Jeff Belkora blogs about leadership, teamwork, and decision-making.
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Sunday
Feb232014

Humanizing your emails

Recently a colleague emailed my intern group list-serve without a clear salutation, addressing them as "you." One intern replied to the email, triggering a copy to the whole list-serve, thinking the you was in fact just her, rather than the collective you.

This got me thinking about how often emails mis-fire in this way, and about the root causes.

In today’s world of mobile devices, I have noticed that people sometimes reply to emails without a full appreciation of who was cc’d on the original email, or whether their reply might be going to many people. I think this happens because mobile devices do not display all the meta-data about a message the way we typically see them on larger computer screens.

Sometimes someone who is bcc’d and receives the message on a mobile device, replies to all because their phone does not show cc and bcc lines. Even though this does not reply to all the people who were bcc’d, it DOES reply to all who were cc’d. This can be extremely problematic.

Therefore, for professionalism and safety and quality reasons, I recommend the following practices, which I try to model:

Begin your emails with a salutation that makes it clear who is being addressed, such as “Dear X”. My colleague did not do this, and the use of "you" may have inadvertently misled each recipient.

If you are cc’ing anyone, mention this explicitly after the salutation, such as “Dear X, and cc’ing Y and Z”

Never bcc anyone. If you want them to see the message, forward it to them after sending.

Be aware when replying to a message that if the message originated as part of a distribution list (list-serve), your reply may go back to the whole list-serve by default, even if it looks like you are only responding to a named sender.

Generally be aware that people may be reading your email on a mobile device with a small screen and more limited formatting options, and in different time zones on devices that may or may not adjust for time zone differences.

If you can, avoid attachments. Paste useful content into the body of the message – with minimalist formatting. People often don’t see that attachments are included, especially if they are checking email on phones. Recently I was in a meeting where someone had received a bunch of attachments but denied getting attachment #7. Their email program (Outlook) displayed two lines of attachments and then you have to scroll to see more attachments. Which this person did not know to do. Therefore they kept denying that they had received attachment 7, even as the sender insisted it was attached. Attachment 7 was a critical part of a proposal that ideally would have been reviewed before the meeting. So if you do include attachments, list them in the body of the email in a numbered list.

Take the time to compose emails that short-circuit several cycles of communication. For example, when trying to arrange a meeting with someone, propose 1 definite time and offer 3 available backup times. Specify time zone. Always include an absolute date (never “tomorrow” or “Friday”). See my blog article on fully specified requests at http://www.jeffbelkora.com/blog/request-cycle.html. When a meeting is confirmed, I will typically send an email with all the pertinent details (date, time, call-in information etc) and send a calendar invite with that information in both the "location" and note fields. The huge advantage of calendar invites is that they generally appear grayed out on people's calendars until they are accepted. Even if recipients overlook the email, they will usually notice something appearing on their calendar. However, email systems are not fully interoperable, so calendar invites may not function for others the way they do for you. That's why I do send a duplicate email summarizing the calendar item for people who are outside of my organization.

Generally in all communications, do some perspective switching and anticipate how the message is going to be received, accessed, interpreted, stored, and shared. The best book I have ever read on strategic communication, in which you anticipate the first, second, and third-order effects of your messages, is the book “When talking makes things worse”. Out of print, available at your library. Along these lines, use the subject line to summarize any request and deadline, as recipients do review subject lines while screening emails. Make judicious use of any ways to flag emails. My email system allows me to add an urgent mark (!), plus request a delivery receipt and read receipt, and schedule a reminder to emails. These layers communicate to recipients that I really, really want to make sure the email does not slip through the cracks. Overusing such flags will backfire, but generally I have good results with them. However, as with other issues, you cannot assume they will work similarly on all email systems.

As for the actual contents of the email, I try to limit each email to a single topic that matches the subject line, and structure the email so that a recipient can respond with a yes or no or very simple and short response, and move our collaboration forward. Finally, as with all communication, proceed with curiosity, fallibility, and perspective-taking. The primary implication of these is that I am always testing my assumptions with my respondents ("Did I understand correctly that you are requesting X, or am I missing something?"). Look over an email and count the question marks before you send it. Typically people make 10 or more statements for every question. When I review transcripts of really productive conversations, I find ratios more in line with 3 or 4 statements for every question. How do you feel when people communicating with you include questions to test their assumptions or solicit your views? My guess is you feel included and collaborative. The philosopher Immanuel Kant pointed out that a key ingredient of humanism was treating people as ends in themselves, not as means to an end. My experience is that asking questions is inherently humanizing.

When I look over these strategies for composing professional emails, they boil down to reconstructing the context for face to face, heart to heart communication that is otherwise likely to go missing from the electronic medium. Context such as the who, what, when, where, and why surrounding the communication. Context is humanizing. What a strange word, humanizing. Why would we need to humanize anything that we are involved with? Isn't our mere presence in an activity inherently humanizing? Well, no, not in the sense of being humane to each other. Something we need to keep in mind when communicating through machines.

As I write this, I've begun to hum one of my favorite songs, Rehumanize Yourself, by The Police, on the great album, Ghost in the Machine. "I work all day in a factory/I'm building a machine that's not for me/There must be a reason that I can't see/You've got to humanize yourself." If we are to build machines through our emails, let's build them for and with each other.

Saturday
Feb012014

Supporting someone with advanced cancer

 

I received an email from a colleague asking how to be a good friend to someone with advanced cancer. Actually my colleague used the words "terminal cancer". Other colleagues tell me they favor the words advanced cancer. I sent the request for advice out to our Advanced Breast Cancer task force at UCSF, and thought I would share their responses.

One research assistant conducted an internet search and found the following links:

- http://www.cancer.gov/cancertopics/coping/when-someone-you-love-has-advanced-cancer (An online booklet for caregivers of those with advanced cancer)

- http://well.blogs.nytimes.com/category/voices-2/living-with-cancer/ ("Living with Cancer" blog on the NY Times, not necessarily about advanced cancer specifically, but reflections on life with cancer from a patient with ovarian cancer)

- http://kathleenbuckstaff.com/when-someone-you-love-has-terminal-cancer/ (blog article with some concrete tips from a woman whose mother had terminal cancer)

- http://www.theguardian.com/lifeandstyle/2012/sep/19/terminal-cancer-how-to-live-with-dying (thoughts from a 30 yo woman with a terminal diagnosis)

A colleague at our UCSF Cancer Resource Center wrote back:

These are some excellently crafted publications. The terminology "friend" is not used; however, the support mechanisms are the same when the word "caregiver" is used. I hope this helps. Please let me know if you are looking for something different.

From Cancer Care - excellent practical and emotional guide http://www.cancercare.org/publications/1-caregiving_for_your_loved_one_with_cancer

From NCI for caregivers - looks at practical and emotional ways to support yourself and loved one http://www.cancer.gov/cancertopics/coping/when-someone-you-love-is-treated

An excellent starting place in assessing one's emotional state from NCI for the patient. However, the friend can learn a lot and develop empathy by reading this http://www.cancer.gov/cancertopics/takingtime

A researcher wrote back:

I just did a quick search and found these books:

http://www.amazon.com/How-Be-Friend-Whos-Sick/dp/1610392833/ref=pd_sim_sbs_b_3 (this one was endorsed by another colleague as well)

http://www.amazon.com/The-Etiquette-Illness-What-Words/dp/1582343837/ref=pd_sim_b_1

http://www.amazon.com/When-Your-Friend-Gets-Cancer/dp/0877889341

http://www.amazon.com/Facing-Cancer-Together-Friend-Loved/dp/0806638338/ref=pd_sim_sbs_b_2

 

I'll add more resources here if/when they come in.

And indeed another colleague writes to add the following websites:

 

 

 

 

 

 

Saturday
Feb012014

High level guide to making flowcharts

 

Flow charts are CRUCIAL visual aids in modern word processing. I rely on them heavily. I use a process that allows me to embed flowcharts in Microsoft Word documents while future-proofing them as much as possible - meaning I want to be able to edit the flowchart in a Word document at some later date. So, no pasting images/pictures of flowcharts.

I have found some issues with creating flowcharts in Office 2010. So here's what I do.

-        Create the flow chart in a powerpoint slide using CONNECTORS instead of arrows. Drag the connectors until they “bond” with the shapes they are connecting (the dot will turn red instead of green when you get the connector lined up with a little placeholder on each side of a shape)

-        Create text as a text box and then add a shape as a border. Do NOT write text and then draw a border around it (like a rectangle or circle). Add the shape as a BORDER. Text should be centered in the box. Boxes should be aligned using powerpoints “Align center” or “Align middle”. This will make the connectors look straight as well. Note that getting things perfectly aligned may require that the dimensions of the connected boxes (height and width) are the same across several boxes.

-        Now, in Powerpoint, select the entire slide in the SLIDE SORTER view of Powerpoint. Copy it to the clipboard. Do NOT try to copy a subset of the flowchart by lassoing and selecting.

-        Switch to Word, and use the PASTE SPECIAL command (look it up and make paste special your friend) to paste as a Microsoft Powerpoint Slide Object.

-        Now, when you want to edit the flow chart, right click on the slide object and choose “Slide Object, OPEN” (not edit). This opens the flowchart in Powerpoint with all commands available. I've found that using EDIT instead of OPEN creates issues, as my diagrams shrink when I close.

The reasons for following this admittedly complex procedure  include:

-        First and foremost, flow charts should be easy to edit by future users of your documents. This means moving boxes and having arrows stay connected. It means minimizing formatting. I can spend 4 hours on a flowchart easily; and I don’t want future editors (including me) to experience any barriers to adding a step or moving a box.

-        Word 2010 does not have good connector capabilities for flowcharting but Powerpoint does. (This is one of these aggravating examples where Word 2010 is worse than previous editions.) That’s why you edit flowcharts in Powerpoint.

-        Powerpoint also has better alignment and other graphics facilities than Word

In general, I write a LOT of flow charts and I almost NEVER use anything exotic (like Inspiration or Visio) because I want future users of my documents (protocols etc) to be able to edit the flow charts with the a very widely available program. So I make sure they show up as powerpoint-editable objects in Word. 

 

Tuesday
Apr302013

Tips for premeds on shadowing doctors

 

One of my interns asked me about shadowing doctors. Shadowing any professional is a great way to learn more about a field. In their new book, Decisive, Chip and Dan Heath point out how we often make career choices with very little knowledge of the professional reality in that field.

For assistance on this question, I emailed our network of 60+ intern alumni, who are mostly in or just emerging from medical school, and asked for their advice.

Here's what they said would be considerations in shadowing doctors...

Location

  • Emergency departments
  • Specialty clinics
  • Community health centers
  • Private practices

The type of work that you want to see

  • Interventional
  • Surgical
  • People/talking
  • Family-heavy
  • Research
  • Administration

What do you want to learn/establish from the experience?

  • Get the gist of what a clinic feels like
  • Mentorship relationship with one of the doctors
    • If they are an alumnus of a certain school that you are applying for, this could be very helpful in the application process
  • Research positions
  • Guidance on the application process  
    • The practice of medicine is so varied and individual, so you should take this time to explore in a broad and open way
  • You do not need to choose a specialty at this point in time; it is more important to determine what type of activity drives you
    • Eventually, you will find “your people” with whom you’ll enjoy spending 80 hours a week during residency and for the rest of your career
  • Because medicine is such a long road, you should love it to get through it
    • The only way you can know is if you experience a doctor’s life
    • After the experience, do a self-reflection and be honest with yourself about whether medicine is the right thing for you

How to contact doctors 

  • Email request or in-person
  • 1 paragraph statement of interest/your background
  • Mention if you have already worked with patients

 

 

Monday
Jun112012

Serving your audience #Huddle12

My professional mission is to help people grow in their capacity for leadership, teamwork, and decision-making. I'm proud to be affiliated with the organization CAMPUSPEAK as one of the speakers on their roster. CAMPUSPEAK connects individuals and organizations on campuses nationwide with experts who contribute to student growth and development. The speakers, facilitators, and consultants at CAMPUSPEAK address  issues such as leadership, diversity, career planning, character development, student physical and mental health, hazing, drug and alcohol abuse, and many others.

In addition to serving students, CAMPUSPEAK invests in the roster's professional development through a biannual Huddle, where we learn from external experts and from each other. I want to briefly share some of the lessons I took away from Huddle12.

This summary itself is an effort to enact one of the themes of  Huddle12. We generally don't make enough time for reflection. Neen James and Justin Jones-Fosu reminded us to schedule appointments with ourselves, for example when returning from conferences, in order to protect time for reflection. So here I am, reflecting...

Another theme was the importance of non-verbal communication. Michael Grinder taught us some very concrete principles and techniques on the effective use of pauses, gestures, objects, and space. For example, when arriving at an agreement with someone, you don't really want the agreement to be between you and your counterpart. You want your counterpart to make the agreement with himself or herself. So you externalize the agreement in a document, and when referring to it, invoke the document object, located in a space, with a gesture. You can do this in presentations, and appeal to people's imagination. Michael presented many other ways to make pauses, gestures, objects, and space the focus of our communication. If you are looking to learn pragmatic techniques for enhancing the power of your non-verbal communication, Michael is the best I've learned from so far. Michael mentioned being inspired by, among other sources, Michael Caine's book on acting, which I am going to check out.

Neen James reminded us to think in terms of serving our audience when we are communicating. I found this to be a powerful frame, compared to informing, educating, persuading, motivating or even inspiring. Along these lines, David Mathison taught us powerful ways to play the game of social media, but reminded us that our deepest relationships and interactions are to be found with a small number of friends, family, and colleagues. We learned all about measuring and increasing our Klout scores (a quantitative measure of online influence), but also how to understand the limitations of Klout, both literally and figuratively.

The thing I like most about CAMPUSPEAK is that the organization and its representatives are all mission-driven. When you are mission-driven, you measure yourself against that mission, which is often hard to quantify. Maybe I'm rationalizing, because my Klout score is rather low, but the lesson I really took away is to develop our own scorecards (which may be qualitative as well as quantitative), and then use David's techniques to harness social media and networks for the mission. As an example, you can raise your Klout score by tweeting questions that many people will comment on (e.g. boxers versus briefs?), but have you advanced your mission? If you're looking to learn about social media and networking, while keeping it all in perspective, David is the best I've learned from to date.

I got to spend some time with Mike Dilbeck. I am such a fan of his Everyday|Hero campaign and the Response Ability project. Mike has taken academic work on bystander behavior and made it his mission to spread the lessons of that research. We've all heard about dramatic situations where bystanders could have intervened, but instead ignored calls for help and a victim died in a crowd. The same principles that apply to dramatic situations also apply to more everyday situations, where you might see someone getting drunk, or saying something discriminatory. How do we teach people to intervene rather than stand around? The earlier you intervene, the easier it is. And the more you intervene early, the more you develop that muscle, so it's there when you need it in more difficult situations. Mike also taught us about social media and networking based on his recent successes. He has combined offline and online activities. For example, he's been traveling to conferences teaching workshops and certifying trainers to carry his message forward. Good old fashioned one-to-many-to-many kind of social networking. But he's also using a ton of video and is moving towards having students self-administer the training they need online. He mentioned a bunch of sources of inspiration that I am going to check out, including Scott Stratten of Unmarketing ("stop marketing, start engaging"), and Brendan Burchard of Experts Academy. Some of his favorite tools include Mailchimp, Infusionsoft, joinspeaker, Kajabi, Audio Acrobat, and the Yeti microphone. It's great to get both strategic and tactical tips from someone who has been there and done that.

Somewhat similar to the issue of overcoming bystander inertia, we learned to form accountability partnerships to make changes stick in our own lives. For example, I am now scheduled for an accountability checkup with my partner, Hudson Taylor. (Hudson is an amazing guy who is on an a personal mission to get rid of homophobia and other forms of discrimination in the college athletic scene.) We'll be calling each other to check in on our resolutions. Having a buddy is such a simple but powerful step. Again, I heard this idea from Neen James (in her workshop), Justin Jones-Fosu (in his book), and Tom Healy. I'm grateful for the repetition - that's another principle of making change.

Speaking of needing a reminder, Rick Barnes reinforced the importance of value-focused thinking - putting the why before the how or the what. Among many other things, Rick teaches campus organizations how to recruit members through better articulation of values and mission. It's so interesting to me that many leading organizations do spend significant time on strategic planning, but so few of us do that for our individual lives. It goes back to making time for reflection, which is what you hear from personal productivity specialists ranging from Stephen Covey to David Allen. So important, and so rare.

We concluded the biannual Huddle with a rapid-fire session, in which we all shared a most valuable tip or tool. Some that stood out to me included Triberr (gather your tribe and communicate with them efficiently); unfollowme (for when you hit your Twitter limit); pdanet (I use this too, it's awesome); the health and professionalism reasons to always use a microphone; scottevest; the dreamzone sleep mask; saying "I get to" instead of "I've got to" (like I choose to instead of I have to); Using your "panda paws" (palms) to give a massage instead of "monkey fingers"; using your passport as well as driver's license even when traveling domestically; exercising with bodyrock.tv; improv tips; the power of benchmarking or modeling role models; and some other more intimate tips that will just have to stay in Vegas, where we were huddling.

Erica Upshaw and Cara Jenkins used their rapid-fire time to remind us of the importance and healing powers of altruism. (Among other things, Erica is preparing a new campaign around preventing substance abuse by setting positive conditions in middle school.) We prepared a message for one of our colleagues who is being treated for cancer, and made donations to preferred causes. 

The Huddle12 theme was "the intelligence to inspire" and indeed we ended on an inspirational note. I can't wait for Huddle14.

Saturday
Feb042012

Continuous improvement through critical reflection

One of the mantras I have adopted in my life is: "there is no such thing as failure, only feedback."

Corollary: Back in my days at a high tech startup, my colleagues and I would regularly try to raise money from venture capitalists. We would come back to the office after making our pitch and employees would ask, "Well, did you get the money?" Our CEO would say, "No, but we learned a lot." So the expression was born in our office: "Learning is what you get what you don't get a check."

I do like to extract maximum learning from failure or feedback or not getting a check or whatever you want to call it. I have evolved a short template for reflecting critically on my performance. After any experience (e.g. giving a talk, putting on a training workshop, writing a grant, etc), I write down my answers to the following questions:

1. Current goals? What was I trying to accomplish? (These are usually carried over from a previous attempt, see last item below.)

2. Achievements? It's important to note and celebrate the ways in which I did accomplish or contribute to my goals. As my daughter's first-grade teacher says: give yourself a pat on the back.

3. Failures? What did not go well or according to plans, hopes, desires?

4. Success factors? What did I or other people say or do, or what was happening in the environment, that contributed to the achievements above?

5. Barriers? What did I or other people say or do, or what was happening in the environment, that contributed to the failures (or inhibited the achievements) listed above?

6. Next goals? What am I going to work on next time? I carry those over to the next performance.

Just as an example, here is my reflection after conducting a workshop that I give periodically on decision making:

Goals? – experiential; shorter (6 hours); same content. Focused only on skills.

Achievements? Individual, realistic practice (e.g. with computers), focused (not distracted by sharing  a computer). Finished on-time. Students were all engaged, even at the end of a long week. Students did arrive at skills they will need (confident).

Failures? Half-trained (not a lot of process training); Not ready to initiate a phone call; Did not present the service delivery lifecycle very well; (in SF Margot took us through the clinic before, recording of Margot initiating a phone call). The context. This was presented week before.

Success Factors? Computers available: kept away until they needed them (no checking emails). Experiential worked (practice, role playing). Undergrads had very fresh perspectives. No model clash.

Barriers? Limited time availability (of medical students – almost sporadic availability).

Goals for next time? Integrate the skills and process training? Immediate follow up and practice? Pipeline of patients waiting to be served? Process training would include scripts, practice calling, etc. Add time and split between two days? Video clip of process (project for student). Course for undergrads (intense), weave in medical students. 

In addition to using this framework to reflect episodically, I use it every week with my team. Each of us responds to those six questions with reference to the week we just completed.

Here are some excerpts of my reflections from last week (redacted for privacy):

LAST TIME GOALS  -  Finalize performance reviews; Film SCOPED promo; Fix budget for Mendocino in CMS Innovation; SSU affiliate agreement; BCT paper – check calculations; SV/O2O/MAP manuscripts; Reimbursements.

ACHIEVEMENTS - Performance reviews; SCOPED promo v1; CMS Innovation grant submitted; BCT paper moving along; PANCAN; Shanti; QL WCRC; IHPS adv bd meetings - leadership summit idea; CERC idea well received. Some progress on SSU.

FAILURES - Did not get to O2O/MAP manuscripts; reimbursements; CS video and marketing materials; 

BARRIERS - Grant collaborator canceled meeting, did not complete draft on time.

SUCCESS FACTORS - Grant collaborator put more resources on project and team rallied to submit a promising proposal.

UPCOMING GOALS - Mtg with John and Jill; SV/O2O/MAP manuscripts; SSU; CHQI Feb privacy mtg; reimbursements; Feedback; BMB syllabus; Promo video to Trina

Each week I share my reflections with my team, and they share theirs with me, and we discuss all the elements. It's a powerful way of going beyond setting/reporting on goals... to reflecting on the dynamics surrounding our productivity.

Thursday
Dec082011

Occupy Your Mind

My wireless carrier recently sent me a text message:

You used 19767713 KB of 12634112 3G/4G data. Overage is 0.05/MB. Usage resets 12/08/2011.

That week, I spoke to a student who was applying to nursing school and was offered a package of loans. She was clearly informed of the total loan amounts and the interest rates, but not what the total monthly payments would be.

Simultaneously, I was reading an article in Rolling Stone about the Occupy movement, and this really resonated with me:

"There's no better symbol of the gloom and psychological repression of modern America than the banking system, a huge heartless machine that attaches itself to you at an early age, and from which there is no escape. You fail to receive a few past-due notices about a $19 payment you missed on that TV you bought at Circuit City, and next thing you know a collector has filed a judgment against you for $3,000 in fees and interest. "

Finally, I was reading Walter Isaacson's biography of Steve Jobs. Regardless of whether you agreed with him or not, Steve Jobs was passionate about Apple's products and committed to continuously improving them. He cared about how people used them.

What do these threads have in common?

Well, I appreciated that my wireless carrier was proactively notifying me of my data usage. But they did not really put much effort into actually communicating what I need to know. Even in 160 characters, they could have done much better than:

You used 19767713 KB of 12634112 3G/4G data.

First, I could not tell whether the first number was larger or smaller than the second. Can you?

That's because they used KB and no commas to parse the numbers into millions or billions or whatever.

They could have saved characters and increased the clarity of the message if they had converted to GB, and mentioned that the second number was my monthly cap:

You used 19.77 GB of your 12.63 GB cap on 3G/4G data.

Now I can see the first number is bigger than the second. 

Then they told me the penalty was 0.05/MB. Notice how they use the unit MB, when in fact they quoted usage in KB, and I really want to know in GB. I would suggest "Overage is $50/GB"

Now this all begs the question: why are they waiting until AFTER I exceed the cap to notify me?

If they cared about their product and service, they would know that I would appreciate a warning, say, at the 10 GB mark (out of 12) because at that time I could adjust my data usage and avoid fees.

Instead, I got on the phone with them to try to get them to reverse a $300+ overage fee. (All this data use related to the fact that I had accidentally backed up a movie file over my mobile hotspot connection.) They "adjusted" my bill based on the fact that I have been a mobile subscriber with this carrier since 1997. I wonder if others would have parsed the text message the way I did, noticed an overage, and called promptly. Calling promptly to contest it was big, because the company had not actually generated my bill yet, and so could still "adjust" things on the data level without having to make adjustments to the actual bill. A less informed consumer might have been stuck with the $300+ tab, and fees, penalties, and ultimately a collection agency.

The relevance to student debt is that apparently we are entering a student debt bubble similar to the mortgage bubble. A common cause of all these problems is that companies are not communicating numbers clearly to a public that is not terribly numerate (literate in the use of numbers.) My student had not yet translated the loans and interest rates into monthly payments over a defined term - which is how you really can make sense of payments.

Based on my coaching, she inquired and calculated and I heard back from her:

"The Stafford loan I received for 5,500 per semester is a little confusing for me. The rate is 3.4% for loans between 2011-2012, and 6.8% for loans between 2012-2013, and the term is 10 years. In either case, an origination fee of .5% is deducted from each disbursement- I've looked this up and it seems it's an extra fee added on for each monthly payment. I can defer this payment up to 6 months after graduation. I used an online financial aid calculator for the loan. I calculated each at their separate rates- so that'd be $5,500 at 3.4% for ten years (plus the fee), plus $16,500 at 6.8% for ten years, and that came to a total of $245.24."

She did the same for other loans, all with different rates and terms (Perkins, Unsubsidized) and came up with

"In total, my monthly payments would be around $328.41 per month."

That's now comprehensible because you can relate it to a monthly take-home on your paycheck, and to expenses such as a car payment or rent. Notice how we went from how the loan is quoted per semester at variable interest rates (because her school term spanned two rate periods), to one monthly payment for ten years.

My student had not really paid a lot of attention to the amount of debt her parents were going to take on. So I pointed out that she should really be helping her parents make sure the debt was affordable for them. They might lose their jobs or pension and she might end up having to carry their portion of the loan or otherwise supporting them in their old age!

"I calculated my parents loan payment- it would be about $965.56 per month, the rate is 7.9% over ten years with a 2.5% origination fee."

These are large monthly payments for a middle class family. The investment in a nursing career might well be worthwhile, but regardless, it's important to translate the blizzard of numbers from the university, into a set of total monthly payments. 

Most human beings are blessed with huge, flexible brains capable of learning the basics of discounted cash flow calculations, including compounding interest. I'd like to see companies and universities putting their collective minds to work on simplifying debt communication; and of course students and families should take on the task of educating themselves to the monthly payment and other implications of the bargains they are striking. I try to approach such tasks as puzzles. It can be fun and confidence building for anyone to brush off our math skills and figure out the details. For anyone who knows what I do in my day job (medical decision making), it should be obvious that all of this applies equally to interpreting the statistics we may hear about risks and benefits of treatments. We are blessed to live in an age where some internet research, or consulting a librarian or consumer/health advocate can usually generate better understanding at low cost.

Occupy your mind, and your wallet (and body) will thank you.

 

 

Wednesday
Oct192011

Cancer Screening Controversies

UPDATE - just got off the air and will add a postcript below.

I have just been invited to speak on KQED Forum, a San Francisco-based radio talk show, regarding cancer screening controversies.

The show will air Wed Oct 19, 2011, at 9 am PST and can be heard at 88.5 FM in San Francisco, or online at http://www.kqed.org/radio/listen/, or by podcast a day later at http://www.kqed.org/a/forum/R201110190900

I'm going to assemble a few resources that I can point listeners to and update this post. Email me if you have anything you want me to share with the public.

My key message about cancer screening or indeed any health-related action, is that all medical interventions have potential risks as well as benefits. It makes sense for individuals to learn what these are. In addition to consulting physicians, there are now educational resources called decision aids that take on specific topics. These decision aids can be print, audio-visual, or web-based materials. What distinguishes a decision aid from other health education materials is that they are organized entirely around a frequently encountered dilemma. Producers of good decision aids are not trying to persuade anyone to do anything in particular; rather they try to present a fair and balanced view of the pros and cons, including both quantitative evidence as well as qualitative stories or testimonials from patients who have experienced treatments and outcomes.

Producers of decision aids include a non-profit, the Foundation for Informed Medical Decision Making, which produces web, audio-visual and print decision aids with its commercial partner, a company called Health Dialog. Disclosure: I am the recipient of both research and implementation grants from the Foundation for Informed Medical Decision Making. Another producer is the non-profit organization Healthwise, which supplies many websites and medical centers with web or print patient education materials. Other sources of good information on medical decisions include the National Cancer Institute and the Mayo Clinic. There's a comprehensive index of decision aids at http://decisionaid.ohri.ca/AZlist.html

Decision aid producers recognize that cancer screening programs create harms as well as benefits. Therefore, these producers have created decision aids targeted at some of the most frequent decisions: breast, prostate, colon cancer. I'll provide some links below. 

So why is there controversy? What could possibly be wrong with people weighing the risks and benefits of screening and making an informed decision with their doctor? I'm the wrong person to ask: I'm personally and professionally committed to informed and involved decisions. I am comfortable, overall, with the ethic of individual patient autonomy and self-determination. Occasionally ethical conflicts arise pitting the welfare of many against the freedom of the few, but these are rare and I don't see them in screening. The controversy may arise because we are still transitioning from paternalism to participation in health care decisions. As William Gibson said, "The future is already here, it's just unevenly distributed." 

Part of this transition is that there are many entrenched viewpoints and interests at stake. Outside of the health effects of screening on individuals and populations, there are people whose wealth or power or status grow with the use of screening technologies and processes. Conversely, some will benefit if screening technologies and processes decline in popularity. This is true in all industries, and health care is no exception. Some people are trying to drive revenue (for example, producers of drugs, devices, procedures and fees), while others are trying to contain costs (employers, insurance companies, government payers.) The patient is a passenger in a car with two drivers, one with a foot on the accelerator, the other with a foot on the brake. This is a dangerous ride. In that situation, the patient's best hope is to find a good doctor and take control of the car together.

OK on to some links:

1. Gary Schwitzer is a journalist who critiques media coverage of controversies, including screening. He has a great blog post at http://engagingthepatient.com/2011/10/17/how-the-news-media-may-hurt-not-help-health-literacy-efforts/. Scroll down to read his third point about cancer screening. A screening program is different from testing someone who is high risk or has symptoms. Testing can have very high benefits with very low risks or harms. Screening is when you go fishing in the general population in the hopes of preventing deaths at relatively low cost in financial or human terms. In actual fact, most screening programs prevent very few deaths at high human and financial cost.

2. Prostate cancer. A company called Health Dialog (see above) normally reaches patients through contracts with insurers, who pay to offer decision aids as a benefit to their members. However, the general public can access Health Dialog's decision aid on prostate cancer screening at https://www.healthcrossroads.com/example/crossroad.aspx?contentGUID=fc326615-5b29-47f1-87c3-9a3e2d946919. Again, Health Dialog works with the non-profit Foundation for Informed Medical Decision Making to assure that the content is fair and balanced. Only medical editors with no financial or other conflicts of interest are allowed to shape the content.

3. Breast cancer - age 40. Regarding screening for breast cancer at age 40, my colleagues at the University of Sydney have produced a decision aid for that dilemma: http://www.mammogram.med.usyd.edu.au/

4. Breast cancer - age 50. A prominent health services researcher, Gil Welch of Dartmouth, has drafted a simple balance sheet that summarizes the benefits and risks of breast cancer screening for women in their 50s, I'm reproducing it here from his article in the British Medical Journal at http://www.bmj.com/content/339/bmj.b1425/T1.expansion.html:

For every 1000 women undergoing annual mammography for 10 years in their 50s:

CreditsDebits
1 woman will avoid dying from breast cancer 2-10 women will be overdiagnosed and treated needlessly
 

10-15 women will be told they have breast cancer earlier than they would otherwise have been told, but this will not affect their prognosis


100-500 women will have at least one “false alarm” (about half of these women will undergo a biopsy)

 

5. Breast cancer - all ages. There is a more detailed presentation, broken down by age groups, in a Canadian decision aid for breast cancer screning: http://www.phac-aspc.gc.ca/cd-mc/mammography-mammographie-eng.php

6. Colon cancer. This screening is considered highly effective. I was a little shocked to review some numbers recently and learn how small the absolute benefit is, or to put it another way, how many people must be screened to detect one colon cancer (thousands!). The National Cancer Institute has helpful resources on screening. They are not exactly decision aids, because they are not structured in such a way as to synthesize the absolute data. But they provide good summaries. The one on colon cancer screening is at http://www.cancer.gov/cancertopics/pdq/screening/colorectal/HealthProfessional/page3

 

Other than websites, I encourage people to review some informative books on the topics of cancer screening and risk reduction:

Gil Welch - Should I Be Tested for Cancer? Maybe Not and Here's Why. http://www.amazon.com/Should-Be-Tested-Cancer-Maybe/dp/0520248368 

Gerd Gigerenzer - Calculated Risks. How to Know When Numbers Deceive You. http://www.amazon.com/Calculated-Risks-Know-Numbers-Deceive/dp/0743205561 

POSTSCRIPT

We had a few callers on the show that with cancers diagnosed through screening. Their understandable reaction is that screening saved their lives. The hard truth is that we don't know what would have happened, whether symptoms would have developed, whether treatments at that point would have been effective. What we do know is that out of 100,000 people screened, we would expect a few lives saved. People have an understandable reaction that "if ANYONE is saved, it's worth it." If you feel that way, I understand, but then all of us should be parking a mile away from our office each day and walking that extra distance to work, because we would save about an equivalent number of lives, at no real harm (look both ways when you cross the street), and with the added benefit of feeling good from exercise. These are not mutually exclusive of course, you can do both. But the point is that we do make decisions that cost people lives - such as commuting to work from further away, in order to save on housing expenses. Lengthening your commute kills people. So if you feel your life was saved by screening, please evangelize people driving less as much as you evangelize screening.

I come away feeling that, in urging caution about screening, I am cast in the role of someone who wants to deny people access to potentially life-saving therapy. Not at all. My professional mission is for people to make informed decisions. If the benefits of screening sound like they are worth the harms, you should advocate for your access to the programs. The key point is self-determination. And the screening slogan should be, not so much, "Screening saves lives" but more accurately, "Screening saves a few lives per 1,000 people screened, and can lead to varying degrees of harm for dozens or hundreds of others. Whether it makes sense for you will depend on your priorities and perspectives. Review a decision aid and talk to your physician about it."

My wish is that people advocate harder for their access to decision aids. The public has long been too satisfied with the news media digesting and (mis)interpreting scientific studies. Ask your hospital or clinic or insurer to obtain decision aids for you if they don't already. Then make a list of questions and consult one or more doctors and record their answers so you don't forget them. These strategies are proven to improve patient understanding, question-asking, and information recall.

POST-POSTSCRIPT

I have now heard from some colleagues who wish to convey their messages on this topic.

Hope Rugo, Director of the Breast Oncology Clinical Trials Program at the UCSF Breast Care Center, writes, "I think it is important for women to know that the reason for the controversy is that rapidly growing tumors that have the highest risk are least likely to be found on screening exams.  So in my mind, what we should learn from that is that: 1.  Screening mammograms are still useful, it is just not clear that you need to get them yearly when you are under the age of 50 as the breasts are very dense and lesions are less visible, as the benefit is low.  2.  Abnormal exam findings should always be thoroughly evaluated.  3.  The less frequent screening may not be the right advice for those with a family history or personal high risk (prior DCIS, calcs, etc)."

On the topic of bi-annual versus annual screening, Laura Esserman, Director of the UCSF Breast Care Center, writes: "Data is pretty clear. There is no demonstrated data that screening every year is better than every 2 years. There is an increased risk of being called back and having an unnecessary biopsy (Annals of internal medicine last week)- by almost 50% if you screen every year. The risk of missing advanced cancers is not statistically significant, and the magnitude of any difference negligible (2-3%). Same benefits, less risks. Screen every 2 years. And it fits biology that fast growing tumors present between screenings- even when annual." I will add from years of working with Laura, her highest priority is always that patients arrive at an informed decision with their doctors based on their personal priorities and unique biology.

From the Palo Alto Medical Foundation, Dr. Edmund Tai writes: "Family history is often overlooked and is tedious to do. We need to enlist patient to help with their own care by providing a more detailed history. THere is a free website run by the NCI called "My Family Health Portrait" that has a nifty software to allow a patient to enter their FH.  It can be tedious if there is a large family but it is a free tool developed by the surgeon general and is actually a good idea.  As I am involved in clinical cancer genetics FH is fundamental in identifying patients who are at the highest risk.  It is estimated that >30% of all cancer patients have some family hisotory of cancer and 2-5% (depends on cancer type) have very high risk hereditary transmission.  We have only developed an indepth understanding of breast, ovary, and colorectal cancer but more are forthcoming.  The reason is that there are only a few genes that have high penetrance and high specificity.  The majority probably are affected by multiple genes with low specificity and we hope newer technology would allow us to pick those up."

 

 


 

Friday
Aug192011

If you have to ebb, make sure you flow

A recent article in the NY Times magazine about decision fatigue got me thinking. Thinking leads to fatigue, and fatigue prevents thinking. So thinking leads inexorably to impulsiveness. Seems like a paradox. I will be brief lest I deplete my thoughts.

Decision scientists know that impulsiveness is not always bad, as Malcolm Gladwell summarizes in Blink. Sometimes we make wiser choices by acting on our unconscious instincts or impulses. My critique of Blink is that the unconscious is most effective when we act based on deep pattern recognition borne of expertise borne of repetition. For example, after years of experience with rock climbing, you might approach a pitch and find yourself troubled about the rope setup without being able to articulate exactly why. As described in The Gift of Fear (de Becker), it can be very important to listen to your unconscious even if it is not articulate.

In the modern world, however, we often encounter brand new situations, some of which involve very high stakes (medical, housing, career, relationship decisions). In these situations, under-thinking and impulsiveness may not channel the informed unconscious, but simply our ignorance. Then we may overlook missing but knowable information, or act out rashly on ill-considered preferences (e.g. fight/flight defensive reactions). This is really stark in medical and financial decision making. We may react impulsively to a perceived threat (pre-cancer diagnosis, stock market churn) and embark on irreversible decisions (surgery, divestments) based on fears that may be, on further reflection, overblown. On the financial topic, Warren Buffett supposedly says, "Be greedy when others are fearful."

I am drawing several connections to this work on decision fatigue. First, fatigue is the result of consequentialism - the commitment to evaluating the pros and cons of different alternatives. Besides impulsiveness, there is another alternative to consequentialism, namely formalism. This is when you resolve to follow a rule rather than constantly evaluate the consequences of your actions.

My favorite example is that I find it very depleting to constantly re-evaluate whether to keep scheduled commitments. I often schedule commitments 3 months in advance, and then find that when the time approaches, there are suddenly three competing claims on that time. I used to re-evaluate: should I reschedule with A so I can do this new activity with B? I now have a rule that I keep commitments in the order I made them. I don't think about it. It's a no-decision. Technically, I might have better optimized my time by rescheduling dynamically. But I have preserved daily capacity for decision making through rule-following.

In my experience, though, there is an even better way to preserve decision capacity than to follow rules. Find Flow. Flow is the state of being perfectly challenged: enough so as not to be bored; not so much as to become frustrated. You know you are in Flow when you lose track of time. It's a form of self-hypnosis. It is inherently energizing. I can spend six hours at a stretch making complex decisions that flow like water in a stream. I might be designing a training exercise, writing a song, or writing a research report. In those cases, I can emerge with full decision capacity. Conversely, if I spend six hours processing my expense reimbursement requests, I achieve a state of anti-Flow and feel totally depleted. Productivity gurus have therefore pointed out we should manage our energy, not our time (see The Power of Full Engagement by Loehr and Schwartz).

When you are conscious of the possibility of decision fatigue, you can anticipate it, and prevent it.

If you have to ebb, make sure you flow.

Tuesday
Apr262011

Unanswered questions, never asked

I got in the elevator this morning at the hospital where I work, and the man who boarded next to me said, in a friendly tone, "So did you get in to see the doctor?"

I was taken by surprise.

This was a presumptive question, in the sense that it presumed I was waiting to see a doctor.

Answering the question truthfully with a "No" might still leave the wrong impression.

That's the problem with a presumptive question.

"I work here. I'm a researcher," I responded. I had put my badge in my bag as I departed my meeting. Next time I'll keep it on.

My first thought was that he mistook me for someone he saw in the waiting room. People have been known to wait for a while to get in to their appontments in our hospital...

I was wrong.

"Oh, I thought you were a sales guy from a drug company, those guys are always trying to get in to see the doctors."

Our brief ride came to an end, leaving me with unanswered questions, mostly because I did not think fast enough to ask them before my outgoing companion disappeared into the day.

My main question was: What did I say or do that led this gentleman to believe I was a drug rep?

There was a cascade of unspoken questions behind that: did he see being a drup rep as a good thing or a bad thing? Was it my appearance? My demeanor? My clothes? Should I be flattered or insulted? Was this the first time in history a systems engineer had been confused with a drug rep? Has anyone ever approached a drug rep and confused them with a systems engineer?

The presence of drug reps is controversial in clinical settings. Basically, where they once roamed the land with relative impunity, they are now banned or on their way to being banned. Many feel that their sales mentality embodies the potential for corruption in our fee for service health care system, where health care providers and producers make more money by pushing more treatment. With this background knowledge, I felt somewhat threatened by my elevator companion's casual branding of me as a pariah. My self-image is much more the knight in shining armor - the patient advocate who helps people work with their doctors against the conflicting forces of insurance companies cutting costs and pharmaceutical companies driving revenue. 

I did see the whole interaction was a gift. I try to be pleasant on elevators, but I'm guarded. This gentleman, who if I may counter with my own attributions, was dressed like a recreational golfer (bright blue collared polo and long green shorts), was not guarded. He gave me the Robert Burns gift: "to see ourselves as others see us."

"Jeff," he was saying, "You may think you are Mr. Patient Advocate, but under some conditions you can come across as Mr. Corporate Rep."

I really wish I had been quicker to ask my follow up questions. This led me to ponder how much we miss because we are too slow to inquire. We often respond to any interaction defensively rather than with curiosity.

For example, I noticed a few years ago that when someone gave me a compliment, I tended to deflect it. Now if someone says, "I really enjoyed your talk/paper/program," I immediately respond, "Thank you. What did you like about it?" I have gained so much valuable, actionable feedback that I would have missed if I had just stammered some awkward thanks and turned the conversation to another topic.

In general, when I hear someone evaluate anything, I now try to get them to say more about what is driving their impression. You can't always trust the specifics you get. Sometimes a holistic impression is driven by unconscious reactions that are not easily surfaced. But often people are aware of their preferences and inferences.

I enjoyed the conversational gambit that my elevator friend employed, opening with a presumptive question. It gave me a lot of food for thought.  It's entertaining in a social setting as an icebreaker.

I don't recommend it professionally though. Your patient or colleague may become as distracted as I was by the implications of your presumption.

But I do recommend developing the conditioned reflex to ask productive questions. Whereas a presumptive question stimulates distraction, a productive question stimulates more concrete and specific examples or gets people to illustrate their reasoning.

Imagine the mysteries we could solve if we surfaced responses to those unanswered questions that we never asked.