The End of Professional Snobbery

By Neil Seeman

Imagine if no prestige attached to professions. Nobody cared about old-world credentials…MD, PhD, JD, MBA, MPH, MHSc: the letters would mean nothing, zip, in this alternate world.

It’s not so far off. Welcome to 2015, the year the Facebook generation is married with kids. This is when Mark Zuckerberg, 24-year-old billionaire, Facebook founder and Harvard dropout, turns 30.

The era of post-professional snobbery will be a very agonizing time…for boomer-generation grandparents. How will they boast about their over-educated children’s accomplishments as quantifiably as they can today? For the rest of society, it will mean a boon to human creativity.

The End of “Perfect Outputs”

In one of the most downloaded videos on the Web – Sir Ken Robinson explains, to roaring applause at a TED conference, how our educational system kills creativity in young people. Our system, he says, is geared to producing one “perfect output”: the university professor. Robinson blames the post-industrial age educational model for vaporizing creativity from children, promoting a culture where test-taking ability, rather than intellectual agility and ingenuity, reigns.

Young people under 30 – the Google Generation, the Facebook Generation, whatever title you fancy – really are different. They care more about social good, and less about status. This is not an original hypothesis. Leading thinkers on innovation - Gary Hamel, Don Tapscott and Jeff Jarvis – have written books on this. What has been less explored is what this means for healthcare.

In the era when newspapers drove the climate of public opinion – about two years ago – OpEds on healthcare were written by PhDs and MDs. Nowadays patient-experts write many of the most popular blogs (with clinically accurate content). Google controls health-seeking behaviour, with at least 70% of all searches on healthcare information originating from the Google search box.

When MDs and PhDs carry less prestige…

Today, the only job titles that earn real respect at cocktail parties are “social entrepreneur” and “artist” (though I admit I attract a fair deal of intrigue when I tell people that I’ve taken up boxing). Why does this matter for healthcare? Why does it matter for governments?

As Gary Hamel has trenchantly written, “Thanks to Enron, WorldCom, Adelphia, FEMA, Lehman Brothers, AIG, Fannie Mae, et al, the generation now joining the workforce has an extraordinarily jaundiced view of authority. They are deeply (and often rightly) suspicious of large organizations and those who run them. In their view, it’s not titles and credentials that make a leader worth following, but mission, self-sacrifice and world-class competence.”

Line management in both the delivery and organization of healthcare will need to get flatter. This means wider scopes of practice – for all members of the care team, which includes patients and their families. Further, CEOs will need to learn how to admit their mistakes. This is the signature virtue of the Facebook generation: humility. I always laugh when people tell me that social networks such as Facebook and MySpace and micro-blogging tools like Twitter show that the “younger generation” is self-centered. In fact, the average age of a user on Linkedin is 41; Linkedin is the fourth-most popular social networking site on the World Wide Web, with 40 million users. People under 30 demonstrate both humility and ego in equal measure. These are not mutually exclusive personality characteristics.

They can chest-thump like the rest of us (witness the scores of Facebook pages boasting about winning beer-chugging contests). But they can also confess to being wrong. Mark Zuckerberg, Facebook’s CEO, did exactly this when he responded to a storm of user protest and removed Beacon, a Facebook application. Zuckerberg famously wrote on his blog in December 2007:

“About a month ago, we released a new feature called Beacon to try to help people share information with their friends about things they do on the web. We've made a lot of mistakes building this feature, but we've made even more with how we've handled them. We simply did a bad job with this release, and I apologize for it. While I am disappointed with our mistakes, we appreciate all the feedback we have received from our users. I'd like to discuss what we have learned and how we have improved Beacon.”

…we will start to measure innovation and good governance differently

Today, we measure “innovation” through reference to numbers of publications, the impact factor of journals, academic citations, numbers of degrees after one’s name, and other proxies of knowledge translation. But if ingenuity and agility are what matters – we are currently preparing our children for jobs that may not exist as we know them. The US Department of Labor predicts that the average learner will have 10-14 jobs by the time they are 38. Niche licensing, already commonplace in healthcare, will intensify. At the same time, there simply won’t be enough people with the requisite prescribed credentials (e.g. health records, information management, and health information technology) to satisfy the HR managers.

And so we will need to recruit very differently. Memo to management: drop the “fast-track executive model”; reward the curiosity-seekers, even if they fall flat-footed on their first, second, or third time round. Beware job applicants who have had perfectly linear career paths.

What is more, we may need to measure innovation capacity in the workplace differently, especially in healthcare (where the jobs will be) by qualities such as tolerance for failure; willingness to admit mistakes; and, most crucially, ability to learn from those mistakes.

Few will ever accuse Facebook’s Mark Zuckerberg of modesty, but his apologia for his Beacon debacle is emblematic of the new age. Imagine if a hospital admitted in a CEO’s blog that its big-budget technology implementation failed miserably? And then have the CEO tell her clients how she had learned from her mistake? That is good governance, Facebook-style.

About the Author

Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell at Massey College, University of Toronto.

Bottom-Up vs. Top-Down Innovation – and Hot Air.

Neil Seeman

“Hot Air” by Marjorie Priceman is a delightful children’s book about the first hot-air balloon – invented by brothers Joseph-Michel and Jacques-Étienne Montgolfier. In September, 1783 their Aerostat Réveillon reached 1,500 feet, its passengers being a sheep, a duck and a rooster. The Montgolfiers thought that smoke propelled the balloon. Years later it was discovered that hot air rises because it weighs less than cool air.

More than two centuries later, the debate over the source of innovation rages on: Does change come from daring researchers (the Montgolfiers)? From the throngs of people who cheer on the invention and send forth news of the sensation (in this case, to Paris)? Or from the monarch (it was King Louis XVI in 1783) who champions the invention?

Health policy wonks – especially those interested in the transformative power of health information technology (HIT) – are fixated on whether innovation comes from the “bottom up” (the patient/consumer) or the “top down” (government or the hospital).

Author Vijay Vaitheeswaran describes the bottom-up/top-down debate in the Economist Magazine’s current special report on health care and technology. Denmark is perhaps most cited as the showpiece for top-down HIT innovation, with almost all Danes having regular access to an electronic health tool to manage their appointments, track medications, and to ensure they don’t take the wrong kind of medication, too much medication or drugs that should not be used simultaneously.

So here’s one top-down formula for the successful adoption of HIT: Mandate common security standards, data-sharing protocols, and consistent interpretations of privacy law.

On the other side of the debate, many “health 2.0” or “peer-to-peer” enthusiasts tend to believe in bottom-up innovation: Give patients the tools (e.g., their complete online medical records), and the doctors and hospital CEOs and government leaders will step into line. I used to believe this. I now understand things are a bit more complex.

Too much focus on the bottom-up/top-down debate misses the real goal: making sick patients healthier faster, or managing and preventing illness altogether. This may happen bottom-up, top-down, or, more often than not in my opinion, by combination or accident. In many cases (as with the hot air balloon) we don’t really know why for years to come.

The management and health policy communities tend to ignore the reality of the happy accident. We are trapped in a cognitive bias: we think that if quality or outcomes improve within any organization, this must be by dint of “process improvement” or because of a charismatic leader who “just got things done.” From the hot air balloon to Twitter to Viagra, history abounds with accident as the seat of innovation. Perhaps the most we can do is make the ground fertile for more accidents to happen: hire lots of smart, diverse people willing every so often to bonk senior management on the head to experiment.

I don’t pretend to know the answer to why innovation and adoption of HIT takes off more quickly in some jurisdictions than in others. I am skeptical of those who think they know the answer to this very difficult question, given the deep socio-cultural differences among neighborhoods in the very same city, much less among countries or continents.

But I do say this: all the energy the academy, consulting firms, large companies and governments spend on debating this question could be channeled into something more productive: curiosity-seeking, idea-generation and free-form debate among patients and providers and others working in the system. Consider parking 15 percent of your organization’s time into tinkering with how to improve healthcare for everyone.

Sometimes a competitor will steal your idea. (Some claim that the hot air balloon was invented some 74 years earlier by the Portuguese priest Bartolomeu de Gusmão.) Sometimes a monarch or government official will take all the credit. Never mind. If just once we soar high, then it will all have been worth it.

Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell, based at Massey College at the University of Toronto. neil.seeman@utoronto.ca

AMA, BMJ, and the Innovator’s Transparency Rule

By Neil Seeman

As of the time of writing, we do not know all of the facts in the current controversy surrounding the Journal of the American Medical Association (JAMA). Reportedly, JAMA editors threatened a researcher, Jonathan Leo, who had criticized the author of a 2008 JAMA research paper. Dr. Leo’s rebuke appeared in an online letter in the British Medical Journal (BMJ).

The American Medical Association has asked an oversight committee to investigate the events. Dr. Leo, a neuro-anatomy professor at Lincoln Memorial University, alleges that senior JAMA editors threatened him and his dean following his publication of the BMJ letter. Dr. Leo’s BMJ letter criticized how results were reported in the 2008 JAMA study that looked at the use of Lexapro, an anti-depressant medication, in stroke victims. Dr. Leo claimed that JAMA did not appropriately disclose the author of the JAMA study’s financial relationship with Forest Laboratories Inc., the maker of Lexapro. Forest disclosed that it had indeed paid the author for speeches, but maintained that his Lexapro research was independent.

According to Dr. Leo, based in Harrogate, Tennessee, JAMA editors insisted that Leo retract the BMJ letter. Further, in an explosive allegation, he reportedly claims JAMA’s executive deputy editor, Phil Fontanarosa, told him, “You are banned from JAMA for life. You will be sorry.” Dr. Fontanarosa has disputed this version of events. Ray Stowers, the dean of Dr. Leo’s faculty, claims JAMA editor-in-chief Catherine DeAngelis told Stowers during a telephone conversation that she would “ruin the reputation of our medical school” unless Stowers forced Leo to retract the BMJ letter and stop speaking to the media. Dr. DeAngelis has denied this.

Further, in an online editorial on the JAMA Web site, Drs. DeAngelis and Fontanarosa accused Dr. Leo of a “serious ethical breach of confidentiality” by wading into alleged problems with the JAMA study whilst the medical journal was investigating the controversy. The JAMA editors said that, in future, anyone complaining of an author failing to report a conflict of interest would “be specifically informed that he/she should not reveal this information to third parties or the media while an investigation is under way.” Here is Dr. Leo's response to the JAMA editorial.

Is the JAMA policy even possible to enforce? Does it serve the interests of innovation and the scientific process? Leaving aside the potential worries about free expression (both for the critic making the allegation, and for the journal publishing it), keep in mind that in the age of health 2.0, most critics of scientific research are not academics. They are patients and their families. In the days since this story emerged, my quick search on Google and online health blogs suggests that at least several dozen bloggers have echoed Dr. Leo’s concerns about conflict-of-interest in the original JAMA article. It can get tricky to try to discipline every research critic on the Web.

The time when editors knew best is passé. Whether or not the army of reader/critics on the Web is right or wrong, they cannot, and will not, be silenced. Transparency governs.

Ignore criticism at your peril

The JAMA controversy reminds me of another industry that failed to heed the transparency rule. When I worked in the newspaper business in the pre-Internet era, we had space for roughly 10 letters, yet 10-15 times that number flowed in by fax or letter every day.

Today, print newspapers are suffering heavy revenue declines (and in some cities, have disappeared altogether) because of not taking criticism and openness seriously. The venerable Rocky Mountain News is defunct. The Tribune Co., owner of the Los Angeles Times and the Chicago Tribune, has filed for bankruptcy. The Seattle Post-Intelligencer is now online only. And just two weeks ago, the San Diego Union-Tribune was sold to a private-equity firm.

Notably, mainstream newspapers such as the Wall Street Journal that were among the first to embrace aggressive reader criticism via blogs, early amid the ascendance of the Internet, are the only ones today that enjoy sustained readership and continued influence. For anyone in the information business, the new mantra is no longer “content is king”. It’s “transparency rules.”

The demise of mainstream newspapers should be a lesson to the titans of research and innovation. Heed the transparency rule: embrace openness or wither on the knowledge vine.

-----------------------------

Neil Seeman, a Longwoods essayist, is Director and Primary Investigator of the Health Strategy Innovation Cell, based at the University of Toronto’s Massey College. He is also an adjunct professor of health services management at Ryerson University and writes the “Second Opinion” health innovation column for the National Post. neil.seeman@utoronto.ca

Privacy has lost its “cool factor”…

Neil Seeman

According to the Talmud, there are two times you’re allowed to boast: when courting a potential spouse, or when looking for a job. In the current recession, many people are searching for a job, and so put their best résumé forward for everyone to see. Scanning the world of healthcare résumés posted freely on social networks such as Linkedin reveals a trend: privacy is out, “publicness” is hot.

As of the time of writing, Linkedin – the leading business professionals’ network online – included the résumés of 653 people working in the “hospital and healthcare sector” who described themselves as privacy professionals. More than twice as many (1,559) described themselves as patient advocates. The largest professionals’ discussion forum dealing with privacy had 867 members; the largest “health 2.0” discussion forum (of which there are many) had 4,888.

A limitation on my analysis: by definition, the very people who use Linkedin to look for employment or to connect with other professionals in their field – 35 million registered users and growing – are people who believe in what author Jeff Jarvis calls “publicness”.

Web 2.0 means social collaboration on the Web. Most “health 2.0” enthusiasts embrace “publicness.” “Publicness” is the new ethic of transparency in all things. Social networking sites such as Facebook, Linkedin, Twitter and MySpace trade off people’s growing willingness to disclose details about their personal lives, accomplishments…and their failures. Twitter, the fastest-growing Web phenomenon, is completely open source. Every entry is searchable on Google.

Contrary to popular myth, the ethic of publicness is much less about vanity than about a fundamental belief that “letting it all hang out” is a value system to be admired. This is part generational (so-called “Generation G”) and partly a function of our loss of faith in Wall Street and its culture of opaqueness. Even Swiss bankers are embracing publicness. Healthcare is not far behind. As the Wall Street Journal’s L. Gordon Crovitz has written, “a right to privacy seems to be transforming into a duty to disclose. We can know more, so we expect to know more.”

…it’s about control

Health 2.0 websites such as patientslikeme – which boasts a heavy contingent of Canadian users – allow members to share treatment and symptom information in real-time in order to monitor and to learn from real-world outcomes. As of March 2009, there were reportedly more than 11,000 users with multiple sclerosis, 8,000 with mood disorders, 3,500 with amyotrophic lateral sclerosis, 3,000 with Parkinson’s disease, and 2,000 users of the site with HIV.

As Jarvis writes in What Would Google Do?, “Privacy is not the issue. Control is. We need control of our personal information, whether it is made public and to whom, and how it is used.” Patients who “let it all hang out” on patientslikeme – name, age, location, symptoms – care more about controlling how their information gets used than about whether fellow sufferers can access it.

The same is true for job-seekers. In the old world, the perfect candidate for the CEO’s office – or for the entry-level position – was someone with an unblemished past. Today, the perfect candidate is someone who has disclosed his or her past missteps online. The superstar healthcare employees of today still boast about their accomplishments, but also about how they have learned from failure and humility.

Neil Seeman is Director and Primary Investigator of the Health Strategy Innovation Cell, based at Massey College at the University of Toronto.

Is the PHR Just a Tool for the Wealthy and Healthy?

Neil Seeman

Is the PHR like the "executive physical"? Some have suggested that personal health records (PHRs) - a system whereby patients enjoy custodial rights to their secure health data anytime, anywhere - is a privilege that appeals just to the wealthy, healthy or "worried well."

Where's the Evidence? From what I can tell, there is very little substance to this argument in the current peerreviewed literature. Yet I have heard it from those unimpressed by travelling PHR corporate merchants. One often-cited study, by Weingart and colleagues (2006), found that "younger, healthier patients are most likely to make use of this technology." But that study looked at one portal, PatientSite, used at a Boston teaching hospital (Beth Israel Deaconess) and affiliated community practices. It had a small sample size, and the authors acknowledged that "results may not be generalizable to other portals or health care systems, practices, or patients." Most important: patients were eligible to enrol in PatientSite only if one of their physicians had enrolled, and recruitment efforts had focused on primary care doctors. The Weingart study, important as it was, looked at data from 2000-2004; consumer behaviour, especially among those suffering from chronic illness, has changed since then. And the new model of the PHR is available to anyone, anywhere, whether or not his or her physician is enrolled. A Tool for the Rich? The notion that only the wealthy will benefit from PHRs can be easily dismissed; the same argument was made against the telephone, the television and the toaster, yet all these innovations are now taken for granted by the middle class and all but the very poorest among us. PHRs through Google or Microsoft HealthVault are free to anyone, and at least 75% of Canadians have Web access from home. I predict (although it is hazardous to make predictions in healthcare) that in five years, the percentage of Canadian homes without regular PHR engagement will be lower than 2% (about the same proportion of homes without a television). Just as Wikipedia re-invented the encyclopaedia and the Web decimated newspaper ad revenues, the ubiquitous PHR will re-invent our relationship with the health system. Keep in mind that Facebook, now the third-most popular website in Canada, was in its infancy five years ago; change occurs rapidly in the world of Web-based consumer engagement. In a recent paper in Healthcare Quarterly, Kevin Leonard and colleagues (2008) make the analogy to automated teller machines (ATMs). Most of us can remember a time when there were no ATMs, when all transactions required long teller queues. And now, as former US House Speaker Newt Gingrich once pointed out at an OHA keynote address, who among us - be honest - has not fidgeted while waiting in a two-minute ATM line? Banking expectations have radically changed, for the rich and poor alike. Just for the Healthy? Let us deal more seriously with another argument: the idea that the PHR - as proselytized by Google Health, Microsoft HealthVault, Revolution Health and more than 200 smaller competitors - is a gimmick so that the already healthy can maintain their health. After all, PHRs do not keep people away from emergency rooms or from acute care when they're really sick. We heard this argument against Health Savings Accounts (HSAs). The two arguments, however (and the supporting data), are different. HSAs, according to their most partisan defenders, reconnect the patient and the provider with the true cost of care. And patients thereby start to make wiser decisions - or so the argument goes. We gain insights like: "Whoa, we have increased our use of generic medications, we should shop around for the best deals." Or, "Maybe an MRI costs a little bit more at this hospital versus that hospital." And so, according to this theory, we start to use the health system more strategically, perhaps through a high-deductible, catastrophic plan, the deductible being a cash account that accrues interest-free. Yet the HSA is hardly a panacea. If crafted unwisely, it potentially creates more burden for providers and payers, and can lead to increased spending on wealthy consumers to the detriment of the poor. Although this is a very different issue from that of PHRs, it is instructive. In the case of the PHR, there is every reason to assume that the highestintensity users of PHRs will be those suffering from chronic disease - a swath of society that transcends socio-economic class. Research has shown that chronic disease communities thrive exceptionally well on social networking sites. Remarkably, these communities, on sites such as Facebook and MySpace, are more active than celebrity or sports communities (Seeman 2008a). Bottom line: the healthy (and their providers) go to Google for generic health information; the poor, the rich, the middle class - those with chronic disease - seek out, on a daily basis, more niche-oriented Web communities, like diabetesmine.com. The same phenomenon will occur with the PHR. My own more recent research has shown that the "stickiest" health-related blogs cater to niche, chronic illness populations (Seeman 2008b). The users, chronic illness sufferers, will serve as free ambassadors and champions for tools like Microsoft HealthVault and other PHR platforms, building their own specialized add-on applications, which will then position them to blog about their own PHR experience. A Whatcom County, Washington, consortium that developed a PHR as part of a Robert Wood Johnson Foundation project implemented in 2002 found that chronically ill patients became a kind of PHR sales force, enlisting friends and family to join (Sprague, Lisa. 2006). There is no reason (other than anti-corporate animus) to suggest that poor people have a lesser understanding of their chronic health conditions than do the wealthy or middle class, or that they have a harder time communicating their issues to a PHR. (PHRs can offer multi-lingual, real-time translation, though admittedly, the technology needs to improve.) Conversely, the people most likely to flock to PHRs are historically underserved and stigmatized populations who now make greater use of online communities than do others. This includes the mentally ill (including young men who are unaccustomed to talking about their mental illness) and populations who are physically dislocated, such as Aboriginal peoples. In a survey by the Markle Foundation (2005), people who perceived themselves as healthy were less likely than all other groups to use a PHR. As one PHR entrepreneur advised me, "The problem with the PHR is that the healthy ignore them, so that many marketing schemes look to make them appealing to disease-specific clusters of patients." The Real Role of PHRs Keep in mind that the PHR is not intended to solve poverty, a multi-factorial problem, or other more systemic drivers of chronic illness. It is meant to improve consumers' understanding of health issues; to give them more access to and autonomy over their health; to support more timely, appropriate preventive services; to support home monitoring for chronic diseases; to support the continuum of care; to avoid duplicate testing; to increase access to providers via e-visits; and to reduce adverse drug interactions and allergic reactions. John Snow and the PHR As many have noted, engagement requires more than usability. The platform applications, whether via Google or Microsoft or other tools, must provide sustained value. But my instinct is that the PHR is akin to John Snow and the water pump. During the cholera outbreak in 1854 in London, Dr. Snow analyzed the geography of water supply and mortality patterns in Soho and found a disproportionate number of cholera cases within a few blocks of a single water pump on Broad Street. At his behest, the pump was removed. This action has been hailed as one of the first public health interventions of the modern era. Although Snow's microscopic examination of a sample of the Broad Street pump water was not conclusive, his studies of the pattern of disease were convincing enough to persuade the local council to disable the pump. The same can be said about PHRs. The evidence is hardly conclusive, but we do know that consumers are keen to engage with the Web and share secure personal health information that they own. The burden of proof against the PHR should lie with those who challenge consumers' good judgment. A related side note: In a future column, I look forward to tackling another myth about the PHR: that it threatens privacy rights. Lawyers, not consumers, are saying this. Consider this statement by Nicolas Terry (2008): "personal health records are dangerously flawed adjuncts to or substitutes for provider-centric records, and while lacking many of the touted quality or cost-reduction benefits of oft-criticized electronic health records they pose substantially higher levels of risk regarding security, privacy, and confidentiality." Sure, identity theft and privacy risks are always legitimate concerns, and there is a role for government to play in ensuring the security of electronic personal health information. But law should be in the service of innovation that matters to chronic disease sufferers throughout the world. (To be continued…) About the Author Neil Seeman is Senior Resident, Health Strategy Innovation Cell Massey College, University of Toronto Adjunct Professor of Health Services Management Ryerson University Toronto, ON References Leonard, K., D. Wiljer and S. Urowitz. 2008. "Yes, Virginia, There Are System Benefits to Be Gained from Providing Patients Access to Their Own Health Information." Healthcare Quarterly 11(4): 64-68. Retrieved January 4, 2009. < http://www.longwoods.com/product.php?productid =20094&cat=563&page=1 >. Markle Foundation. 2005 (October). "Attitudes of Americans Regarding Personal Health Records and Nationwide Electronic Health Information Exchange." Retrieved January 4, 2009. < http://www.markle.org/downloadable_assets/ 101105_survey_summary.pdf > Seeman, N. 2008a. "Web 2.0 and Chronic Illness: New Horizons, New Opportunities." ElectronicHealthcare 6(3): 104-10. Retrieved January 4, 2009. < http://www.longwoods.com/product.php?productid =19506&cat=524 >. Seeman, N. 2008b. "Inside the Health Blogosphere: Quality, Governance and the New Innovation Leaders." ElectronicHealthcare 7(3): 101-8. Retrieved January 4, 2009. < http://www.longwoods.com/product.php?productid =20298 >. Terry, N.P. 2008 (August 22). "Personal Health Records: Directing More Costs and Risks to Consumers?" Social Science Research Network. Retrieved January 4, 2009. < http://ssrn.com/abstract=1248768 >. Weingart, S., D. Rind, Z. Tofias and D.Z. Sands. 2006. "Who Uses the Patient Internet Portal? The PatientSite Experience." Journal of the American Medical Informatics Association 13: 91-95. Retrieved January 4, 2009. < http://www.jamia.org/cgi/content/abstract/13/1/91 >. Sprague, Lisa. 2006. "Personal Health Records: The People's Choice?" Lisa, Nation Health Policy Forum Issue Brief - No. 820. Retrieved January 4, 2009. < http://www.nhpf.org/pdfs_ib/ IB820_PHRs_11-30-06.pdf >