Gene's Joint

Motivation

What is motivation? According to wikipedia the word is defined as “the activation of goal-oriented behavior”. As I sit in my house looking at my google calendar, at all the meetings later this week, putting the final touches on my vacation schedule, noting the 7 overnight calls i will start the following month, I feel a mild anxiousness. Its not a full blown dread at the work that is forthcoming or even an anticipatory nervousness or performance anxiety. Rather is a dull agitated feeling in my gut that I am not doing what I should be in life. Its an uneasy sense that I am not going the right direction coupled with a mild frustration at not being able to find the right direction combined with a paradoxical nihilism of why finding a direction even matters. Either way I feel particularly lazy, unmotivated, stagnant.

So why is it that I feel like I am procrastinating even though I have nothing really to do? I suppose even though I am still undergoing my medical training, have made a ton of friends in my new program, I have gotten into a routine of having extrinsic goals set for me over the last 5 years to the extent that I have lost a lot of intrinsic motivation to set and execute my own goals. Its interesting, even doing laundry or cleaning my room as gotten to be a chore whereas presenting at a conference or turning in IRB proposals and setting up meetings for research have become routine.
It doesn’t help that in the midst of all of this, I am feeling my attention span get shorter and shorter as I get tired, have even less time as a resident and feel the pressures of the mid 30s modern day life start creeping up.
Hmmm, we’ll keep thinking bout this one

as I think back to why I decided on medical school now 7 years ago and the last time I had this uneasy feeling

Habits of the mind

President Kim likes to talk about “habits of the mind” in his speeches to the undergraduates. I recently read a piece at convocation for the entering Dartys (Class of 2014):

http://now.dartmouth.edu/2010/09/convocation-address-by-president-jim-yong-kim/

It hit me when he discusses his example of procrastinating . . . I mean “writers block” while writing his own PhD thesis which he overcame by doing exercises he called “morning pages” in which he just woke up in the morning and wrote about anything.

It is interesting to map this onto my own experience in which I have developed since b-school the habit of being a little hypomanic in order to improve my productivity. For example, to overcome my own procrastination, I use deadlines both real and artificial and set them closer together so that my time being productive can be maximized.

The unusual problem which I have encountered with this method though is that I end up having to “pay the price” of this adrenaline and hypomania with some subclinical depression when I feel like I must just lay around and do nothing for as long as a night to a few days and as long as two weeks.

For example, during my last 3 months at Dartmouth, I organized the Dartmouth Summit on Healthcare Delivery, matched at Hopkins Anesthesiology, got two business job offers and started a business while finishing my last term of business school. After this, I had about two weeks to finish packing and say good bye to friends, instead I lay around sometimes feeling so disinterested I literally did nothing or perseverated playing video games etc.

I had an interesting conversation with Ji Soo who I just saw for the first time in 5 years. We discussed the advantages and disadvantages of focus vs the approach I have been taking to a dual track life and career. On the one hand, defining success as creating something valuable, achieving something prestigious which is what Ji Soo suggested involves spending 110% of one’s time on one thing. Especially as he describes when everyone else competiting with you is doing the same. However, I simply love being involved in multiple things. I think there is a synergy for me in climbing up the first 80% of my attention and focus curve and once my productivity/attention/focus/effectiveness plateaus moving onto another project so that I can constantly stay on the steep part of my learning and passion curve. For example in bschool I remember spending one term focused completely on school then the next term doing 2-3 things while taking classes and noting that I sometimes did better in the classes despite doing other things. I suppose if you assume my grade reflects what I actually learned in the class then this means that somehow I can get a “twofer” by doing more things at once. Either way, this may just be a habit I cannot change. Something tells me that I am destined to a life of throwing on multiple hats and loving every minute of it. ;)

Why is there no Chinese Football team at the World Cup?

The China team is so bad it can barely beat middle schoolers
http://mobile.shanghaiist.com/2009/04/17/how_terrible_is_the_chinese_footbal.php

but seriously why so terrible? It’s not cuz they don’t have the resources, just look at how much they spent on the olympics. It’s not because Asians are too short or physically unfit just look at South and even North Korea or Japan. That leaves politics and economics. The CFA is under the Chinese State Council while also being supposedly a nonprofit with profit seeking subsidiaries like the China Superleague. This leaves it vulnerable to mixed mission and profit motives, thr nowhere land for effective organizations!

Concept of Leverage

Was chatting with Eric today and thought his idea of leverage was really interesting. Basically, the idea is that operationally there are three types of leverage in increasing order of potency: rules, tools, people. Interestingly we seem to always gravitate toward the least potent form of leverage to solve our problems by throwing people at it. However, people are often the source of the problem due to their inconsistency, irrationality, etc etc. Interestingly in medicine similarly to other industries, we have tried to solve the problems of poor quality and increasing costs by throwing more people at it when in fact what we might need are better rules in the form of evidence based checklists and procedures and tools in the form of diagnostics that would help to risk stratify patients.

The Best ____ are the Best people

Who knew one could learn something about being a good venture capitalist, healthcare delivery scientist, doctor, leader from former NBA player Chris Webber?

I was listening to the ESPN preview Lakers-Celtics game 1 (whoo hoo) and I heard Webber say “the best coaches are the best people” referring to Doc Rivers, coach of the Boston Celtics who believed in his team when they didn’t believe in themselves and has coached a #5 seed to the NBA finals against conventional wisdom.

This is so true about so many things related to leadership. Its about caring about the end state not promoting oneself that makes good leaders who they are. I have absolutely learned this from the key leaders I have had the pleasure of working with and the ones I gravitate towards are the ones who combine being a genuinely good person with a track record of effectiveness in the organizations they lead: Jim and Steve leading a University, Errik and Tillman running a biotech firm and others have all show amazing track record with being genuinely good people and its these people that I hope to be like someday.

Different theories on the bottleneck in Healthcare

Jim Kim has a slide that he likes to use in his talks about what is wrong with the healthcare system. The logic goes something like this: we spend billions on high tech R&D for new drugs and devices when we don’t yet utilize our current technologies in a judicious and cost effective way. In fact, we don’t even know how well we use our current technology because that data on outcomes and the quality of patient care is often not even collected. Thus the need is for a science of implementation aka the science of healthcare delivery to go alongside the traditional basic and clinical sciences.

I learned the other point of view today which can probably be best illustrated through an example of two conditions which are both treated by antibiotics: Cdiff infection vs Cellulitis. Cdiff may well be an area in which the value of healthcare delivery can be easily seen. Both the diagnosis using a highly sensitive and specific test Cdiff toxin in stool as well as  the outcome, cessation of the cardinal symptom (diarrhea) supported by laboratory evidence from stool samples of negative Cdiff antigen is quite clear. This is an area where providers can be assessed on the proper diagnosis and the outcome of treatment. Perhaps this is an area amenable to the science of healthcare delivery.

On the other hand, take cellulitis, an area where the diagnosis is often by expert opinion and prescribing patterns are highly variable. Science of HCD people may argue, well thats exactly where we should apply the science to systematize the expert opinion and measure improvement in outcomes. However, one may also see this as an area in desperate need of better diagnostic and treatment modalities.

Thus the alternative point of view is that until a disease can be diagnosed and its natural history predicted with 90% accuracy and its treatment is 90% effective, there will always be a need for further products.

Which one is right? I personally intend to hedge myself so that I can learn about and participate in both as an academic physician working in healthcare delivery and life science entrepreneur building disruptive innovations.

Greece – who cares?

1) Eu growth slows demand for US products
2) Depreciated euro will compete in exports with US/China
3) Will capital markets crisis devolve into 2008 style crisis? Niall Ferguson

When gov outspends taxes choices
-sell debt to private investors
-default (in 3yrs?)
-transfers from other gov (145bn bailout)
-inflate away value of debt by selling to central bank print money (ECB buying Greek debt)

Greece has funded large CA deficit with capital account surplus which is savings of other countries vs Japan who funds their large debt/GDP with their large savings rate

Happiness is cheap!

I’m sitting on the steps of Collis on a perfect sunny New England day, sipping a smoothie getting ready to read all about how the Brits got massacred in Kabul in Peter Hopkirks book the Great Game. I had lunch at Yamas with Kevin and I think his passion for the topic really inspired me to want to read about blood gore and adventure. I am still looking for that job where I can make relationships for a living with interesting people. I suppose that is why I chose medicine and business but even in those there really isn’t a perfect function where all you do is build relationships without the crap of staying up all night filling out forms and writing notes all night. Sigh, maybe life is all about being able to be on vacation or unemployed . . .

Medicine is one large decentralized organization

It occurs to me that healthcare suffers from a simple issue that many large organizations face. Namely as individual practitioners are given autonomy over major decisions that affect quality and costs, of course you will have variation in outcomes. The management solutions in this situation are simple, to centralize decision making (lobbying medicare to require certain algorithms of care), changing performance system (Pay for Performance), change accounting system to take into consideration poor outcomes.

Stop apologizing

I am taking a course called Communicating with Presence in my last term at Tuck. We did an exercise recently called “Conversation with your Inner Critic” that I found illuminating. It basically consisted of assuming one’s critical voice when it comes to public speaking and voicing ones own doubts about oneself. It was a strong example of how we are all our own worst self critics. I remember being suprised at how critical I was when we role played in class going so far as to tell myself to “go home” since I was never going to be a good public speaker. Pretty crazy.

What I found quite interesting in all of the relaxation and self reflection exercises is this. In finding one’s confidence, one’s voice, one only has to overcome ones own fears and self doubts. For me, I have decided that this means to STOP apologizing for things I do and just try to be myself and accept both the good and the bad decisions I make.

Let’s see how we do! :)