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 U4K@UnifiedPotential.org.

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.    

Getting it.

Let me state a hard truth: if this is a far as you are going to read, you aren’t going to get it.  Which is really frustrating, if getting it turns out to be important.  Like vaccinations.  On the other hand, sometimes it doesn’t matter if you get it or not, it’s still going to work. Like vaccinations.  But you do have to go along, and that’s where things can start to get frustrating.  It took some three hundred years for people to start taking the germ theory of disease seriously.  For a few scientists, those must have been some frustrating times.  

Hard truth: if you can’t explain something in three bullet points or less, you are done.  Let me tell you another hard truth: those three bullet points are holding us back.  Big time.  And the reason is this: all three bullet points have to be common knowledge.  If any one of them is an unknown – or even worse: debatable – then it doesn’t matter if you have the cure for cancer, you are done.  Unless the cure is a vaccine, because everyone knows that will work. 

And that’s where the three bullet points go from holding us back to shooting us in the back.  As life gets complicated, it is just as easy to be led down a back alley with three bullet points.  And even when this little soirée is every bit of fun and excitement that you thought it could be, you might get a little more than you bargained for.  I hope you got your vaccinations, they might keep you from getting cancer.

Here are my three bullet points:

  • Connections are valuable.
  • Smartphones aren’t going away.
  • Smartphones make connections.

I tried to pluck out the most fundamental hard truths, the ones that are common knowledge, not debatable.  Even so, that second line is the one that my generation and older is going to try to debate.  But smartphones are a bit like teenage sex: it doesn’t matter how you think the world should be, some things are unstoppable.  Smartphones aren’t going away, and ironically appear to be reducing teenage sex.  Be careful what you wish for. 

Connections, in any form, are valuable.  They are a fundamental human need, right along with water, food, and shelter.  We could slip into a dim alley and discuss at length the different types of connections and the relative value of those connections, but let’s just leave it as a bullet point on which we should all be able to agree: connections are valuable. 

Smartphones make connections.  In fact, that is their power, it is what draws us to them, and it is why they are never going away, and why they are replacing teenage sex.  (The irony is never ending).  Over time, they may change forms, and the adoption of those changes will be personal (wearables like watches and <shudder> implants), but those changes will be driven by the ability to connect.

Right about now you should be asking WTF this has to do with anything. 

Where vaccines have saved us from unmeasurable human suffering, smartphones may save the free world from collapsing.  Go back, read it again, it’s not a misprint: smartphones may save the free world from collapsing.  In what I find to be par for the course of universal irony, our salvation may come from a device brought to life by a man who died of cancer, arguably because he did not understand the disease.

I think it’s time for three more bullet points:

  • In free society, we are going to pay all of the costs of everyone’s healthcare, no matter what.
  • As we develop new treatments for diseases, the cost of healthcare will continue to increase. 
  • When we run out of money, our society is going to collapse.

You can try and debate these things, but the end result is coming whether you get it or not.  It didn’t matter if the victims of the great plague understood the germ theory of disease, they died just the same.

I think this is a problem. 

Wanting to fix a problem and actually fixing a problem are two different things.  The bigger the problem, the more we are willing to keep trying things that clearly aren’t working.  That’s called desperation.  The people of Europe in the mid-1300s were desperate (the germ theory was not a big thing then).  Desperate times call for desperate measures, like blaming Jews.  Because that’s one of the things we like to do when things are going to shit, blame someone else.  And let’s not forget to capitalize on the shitty situation, we are good at that too, a sorta desperate version of the lemonade-out-of-lemons thing, except it’s more of a shit sandwich, and we all get to eat it.  Because it still doesn’t fix the problem.

If you think this is not a problem, well, that’s a problem.

The earlier you begin treating a disease, the better.  (Ask Steve Jobs).  This explains both my frustration and desperation.  If we are going to try something different, now is the time.  If we wait until the fighting starts, it’s too late.  If you time-travelled a team of trained healthcare providers with a world’s supply of antibiotics into Crimea as the first infected fleas jumped from the backs of the rats on which they had been napping, I doubt you would make a dent in the death toll to follow.  You’d probably be swept up in the blame and desperation, like nuts and corn in a gourmet shit sandwich.

Did you know that John Snow was one of the first to describe germ theory?  I guess he did know something…

The only solution to our problem is this: we have to find a way to make everyone healthier

One more clip of bullets:

  • The more resources you have, the healthier you tend to be.
  • Connections are valuable.
  • Connections are the one resource that can be distributed without a cost to society.

Unlike water, food, shelter, or more complex resources like education and transportation, connections can now be created and given away to anyone and everyone, free of charge, without cost to manufacture or deliver, without the side effects of shifting assets from one group to another.  It does not hurt your situation one bit for someone else to have all the connections they need and want.  In fact – because we are going to pay for all of the costs of everyone’s healthcare, no matter what – other people being connected is tremendously valuable to each of us, and that value is amplified across the entire population.  These are unique properties, because every other resource comes with both a cost to society and a finite supply; the more water you get, the more it costs me, and the less there is.  Furthermore, the healthier the network that we are all connected to, the more powerful the connections become for all of us. 

Connections may be the treatment for the disease of our society, and smartphones are a syringe.

In many ways, Facebook and Uber are analogous to blaming the Jews for the plague.  These are systems that masquerade as solutions but exist solely to capitalize on our needs, in this case, our need for connections.  It’s not even ironic that Mark Zuckerburg pledged to give away 99% of his wealth to end childhood disease, it’s offensive.  As if millions of people hadn’t already been devoting their lives to a similar goal, but all along they just lacked his money and resources.  If Facebook reshaped itself into a purpose-built, uncorrupted social network with the goal of allowing us to connect as we see fit, it would go further to improve the health of children (and the rest of us) than every charitable foundation on earth.  Or vaccines, for that matter.  But that would mean letting go of the money, and that’s just not going to happen, even if it all burns down around us.

Uber is a nothing more than a smartphone app.  It is a way to make a connection.  It is not an altruistic entity that intends to improve the health of society by facilitating better transportation.  It is smartphone app that makes a connection, and that connection is sold to us by a for-profit, investor-driven company that wants to squeeze as many dollars out of our pockets as it can so that the wall-street perception of its value continues to climb.

But here’s the catch: they can’t stop us from doing things differently, and we don’t need someone to cleverly manufacture our cure.  We can make it ourselves.

MoveUP is my way of proving this to you, and I am going to deliver this drug, even if I have to hold you down and inject it in your butt.  Thus far, I have made the mistake of trying to convert the people who are least likely to see the light: grownups.  My generation does not understand the power of the smartphone.  They understand the 100 billion dollar valuation of Uber, because that’s the world they grew up in, the one where new products cost money and make money, a world that turns to the tune of big business.  I appealed to industry, but industry exists for the profit, even when the product fights disease.  I appealed to the government, but the government feeds on blame and desperation.  And both industry and the government are run by grownups. 

And grownups don’t get it.  But young people get it.  Even better, they don’t even know how powerful they can be, and once they see what they are capable of when they connect, they will be unstoppable.  I don’t want their money, and I don’t want their vote, I just need them to get it, to connect them.  And then they will get it.  And it won’t matter if you don’t.

Goals for 2019

It’s time to look back at my 2018 goals, see how I did, and set a few for 2019.  Of paramount importance is looking where you want to go, but a glance in the rear-view mirror is a good thing to do, just don’t linger on the past.

  1. Communication system for the medical system. Status: ongoing.  Doctors are a fickle bunch, but the network is growing (still using the brilliant little communication app called Qlqisoft).  Furthermore, we have successfully bridged across different medical systems, and even into the community.  The larger the network becomes, the more powerful it is.  I am predicting even more engagement in 2019.
  2. Re-engineering the way cancer patients move through our system. Status: ongoing.  We successfully created our hub and navigation process, and now we are beginning to exploit the possibilities.  Our goals for 2019 include providing nurse navigation services to our colon cancer or other gastrointestinal cancer patients, a large group that historically has been difficult to corral; a bit like herding cats, actually.  We are also building a community-based survivorship program centered around the newly-created YMCA-LiveSTRONG program, and we have a few wild cards up our sleeve for this one.  Stay tuned.
  3. Establish a sustainable, annual, city-wide elementary school anti-smoking program. Status: one down, improvements on the way.  It was no mean feat to coordinating a small army of enthusiastic Liberty Public Health graduate and undergrad students to engage with 31 classes of 5th graders across the entire school system, but I just kinda kicked the ball into the field and let Shauntee, Anita and Cheryl run with it.  And run they did!  We made quick changes to account for vaping and a new evil: Juul.  This is probably the most egregious scourge to come out of the minds of creative venture capitalists since the payday loan or price gouging on pharmaceuticals, and for 2019 I intend to spread the word to all that will listen, and a few that won’t.  They have targeted our kids directly with the most addictive nicotine delivery system ever created (it’s patented!) and if you don’t know anything about it, you should ask yourself why (because they never intended to sell it to you).  There is a special place in hell…
  4. School system stuff. Status:  I didn’t do shit.  (Can’t do it all).
  5. Online training program for phlebotomy. Status:  hard copies done, online version being submitted as I type this.  This effectively enables high school grads to start a job in phlebotomy three months earlier and $3000 richer (and better trained, IMO).  That’s not a small thing, and I hope it becomes a discussion point for critically evaluating the cost of education, because we need some of that ($250,000 for college?  $400,000 to become a doctor?  WTF?)  It is also allowing college students interested in pursuing careers in healthcare to develop a valuable skill and gain invaluable experience while bolstering our available workforce.  I am going to count this one as a big win.
  6. Create an integrated electronic infrastructure for the city. Status: ongoing.  MoveUP is just the first phase of my nefarious plan to get you all to live together better, and you can’t stop me now!  Muwhuhahaha!
  7. Compete in the entire IMSA Prototype Challenge Series in 2018. Status: Nope.  I did get to race at Daytona, and that was pretty epic.  Unfortunately, I will always remember that race as the weekend before coming home to the literal destruction of my extended family, and I have struggled all year as I watched the inevitable come to fruition.  It almost destroyed me, and that’s not an exaggeration.  The only thing I was able to pull from the smoldering ruins was a guiding theory on human connections.  This new viewpoint helped me to recognize the paramount importance of those very same connections in my own life, such as the one between myself and my wife.  Connections I will never allow to be threatened again.  And I decided to keep the racecar, so it might be that Marty will ride again in 2019, albeit in a much more low-key manner better suited to my cooperative ideology.

Changes for 2019:  I took too much away from my family and myself, and that won’t do.  Denying yourself the things that make life worth living is counter-productive.  Family, fun, fitness, these will get more directed attention, and I encourage you to do the same.  If there is one guiding principle the millennials nailed, it’s that you only live once.  Just don’t use the acronym, it just encourages them, and we don’t need any more acronyms, IMHO.

Look where you want to go!

Figuring it out is all that matters.

We have to stop asking who is to blame, because it just doesn’t matter.

Over the last few days I watched as a young lady went into diabetic ketoacidosis – aka got sick as shit from uncontrolled diabetes – and then spent a few days in the medical ICU recovering.  Yes, I am a doctor, but I am more about cancer diagnostics and lab medicine than actual boots-on-the-ground care like this, so it wasn’t particularly fun to see.

The amazing part was how commonplace this was to everyone else, especially the providers.  Because it is commonplace.  She doesn’t have insurance, and getting glucose monitoring stuff and medicines and keeping it all together as a pretty twenty-something is a bit of a hassle, so when push comes to shove or a co-pay goes up or a meter breaks, one thing commonly leads to another.

And let’s face it, this is not my responsibility.  I have a wife and two daughters of my own, impeding holidays, college tuition to deal with, and car parts to buy.  This girl’s care is not on my balance sheet, and why should it be?

I hate to ball up your accounting report, because it sure as hell is on my balance sheet.  And yours too.  And the details don’t matter.  It doesn’t matter if she is lazy and worthless (she is not), uneducated and unmotivated (she is not), or even a drug addict or criminal (again, no and no).  It just doesn’t matter, because this year alone, you and I are looking at about a hundred thousand in medical bills that we are going to pay.

You might pay it buddy, but not me! you growl through gritted teeth, with an eye-roll for effect.

Like it or not, you sure as hell are.

BS: SHE has to pay! Not me!

Really?  Where is it going to come from?  And should we stick it to her?  Think about it for a minute.  Who out there is prepared to absorb 100k in medical bills?  And if we forced that burden on her, how well do you think her future care is going to go?  Because I think she will be right back in the ICU, and again, and again, until her kidneys fail and she is on dialysis and disability and then you and I are going to pay for EVERYTHING.

How about we just take care of her – help her take better care of herself – and get her back to life and work and play where she can be an active part of our community, instead of being a liability?  Even if you have your own mound of problems and you don’t really give a happy crap about others, it’s going to be a helluva lot cheaper.  So let’s try it this other way, and save some money, shall we?  Wouldn’t you rather invest a little time and money and have her making a paycheck and paying taxes and buying stuff instead of pouring Medicaid money into a giant hole?

We are all responsible for each other.  It doesn’t matter whether you like it or not, it’s the way it is.  So we have to build systems that enable us to help each other out, that connect us, that make life easier.  This all seems so completely unrelated to some transportation app, but these things have everything to do with one another.  If we don’t figure out how to manage the little bills like test strips and insulin for people with diabetes or transportation for people without cars, we are going to be on the hook for much larger bills like ICU visits or lifetimes without employment.

On Tuesday (provided some snow melts) I will be discussing MoveUP with City Council.  This is more than a transportation app, it is our city coming together to learn how to live cooperatively.  This is not about free stuff for some group of people or continuing to fund a service that isn’t working, it’s about building something that works for all of us.  December 11, 4:00 pm, Council Chambers.  Please come and add to the momentum.

Cultural Shift

Our culture has long been one based on competition, and that’s a hard core value to shake.  So every time I see evidence that someone else has beaten us to an idea or solution, I have to suppress the gut reaction that we are too late. Because in a competitive world, that’s a fail.  But in a cooperative world where the goal is finding solutions, other people’s solutions become our collaborative success.

We are trying to cure poverty, and it doesn’t matter who figures it out.  Just do it already.

It’s all about connections.  Joan Foster sent me a link to an article about some progressive ideas in DC, and that led me to start following the work of their Director of For-Hire Vehicles, Ernest Chrappah.  And he just posted their proposed revisions to code governing For-Hire vehicles.

Peruse those a bit, and I think you will come to the same conclusions I have:

  1. Managing the interaction of 6 million people is trickier than 100,000.
  2. We are going in the same direction.

Remember how difficult change is?  Well one of the problems we are facing as a society is that we continue to look to the big players for solutions, but it’s much harder to change the direction of a massive ship than it is a kayak.  The scope of the regulations proposed in DC is almost impossible to take in, with many more classes of vehicles and markets and populations and variables that will interact such that a change here may have unexpected consequences over there.

We make a better test site.

We are smaller, with less variables to deal with, faster moving, and better able to react to those inevitable unintentional consequences (yes, it’s OK to try something and see if it works, and if it doesn’t, try something different).

These changes are inevitable.

We are going in the same direction (in this case, a continued evolution of what defines a for-hire vehicle and how we manage cooperative transportation solutions in our society). Once this stuff starts, you won’t be able to hold it back.  When someone makes a change that works, everyone is going to go there.  When someone builds a system that works, everyone is going to want it.  Once we move to a place where we work cooperatively and we see how much better life can be, we will all go there, and we will never go back. And when we go cooperative, the faster anyone gets to the finish line, the faster we all get there.

This all just makes me excited to dive into some progressive proposed regulatory changes concerning for-hire vehicles!  And that is certainly a change.

Confidence in Chemistry

In my job, overconfidence doesn’t work out (just another of the many reasons I am not so good at racing).  So this may be the first time I have had this experience, one where I look around and just know what is going to happen.  It’s very similar to chemistry: molecules behave with absolute predictability.  And people are exactly the same.

So I end up trying to explain it – often – and lately I have spent more time pondering a new question: why do I seem to be the only one that gets it?  That part does make me uncomfortable, because there are a lot of really smart people out there, many of whom have had to listen to me prattle on, so this is like saying I am smarter than them.  And that shoots past overconfidence into arrogance.

There are two possibilities: I am wrong, and everyone else knows it; or it’s just really hard to get your hear around it, even for smart people.

Or, maybe we have all been trained to believe it’s just not possible.  That’s actually what I think is going on.

If I tell you I am going to give you something you want and need for no cost with strings attached, you will not believe me.  Somewhere, there is a catch.  People have been inventing clever ways to use that as bait for tens of thousands of years.  Whether these is advertising involved, it’s a trial period, you are being used as a guinea pig, or you will soon be addicted, there is always a catch.  We have all been jaded enough that we will never be fooled.  People just don’t do things if there is not something in it for them.  It may be a paycheck, a tax write-off, publicity, or just a chance to feel good, but true altruism is rare, and it is always on a limited scale, with some underlying benefit.

That part of human nature hasn’t changed, and I am not ignoring it.  On the contrary, unwillingness to accept the realities of how people are going to behave has been the failing of many benevolent causes.  Resources always have limits, and someone has to pay the cost.

But, two things have changed: one is embedded in the word need.  That’s absolutely critical: I am going to give you something you want and need, at no cost, and with no strings attached.  The need part is how I am going to benefit.  Because you are absolutely right: I am not doing this for nothing, I am doing this for tremendous personal benefit.  Because if this city expands its economy and reduces its poverty rate, I am going to benefit proportionally.  Exponentially, actually, because everything will get better as things get better.  And I have kids that will benefit, too.  So don’t be fooled into thinking I don’t see this all as an investment I will capitalize on, because I will.  Right now I am paying – we are all paying – for all of the bad things that happen to people who don’t get what they need.  I would like to stop doing that.  So instead, I am going to show you how we can give people what they want and need, at no cost, and with no strings attached.

And the second thing that has changed is the tools we have at our disposal.  It turns out that giving people what they want and need at no cost and with no strings attached is actually quite easy.

But wait!  You can’t just give people stuff, that never solves problems.  It just makes them dependent on the source, and someone has to pay!  This is all just another scam!  I knew it!

Ah, but I am not talking about widgets or money or even shelter or food or water.  With all of these things, that is very true.  But I am talking about connections.  Connections are like a magic commodity: there is no limit, they are extremely fulfilling and powerful, they are a critical functional, emotional, and physiologic need.  And they are free.  They don’t have to be manufactured, and both sides of the equation benefit.  The same rules don’t apply here, and that is why it’s so hard to accept.  This entire project goes against everything we have all learned and experienced throughout our entire collective lives.  But it is truly different.

If you have ever seen some crazy chemistry experiment where you mix things together just so (or drop a couple of mentos into a coke bottle) and something wild happens, then you know it’s not magic.  The rules of the universe are being followed with exacting precision, you just weren’t aware of some of those rules, so you didn’t predict the result.  The rules are never bent or broken.

Everyone wants to be connected.  Everyone needs connections.  We can now provide safe, effective, connections without cost, and without strings attached.  People want them, so they will take them.  People need them, so we need to provide them.  This doesn’t break any rules or make any false assumptions or expect things to happen in ways that just won’t happen.  On the contrary: if I truly give people something they want and need for no cost and with no strings attached, the one thing I can be absolutely sure of: they are going to take it.  And no amount of money or effort spent by someone else to try to bait them into something that looks similar but has hidden costs or strings will prevent that.

Overconfidence means you believe something will happen when there is still a good chance it will not.  Here, it’s no longer a matter of can it be done, it is that it can’t be stopped.