Fractals of Change

WHO Doesn’t Like the Gates Foundation

From a recent article in the New York Times:

“The chief of malaria for the World Health Organization has complained that the growing dominance of malaria research by the Bill and Melinda Gates Foundation risks stifling a diversity of views among scientists and wiping out the world health agency’s policy-making function.

“In a memorandum, the malaria chief, Dr. Arata Kochi, complained to his boss, Dr. Margaret Chan, the director general of the W.H.O., that the foundation’s money, while crucial, could have ‘far-reaching, largely unintended consequences.’”

WHO is a UN organization, in case you didn’t know. UN agencies, even those that don’t do their job very well (most of them), don’t like to have their “policy-making function” wiped out.

Dr. Kochi, according to the NY Times article from which all facts following in this post come,  says the Gates Foundation is forcing recipient scientists into “group think”. A Dr. Amir Attaran at the University of Ottawa agrees with Dr. Kochi but “…believed that scientists were not afraid of the foundation, but of its chief of malaria, Dr. Regina Rabinovich, whom he described as ‘autocratic.’”

The Gates Foundation has spent about $1.2 billion on malaria research. Before their involvement in 2000, less than $100 million a year was being spent on this and drug companies had pretty much abandoned the field. You’d think the Foundation would be entitled to have an opinion and influence policy since it pays the bills but not according to Dr. Kochi who complains that the foundation “even takes its vested interest to seeing the data it helped generate taken to policy.”

I had a lot of contact with Bill Gates and Melinda and I were peers when I worked at Microsoft. I’d much rather have them setting policy – particularly on how their money is spent - than UN bureaucrats. Yeah, Bill can be arrogant; yeah, people who work for him sometimes think aping the arrogance will also make them as brilliant and successful as them. But, when Bill gets “hard core” about things, they get done. The things the Gates Foundation is doing need someone getting hard core about them. They need much more rigorous analysis and much better execution than the UN especially but also many other governmental and non-governmental have shown themselves capable of.

The last few paragraphs of the Times story may well explain what the Gates Foundation has done to raise the ire of UN officials:

“There have been hints in recent months that the World Health Organization feels threatened by the growing power of the Gates Foundation. Some scientists have said privately that it is ‘creating its own W.H.O.’

“One oft-cited example is its $105 million grant to create the Institute for Health Metrics and Evaluation at the University of Washington. Its mission is to judge, for example, which treatments work or to rank countries’ health systems.

“These are core W.H.O. tasks, but the institute’s new director, Dr. Christopher J. L. Murray, formerly a health organization official, said a new path was needed because the United Nations agency came under pressure from member countries. His said his institute would be independent of that.”

Maybe we ought to find out what other UN functions the Gates Foundation would be willing to take over.

Answers to Probability Puzzle

As usual, smart readers knocked the cover off the ball almost immediately. Some day I’ll stump you.

First question taken from Randomness by Deborah J Bennett:

“If a test to detect a disease whose prevalence is one in a thousand has a false positive rate of 5%, what is the chance that a person found to have a positive result actually has the disease, assuming you know nothing about the person’s symptoms or signs?”

First to answer correctly was Matt Crawford:

“Assume that the test is performed on everyone regardless of symptoms of the disease. Then out of every thousand people who receive the test, one has the disease and 999 do not. Further, assume that the test has no false negatives: anyone who actually has the disease gets a positive result. Then 1 out of every thousand tests are true positives. The remaining 999 should be negative results, but the 5% false positive rate means that 49.95 (so round to 50) of these people will receive false positive results. Then out of our 1000 tests, 51 return positive results. But only one of these is a true positive, so the chance that a positive test identified someone who actually has the disease is 1/51 or about 2%.”

You might quibble that 5% false positives means 50 false positive out of a population of 1000 (plus one correct positive) but this is close enough. It’s fair to make the assumption that there are no false negatives since this isn’t stated in the question (and otherwise you’d be unable to answer) but Aswath is right to point out this should have been specified.

Second question: “what percentage of the physicians, residents, and fourth year medical students at a prominent medical school who were asked this question got it right?”

jb guessed that 80% of those tested would give the tempting wrong answer of 95%. Actually, only 19% gave the right answer but only 50% said 95%. jb, you would’ve nailed it if you hadn’t given more detail in your answer than called for. Rob’s an optimist and hoped that 80% would get it right because their care is so important and getting into medical school requires critical thinking. He’s dead right that it’s scary that so many get it wrong.

Interesting answers to third question: “why is it critically important that doctors be able to get this one right? Give one example.” Most not about doctors, though. This type of bad thinking does cover lots of ground.

Matt Crawford cites the Red Cross using an HIV test on donated blood which is known to have a high incidence of false positives and speculates that many donors are probably panicked by the result. “However, the Red Cross continues to use the same test, probably because it combines low cost with very low false negative rate. In this case it may be justified to trade a high false positive rate for a low false negative rate, because a false positive merely requires a second test but a false negative would spread HIV through transfusions.”

Curtis Carmack says: “the medical profession as a whole has given insufficient thought to how to address the false positive issue with patients, leading to much more angst than is necessary when patients receive a positive test result -- invariably late on Friday -- and have to wait at least a couple of days to ask questions about it. ;-)”

Dennis Shanley posts: “This directly effects the overall cost of health care in a huge way. Assume that it costs $10,000 to cure a patient who presents positive. Not an unlikely assumption. Assume further that the 50 false positive patients do not exhibit negative effects as a result of their treatment that require further medical treatment and they do not litigate as a result of the unnecessary treatment. This is a highly improbable assumption made for the sake of simplicity.

“The true cost to cure 1 patient is $10,000.

“The cost to cure that one patient and treat the 50 false positives is $510,000.”

Aswath writes: “Suppose now we are told that the false positive predominantly affects a biological group - gender or a racial group. Will that decision stand reason? Let us assume that the situation is internment during WWII in US. A nation has to live with the effects of a callous operation decision to accept a large false positive.”

Otmar: “There is another interesting application for this kind of statistics: The beloved war on terror. The chance of a random person to be a terrorist is hopefully less than 1/1000. Imagine you manage to build some automated system which somehow claims to spot suspicious behavior, known faces, or miscreants by some other clever scheme.

These systems all have a non-negligible error-rate. If you're really lucky, you might push that one down to less than 1%.

“Now do the math again, assuming a 1/100000 terrorist-rate and 1% false positives. No wonder I read that one trial for such a system got terminated.”

The point is that you must weight the costs of being right and the costs of being wrong both for the positive and the negative case. Back to medicine, suppose your doctor is one of the benighted 81%. He or she tests you using the test in the first question and you come up positive. Let’s suppose that the disease is always fatal if not treated and there’s a treatment available but it has a 25% chance of killing you itself. If the doctor believes that there’s a 95% chance you have the disease, the dangerous treatment is clearly justified; but, since the true likelihood is less than 2%, the treatment is more dangerous than your untreated prognosis. Always a good idea to get a second opinion AND check your doctor’s math.

A Probability Puzzle

From Randomness by Deborah J Bennett:

“If a test to detect a disease whose prevalence is one in a thousand has a false positive rate of 5%, what is the chance that a person found to have a positive result actually has the disease, assuming you know nothing about the person’s symptoms or signs?”

For extra credit: what percentage of the physicians, residents, and fourth year medical students at a prominent medical school who were asked this question got it right?

Extra, extra credit: why is it critically important that doctors be able to get this one right? Give one example.

This is an honor system non-open book test.

Answers in comments, please. Will highlight correct answers in a subsequent post. Hat tip to Nassim Taleb in Fooled by Randomness for citing Bennett’s test.

Answers here.

Livestrong

The post below was written by my nephew Cody Clinton, a second year medical student. The "grandmother" he writes about is my mother who, for the last twenty plus years has bravely battled the horrors of Parkinsons and the side effects of the medicines which slow but don't stop its progression.

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LIVESTRONG

What does this word mean to you? Is it about living healthy, exercising, and studying hard? Most medical students would probably agree. Could it be a state of mind; a belief system affirming you will not accept what others tell you will inevitably occur? For a lot of cancer survivors, this may have been a mantra that kept them alive. But could it be the exact opposite? Could it be accepting what others tell you about your road ahead, even when you know it scares the hell out of you? Ask a terminally ill patient. My guess is that they relate better to this last admission, are prepared to end their life, and may even feel more at peace about their situation than you do. For a family member, this is a tough pill to swallow.

So, what is the true meaning of livestrong? This was a question I asked myself over the last few weeks. I experienced all of these different scenarios above, albeit some vicariously, and still struggled with the answer. The problem being, that each group of people was absolutely committed to their own ideals. They were convinced that they were right and were not about to change their minds, in spite of the best advice of those around them. Never had I seen more determined individuals in all of my life. Unfortunately, it took 24 years to see it. Fortunately, it took getting my head out of the books and grasping the opportunity to experience real medicine for the first time since I entered medical school.

It all began on August 26^th, when students at our college provided medical support for bike riders taking part in a 100 mile Livestrong Challenge. First, let me preface by saying that a 100-mile bike race in extremely hot conditions, on a hilly course is not easy. It is a grueling test of your endurance, muscle strength, and mental composure. In short, it is downright masochistic. I do not recommend it. Yet these riders were out in full force. The riders were largely composed of cancer survivors, as well as family members, friends, and loved ones of cancer victims. There was even one female rider who flew in from Chicago and completed the entire course while in the middle of a chemotherapy regimen! It was absolutely jaw dropping. A member of our medical team, who had recently battled Non-Hodgkin’s lymphoma, described this rider as “ needing to finish the race, in order to keep her mind off the reality and gravity of her own situation.” By the way, this medical student waited at the finish line, even while the race was over, and made sure that her newly found friend made it to the end.

Over the course of the day, we witnessed riders speeding down flats and attacking hills, completely by themselves. Yet, you could feel that deep down they were back on the pavement with their old friends or loved ones, rehashing past experiences. It is a very difficult scenario to have to imagine and an extremely sobering sight to see. It meant much more that simply finishing a long bike ride, instead signifying a step closer to maybe finding some closure to a situation that they were not ready to face. You could see in all of the riders’ faces that living strong was much more than just a physical challenge, but an emotional challenge one as well.

The next unexpected development occurred shortly thereafter, on a morning when the only decision I was planning on making was whether I wanted hazelnut or regular coffee to get me through the morning. I received a call from my family notifying me that my grandmother was in septic shock and might not make it through the day. I immediately rushed up to the hospital where she was being treated, not knowing whether I would be staring at a blank corpse or my last remaining grandparent. Thankfully, she was still alive, was being stabilized, and had a good prognosis. Yet, even stable, she was suffering from Parkinson’s disease, congestive heart failure, a collapsed lung, immobility, and blindness. I wanted to do everything in my power to get her better as quick as possible and back into her home where we could take care of her. But this was not what she wanted. What she desired, and had told my mother repeatedly, was not to be resurrected every time she fell ill, but rather left to let “nature take its course” and die in her own home. I wasn’t ready to hear this kind of news. After some tough reflective time, it soon became clear that the choice my grandmother had made was completely justified because it was what she wanted, not what the people around her felt was best.

Witnessing these difficult decisions gets me thinking about what the term livestrong means for patients that are nearing the end of their lives. For them, living strong is about being confident in their choice to die. Terminally ill patients, unlike the riders and cancer patients, do not find strength from rage or unresolved opportunities. They take solace knowing that they have fought hard, and hopefully will find a place that rids them of their suffering and rewards them for their sacrifices. For them, livestrong is about resolution.

The truth is, as I am sure you know, is that the meaning of this word conjures a different ideology for each person and likely will vary throughout his or her life.  Gratefully, we are all distinct. Yet, we all share a similar passion. Health professionals, cancer survivors, and hospice patients alike, we all want to be content with our actions and decisions throughout our lives. It doesn’t matter if these decisions might not be the most sensible, or if we are going “against the norm”. As long as in the end, we have weighed all our options and trusted our own instincts, can we can go to sleep soundly. Only then, will the word livestrong hold meaning.

Treatment monitoring and thermometry for therapeutic focused ultrasound

If the title above doesn’t sound like it belongs on Fractals of Change, that’s because it’s from a paper co-authored by son-in-law Hugh Morris which has just been published by the International Journal of Hyperthermia. Last year I blogged about the research Hugh is doing in London on using ultrasound for non-invasive surgery. This paper is an outgrowth of that research.

The technique they’re using to zap cancers is an interesting one: a number of high-frequency sound waves are beamed into the body.  None of the waves by itself has enough energy to do any damage as it passes through skin and other tissue. Aimed right, the beams converge at the site of malignity.  When focused, the beams together have enough energy to heat up bad cells and cause them to die.

The problem Hugh has been working on is how to measure the actual temperature being produced so that treatment can be best calibrated to kill all the bad cells with minimal damage to surrounding tissue. Sticking a thermometer into the patient is one option but this is invasive and also can interfere with the treatment since the thermometer itself may scatter or affect the beams and interaction between the beams and the probe may actually change the temperature you’re trying to monitor.

So it would be better to use MRI or some other non-invasive technique to measure temperature indirectly.  In fact, ultrasound itself can be used to measure the temperature by reporting on tissue changes. But how do you know what MRI or ultrasound reading corresponds to what temperature? How do you know which temperatures are most effective in the first place if you don’t know what temperature you’re operating at?

Hugh has been working on using probes in bovine liver (he buys the livers without the cows) to measure temperature induced and calibrate that with the readings given by non-invasive techniques. The problem he’s had to contend with are that the probes do affect the temperature being measured.  You could correct for that if you only knew how much effect is induced over how much time.

In case you didn’t guess the solution: “Morris et al. proposed a refinement to this [earlier] technique. Instead of assuming an arbitrary time for the end of the first phase [of induced heating] , the time was chosen from analysis of the second differential of the temperature with respect to time…. Morris et al. have also used thin-film thermocouples as a viscous-free reference, and calculated the viscous effect for a wire thermocouple as a function of time by subtracting the TFT measurement from the wire measurement.” Makes sense to me (not really).

What I do understand (because we saw it) is the dedication of young scientists constructing experiments, failing, correcting, trying again, avoiding false positives, questioning, retesting, and (sometimes) coming up with something very exciting.

We’re proud of Hugh.

DIYS Pharmacy Benefits Management

The Democrats have promised to repeal the portion of Medicare law which prohibits the federal government from negotiating the cost of prescription drugs with drug companies.  Republicans prefer the current elaborate system of private insurers and outsourced benefit management. They’re both wrong; there’s a much simpler solution available to reducing drug costs both to the drug takers and to the taxpayers.

Drug purchasers can be their own benefit managers.  We don’t need the feds to do this – can you imagine the litter of earmarked grants to establish drug warehouses, outlets, and bargaining units in the districts of committee chairman? We don’t need a bevy of overpaid middlemen adding cost to the middle of the supply chain either.  All we need is a way to shop and an incentive to spend time searching out lower prices. More on both below.

A company called BidRX is an example of how this might work. You go to their site, put in all your prescriptions, say how far you’re willing to travel to have them filled and whether you’ll take mail order, and you get back bids from qualified pharmacies that want to be your suppliers. Obviously depends on getting to a critical mass of participating pharmacies and patients but certainly sounds like a good idea. It’s free to the patients.  Since these are US pharmacies you’re getting the same FDA approved product whether you overpay for it or not so quality is not an issue. Perfect for an auction.

I’m going to try BidRX for our drugs so I’ll let you know how well it works. Results probably vary by location though.

Guess who else is bargaining with drug companies on our behalf: Wal-Mart.  The company politicians love to hate yesterday went completely national (except for North Dakota) with its program of a fixed $4.00 price for a 30 day supply of over 300 generic drugs which their press release says include 14 of the 20 top prescribed drugs in the United States. Two catches:  STATE law in some states doesn’t allow such LOW prices (one more reason why we don’t want politicians doing this) and you have to go into the store to pick up the order. Don’t know if the latter restriction is because this program is a loss leader meant to get people into the store.

Competitor Target has responded with a $4.00 generic program of its own.

There isn’t going to be much fat left in drug prices if Wal-Mart and Target are buying and competing to resell.

In many cases four bucks is less than the co-pay you fork over even when your insurance company or Medicare is reimbursing you for the drugs.  But a fixed dollar co-pay is a dumb thing which takes away the incentive to find a drug bargain. This is something government can and should fix in Medicare and probably Medicaid as well.  Companies with health care benefits can also use a better incentive

Enlistees in drug insurance programs should be reimbursed a percentage of the prior year AVERAGE cost of the drugs they are buying. If they spend enough less, they’ll get to pocket the difference. Sounds weird until you think that we’re paying us to be benefit managers rather than paying somebody else or over-paying for the drugs. Of course, the average price and the cost of the drugs will go down year-over-year, at least for a while, but that’s the point of the whole program.

Zap! Pfffft! Mind the Bubbles

A highlight of Mary and my recent trip to London was a visit to the Institute of Cancer Research where son-in-law Hugh Morris is looking for better ways to use ultrasound to kill tumors.  The Institute shares building with a cancer hospital so they are in no danger of having their work become too theoretical.  Cancer sucks and it’s good to be where people are doing something about it.

Ultrasound is both used diagnostically to locate tumors and surgically to attack them without invasive surgery.  To over-simplify, multiple beams of ultrasound converge on a tumor.  None of the individual beams has enough energy to damage the skin and other tissues it is passing through.  But, at the convergence point, pfffft!.  No need for an incision. Little collateral damage.  No general anesthesia.

But, in real life, nothing is quite this simple.  Bubbles form where the heat is high.  These bubbles can both scatter energy back to innocent tissue and block energy from reaching the cancerous cells.  So how to avoid the bubbles?  Avoid building up to critical temperatures.  What are critical temperatures?  How does heat travel through the tissue in the few seconds the beams are being applied?  How do you measure temperature since you don’t want a probe at the point of convergence which would also deflect energy?

These are the issues Hugh is working on with cow livers fresh from the butcher.  He thought we might be put off by the sight and smell of the experiments.  We were fascinated and proud.  BTW, experimenters still keep notebooks full of observations of each experiment even though they have plenty of computers around and in use.

Being around young scientists (I’m old; I’m allowed to age-discriminate) is fun.  One woman wants to know why the cells die when they get zapped.  Not enough to say “of course they die; they were zapped.”  Forensics are helpful in better targeting cancer cells and minimizing dangers to the rest of the body.  Turns out there is almost nothing known (yet) about the exact cause of cell death from this relatively minor heating.

Another scientist asks: “who says bubbles are bad?”  Maybe they can be used to BETTER focus the beam.  He’s experimenting with a second ultrasound source which induces bubbles before the zapper zaps.

As always the toolmakers are in great demand in a lab.  At tea, we met a woman from China who builds the custom hardware and software they need for their experiments.

Hugh set up a discussion with colleague Alex who’s working on ultrasound for treatment of prostate cancer – always interesting to us old guys.  One of the more interesting points was the social consequence of better diagnostic tools.  The more we see, the more scary stuff we see.  First reaction is to operate more often.  But, operations are also risky.  Turns out that a lot of that scary looking stuff is pretty prevalent and may never turn into anything really dangerous.  So what to do?

People don’t like being told “you have a pre-cancerous condition; we’re not going to do anything” even though doing nothing may well be the best course of action.  This course of non-treatment used to be called “watchful waiting” because follow-up surveillance is done.  Bad marketing name.  People hated it.

Now people are much happier with a course of treatment called “active monitoring”.  Same procedures as watchful waiting but it’s much more satisfying to being doing something “active”.  I agree.

And we’re glad Hugh is on the case.

RoboDoc

Last night Mary and I went to a reception – actually a fundraiser – for a robot. I’m the one in the tux; he’s the tall one with all the arms.  His name is da Vinci and you can buy one of his clones from Intuitive Surgical for about $2 million.  He’d be cheap at twice the price.

Robots like da Vinci are already disrupting the traditional practice of medicine with very positive results both for patients and those docs and hospitals who are employing the technology.

Actually, “robot” is somewhat of a misnomer.  Da Vinci doesn’t operate autonomously; he is a tool used by a surgeon to perform operations. Da Vinci’s incredible articulating hands, arms and wrists,  are guided by the surgeons hands and fingers. Da Vinci’s cameras are controlled by the surgeon in the driver’s seat (see Mary in the driver’s seat below) and, since there are separate screens for each eye, the cameras provide the surgeon with a very effective three dimensional image of the inside of the patient.

The three major advantages of da Vinci use so far are tiny incisions, great visibility inside the patient, and the ability to do “scaled” operations – a one inch move of the surgeon’s hand can be scaled to a tenth of an inch motion by the instrument.

Without a tool like da Vinci, a surgeon has to make a big hole in you so that she can get her wrists inside and so that she can see what she’s doing.  The deeper in you the problem is, the deeper the hole that has to be cut.  Yuk! Recovering from the incision is often more difficult and more dangerous than recovering from the actual repair that was made. Da Vinci only needs a tiny incision to get his pincers in.  The pincers have fiber optic cameras and lights so the little holes provide the doc with visibility as well as access.

The predecessor technology to da Vinci uses the pincers-like tool pictured here and a small television camera for laparoscopic surgery. 

The instrument provides approximately three times scaling of the surgeon’s movement and the surgeon operates by watching a two dimensional image on a TV screen.  Very twentieth century.  As part of our test drive of da Vinci, the demonstrator switched it from two dimensional to three dimensional mode.  Incredible difference.  I was instantly ready to try some DIYS brain surgery.

The scaling allows tiny repairs of tiny things – mitral valves for example.  And no need to saw open the breastbone to get at the heart.  Even the valves of babies or fetuses are operable with da Vinci.  Prostate surgery can be done more precisely with less risk of incontinence or impotence; myomectomies can often be substituted for hysterectomies.  When a hysterectomy is needed, use of da Vinci makes it minimally invasive and less risky.

It’s all cool engineering but some of the features are enough to make any nerd sit up and take notice.  My favorite: an infrared beam scans the doc’s eyes in the scope.  If the eyes move away, all motion of the robotic arms is frozen.  So someone says “hey, Doc” and the doc looks up.  “The Met’s won again.” No danger that his twitch of delight will snip something off inside the patient.

In the current setup, the controls, the rack of equipment, and da Vinci and the patient are all within a few feet of each other as you see here. 

You don’t need to be a futurist to understand that the communication between the surgeon and da Vinci is all electronic.  The doc could be half way around the world (as long as no geostationary satellites are in the data path).

The ability to remote robots surgeons may well turn out to the most disruptive aspect of this technology.  It’s an unquestioned good that the most capable surgeon for a particular operation will be able to operate on patients anywhere from anywhere (licensing permitting).  It is inevitable, says I, that this will also lead to international outsourcing of medical operations after a huge fight to prevent this through application of obsolete local licensing rules.  A very real question we will have to deal with is how should licensing and liability work when surgery is done remotely and internationally.

My guess is that Andy Kessler will have something to say about all this in his about to be published book The End of Medicine.

But meanwhile Vermont is one of the three states in the country without this capability.  Hence the fund raiser.  It was sponsored by Dr. Samuel Trotter who’s Chief of Urology at Vermont’s Fletcher Allen Health Care and Dr. Richard Daum who’s an Attending Physician in Cardiology and Medicine there as well as my doctor (see this post).  Dr. Melinda Estes, President and CEO of Fletcher Allen, talked persuasively not only of the immediate benefits to patients of having one of these here but also of the better job Fletcher Allen can do as both a teaching and a research hospital if it has current equipment.

I’m convinced.

Full disclosure:  I currently have both a prostate and mitral valves. Who knows?

Hands On Medicine and Management

Hands on is good.

My GP is a board certified cardiologist (probably a good thing at my age). Dr. Richard Daum used to run a huge practice in Boston.  Several years ago he moved to Vermont.  He is affiliated with the very good Fletcher Allen Hospital in Burlington but he is a sole practitioner with no medical assistance.

So when you get an EKG and a stress test from Dr. Daum, as I recently did, there are no assistants involved either in placing the probes or administering any part of the tests.  There is the latest technology from the monitors to the tablet he uses for entering history, observations, prescriptions and everything else.  But he places the electrodes, reads the charts, and makes the adjustments.

In a standard American practice I might never have seen Dr. Daum unless he had some bad news to give me.  A technician would have placed the probes, taken the readings, and told me how fast to run on the treadmill.  Dr. Daum would have seen the results and drawn his conclusions from them.  The idea, of course, is that someone as highly trained as a cardiologist shouldn’t waste his or her time in the routine work of administering the tests.  I’m sure the people who do nothing but give the tests are very good at doing that.

But there were some anomalies.  Dr. Daum quickly traced those to instrumentation problems (and too much hair on my chest).  The instruments were replaced; the hair removed; and testing resumed.  During the stress test the computer measuring my heart gave me too many beats per minute for the work I was doing.  Dr. Daum could see from  simultaneous charts that it was counting some of the minor beats as major beats so he could adjust his observations and conclusions appropriately ( he didn’t offer to let me reprogram the computer).

Turns out my heart works fine for now except for a little valve leakage.  But, if Dr. Daum had been reading the results of a test administered by someone else, I think it is quite possible that the anomalies would have led him to the wrong conclusion.  At best I would have had to take the tests again.  At worst I might have been scared or gotten the wrong medical advice.  Being hands on meant that Dr. Daum was seeing the real data and NOT the anomalies.

Same thing works for management – especially for a CEO. You gotta be hands on.  Obviously doesn’t mean you know everything or do everything but you still gotta be hands on.  Otherwise you end up managing either to the anomalies in the data or to badly filtered second-hand information.

I was too hands on as a CEO, didn’t delegate enough.  But I did know what was happening in my companies.  From the beginning we built web access into our monitoring systems at wholesale VoIP carrier ITXC.  Wherever I was in the world, I could watch the flow of voice minutes through our system or between any two locations or carriers in the world; the reports were at most 15 minutes old.  I watched obsessively from the initial trickle until the time we were doing nearly a billion minutes a month and were one of the largest wholesale international carriers in the world.

Often when I thought I saw something wrong, it was an instrumentation error.  Then  I could make sure the instrument was fixed.  Once Network Operations gets too many false alarms, they start ignoring the real ones.  It’s human nature.  Sometimes I spotted things other people didn’t.  That meant either that we needed better tools, better training, or better people. Sometimes I saw opportunities to make things better; sometimes I saw business rather than technical problems – sudden loss of traffic from a specific carrier or too much traffic from a carrier, which meant we better run a quick credit check and make sure we weren’t getting the traffic because everybody else had cut them off.

In departmental reviews or staff meeting, people knew to be prepared to discuss what went wrong and how they planned to fix it.  It’s very important that everyone in the company believe that you have eyes in the back of your head and never sleep so that they will not try to hide problems from you or gloss over them.  It is important that you discover problems before your customers do.

BTW, I had great people at ITXC.  Sometimes my hands on approach probably frustrated them.  I think it also gave them assurance that I knew who was contributing and who wasn’t and that I cared passionately about what they were doing and how they were doing it.  I’m also sure I didn’t know as much as I think I did about what was going on and that they could tell you plenty of what I missed.

When I was at Microsoft in the early 90s Bill Gates was very hands on.  He reviewed every product and strategy regularly and personally.  We always assumed he was attentive although this was a little hard to tell because he often rocked back and forth with his eyes closed during presentations.  But he drilled down.  You brought the people doing the work to many of these reviews and Bill didn’t hesitate to question (or terrorize) them.  Bill remembered stuff from one review to another.  I’m sure he didn’t remember everything but you couldn’t tell what he was going to remember so subtly changing your story (or dates, especially dates) was dangerous.

Being hands on let Bill Gates make the transition from single talent to startup guy to CEO of a fast growing company to world domination.  Don’t know how hands on Bill is now but he certainly was with 10,000 employees.

They say the captain of a ship wakes up if the pitch of the engines or the motion through the sea changes.  You have to have the same sense for your company.  You don’t get it by being an imperial CEO too important to have hands on or talk to the crew.

Be Prepared!

Mary and I've known Rob Shurtleff for a long time.  He was a program manger at Microsoft (tough job) when I first met him.  He was our customer for a while; helped recruit me to Microsoft; and we worked together there.  He's been a successful entrepreneur and investor and is now a VC.  But he's also always been a Boy Scout in the best sense of the word.

Rob sent me the guest blog below:

Many years ago when I worked at HP we were all encouraged to take public service classes like CPR. When our son joined a Boy Scout troop, I tagged along and took the course again. Knowing Tom and Mary have been active in Red Cross activities for many years led me to share the following story.

Saturday night I was at a remote restaurant when the call went out for someone that knew CPR. I looked around and found none of the 30 or so folks in the room indicated that they were trained. With much trepidation, I raised my hand...

Jumping to the end of the story, I didn't need to do full CPR, however knowing the simple ABC CPR drill (step A was sufficient, getting an airway cleared) was adequate to stabilize an elderly gentleman for the thirty minutes it took the EMTs to arrive on the scene.

After the situation had been handed off to the professionals, a few thoughts crystallized:

I am sure in casual conversation if you had asked me to recite the ABCs of CPR, I might have struggled, but the combination of adrenaline and the urgency of the moment popped that training right to top.

I realized how grateful I was that I had picked up this training. If you get a chance, take that refresher course or introductory course in CPR. Although I was scared stiff when I raised my hand, I know I would have been much more uncomfortable if no one in the room could have helped.  You never know when CPR skill will be needed.

This is Tom again:

Mary and I get our CPR training and refreshers at the Red Cross.  Never had to use it but hope Rob's right that adrenaline'll will help and not hurt my ability to perform.  I am rusty though and will get a refresher.  It's too dumb not to.

Atrial Fibbers

My brother Bill has a condition called atrial fibrillation.  My friend Jeff Jarvis also has atrial fib.  Jeff describes an incident as “a convention of Mexican jumping beans is staging a revolt somewhere south of my sternum.”  It’s easy to understand why it is upsetting to have your heart suddenly and palpably beat to a different drummer.

Since Billy’s an MD and Jeff is an uber-blogger whose buzzmachine.com is very widely read and widely quoted, there’s a chance they’ll be able to do something to help find causes, cures, or palliatives for this somewhat frightening and somewhat mysterious malady.  It’s all based on the blogosphere being a two-way street.

As Jeff posted today, he and Bill are interested in collecting both survey forms AND anecdotal evidence from people with afib and those who treat them.  Anecdotal evidence is usually frowned on by scientists; but, if there’s enough of it and if it’s mined properly, it can be invaluable in finding in finding elusive correlations,

Since blogging and commenting on blogs and in forums gives the willing a way to communicate at almost no cost (assuming they already have a computer and an Internet connection), collecting huge amounts of data is cheaply doable – just depends on having enough willing data donors.  One of the tools to analyze anecdotal data can be the search engine indexing technology which is already so much a part of our lives.

If we let the indexer decide which words co-occur in anecdotes, we eliminate the danger which so often hampers traditional research – preconceptions.  Also, as Jeff points out, statistical techniques can eliminate the coincidences and crackpot theories – even outright spoofing – which is bound to be contributed as well.  This is data mining with the most noble of purposes.

Even if nothing is found but clues, that’s a great start.

If you have experience with atrial fib and want to help, here’s how to get started:

1. read Jeff’s posts in his category afib.
2. if you want to post something right away, do that as a comment on one of these posts.
3. if you are a blogger yourself and are writing about afib, please use the category afib so your writing can be found.  Make sure your posts are tagged with afib in Technorati and elsewhere.
4. if you use del.icio.us or some like tagging tool, tag relevant articles you read with afib.  Of course fine to use other tags to further define.
5. if you’re a digg or pligg (medical digg) user, digg or pligg articles you think are relevant.
6. be sure to comment on Jeff’s post or mine if you have more ideas to contribute on how to do this.
7. Keep reading buzzmachine.com to look for the survey form and further developments.  I’ll link to major posts on this subject there from Fractals of Change.
8. If you want to know what’s being posted about afib, you can subscribe to this url http://www.technorati.com/watchlists/rss.html?wid=295728 to get the latest as gathered by Technorati.