All posts by blackfriar

business, complex adaptive systems, cool, health market quality, healthcare, management and leadership, meaning, policy, politics, storytelling

Thanks CT.

This is bang on. Good to see some good people agreeing. I don’t feel nearly as mad.

http://www.afr.com/Page/Uuid/1fec72e4-07d2-11e4-a983-9084720e3436

ROSS GARNAUT AND PETER DAWKINS

Melbourne forum aims for politics-free economic thought

PUBLISHED: 8 HOURS 13 MINUTES AGO | UPDATE: 2 HOURS 3 MINUTES AGO

Melbourne forum aims for politics-free economic thought

The discussion of necessary reforms is dominated by special pleading by vested interests. Photo: Gabriele Charotte

ROSS GARNAUT AND PETER DAWKINS

Australia needs rigorous, independent economic policy debate and analysis to inform economic policy. The Melbourne Economic Forum seeks to contribute to meeting that need by bringing to account the considerable analytic capacity in economics based in the city.

A joint endeavour of the University of Melbourne and Victoria University, this new forum will bring together 40 leading economists, from or with institutional connections to Melbourne to discuss the great economic policy issues confronting Australia and the world.

The forum is independent of vested interests and partisan political connections. It will not support the position of any political party or campaign of any group. It will focus on analysis of policy in the public interest. Almost any policy proposal has implications for the distribution of incomes and wealth and income amongst Australians. Our objective will be to make these implications explicit and to point out their implications for wider conceptions of the public interest.

It would be surprising if high quality analysis of policy choice for Australia does not, from time to time, earn the criticism of participants from all corners of the political contest and from many groups with vested interests in particular uses of public resources and government power. The test of the forum’s value will be its success in illuminating the consequences of policy choice and not its immediate and direct influence on government decisions.

Through the final four decades of last century, dispassionate economic analysis and debate played a major role in illuminating government decisions on economic policy. Rational economic analysis became more important in underpinning serious discussion of policy choice. It emerged from interaction of economists in some of the universities with the predecessor to the Productivity Commission, the national media and later the public service and some parts of the political community. This interaction gradually built support for an open, competitive economy. The ideas preceded their influence, but eventually were of large importance in guiding the reform era under the Hawke, Keating and Howard governments. The resulting reform era laid the foundations for 23 years of economic growth without recession.

CHANGE IS A NECESSITY

 

Business organisations and the trade union movement joined the consensus and joined the discussion in constructive ways. The Business Council of Australia was formed to develop policy positions that were in the national economic interest, though not necessarily in the commercial interests of every one of its members.

Both rational economic analysis in the public interest and Australia’s high standard of living have been weakened by developments in the early twenty first century and are now under threat.

As mineral prices fall, productivity growth languishes and our population ages, Australia needs a new program of economic reform. Yet the discussion of necessary reforms is dominated by special pleading by vested interests.

Of course there is room for disagreement about the size of the challenge Australia faces if it is to maintain high levels of employment and prosperity. And different policy prescriptions will have different consequences for the distribution of the burden of adjustment to a more sombre economic outlook. A lazy policy response would shift the burden onto the shoulders of those Australians who lose their jobs or cannot find one.

Yet a budget that is viewed by the community as unfair is inimical to the task of building a consensus for reform.

The Melbourne Economic Forum will contribute to these debates, starting with a session on the economic outlook for Australia and the impacts of alternative policy responses. In September we will take on the international policy challenges most pertinent to the G20 meeting in Australia later in the year.

In November, we will venture into the hazardous territory of tax system reform and federal-state financial relations.

Bi-monthly forums in 2015 will tackle issues such as infrastructure, investment, foreign investment and trade policy.

Reviving the tradition of rigorous, independent policy thinking is not a hankering for the past but an essential precondition for a new wave of economic reform to secure employment growth and rising prosperity for all Australians in a far more challenging global economic environment.

Professor Ross Garnaut is professor of economics at the University of Melbourne. Professor Peter Dawkins is vice-chancellor at Victoria University. For more details on the Melbourne Economic Forum see melbourneeconomicforum.com.au.

The Australian Financial Review

health market quality, policy, politics

Why Good People Do Bad Things

People don’t commit fraud because they are greedy, but because they are nice…

Audio:

http://www.npr.org/2012/05/01/151764534/psychology-of-fraud-why-good-people-do-bad-things

Enron, Worldcom, Bernie Madoff, the subprime mortgage crisis.
Over the past decade or so, news stories about unethical behavior have been a regular feature on TV, a long, discouraging parade of misdeeds marching across our screens. And in the face of these scandals, psychologists and economists have been slowly reworking how they think about the cause of unethical behavior.
In general, when we think about bad behavior, we think about it being tied to character: Bad people do bad things. But that model, researchers say, is profoundly inadequate.
Which brings us to the story of Toby Groves.
Chapter 1
Toby grew up on a farm in Ohio. As a kid, the idea that he was a person of strong moral character was very important to him. Then one Sunday in 1986, when Toby was around 20, he went home for a visit with his family, and he had an experience that made the need to be good dramatically more pressing.
Toby Groves origin story.
Twenty-two years after Toby made that promise to his father, he found himself standing in front of the exact same judge who had sentenced his brother, being sentenced for the exact same crime: fraud.
And not just any fraud — a massive bank fraud involving millions of dollars that drove several companies out of business and resulted in the loss of about a hundred jobs.
In 2008, Toby went to prison, where he says he spent two years staring at a ceiling, trying to understand what had happened.
Was he a bad character? Was it genetic? “Those were things that haunted me every second of every day,” Toby says. “I just couldn’t grasp it.”
This very basic question — what causes unethical behavior? — has been getting a fair amount of attention from researchers recently, particularly those interested in how our brains process information when we make decisions.
And what these these researchers have concluded is that most of us are capable of behaving in profoundly unethical ways. And not only are we capable of it — without realizing it, we do it all the time.
Chapter 2
Consider the case of Toby Groves.
In the early 1990s, a couple of years after graduating from college, Toby decided to start his own mortgage loan company — and that promise to his father was on his mind.
2a
So Toby decided to lie.
He told the bank that he was making $350,000, when in reality he was making nowhere near that.
This is the first lie Toby told — the unethical act that opened the door to all the other unethical acts. So, what was going on in his head at the time?
“There wasn’t much of a thought process,” he says. “I felt like, at that point, that was a small price to pay and almost like a cost of doing business. You know, things are going to happen, and I just needed to do whatever I needed to do to fix that. It wasn’t like … I didn’t think that I was going to be losing money forever or anything like that.”
Consider that for a moment.
Here is a man who stood with his heartbroken father and pledged to behave ethically. Anyone involved in the mortgage business knows that it is both unethical and illegal to lie on a mortgage application.
How could that promise be so easily broken?
The Promise Flashback 2Chapter 3
To understand, says Ann Tenbrunsel, a researcher at Notre Dame who studies unethical behavior, you have to consider what this looks like from Toby’s perspective.
There is, she says, a common misperception that at moments like this, when people face an ethical decision, they clearly understand the choice that they are making.
“We assume that they can see the ethics and are consciously choosing not to behave ethically,” Tenbrunsel says.
This, generally speaking, is the basis of our disapproval: They knew. They chose to do wrong.
But Tenbrunsel says that we are frequently blind to the ethics of a situation.
Over the past couple of decades, psychologists have documented many different ways that our minds fail to see what is directly in front of us. They’ve come up with a concept called “bounded ethicality”: That’s the notion that cognitively, our ability to behave ethically is seriously limited, because we don’t always see the ethical big picture.
One small example: the way a decision is framed. “The way that a decision is presented to me,” says Tenbrunsel, “very much changes the way in which I view that decision, and then eventually, the decision it is that I reach.”
Essentially, Tenbrunsel argues, certain cognitive frames make us blind to the fact that we are confronting an ethical problem at all.
Tenbrunsel told us about a recent experiment that illustrates the problem. She got together two groups of people and told one to think about a business decision. The other group was instructed to think about an ethical decision. Those asked to consider a business decision generated one mental checklist; those asked to think of an ethical decision generated a different mental checklist.
Tenbrunsel next had her subjects do an unrelated task to distract them. Then she presented them with an opportunity to cheat.
Those cognitively primed to think about business behaved radically different from those who were not — no matter who they were, or what their moral upbringing had been.
“If you’re thinking about a business decision, you are significantly more likely to lie than if you were thinking from an ethical frame,” Tenbrunsel says.
According to Tenbrunsel, the business frame cognitively activates one set of goals — to be competent, to be successful; the ethics frame triggers other goals. And once you’re in, say, a business frame, you become really focused on meeting those goals, and other goals can completely fade from view.
4b
Tenbrunsel listened to Toby’s story, and she argues that one way to understand Toby’s initial choice to lie on his loan application is to consider the cognitive frame he was using.
“His sole focus was on making the best business decision,” she says, which made him blind to the ethics.
Obviously we’ll never know what was actually going through Toby’s mind, and the point of raising this possibility is not to excuse Toby’s bad behavior, but simply to demonstrate in a small way the very uncomfortable argument that these researchers are making:
That people can be genuinely unaware that they’re making a profoundly unethical decision.
It’s not that they’re evil — it’s that they don’t see.
And if we want to attack fraud, we have to understand that a lot of fraud is unintentional.
Chapter 4
Tenbrunsel’s argument that we are often blind to the ethical dimensions of a situation might explain part of Toby’s story, his first unethical act. But a bigger puzzle remains: How did Toby’s fraud spread? How did a lie on a mortgage application balloon into a $7 million fraud?
According to Toby, in the weeks after his initial lie, he discovered more losses at his company — huge losses. Toby had already mortgaged his house. He didn’t have any more money, but he needed to save his business.
The easiest way for him to cover the mounting losses, he reasoned, was to get more loans. So Toby decided to do something that is much harder to understand than lying on a mortgage application: He took out a series of entirely false loans — loans on houses that didn’t exist.
Creating false loans is not an easy process. You have to manufacture from thin air borrowers and homes and the paperwork to go with them.
Toby was CEO of his company, but this was outside of his skill set. He needed help — people on his staff who knew how loan documents should look and how to fake them.
And so, one by one, Toby says, he pulled employees into a room.
3a
“Maybe that was the most shocking thing,” Toby says. “Everyone said, ‘OK, we’re in trouble, we need to solve this. I’ll help you. You know, I’ll try to have that for you tomorrow.’ ”
According to Toby, no one said no.
Most of the people who helped Toby would not talk to us because they didn’t want to expose themselves to legal repercussions.
Of the four people at his company Toby told us about, we were able to speak about the fraud with only one — a woman on staff named Monique McDowell. She was involved in fabricating documents, and her description of what happened and how it happened completely conforms to Toby’s description.
If you accept what they’re saying as true, then that raises a troubling scenario, because we expect people to protest when they’re asked to do wrong. But Toby’s employees didn’t. What’s even more troubling is that according to Toby, it wasn’t just his employees: “I mean, we had to have assistance from other companies to pull this off,” he says.
To make it look like a real person closed on a real house, Toby needed a title company to sign off on the fake documents his staff had generated. And so after he got his staff onboard, Toby says he made some calls and basically made the same pitch he’d given his employees.
“It was, ‘Here is what happened. Here is the only way I know to fix it, and if you help me, great. If you won’t, I understand.’ Nobody said, ‘Maybe we’ll think about this. … Within a few minutes [it was], ‘Yes, I’ll help you.’ ”
So here we have people outside his company, agreeing to do things completely illegal and wrong.
Again, we contacted several of the title companies. No one would speak to us, but it’s clear from the legal cases that title companies were involved. One title company president ended up in jail because of his dealings with Toby; another agreed to a legal resolution.
So how could it be that easy?
Chapter 5
Typically when we hear about large frauds, we assume the perpetrators were driven by financial incentives. But psychologists and economists say financial incentives don’t fully explain it. They’re interested in another possible explanation: Human beings commit fraud because human beings like each other.
We like to help each other, especially people we identify with. And when we are helping people, we really don’t see what we are doing as unethical.
Lamar Pierce, an associate professor at Washington University in St. Louis, points to the case of emissions testers. Emissions testers are supposed to test whether or not your car is too polluting to stay on the road. If it is, they’re supposed to fail you. But in many cases, emissions testers lie.
“Somewhere between 20 percent and 50 percent of cars that should fail are passed — are illicitly passed,” Pierce says.
Financial incentives can explain some of that cheating. But Pierce and psychologist Francesca Gino of Harvard Business School say that doesn’t fully capture it.
They collected hundreds of thousands of records and were actually able to track the patterns of individual inspectors, carefully monitoring those they approved and those they denied. And here is what they found:
If you pull up in a fancy car — say, a BMW or Ferrari — and your car is polluting the air, you are likely to fail. But pull up in a Honda Civic, and you have a much better chance of passing.
cars
Why?
“We know from a lot of research that when we feel empathy towards others, we want to help them out,” says Gino.
Emissions testers — who make a modest salary — see a Civic and identify, they feel empathetic.
Essentially, Gino and Pierce are arguing that these testers commit fraud not because they are greedy, but because they are nice.
“And most people don’t see the harm in this,” says Pierce. “That is the problem.”
Pierce argues that cognitively, emissions testers can’t appreciate the consequences of their fraud, the costs of the decision that they are making in the moment. The cost is abstract: the global environment. They are literally being asked to weigh the costs to the global environment against the benefits of passing someone who is right there who needs help. We are not cognitively designed to do that.
“I’ve never talked to a mortgage broker who thought, ‘When I help someone get into a loan by falsifying their income, I deeply consider whether or not I would destabilize the world economy,’ ” says Pierce. “You are helping someone who is real.”
Gino and Pierce argue that Toby’s staff was faced with the same kind of decision: future abstract consequences, or help out the very real person in front of them.
And so without focusing on the ethics of what they were doing, they helped out a person who was not focusing on the ethics, either. And together they perpetrated a $7 million fraud.
Chapter 6
As for Toby, he says that maintaining the giant lie he’d created was exhausting day in and day out.
5a
So in 2006, when two FBI agents showed up at his office, he quickly confessed everything. He says he was relieved.
Two years later, he was standing in front of the same judge who had sentenced his brother. A short time after that, he was in jail, grateful that his father wasn’t alive to see him, wondering how he ended up where he did.
“The last thing in the world that I wanted to do in my life would be to break that promise to my father,” he says. “It haunts me.”
The Promise Flashback 1
Now if these psychologists and economists are right, if we are all capable of behaving profoundly unethically without realizing it, then our workplaces and regulations are poorly organized. They’re not designed to take into account the cognitively flawed human beings that we are. They don’t attempt to structure things around our weaknesses.
Some concrete proposals to do that are on the table. For example, we know that auditors develop relationships with clients after years of working together, and we know that those relationships can corrupt their audits without them even realizing it. So there is a proposal to force businesses to switch auditors every couple of years to address that problem.
Another suggestion: A sentence should be placed at the beginning of every business contract that explicitly says that lying on this contract is unethical and illegal, because that kind of statement would get people into the proper cognitive frame.
And there are other proposals, of course.
Or, we could just keep saying what we’ve always said — that right is right, and wrong is wrong, and people should know the difference.
Web story produced and edited by Maria Godoy; on-air story edited by Planet Money and Anne Gudenkauf

data saving lives, entrepreneurship, healthcare, healthy habits, quotes & aphorisms

Google founders on their distaste for health data regulators

 

http://www.forbes.com/sites/davidshaywitz/2014/07/04/google-co-founders-to-healthcare-were-just-not-that-into-you/

David ShaywitzContributor

I write about entrepreneurial innovation in medicine.

Opinions expressed by Forbes Contributors are their own.

PHARMA & HEALTHCARE  17,430 views

Google Co-Founders To Healthcare: We’re Just Not That Into You

Comment Now

At his yearly CEO summit, noted VC Vinod Khosla spoke with Google co-foundersSergey Brin and Larry Page (file under “King, Good To Be The”).

Towards the end of a wide-ranging conversation that encompassed driverless cars, flying wind turbines, and high-altitude balloons providing internet access, Khosla began to ask about health.

Specifically, Khosla wondered whether they could “imagine Google becoming a health company? Maybe a larger business than the search business or the media business?”

Their response, surprisingly, was basically, “no.”  While glucose-sensing contact lenses might be “very cool,” in the words of Larry Page, Brin notes that,

“Generally, health is just so heavily regulated. It’s just a painful business to be in. It’s just not necessarily how I want to spend my time. Even though we do have some health projects, and we’ll be doing that to a certain extent. But I think the regulatory burden in the U.S. is so high that think it would dissuade a lot of entrepreneurs.”

Adds Page,

“We have Calico, obviously, we did that with Art Levinson, which is pretty independent effort. Focuses on health and longevity. I’m really excited about that. I am really excited about the possibility of data also, to improve health. But that’s– I think what Sergey’s saying, it’s so heavily regulated. It’s a difficult area. I can give you an example. Imagine you had the ability to search people’s medical records in the U.S.. Any medical researcher can do it. Maybe they have the names removed. Maybe when the medical researcher searches your data, you get to see which researcher searched it and why. I imagine that would save 10,000 lives in the first year. Just that. That’s almost impossible to do because of HIPAA. I do worry that we regulate ourselves out of some really great possibilities that are certainly on the data-mining end.”

Khosla then asked a question about a use case involving one of my favorite portfolio companies of his, Ginger.io, related to the monitoring of a patient’s psychiatric state.

Responded Page, “I was talking to them about that last night. It was cool.”

That pretty much captures Brin and Page’s view of healthcare – fun to work on a few “cool” projects, but beyond that, the regulatory challenges are just too great to warrant serious investment.

(To be clear, Brin and Page emphasized their personal distance from Google Ventures, which has conspicuously pursued a range of health-related investments.  “Medicine needs to come out of the dark ages,” Google Ventures Managing Partner Bill Maris recently told Re/code.)

On the face of it, it’s pretty amazing that a company that doesn’t think twice about tackling absurdly challenging scientific projects (eg driverless cars) is brought to its knees by the prospect of dealing with the byzantine regulation around healthcare (and more generally, our “calcified hairball” system of care, as VC Esther Dyson has put it).  A similar sentiment has been expressed by VC and Uber-investor Bill Gurley as well; evidently taking on taxi and limousine commissions is more palatable than taking on the healthcare establishment.

Yet others – with eyes wide open – are taking on the challenge.  AthenaHealth’s Jonathan Bush, for instance, is maddened by the challenges of regulatory capture (see my WSJ review of his book here), yet he shows up each day to fight the battle.

Similarly, while I’ve not always agreed with Khosla’s perspective on algorithims, I’ve consistently admired his willingness to enter the fray (see here and here).

This morning on Twitter, he asked whether his willingness to invest in healthcare means he’s courageous (as I suggested) or naïve.

The answer, I imagine, is probably both.  The challenges in healthcare, especially regarding regulation, are real, and disruption is hard to come by.  As Brown University emergency physician Megan Ranney comments, there are “big risks, lots of roadblocks” but also “huge potential for humankind.”

I suspect the key to overcoming the regulatory roadblocks will be making the use cases more persuasive and immediate.  After all, most people have the enlightened self-interest to embrace life-saving innovations (anti-vaxers notwithstanding).

The challenge is that to this point, the benefits of technology generally seem less than persuasive – the tech seems “cool,” as Page and Brin might say, but not exactly convincing.  I’m not just talking about Google Glass (which perhaps defines the genre) and Google’s contact lenses (I’ve not met many experts who’ve bought into this technology), but also approaches like 23andMe.  When they ran up against regulators, there wasn’t exactly an outcry, “this technology has transformed my life and now you’re shutting it down.”  If only.

In contrast, efforts to shut down Uber typically generate far more impassioned protests.  Why? Because it’s immediately apparent to users how Uber improves their lives.  To use the service once is to be convinced.

What healthcare technology needs is to find a way to be similarly indispensable.  Page may cite the potential to save 10,000 lives, but the challenge is to convince anyone this applies to their own N of 1.  More directed examples of instances where technology could immediately impact lives, and could impact more were it not for oppressive regulation, would go a long way to rolling back the regulations that seem to impede progress.

Rather than focusing on the thousands of lives that could be saved in an imagined future, technologists would do well to provide a compelling demonstration of what big data and sophisticated analytics can achieve for the health of discrete individuals in the present, even with current limitations; success here could help innovative entrepreneurs push back on antiquated regulations, and bring healthcare delivery into the modern age while ushering in a new era in biomedical research driven by access to rich coherent datasets.

The truth is, Page is probably right about the underlying opportunity.  In particular, as I’ve long-argued, there’s tremendous potential to be found by thoughtfully combining comprehensive genomic and rich phenotypic data – immediate opportunities to impact clinical care, and the chance for a longer-term impact on scientific understanding.

I’m perhaps more optimistic than Page is, however, both about our collective ability to succeed meaningfully even within the constraints of our existing system, and about the ability of demonstrated success to move even the most intransigent stakeholders.

family matters

Philosopher’s Mail

 

 

http://www.philosophersmail.com/relationships/how-we-end-up-marrying-the-wrong-people/

How we end up marrying the wrong people

Anyone we could marry would, of course, be a little wrong for us. It is wise to be appropriately pessimistic here. Perfection is not on the cards. Unhappiness is a constant. Nevertheless, one encounters some couples of such primal, grinding mismatch, such deep-seated incompatibility, that one has to conclude that something else is at play beyond the normal disappointments and tensions of every long-term relationship: some people simply shouldn’t be together.

Prince Charles, Prince of Wales with his fiance Lady Diana S

How do the errors happen? With appalling ease and regularity. Given that marrying the wrong person is about the single easiest and also costliest mistake any of us can make (and one which places an enormous burden on the state, employers and the next generation), it is extraordinary, and almost criminal, that the issue of marrying intelligently is not more systematically addressed at a national and personal level, as road safety or smoking are.

It’s all the sadder because in truth, the reasons why people make the wrong choices are easy to lay out and unsurprising in their structure. They tend to fall into some of the following basic categories.

One: We don’t understand ourselves

Exhibition - 2013

When first looking out for a partner, the requirements we come up with are coloured by a beautiful non-specific sentimental vagueness: we’ll say we really want to find someone who is ‘kind’ or ‘fun to be with’, ‘attractive’ or ‘up for adventure…’

It isn’t that such desires are wrong, they are just not remotely precise enough in their understanding of what we in particular are going to require in order to stand a chance of being happy – or, more accurately, not consistently miserable.

All of us are crazy in very particular ways. We’re distinctively neurotic, unbalanced and immature, but don’t know quite the details because no one ever encourages us too hard to find them out. An urgent, primary task of any lover is therefore to get a handle on the specific ways in which they are mad. They have to get up to speed on their individual neuroses. They have to grasp where these have come from, what they make them do – and most importantly, what sort of people either provoke or assuage them. A good partnership is not so much one between two healthy people (there aren’t many of these on the planet), it’s one between two demented people who have had the skill or luck to find a non-threatening conscious accommodation between their relative insanities.

The very idea that we might not be too difficult as people should set off alarm bells in any prospective partner. The question is just where the problems will lie: perhaps we have a latent tendency to get furious when someone disagrees with us, or we can only relax when we are working, or we’re a bit tricky around intimacy after sex, or we’ve never been so good at explaining what’s going on when we’re worried. It’s these sort of issues that – over decades – create catastrophes and that we therefore need to know about way ahead of time, in order to look out for people who are optimally designed to withstand them. A standard question on any early dinner date should be quite simply: ‘And how are you mad?’

Marital Problems

The problem is that knowledge of our own neuroses is not at all easy to come by. It can take years and situations we have had no experience of. Prior to marriage, we’re rarely involved in dynamics that properly hold up a mirror to our disturbances. Whenever more casual relationships threaten to reveal the ‘difficult’ side of our natures, we tend to blame the partner – and call it a day. As for our friends, they predictably don’t care enough about us to have any motive to probe our real selves. They only want a nice evening out. Therefore, we end up blind to the awkward sides of our natures. On our own, when we’re furious, we don’t shout, as there’s no one there to listen – and therefore we overlook the true, worrying strength of our capacity for fury. Or we work all the time without grasping, because there’s no one calling us to come for dinner, how we manically use work to gain a sense of control over life – and how we might cause hell if anyone tried to stop us. At night, all we’re aware of is how sweet it would be to cuddle with someone, but we have no opportunity to face up to the intimacy-avoiding side of us that would start to make us cold and strange if ever it felt we were too deeply committed to someone. One of the greatest privileges of being on one’s own is the flattering illusion that one is, in truth, really quite an easy person to live with.

With such a poor level of understanding of our characters, no wonder we aren’t in any position to know who we should be looking out for.

Two: We don’t understand other people

This problem is compounded because other people are stuck at the same low level of self-knowledge as we are. However well-meaning they might be, they too are in no position to grasp, let alone inform us, of what is wrong with them.

Naturally, we make a stab at trying to know them. We go and visit their families, perhaps the place they first went to school. We look at photos, we meet their friends. All this contributes to a sense we’ve done our homework. But it’s like a novice pilot assuming they can fly after sending a paper plane successfully around the room.

COUPLES - 1964

In a wiser society, prospective partners would put each other through detailed psychological questionnaires and send themselves off to be assessed at length by teams of psychologists. By 2100, this will no longer sound like a joke. The mystery will be why it took humanity so long to get to this point.

We need to know the intimate functioning of the psyche of the person we’re planning to marry. We need to know their attitudes to, or stance on, authority, humiliation, introspection, sexual intimacy, projection, money, children, aging, fidelity and a hundred things besides. This knowledge won’t be available via a standard chat.

In the absence of all this, we are led – in large part – by what they look like. There seems to be so much information to be gleaned from their eyes, nose, shape of forehead, distribution of freckles, smiles… But this is about as wise as thinking that a photograph of the outside of a power station can tell us everything we need to know about nuclear fission.

We ‘project’ a range of perfections into the beloved on the basis of only a little evidence. In elaborating a whole personality from a few small – but hugely evocative – details, we are doing for the inner character of a person what our eyes naturally do with the sketch of a face.

image001

We don’t see this as a picture of someone who has no nostrils, eight strands of hair and no eyelashes. Without even noticing that we are doing it, we fill in the missing parts. Our brains are primed to take tiny visual hints and construct entire figures from them – and we do the same when it comes to the character of our prospective spouse. We are – much more than we give ourselves credit for, and to our great cost – inveterate artists of elaboration.

The level of knowledge we need for a marriage to work is higher than our society is prepared to countenance, recognise and accommodate for – and therefore our social practices around getting married are deeply wrong.

Three: We aren’t used to being happy

We believe we seek happiness in love, but it’s not quite as simple. What at times it seems we actually seek is familiarity – which may well complicate any plans we might have for happiness.

We recreate in adult relationships some of the feelings we knew in childhood. It was as children that we first came to know and understand what love meant. But unfortunately, the lessons we picked up may not have been straightforward. The love we knew as children may have come entwined with other, less pleasant dynamics: being controlled, feeling humiliated, being abandoned, never communicating, in short: suffering.

As adults, we may then reject certain healthy candidates whom we encounter, not because they are wrong, but precisely because they are too well-balanced (too mature, too understanding, too reliable), and this rightness feels unfamiliar and alien, almost oppressive. We head instead to candidates whom our unconscious is drawn to, not because they will please us, but because they will frustrate us in familiar ways.

We marry the wrong people because the right ones feel wrong – undeserved; because we have no experience of health, because we don’t ultimately associate being loved with feeling satisfied.

Four: Being single is so awful

One is never in a good frame of mind to choose a partner rationally when remaining single is unbearable. We have to be utterly at peace with the prospect of many years of solitude in order to have any chance of forming a good relationship. Or we’ll love no longer being single rather more than we love the partner who spared us being so.

Unfortunately, after a certain age, society makes singlehood dangerously unpleasant. Communal life starts to wither, couples are too threatened by the independence of the single to invite them around very often, one starts to feel a freak when going to the cinema alone. Sex is hard to come by as well. For all the new gadgets and supposed freedoms of modernity, it can be very hard to get laid – and expecting to do so regularly with new people is bound to end in disappointment after 30.

VARIOUS

Far better to rearrange society so that it resembles a university or a kibbutz – with communal eating, shared facilities, constant parties and free sexual mingling… That way, anyone who did decide marriage was for them would be sure they were doing it for the positives of coupledom rather than as an escape from the negatives of singlehood.

When sex was only available within marriage, people recognised that this led people to marry for the wrong reasons: to obtain something that was artificially restricted in society as a whole. People are free to make much better choices about who they marry now they’re not simply responding to a desperate desire for sex.

But we retain shortages in other areas. When company is only properly available in couples, people will pair up just to spare themselves loneliness. It’s time to liberate ‘companionship’ from the shackles of coupledom, and make it as widely and as easily available as sexual liberators wanted sex to be.

Five: Instinct has too much prestige

Medieval miniature. Meeting of the Roman Senate. Discussion on marriage between a plebeian woman and a roman patrician. 15th century.

Back in the olden days, marriage was a rational business; all to do with matching your bit of land with theirs. It was cold, ruthless and disconnected from the happiness of the protagonists. We are still traumatised by this.

What replaced the marriage of reason was the marriage of instinct, the Romantic marriage. It dictated that how one felt about someone should be the only guide to marriage. If one felt ‘in love’, that was enough. No more questions asked. Feeling was triumphant. Outsiders could only applaud the feeling’s arrival, respecting it as one might the visitation of a divine spirit. Parents might be aghast, but they had to suppose that only the couple could ever know. We have for three hundred years been in collective reaction against thousands of years of very unhelpful interference based on prejudice, snobbery and lack of imagination.

T,V, and Films, 16th January 1954, San Francisco, USA, Legendary Hollywood Film actress Marilyn Monroe prepares to kiss her husband former US Baseball player Joe DiMaggio after their wedding

So pedantic and cautious was the old ‘marriage of reason’ that one of the features of the marriage of feeling is its belief that one shouldn’t think too much about why one is marrying. To analyse the decision feels ‘un-Romantic’. To write out charts of pros and cons seems absurd and cold. The most Romantic thing one can do is just to propose quickly and suddenly, perhaps after only a few weeks, in a rush of enthusiasm – without any chance to do the horrible ‘reasoning’ that guaranteed misery to people for thousands of years previously. The recklessness at play seems a sign that the marriage can work, precisely because the old kind of ‘safety’ was such a danger to one’s happiness.

Six: We don’t go to Schools of Love

School children walk behind three-dimens

The time has come for a third kind of marriage. The marriage of psychology. One where one doesn’t marry for land, or for ‘the feeling’ alone, but only when ‘the feeling’ has been properly submitted to examination and brought under the aegis of a mature awareness of one’s own and the other’s psychology.

Presently, we marry without any information. We almost never read books specifically on the subject, we never spend more than a short time with children, we don’t rigorously interrogate other married couples or speak with any sincerity to divorced ones. We go into it without any insightful reasons as to why marriages fail – beyond what we presume to be the idiocy or lack of imagination of their protagonists.

In the age of the marriage of reason, one might have considered the following criteria when marrying:

– who are their parents

– how much land do they have

– how culturally similar are they

In the Romantic age, one might have looked out for the following signs to determine rightness:

– one can’t stop thinking of a lover

– one is sexually obsessed

– one thinks they are amazing

– one longs to talk to them all the time

We need a new set of criteria. We should wonder:

– how are they mad

– how can one raise children with them

– how can one develop together

– how can one remain friends

Katharine Hepburn

Seven: We want to freeze happiness

We have a desperate and fateful urge to try to make nice things permanent. We want to own the car we like, we want to live in the country we enjoyed as a tourist. And we want to marry the person we are having a terrific time with.

We imagine that marriage is a guarantor of the happiness we’re enjoying with someone. It will make permanent what might otherwise be fleeting. It will help us to bottle our joy – the joy we felt when the thought of proposing first came to us: we were in Venice, on the lagoon, in a motorboat, with the evening sun throwing gold flakes across the sea, the prospect of dinner in a little fish restaurant, our beloved in a cashmere jumper in our arms… We got married to make this feeling permanent.

Unfortunately, there is no causal necessary connection between marriage and this sort of feeling. The feeling was produced by Venice, a time of day, a lack of work, an excitement at dinner, a two month acquaintance with someone… none of which ‘marriage’ increases or guarantees.

Marriage doesn’t freeze the moment at all. That moment was dependent on the fact that you had only known each other for a bit, that you weren’t working, that you were staying in a beautiful hotel near the Grand Canal, that you’d had a pleasant afternoon in the Guggenheim museum, that you’d just had a chocolate gelato…

Getting married has no power to keep a relationship at this beautiful stage. It is not in command of the ingredients of our happiness at that point. In fact, marriage will decisively move the relationship on to another, very different moment: to a suburban house, a long commute, two small children. The only ingredient in common is the partner. And that might have been the wrong ingredient to bottle.

The Impressionist painters of the nineteenth century had an implicit philosophy of transience that points us in a wiser direction. They accepted the transience of happiness as an inherent feature of existence and could in turn help us to grow more at peace with it. Sisley’s painting of a winter scene in France focuses on a set of attractive but utterly fugitive things. Towards dusk, the sun nearly breaks through the landscape. For a little time, the glow of the sky makes the bare branches less severe. The snow and the grey walls have a quiet harmony; the cold seems manageable, almost exciting. In a few minutes, night will close in.

wateringplaceAlfred Sisley, The Watering Place at Marly-le-Roi, 1875

Impressionism is interested in the fact that the things we love most change, are only around a very short time and then disappear. It celebrates the sort of happiness that lasts a few minutes, rather than years. In this painting, the snow looks lovely; but it will melt. The sky is beautiful at this moment, but it is about to go dark. This style of art cultivates a skill that extends far beyond art itself: a skill at accepting and attending to short-lived moments of satisfaction.

The peaks of life tend to be brief. Happiness doesn’t come in year-long blocks. With the Impressionists to guide us, we should be ready to appreciate isolated moments of everyday paradise whenever they come our way, without making the mistake of thinking them permanent; without the need to turn them into a ‘marriage’.

Eight: We believe we are special

The statistics are not encouraging. Everyone has before them plenty of examples of terrible marriages. They’ve seen their friends try it and come unstuck. They know perfectly well that – in general – marriages face immense challenges. And yet we do not easily apply this insight to our own case. Without specifically formulating it, we assume that this is a rule that applies to other people.

That’s because a raw statistical chance of one in two of failing at marriage seems wholly acceptable, given that – when one is in love – one feels one has already beaten far more extraordinary odds. The beloved feels like around one in a million. With such a winning streak, the gamble of marrying a person seem entirely containable.

We silently exclude ourselves from the generalisation. We’re not to be blamed for this. But we could benefit from being encouraged to see ourselves as exposed to the general fate.

Nine: We want to stop thinking about Love

Before we get married, we are likely to have had many years of turbulence in our love lives. We have tried to get together with people who didn’t like us, we’ve started and broken up unions, we’ve gone out for endless parties, in the hope of meeting someone, and known excitement and bitter disappointments.

No wonder if, at a certain point, we have enough of all that. Part of the reason we feel like getting married is to interrupt the all-consuming grip that love has over our psyches. We are exhausted by the melodramas and thrills that go nowhere. We are restless for other challenges. We hope that marriage can conclusively end love’s painful rule over our lives.

Wedding Bells Ring For Same Sex Couple In Washington, D.C.

It can’t and won’t: there is as much doubt, hope, fear, rejection and betrayal in a marriage as there is in single life. It’s only from the outside that a marriage looks peaceful, uneventful and nicely boring.

****

Preparing us for marriage is, ideally, an educational task that falls on culture as a whole. We have stopped believing in dynastic marriages. We are starting to see the drawbacks of Romantic marriages. Now comes the time for psychological marriages.

 

data saving lives, health market quality, healthcare, policy, rapid learning health systems

Healthcare, meet capitalism – Jonathan Bush

The $2.7 trillion industry lacks accountability for exorbitant costs. The system incentivizes doctors (and hospitals) to do tests and procedures, instead of paying them to do their jobs—keeping people healthy. It’s like paying carpenters to use nails.

“The biggest lie that we baked into our thinking,” Bush said in Aspen, is that “starting in 1958, in the wake of World War II, the government wanted to control wage inflation, so they let employers provide healthcare as an incentive (What could go wrong? It’s 1958!)—was this idea that healthcare itself is just a monolithic, identical thing. That there’s no value in price shopping. That there’s no value in choosing whether or not to get [a certain health service]. We act, as a society, on the unconscious level, like we’re not in charge. This is a massive problem. Not just because we utilize expensive things, but because we give up the opportunity for those things to get better.”

 

http://www.theatlantic.com/health/archive/2014/07/a-case-against-donating-to-hospitals/373637/

Video: https://www.youtube.com/watch?v=pWBf7G2JH2M#t=1830

Healthcare, Meet Capitalism

If transparent competition can drive the reinvention of U.S. healthcare, some creative thinkers stand to become unabashedly wealthy—and improve the quality of care in the process.
Athena (Aris Messinis/AFP/Getty)

Self-described “lunatic-fringe disruptors” depict U.S. healthcare like one of Ayn Rand’s dystopias. The $2.7 trillion industry lacks accountability for exorbitant costs. The system incentivizes doctors (and hospitals) to do tests and procedures, instead of paying them to do their jobs—keeping people healthy. It’s like paying carpenters to use nails.

“I believe we are on the cusp of an oil rush—a fabulous revolution of profit-making and cost-saving in health care,” disruptor Jonathan Bush told a rapt audience at the Aspen Ideas Festival last week. In the Rand comparison, Bush might be John Galt—were he not exuding as much benevolence as relentless capitalism. And he’s not giving up on the system; he’s trying to upend it.

Last week I moderated a discussion that became heated—by moderated-panel standards, and by no part of mine—between Bush, Toby Cosgrove (CEO of the Cleveland Clinic), Rushika Fernandopulle (CEO of Iora Health), and Dena Bravata (CMO of Castlight Health). It ended in an emphatic plea by Bush to never donate money to a hospital.

That was met with equal parts laughter and applause. From Cosgrove, seated three inches to his right, neither.

Logos of healthcare disruptors

To Bush, CEO and co-founder of the $4.2 billion health-technology company Athena Health healthcare is a business, driven by markets like any other. Altruism and profit-driven business need not be at odds. It’s incomprehensible and unsustainable that people have no idea what their care costs and have no incentive to consider cheaper options.

“Profit is a dirty word among the corduroy-elbow crowd in the research hospitals and foundations,” Bush wrote in his recently-released book, Where Does It Hurt? “But just like any business, from Samsung to Dogfish Head Brewery, this industry will grow and innovate by figuring out what we need and want, and selling it to us at prices we’re willing and able to pay.”

In Aspen, Bush mentioned Invisalign braces and LASIK surgery as procedures that have been driven by the free market. These things started off exorbitantly expensive, but prices fell and fell. For LASIK, the procedure was “$2,800 per eye [in the 1990s]; now it’s $200 per eye, including a ride to and from the procedure.”

The oft-cited, disquieting numbers—the U.S. spends the largest percentage of its GDP on healthcare of any country (by far) but ranks 42nd in global life expectancy and similarly underwhelms in many other health metrics—are projected to worsen. Massive hospitals systems are buying out their competition across the country, charging exorbitant premiums without incentive to cut costs or optimize the care they provide. Bush’s gushing proposition is that when patients can “shop” for healthcare based on quality and price, it will drive innovation and better care. Innovation will inevitably disrupt the bloated status quo. But the current system has to be allowed to fail. That might sound bleak, but to innovators like Bush, Fernandopulle, and Bravata, it’s an opportunity for reinvention.

Forecasting of this sort is the currency of the Aspen conference (hosted by the Aspen Institute and The Atlantic), but Bush has the infectious passion that makes it feel like he’s one of those people who, while giving a keynote on the need for change, is already halfway out the door to make something happen.

Here’s the second half of the discussion, which neatly explains some fundamental problems with healthcare delivery:

Dena Bravata is the chief medical officer of Castlight, whose platform helps patients compare cost and quality to make informed healthcare decisions—shifting incentives for doctors toward lower-cost, higher-quality care.

Rushika Fernandopulle is a primary care physician and co-founder of a small company called Iora Health that is trying to fix healthcare from the bottom up.

“We start by changing the payment system,” Fernandopulle said, “which I think is part of the problem. Instead of getting paid fee-for-service, we blow that up and say we should get a fixed fee for what we do. That allows us to care for a population, and our job is to keep them healthy. If you believe that, you completely change the delivery model.”

Iora assigns each patient a personal health coach who does the blocking and tackling in dealing with the healthcare system. They interact by email and video chat, reaching out to patients instead of leaving the onus on the patient to follow up on their care. In Fernandopulle’s view, athena health, which is still contingent on the current fee-for-service model, is something of a dinosaur. Fernandopulle is a disruptor of disruptors.

Toby Cosgrove, the former surgeon and current CEO of one of the largest healthcare systems in the U.S., the Cleveland Clinic, cites redundancy: “What we need to understand is that not all hospitals can be all things to all people.” The Cleveland Clinic, for example, has become expert in cardiothoracic surgery, drawing patients from across the country. In Cosgrove’s model, there might be only one hospital in the country that does a certain complex procedure—but it does the procedure extremely well, efficiently, and on a scale that is maximally cost-effective. Drawing on his experience in Vietnam evacuating injured soldiers, Cosgrove argued for moving patients to expert physicians, rather than trying to have sub-sub-specialized experts everywhere.

So the future of U.S. healthcare will not come in the form of more hospitals. As Cosgrove noted, we already have plenty. Hospital occupancy in the U.S. right now is 65 percent. “Twenty years ago [the U.S.] had a million hospital beds, Cosgrove said. “There are now 800,000, and we still have too many.”

Bush recognizes that the core of healthcare is the relationship between the doctor and the patient. He says that any successful health-business model will be predicated on maximizing the act of total presence during a doctor visit. Ancillary staff will do the busy work that might keep a physician away from her patients. The doctor’s undivided attention is what patients want, and giving it is what makes a doctor’s job meaningful and effective. Despite demand from patients and doctors for more time together, Bush notes, the average visit is eight minutes.

When large hospital systems leverage their market position and brand names to overcharge for basic services, they not only subsidize research, but they perpetuate inefficiency. A cornered market favors complacency and maintenance of the status quo. In every other industry, if you’re still using a pager in 2014—as many doctors are—your business fails when your clients go to Iora Health, where they can video chat.

In his book, Bush calculated the fortune that could be made if a person wanted to start their own MRI business. At Massachusetts General Hospital, an MRI can be billed to an insured patient for $5,315. Bush proposes that an industrious person could rent an MRI machine for around $8,000 per month, a suburban park office for $1,000, two technicians for $6,500 each (including benefits), and around $3,000 for taxes and fees. That’s $25,000 per month in cost. If you can do three scans per hour and run twelve hours per day, you’d break even at $28 per MRI.

“The biggest lie that we baked into our thinking,” Bush said in Aspen, is that “starting in 1958, in the wake of World War II, the government wanted to control wage inflation, so they let employers provide healthcare as an incentive (What could go wrong? It’s 1958!)—was this idea that healthcare itself is just a monolithic, identical thing. That there’s no value in price shopping. That there’s no value in choosing whether or not to get [a certain health service]. We act, as a society, on the unconscious level, like we’re not in charge. This is a massive problem. Not just because we utilize expensive things, but because we give up the opportunity for those things to get better.”