in a cost-effective manner will require industry and community cooperation.
      1. Will provide increased fleet mobility, capability, and safety.
      1. Will not replace drivers (autonomous cars cannot help you in and out of the car or help carry groceries into the house).
    1. Central charging and service center.
      1. Reduced operating costs via commercial vs. residential power rates ($0.08/KWH vs $0.12/KWH).
      1. Efficient use of solar energy through centralized application.
      1. Better ability to balance available grid power supply (centralized battery-based energy storage, ala Tesla PowerWall).
  3. Replacing the current model of vehicle ownership.
    1. Current vehicles sit idle for >95% of their usable life.
      1. Cost of a vehicle ownership is at least 5 times more expensive than needed.
        1. Cost of transportation is major component of cost of living.
        1. Reducing cost of living improves the lives of everyone in the community.
      1. Service costs persist due to material degradation with time regardless of mileage.
      1. Insurance models are based on continuous use.
    1. Shared vehicle ownership models (ala ZipCar).
      1. Pay only for what you use.
      1. Markedly reduced parking requirements for localities.
      1. Reduced living expenses through reduced parking requirements with housing.
    1. Shared vehicle use models (ala Uber, Lyft).
      1. Combined private and for-hire use.
      1. Reduce the costs of transportation for all, whether private or for-hire.


Most people have effective transportation options, but some do not.  We often focus on people who do not have enough money to own a car, but there are many reasons that a person may not have adequate transportation, and we need solutions for all of them.  If we only focus on helping those who for whatever reason are failing, we end up with a system that is unsustainable, because it is not designed for the majority of the people in the community.  A sustainable transportation model is one that is engineered to serve the needs of the entire community, not just a small segment.

Because the majority of people can own and operate cars and this is the most desirable option available to them, it is the most highly utilized system.  The reason the majority of people don’t use buses is simply that it is not an effective or attractive option.  If they don’t have to, they will find a more appealing way.  To create a sustainable and effective transportation network, it must be more attractive than the current standard (personal car ownership) to a large enough group of people that the system is self-sufficient.  That means that it must be convenient, effective, clean, safe and desirable.   This is your target customer base, and by building a sustainable system that is utilized preferentially by most in the community, you can then leverage this system to address the needs of those in the community that do not have adequate options.    

Buses have long been an effective method of mass transit, and in the right setting are efficient and useful. However, the effectiveness of buses declines proportionally with the population density.  A bus service is ineffective and inefficient in rural areas where people and assets are spread over a large area.  The bus service in Lynchburg Virginia is inadequate for use as a commuter or regular transportation system.  This is not the fault of the GLTC, it an inherent limitation in the type of service that buses provide within the service area. 

In all rural areas, buses are expensive to operate and do not provide the type of service needed.  In the Lynchburg area, they represent a significant financial burden that poorly assists a very small percentage of the population.  By creating a system that is both advantageous and attractive to everyone in the area using modern vehicles connected with modern technology, a more sustainable, effective, and usable system can created that can then be leverage to address transportation needs that are not being met.


1.  I thought this was about patient transportation?

If we want everyone to have transportation, then we have to engineer a system for everyone.  If we focus only on one issue – like patients getting to doctor’s appointments – we end up with a bunch of fragmented systems, none of which are robust.  If we build a single sustainable system that takes everyone into account – no matter who they are or what their needs – then we can use it to solve these individual problems that continue to elude us. 

2.  If you are trying to build a system for everyone, why are you suggesting we buy a small fleet of very expensive cars (Tesla Model X SUVs)?

At $90,000, the Tesla Model X appears to be a frivolous choice, but there are several factors that make this in an extremely valuable investment, particularly as a core component for a rural transportation system:

  • All electric drivetrain from the company with the most experience with all electric drive.  Electric is not only cheaper and cleaner to operate, it has much lower service costs and intervals, particularly in high mileage applications.
  • Tesla has reintroduced the unlimited supercharging option with the Model X, which means the cars can be charged for free for the lifetime of the vehicle.  The Model X has not been attractive to its current customer base, which is individuals (partly because it looks like an egg).  It is the perfect form factor for a city taxi.4,5

3.  There are other all-electric vehicles, such as the Chevy Bolt, and they are much cheaper. 

The Model X is a larger and more suited to a for-hire transport vehicle.  But the main differentiator is autonomous drive. 

  • Tesla has the most experience with autonomous drive.  Autonomous drive is going to be extremely valuable (an estimated 800 billion dollar annual industry).  The current Tesla models allow for a one-time charge of $7000 for a lifetime of autonomous drive.  Even more than unlimited charging, this will prove incredibly valuable in coming years (20 autonomous cars running 3 shifts each assuming a reasonable driver salary is easily 3 million dollars annually).  In addition, their current semi-autonomous drive when combined with excellent drivers will provide the most capable combination available today.6   
  • Tesla vehicles have the most robust software integration.  This will allow integration of innovative solutions like MoveUP directly into the operating system of the car.  For example, the car’s functions and features can be modified depending on whether it is being used as a private vehicle or a for-hire vehicle.
  • We can help Tesla achieve autonomous drive.   The biggest hurdle to fully-autonomous drive is enabling the car to perform properly in every conceivable scenario.  By implementing the vehicles in a smaller, more controlled environment such as the City of Lynchburg and fostering collaboration between the Tesla engineers and the city, we can address limitations (difficult intersections, fixed positional markers or other vehicle-environment communications, connected traffic signals, etc.) and achieve working autonomy for our community with solutions that can be applied in more complex environments.     

The submitted plan includes a shift to the Tesla Model Y in FY2022 when it becomes available.  It is less expensive ($60,000) though still more expensive than other options like the Bolt.  One hope is to have a core fleet from a single manufacturer to reduce service and maintenance costs.  However, we have the ability to go with another vender if that becomes the more logical choice when considering all of the variables.

4.  Still, these are fancy cars, I am not sure this makes sense.

In our current world, personal transportation is the preferred method of travel.  If we want to change that, it’s got to be attractive.  Tesla’s are trendy, especially the Model X with its “falcon” doors.  Particularly in these early stages, image will be extremely important.    

5.  In your budget, you are pretty much giving these cars away.  I don’t understand – if you charge more for the cars, you can make money. 

Remember that the goal is to solve a problem – transportation – not capitalize on a need.  Our bus system consumes at least 8 million dollars annually and does not solve our problems.  The goal of this project is to see if we can build a more effective system that is financially self-sufficient.  Because this is a prototype, we don’t have data on how to do this.  We don’t know how many vehicles will be used, how many miles, or how much it will really cost.  We haven’t created the ideal insurance product.

Because transportation is a need that is costing us tremendously, we should reward the ones that provide our solution: drivers.  One of the fundamental issues with current taxi drivers is that the pay is very low.  If we want quality drivers – safe, friendly, helpful – we will need to pay them for the important service they provide.  This is not about making money on a vehicle fleet, it is about providing a much needed service to our community.  Unified Potential is not intending to become a transportation company; we will simply provide the tools (vehicles, connectivity) that enable people to create new and effective systems, and then those systems can be implemented by others.  We aim to completely transform the image of the taxi.     

6.  What about insurance? 

Developing the insurance product is an incredibly important component of this demonstration project.  There is no truly effective insurance product that exists right now, primarily because thus far no system like this has been operational.  This project will generate the actuarial data to build the lowest cost insurance option that we can.  That will create a new market opportunity, and will also decrease the overall cost of everyone’s transportation.

For this project, we have budgeted standard commercial insurance, as that is the only available option at this time.  Using semi-autonomous drive and the best drivers, our target is a zero incidents.  If we can build a less expensive insurance product, we will reduce our expenses during the project, and we will also be able to apply that solution anywhere in the future. 

7.  What about safety?

Safety has been a concern from day one, and we are assembling every feature, including a few new ideas.  For example, we are not just implementing a comprehensive background check process, we are creating a collaborative database such other entities for which background checks are important can share this needed resource. 

We are implementing state of the art security within the vehicles, including high-definition in car cameras and continuous gps tracking with emergency connectivity and comprehensive data collection.  We will be able to effectively vet drivers and provide suitable vehicles for transportation of children, a critical unmet need. 

8.  I thought this was about an app, this “MoveUP” thing? 7,8

It is, and that may be the most powerful component of the system.  The goal of the DRPT for 2019 was to unify all transportation assets onto a single network.  We are going to do that, and we are going to demonstrate how powerful that is.  For example, we have user agreements with two important non-profits in Lynchburg: Park View Mission and Meals on Wheels.  These are two of twenty-eight different non-profits which deliver food and other goods to people in the city, and none of these entities works together.  By enabling each of them to build and manage their own transportation networks as they see fit – managing drivers and connecting them to riders or goods for delivery – they will begin using a shared resource that is stronger for each of them than their current fragmented individual networks.  All of these will now be working together, but without being asked to work together.  And that is just a small example, because the real power will come when all of the assets throughout the city are connected.  

9.  I just can’t get my head around the Tesla thing.  Why not use Chrysler plug-in hybrid mini-vans that cost $40,000?  We could wear out a fleet of Chryslers while figuring out the autonomous thing with one Tesla.

As the (satisfied) owner of a Chrysler plug-in hybrid, I am in a particularly good position to answer this.  Hybrids represent the absolute highest cost of service, as they have all of the complexity of an internal combustion engine combined with a battery and electric motor and the complex hybrid system that has to tie these 2 very different systems together.  Furthermore, the electric range is only 35 miles, after which the vehicle becomes essentially a minivan, and though it gets very good mileage, it is still burning gas at 25 mpg or less in the city.

We want to assemble all of the best components together into a cohesive system with maximum benefit.  The exciting thing about this project is that the end result appears to be science fiction and yet everything in this proposal exists today, and everything we do here can be applied anywhere else. 



About Unified Potential, Inc.

After twenty years as a practicing pathologist in Lynchburg VA, I am transitioning out of “regular” medicine to pursue what can only be described as a calling in search of collaborative solutions to age-old problems rooted in the way we live together.  The success of healthcare systems depends on the health of our communities, and yet providers have no tools with which to affect change in this most critical environment.  Transportation is a fundamental need.  The ultimate goal with this project is to demonstrate a new and more effective way to approach problems like transportation, and continue to apply successful techniques in a broadening array of interconnected solutions that improve the lives of everyone.  Furthermore, what started as one idealist has grown into a team of highly capable and similarly motivated people who share this common goal.

Old people (like me), the future, and the past.

Rounding Oak Tree in my RS4, my instructor in the passenger seat.

It’s not the same world I grew up in, and people don’t like change.

As we get older, we are naturally drawn to the things that shaped us into who we are.  As usual, cars become an example (C’mon…you had to see that coming…).  What drives the market for people who invest in cars is the desire of those buying them to relive the days of old.  Right now, everything with a manual transmission is being bought up by speculators like there are cases of EpiPens hidden in the trunk.  Personally, I think these investors are going to lose their shirts, because the next generation of wealthy buyers – the young people of today who will make their fortunes with smartphones and social media and apps – they don’t give a happy crap about driving a stick shift.  To be honest, most of them don’t care about driving at all.  It’s just not the same world I grew up in.  No, I don’t like these changes, but what I think doesn’t affect reality: this is the future, and I am getting old.

Which is why I traded my favorite car – my 2016 GT350, a total beast, possibly the best all-around sports car I have ever owned – for a Porsche Turbo.  Hell, I am not even a Porsche guy.  I have tried to like them, because they do make sense, but they just are not the car I lusted after as a 16 year old kid who thought I might get some attention from the girls if only I had a Ferrari.  But there is one Porsche in my past, and not just any Porsche, this Porsche: a 996 model 911 Turbo, metallic grey with black interior, tuned for the track.  And as I have been forced to embrace a future that I am not all that fond of but simply cannot ignore, I feel compelled to reach back and connect with special events from my past.  If nothing else, perhaps I can retain a little of what I consider to be me.

It’s November 2007, Virginia International Raceway, Audi Club.  I am there in my new, and very blue RS4, a car built to be a dual-duty practical family hauler and weekend track weapon. See the picture? I have a bunch like that.  But it’s my instructor and her car that will leave a smoldering imprint in my brain. I don’t have any pictures of her.

Now, I am going to make a disclaimer, because there are many ways in which the world has changed, and I am getting ready to wade into swirling rapids: I believe women and men are equal (except at Hockey in Letterkenny, but that’s splitting hairs).  In the world I grew up in – even in 2007 – you didn’t see a lot of women instructors at track days.  You still don’t, but that’s not because they aren’t equally good, so I am splitting hairs again.  But in my youth, if you put a woman in a non-traditional role – like a welder that also happened to be a dancer – it was considered attractive.  I have become uncomfortable at even talking about what I might consider attractive, as this realm has become a veritable minefield. 

By the way, Van Halen’s “Hot For Teacher” is now stuck in my head.  But only because it has an epic guitar solo, which is yet another thing from the past that has simply disappeared.  <I don’t feel tardy…>

I am terrible with names, but I remember hers.  That says something, but I sure as hell am not going to say it here.

Anyway, my instructor, she had a metallic grey 996 model 911 turbo.  Hers was a tuned X50, which in the Porsche world is “the one to have,” but it makes little difference here.  What matters is the memory: I remember going for a ride along with her in a slower run group.  I remember her very calm, very clinical demeanor, which was one of the things that made her an effective teacher.  I mean instructor.  Anyway, I remember her positioning the nose of her 911 inches from the rear bumper of unwitting students in her way, patiently waiting for the next straight so that they might ever so kindly get the f*#& out of the… well, give us a point-by.

And I remember rounding Oak Tree, the slowest turn on the track leading on to the longest straight, whereupon she apparently harnessed the warp drive from the Millennium Falcon and quite literally bent the time-space-continuum in my head.  I remember slower cars – hell, every car – being sucked into our vortex and unceremoniously spit out behind us if this epic machine had reached out to the horizon and literally dragged it inexorably towards us, stopping only at the absolute end of the straight, where we would again find ourselves gently rubbing the rear bumper of the next hapless wannabe in our way. 

And I remember giggling like a school girl. Or maybe it was hysterical laughter.  Or cackling.  I don’t know.  I am sure it wasn’t cool, but I couldn’t help myself, because day-em that car was fast!!! 

And you wanna know what?  It still is.  Or at least it still feels that way.  Because things have changed, and cars have changed, too.  Yes, they are faster, but they are also more advanced.  They have all of these computers and scientifically designed aero flaps and appendages and software and all of this stuff that lets anyone go extraordinary speeds, speeds that would have been unimaginable then, with little to no drama.  But not this thing.  It retains all of the drama of a car that rightfully earned the nickname “the widow-maker.” 

And it reminds me of a very special experience from my past.

And the more I have to embrace the future, the more I want to hold on to the past.  And like it or not, as much as none of us likes change, we simply can’t avoid the future anymore. 

Smartphones, social media, and apps.  These things are here to stay.  They have changed the way we interact, the way we are educated, the way we get our news, the way we do business, even the way we fight wars.  They have changed the way we live, and they are here to stay. 

My entire education was directed towards my career as a doctor, specifically as a pathologist: chemistry, medical school, residency, fellowship.  I have practiced in this traditional role for almost twenty years.  But the world has changed.  The challenges we face today are not the same as when I was in high school, in college, or medical school. They are not the same as when I was in residency, or even when I moved to Lynchburg and started working what was and is my first and only “real” job.

I am very much like the people of my generation: I don’t like a lot of what I see.  Though I use smartphones and social media and apps and am probably just as dependent on them as anyone else, I am not happy with the changes brought on by these things.  Like many of my peers, I have thought about ways we might limit their scope, to curb this surging tide of change.  But these things will not be held back.  And therein lies the problem: our dislike for change, our reluctance to accept the inevitable, it has put us in a position where we don’t have any idea what we are dealing with. 

The youth of today are our future leaders, but we – the old people like me – we are the ones currently in control.  And yet we have absolutely no idea what we are dealing with.  And that’s precisely why things aren’t going so well.  If you take a government run by people that know nothing of smartphones and social media and apps and whose only real goal is to stay in office, and combine that with industry leaders who know nothing of smartphones or social media or apps – or worse: ones who do, but whose only real goal is to make money; well, you can just look around to see the results: electronic medical record systems that cost hundreds of millions of dollars but make things worse, not better.  Or Facebook.  Or Uber.

Which means we have no choice but to face the future, to embrace it, to learn everything we can about smartphones and social media and apps, and see if we might not be able to use these things to our collective advantage.  And that means that just as the world is changing, we – and again I am speaking to the old people like me – we have no choice but to change with it.  It’s not the same world that we grew up in, and we don’t like change, but it’s time we let go of the past and do our real jobs and help lead the way into the future.

Still, I think I’ll hold onto one or two things from the past, a few things that are sentimental.  Pardon me while I will grab my original copy of 1984 and feed it into the CD player of a tuned Porsche Turbo… I have some thinking to do.                                                   

Moving the Needle

A very important two day meeting just finished.  I have been to a lot of meetings over the past three years, but this one is going to stand out for a long time.  Five senior executives from a very big company – a multi-billion dollar industry leader – came to our city to begin the step-by-step process of assisting us in becoming the healthiest city in the world. That’s a lot to get your head around, but that is not why I will remember it.  I will remember it as the meeting that allowed me to explain – finally – how  a silly little app will change the world.  (There I go sounding crazy again…)

The meeting itself was irritatingly similar to all of the ones before it; we are all keenly aware of the problems.  If I had a nickel for every time I have heard the word “silo,” MoveUP would be fully funded.  (Actually, we could probably finish the coding for less than what it cost to send these guys here for two days.   But it was super cool, so I’ll just let that go).  It’s not identifying the problems that is the problem, it’s doing something about them that remains the ultimate problem.  And the biggest problem: some things are never going to change.  Like gravity.  And human nature.

And the inability to get companies to work together. 

Or people, for that matter.  Especially at the top.  There are reasons why companies – why people – operate in silos.  You cannot change that.  So stop trying. 

There was much talk about buy-in, about getting the influential people in the city to come together to make this happen.  But that’s not a difficult task, it’s impossible.  It is the core reason why everyone keeps talking, and nothing is getting done.  We can all see what the world might be like if we would all just get along, so we close our eyes and hold our breath.  And when we open our eyes, the world is exactly the same as it was before.

And that is precisely why it appears this little app has melted the cheese right off my cracker: we don’t need them.  In fact, it’s quite the opposite: they can’t stop us.  Which is important, because they will try.  No matter how beneficial something is, there are people that will not buy-in, and there are some that will try to stop it, if nothing else, because it’s not theirs.  That’s human nature, and you can’t change that. 

About midday on the first day, Laura Bauer and Ashley Steinweg of Park View Community Mission came to explain what their group does and what this all might mean both to their organization and to the city (this is one of our most important non-profits).  They were in negotiations with Uber in an attempt to better serve the community.  I showed them how MoveUP works, how they can use it to do everything they want to do, but on their terms, and for free.  They don’t have to sign a contract, they don’t have to adapt to someone else’s model, they just do what they do, only more and better.

And they don’t need anyone’s buy-in. 

So just like that, they ended their talks with Uber.  And that’s how a little app is going to change the world.  Because it’s not trying to get us to do something we are never going to do.  It’s just going to let us do what we are already doing, but more and better.  With MoveUP, there are no losers, we all benefit.  And it doesn’t matter if our leaders buy-in.  They don’t even have to understand.  And there is nothing anyone can do to stop us.          

Road Trip!

I bet you never thought small aftermarket auto parts companies could be critical to community health, but give me a bit to circle back around on this one.  I am going to ramble in parallel with the road trip I am on as I head to Houston, Texas, stopping a bit to visit with some good friends and family.  This is the final journey for my beloved Shelby GT350, and I will miss her dearly.  She has helped me through some tough times.  Everyone is different, but I am not only one that finds burnouts to be medicinal.

Work can be stressful, but nothing can punch holes in your soul like family drama.  There are two drugs I used in 2018 when I was keen on zipping up the squirrel suit and jumping off the ledge: repeated viewing of Deadpool (which is all about cancer survivorship) and the YouTube/MotorTrend show Roadkill.

I am not a diehard drag racer as the RK guys are, but they live by the tenets of donuts and burnouts, and some days, a burnout is just what the doctor ordered (or needs, depending on your perspective).

This is a problem for Audi people like me, as the whole quattro/all-wheel-drive thing sorta dampens the fun. 

Enter the GT350, which is so about wheelspin it is genuinely frightening.  Except the axle hop.  It’s a real buzzkill when you tromp the gas and the whole ass-end of the car starts bouncing up and down like one of those vibrating beds.  And that’s where small aftermarket auto parts folks enter into the mental health arena: it seems there is a need for fixin’ the flaws inherent in the Mustang’s rear geometry.  It’s good to know I am not alone.  With the solid rear toe-links, the GT spools up the rear tires so smoothly that only the buried tach needle and screaming V8 – and billowing smoke – alert you to the violence.  It’s truly cathartic. 

Unfortunately, every drug’s potency wanes.  So, it’s time to get a new drug.

And one of my other favorite drugs is the road trip.  It is why the car represents freedom: throw in some supplies, fire it up, crank some tunes, and the horizon becomes your destination. 

As I churn away the miles, I have a habit of ruminating on some inherent issues in our society that are well and truly idiotic.  Like police speed traps.  Perhaps these held some value in the past, but they have evolved into a pointless waste of money and resources.  Before you think I just arrogantly believe my own driving skills are well beyond average (guilty as charged), go through the logic, and don’t forget that good driving is far more about attention than skill: I am travelling in a car that is capable of going deep into the braking zone on the back straight at VIR at over 150, so 85 mph on an arrow-straight, deserted road is as sedate as a cruising Blackwater Creek Trail on a beach cruiser.  And yet this criminal activity would provoke a mandatory reckless driving charge in Virginia, a first-class misdemeanor with a sentence that can be as long as a year in jail.  Seriously? 

Do speed traps make us safer?  Being impaired or distracted are the real risks, not speed.  And most who are impaired or distracted actually driver slower (which is all the more frustrating).  So no, speed traps don’t make us safer.  What they do make is money, and that money is desperately needed by police, who – like teachers – are totally under-appreciated and under-paid.  Follow the money: we raise tax money to pay police, we buy them expensive but functional, purpose-built vehicles, and then we have them drive out and park on the roadways with exotic speed-detection gear in stealthy spots to nab any would-be criminal that drifts above some ambiguous threshold.  And we are paying money for all of this, while the officers are unable to do any other work that might actually be effective.  I am going to assume that someone has done the accounting to be sure the whole process ends up in the black, but I can’t help but think that we are spinning our wheels.

Has anyone ever thought about exempting public K-12 school teachers and police from federal income tax?  None of them make shit, so how much could it really cost us?  In the stroke of a pen, these would be two of the most desired jobs in the country.

I have another idea: why not develop a crowd-sourced app that lets us alert police when there is genuine Tom-foolery (similar to Waze), to make a real dent in distracted driving, since it is genuinely dangerous and thoroughly annoying? 

Which brings me back to Apple and Google and Waze… (which, ironically is kinda Google too) and their frustrating inability to play nice in the sandbox with anyone that they can’t buy outright (and that’s how Google got Waze).  These are now the three top navigation apps, subtracting out the 3% of people who are still using the proprietary nav systems that came with their cars.  You see, navigation is good for all of us, and it doesn’t do me any harm if you are able to get where you want to go, pronto.  In fact, it’s better for all of us if all of us can do just that.   But we just don’t do anything these days unless we can make money on it, so we are all left with this battle of the juggernauts. 

Do you understand how much better it would be for all of us if we were all on the same network?  Like ten times better.  OK, I am exaggerating: if it’s 3 equally utilized networks, it would really be nine times better (3 squared, or nine times).  When I am done with MoveUP, which will put everything on one network and you will see how much better it is, I’ll revisit this.

While driving, I did my first bit of podcast listening (I typically listen to hair metal and sing… horribly).  Ironically, I went through a fascinating one on NPR about the Liberty City – a tiny town in Texas that performed its own experiment in Libertarianism.  Summing up, a fairly visionary citizen recognized that they would probably be annexed by nearby San Antonio, so he rallied the people and they formed the city of Von Ormy.  He then set out to eliminate virtually all taxes.  In my view, they ultimately uncovered the reality of extremes of belief: Libertarians want zero government, but society requires some collective works.  Like sewers.  And you can’t get something for nothing, so with zero money, you get exactly the same amount of progress.  In the end, Von Ormy found a source of revenue without resorting to taxes: speeding tickets.

Sorry, but that whole idea was a kick in Karma’s knackers, and the fact that it didn’t work out as planned makes me feel a bit warm and fuzzy… (read about it here).  

I did wholly relate to Von Ormy’s most basic ideology: we are better off to do this ourselves than to be annexed by the big city and become beholden to their whims.

As I stewed on all of this and bounced along the thoroughly horrid roads in Louisiana, I casually and unknowingly drifted upward into the realms of revenue generation (I am sorry, officer, but 10 over is just crap, no matter how poor your state is, or how reprehensibly below the poverty-line your yearly salary may be).  At least an online “driving safety” course – which generates even more revenue – will keep said offense from my insurance or DMV records.  It’s all about safety…

And then to Houston, to drop the Shelby off and meet my new mistress. 
If you want to own what no doubt will be an incredibly valuable car after I save the world and become an icon (it’s just as likely as your winning the Powerball), it will be right here for the taking. But it won’t last long after THE movie comes out and regular folks have a better understanding of the impact of Carrol Shelby. Where the Mustang was all about purging frustrations from one’s innards through the creation of two equally wide black lines on the pavement, this new chapter is about revisiting a different kind of debauchery that teases me from my past: warp drive.

Imagine my surprise when I discovered that – despite all-wheel-drive – she, too, will do burnouts.

Murica IS the best :) !!!

I do like to be right.  Maybe I haven’t convinced you that we can push aside a multi-billion dollar company with a $250,000 piece of software and some cooperation, but I’ll  take it where I can get it: ‘Murica makes the best sports cars.  Period.  Having recently bought a Ferrari, I can prove it. 

A bit ago, I picked up a twenty one year old 355 F1 berlinetta, my third example of this model, making my car ownership look much like the marriage history of a corporate executive or pro team owner.  I know my way around these beauties, I know their temperament, their needs, their quirks.  I think I can make her happy, and that will make me happy.  And maybe a little money, as I am betting they are at the bottom of their depreciation curve, another similarity to the next Ms. Ex-Wife-To-Be.

I have said it before (here) and I will say it again: there is something magical about Ferrari, about the way they look, the way they sound, the way they feel.  But as sure as God’s car has a normally aspirated V12, they are not for everyone. 

Sports cars are meant to be enjoyed.  But what good is that if only a few can enjoy them?  Or if that enjoyment is limited to a smug feeling of superiority because the thing is pretty much useless and actually driving it is both impractical and financially crippling?

I started writing this in a house in the mountains outside Blowing Rock, North Carolina, situated on the side of a cliff on a winding gravel road in some seriously rugged country, and I didn’t leave anything behind.  I brought my mountain bike and all of the needed gear, my clothes for a week in any weather, my stuff to swim – and not the hot tub, mind; goggles and fins and paddles and shit so I can do my best Michael Phelps impression.  Laptop and stuff for work (because you can never truly unplug anymore), all my gear for a day at the track (because – fingers crossed – I am getting back in the race car next weekend), food for an army, and even my daughter’s violin, all crammed in the back of the best sports car I have owned and possibly the best ever made: my ’16 Mustang. 

Yes, that’s a complete mountain bike and all my shit in the trunk.

I do want to take a second a send a message to everyone at Apple: bite me.  When you created something that people really rely on, working code into the latest operating system of my old iPhone such that it no longer considers Ford to have paid enough royalties to you to keep your stock on the up and up such that it will out-of-the-blue stop allowing the phone to charge via the USB port while using it as a sole source of both navigation and the actual address of my destination, well that’s just beyond unacceptable.  My next phone will be an Android, so you know where you can stuff your lightning cable, and why don’t you cram in a couple of those stupid headphone adapters while you are getting busy.

I have to admit, the GT350 is a very special Mustang (and technically is a “Shelby” but I think we can all get past the branding at this point).  The motor is well and truly a race motor for the street, every bit as special as the stuff Porsche puts into its track-focused models, and just about everything else significant is bespoke to the model: transmission, suspension, brakes, even bodywork.  But the entire car costs less brand new than the typical options list on a Ferrari.  More importantly, it remains a Mustang at its core, and that is precisely why it is so special.

Sweet cheese and crackers does it sound good

Once again, I am assuming any petrol-head reader has a somewhat slack jaw right now, trying to put together this dizzying logic: the GT350 is special because it has all of these go-fast bits that work in synergy to make it one of the most exciting drives I have had the opportunity to enjoy, and yet it is the Mustang part of it – the inexpensive, corner-cutting for production costs, inadequate performance due to the realities of life – that makes it well and truly special.  What the what…?

Here is the thing: what good is fun if you can’t have it?

A bit of history on the GT350:  Somewhere about 2012 (give or take) the true car nuts at Ford had a plan: win the 24 hours of le Mans in 2016.  Why?  Because that’s exactly 50 years after Ford showed Ferrari how we do things across the pond. (We 84REN66).  This was no small feat then (see the upcoming Movie Ford v Ferrari…. November 15) and it’s no small feat today.  So they set to building a GT race car – one that must be built on a road car – from the Mustang.  At least two full years they labored, and faster and faster it became, until they finally threw in the towel: a front-engined, 2+2 coupe was not going to be able to reliably fight a plethora of purpose-built race machines with decades of development in their genome.  So Ford scrapped that plan and went a different way.  And from that after-birth I give you the 2016 le Mans winning Ford GT. 

The GT350 is quite literally, a failure.  And yet it is everything that Ford developed during that intense period, and that everything is quite literally some serious shit.  The motor, the aero, the chassis; it is epic.  But the best thing about it: it’s a Mustang.    

From inception, the Mustang was about bringing a little fun to the people.  No, you can’t bring the type exquisite craftsmanship and attention to detail that characterisze objects of desire at the pinnacle of man’s capabilities (Aston Martin, Ferrari).  In fact, the word “exquisite” shouldn’t be allowed anywhere in the promotional flyer.  But that doesn’t make the goal any less important.  Everyone deserves a little fun. 

And it doesn’t have to be exquisite to be fun; it doesn’t have to be the best. Think on this: I can (kinda) do a back flip off a dock.  Who cares that the judges at the Olympics would be looking for fractions and negative numbers, or just vomiting in their mouths a bit.  It’s no less fun for me.  If you can’t enjoy stuff that’s a bit more basic, maybe you need to relax your sphincter a smidge.

Back to that Ferrari – MY Ferrari – it is over 20 years old.  The Mustang is 3.  They now have pretty close to the same mileage on them.  If you are good at maths, the Ferrari has it’s work cut out for it in the fun-per-unit-time competition.   

The last maintenance bill on the Ferrari is just a bit below the trade-in value of the Mustang. I am not making that up, I have all the records.  When I saw it, when I held it in my trembling, unbelieving hand, I threw up in my own mouth a bit.  Ferrari people demand records of everything that happens to their cars, and how much it cost.  Why would you want to keep a memento of being robbed?  I planned from the beginning to do all the work on this car myself, so I am somewhat insulated from these intrusions.  But that’s not everyone’s cup of tea, and it didn’t take long before I got to take a big swig of my own brew: I heard a funny noise.  That’s never good…

Not everyone wants to be beholden to a small network of specialized shops that require open access to a home equity line to keep their car running properly.  Nor do they find joy in having a car in varying states of disrepair for literally months on end while they go after what is likely a bad bearing in the transmission (fingers crossed). 

Fast forward some additional time and the transmission is in Houston being rebuilt.  Eventually it will be shipped back and a few more 6-packs will see it re-installed.  It will likely be spring.  No worries, I chose this path, and I knew what the scenery would look like.  In the meantime, the Shelby is pushing up against 30,000 miles and had another $160 service.  And it still drives and feels and sounds just as epic.

Power to the people: the ‘Murican beast is simply the better car, providing the absolute most fun per unit time of any car I have owned, all wrapped in a functional package that is accessible to just about anyone who really loves cars.   

I am going to miss it…Because I am getting ready to drive it to Houston – where the ill-fated transmission is languishing – and exchange it for another chapter in this ongoing story.   Another time McClure…

Risky Business

Man has always been at his best when he is goofing off.  A friend snapped this picture of me coming back from the grocery store today.  (Dude, eyes on the road, please!)  This is the contraption I mentioned in my last ramble, and I think it is one of the coolest inventions in years.  It’s called a One Wheel, and the technology to make this work easily exceeds what was needed to go for a stroll on the surface of the moon.  It’s a hoot! 

It’s also kinda risky.  I am not the most coordinated chap to walk about, and when you add balance and uneven concrete to the mix, my skeleton is probably running on borrowed time.  Many would say this is too risky – maybe even irresponsible – considering I have a family to support with a job that needs doing.  I say that’s hogwash: one of our societal problems is that we have become way too risk averse. 

It’s no wonder we can’t get anything done: we are terrified of trying something new, of stepping into the unknown.  You can’t buy a bar of soap without being made to feel guilty at the counter for refusing the extended service plan; how dare you gamble your hard earned dollars and the cleanliness of your family’s nether regions to the quality control systems at one of Unilever’s foreign manufacturing plants!

I think a lot of it comes from our quality of life.  I used to wonder how anyone could possibly be compelled to crawl into the hold of some leaky (and thoroughly untested) wooden boat and risk their lives crossing an ocean they weren’t completely sure had an actual shoreline on the other side.  It was probably a bit easier when life had exactly zero guarantees and was quite literally a continuous, painful, disease-ridden struggle.  At that point, the concept that everyone should be given a shot at the pursuit of happiness had not been spelled out, much less our current mindset that happiness is a universal right, its interruption or absence a clear indication that there is someone to blame. 

There’s one thing we have really honed to an art: blaming others.  You can make a good living at it. 

But I refuse to dwell on that.  Instead, let’s think about the slow shift in our mindset from our early quest for speed.  I remember an exhibit at the Deutsches Museum in Munich where some idiots had strapped a dozen or so rockets straight out of Wile E Coyote’s storage closet to a sled.  I don’t remember whatever record or speed they achieved, but it had to be epic to make it into the world’s oldest museum of technology.  Crazy?  Yes.  Progress?  Also yes. 

You will see more of this mindset if you go to see the upcoming movie Ford v Ferrari (LeMans ’66 if you are one of the two or three people that happen to read this outside the US of A).  I have been anticipating this flick since blasting through A. J. Baime’s Go Like Hell, which should be required reading for all Americans or anyone aspiring to citizenship.  This insanely dangerous era in motor racing represents the turning point in society from a time in which death in recreational activities was pretty much par for the course (though we had certainly moved on from the Roman Coliseum) to one in which significant risk in any leisure activity is largely unacceptable and requires signing numerous waivers that don’t actually protect the instigators of whatever Tom F-ery you want to get into.  In today’s world of umbrella policies and safety mandates, I am a bit surprised that “adrenaline junky” hasn’t been given an ICD10 diagnostic code that qualifies as a legitimate disability.      

And now we are paralyzed at the thought of trying anything new.  Which is, in yet another fit of incredible irony, killing us.  We kinda need to try new stuff. 

Like this super-cool electric skateboard.  Yes, it’s wobbly at first, but it quickly becomes so intuitive that you have to constantly remind yourself that you are riding a contraption with all of the safety features of a magic carpet, except magic carpets are from an era of wanton death and destruction and thus have exactly zero safety features, and might even try to kill you deliberately.  Pay attention, because an unseen hole or a loose electrical connection can send you ass-over-tea-kettle into the weeds.  Or traffic.      

And that is part of the fun.

People look at my Zebra-liveried race car and think it is ridiculously dangerous.  After this movie comes out, that sentiment will be supercharged.  Believe it or not, I bought the car because of its safety.  My prior race car was an 800 pound formula car from 1978 that is quite literally a coffin on wheels.  Open wheels, mind, that will jettison the thing into the air should they come in contact with other open wheels on some other race car.  And a roll bar better suited to mounting a GoPro than protecting the driver. 

The Elan wraps the driver in an FIA-spec carbon tub that might not be a bad place to hide in a tornado.  The motor makes (exactly) the same power as a tuned Miata, keeping the top speed and resulting kinetic energy to much more reasonable values than the sports cars of today, many of which are pushing 600 or even 700 horsepower. 

But for sure the risk is well above zero.  And that makes it real.  As opposed to iRacing, which I absolutely love for the mind-blowing reality that it simulates.  But where iRacing allows a safe place to learn new techniques and hone skills and work towards some level of comfort in challenging and complex scenarios, it will always be lacking the critical ingredient that draws one in like a moth to a flame: risk. 

Maybe if we all took a few more chances in our spare time we wouldn’t find it so impossibly scary to take a chance or two at work.  Why not green-light some project that looks promising on paper, even though you can’t point a finger at a competitor who has successfully implemented it?  What’s the worst that could happen?  And don’t just flip a switch and close your eyes; take ownership, adapt to uneven ground, and look where you want to go.  It’s not like anyone is asking you to zip up a squirrel suit and jump off a skyscraper.  So put on a proverbial helmet, strap on some proverbial wrist guards, and make that proverbial electric skateboard your bitch.

Nothing ventured, nothing gained.  And we got a lot of gaining to do!       

Letter on Vaping to Governor Ralph Northam

Governor Northam,

I am genuinely sorry to bother you, as I know you are extremely busy with this governing thing (I do not envy you there).  Unfortunately, I promised my friend here In Lynchburg, VA that I would write you, and she happens to be a pediatrician.  You know how they are: always wanting to save the world, especially when there’s kids involved. 

I will try to be quick (but I usually fail at it): this vaping thing? There’s a lot of yelling back and forth and all kinds of data and money being thrown around so much that it’s hard to figure out what the truth is.  Plus, this is all new to our generation, so you almost have to ask kids what’s going on, and it’s not like youngsters are big into prospective, randomized clinical trials.  Personally, I think all of the arguing is just a big distraction.  Is it safe?  Should it be legal?  Should it be taxed?  On and on.  Who cares?  The most important fact is written (by law) right on the side of the box: nicotine is addictive.  Period.

Who cares if it’s safe?  The whole reason anyone goes to the trouble to make this stuff is because it’s addictive, and they know the kids that get started using it will keep using it for rest of their lives.  We saw this with cigarettes, and that was when everyone knew they were terrible for you.  Because kids don’t understand future consequences, which is exactly why the industry markets this stuff to kids in the first place (although no one is going to actually admit it…)

And some of these people making these vapes are really smart.  I don’t know how much you know about this company Juul, but they are some clever bastards, I tell you.  They captured 70% of the tobacco market in like 9 months, before anyone even knew what was happening.  Doesn’t that make you wonder?  I mean, they say they made this thing to help people quit smoking.  We’re both doctors; don’t you think it’s odd that they never talked to us about it?  And how did they do all that without putting ads on TV and in magazines, things that smokers would see?  Our little city of 85,000 has seventeen vape shops.  Seventeen

And good luck stopping them through legislation.  The law never stopped kids from starting smoking, and that was before the internet.  That’s how those Juul folks got it done so fast: they marketed straight to kids on social media, knowing they could easily get around any regulations and have it delivered.  They even made it look like one of these new computer gadgets, so you and I wouldn’t even know what it was.  Real clever bastards, I tell you. 

So now we have all these teens addicted.  I hope they were genuine about finding ways to get people off nicotine, because we are going to need it.

This is a new threat in a smoldering battle that has been going on as long as I have been in practice. As the director of our lung cancer program, I am well past tired of seeing people die from a disease that largely wouldn’t exist were it not for smoking.  Most adults who smoke would rather not smoke, but that is addiction.  People compare this to alcohol, but they are not the same at all.  I know recovering alcoholics.  I have seen people – young and old – die because of alcohol.  But most of the adults I know drink socially, and virtually all are not addicted to alcohol.  I don’t know anyone who uses nicotine that is not addicted.  None.  That is the difference.

So what do we do?  I suggest that we look at what we did in the past that worked, (which arguably wasn’t enough, but it’s all we have).   And don’t pour money into something doesn’t work just because it feels good, because we don’t have much extra.

First, don’t be fooled: all of these things should be lumped together.  Vaping is just the direction this industry wants to go so they can expand on markets that have been contracting.  It doesn’t matter that it is safe, it remains incredibly addictive.  If we treat one product one way and one product another, it just opens a door that becomes a cultural floodgate.  No teacher can tell what is in vapor, nor can I.  When I see a cloud of smoke coming out a car window that looks like someone is heading to a casting call for a reboot of Cheech and Chong, I don’t care who says it’s safe, I don’t want to be breathing that crap.  And I shouldn’t have to: I have a right to clean air, and so do our kids.  This stuff should not be in public places, and all vaping should be lumped in with smoking as far as community health is concerned.

Next: hold them to their claims: if this is about saving all the current smokers, then act like it.  Much of it should be coming from doctor’s offices or smoking cessation programs. What is sold over-the-counter should be sold in pharmacies, which would not be an inconvenience to any existing user.  Vape shops are not about quitting smoking.  If that’s what vaping is about, there is no need for the shops.   

And finally, educate.  Unfortunately, the folks we really need to educate are kids – young kids.  This stuff starts in middle school, and that’s why in Lynchburg we are starting with 5th graders.  Last year, we began a program in our city schools that was patterned after an anti-smoking program put out by the American Academy of Family Physicians called Tar Wars, but since this whole issue is changing, we are changing too.  We have now taken to calling it VaporLies.  We built it to be sustainable and to connect with every fifth grader across the city.  We enlist the help of local college and graduate students and train them to connect with these kids in hopes of delivering a message that they are already hearing, but in a way that may be more effective (the young preceptors are more like peers than their teachers or some grumpy old doctor).  Some good news: it’s cheap.  Really cheap.  That makes it good value for dollar.  But the best news: any town can do this.  This is a program that every school system across the state could emulate, this year.  Let’s work together to perfect it, to streamline it, and get the word out to all our kids. 

Those kids: every single one of them is our collective responsibility, like it or not.  The downstream repercussions of addiction – whatever they turn out to be – will someday fall in our laps.  And I don’t want to go through this all over again.      


John M. Salmon IV, MD

Pathology Consultants of Central Virginia

Physician Liaison to the Commission on Cancer, Alan B. Pearson Regional Cancer Center

Director, Thoracic Cancer Program, Centra Health, Lynchburg, Virginia

Founder, Unified Potential, Inc.     


Unified4Kids is a cooperative community support program for kids with cancer, and the best thing about it is how it is going to enable everyone to make a meaningful impact in what has to be the most unjust disease process in the known universe.

We don’t treat kids with cancer in Lynchburg, because we don’t have pediatric oncology here. That means every kid with cancer in our town has to go out of town for treatment. And that’s by definition a pain in the ass. It means travelling. And needing a place to stay. And missing out on life at home.

It also means it’s hard for the providers here in town to help. We generally don’t have any idea what is going on. If one of these kids gets sick and has to come to the ER, we have no records, no connection to the people directing the care.

We are going to change that.

It also means that any support system for these kids and their families is also located at a remote site.

So we are going to change that too.

The program is split into two arms: treatment and support. On the treatment side, we have a very simple but extremely effective communication system (QliqSOFT) that will enable us to connect those distant providers and the local docs, as well as nurses and pharmacy and everyone else involved, and parents and other caregivers, too. We will be able to make important records and lab results and treatment specifics readily available to all, and be able to quickly and effectively discuss issues. We will also be able to send providers to the kids, as opposed to having them come to the hospital or an office, keeping them at school or activity or home. We will be able to let them just be kids as much as possible.

On the support side, our assets are already tremendous, and they are growing daily. Our town has no shortage of talent and capability; it’s all about getting the right stuff to the right people, and every kid and every family is different. Whether it is help at home (HumanKind), school (tutoring support by VES), mind (Wyndhurst Counseling), spirit (Interfaith Outreach), we can connect families to the help they need. The YMCA, American National Bank, Flint Construction, on and on. I am using MoveUP to build a cooperative transportation system for kids (you had to see that coming…).

It’s a full-court press.

This entire program – in fact the concept itself – is made possible by Mustaches4Kids, which raises money for local children’s programs. It is about the money, and yet its not the money. I know, as usual, I am confusing you. But as usual, life is complicated…

Look at the ability to provide mobile care. It is unheard of, simply because insurance won’t pay for it. So even if it’s $75 and the treatment plan is $30,000 a month, we “can’t” send a phlebotomist to a patient’s house. Well, no more of that nonsense, because M4K is breaking down those barriers. There will be no cost to patients for any of this. And then we will be able to show that this is actually better in every way. Beyond being better for the patient and family, it will lead to better outcomes, and lower costs. It’s a win-win-win.

Last week, the American Cancer Society endorsed U4K. It’s hard to explain the significance of that, and in fact I am still trying to get my head around it. But for sure it means we cannot fail – we will not fail. But I am not worried, because cooperatively, there is nothing we can’t do.

Do get more information or to enroll, send a email to

Electric skateboards, social media, and the future of human society

What could these possibly have in common?  Quite unexpectedly, consent.    

Confused?  Me too.  For sure, I didn’t see this coming.  I have had plenty of crazy ideas, chance interactions, and eerie coincidences, but who would have thought the missing element would be something so simple and yet so frustratingly complex as consent.

Last Monday night, a friend showed our “man night” group the 2018 documentary Three Identical Strangers (which says more than a little about our group; it’s OK, I am proud to be a nerd).  This is the true story of identical boys who were separated at birth and adopted by three different families, only to discover each other’s existence some nineteen years later.  What unfolds is the fact that they were just one set of twins that were part of a well-orchestrated medical study seeking answers about the fundamental debate on nature vs. nurture.  Though that discussion is intellectually compelling, I tend to lump it in with discussions about the nature of the universe: realistically pointless.  I say that because I am much more interested in issues that you can actually do something about, and these are not those.  If it’s all nature, does that mean we lock up kids whose parents break the law because it’s in their DNA?  If there is no God, does that mean it’s OK to be an asshat?

The much more actionable debate is the one about consent, because whether you know it or not, it is fundamental to what is currently going wrong with our world.  And we may be able to actually do something about it. 

The ethical issues relating to this twin study parallel those demonstrated in Rebecca Skloot’s The Immortal Life of Henrietta Lacks.  Both of these stories follow societal changes in medical ethics, and most significantly, changes in our definition of consent.  In the 1950s and 60s, this wasn’t even a topic of discussion.  In medicine today, the term consent isn’t even sufficient: it is informed consent.  And that’s where things take a hard turn.

Sixty years ago, scientists were just as thirsty for knowledge as they are today, and the need to expand our understanding of things like human disease was used to justify being, perhaps, a bit less than forthcoming with potential research subsects.  Just as no one told Henrietta Lacks that they were going to clone the cells of her cervical cancer, no one told the families adopting these babies that they were involved in a twin study.  They didn’t even tell them the kids had siblings.  Look, if we tell them we are studying them, it will muck up the data.  So let’s just not tell them, mmmK?  It’s all for the greater good. 

But it wasn’t all for the greater good.  Studies can be poorly designed so they won’t teach us anything of value, or extremely dangerous and expose people to unnecessary harm.  The ethical principles of medical research were more formally defined in The National Research Act of 1974, which created the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research.  The guiding tenants include respect for persons and specifically vulnerable populations like children or the incarcerated; and beneficence, which expands upon that protection and requires weighing risks against the potential benefits to society.

There is also another important factor with exponentially increasing influence: money.  Just as Cyndi Lauper said, money changes everything.  

Today, any study on human subjects of any kind in the US should be reviewed by an institutional review board.  The role of an IRB is to determine whether the design of a study meets our current ethical principles.  That review includes careful evaluation of informed consent.    

It’s not enough to design a safe and important study, your subjects have to agree to participate.  And to agree, they have to completely understand what they are agreeing to, every possible risk, every possible benefit, all of it.  The burden is on the researchers to explain it to them and to be sure they understand.  It’s not enough to just have them sign some form, you have to have someone trained in obtaining informed consent go through the documentation.  They have to be able to say no without any adverse consequences, and they have to be able to opt out at any time.

And it can’t be about money.  Not even a little.

But it doesn’t stop there, because there is something so inherently obvious in any research experiment that we often forget about it: no one knows what is going to happen.  (Uh, that’s the point, eh?)  So, another job of the IRB is to monitor for unintended consequences, and mandate changes to the protocol or even cancel the study all together if unforeseen adverse outcomes cannot be mitigated.

This is an article about a Harvard study that went a bit sideways.  The researchers used de-identified social data from Facebook.  The study was IRB approved.  They were careful in the design – this was not some nefarious plot – but they ran into unintended consequences: when research assistants downloaded the information they realized that it was possible to piece together who some of the people were, simply because the data itself contained information which could re-identify them (they were in these classes and did these activities and ate at these places, etc.).  So now information that was intended to be anonymous was very much not anonymous.  Oops. 

Turns out, these are really difficult studies to do, because the technology and the way we interact with it is changing so rapidly that neither researchers nor IRBs can keep up. 

And here’s the real kicker: anyone reading this droning blog is already participating in a variety of similar, ongoing research studies.  And not one of these studies would pass the most lax IRB on earth for about a half a dozen reasons.  Because they aren’t being called research.  And they never get to an IRB.

And they are all about money. 

Google.  Apple.  Facebook.  Siri.  Alexa.  Exactly where is your data going?  Why does my iPhone know I am going to trivia at the Yellow Sub on Wednesday?   How did maps know to fill in the exact street this morning when I punched 2-4-0 into the search window without entering a single letter?  Why after a discussion of drones one night at a friend’s house did my wife’s Facebook page begin showing ads for drones – that night?

This is medical research on human subjects.  These experiments are associated with very real risk, and not just to privacy: emotional, financial, even physical risk.  And the only people the designers are talking to about this risk are people with a vested interest in the outcomes.  And lawyers.  Lawyers who also have a vested interest in the outcome, which is a whole different level of wrong.  And these experiments are all about money, which is a fundamental no-no.

Yes, you checked a box, and you “accepted” the risks.  Or did you?   Did someone explain those risks?  Did an external third party assure that every remote possibility was adequately described in a language that you understand?  Remember, ethics mandates that the onus is on them to do their due diligence as researchers when they invite you to participate. 

But that’s the rub, isn’t it?  It’s not medical research, it’s business.  And business ethics are governed by one set of rules: whatever you can get away with.  Just look at Juul.

The following Thursday, I had the incredible privilege of meeting with a team of some of the smartest people I have ever been exposed to, kinda the nerd equivalent of a backstage pass.  As he often does when I get to ranting, Mark Zuckerberg came up.  The point made was that when it all started, no one, not even Zuckerberg, knew what Facebook would become.  Like the iPhone itself, it was impossible to predict the individual or societal impact.  Facebook today was likened to a country – a virtual nation – which is now a nation without a government.

Unintended consequences. 

Social networks are here to stay.  Smartphones are here to stay.  And no one can predict how all of this is going to shake out.  But one thing is imperative: we need to at least try to do it right.  Which, in the case of Facebook, would mandate the removal of money from the equation. Let me know how that idea goes at the next shareholder meeting.

When I go on about a purpose-built social network, this is what I mean.  Your data really is yours, and more and more, that data can be used to help you live better.  And since we now all have a vested interest in the success or failure of everyone else, we need to think about how we might empower people to both use their data effectively, and keep it safe.

And you have to obtain informed consent. 

Which means that individuals control their data. All of it. Not just a few things like social security numbers or credit card info, every single bit and byte. Because no one has any idea when it is all going to go sideways.

Here is an interesting tidbit I have learned while getting informed consent from patients for medical research: if you try to take something from someone, they almost always say no.  But if you ask, and what you are doing might help advance mankind (even just a little), they almost always say yes.  You will get more and better data if you just ask.  But you have to be genuine, both in the way you ask and in what you are doing.

The standard practice today is to try to take.  We need to change that to one in which we ask.  Only then will we be able to actually achieve the things we are trying to do, the things we need to do.  Like help people be successful in life, to be happier in life, to be healthier in life.  It’s such a subtle difference, but sometimes the devil is actually in the details. 

Wait a minute – what about the electric skateboard?  That’s what I came here for.  I thought there would be videos of people falling off electric skateboards…

So I got this One Wheel, and who would have predicted this thing would be so useful?  Probably not the guys who built it, who were really looking to emulate snowboarding.  This thing primarily appeals to kids who are very used to falling off of things and getting hurt and posting videos of people falling off of things and getting hurt.  Of course, the thing came with a dozen warnings and pesky little lawyer-written terms and use agreements jammed in various places in the box. The risks of falling off and getting hurt are more than obvious.

And then the thing turns out to be useful.  And old people like me start using them.  Old people who aren’t used to falling off things and getting hurt and would rather not fall off anything or get hurt, and sure don’t want to be in any online video doing any such thing.

Those included warnings? They give you information about how the thing works and what not to do.  No one can fault them for that.  But there isn’t anything about what might happen if the battery or some controller fails, at which point the thing apparently suddenly stops and does what the kids online call a “nosedive”.  Which often results in you falling off and getting hurt.

Unintended consequences. 

And this is business, not research.  So the lawyers and those with a vested interest aren’t going to inform the participants anything about how this might occasionally go a little sideways (or suddenly stop dead, as the case may be).  Because that would be bad for business.  And the plan would probably be OK were the thing not so damn useful.  Because those kids are used to falling off and getting hurt.  No one predicted that old people might end up in the mix.  And I have a feeling that is going to go about like it did when three genetically identical brothers stumbled into each other.

MoveUP, Cycling, and Mental Health

What do a cooperative transportation app, riding a bike, and mental health have to do with each other?  Actually quite a lot.  How would your mental health be if you couldn’t get where you need to go?  What do you do on a bad day to clear your head?  Is there any aspect of health more important than mental health?

MoveUP started as a way to improve patient transportation, but it didn’t take long to realize that all transportation is important.  Though there are plenty of grant-funded or volunteer-driven systems for getting people to a doctor’s appointment, there isn’t much to help people just get to where they want or need to go.  And that’s too bad.  Because there is a lot more to life – a lot more to health – than going to the doctor.  MoveUP is going to be a huge asset for our mental health, allowing everyone more options for getting around, whether it’s some important appointment or just something fun.  There aren’t near as many grant-funded or volunteer-driven systems to help you get to something that’s nothing but fun, and that’s a shame.  Because without a little fun, life’s not a lot of fun. 

Cycling has long been a way for me to clear my head; it’s good for my mental health.  Of course, that’s just me.  The thing about stuff that clears your head is that it depends on the head.  What’s good for me may not be your cup of tea.  But we all have that thing – exercise, reading, knitting – whatever.  And no matter who you are, your physical self is directly tied to your mental self. 

People with chronic illness have a much higher rate of mental illness, and vice versa.  It’s hard to be happy if your back is killing you.  If you can’t do the things that make life fun, it’s pretty tough to stay chipper.  And if you are suffering from major depression, all of the joy of life and the drive to do anything is sucked away.

The problem with our focus on delivery of care as a solution to our healthcare issues is that healthcare is much more about community health than delivery of care (I know, you have heard that from me once or twice).  And that means that reliable, effective transportation to the things that help you clear your head is actually more important than treatment of mental illness.  Don’t get me wrong: excellent care for people in need is priceless.  But the ideal is that more of us find less need for that care. 

And that may just mean a bit more fun is the best prescription.