Nurse as Maker: Democratizing Medical Innovation Starts Here

Inventing and improving medical devices can be a long and arduous process. Oftentimes it’s also a process that takes place far from the end user—the patient.

But what if research and development of medical devices was democratized? What if the practitioners who work most closely with patients were brought into the product innovation pipeline?

This is what Anna Young, co-founder at MakerNurse and MakerHealth, spoke about last week at Singularity University’s Exponential Medicine summit.

Young believes nurses, when empowered with the right tools, can use their own ingenuity to create effective medical devices. This is exactly what MakerNurse is after.

MakerNurse was launched in 2013 as a community of nurses focused on creating inventive new solutions that improve patient care. The MakerNurse community is paired with the founding company, MakerHealth, which builds clinical makerspaces in hospitals to provide training and tools for nurses to create new medical devices.

Historically, nurses have always been makers and creative problem solvers for patient needs. In fact, from the early 1900s until the late 1970s, nurses even had a publication devoted to showcasing new medical devices and outlining how other nurses can re-create them.

Considering how closely nurses work with their patients, it makes sense that this would be a powerful group for inventing new patient solutions.

Young says, “Nurses are faster than a medical device company and they’re closer to the patient than an engineer ever will be…the timelines, turnarounds, and the feedback loops that nurses have with their patients are unlike anything else inside of our healthcare system.”

Back in 2009 Young and her team first dove into this idea during a partnership with MIT’s Little Devices Lab and the International American Development Bank.

Together, they launched a health prototyping tool kit across Nicaragua called MEDIKit. It was a test to see whether mixing in-lab technology with local supply chains would change how medical devices were made.

From this initial idea, the team took it a step further.

Young says, “We thought, ‘What if we installed a makerspace in Nicaragua? What if we get a clinical makerspace and give people access to it?’”

The team installed a makerspace between a hospital and a nursing school. The space was 100 feet away from the hospital, but even this small distance proved to be too far. The hospital staff was too busy to leave and use the space.

Anna-Young-speaking-Singularity-University-Exponential-Medicine-2017
Anna Young speaking at Singularity University’s 2017 Exponential Medicine Summit in San Diego, CA.

This frustrating discovery, however, helped the team learn that they needed to build the makerspaces inside the hospital, which is exactly what MakerHealth now does. What’s inside the spaces?

Through the MakerNurse community, Young’s team conducted a research study to learn what tools and materials are most critical at the point of care.

“We overlaid this information with the tools and materials we’ve been using inside the lab to land on what’s inside the MakerHealth space today,” Young explained.

As MakerHealth has grown, they’ve learned that providing tools alone isn’t always enough; education in technology literacy for nurses is critical too.

With this in mind, the team is building programs to create technology literacy for practitioners, and is also working to build a platform to support a global network of health makers to engage in peer-to-peer learning.

Nurses aren’t the only people empowered when given the necessary tools for innovation. The patient is the true beneficiary of democratizing the medical innovation process.

It’s a great example of how a new shiny product alone isn’t always the best solution. Sometimes the best solutions are scrappy and created in close feedback loops packed with insights from real users—in this case, patients.

Image Credit: Romaset / Shutterstock.com

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Forever 21 tells customers that some credit card numbers may have been stolen

 This week, the clothing retailer Forever 21 disclosed to customers that it was hacked earlier in 2017. While the company has not yet offered many details about the intrusion, we know that it is looking into a portion of credit card transactions between March 2017 and October 2017 that were conducted over machines that appear to have been insecure. “Because of the encryption and… Read More

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The Generalized Specialist: How Shakespeare, Da Vinci, and Kepler Excelled

“What do you want to be when you grow up?” Do you ever ask kids this question? Did adults ask you this when you were a kid?

Even if you managed to escape this question until high school, then by the time you got there, you were probably expected to be able to answer this question, if only to be able to choose a college and a major. Maybe you took aptitude tests, along with the standard academic tests, in high school. This is when the pressure to go down a path to a job commences. Increasingly, the education system seems to want to reduce the time it takes for us to become productive members of the work force, so instead of exploring more options, we are encouraged to start narrowing them.

Any field you go into, from finance to engineering, requires some degree of specialization. Once you land a job, the process of specialization only amplifies. You become a specialist in certain aspects of the organization you work for.

Then something happens. Maybe your specialty is no longer needed or gets replaced by technology. Or perhaps you get promoted. As you go up the ranks of the organization, your specialty becomes less and less important, and yet the tendency is to hold on to it longer and longer. If it’s the only subject or skill you know better than anything else, you tend to see it everywhere. Even where it doesn’t exist.

Every problem is a nail and you just happen to have a hammer.

Only this approach doesn’t work. Because you have no idea of the big ideas, you start making decisions that don’t take into account how the world really works. These decisions ripple outward, and you have to spend time correcting your mistakes. If you’re not careful about self-reflection, you won’t learn, and you’ll make one version of the same mistakes over and over.

Should we become specialists or polymaths? Is there a balance we should pursue?

There is no single answer.

The decision is personal. And most of the time we fail to see the life-changing implications of it. Whether we’re conscious of this or not, it’s also a decision we have to make and re-make over and over again. Every day, we have to decide where to invest our time — do we become better at what we do or learn something new?

If you can’t adapt, changes become threats instead of opportunities.

There is another way to think about this question, though.

Around 2700 years ago, the Greek poet Archilochus wrote: “the fox knows many things; the hedgehog one big thing.” In the 1950s, philosopher Isaiah Berlin used that sentence as the basis of his essay “The Hedgehog and the Fox.” In it, Berlin divides great thinkers into two categories: hedgehogs, who have one perspective on the world, and foxes, who have many different viewpoints. Although Berlin later claimed the essay was not intended to be serious, it has become a foundational part of thinking about the distinction between specialists and generalists.

Berlin wrote that “…there exists a great chasm between those, on one side, who relate everything to a single central vision, one system … in terms of which they understand, think and feel … and, on the other hand, those who pursue many ends, often unrelated and even contradictory, connected, if at all, only in some de facto way.”

A generalist is a person who is a competent jack of all trades, with lots of divergent useful skills and capabilities. This is the handyman who can fix your boiler, unblock the drains, replace a door hinge, or paint a room. The general practitioner doctor whom you see for any minor health problem (and who refers you to a specialist for anything major). The psychologist who works with the media, publishes research papers, and teaches about a broad topic.

A specialist is someone with distinct knowledge and skills related to a single area. This is the cardiologist who spends their career treating and understanding heart conditions. The scientist who publishes and teaches about a specific protein for decades. The developer who works with a particular program.

In his original essay, Berlin writes that specialists “lead lives, perform acts and entertain ideas that are centrifugal rather than centripetal; their thought is scattered or diffused, moving on many levels, seizing upon the essence of a vast variety of experiences and objects … seeking to fit them into, or exclude them from, any one unchanging, all embracing … unitary inner vision.”

The generalist and the specialist are on the same continuum; there are degrees of specialization in a subject. There’s a difference between someone who specializes in teaching history and someone who specializes in teaching the history of the American Civil war, for example. Likewise, there is a spectrum for how generalized or specialized a certain skill is.

Some skills — like the ability to focus, to read critically, or to make rational decisions — are of universal value. Others are a little more specialized but can be used in many different careers. Examples of these skills would be design, project management, and fluency in a foreign language.

The distinction between generalization and specialization comes from biology. Species are referred to as either generalists or specialists, as with the hedgehog and the fox.

A generalist species can live in a range of environments, utilizing whatever resources are available. Often, these critters eat an omnivorous diet. Raccoons, mice, and cockroaches are generalists. They live all over the world and can eat almost anything. If a city is built in their habitat, then no problem; they can adapt.

A specialist species needs particular conditions to survive. In some cases, they are able to live only in a discrete area or eat a single food. Pandas are specialists, needing a diet of bamboo to survive. Specialist species can thrive if the conditions are correct. Otherwise, they are vulnerable to extinction.

A specialist who is outside of their circle of competence and doesn’t know it is incredibly dangerous.

The distinction between generalist and specialist species is useful as a point of comparison. Generalist animals (including humans) can be less efficient, yet they are less fragile amidst change. If you can’t adapt, changes become threats instead of opportunities.

While it’s not very glamorous to take career advice from a raccoon or a panda, we can learn something from them about the dilemmas we face. Do we want to be like a raccoon, able to survive anywhere, although never maximizing our potential in a single area? Or like a panda, unstoppable in the right context, but struggling in an inappropriate one?

Costs and Benefits

Generalists have the advantage of interdisciplinary knowledge, which fosters creativity and a firmer understanding of how the world works. They have a better overall perspective and can generally perform second-order thinking in a wider range of situations than the specialist can.

Generalists often possess transferable skills, allowing them to be flexible with their career choices and adapt to a changing world. They can do a different type of work and adapt to changes in the workplace. Gatekeepers tend to cause fewer problems for generalists than for specialists.

Managers and leaders are often generalists because they need a comprehensive perspective of their entire organization. And an increasing number of companies are choosing to have a core group of generalists on staff, and hire freelance specialists only when necessary.

The métiers at the lowest risk of automation in the future tend to be those which require a diverse, nuanced skill set. Construction vehicle operators, blue collar workers, therapists, dentists, and teachers included.

When their particular skills are in demand, specialists experience substantial upsides. The scarcity of their expertise means higher salaries, less competition, and more leverage. Nurses, doctors, programmers, and electricians are currently in high demand where I live, for instance.

Specialists get to be passionate about what they do — not in the usual “follow your passion!” way, but in the sense that they can go deep and derive the satisfaction that comes from expertise. Garrett Hardin offers his perspective on the value of specialists: 

…we cannot do without experts. We accept this fact of life, but not without anxiety. There is much truth in the definition of the specialist as someone who “knows more and more about less and less.” But there is another side to the coin of expertise. A really great idea in science often has its birth as apparently no more than a particular answer to a narrow question; it is only later that it turns out that the ramifications of the answer reach out into the most surprising corners. What begins as knowledge about very little turns out to be wisdom about a great deal.

Hardin cites the development of probability theory as an example. When Blaise Pascal and Pierre de Fermat sought to devise a means of dividing the stakes in an interrupted gambling game, their expertise created a theory with universal value.

The same goes for many mental models and unifying theories. Specialists come up with them, and generalists make use of them in surprising ways.

The downside is that specialists are vulnerable to change. Many specialist jobs are disappearing as technology changes. Stockbrokers, for example, face the possibility of replacement by AI in coming years. That doesn’t mean no one will hold those jobs, but demand will decrease. Many people will need to learn new work skills, and starting over in a new field will put them back decades. That’s a serious knock, both psychologically and financially.

Specialists are also subject to “‘man with a hammer” syndrome. Their area of expertise can become the lens they see everything through.

As Michael Mauboussin writes in Think Twice:

…people stuck in old habits of thinking are failing to use new means to gain insight into the problems they face. Knowing when to look beyond experts requires a totally fresh point of view and one that does not come naturally. To be sure, the future for experts is not all bleak. Experts retain an advantage in some crucial areas. The challenge is to know when and how to use them.

Understanding and staying within their circle of competence is even more important for specialists. A specialist who is outside of their circle of competence and doesn’t know it is incredibly dangerous.

Philip Tetlock performed an 18-year study to look at the quality of expert predictions. Could people who are considered specialists in a particular area forecast the future with greater accuracy than a generalist? Tetlock tracked 284 experts from a range of disciplines, recording the outcomes of 28,000 predictions.

The results were stark: predictions coming from generalist thinkers were more accurate. Experts who stuck to their specialized areas and ignored interdisciplinary knowledge faired worse. The specialists tended to be more confident in their erroneous predictions than the generalists. The specialists made definite assertions — which we know from probability theory to be a bad idea. It seems that generalists have an edge when it comes to Bayesian updating, recognizing probability distributions, and long-termism.

Organizations, industries, and the economy need both generalists and specialists. And when we lack the right balance, it creates problems. Millions of jobs remain unfilled, while millions of people lack employment. Many of the empty positions require specialized skills. Many of the unemployed have skills which are too general to fill those roles. We need a middle ground.

The Generalized Specialist

The economist, philosopher, and writer Henry Hazlitt sums up the dilemma:

In the modern world knowledge has been growing so fast and so enormously, in almost every field, that the probabilities are immensely against anybody, no matter how innately clever, being able to make a contribution in any one field unless he devotes all his time to it for years. If he tries to be the Rounded Universal Man, like Leonardo da Vinci, or to take all knowledge for his province, like Francis Bacon, he is most likely to become a mere dilettante and dabbler. But if he becomes too specialized, he is apt to become narrow and lopsided, ignorant on every subject but his own, and perhaps dull and sterile even on that because he lacks perspective and vision and has missed the cross-fertilization of ideas that can come from knowing something of other subjects.

What’s the safest option, the middle ground?

By many accounts, it’s being a specialist in one area, while retaining a few general iterative skills. That might sound like it goes against the idea of specialists and generalists being mutually exclusive, but it doesn’t.

A generalizing specialist has a core competency which they know a lot about. At the same time, they are always learning and have a working knowledge of other areas. While a generalist has roughly the same knowledge of multiple areas, a generalizing specialist has one deep area of expertise and a few shallow ones. We have the option of developing a core competency while building a base of interdisciplinary knowledge.

“The fox knows many things, but the hedgehog knows one big thing.”

— Archilochus

As Tetlock’s research shows, for us to understand how the world works, it’s not enough to home in on one tiny area for decades. We need to pull ideas from everywhere, remaining open to having our minds changed, always looking for disconfirming evidence. Joseph Tussman put it this way: “If we do not let the world teach us, it teaches us a lesson.”

Many great thinkers are (or were) generalizing specialists.

Shakespeare specialized in writing plays, but his experiences as an actor, poet, and part owner of a theater company informed what he wrote. So did his knowledge of Latin, agriculture, and politics. Indeed, the earliest known reference to his work comes from a critic who accused him of being “an absolute Johannes factotum” (jack of all trades).

Leonardo Da Vinci was an infamous generalizing specialist. As well as the art he is best known for, Da Vinci dabbled in engineering, music, literature, mathematics, botany, and history. These areas informed his art — note, for example, the rigorous application of botany and mathematics in his paintings. Some scholars consider Da Vinci to be the first person to combine interdisciplinary knowledge in this way or to recognize that a person can branch out beyond their defining trade.

Johannes Kepler revolutionized our knowledge of planetary motion by combining physics and optics with his main focus, astronomy. Military strategist John Boyd designed aircraft and developed new tactics, using insights from divergent areas he studied, including thermodynamics and psychology. He could think in a different manner from his peers, who remained immersed in military knowledge for their entire careers.

Shakespeare, Da Vinci, Kepler, and Boyd excelled by branching out from their core competencies. These men knew how to learn fast, picking up the key ideas and then returning to their specialties. Unlike their forgotten peers, they didn’t continue studying one area past the point of diminishing returns; they got back to work — and the results were extraordinary.

Many people seem to do work which is unrelated to their area of study or their prior roles. But dig a little deeper and it’s often the case that knowledge from the past informs their present. Marcel Proust put it best: “the real act of discovery consists not in finding new lands, but in seeing with new eyes.”

Interdisciplinary knowledge is what allows us to see with new eyes.

When Charlie Munger was asked whether to become a polymath or a specialist at the 2017 shareholders meeting for the Daily Journal, his answer surprised a lot of people. Many expected the answer to be obvious. Of course, he would recommend that people become generalists. Only this is not what he said.

Munger remarked:

I don’t think operating over many disciplines, as I do, is a good idea for most people. I think it’s fun, that’s why I’ve done it. And I’m better at it than most people would be, and I don’t think I’m good at being the very best at handling differential equations. So, it’s been a wonderful path for me, but I think the correct path for everybody else is to specialize and get very good at something that society rewards, and then to get very efficient at doing it. But even if you do that, I think you should spend 10 to 20% of your time [on] trying to know all the big ideas in all the other disciplines. Otherwise … you’re like a one-legged man in an ass-kicking contest. It’s not going to work very well. You have to know the big ideas in all the disciplines to be safe if you have a life lived outside a cave. But no, I think you don’t want to neglect your business as a dentist to think great thoughts about Proust.

In his comments, we can find the underlying approach most likely to yield exponential results: Specialize most of the time, but spend time understanding the broader ideas of the world.

This approach isn’t what most organizations and educational institutions provide. Branching out isn’t in many job descriptions or in many curricula. It’s a project we have to undertake ourselves, by reading a wide range of books, experimenting with different areas, and drawing ideas from each one.

Still curious? Check out the biographies of Leonardo da Vinci and Ben Fraklin. 


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Former Time Warner CEO and Investment Head Launch New VC Firm

Former Time Warner CEO Richard Parsons and investment head Rachel Lam plan to invest in digital media, machine learning, big data and esports startups.

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Why the Best Healthcare Hacks Are the Most Low-Tech

Technology has the potential to solve some of our most intractable healthcare problems. In fact, it’s already doing so, with inventions getting us closer to a medical Tricorder, and progress toward 3D printed organs, and AIs that can do point-of-care diagnosis.

No doubt these applications of cutting-edge tech will continue to push the needle on progress in medicine, diagnosis, and treatment. But what if some of the healthcare hacks we need most aren’t high-tech at all?

According to Dr. Darshak Sanghavi, this is exactly the case. In a talk at Singularity University’s Exponential Medicine last week, Sanghavi told the audience, “We often think in extremely complex ways, but I think a lot of the improvements in health at scale can be done in an analog way.”

Sanghavi is the chief medical officer and senior vice president of translation at OptumLabs, and was previously director of preventive and population health at the Center for Medicare and Medicaid Innovation, where he oversaw the development of large pilot programs aimed at improving healthcare costs and quality.

“How can we improve health at scale, not for only a small number of people, but for entire populations?” Sanghavi asked. With programs that benefit a small group of people, he explained, what tends to happen is that the average health of a population improves, but the disparities across the group worsen.

“My mantra became, ‘The denominator is everybody,’” he said. He shared details of some low-tech but crucial fixes he believes could vastly benefit the US healthcare system.

1. Regulatory Hacking

Healthcare regulations are ultimately what drive many aspects of patient care, for better or worse. Worse because the mind-boggling complexity of regulations (exhibit A: the Affordable Care Act is reportedly about 20,000 pages long) can make it hard for people to get the care they need at a cost they can afford, but better because, as Sanghavi explained, tweaking these regulations in the right way can result in across-the-board improvements in a given population’s health.

An adjustment to Medicare hospitalization rules makes for a relevant example. The code was updated to state that if people who left the hospital were re-admitted within 30 days, that hospital had to pay a penalty. The result was hospitals taking more care to ensure patients were released not only in good health, but also with a solid understanding of what they had to do to take care of themselves going forward. “Here, arguably the writing of a few lines of regulatory code resulted in a remarkable decrease in 30-day re-admissions, and the savings of several billion dollars,” Sanghavi said.

2. Long-Term Focus

It’s easy to focus on healthcare hacks that have immediate, visible results—but what about fixes whose benefits take years to manifest? How can we motivate hospitals, regulators, and doctors to take action when they know they won’t see changes anytime soon?

“I call this the reality TV problem,” Sanghavi said. “Reality shows don’t really care about who’s the most talented recording artist—they care about getting the most viewers. That is exactly how we think about health care.”

Sanghavi’s team wanted to address this problem for heart attacks. They found they could reliably determine someone’s 10-year risk of having a heart attack based on a simple risk profile. Rather than monitoring patients’ cholesterol, blood pressure, weight, and other individual factors, the team took the average 10-year risk across entire provider panels, then made providers responsible for controlling those populations.

“Every percentage point you lower that risk, by hook or by crook, you get some people to stop smoking, you get some people on cholesterol medication. It’s patient-centered decision-making, and the provider then makes money. This is the world’s first predictive analytic model, at scale, that’s actually being paid for at scale,” he said.

3. Aligned Incentives

If hospitals are held accountable for the health of the communities they’re based in, those hospitals need to have the right incentives to follow through. “Hospitals have to spend money on community benefit, but linking that benefit to a meaningful population health metric can catalyze significant improvements,” Sanghavi said.

Darshak-Sanghavi-speaking-Exponential-Medicine-Singularity-University-2017-XMED
Darshak Sanghavi speaking at Singularity University’s 2017 Exponential Medicine Summit in San Diego, CA.

He used smoking cessation as an example. His team designed a program where hospitals were given a score (determined by the Centers for Disease Control and Prevention) based on the smoking rate in the counties where they’re located, then given monetary incentives to improve their score. Improving their score, in turn, resulted in better health for their communities, which meant fewer patients to treat for smoking-related health problems.

4. Social Determinants of Health

Social determinants of health include factors like housing, income, family, and food security. The answer to getting people to pay attention to these factors at scale, and creating aligned incentives, Sanghavi said, is “Very simple. We just have to measure it to start with, and measure it universally.”

His team was behind a $157 million pilot program called Accountable Health Communities that went live this year. The program requires all Medicare and Medicaid beneficiaries get screened for various social determinants of health. With all that data being collected, analysts can pinpoint local trends, then target funds to address the underlying problem, whether it’s job training, drug use, or nutritional education. “You’re then free to invest the dollars where they’re needed…this is how we can improve health at scale, with very simple changes in the incentive structures that are created,” he said.

5. ‘Securitizing’ Public Health

Sanghavi’s final point tied back to his discussion of aligning incentives. As misguided as it may seem, the reality is that financial incentives can make a huge difference in healthcare outcomes, from both a patient and a provider perspective.

Sanghavi’s team did an experiment in which they created outcome benchmarks for three major health problems that exist across geographically diverse areas: smoking, adolescent pregnancy, and binge drinking. The team proposed measuring the baseline of these issues then creating what they called a social impact bond. If communities were able to lower their frequency of these conditions by a given percent within a stated period of time, they’d get paid for it.

“What that did was essentially say, ‘you have a buyer for this outcome if you can achieve it,’” Sanghavi said. “And you can try to get there in any way you like.” The program is currently in CMS clearance.

AI and Robots Not Required

Using robots to perform surgery and artificial intelligence to diagnose disease will undoubtedly benefit doctors and patients around the US and the world. But Sanghavi’s talk made it clear that our healthcare system needs much more than this, and that improving population health on a large scale is really a low-tech project—one involving more regulatory and financial innovation than technological innovation.

“The things that get measured are the things that get changed,” he said. “If we choose the right outcomes to predict long-term benefit, and we pay for those outcomes, that’s the way to make progress.”

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Marketing email company SendGrid raises $131 million after pricing its IPO at $16

 SendGrid, the Denver-based marketing email company, raised $131 million after pricing its IPO at $16, above the expected range of $13.50 to $15.50. The company also upsized its IPO, selling 8.2 million shares, instead of 7.7 million. The company begins trading Friday on the New York Stock Exchange, under the ticker, “SEND.” SendGrid helps businesses send marketing emails. It says… Read More

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