Being opportunistic, going with the flow

I feel like I’m in such a rut lately. The second year of med school is finally winding down but I feel like I’ve been so bored, boxed in, confined for the last two years that I’ve become downright boring . . . and really bored

So much so that the only things that seem to offer me some kind of escape tend to be thinking about the future, about my career, about taking care of patients, etc etc etc

Its at times like these that its good to get some perspective. Dr. Payson, the “godfather” of the MD/MBA program here at Dartmouth had some great advice. He said that in the end, allow yourself to be opportunistic and take what comes to you. In other words, though we may all think that we can plan and plan our careers to maximize our productivity, time, happiness, Norm’s message is quite the contrary: don’t plan

He’s the second person (along with Prof Michael Chu, another person who I want to emulate) who has had great societal and personal success in life, a happy home life, successful career, does philanthropic work, etc. Like Prof Chu, Dr. Payson’s career as turnaround guru in the insurance industry and a big time private equity zonk was not something he mapped out but rather stumbled into and became good at because he liked it. In fact, he started his career as a family doc in the Indian Health Service in Arizona before joining the first group practice which he later became CEO of and sold before starting a successful HMO and then turning around a major insurance company in Oxford health and selling that. Its interesting to hear him say now that despite all of his success in business and all the impact that he has had to insurance companies, doctors and patients that he doesn’t think there is anything one could do that has the same emotional impact as helping a patient especially one from a vulnerable population. So as to the questions of what do I want to do with my career, my degree, my life (questions I get asked and ask myself all the time), in the end, I think I’m gonna just do what I feel like.

As Norm says, no matter how much you plan, its very unlikely that you’ll map your way into being uber-rich but if you follow your passions, you have a good chance of living a happier life.

What makes the time fly by?

Lately, I’ve been talking with Jane and others about the idea of being simply satisfied with your life vs being truly happy. The latter obviously more important one always seems so elusive and as I think about what I really enjoy doing I think it really all comes back to talking with people in a time of need. For example, I recently I had a long talk with a friend about a major career change. It was a difficult decision that had major consequences on his personal and professional direction and somehow counseling him, establishing the relationship, listening and offering good advice all was really fun for me. So much so that the two hours we spent together literally “flew by” and I found myself having to run to my next meeting and almost getting late.

Anyway, this all makes me think that perhaps counseling and mentoring folks is my “happy place”. Developing a relationship, working toward a goal with someone. The problem is that somehow this all sounds a lot like psychiatry, resolving unresolved conflicts, listening to people, cognitive behavioral therapy and the like. The only problem there is that psychiatry is the antithesis of all the symbols of prestige and power that I have surrounded myself with my whole life even if it would fulfill the side of me that wants to help people. So maybe I should just be a psychiatrist after I have had a successful business career and satisfied my business ego? Counseling and motivating CEOs as my patients, hmmmm . . .

Fashionable Health: How to make money helping the poor

It just occurred to me thinking again about my last few meetings with Prof Chu and the idea that instead of preaching behavioral changes for the sake of health, mental sanity, prolonging life or other seemingly far away risks with uncertain consequences, the goal of changing someones health maintenance behavior really ties in very well with culture, social image, fashion. Its amazing how willing we all are to change our behavior, even enduring pain (such as by putting on high heeled shoes) to look fashionable, attractive to the opposite sex etc. Well, why can’t we channel this insatiable urge to look “cool” in front of our peers or “fit in” toward a beneficial health consequence? In my own case, I think to the time I was trying to fit in during high school and ended up learning how to read Chinese characters by singing KTV. Every week, I would buy the latest CDs and bring them home to play them and memorize the characters and every weekend, when my friends and I would go singing, the boys would croon their newest tunes in front of the ladies. It was silly and in any other context, I would not be caught dead trying to sing nor did I have any desire to really learn how to read Chinese at the time, but somehow the incredible need to fit in and be cool and the unquenchable teenage sex drive I had really made “studying” Chinese an imperative part of my life.

So this is really the fundamental idea behind commercializable health interventions, the idea that people don’t change their health behavior for the sake of good health but they might really take to the idea that good health is not just healthy but can be fashionable, sexy or cool too.

Case in point: the explosion of this DMS alum founded website: http://www.grassrootsoccer.org/

Dartmouth to San Francisco? Sweet

Just heard from Dr. N that we might be setting up a deal with a hospital in San Fran to add more clerkship sites for 3rd year! Sweeeet

That is, IF I pass my boards in June

Finally starting to get this health prevention stuff

So I met with Prof Chu again, the HBS professor I have been meeting with who made a few very convincing points about health prevention and economic decision making. The interesting thing is that human beings can be both extremely rational yet also extremely irrational. Rational when for example, deciding between planting cassava and potatoes as a farmer in Burundi and irrational when making health prevention decisions. For instance, we are very irrational in changing our behavior when the doctor tells us that we shouldn’t eat that fifteenth donut because of pre-diabetes and hypertension. Yet we are also irrational when for example women decide to wear high heeled shoes which kill your feet but are “fashionable”. Is there a way that our irrationalities could actually cancel one another out in a productive, health improving way? Prof Chu’s belief is that it can in a sustainable way. His current project between HBS and Harvard School of Public Health is trying to figure out some projects that would do exactly this.

Staying totipotent

It seems to me that I like to think a lot about what I want to do with my life . . . that’s all well and good but like I told Dr. Comi (one of my fav profs today), the MD will make me a better businessman, the MBA will make me a better doctor and the combination will make me a better person.

Maybe what I should do instead of trying to figure out what narrow specialty I want to do is to remain as flexible and open to new things and new experiences as I have always been. I have always trying to combine stuff US and China, business and medicine, economics and literature when what I have always really valued most is flexibility, the ability to shop around, have options, try new things, change course, dabble, sample. As I start to enter 3rd year of med school with new opportunities and increasing pressure on finding new things to do, I think I will try to stick with what a friend of mine who is in his sixties and very well established once told me, “I still don’t know what I want to do when I grow up”.

Ruminatin’ in the storm

So apparently ruminating literally means swallowing and then bringing your food back up during a meal and chewing on it some more. As you guys might have heard, we have had a storm recently (here’s a pic of the Hopkins Center at Dartmouth which is our student center where we have performances – $5 bucks for Wynton Marsalis last year baby!) Anyway, as usual, whenever I have time off I end up thinking about the career. I honestly dunno if its ambition anymore or insecurity but here are my current thoughts about potential career paths and their inadequacies.

In general, I still haven’t found the perfect career. This may be because I am really looking for a career in which I can have it all: be able to do something that is interesting and constantly stimulating, honorable and worthy of respect, get paid handsomely, while having free time to do things I like (travel, interact with diff cultures) and to raise a family and finally something where I can feel like I am having a social impact. That said, here are some of my recent thoughts on potential career tracks and their potential shortcomings.

1) Venture capital – its cushy, you get paid handsomely, you get to feed your ego (once you have raised that billion dollar fund), its very stimulating and you get to interact with all kinds of experts, lots of excuses to travel and meet new people

drawbacks: you really don’t get a sense that you are making any kind of social impact although this is a great profession to make enough money and have the time to do philanthropy on the side. You also pretend that you are starting businesses more than you actually are although I am not sure just how much I want to “get my hands dirty” as an entrepreneur these days.

2) Working for McKinsey in one of their more entrepreneurial practices (like Beijing) – very prestigious, you don’t get paid that well but its a stepping stone into bigger and better things, the networking is phenomenal (for example, there are 5 McKinsey projects apparently studying the Iraq rebuild strategy), they give you weekends off which is pretty cool, you travel a lot, its very international

drawbacks: its really not very entrepreneurial and can be very academic and rigid, seems like its more of a stepping stone than a long term career for me. Again a big drawback is that you don’t really get to feel much of a social impact in your work although I guess there are pro-bono projects you can do (e.g. Gates Foundation is a client of McKinseys as well as several African governments)

3a) Neurosurgery – my latest fad specialty in medicine, you get to put your hands in people’s brains! How cool is that? ;) This may be nothing or it may be something but its very prestigious and we have really only hit the tip of the iceberg in terms of what we can already and will be able to do in applied neurobiology in the next decade. Already there are experiments being done that are making people walk and talk again, curing people with tremors (I have seen this myself, its literally miracle work). You really really get to help people, it is prestigious, well paying, very secure.

drawbacks: apparently you can sacrifice your life for this specialty very easily and in some places that is even expected, 7 years of residency, hard to have a family life, you are on call the rest of your life, working with very sick patients

3b) Interventional Neuroradiology – you do minimally invasive neurosurgeries basically by going through blood vessels and doing microprocedures on people, this may be to neurosurgery what balloon angioplasty and stents have been to heart surgery. This is a happy medium in many senses, there is cutting edge work being done also in this field, there is tons of potential AND you get a life, only problem is that it is VERY competitive to get into any of these programs and still a long residency process if you include the fellowship time (6 years total)

3c) Emergency Room Doc – its shift work, you work a couple of days a week and then take the rest of the time off, its very intense extremely challenging exciting and you really get to help people. You are paid well, the residency is short (3 years) and the people you help are really the people most in need and it is very financially challenging to be in ER medicine (most ER depts in the US do not do research, don’t get as much grant funding and take in all the sick uninsured people so they are cost centers to the administration).

drawbacks: this may be a happy medium within the constraints of medicine. You still have to do residency you still have to stay local mostly.

4) Working for or running an NGO building social justice in places like Burundi or doing barefoot doctor work in China

drawback: no $$, no real prestige although lots of self respect, tough life but you get to travel and meet a lot of needy people and build the things we take for granted here. I think ultimately I might be better suited to directing an NGO from the board as a philanthropist though.

back on the farm

the cold cold cold farm

8 hours of class yesterday, 7 today . . . boards in 6 months . . . wait, why did I leave VC for this again?

Merry Xmas all!

Merry Xmas 2006 everyone from Addis Ababa, Ethiopia (well, the airport internet cafe anyway)!

Great conversation

Probably the best thing about being in an academic setting is the opportunity to exchange ideas with extremely thoughtful and accomplished people like MC. MC is a professor at HBS, general partner at a Latin American VC firm that he founded, on the board of Accion a very successful microfinance organization and a member of the Board of Trustees of Dartmouth College. By some external measures of success, he’s got it all, a supportive and healthy family life, financial security (he had a lot of success in his career at KKR), social impact (Accion is one of the leading firms in providing financial services to the poor), academic advancement in his field of social entrepreneurship which he teaches about and researches at HBS. Today I had the opportunity to sit down with him and talk about his story, career advice and making money by helping the poor.

It was one of those memorable discussions where you are in the right place both physically and developmentally to really engage and benefit from a discussion with another person who has been through and experienced some of the things you want to experience.

MC started his career at Dartmouth in the 60s at a time of social change and revolution where governments were changed and the idea of government debated. After graduation he did not know what he wanted to do but knew firmly that he DID NOT want to paricipate in business which he believed at the time to be the source of social ills. He would tell his business friends that someday they would be up against the firing squad. Upon returning to Latin America and joining in the political opposition there he was given some words of advice by a friend who managed a part of what is today Unilever’s business in Latin America: “If you truly believe that business is the enemy, why not learn about the beast from within? And oh btw, I need a purchasing manager for my business here. From then on MC embarked on a successful career in business which took him to HBS for business school, BCG for consulting, and KKR doing leveraged buyouts. In the meantime he continued to tell himself that someday he was going to help cure the social ills of the world as he set out to do when he was younger. At some point, the same friend “Scott” from Unilever made him aware of an opportunity to be on the board of Accion International whose mission was to provide financial services to the poor. This became an opportunity which he began to learn fit in with both his beliefs of addressing social inequities and his skills and experience from the financial world. So at some point he had a choice to make – continue making a boatload of money doing very interesting things at KKR or taking a large paycut and being the person he has always said he wanted to be. Ultimately he decided on the latter because he realized if he did not, he would always be the person who “just talked about curing social ills” and would never actually do it. He realized that making such decisions will DEFINE who you are.

MC’s view is that there are no moral compasses or even social compasses by which you should judge whether a career choice is a good or a bad one, rather a given opportunity is simply the right one for you or not the right one for you. Simply the feeling you get when you walk into the door will tell you whether all the components are there that you hope to achieve. Analyze with your mind, choose with your heart. Don’t spend your career building a resume only to one day get hit by a car crossing the street (“what’s your tombstone gonna say? he never did what he wanted but he sure built a damn fine resume!”)

This was all extremely wonderful for me to hear about from someone who has been through it and made difficult choices but in the end was able to have his cake and eat it too. The key takeaway for me really was in how all of this came about without planning but with a crossing the stream by sensing the rocks approach. In that way, I also feel that in my past experiences I’ve learned more and more about what fits me and what will fascinate and challenge me for the future. For example, at JJDC this summer getting paid well, building a resume, doing interesting and important stuff with brilliant people was fabulous but the missing piece was the social impact of my work. In much the same way, seeing patients as I understand it so far in medical school is socially useful, personally gratifying but lacks a wider social impact and the intellectual challenges of creativity, initiative and risk that I love so much about entrepreneurship and venture capital.

In the course of talking about careers, I also learned a lot from MC about microfinance and social entrepreneurship that I would like to touch on briefly here. First, the now validated evidence that YOU CAN MAKE MONEY BY HELPING POOR PEOPLE is something that he has demonstrated through his career and success with Accion and this is one of my most fundamental beliefs or hopes about what I can do with my life and career. Second, MC pointed out that microfinance is NOT for everyone, you do not want to loan money to someone who does not have sufficient caloric intake to work. “The only thing worse than being desperately poor is desperately poor with DEBT”. Rather you want to provide microfinance to those who are already delivering the 6 bottles of oil every day and by allowing them through access to working capital to decrease their costs increase their supply and efficiency to lower the price of oil for everyone in that community, including the starving person.

Third, MC’s take on the current impasse in helping the poor is in health care DELIVERY. The treatments (such as vitamin A for blindness) are available often for pennies but the challenge is how to deliver these interventions to the poor? He has also learned that no organization for profit or not can succeed without four elements: SCALE, PERMANENCE, IMPACT and EFFICIENCY. For example, he is currently working on a joint project between HBS and Harvard School of Public Health called Antaries that aims to identify commercial interventions using the 80/20 rule where interventions can be rethought and redesigned from being “public goods” provided by government or NGOs to private goods that the private sector can validate and model and mass market to the poor. It involves rethinking of the poor as “end users” instead of the doctor-disease-patient centric approach in medicine or disease impact on society perspective of public health. For example, instead of treating iron-deficient anemics in low income communities with government mandated policies to distribute bad tasting pills through underresourced clinics or schools, how does one make a good tasting soda supplemented with iron and market it (say with Shakira advertising it) to the kids in these communities as great tasting and oh btw it will improve your health rather than the other way around. Ironically, the current soft drink makers that do similar things tout the “health benefits” of drinks rather than focus on making it a great product first.

Another example is paint that has anti-malarial insecticide in it which people would buy because 1) its a great color and has great protective properties 2) is affordable 3) will keep more mosquitoes away. This would help replace malaria nets which are hard to use and uncomfortable and potentially not useful for people to use. It would be distributed not by enthusiastic NGOs or inefficient governments but by the private sector who sees one organization being successful at it and that organization spawns an industry wide adoption of similar products and concepts. Like microfinance, success in a few leading organizations will catalyze an entire industry of profit seeking companies that because they are seeking profit delivery advertently or inadvertently a social good.

Another example is of drug stores that contract out the sales of condoms to peers and thereby allow young people to earn money by selling condoms that are cheaper than the competition. It is a superior product, sold in a more effective way that reaches more people.

Mexican “minute clinics” where you charge 2 dollars a visit for a no-wait consultation with a doctor and meds that are 30% cheaper than at the hospital which the poor prefer to no-cost 12hr waits at hospitals for “free healthcare”.

MC was quick to point out from his prior experiences that the key to success of Bancosol in Bolivia which is a commercial entity that provides financial services to low income community was a first mover advantage, scale and STRONG management which drives increasing cost efficiencies despite price competition. This example has spawned hundreds of similar banks throughout latin america.

Personal notes: MC has 1 son working for a NY law firm and lives in Boston. I will keep him updated on my career both in terms of the MD/MBA and my experience in Burundi this winter. I think documenting these rituals in Burundi and finding opportunities for commercial ventures is one of my goals for the upcoming trip to Burundi.