Archivi delle etichette: Public Health

La rinascita delle città-stato: lettura consigliata ai neo-centralisti @WRicciardi @drsilenzi

Come governare il mondo al tempo della devolution. Questo è il sottotitolo di un aureo libretto di Parag Khanna sulla democrazia e sulla governance delle società complesse quali quelle attuali e future.

“La democrazia non è un fine in sé: i veri obiettivi sono una governance efficace e il miglioramento del benessere della nazione”.

Sotto questa luce, la celebre battura di Churchill “L a democrazia è la peggior forma di governo eccezion fatta per tutte le altre” va ripensata secondo l’Autore.

Khanna è a favore di una democrazia guidata collettivamente (l’esempio della Svizzera è continuamente richiamato) e di una governance tecnocratica (come a Singapore). La critica del sistema USA, così caro a Tocqueville, è feroce.

La classica democrazia rappresentativa è inefficace e inefficiente: finisce per cristallizzare il dibattito nelle “posizioni” (destra, sinistra, conservatori, liberali, ecc.). La politics intralcia la policy perché la policy ha a che fare con le decisioni non con le posizioni. Il discorso sulle posizioni politiche, rispetto alle decisioni, è così vero oggi che J.C. Junker dice: “Sappiamo tutti che cosa fare, ma non sappiamo come essere rieletti dopo che l’abbiamo fatto”.

Khanna, del sistema americano, apprezza l’efficacia ed efficienza della tecnocrazia che gestisce le grandi città americane che misurano i risultati amministrativi attraverso la definizione e il monitoraggio pubblico di una serie di KPI (key performance indicators) e cita la frase dell’ex Sindaco di New York, Bloomberg, “Quello che non sai misurare non sai governare”! Estendere questi metodi al sistema federale implicherebbe che “Una tecnocrazia al governo degli Stati Uniti non parlerebbe certo la lingua della centralizzazione, ma, al contrario, quella del decentramento dei poteri”.

Una lettura, come quella del precedente Connectography, obbligata!

Che cos’è un leader: tutto dipende dalla definizione di leadership

Interessante articolo di Travis Bradberry su Inc. Author, Emotional Intelligence 2.0 


What makes someone a leader anyway?

Such a simple question, and yet it continues to vex some of the best thinkers in business. I’ve written books on leadership, and yet it’s a rare thing to actually pause to define leadership.

Let’s start with what leadership is not …

Leadership has nothing to do with seniority or one’s position in the hierarchy of a company. Too many consider a company’s leadership to refer to the senior most executives in the organization. They are just that, senior executives. Leadership doesn’t automatically happen when you reach a certain pay grade. Hopefully you find it there, but there are no guarantees.

Leadership has nothing to do with titles. Similar to the previous point, having a C-level title doesn’t automatically make you a leader. You don’t need a title to lead. You can be a leader in your workplace, your neighborhood, or your family, all without having a title.

Leadership has nothing to do with personal attributes. Say the word leader and most people think of a domineering, take-charge, charismatic individual. People often think of icons from history such as George S. Patton or Abraham Lincoln. But leadership isn’t an adjective. We don’t need to be extroverted or charismatic to practice leadership. And those with charisma don’t automatically lead.

Leadership isn’t management. This is the big one. Leadership and management are not synonymous. You have 15 people in your downline and P&L responsibility? Good for you; hopefully, you are a good manager. Good management is needed. Managers need to plan, measure, monitor, coordinate, solve, hire, fire, and so many other things. Managers spend most of their time managing things. Leaders lead people.

So, again, what makes a leader?

Let’s see how some of the most respected business thinkers of our time define leadership, and let’s consider what’s wrong with their definitions.

Peter Drucker: “The only definition of a leader is someone who has followers.”

Really? This instance of tautology is so simplistic as to be dangerous. A new Army captain is put in the command of 200 soldiers. He never leaves his room or utters a word to the men and women in his unit. Perhaps routine orders are given through a subordinate. By default, his troops have to follow orders. Is the captain really a leader? Commander, yes; leader, no. Drucker is of course a brilliant thinker, but his definition is too simple.

Warren Bennis: “Leadership is the capacity to translate vision into reality.”

Every spring you have a vision for a garden, and with lots of work carrots and tomatoes become a reality. Are you a leader? No, you’re a gardener. Bennis’s definition seems to have forgotten “others.”

Bill Gates: “As we look ahead into the next century, leaders will be those who empower others.”

This definition includes “others,” and empowerment is a good thing. But to what end? We’ve seen many empowered “others” in life, from rioting hooligans to Google workers who were so misaligned with the rest of the company they found themselves unemployed. Gates’s definition lacks goals and vision.

John Maxwell: “Leadership is influence–nothing more, nothing less.”

I like minimalism, but this reduction is too much. A robber with a gun has influence over his victim. A manager has the power to fire team members, which provides a lot of influence. But does this influence make a robber or a manager a leader? Maxwell’s definition omits the source of influence.

So what is leadership?

Definition: Leadership is a process of social influence that maximizes the efforts of others toward the achievement of a greater good.

Notice the key elements of this definition:

  • Leadership stems from social influence, not authority or power.
  • Leadership requires others, and that implies they don’t need to be “direct reports.”
  • No mention of personality traits, attributes, or even a title; there are many styles, many paths to effective leadership.
  • It includes a greater good, not influence with no intended outcome.

Leadership is a mindset in action. So don’t wait for the title. Leadership isn’t something that anyone can give you–you have to earn it and claim it for yourself.

So what do you think of my definition of leadership? Please share your thoughts in the comments section below, as I learn just as much from you as you do from me.

Special thanks to Kevin Kruse for help with this post.

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The Dying Art of Disagreement @WRicciardi @drsilenzi @dr_enricorosso

Pubblicato ieri sul New York Times: a must read!

The Dying Art of Disagreement

SEPTEMBER 24, 2017

Bret Stephens
Bret Stephens

This is the text of a lecture delivered at the Lowy Institute Media Award dinner in Sydney, Australia, on Saturday, Sept. 23. The award recognizes excellence in Australian foreign affairs journalism.

Let me begin with thanks to the Lowy Institute for bringing me all the way to Sydney and doing me the honor of hosting me here this evening.

I’m aware of the controversy that has gone with my selection as your speaker. I respect the wishes of the Colvin family and join in honoring Mark Colvin’s memory as a courageous foreign correspondent and an extraordinary writer and broadcaster. And I’d particularly like to thank Michael Fullilove for not rescinding the invitation.

This has become the depressing trend on American university campuses, where the roster of disinvited speakers and forced cancellations includes former Secretaries of State Henry Kissinger and Condoleezza Rice, former Harvard University President Larry Summers, actor Alec Baldwin, human-rights activist Ayaan Hirsi Ali, DNA co-discoverer James Watson, Indian Prime Minister Narendra Modi, filmmaker Michael Moore, conservative Pulitzer Prize-winning columnist George Will and liberal Pulitzer Prize-winning columnist Anna Quindlen, to name just a few.

So illustrious is the list that, on second thought, I’m beginning to regret that you didn’t disinvite me after all.

The title of my talk tonight is “The Dying Art of Disagreement.” This is a subject that is dear to me — literally dear — since disagreement is the way in which I have always earned a living. Disagreement is dear to me, too, because it is the most vital ingredient of any decent society.

To say the words, “I agree” — whether it’s agreeing to join an organization, or submit to a political authority, or subscribe to a religious faith — may be the basis of every community.

But to say, I disagree; I refuse; you’re wrong; etiam si omnes — ego non — these are the words that define our individuality, give us our freedom, enjoin our tolerance, enlarge our perspectives, seize our attention, energize our progress, make our democracies real, and give hope and courage to oppressed people everywhere. Galileo and Darwin; Mandela, Havel, and Liu Xiaobo; Rosa Parks and Natan Sharansky — such are the ranks of those who disagree.

And the problem, as I see it, is that we’re failing at the task.

This is a puzzle. At least as far as far as the United States is concerned, Americans have rarely disagreed more in recent decades.

We disagree about racial issues, bathroom policies, health care laws, and, of course, the 45th president. We express our disagreements in radio and cable TV rants in ways that are increasingly virulent; street and campus protests that are increasingly violent; and personal conversations that are increasingly embittering.

This is yet another age in which we judge one another morally depending on where we stand politically.

Nor is this just an impression of the moment. Extensive survey data show that Republicans are much more right-leaning than they were twenty years ago, Democrats much more left-leaning, and both sides much more likely to see the other as a mortal threat to the nation’s welfare.

The polarization is geographic, as more people live in states and communities where their neighbors are much likelier to share their politics.

The polarization is personal: Fully 50 percent of Republicans would not want their child to marry a Democrat, and nearly a third of Democrats return the sentiment. Interparty marriage has taken the place of interracial marriage as a family taboo.

Finally the polarization is electronic and digital, as Americans increasingly inhabit the filter bubbles of news and social media that correspond to their ideological affinities. We no longer just have our own opinions. We also have our separate “facts,” often the result of what different media outlets consider newsworthy. In the last election, fully 40 percent of Trump voters named Fox News as their chief source of news.

Thanks a bunch for that one, Australia.

It’s usually the case that the more we do something, the better we are at it. Instead, we’re like Casanovas in reverse: the more we do it, the worse we’re at it. Our disagreements may frequently hoarsen our voices, but they rarely sharpen our thinking, much less change our minds.

It behooves us to wonder why.

* * *

Thirty years ago, in 1987, a philosophy professor at the University of Chicago named Allan Bloom — at the time best known for his graceful translations of Plato’s “Republic” and Rousseau’s “Emile” — published a learned polemic about the state of higher education in the United States. It was called “The Closing of the American Mind.”

The book appeared when I was in high school, and I struggled to make my way through a text thick with references to Plato, Weber, Heidegger and Strauss. But I got the gist — and the gist was that I’d better enroll in the University of Chicago and read the great books. That is what I did.

What was it that one learned through a great books curriculum? Certainly not “conservatism” in any contemporary American sense of the term. We were not taught to become American patriots, or religious pietists, or to worship what Rudyard Kipling called “the Gods of the Market Place.” We were not instructed in the evils of Marxism, or the glories of capitalism, or even the superiority of Western civilization.

As I think about it, I’m not sure we were taught anything at all. What we did was read books that raised serious questions about the human condition, and which invited us to attempt to ask serious questions of our own. Education, in this sense, wasn’t a “teaching” with any fixed lesson. It was an exercise in interrogation.

To listen and understand; to question and disagree; to treat no proposition as sacred and no objection as impious; to be willing to entertain unpopular ideas and cultivate the habits of an open mind — this is what I was encouraged to do by my teachers at the University of Chicago.

It’s what used to be called a liberal education.

The University of Chicago showed us something else: that every great idea is really just a spectacular disagreement with some other great idea.

Socrates quarrels with Homer. Aristotle quarrels with Plato. Locke quarrels with Hobbes and Rousseau quarrels with them both. Nietzsche quarrels with everyone. Wittgenstein quarrels with himself.

These quarrels are never personal. Nor are they particularly political, at least in the ordinary sense of politics. Sometimes they take place over the distance of decades, even centuries.

Most importantly, they are never based on a misunderstanding. On the contrary, the disagreements arise from perfect comprehension; from having chewed over the ideas of your intellectual opponent so thoroughly that you can properly spit them out.

In other words, to disagree well you must first understand well. You have to read deeply, listen carefully, watch closely. You need to grant your adversary moral respect; give him the intellectual benefit of doubt; have sympathy for his motives and participate empathically with his line of reasoning. And you need to allow for the possibility that you might yet be persuaded of what he has to say.

“The Closing of the American Mind” took its place in the tradition of these quarrels. Since the 1960s it had been the vogue in American universities to treat the so-called “Dead White European Males” of the Western canon as agents of social and political oppression. Allan Bloom insisted that, to the contrary, they were the best possible instruments of spiritual liberation.

He also insisted that to sustain liberal democracy you needed liberally educated people. This, at least, should not have been controversial. For free societies to function, the idea of open-mindedness can’t simply be a catchphrase or a dogma. It needs to be a personal habit, most of all when it comes to preserving an open mind toward those with whom we disagree.

* * *

That habit was no longer being exercised much 30 years ago. And if you’ve followed the news from American campuses in recent years, things have become a lot worse.

According to a new survey from the Brookings Institution, a plurality of college students today — fully 44 percent — do not believe the First Amendment to the U.S. Constitution protects so-called “hate speech,” when of course it absolutely does. More shockingly, a narrow majority of students — 51 percent — think it is “acceptable” for a student group to shout down a speaker with whom they disagree. An astonishing 20 percent also agree that it’s acceptable to use violence to prevent a speaker from speaking.

These attitudes are being made plain nearly every week on one college campus or another.

There are speakers being shouted down by organized claques of hecklers — such was the experience of Israeli ambassador Michael Oren at the University of California, Irvine. Or speakers who require hundreds of thousands of dollars of security measures in order to appear on campus — such was the experience of conservative pundit Ben Shapiro earlier this month at Berkeley. Or speakers who are physically barred from reaching the auditorium — that’s what happened to Heather MacDonald at Claremont McKenna College in April. Or teachers who are humiliated by their students and hounded from their positions for allegedly hurting students’ feelings — that’s what happened to Erika and Nicholas Christakis of Yale.

And there is violence. Listen to a description from Middlebury College professor Allison Stanger of what happened when she invited the libertarian scholar Charles Murray to her school to give a talk in March:

The protesters succeeded in shutting down the lecture. We were forced to move to another site and broadcast our discussion via live stream, while activists who had figured out where we were banged on the windows and set off fire alarms. Afterward, as Dr. Murray and I left the building . . . a mob charged us.

Most of the hatred was focused on Dr. Murray, but when I took his right arm to shield him and to make sure we stayed together, the crowd turned on me. Someone pulled my hair, while others were shoving me. I feared for my life. Once we got into the car, protesters climbed on it, hitting the windows and rocking the vehicle whenever we stopped to avoid harming them. I am still wearing a neck brace, and spent a week in a dark room to recover from a concussion caused by the whiplash.

Middlebury is one of the most prestigious liberal-arts colleges in the United States, with an acceptance rate of just 16 percent and tuition fees of nearly $50,000 a year. How does an elite institution become a factory for junior totalitarians, so full of their own certitudes that they could indulge their taste for bullying and violence?

There’s no one answer. What’s clear is that the mis-education begins early. I was raised on the old-fashioned view that sticks and stones could break my bones but words would never hurt me. But today there’s a belief that since words can cause stress, and stress can have physiological effects, stressful words are tantamount to a form of violence. This is the age of protected feelings purchased at the cost of permanent infantilization.

The mis-education continues in grade school. As the Brookings findings indicate, younger Americans seem to have no grasp of what our First Amendment says, much less of the kind of speech it protects. This is a testimony to the collapse of civics education in the United States, creating the conditions that make young people uniquely susceptible to demagogy of the left- or right-wing varieties.

Then we get to college, where the dominant mode of politics is identity politics, and in which the primary test of an argument isn’t the quality of the thinking but the cultural, racial, or sexual standing of the person making it. As a woman of color I think X. As a gay man I think Y. As a person of privilege I apologize for Z. This is the baroque way Americans often speak these days. It is a way of replacing individual thought — with all the effort that actual thinking requires — with social identification — with all the attitude that attitudinizing requires.

In recent years, identity politics have become the moated castles from which we safeguard our feelings from hurt and our opinions from challenge. It is our “safe space.” But it is a safe space of a uniquely pernicious kind — a safe space fromthought, rather than a safe space for thought, to borrow a line I recently heard from Salman Rushdie.

Another consequence of identity politics is that it has made the distance between making an argument and causing offense terrifyingly short. Any argument that can be cast as insensitive or offensive to a given group of people isn’t treated as being merely wrong. Instead it is seen as immoral, and therefore unworthy of discussion or rebuttal.

The result is that the disagreements we need to have — and to have vigorously — are banished from the public square before they’re settled. People who might otherwise join a conversation to see where it might lead them choose instead to shrink from it, lest they say the “wrong” thing and be accused of some kind of political -ism or -phobia. For fear of causing offense, they forego the opportunity to be persuaded.

Take the arguments over same-sex marriage, which you are now debating in Australia. My own views in favor of same-sex marriage are well known, and I hope the Yes’s wins by a convincing margin.

But if I had to guess, I suspect the No’s will exceed whatever they are currently polling. That’s because the case for same-sex marriage is too often advanced not by reason, but merely by branding every opponent of it as a “bigot” — just because they are sticking to an opinion that was shared across the entire political spectrum only a few years ago. Few people like outing themselves as someone’s idea of a bigot, so they keep their opinions to themselves even when speaking to pollsters. That’s just what happened last year in the Brexit vote and the U.S. presidential election, and look where we are now.

If you want to make a winning argument for same-sex marriage, particularly against conservative opponents, make it on a conservative foundation: As a matter of individual freedom, and as an avenue toward moral responsibility and social respectability. The No’s will have a hard time arguing with that. But if you call them morons and Neanderthals, all you’ll get in return is their middle finger or their clenched fist.

One final point about identity politics: It’s a game at which two can play. In the United States, the so-called “alt-right” justifies its white-identity politics in terms that are coyly borrowed from the progressive left. One of the more dismaying features of last year’s election was the extent to which “white working class” became a catchall identity for people whose travails we were supposed to pity but whose habits or beliefs we were not supposed to criticize. The result was to give the Trump base a moral pass it did little to earn.

* * *

So here’s where we stand: Intelligent disagreement is the lifeblood of any thriving society. Yet we in the United States are raising a younger generation who have never been taught either the how or the why of disagreement, and who seem to think that free speech is a one-way right: Namely, their right to disinvite, shout down or abuse anyone they dislike, lest they run the risk of listening to that person — or even allowing someone else to listen. The results are evident in the parlous state of our universities, and the frayed edges of our democracies.

Can we do better?

This is supposed to be a lecture on the media, and I’d like to conclude this talk with a word about the role that editors and especially publishers can play in ways that might improve the state of public discussion rather than just reflect and accelerate its decline.

I began this talk by noting that Americans have rarely disagreed so vehemently about so much. On second thought, this isn’t the whole truth.

Yes, we disagree constantly. But what makes our disagreements so toxic is that we refuse to make eye contact with our opponents, or try to see things as they might, or find some middle ground.

Instead, we fight each other from the safe distance of our separate islands of ideology and identity and listen intently to echoes of ourselves. We take exaggerated and histrionic offense to whatever is said about us. We banish entire lines of thought and attempt to excommunicate all manner of people — your humble speaker included — without giving them so much as a cursory hearing.

The crucial prerequisite of intelligent disagreement — namely: shut up; listen up; pause and reconsider; and only then speak — is absent.

Perhaps the reason for this is that we have few obvious models for disagreeing well, and those we do have — such as the Intelligence Squared debates in New York and London or Fareed Zakaria’s show on CNN — cater to a sliver of elite tastes, like classical music.

Fox News and other partisan networks have demonstrated that the quickest route to huge profitability is to serve up a steady diet of high-carb, low-protein populist pap. Reasoned disagreement of the kind that could serve democracy well fails the market test. Those of us who otherwise believe in the virtues of unfettered capitalism should bear that fact in mind.

I do not believe the answer, at least in the U.S., lies in heavier investment in publicly sponsored television along the lines of the BBC. It too, suffers, from its own form of ideological conformism and journalistic groupthink, immunized from criticism due to its indifference to competition.

Nor do I believe the answer lies in a return to what in America used to be called the “Fairness Doctrine,” mandating equal time for different points of view. Free speech must ultimately be free, whether or not it’s fair.

But I do think there’s such a thing as private ownership in the public interest, and of fiduciary duties not only to shareholders but also to citizens. Journalism is not just any other business, like trucking or food services. Nations can have lousy food and exemplary government, as Great Britain demonstrated for most of the last century. They can also have great food and lousy government, as France has always demonstrated.

But no country can have good government, or a healthy public square, without high-quality journalism — journalism that can distinguish a fact from a belief and again from an opinion; that understands that the purpose of opinion isn’t to depart from facts but to use them as a bridge to a larger idea called “truth”; and that appreciates that truth is a large enough destination that, like Manhattan, it can be reached by many bridges of radically different designs. In other words, journalism that is grounded in facts while abounding in disagreements.

I believe it is still possible — and all the more necessary — for journalism to perform these functions, especially as the other institutions that were meant to do so have fallen short. But that requires proprietors and publishers who understand that their role ought not to be to push a party line, or be a slave to Google hits and Facebook ads, or provide a titillating kind of news entertainment, or help out a president or prime minister who they favor or who’s in trouble.

Their role is to clarify the terms of debate by championing aggressive and objective news reporting, and improve the quality of debate with commentary that opens minds and challenges assumptions rather than merely confirming them.


Una lettura obbligatoria: Exponential Organizations di Salim Ismail @WRicciardi @leadmedit

Una lettura estiva (forse sarebbe meglio dire uno studio estivo) di un libro affascinante: Exponential Organizations di Salim Ismail, edito da Marsilio nella collana Nodi.

Che cos’è un’organizzazione esponenziale? Essa è un’organizzazione il cui impatto (o output) risulta notevolmente superiore – almeno dieci volte – rispetto ai competitor, grazie all’utilizzo di nuove tecniche organizzative, che fanno leva sulle tecnologie in accelerazione.

Gestire organizzazioni esponenziali focalizzate sui clienti e non sui competitor esterni e sulle strutture interne tradizionali richiede una svolta epocale, paragonata a una nuova “era cambriana”. Richiede una nuova cultura e nuove e più dinamiche competenze.

Ho raccolto alcune frasi che mi hanno particolarmente colpito! Buona meditazione a tutti noi perché molti dei temi trattati riguardano anche la sanità!

  1. L’unica costante del mondo d’oggi è il cambiamento, e il ritmo del cambiamento sta aumentando.
  2. L’accelerazione (del cambiamento) è costituita dalle 6 D: digitalized, deceptive (ingannevole), disruptive (dirompente), dematerialized, demonetized, democratized.
  3. L’utilizzo di strumenti lineari e di tendenze del passato per fare previsioni su di un futuro in accelerazione è deleterio (vedi i casi di Iridium e Kodak).
  4. Gli esperti, in quasi tutti i campi, messi di fronte ad una crescita di tipo esponenziale, continuano sempre a pensare in un’ottica lineare, ignorando l’evidenza davanti ai loro occhi.
  5. Il vecchio detto secondo cui un esperto è “qualcuno che ti dice perché qualcosa non può essere fatta” è oggi più vero che mai.
  6. Nessuno degli indicatori tradizionali quali l’età, la reputazione e le vendite attuali possono garantire la sopravvivenza di un’azienda.
  7. La legge di Moore afferma che il rapporto prezzo/prestazione della potenza di calcolo raddoppia ogni diciotto mesi.
  8. “Le nostre organizzazioni sono fatte per resistere ai cambiamenti che arrivano dall’esterno” piuttosto che per accoglierli, anche quando sono utili (da John Hagel).
  9. Le strutture organizzative aziendali esistono proprio per annientare i fattori dirompenti di cambiamento.
  10. La maggior parte delle organizzazioni complesse si basa sulla cosiddetta “struttura a matrice” … Questa struttura è efficace nel garantire il controllo, ma è disastrosa in termini di individuazione delle responsabilità, di velocità e di propensione al rischio … Con il tempo, le funzioni orizzontali acquistano sempre più potere … Per le grandi organizzazioni con struttura a matrice attuare il cambiamento rapido e dirompente è qualcosa di estremamente difficile. Quelle che ci hanno provato, infatti, hanno sperimentato che il “sistema immunitario” dell’organizzazione tende a rispondere alla minaccia percepita attaccando.
  11. Le organizzazioni esponenziali hanno la capacità di adattarsi a un mondo in cui l’informazione è pervasiva e onnipresente e di convertirla in vantaggio competitivo.
  12. I tratti comuni delle organizzazioni esponenziali sono: il Massive Transformative Purpose (Mtp), cinque caratteristiche esterne denominate Scale e cinque interne denominate Ideas. Per essere un’organizzazione esponenziale, un’azienda deve avere il Mtp e almeno quattro caratteristiche.
  13. Il Mtp non è la missione: il Mtp è aspirational. Il fuoco è su ciò che si aspira a raggiungere.
  14. Scale: staff on demand; community and crowd; algoritmi, leveraged asset; engagement
  15. Ideas: interfacce; dashboard; experimentation; autonomia; tecnologie sociali.
  16. Il concetto di autonomia non implica non rendere conto a nessuno delle proprie azioni. Secondo Steve Denning, “In un network esistono ancora le gerarchie, ma esse tendono ad essere basate sulle competenze, e fanno affidamento più sull’accountability tra colleghi che su quella dovuta all’autorità, cioè sul dover rendere conto a qualcuno perché sa qualcosa e non per il semplice fatto che occupa una determinata posizione indipendentemente dalle competenze. Il ruolo del manager si trasforma, non viene abolito”
  17. Un’organizzazione esponenziale tende a essere una zero latency enterprise cioè un’azienda in cui si annulla l’intervallo tra ideazione, approvazione e realizzazione.
  18. In passato il lavoro si concentrava principalmente sull’importanza del quoziente intellettivo (QI), oggi il quoziente emotivo (QE) e quello spirituale (QS) stanno diventando indicatori sempre più rilevanti.
  19. Un secolo fa, la competizione si giocava principalmente sulla produzione, Quarant’anni fa, invece, il fattore decisivo divenne il marketing. Oggi, nell’era di internet, in cui produzione e marketing sono diventati merci e sono stati democratizzati, tutto ruota intorno a idee e ideali.
  20. Il piano strategico quinquennale è in sé uno strumento obsoleto … Esso è un suicidio per un’organizzazione esponenziale … L’unica soluzione è stabilire un Massive transformational Purpose (Mtp), costruire la struttura aziendale, adottare un piano (al massimo) annuale e osservare la crescita, con aggiustamenti progressivi e in tempo reale a seconda delle necessità.
  21. Nel mondo delle organizzazioni esponenziali, lo scopo (Mtp) è più importante della strategia e l’execution ha la precedenza sulla pianificazione.
  22. Arianna Huffington ha detto: “Preferisco lavorare con una persona meno brillante ma che sa fare gioco di squadra ed è chiara e diretta, piuttosto che con qualcuno molto brillante ma dannoso per l’organizzazione”.
  23. In un’organizzazione esponenziale, la cultura (con il Mtp e le tecnologie sociali) è il collante che garantisce la tenuta del team nonostante i salti quantici della crescita esponenziale. Secondo Chip Conley “la cultura è ciò che accade quando il capo non c’è”. E secondo Joi Ito “la cultura si mangia la strategia a colazione”.
  24. Sta diventando sempre più facile acquisire potere, ma è sempre è più difficile mantenerlo.
  25. Consiglio ai CEO delle grandi aziende di affiancare a chi occupa posizioni di leadership i venticinquenni più brillanti, per colmare il gap generazionale e tecnologico, per permettere a questi giovani di crescere più velocemente e per innescare un meccanismo di mentoring al contrario.
  26. Se siete un manager di Amazon e un dipendente viene da voi con una grande idea, la vostra risposta di default deve essere : Se volete dire di no, dovete motivare questo rifiuto con una relazione di due pagine spiegando perché non ritenete l’idea valida.
  27. Jeff Bezos (Amazon) ha detto: “ Se sei focalizzato sui competitor, devi aspettare che siano loro a fare la prima mossa, prima di agire. Concentrarsi sui clienti, invece, consente di essere dei pionieri”.
  28. Il miglior modo per definire questa macrotransizione verso organizzazioni esponenziali è considerarla un passaggio dalla scarsità all’abbondanza … Secondo Dave Blakely “queste nuove organizzazioni sono esponenziali perché prendono qualcosa di scarso e lo fanno diventare abbondante”.

Il CV efficace: lo ha inventato Leonardo Da Vinci! Copiate! @drsilenzi @redhenry88

Tempo fa, sui social, Roberta Zantedeschi che si occupa di ricerca e selezione di personale e diformazione e orientamento professionale, ha pubblicato un interessante post su come stendere un CV efficace prendendo Leonardo da Vinci come testimonial.

Eccolo: interessante!

Quel gran secchione di Leonardo Da Vinci tra le varie cose è fautore pure del CV efficace.

Quel CV cioè che non descrive ogni singola esperienza lavorativa (quello che hai fatto in passato) ma che mette in evidenza le capacità maturate (ciò che potrai fare presso chi ti assumerà).

Un CV non autoreferenziale ma concreto, pragmatico e rivolto ai bisogni e ai problemi di chi legge.

La lettera è indirizzata al Duca Ludovico Sforza detto Il Moro in occasione del trasferimento dello stesso Leonardo a Milano e pare proprio una moderna domanda di assunzione.

Eccola tradotta in Italiano corrente:

Avendo constatato che tutti quelli che affermano di essere inventori di strumenti bellici innovativi in realtà non hanno creato niente di nuovo, rivelerò a Vostra Eccellenza i miei segreti in questo campo, e li metterò in pratica quando sarà necessario. Le cose che sono in grado di fare sono elencate, anche se brevemente, qui di seguito (ma sono capace di fare molto di più, a seconda delle esigenze):

1- Sono in grado di creare ponti, robusti ma maneggevoli, sia per attaccare i nemici che per sfuggirgli; e ponti da usare in battaglia, in grado di resistere al fuoco, facili da montare e smontare; e so come bruciare quelli dei nemici.

2- In caso di assedio, so come eliminare l’acqua dei fossati e so creare macchine d’assedio adatte a questo scopo.

3- Se, sempre in caso di assedio, la fortezza fosse inattaccabile dalle normali bombarde, sono in grado di sbriciolare ogni fortificazione, anche la più resistente.

4- Ho ideato bombarde molto maneggevoli che lanciano proiettili a somiglianza di una tempesta, in modo da creare spavento e confusione nel nemico.

5- Sono in grado di ideare e creare, in modo poco rumoroso, percorsi sotterranei per raggiungere un determinato luogo, anche passando al di sotto di fossati e fiumi.

6- Costruirò carri coperti, sicuri, inattaccabili e dotati di artiglierie, che riusciranno a rompere le fila nemiche, aprendo la strada alle fanterie, che avanzeranno facilmente e senza ostacoli.

7- Se c’è bisogno costruirò bombarde, mortai e passavolanti [per lanciare sassi e ‘proiettili’] belli e funzionali, rielaborati in modo nuovo.

8- Se non basteranno le bombarde, farò catapulte, mangani, baliste [macchine per lanciare pietre e ‘fuochi’] e altre efficaci macchine da guerra, ancora in modo innovativo; costruirò, in base alla situazione, infiniti mezzi di offesa e difesa.

9- In caso di battaglia sul mare, conosco efficaci strumenti di difesa e di offesa, e so fare navi che sanno resistere a ogni tipo di attacco.

10- In tempo di pace, sono in grado di soddisfare ogni richiesta nel campo dell’architettura, nell’edilizia pubblica e privata e nel progettare opere di canalizzazione delle acque. So realizzare opere scultoree in marmo, bronzo e terracotta, e opere pittoriche di qualsiasi tipo. Potrò eseguire il monumento equestre in bronzo che in eterno celebrerà la memoria di Vostro padre [Francesco] e della nobile casata degli Sforza.

Se le cose che ho promesso di fare sembrano impossibili e irrealizzabili, sono disposto a fornirne una sperimentazione in qualunque luogo voglia Vostra Eccellenza, a cui umilmente mi raccomando.

Che cosa fa Leonardo?

Per prima cosa sintetizza le sue competenze in un elenco numerato, così facendo facilita l’organizzazione dei contenuti e la lettura da parte di chi riceve la missiva.

Inoltre, e ancora più importante, contestualizza la lettera citando soprattutto le sue competenze in ambito bellico. Lui, che era prima di tutto un artista e pure pacifista, scrive un CV promuovendo una gamma ben specifica di abilità, quelle che ritiene possano servire al Duca. Delle sue qualità di artista ne accenna solo al decimo punto, senza forzare la mano.

Da Vinci docet quindi, il CV moderno l’ha inventato lui, e non ha niente a che fare con il formato europeo.

È invece un CV lean, contestualizzato, funzionale, che punta dritto all’obiettivo facendo leva sui bisogni di chi dovrebbe ingaggiarlo. Funziona così anche oggi: chi assume lo fa perché ha un problema e sceglie la persona che ritiene possa risolverlo nel migliore dei modi.

Quando scrivete un CV chiedetevi sempre: che problemi ha il mio interlocutore? In che modo io posso contribuire a risolverli? E poi scrivete di questo! Tutto il resto che vi verrà voglia di inserire nel CV potrebbe essere inutile, pensateci bene prima di occupare spazio con parole e informazioni che non portano valore aggiunto.

E strutturate il testo perché sia immediato e fluido, gli elenchi puntati sono i vostri migliori alleati.

HTA in Italia: pessimismo dell’intelligenza, ottimismo della volontà

Il 24 ottobre scorso sono stato invitato da Giovanni Morana, dinamico direttore della radiologia dell’ospedale di Treviso, ad un convegno sul tema della TAC Dual Energy. Il programma prevedeva una parte dedicata a questa interessante tecnologia ancora in fase di sviluppo e ricerca e una dedicata all’HTA.


L’incontro si è tenuto all’Ateneo Veneto, una fondazione istituita da Napoleone dopo il disfacimento della Serenissima Repubblica di Venezia, in uno splendido palazzo a fianco del Gran Teatro La Fenice.

Per un accidente della storia, il 9 ottobre 1996, nella stessa sede avevo organizzato un workshop, alla presenza dei politici e direttori generali della aziende sanitarie del tempo, dal titolo: “Razionamento o razionalizzazione dell’assistenza sanitaria – il ruolo dell’HTA”, starring Renaldo N. Battista al quale il collega direttore generale di Venezia (il compianto Carlo Crepas) aveva tributato gli onori che la Serenissima Repubblica tributava ai Capi di Stato e agli Ambasciatori in visita a Venezia: il corteo in barca lungo il Canal Grande.


L’invito di Giovanni Morana ha suscitato in me due sentimenti: il piacere di discutere oggi con i clinici (italiani, stranieri e un brillante giovane collega italiano che lavora a Charleston, Carlo De Cecco) e i produttori di tecnologia i metodi e le opportunità offerte dall’HTA; l’amarezza di toccare con mano la lentezza con la quale in questi vent’anni l’HTA si è diffusa in Italia!

Quanta strada ancora da percorrere! Se smettessimo di buttarci a pesce sulle cose urgenti e ci occupassimo un po’ di più delle cose importanti (De Gaulle) …..!!!

Il XXI secolo non ci ha portato ancora superare lo storicismo gramsciano: “Tutti i più ridicoli fantasticatori che nei loro nascondigli di geni incompresi fanno scoperte strabilianti e definitive, si precipitano su ogni movimento nuovo persuasi di poter spacciare le loro fanfaluche. D’altronde ogni collasso porta con sé disordine intellettuale e morale. Pessimismo dell’intelligenza, ottimismo della volontà”. (Q28, III)



BETTER HEALTH CARE AND LOWER COSTS @leadmedit @medici_Manager @pash22 @WRicciardi


Executive Summary

In recent years there has been success in expanding access to the health-care system, with millions gaining coverage in the past year due to the Affordable Care Act. With greater access, emphasis now turns to guaranteeing that care is both affordable and high-quality. Rising health-care costs are an important determinant of the Nation’s fiscal future, and they also affect the budgets for States, businesses, and families across the country. Health-care costs now approach a fifth of the economy, and careful reviews suggest that a significant portion of those costs does not lead to better health or better care.

Other industries have used a range of systems-engineering approaches to reduce waste and increase reliability, and health care could benefit from adopting some of these approaches. As in those other industries, systems engineering has often produced dramatically positive results in the small number of health-care organizations that have implemented such concepts. These efforts have transformed health care at a small scale, such as improving the efficiency of a hospital pharmacy, and at much larger scales, such as coordinating operations across an entire hospital system or across a community. Systems tools and methods, moreover, can be used to ensure that care is reliably safe, to eliminate inefficient processes that do not improve care quality or people’s health, and to ensure that health care is centered on patients and their families. Notwithstanding the instances in which these methods and techniques have been applied successfully, they remain underutilized throughout the broader system.

The primary barrier to greater use of systems methods and tools is the predominant fee-for-service payment system, which is a major disincentive to more efficient care. That system rewards procedures, not personalized care. To support needed change, the Nation needs to move more quickly to payment models that pay for value rather than volume. These new payment models depend on metrics to identify high-value care, which means that strong quality measures are needed, especially about health outcomes. With payment incentives aligned and quality information available, health care can take advantage of an array of approaches using systems engineering to redesign processes of care around the patient and bring community resources, as well as medical resources, together in support of that goal.

Additional barriers limit the spread and dissemination of systems methods and tools, such as insufficient data infrastructure and limited technical capabilities. These barriers are especially acute for practices with only one or a few physicians (small practices) or for community-wide efforts. To address these barriers, PCAST proposes the following overarching approaches where the Administration could make a difference:

  1. Accelerate alignment of payment systems with desired outcomes,
  2. Increase access to relevant health data and analytics,
  3. Provide technical assistance in systems-engineering approaches,
  4. Involve communities in improving health-care delivery,
  5. Share lessons learned from successful improvement efforts, and
  6. Train health professionals in new skills and approaches.

Through implementation of these strategies, systems tools and methods can play a major role in improving the value of the health-care system and improving the health of all Americans.

Summary of Recommendations

Recommendation 1: Accelerate the alignment of payment incentives and reported information with better outcomes for individuals and populations.


1.1  HealthandHumanServices(HHS)shouldconvenepublicandprivatepayers(includingMedicare,Medicaid, State programs, and commercial insurers) and employers to discuss how to accelerate the transition to outcomes-based payment, promote transparency, and provide tools and supports for practice transformation. This work could build on current alignment and measurement-improvement efforts at the Center for Medicare and Medicaid Services (CMS) and HHS broadly.

1.2  CMS should collaborate with the Agency for Healthcare Research and Quality (AHRQ) to develop the best measures (including outcomes) for patients and populations that can be readily assessed using current and future digital data sources. Such measures would create more meaningful information for providers and patients.

Recommendation 2: Accelerate efforts to develop the Nation’s health-data infrastructure.
2.1 HHS should continue, and accelerate, the creation of a robust health-data infrastructure through widespread adoption of interoperable electronic health records and accessible health information. Specific actions in this vein were proposed in the 2010 PCAST report on health information technology and the related 2014 JASON report to the Office of the National Coordinator for Health Information Technology (ONC).

Recommendation 3: Provide national leadership in systems engineering by increasing the supply of data available to benchmark performance, understand a community’s health, and examine broader regional or national trends.

3.1 HHS should create a senior leadership position, at the Assistant Secretary level, focused on health-care transformation to advance information science and data analytics. The duties for this position should include:

  • Inventory existing data sources, identify opportunities for alignment and integration, and increase awareness of their potential;
  • Expand access to existing data through open data initiatives;
  • Promote collaboration with other Federal partners and private organizations; and
  • Create a more focused and deep data-science capability through advancing data analytics and
  • implementation of systems engineering.

3.2 HHS should work with the private sector to accelerate public- and private-payer release of provider-level data about quality, safety, and cost to increase transparency and enable patients to make more informed decisions.

Recommendation 4: Increase technical assistance (for a defined period—3-5 years) to health-care professionals and communities in applying systems approaches.

4.1 HHS should launch a large-scale initiative to provide hands-on support to small practices to develop the capabilities, skills, and tools to provide better, more coordinated care to their patients. This initiative should build on existing initiatives, such as the ONC Regional Extension Centers and the Department of Commerce’s Manufacturing Extension Partnership.

Recommendation 5: Support efforts to engage communities in systematic health-care improvement.


5.1  HHSshouldcontinuetosupportStateandlocaleffortstotransformhealthcaresystemstoprovidebetter

care quality and overall value.

5.2  Future CMS Innovation Center programs should, as appropriate, incorporate systems-engineering

principles at the community level; set, assess, and achieve population-level goals; and encourage grantees

to engage stakeholders outside of the traditional health-care system.

5.3  HHS should leverage existing community needs assessment and planning processes, such as the

community health-needs assessments for non-profit hospitals, Accountable Care Organization (ACO) standards, health-department accreditation, and community health-center needs assessments, to promote systems thinking at the community level.

Recommendation 6: Establish awards, challenges, and prizes to promote the use of systems methods and tools in health care.

6.1 HHS and the Department of Commerce should build on the Baldrige awards to recognize health-care providers successfully applying system engineering approaches.

Recommendation 7: Build competencies and workforce for redesigning health care.


7.1  HHS should use a wide range of funding, program, and partnership levers to educate clinicians about

systems-engineering competencies for scalable health-care improvement.

7.2  HHS should collect, inventory, and disseminate best practices in curricular and learning activities, as well as encourage knowledge sharing through regional learning communities. These functions could be accomplished through the new extension-center functions.

7.3  HHS should create grant programs for developing innovative health professional curricula that include systems engineering and implementation science, and HHS should disseminate the grant products broadly.

7.4  HHS should fund systems-engineering centers of excellence to build a robust specialty in Health-

Improvement Science for physicians, nurses, health professionals, and administrators.

Full Report:

How and why do countries vary so much in their use of health services? @WRicciardi @leadmedit @Medici_Manager @pash22


I’ve been struck recently by how little we (or at least I) seem to know about variations in use of health services across the world, and what drives them. Do people in, say, India or Mali use doctors “a lot” or “a little”. Even harder: do they “overuse” or “underuse” doctors? At least we could say whether doctor utilization rates in these countries are low or high compared to the rate for the developing world as a whole. But typically we don’t actually make such comparisons – we don’t have the numbers at our fingertips. Or at least I don’t.

I’m also struck by how strongly people feel about the factors that shape people’s use of services and what the consequences are. There are some who argue that the health problems in the developing world stem from people not getting care, and that people don’t get care because of shortages of doctors and infrastructure. There are others who argue that doctors are in fact quite plentiful – in principle; the problem is that in practice doctors are often absent from their clinic and people don’t get care at the right moment. There are others who argue that doctors are plentiful even in practice and people do get care; the problem is that the quality of the care is shockingly bad. Who’s right?

WHS to the rescue – again

As in a recent post of mine on Let’s Talk Development, I thought the World Health Survey might shed some light on these issues. The WHS was fielded in the early 2000’s in 70 countries – spanning the World Bank’s lower-, middle- and high-income categories. The WHS enumerators asked a randomly-selected adult in each household about his or her use of inpatient care and outpatient care; in the numbers that follow I’ve focused on use in the last 12 months. As I said in the earlier blog post, the WHS does have some drawbacks: it covers some regions fairly fully, other much less fully; it’s 10 years old; and all we can tell is whether inpatient or outpatient care was received, not the number of contacts. But despite these problems, the WHS gets us quite a long way.

A lot of variation – but not necessarily what you’d expect

The maps below show the inpatient admission and outpatient visit rate – actually the fraction of people who had at least one admission or visit in the last 12 months. Green countries are above the developing-country average; red countries are below it.
For IP admissions, most of the OECD countries are above the developing-country average (6.98%). Brazil, Namibia and the European and central Asian countries are also above it. African and Asian countries are mostly below or close to the developing-country average.

The picture is different for outpatient visits. Several OECD countries are actually below the developing-country average (27.52%). And for the most part, the countries below the developing-country average are in Africa: many are considerably below it (Mali stands out dramatically); only a few are above it (Kenya and Zambia stand out). By contrast, several countries in Asia are above the developing-country average: India and Pakistan are dramatically above it, but China and Vietnam are also above it; a few Asian countries are below it – Laos and Myanmar are considerably below it, Malaysia and the Philippines less so.

Do variations in doctor numbers and infrastructure explain variations in utilization?

The maps below show data on doctors and hospital beds per 1,000 persons. I got the data from the World Development Indicators, and took the country averages for the first half of the 2000s. As before, green countries are above the developing-country average; red countries are below it. The countries above the developing-country averages are mostly those in the OECD and Europe and central Asia, though in the case of doctors per 1,000 some of them are also in Latin America and the Caribbean. Except for China, most of Asian countries fall below the developing country average.

Correlating the WHS utilization data with the WDI doctor and beds data shows that doctors and beds per 1,000 persons are positively associated with outpatient visit and inpatient admission rates. A lack of doctors and beds looks like it could indeed be part of the explanation for low utilization rates, though of course we haven’t established causality.

But a lack of doctors and hospital beds is only part of the story. Together they “explain” only 60% of the cross-country variation in inpatient admission rates, while doctors “explain” an even smaller 20% of the cross-country variation in outpatient visit rates.

Some countries – India and Pakistan are examples – are below the developing-country average on doctors per 1,000 persons, but above the developing-country average on the outpatient visit rate. Doctors and hospitals in these countries treat far more patients than one would expect given the number of doctors and hospital beds in these countries. In these countries, it doesn’t look like accessibility is the pressing issue; as research by my colleague Jishnu Das confirms, at least in India, poor quality is the bigger problem.

By contrast, much – but not all – of Africa is in the opposite camp: these countries have inpatient admission and outpatient visit rates that are below what would be expected on the basis of their doctor and beds per 1,000 figures. So it’s not just that these countries lack doctors and beds; it’s also that people are not getting the level of contacts you’d expect from the existing staff and infrastructure. Here it looks like absenteeism could well be part of the story; recent research from my colleague Markus Goldstein confirms it – pregnant women whose first clinic visit coincided with a nurse’s attendance were found to be 46 percent more likely to deliver their baby in a hospital.

Two take away messages

Message #1 is that countries differ considerably in their utilization rates. Much of Asia visits doctors more regularly than both the developing world and the entire world; India’s consultation rate is a third higher than the global average. Africa stands out as the continent where outpatient visits and inpatient admissions lag behind the rest of the world.

Message #2 is that these variations are partly explained by differences in doctors and hospital beds per capita, but only partly. The problem goes deeper than hiring more doctors and building more hospitals. Africa has lower outpatient visit rates than its doctors per 1,000 figures would suggest, while the opposite is true of India and Pakistan. In Africa, it looks like the binding constraint may well be absenteeism, while in S Asia it looks like the first-order problem is the poor quality of care that’s actually delivered.

Science alone can’t make tough decisions for us @kevinmd @Medici_Manager @pash22


On April 14, The United States Preventive Services Task Force concluded that women with an elevated risk of breast cancer – who have never been diagnosed with breast cancer but whose family history and other medical factors increase their odds of developing the disease–should consider taking one of two pills that cut that risk in half. The Task Force is an independent panel of medical experts who review the medical literature to estimate the pros and cons of preventive interventions. This is the same Task Force that in recent years raised questions about the benefits of mammograms in 40 to 50-year-old women, and PSA tests for men of all ages, tests that screen respectively for breast and prostate cancer. Despite the popularity of both of these tests, the Task Force concluded that their harms often outweigh their benefits.

The irony now is that with this report on breast cancer prevention pills, the Task Force has switched from rejecting something patients believed in to endorsing something most patients will reject.

The seemingly strange way the Task Force ping-pong’s between popular and unpopular recommendations is inevitable, because these kinds of recommendations must necessarily go beyond the medical facts – it is impossible to decide what preventive measures people need without making value judgments.

To understand the way facts and value judgments get mixed together in these kinds recommendations, let’s take a closer look at these breast cancer prevention pills.

For many years now, doctors have been prescribing tamoxifen as secondary prevention to women who have already undergone treatment for breast cancer, in an attempt to thwart any breast cancer cells remaining in their body. In women whose breast cancer cells express “estrogen receptors”, tamoxifen reduces the chance that this cancer will recur, by attaching itself to those receptors, in effect crowding outestrogen. In breast cancer cells, any estrogen landing on these receptors will spur that cell to divide and multiply. But when tamoxifen lands on these receptor sites, it does not stimulate cell growth.

Raloxifene is a close cousin of tamoxifen, which has primarily been used to treat women with osteoporosis. Like tamoxifen, it competes with estrogen for the attention of estrogen receptors. Also like tamoxifen, it slows down breast cancer by preventing estrogen from stimulating cell growth. As it turns out, both raloxifene and tamoxifen also have the strange property that when they collide with bone cells, they don’t fight against estrogen, but seem to mimic estrogen, and thereby improve bone health. (Because these drugs and sometimes act like estrogen and other times act like anti-estrogen, they are called selective estrogen blockers.)

Two very similar drugs, then. Both slow down breast cancer cells while stimulating bone cells. Each drug has been shown to cut the risk of a first breast cancer in half for women with a high risk of experiencing this disease. In what is known as the P1 trial, for example, women who faced an average five year risk of breast cancer of 6% saw that risk drop to 3%, if they took tamoxifen.

Sounds like a good deal, yes? Take a pill for five years, and cut your risk of breast cancer in half. But keep in mind, most women do not face a 6% chance of breast cancer in the next five years. Women with this kind of risk are generally retirement age or beyond, and usually have a bad combination of family history, early onset of menses, and late age of first pregnancy. It is these women the Task Force believes should talk with their doctors about whether to take these medications. And how did the Task Force reach this conclusion? By determining that for some women, at least, the benefits of these pills outweigh their harms. Before looking at this harm benefit ratio more closely, let’s put this Task Force conclusion into context.

The Task Force essentially produces three kinds recommendations, which I have taken the liberty to name.

  1. NADA: When it concludes that the harms of an intervention outweigh the benefits, the Task Force recommends that doctors and patients avoid the intervention. Think: ultrasound screening for pancreatic cancer.
  2. OUGHTA: When the Task Force concludes that the benefits outweigh the harms, it pushes to make the intervention standard of care. For example: routine screening for colon cancer in people 50 years or older.
  3. UP TO THE INDIVIDUAL: When the Task Force concludes that the benefits of an intervention potential outweigh the harms, depending on the patient’s individual preferences, it leaves the decision up to individual patients and their doctors to weigh. This is the recommendation the Task Force made both for mammography in 40 to 50-year-olds, and for tamoxifen and raloxifene to prevent breast cancer.

When making NADA or OUGHTA recommendations, the Task Force essentially makes its own value judgment. It looks at the risks and benefits of an intervention, and concludes that no sensible person could decide differently from the Task Force. In this third type of recommendation, however, the Task Force concludes that reasonable people could make different choices, based on how they weigh the risks and benefits of the interventions.

In the case of tamoxifen and raloxifene to prevent a first breast cancer, I expect the vast majority of women will conclude that the risks of the pills outweigh the benefits.  In the past two years, I have collaborated with a team of researchers at the University of Michigan (led by Angie Fagerlin, a decision psychologist in their medical school), to help women decide whether to take either of these pills. We developed an Internet-based decision aid, a tool designed to help patients weigh the pros and cons of their medical alternatives. (I write about the history of decision aids in my book, Critical Decisions.) Our decision aid provided women with individualized estimates of their odds of developing breast cancer in the next five years. We only directed women to the decision aid whose risk was high enough to have qualified for the P1 trial.

In the decision aid, we described the benefits of both drugs – the reduced risk of breast cancer and the strengthening of their bones. We also laid out the risks – a very small chance of endometrial cancer, a slightly larger chance of heart attack or stroke, a modest risk of cataracts, and finally a very strong likelihood of experiencing menopausal symptoms such as irregular menstrual bleeding and hot flashes. We actually provided them with precise numerical estimates of these side effects, with pictures illustrating the risks to make them easier to comprehend.

Women pondered the pros and cons and concluded, almost unanimously, that the side effects of these drugs outweighed the benefits.

The decision whether to take tamoxifen and raloxifene is no doubt a personal one, and the right choice will vary depending on how a given person weighs the respective risks and benefits of these medicines. For a woman with an extremely high risk of breast cancer over the next five years – say 10% or more – cutting that risk in half might very well be worth the hot flashes and the chance of experiencing blood clots. But very, very few women faced a five year risk is highest.

Consider, instead, a woman with a 3% chance of developing breast cancer over the next five years. That risk is much higher than average – most women face a five year risk of less than 1% – but is it high enough to justify taking one of these pills? For such a woman, tamoxifen and raloxifene only reduce that risk by 1.5%. Over five years. Five years with possible hot flashes. For a cancer women have not experienced yet. These modest benefits simply do not loom large enough to interest most women in these pills.

You might wonder at this point whether our decision aid biased women against these medications. As a physician trained in behavioral economics, I’m constantly on the lookout for decision biases. In the case of our study, however, we designed our decision aid in a manner that allowed us to test for well-known behavioral economic biases. For instance, research has shown  that when people face a choice between three options and two of the options are similar, they often opt for the more different alternative even if the other options are better. In other words, a person might believe that A > B, and A’ > B, but still choose B over A and A’, because they cannot decide between A and A’.

Aware of this problem, we created several different versions of our decision aid. In one version, we presented women with a choice between tamoxifen, raloxifene or no pill. Three choices in other words, two of which – the two medications – are quite similar to each other. In another version of the decision aid, we simply presented women with the choice between pill or no pill. We thought this simpler choice would increase women’s interest in these pills, by minimizing the difficulty of choosing between the two of them. But instead, this reframing of the decision did not increased women’s interest in either of these preventive medicines.

We also designed our decision aid to take account of another well-known decision bias, what are known as recency effects. When people learn about the risks of a medication and then learn about its benefits, that order of information leads them to look favorably upon the medication, because the information they remember best, the last information they receive, is about the pill’s benefits. By contrast, people who receive the same information about this medicine, but in the opposite order, like the pill less, because the last thing they learn about are the pill’s risks, and this information sticks in their minds. To make sure this recency effect was not influencing women’s decisions, we varied the order of information across women. We discovered that this did nothing to change their willingness to take either of these medications, mainly because whichever order women received information in, they did not like the idea of taking either pill.

If these pills are so unpopular among well-informed women, why would the Task Force come out in favor of them? It comes down to judgment. The Task Force concluded that a reasonable person could look at these risks and benefits and decide that the hot flashes and blood clots are acceptable prices to pay to reduce the chance of breast cancer. The majority of women don’t have to agree with this view for the Task Force’s recommendation to be correct. Even if only a small percentage of women decide these pills are worth taking, at least they have the freedom to make that choice. And at least they know that medical experts have concluded that such a decision is a reasonable one to make.

The same goes for whether to start mammograms before the age of 50 in women at normal risk of breast cancer. The Task Force never said that women shouldn’t start mammograms at this earlier age. They just said that it was a tough judgment call, and that some women, perhaps the majority even, might conclude that the harms of early screening – the anxiety caused by false negative tests, the pain caused by unnecessary biopsies – aren’t worth the modest benefits of screening at this age.

If the Task Force is going to leave all these tough decisions up to individual patients and their doctors, why should we care about their recommendations? For starters, you will have a hard time finding a more thorough and levelheaded evaluation of the pros and cons of these kinds of interventions. These people are very good at what they do. In addition, anyone reading through Task Force reports will be forced to recognize that science alone can’t make tough decisions for us. Ultimately, science can only provide us with the facts. The rest of us eventually need to make tough judgment calls. In effect, the Task Force is doing us a huge favor, by showing us which judgments are close calls, and which ones are no-brainers.

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together.

Clinician Engagement: The Role of the Physician @Medici_Manager

By Amy Collins, M.D.
HealthCare Sustainability Consultant, Vanguard Health Systems

I was living a pretty green life, or so I thought. I had been composting for years, was an avid recycler, was known for turning off lights and computers not in use and grew up using reusable grocery bags – doing it all because it just made sense. But my attitude towards greenness and reason to be environmentally responsible changed in one minute back in April of 2007. On one of my days off from my full time job as an emergency physician, I was sitting in my car in the pick up line at my son’s school, absent-mindedly texting and listening to the radio while IDLING! My very wise 4th grader took no time to begin reprimanding me for my lapse in environmental responsibility. “You are idling,” he scolded.  “Ms. Gruenfeld (his teacher) taught us about climate change today and what is happening to the polar bears.” He went on. “I better not catch you idling EVER again and there’s a lot more you should be doing about climate change and to help the polar bears.”  Shame faced, I agreed and assured him that I would get right to work to try and correct my wrong. As a family, we watched “An Inconvenient Truth,” then set out to make our home as green as possible. Inspired by the urgency in the movie and by a wise little boy, we started doing such things as changing all of our light bulbs to fluorescents, drying clothes on a clothes line, planting a vegetable garden, making homemade cleaning products and much more.

Soon it became uncomfortable living one way at home and another at the hospital. It grew harder and harder to leave my environmental conscience at the door when I went to work. In response to this discomfort, I set out to start a recycling program in my ER but was told by a fellow employee that recycling was “illegal” in a hospital. Not satisfied with this response, I turned to the Internet and learned that not only was recycling not illegal in a hospital and that there were many exciting and practical opportunities for a hospital to reduce it’s environmental impact. It was at this moment that I knew that I had found my calling. I wrote a letter to my administrators and requested that we take steps to become a more sustainable operation, was given permission to run, started a green team and so began my mid-life second career path.

I realize that not all physicians will share my passion for health care sustainability or have the time to commit to a leadership role at their hospital, but there are many important opportunities for physician engagement at local and broader levels. When speaking to physicians I focus on sustainability as a preventative health strategy and an opportunity for improved health and health care delivery.  Let’s look at some of the issues. According to The Lancet, “Climate change is the biggest global health threat of the 21st century – the impacts will be felt all round the world – and not just in some distant future but in our lifetimes and those of our children.” Physicians need to advocate for health to be at the center of the climate debate as the health impacts are anticipated to be significant, including increases in respiratory illnesses, allergies, food and water borne illnesses, infectious diseases along with health impacts of weather disasters and heat waves.  In addition, there is scientific evidence linking the combustion of fossil fuels to lung cancer, respiratory illness, heart disease and other chronic illnesses.  I think that Margaret Chen, Director General of the World Health Organization, says it best, “The health sector must add it’s voice loud and clear – and fight to place health issues at the center of the climate agenda.”

Let’s briefly look at some of the other things I have learned over the past few years that concern me as a parent and a physician. The US spends billions annually to treat chronic diseases such as obesity and diabetes, both of which are increasing in incidence at an alarming rate and burdening our health care system. Scientists now suspect that endocrine disrupting chemicals may play a role in the development of both diabetes and obesity. These chemicals even have a name – “obesogens” – chemicals that may promote weight gain and obesity. Bet you never learned about this in medical school! The incidence of other chronic diseases with potential environmental links, such as asthma, autism and certain cancers are increasing at alarming rates. A 2008 Associated Press study found traces of pharmaceuticals in the drinking water of millions of Americans.  A 2005 study by the Environmental Working Group found over 200 industrial chemicals in the cord blood of ten newborn infants. DEHP, a plasticizer, which is an androgen antagonist, is found in many medical devices including IV bags and tubing. A 2007 Lancet study showed that nurses have the highest incidence of occupational asthma of any profession.  We have mercury, a potent neurotoxin, in our clinical and facility devices, pharmaceuticals and lab reagents. Around 80% of the antibiotics used in this country are used non-therapeutically in livestock, which experts agree is linked to antibiotic resistance in humans. I could go on and on, but it is beyond the scope of this blog.

So, what’s a busy physician to do with all this disturbing information?

At The Bedside

  • Incorporate environmental history taking into practice
  • Evaluate diagnostic imaging ordering practices and reduce patient’s exposure to unnecessary radiation
  • Educate patients about environmental exposures, healthy food and beverage options, proper medication disposal and the public health impacts of climate change
  • Practice “Green Pharmacy” – evaluate personal prescription practices (i.e. limit refills and quantities), consider non-pharmaceutical treatments when appropriate, regularly review medications with patients

In the Hospital

  • Advocate for procurement of healthy, local and sustainable food and beverages and for the elimination of sugar sweetened beverages
  • Advocate for toxicity reduction
    • ​Use of Green Seal Certified cleaning products
    • Mercury elimination
    • DEHP reduction
    • Fragrance-free and no-smoking policies
  • Advocate for pharmaceutical waste management program and education about proper medication disposal
  • Advocate for Grand Rounds and educational programs about environmental topics (or give a talk yourself!)
  • Advocate for a climate policy and preparedness
  • Encourage reprocessing of single use surgical devices and other sustainable initiatives in the OR
  • Join or start a green team
  • Encourage your hospital to join PGH and enroll in HHI
  • Agree to be your hospital’s “Clinical Champion”
  • Lead by example – support your hospital’s recycling program, use red bags properly, turn off lights not in use, reduce your paper usage!

Get Educated!!

Most physicians haven’t had any formal training or education about health care sustainability but there are some great opportunities for education

Advancing sustainability in the health care sector

  • Engage in research activities – the industry is in need of science based evaluation of sustainable best practices
  • Publications – write an article for your hospital newsletter, local newspaper or write a peer –reviewed article
  • Speaking engagements – speak to a variety of health care audiences

National Advocacy: advocate for climate change policy, chemical reform, antibiotic legislation and more. Let your voice be heard!

More and more physicians are recognizing the link between environmental choices and health and the environmental impact of hospital operations. Physicians have many opportunities to advance sustainability within their organizations and the health care sector and to bring this important work to our patients. Sustainability broadens my understanding of the Hippocratic Oath, as in my practice I now consider “First, Do No Harm” to mean doing no harm to patients, workers, the community and the environment.

6° Congresso Medici Manager inizia 21novembre a Roma @Medici_Manager @muirgray

Ecco il programma definitivo del 6° Congresso della Società Italiana Medici Manager che si terrà a Roma il 21 e 22 novembre 2013.

Dalla presentazione:

“Non può esserci crescita infinita in un sistema a risorse limitate, soprattutto se il sistema in questione è chiuso, complesso ed ha come obiettivo la tutela del diritto alla salute. La complessità, limite e forza della sanità del XXI secolo, nasce della definitiva emancipazione di tutti gli attori in gioco, dai cittadini alle professioni sanitarie, dai manager all’Industria: il risultato di questa evoluzione di ruoli e consapevolezze produce un vibrante tentativo di cambiamento, ma mai armonico.

La crisi internazionale, in aggiunta, sta colpendo duramente la tenuta del welfare in Europa e tra i primi interventi di razionalizzazione possono essere annoverati proprio quelli che hanno interessato i sistemi sanitari: Spagna, Grecia e Portogallo sono soltanto alcuni esempi. In Italia l’esperienza della regionalizzazione spinta, che ha generato 21 sistemi concorrenziali in perenne conflitto con il livello centrale, va probabilmente ripensata per creare una vera autonomia responsabile ed evitare il naufragio generale.

La Società Italiana Medici Manager (SIMM), nella consapevolezza che lo stato inerziale sia l’anticamera dello sfaldamento di un Servizio Sanitario Nazionale (SSN), equo, universale e solidale così come lo abbiamo finora conosciuto, ha deciso di dedicare il proprio VI Congresso Nazionale all’unità dei professionisti della salute ed alla centralità della leadership medica in sanità come strumenti per rivoluzionare e rilanciare il SSN. In questo la recente esperienza inglese di ristrutturazione del National Health Service (NHS), così vicina e così lontana allo stesso tempo, deve esserci di immediato aiuto per evitare errori da non commettere e, nel contempo, fornirci gli strumenti per disegnare ed esplorare vie del tutto nuove.

Tutti concordano sulla necessità di salvare il SSN ma nessuno possiede le coordinate della rotta da seguire, quanto mai incerta. Pertanto serve il coraggio di rivoluzionare, non solo di riorganizzare poiché soltanto un nuovo approccio culturale da parte dei medici e la valorizzazione delle energie e delle competenze migliori può guidare il cambiamento e fermare il declino.”

Concluso con successo il 6° Congresso SIHTA tenutosi a Bari dal 7 al 9 novembre 2013 @Medici_Manager

Si è concluso con successo il 6° Congresso Nazionale della SIHTA.

Esso ha dato un contributo, in un momento storico come quello attuale, caratterizzato da una forte crisi economica e da un’esasperata attenzione al contenimento della spesa, a compiere scelte che siano anche eticamente accettabili e socialmente condivise, un paradigma fondamentale per rendere sostenibili le decisioni che incidono in grande misura sul livello qualitativo dei sistemi sanitari.

E’ stata indagata la dimensione etica e d’impatto sociale dell’Health Technology Assessment affinché in ogni processo decisionale, non prevalgano più orientamenti poveri di dimensione valoriale quasi esclusivamente orientati ai tagli lineari piuttosto che a un sapiente disinvestimento che non incida sulla salute dei cittadini.

Si è ricordato che il percorso decisionale suggerito dalle metodologie di HTA costituisce un’ulteriore garanzia affinché le stesse vengano realmente interpretate come una leva per lo sviluppo economico del Paese.

Il Congresso si è articolato in quattro sessioni plenarie dedicate a:

1. La valutazione etica e di impatto sociale in HTA
2. HTA come leva per lo sviluppo economico del Paese
3. HTA tra innovazione e disinvestimento
4. Equità e sostenibilità del Servizio Sanitario Nazionale

Numerosi workshop, due dei quali svolti in collaborazione con l’Associazione Italiana Medicina Nucleare e l’Associazione Italiana di Fisica medica, e molte sessioni parallele hanno dato pregnanza al Congresso.

Da segnalare l’elevato livello scientifico delle presentazioni proposte dai partecipanti.

Prossimo appuntamento a Roma, nell’autunno 2014: il tema conduttore sarà “HTA e definizione dei LEA”. E’ un obiettivo ambizioso, ma ineludibile!

Direct costs of inequalities in health care utilization in Germany 1994 to 2009: a top-down projection

Lars Eric Kroll and Thomas Lampert


Social inequalities in health are a characteristic of almost all European Welfare States. It has been estimated, that this is associated with annual costs that amount to approximately 9% of total member state GDP. We investigated the influence of inequalities in German health care utilization on direct medical costs.


We used longitudinal data from a representative panel study (German Socio-Economic Panel Study) covering 1994 to 2010. The sample consisted of respondents aged 18 years or older. We used additional data from the German Health Interview and Examination Survey for Children and Adolescents, conducted between 2003 and 2006, to report utilization for male and female participants aged from 0 to 17 years. We analyzed inequalities in health care using negative binomial regression models and top-down cost estimates.


Men in the lowest income group (less than 60% of median income) had a 1.3-fold (95% CI: 1.2-1.4) increased number of doctor visits and a 2.2-fold (95% CI: 1.9-2.6) increased number of hospital days per year, when compared with the highest income group; the corresponding differences were 1.1 (95% CI: 1.0-1.1) and 1.3 (95% CI: 1.2-1.5) for women. Depending on the underlying scenario used, direct costs for health care due to health inequalities were increased by approximately 2 billion to 25 billion euros per year. The best case scenario (the whole population is as healthy and uses an equivalent amount of resources as the well-off) would have hypothetically reduced the costs of health care by 16 to 25 billion euros per year.


Our findings indicate that inequalities and inequities in health care utilization exist in Germany, with respect to income position, and are associated with considerable direct costs. Additional research is needed to analyze the indirect costs of health inequalities and to replicate the current findings using different methodologies.

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

The case for change slidepack @Medici_Manager @WRicciardi

Our Time to Think Differently programme has made the case for change and highlighted the trends that will influence the way health and social care is delivered in future.

To help you explore and share this work, we are creating a series of downloadable slidepacks. We hope that they will inform your thinking and discussions about the future of care.

The first pack in this series explores the pressures on the health and social care delivery system and why it needs to change to meet the challenges of the future.

You can download a powerpoint version of these slides here: The case for change slide pack. These slides cannot be edited in this format, but you can copy individual slides across to your own presentations. Please credit The King’s Fund if you use the slides elsewhere.

King’s Fund

Richard Smith: Health and social care: lots of activity, little value @Richard56 @Medici_Manager

21 Jun, 13 | by BMJ Group

My mother is a wonderful woman but has no short term memory and drinks too much alcohol. When she’s sober her language is complex and her sense of humour magnificent. “What a terrible world,” she says, watching the television news, “I’m glad I’m not in it.” In a way, she isn’t. She’s mildly disinhibited even when sober and chats to everybody. “You’re one of the sights of Barsetshire,” I say to her, “they’ll be organising coach parties.” “Well, nobody ‘ll pay,” she answers laughing. But how much have the health and social services helped my mother?

She’s clear that she wants to live on her own as long as possible. In an age gone by, but still present in most of the developing world, she would have lived with me or my brothers. It would be unthinkable that when widowed she should live alone. But those days are finished. We couldn’t stand it and nor, I’m confident (but maybe deceiving myself), could she.

It’s fascinated me how well and for how long she has lived alone despite having no short term memory. It’s been some six years. I thought an intact short term memory essential for living alone, but I was wrong. Luckily she doesn’t cook, so doesn’t leave the gas or the oven on. She forgets to put water in the electric kettle and sometimes blows the fuses, but she doesn’t blow up the house.

Every day is much the same. She gets up at about 8.30, has a cup of black coffee, looks at the Guardian (making no sense of it), puts on her shoes, and “stomps,” as she describes it, the mile into the centre of Barset. Greeting the man in the newsagent, she buys a bottle of wine, stomps home, hailing people as she goes, drinks the wine, and goes to bed. Perhaps two hours later she gets up and does it all again. And when the days are longest, she may attempt it a third time—unaware that it’s evening not morning and unsteady on her feet after two bottles of wine. That’s why I’m sat here in Barset writing this. I’m “mothersitting.” She giggles at the term but doesn’t really like it.

Back at the beginning I thought that we ought to “get her into the system.” I thought that we’d need some support and that it would be essential to be “on the books” to receive it. So we went to the GP, which she doesn’t like. The trainee said that she should have some blood tests and come back to have “the long test for memory.” That was two trips, 140 miles driving, and when we had the appointment for the long test, the doctor didn’t have time to administer it and so simply referred her to the memory clinic. There was no value added by all this as the postman could have told us that she has no short term memory.

The adventures with the memory clinic were long and drawn out with MRI scans, psychological tests, many interviews with a variety of people, and some 350 miles of driving. My mother hated it all, but in the end she was prescribed drugs to help her memory. She forgot to take them and didn’t, I think, want to take them anyway, although she said she did to please us all. Even if she had taken the drugs there was only a small chance that they would have done any good. Everybody was charming and helpful, but no value was added by all this activity—except that the diagnosis released some state benefits.  It was bureaucratic value that was added.

Social services became involved. They came and did a long assessment. Eventually, they said, she’d have to go into a home. This wasn’t surprising. They couldn’t do anything except give us a list of services. They couldn’t recommend any service even though they presumably know which are better than others. So no value in this.

We arranged for a “sandwich lady” to come three times a week to encourage my mother to eat. But that was hopeless, and eventually my mother herself told the sandwich lady that she didn’t need her anymore.

Social services assessed her again and told us the same as before. They did arrange a bath chair, which did add a little value. Unfortunately it broke down almost immediately and took a long time to fix. Now they’ve taken it away. I’m not sure why.

We arranged for carers to come in twice a day, and they have added value. But we found them and have to pay as my mother owns her house.

What about resuscitation, the care company asked. My mother is very clear that she doesn’t want to be resuscitated. We talk about death a lot. She’s not scared of death. But we can’t have a DNR in place without having the doctor approve it. So we haven’t bothered. If the carers find her in cardiac arrest they are highly unlikely to succeed in resuscitating her anyway. Having to have a doctor determine your eligibility for a DNR seems to me a process that subtracts value.

Now things have reached a crisis. With the long evenings my mother is going out late and drunk and having all kinds of adventures with neighbours, the police, and the burghers of Barset. The care company has contacted social services worried that it might be blamed if she goes under a bus. So have some neighbours. A young man from social services rings me in a state of high excitement. He asks me things that we have told social services many times. He’s rung the GP asking for an assessment. He offers us another assessment. “What good will that do?” I ask. He’s not clear. I say that we recognise she can no longer live alone even though she insists that she wants to. We’ve started finding a home.

They can’t, it’s apparent, really do anything. I ring the GP and speak to a friendly understanding doctor. They have been contacted by social services and discussed her in their meeting. But nobody knows anything about her. A doctor has visited twice but never got an answer. Somebody is going to try again. The young doctor agrees that they have little to offer. I’ve not heard from them since.
Social services keep ringing because people are ringing them. The care company tells me that they will do anything to help but in the same call, without irony, tell me that they can’t supply somebody in the light evenings.

My brother asks who social services are serving?  Are they there for my mother or the neighbours? We recognise the strain on the neighbours, and we know most of them. Some have been very helpful. Ages ago I delivered them all a letter asking them to contact any of us if they had worries. I’m not sure why they ring social services rather than us.

Then my mother has a fall. It had to happen. Indeed, it’s happened before. This time she has a scalp wound, and we doctors (and surely most others) know that scalps can bleed generously. I was abroad unfortunately, so my brother rings 111. Risk averse, as they have to be, they recommend a visit to A and E. Nobody can be sure that she wasn’t unconscious. A young doctor thinks she might have a urinary tract infection to account for her confusion and prescribes antibiotics. They can’t be taken with alcohol. He suggests a visit to the GP in four days’ time. I say poppycock to all this when I return, and we forget the antibiotics and the visit to the GP. She is fine. So again more activity, more expense for the NHS, and no value. At least she hasn’t developed diarrhoea through taking antibiotics.

A woman from social services rang again today. She’s weary. I tell her that we are in the final stages of the bureaucracy of finding a home. She’s relieved. I ask her what she might do if we weren’t doing anything. Eventually she would have to use the law to have my mother admitted to a care home. She could arrange an emergency admission to a home, but we agree that we should do all we can to avoid having to move her twice.

My mother is unaware that the phone lines of Barset are buzzing with concern about her. She’s not keen on moving to a home but will do what we advise. Seconds after we’ve had the conversation she has of course forgotten it.

When I reflect on the saga so far I can’t see that statutory health and social services have added anything but minimal value. But there’s been plenty of activity, form filling, and expense. My mother is not that unusual. We surely need better ways to get value out of the system.
I also reflect that people who have added a lot of value are those who work in the newsagent she visits every day. She likes them, and they are not only kind to her but also let her have goods without paying when she forgets her money and arrange a taxi to take her home when she’s tired and exhausted. Perhaps we need fewer expensive professionals and a revitalisation of communities.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.