Xtranormal makes that Op-Ed zing

With Xtranormal, you choose some visual characters, type a dialog, and produce a video. Regular readers have seen at least one of these productions in this blog recently. (In each case, for those reading in formats which won’t show embedded videos click on [LINK] to get to the YouTube site.)

Here is my first try – took my 60 seconds. The Brits in the audience can groan at the formula. [LINK]

A picture is worth a thousand words, and a movie a thousand pictures. Sometimes these little videos can produce a greater effect than the same words on paper.

Here are the same characters someone else put together talking about a web startup. (Beware, not safe for family – f-bombs!). [LINK]

Again, regular readers know of my interest in the healthcare world. This next one is for those who share that interest, and is a biting comment on how the US health care system has worked for many years, and seems set to continue to work in the future. [LINK]

Finally, to earn the VC:VC label comparing my venture capital life with my cycling, a whimsical interchange that captures the life of a recumbent bike rider. [LINK]

2.0 3.0 = 4.0?

No-one was quite sure what Web 2.0 was when the term was first used. Did it refer to the technology behind Google Maps? This revolutionary approach allowed the server to update the browser as you dragged your cursor around the map, without having to press Submit to get a new response. Did Web 2.0 refer to user generated content such as blogs and wikis (and much later, social media like Twitter and Facebook)? No one really knew then, or really knows now. (Even Wikipedia, at the end of November 2010, is not sure about it, saying in its Web 2.0 article “This article needs attention from an expert on the subject.”)

But Web 2.0 was exciting, and indeed the subject of trademark claims. We all knew Web 2.0 was not Web 1.0 (which only existed as a counterpoint to Web 2.0 – no-one used Web 1.0 before Web 2.0 was coined). Web 1.0 was the old web, the static web pages, boring forms with submit buttons – nothing changed unless the whole page changed, and basically you read Web 1.0, and someone else wrote it. Web 2.0 was exciting because it was dynamic, and maybe even you helped write it, even if we didn’t know exactly what it was.

Then someone coined the phrase Web 3.0. This is never really caught on except with uber geeks, and I think it refers to semantic web technologies, where computers can read online data and make sense of it. The whole march of 1.0, 2.0, 3.0 then seemed to peter out.

Until now that is … Apparently the Marketplace Economy blog is called “Economy 4.0”. There is just too much wrong with this to spill ink (or bits) on it. Just don’t let me catch anyone doing anything 5.0.

What the hell does a VC do (NSFF)?

Usually you see NSFW, meaning Not Safe For Work (don’t open the video if at work in case it gets you in trouble). I choose NSFF meaning Not Safe for Family because your work site can probably handle a couple of f-bombs, but you may not want your kids to hear it.

It turns out that VCs spend lots of time listening to jargon laden pitches which we barely understand, and this seems to be the case particularly acutely in the advertising technology world.

Click for the YouTube link if this isn’t showing up in the blog feed for you. Hat-tip to Brad Feld, for bringing this to my (and the world’s) attention.

VC:VC Can I offer you a euphemism?

The very excellent Blue Avocado non-profit website and newsletter, issue 56 (with an excellent article on Board-Staff agreement over financial governance), offered this to “decode the code”:

· Charismatic means . . .  bad manager. Example: "We have a charismatic executive director."

· As you know means . . . "as you don't know." "As you know from our grant report . . ."

· Articulate means . . . well-educated, polite African American: "He's very, you know, articulate."

· Bright means . . . young and well-educated. "Will you do an informational interview with my cousin? She's very bright."

· Seasoned means . . . old. "Will you do an informational interview with my cousin. She's quite seasoned."

· Extend the deadline . . . no one is signing up: "We've extended the deadline to be a sponsor for our fall fundraiser!"

· Good reputation . . .  they don't have money troubles: "I want to work for a nonprofit with a good reputation."

· Strategic (from a foundation) . . . less responsive to nonprofits: "Our ten-month planning process has resulted in a decision that our grantmaking will be more strategic."

· Tough decision means . . . unpopular decision: "He just can't make the tough decisions."

· We'll start promptly at 9 means . . "We'll start around 9:15."

It made me think about the equivalent in the high tech world…

AND ITS EXACTLY THE SAME (just insert CEO for Exec Director, VC for foundation, investing for grantmaking, etc).

There are many kinds of database

Bob Metcalfe always used to say there are just two kinds of network: Ethernet and Ethernot. He was commenting that any network not based on Ethernet was going to end up losing to Ethernet in the marketplace. With the demise of AppleTalk (Apple), Token Ring (IBM) and DECnet (Digital), he was more or less proved right.

Bob has an axe to grind, as one of the co-inventors of Ethernet, but that doesn’t make him wrong. This is not Metcalfe’s Law, coined by the same Bob Metcalfe, that the value of a network increases proportionally with the square of the number of participants. Perhaps I can call the Ethernet/Ethernot comment Metcalfe’s Hypothesis (not all his predictions were correct).

Sigma’s investment in Gainspan is a bet that Metcalfe’s Hypothesis will continue to be right, this time with respect to Zigbee and other approaches proposed for sensor networks.

The database world has been dominated by the relational database model for many years, and all the famous commercial databases such as Oracle, Sybase, IBM DB2, MS SQL Server and open source MySQL are relational database management systems (RDBMSs). The relational data model referred to can be thought of as tables of data which are related to each other (like a table of bank accounts is related to a table of banking transactions). These systems are also known as SQL databases because they use Structure Query Language (SQL) for programming, and SQL was created for RDBMSs and is an absolute standard for their use. Separate from the data model and the language to talk to the data, RDBMSs are mostly expected to be able to manage transactions properly (and be ACID compliant). Simply put, this is the capability to ensure that, for example, a money transfer is properly recorded in both the sending and receiving accounts, and making it impossible to record only one side of the transaction without the other.

Now there are a new gang of databases in town, and they have gathered themselves together under the “NoSQL” banner. These are clustered around BigTable and Hadoop technologies made famous most notably because of their Google-related provenance.

Many (most? all?) NoSQL databases do not have transactional or ACID capabilities, and don’t seem to need it, at least for now, because the use cases that prompted their development really are that different. NoSQL databases are not gaining popularity because they are better at the same things as an RDBMS. This is not about more or faster money transfers. This is about new problems which don’t need transactional integrity and do need to analyze data sets bigger than an RDBMS can economically manage (or manage at all). Sigma’s investments with Michael Stonebreaker (see earlier post) are, in many ways, bets on the future of multiple kinds of databases flourishing.

So I am tempted to postulate Dale’s Hypothesis, somewhat in opposition to the idea of Metcalfe’s Hypothesis, that there can be many kinds of database, and you don’t need SQL to have a sequel.

Is a VC letting you eat your lunch?

Many people emphasize the need to be wary of VCs (“vulture capitalists”) because they are out to screw you, to “eat your lunch”. It’s not whether a venture capitalist is going to eat your lunch, it’s whether he or she is going to let you eat it yourself.

By the way, whoever gets to eat lunch, if the VC doesn’t pay for it, don’t take their investment… But that is a topic for another blog posting.

Consider this: you are having lunch with a VC. The truth is if you are lucky, you won’t get to eat yours. The VC will be listening intently, asking good questions, and leaving you the time to answer fully and clearly. He or she will be chomping away, listening hard, but enjoying the food and filling up nicely. On the other hand, every time you take a mouthful the VC will ask another question and you will have to stop eating to answer. (Hint, choose something to eat that doesn’t take too long to chew. Soup, anyone?)

If you are eating and the VC is talking, don’t take their investment. They think they know more than you about your business. If they truly do know more, then give up that plan and do something else. If the VC is the smartest guy in the room about your business, then everyone is in trouble. Most likely the VC doesn’t know more than you about your business, but they seem to like the sound of their own voice. Beware!

Techie at Heart

I came to the US in 1989 with a strong background as a software engineer (working in C) and an expert in the Oracle database system (version 5 and then version 6). Within a few years I was working in management roles and then as an entrepreneur mostly on the business side of things. However, I remain a techie at heart, and still enjoy the little bits of hobbyist programming I do.

At the time I was last working as a techie, Michael Stonebraker was already well into a great career with some great successes under his belt. Sigma is currently an investor in two of Michael’s startups, and it is a privilege to work with someone who continues to contribute so much to both the academic and commercial fields.

All this is warm-up to suggesting that those of you who, like me, are (database) techies at heart, should read Michael’s Top 10 Assertions about Data Warehouses, recently published in the Communications of the ACM website.

10th Annual Hazon NY Bike Ride

It's that time of year when I set off on the annual Hazon NY Jewish Environmental Bike Ride, and if you have not already considered making a donation to me or any other rider, please consider doing so now. This will be my fifth year participating (and the 10th such ride), and I continue to be proud to be associated with Hazon’s work.

Hazon is the leading environmental group in the US Jewish community, working in areas of education, action and advocacy to make environmental concerns important in our community, and to make the Jewish voice important to the environmental movement. Hazon’s programming is multi-generational, and open to people of all faiths and every stream of Judaism.

To give you some examples of Hazon’s work, we sponsor the leading conferences for the new Jewish Food movement and we have developed educational tools around the intersection of modern food issues and Jewish tradition. A portion of the money raised will help small-scale environmental projects in the Jewish communities, such as green roofs at synagogues, gardens at day schools, and other local initiatives. A key part of Hazon’s mission is to support the growing environmental movement in Israel. Money raised from the New York Ride will also help support Hazon's partners in Israel including the premier environmental leadership program, the Arava Institute for Environmental Studies. Since its inception the Hazon NY Ride has supported a wide range of other environmental projects in Israel including Table to Table for Project Leket, Kibbutz Lotan for the Green Apprentice program in practical ecology, Society for the Protection of Nature for a community garden in Jerusalem, the Israel Bike Association to promote safe cycling in Israel and many others. Read about all this and more on the Hazon website www.hazon.org.

Like many other small non-profits, Hazon continues to face fundraising challenges this year, and I am hoping to meet or beat my own fundraising from last year. In previous years I have ridden with my daughter Hannah who has also raised money. This year she is joining as a non-fundraising crew member, and so I am hoping to make up for her fundraising as well!
Please click here to make a donation. http://hazon.kintera.org/2010nyride/rdale
Many, many thanks in advance.

Last word on Venn Diagrams

I thought I was all done with Venn Diagrams (after my last post), especially about nerds and geeks, but here is the last word, from XKCD:


Here is the last word on bikes:

Recumbent Venn

And this really is the last word:

Last Word

Venn Diagrams of the World, Union!

After my posting What about Dweebs, which neatly shows a Venn Diagram taxonomy of Dweebs, Geeks, Dorks and Nerds, I let my obsessive side loose looking for other Venn Diagrams relevant to the various parts of my VC:VC world. In case you want to refer to it as I make wry comments later, I reproduce the picture here. It turns out there are a bunch of us obsessing about Venn Diagrams right now (some googling will confirm that).

UKAs a Brit, I liked this one, explaining the whole “United Kingdom of Great Britain and Northern Ireland” thing. 

And now, to prove I am a nerd, and a British one at that, a Venn Diagram Pun:

VentureCyclistThe VC:VC construct itself is a Venn Diagram of some of my life interests … where my venture capital world, my cycling, and my community interests coincide (or overlap).

SweetspotwhatwedowellHere’s another Venn Diagram I first saw on the walls of Techstars Boston, originally posted by Bud Cadell on his blog under the title How to be Happy in Business. This is a non-trivial commentary on building and running a business (geeks and nerds in particular need no further prompting to study this closely). I found another variation (see right) on this theme on Flowing Data (which also links back to Bud’s graphic as well). Both make important points… but, if only business was so easy.

Stan Nowak, Founder and CEO of Silverlink Communications, a Sigma portfolio company on whose board I sit, talks about the importance of seeking out markets with scale, urgency and willingness to pay. With a tip of the hat to Stan, here is it is as a Venn Diagram.

How about a diagram describing something technical… well, I previously shared my sketch of Dennis Devlin Devlin Security Diagsuggestion about information systems security, noting that a system is secure when it does exactly what it is supposed to do, and nothing more! (It strikes me this is a good definition of quality as well as security.) 

TwitterVennFor fun, check out this interactive TwitterVenn website that uses a Venn Diagram to show overlap between terms you can find in the tweets over a the last day. You can use your own search terms … these are “chocolate, milk, hot”.

Over in the non-profit world, check out the questions Sasha Dichter asks with “The Simplest non-profit Venn Diagram ever”.ven-a2
How much overlap do think there is between the circles?

And finally, my own comment on how too few charities and too many startups are in the wrong place…
For-Not Profit Venn

Techstars Boston Pitch Night 2010: Beware HIPPOs

Last night, Techstars Boston had its second annual pitch night, where the graduates of the 2010 session each got eight minutes to wow the crowd of angels, VCs and other local tech luminaries.

I was a mentor to some of the teams again this year, and was thrilled to see how far they had each progressed during the program. Kudos most of all to Shawn Broderick, who runs the Boston program, but also to Bill Warner, Brad Feld, David Cohen and all the other mentors, as well as the teams themselves.

Xconomy has a great writeup of the event and the companies – so check that out here.

My favorite quote of the night was about the danger of HIPPOs, and the use of data to overcome that danger. Daniel Sullivan, CEO of Appswell, noted the problem of the HIPPO, the “Highest Paid Person with an Opinion”. Absent strong data (about whatever it is), the HIPPO will always get to make the decision (right or wrong). This is similar in some ways to the Peter Principle, that “in a hierarchy every employee tends to rise to his level of incompetence”.

Even if the Peter Principle is in operation, HIPPOs do not want to look stupid, and will be swayed by compelling data. If your organization suffers from HIPPOs making decisions purely on whim, then make sure you have good data to present, so that you get to shape those opinions.


I got to listen to the Radio Lab program on my way home from a meeting last night on my local NPR station, WBUR. The final segment discussed the limits of human knowledge in science, and in particular the possibility that humans might reach limits of insight especially when scientific discovery is computer-aided.

As reported, a computer program called Eureqa was able to independently discover Newton’s law F=ma just by watching a double pendulum for a day. With input from a completely different field, it then discovered some rules by which simple cellular mechanisms work. These rules seem to be correct, because they accurately predict what will happen in the cell. However, as scientists look at those rules, they are at loss to understand them. They have no insight as to why the rules are correct.

You can listen to the segment and see the comments here.

At 8:05 into the segment, the hosts say that the scientists are “in this awkward position where they’ve got the answer, but they don’t have [pause] the insight.” And in that pause, all I could think was they would finish the sentence with “the question” … as in “they’ve got the answer, but they don’t have the question”. And why would I think that? Because of Deep Thought, Hitchhiker’s Guide to the Galaxy, and the answer to the meaning of life, the universe and everything. Douglas Adams fans (like me) know what I am talking about, and others can read about it here. I was gratified to see the comments on the Radio Lab website went exactly to the same thoughts.

What about Dweebs?

John Halamka’s recent post Geeks, Dorks and Nerds missed out the fourth scooter-rider of the apocalypse: Dweebs.

The folks at Techstars Boston have a grainy photocopy of this image on the wall, and so when I saw John’s posting (I especially like the video he references), I realized I had to post this taxonomy to support the Dweebs among us.


The tech industry is full of people with these characteristics, and perhaps these are key ingredients in technical or entrepreneurial success.

When searching on Google, it appears difficult to find the original source of this diagram … but I welcome someone finding the original source to attribute (just add a comment).  

Neologism: Administrative Loss Ratio

In the US Healthcare world, everyone calls the money spent on looking after patients “Medical Loss Ratio”. The new health care law requires (approximately) that the MLR be at least 85% (meaning, more or less, that at least 85% of insurance premiums go to spending on care, as opposed to administration or profit).

All this is very well, but why do they call it Medical Loss Ratio? Why is looking after me (or you) called “Medical Loss”, when the whole point of a health care system is to look after me (or you)?

What they should do is call that money “Healthcare Expenditure” (and some of it might even be “Wellness Investment”)… and instead we should talk about “Administrative Loss Ratio”. When the insurers take our healthcare dollars and overspend on administration (or corporate profit), then that is a loss ratio – not the healthcare itself.

VC:VC Haikus

I love the Haiku form … the constraints force you to find the perfect words and to trade off one word for another.

I felt only a Haiku could capture a mystery that was presented to me, and solved a moment later, during my wonderful ride with friends on Sunday morning.

Bright red mess ahead.
Dead squirrel in biker’s path?
Smells rise: fries, ketchup.

This got me thinking about other topics for Haikus. How about something from the fabulous Haikus for Jews by David Bader.

Monarch butterfly,
I know your name used to be

For the venture capital world, some commentary on a still topical trend from a 2006 Business Week haiku competition; this entry by Andrew Watson.

Web two point zero
Last year’s catch phrase, this year’s thing
Whatever it means

For the world of non-profits, I found this from someone called Rhonda on the 29 Gifts website.

a new day has dawned
another day of giving
i can't wait to start

(“Giving” in the context of the 29 Gifts website is different from charitable giving, but the haiku works for either!)

To round this off, a couple more from me… first a venture capitalist’s lament

Another quarter;
sales, cash targets missed again.
Why did we invest?

and, at last, a celebration

10-bagger! Hooray!
At last, a celebration.
IRR triumph.

(10-bagger: a venture capital investment in which we make 10 or more times our money when we our shares in the company. 
IRR: Internal Rate of Return: a standard measure of Venture Capital fund performance.)

Build a better mousetrap and …

A press release on Monday noted

L-1 Identity Solutions, Inc. (NYSE: ID), a leading provider of identity solutions and services, today announced it acquired substantially all of the tangible and intangible assets of Retica Systems, Inc. including iris-on-the-move and iris-at–a-distance product inventory, algorithms and software, and related intellectual property rights and customer contracts.

Sigma invested in Retica early on and, along with John Mandile, I was a board member for the entire journey. Retica’s tale is a cautionary one, but one which will be repeated many times, whether histories like this are remembered or not.

”Build a better mousetrap and the world will beat a path to your door” has been a siren song for inventors for over 100 years. Such sentiments are the cause of much entrepreneurial angst, and failure. None are totally immune to the lure of building a better mousetrap.

Sigma invested in Retica a few years ago, when its primary technology was retinal scaning equipment for security/ID uses(think Minority Report). The world did not beat a path to our door. Despite retinal scans being superior in many ways, the world’s security experts had already staked their careers on iris scanning as the solution they were going to use. Retica founder and CEO David Muller saw the opportunity to reuse some of the company’s IP in this field and, with Engineering VP Marc Friedman and his technical team, managed successfully to pivot the company to the new direction within a few months.

Entering commercialization, Barry Morse led partnership efforts with all the industry leaders, and sales efforts with government agencies, first as COO and then CEO (on Muller’s departure to a new startup). By the end of 2009 we had the best dual-iris scanner, the best iris algorithms and beta versions of the only system that can identify people walking at normal speeds at distances of up to 30 feet. Surely success was just around the corner.

For those who are well-versed in reading the tea-leaves of such a press-release, this was not a great outcome for Sigma or for the Retica team. Unable to achieve a path to commercial sustainability, the board and investors had decided we needed to sell the company or its assets to recover as much of our investment as we could. When you sell a company in such circumstances, it rarely leads to fabulous outcomes. The team built a better mousetrap, but the world did not beat a path to our door. Why not?

I believe this came down to distribution – our path to making sales in the industry. Customers of security equipment buy from large, well-established companies. These customers may not like their vendors, and may even know about better mousetraps being developed by startups, but they are afraid to purchase from small firms with all the attendant risks. Startup companies who successfully partner with the larger firms can do well, but creating such partnerships can take many years, not least because they upset existing supplier relationships. No-one gets fired for buying from the big guy, even if the mousetrap isn’t quite so good. Thus it was with Retica. The government agency procurement teams were understandably wary of a small startup with no balance sheet and no track record, however good the technology. Commercial buyers (of security systems for banks or casinos) waited to see if the government buyers would validate the system by making purchases. Large integrators were happy to continue to sell what they had previously been selling; it was almost as good and had far less risk in their eyes.

It is possible to succeed with a better mousetrap. Disruptive innovation usually involves bringing a better mousetrap to market. But the more entrenched the existing players, and the more conservative the buyers in the marketplace, the more difficult it becomes to achieve such success. Venture capital is about trying to calibrate all the varied risks, including this one.

So, knowing all this ahead of time (which we did), why did we invest in Retica? Two reasons; we loved the team, and they were building a better mousetrap.

Data, data everywhere

Data, data everywhere” is the title of a survey in the Feb 25 issue of The Economist. The survey starts with the subhead “Information has gone from scarce to superabundant. That brings huge new benefits […] but also big headaches.”

I love it; Sigma loves it. These benefits and headaches drive innovation in the startup world which play to our strengths. Several of the Sigma team, myself included, have deep technical, sales or operating backgrounds working with database and data management technologies. The trends described wonderfully in The Economist’s survey are fuelling a surge in related startups, and we are seeing many of them as they seek funding. We even invest in a few of them.

This surge in data, in data management and analysis tools is changing our lives. Mostly this is in mundane ways, but we still live at the start of the era where all this data is available to us wherever we are … anyone who has done a Google search from their phone over a dinner table conversation (and has thought wryly to themselves “my how things have changed”) is a beneficiary. The dangers and headaches are also the subject of good writing in The Economist and elsewhere, but there is no stopping this tide.

Mastery of statistics, data analysis, data visualization and knowledge distillation are skills that already underpin large parts of our economy. This will only increase. If you are not familiar with these trends, go back to the top, click on that Economist link, and enjoy the read. (Oh, I’ll make it easy … here it is again).

VC:VC Leadership

There have been hints in my blog that I love dancing. There are even a few videos of me dancing knocking around if you know where to look. My favorite quote (or at least one of them), ascribed to Emma Goldman, is “If you can’t dance to it, it’s not my revolution.”

So, I was delighted when my friend Barbra Batshalom sent me a link to this video, which is relevant to leadership for any kind of organization, whether a for-profit startup or a non-for-profit movement.

Improving Airline Travel

Yesterday evening I was on a train back from NYC which, because of the impending snow storm, was pretty chaotic. In a crowded train, folks are chatty, and the table conversation on the Acela was fabulous. One of my travelling companions, Theresa Podrebarac, suggested during the conversation that the airlines should not charge for checked baggage but instead for carry-on baggage.

We all agreed this was a great idea … the convenience is in the carry-on bags, and because of the checked-bags charge, more people are bringing overstuffed carry-on bags, making the entire experience less pleasant than ever. By charging for the carry-ons (probably for anything over a specified size) you would provide an incentive to check bags, and make the cabin less cluttered, boarding and exiting easier, and the airlines could probably charge more, too.

I tweeted this from my trusty Droid and within an hour or so I had five retweets, and by now I am up to a dozen (see live search results).

Perhaps I am on to something. Airlines, listen up!

Multitasking redux

A while ago I wrote about multitasking, why it’s bad for you and that I was going to stop doing it.

Well, as soon as I have finished writing this blog post, listening to this podcast, answering the phone and finishing off breakfast I will stop multitasking.

I don’t think I can stop entirely, however. Like many, I find I need to do something else while on telephone conference calls. Early last year there were several reports (e.g., Time) that doodling helps you pay attention, and hence justifies some small niche for multitasking.

In a similar vein, when on the phone for an extended call, I find myself playing with my kids’ lego blocks, and recently I am also doing jigsaw puzzles. I find these activities lead to no reduction in focus on the conversation (unlike doing email). I think this works because neither endeavor taps into the part of the brain needed for language. There is no semantic processing involved in legos or jigsaws. It is all about spatial and visual patterns. My own anecdotal experience is that this doesn’t distract me from listening or speaking at all.

Happy doodling, lego building, jigsaw puzzling!

What is Knowledge?

About this time last year I published a post about The Anatomy of Hope by Jerome Groopman. The book delved into the interaction of mind and body, and the real, scientifically observable phenomena which cause real healing (or suffering) in the face of placebo triggers. As you can tell, I am fascinated by these topics, and their interplay with the business of healthcare.

Knowledge in healthcare is about conducting scientific experiments, studies and clinical trials. There are well known formulations and standards in research, including statistical testing, which must be used in order to say we know something about a condition, a disease or a treatment. For example, what do you think the scientific consensus knows about the medical effects of radiation related to cell phone usage? Score two points for knowing the scientific consensus is that there is NO evidence of harm. Score two extra points for knowing that there is now one scientific study that may have uncovered beneficial effects related to Alzheimer’s (as reported by Reuters). Knowledge is often unexpected, but it turns out it is not even as simple as that. The nature of knowledge in this field is much less concrete than we would like.

Good friend Ted Kaptchuk once told me that he studies the nature of scientific knowledge, and that whatever is encapsulated solely in the clinical trials paradigm is sorely lacking. In 1998 The Annals of Internal Medicine published one of his papers The Persuasive Appeal of Alternative Medicine about these themes. In the abstract he states

It may be that independent of any such efficacy, the attraction of alternative medicine is related to the power of its underlying shared beliefs and cultural assumptions. … These themes offer patients a participatory experience of empowerment, authenticity, and enlarged self-identity when illness threatens their sense of intactness and connection to the world.

Although Ted had more than an instinctive understanding of the power of participation, that word “participatory” has taken a while to show up in the mainstream healthcare world. Personal Health Records (discussed here), like those from Microsoft, Google and others, are all about patient participation in their own health care. Leroy Hood of the Institute for Systems Biology is giving a talk at the American Association for Clinical Chemistry 2010 Annual Meeting entitled The "4P" Healthcare Approach: Predictive, Personalized, Preventive and Participatory. Participation has arrived. Why?

Last August, Wired Magazine published an article Placebos Are Getting More Effective. Drugmakers Are Desperate to Know Why (tip of the hat to Guy S for sending me this one). In it we discover that “the placebo effect is somehow getting stronger”. A more recent Ted Kaptchuk study is quoted showing the efficacy of placebo treatment, and suggesting that this be harnessed in our healthcare system (rather than used just to screen out ineffective treatments). It turns out that our level of knowledge about medical treatments changes our susceptibility to the placebo effect (which is why placebos are getting more effective). This article concludes that the statistically determined efficacy of a new drug treatment is related to the education level (and cognitive functioning) of the population on which it is tested!

Assumption number one was that if a trial were managed correctly, a medication would perform as well or badly in a Phoenix hospital as in a Bangalore clinic. Potter discovered, however, that geographic location alone could determine whether a drug bested placebo or crossed the futility boundary. By the late '90s, for example, the classic antianxiety drug diazepam (also known as Valium) was still beating placebo in France and Belgium. But when the drug was tested in the US, it was likely to fail. Conversely, Prozac performed better in America than it did in western Europe and South Africa. It was an unsettling prospect: FDA approval could hinge on where the company chose to conduct a trial.

This is not just about treatment. In the book review for 59 Seconds by Richard Wiseman, the Wall Street Journal reviewer notes quotes "people exposed to fake poison ivy developed genuine rashes, …" This book shows that harnessing the power of the mind can lead to real physical results in all sorts of ways.

A certain geeky group used to joke with each other about the quantum mechanics phenomenon of the observer changing the reality of what they are observing. The joke is in imagining effects that occur at the sub-atomic scale might directly impact the world we see and experience (of course, as “everyone” knows, this particular quantum effect does not scale up) – funny, huh?!

Such jokes are no longer funny even to the geeks, because mind body effects are no longer just hippie imaginings – they are the stuff of mainstream science. We have found that the human mind changes the world of the individual in very real and meaningful ways. More than that, this effect is universal enough that it effects the conduct of clinical trials, and hence changes the nature of scientific knowledge. The very standard by which we judge whether a treatment is effective is fluid enough to be, possibly, useless!

Before I finish, let me point you to another problem in our scientific knowledge documented in British Medical Journal article How citation distortions create unfounded authority: analysis of a citation network by Steven Greenberg. The article shows that even if the standard approach to scientific experimentation is able to withstand these complexities, the mechanisms of disseminating knowledge in the scientific community, peer reviewed articles citing and building on previous articles, are subject to arbitrary human biases. Since citation analysis (seeing how many times another paper is cited) influences future citations, this can lead to a pernicious (even if not malicious) distortion of the truth.

So what do we know? We know that our own participation in our healthcare is now considered key to successful medical outcomes, sometimes more important that specifics of treatment. We know that what we think we know can be wrong (cell phone radiation). We know that what we know can impact how we react to a treatment (placebo effect). We know that what someone else knows may be falsely transmitted as authoritative (citation distortions).

In summary (along the lines of the famous “the future ain’t what it used to be”), I guess I knew a lot more about knowledge before I knew so much about knowledge.

Graphics that tell a story

Graphics, well done, can tell stories with wonderful clarity. If you are not familiar with the work of Edward Tufte in this area, you should be.

Take this chart from National Geographic, discussed eloquently by Andrew Sullivan in The Daily Dish from The Atlantic. Don’t tell me the US healthcare system doesn’t need fixing after you look at this!


This one is less serious in nature, picturing the past 10 years, and worth clicking through to the NY Times to see in its full resolution.