I’ve been reading Jack London’s The Call of the Wild this afternoon and came upon this paragraph, which I missed the last time I read the book about half a lifetime ago. Now more experienced, this passage seems to ring more and more true.

“There is an ecstasy that marks the summit of life, and beyond which life cannot rise. And such is the paradox of living, this ecstasy comes when one is most alive, and it comes as a complete forgetfulness that one is alive. This ecstasy, this forgetfulness of living, comes to the artist, caught up and out of himself in a sheet of flame; it comes to the soldier, war-mad on a stricken field and refusing quarter; and it came to Buck, leading the pack, sounding the old wolf-cry, straining after the food that was alive and that fled swiftly before him through the moonlight. He was sounding the deeps of his nature, and of the parts of his nature that were deeper than he, going back into the womb of Time. He was mastered by the sheer surging of life, the tidal wave of being, the perfect joy of each separate muscle, joint, and sinew in that it was everything that was not death, that it was aglow and rampant, expressing itself in movement, flying exultantly under the stars and over the face of dead matter that did not move.”

– The Call of the Wild Chapter 3,

Peeling back the layers of WordPress's success

I’ve been thinking a lot recently about what drives me and what I’d like to do with my next start-up.  AKA the “right” space and opportunity for me – and I think that I’ve been thinking about it somewhat from the wrong perspective and too hard. I’ll explain. The last time I was in Seattle I had a chance run in and conversation with Matt Mullenweg of WordPress and Automattic founding fame.  We talked about a number of things, but what’s stuck with me is how he talked about what continues to drive him to push  both WordPress and Automattic.  It wasn’t more money, or a dominant market share – rather, it was clear that for him it’s a larger, more fundamental life passion that underpins his work. And I took that perspective to heart.  To boot, it’s much more basic than I would have thought.

Automattic seems like it it’s a wildly successful business.  Millions of users host their blog on WordPress.com, millions of downloads of WordPress itself (Medicine Think is a WordPress blog – and I’m grateful!)  and WordPress continues to grow.  Some sites state that 23 million blogs and sites are based on WordPress.  I would have expected Matt to say that reaching another million users or seeing 80% of the Fortune 500 utilize the WP platform were his main goals.  Or a specific sales target number.  It wasn’t. And although WordPress’s success to date seemed to fulfill him, it was pretty clear that success wasn’t at the core of what drives him.

What Matt said, and I’m going to butcher his exact words, is that his underlying drive and passion is powered by a “desire to create platforms that empower free and open human expression on the internet and in the world.”  He said it much more eloquently than I just did, but you get his main gist.  His mission wasn’t to gain 20 million more users, or to crush Blogger (a competitor), or some other business goal – his passion is driven by an innate desire to enable humans to freely express themselves.  Basic. Simple.

The interesting thing about this goal is that it’s hard to measure, but easy to keep in mind and continually work toward.  I’d argue that all too often we’re driven by specific business goals or material objects.  Or even a desire to be rich.  Just about any highly successful entrepreneur I’ve met in Silicon Valley has Matt’s type of passion and drive – and in some basic way that translates into a drive that then brings success.  That success may not be financial, but what I can say is that most very financially successful entrepreneurs I’ve met have this kind of basic drive.  For example Bill Gates famously recruited Steve Ballmer with the vision of “A PC in every home.”

Passion and Desire - somehow that evokes Rocky in my head.

WordPress fits in to Matt’s passion – it’s part of a larger effort and movement.  WordPress is a free platform used by millions.  And, although Automattic is a for-profit businesses, it enables millions of people to blog and express themselves at a very reasonable cost.

It was quite obvious that Matt didn’t mean that he wanted to be the player that 100% dominated the market.  Rather, his goal was clearly to be a leader in the effort and to contribute in the best way he knows how.

This passion is a beautiful sentiment and approach.  But it’s also powerful and fundamental – something that can motivate you.  It’s concise, yet allows you to build toward it every day. Matt can wake up and clearly and concisely state what he’s working toward.  It’s a known quantity. Such a sentiment can also be felt by others within the company (or those in a movement around you) and can inspire them to work harder and smarter toward they company’s success.  In fact, I believe this basic passion is critical to the fundamentals of highly successful businesses.

One of the other, biggest lessons I learned in life was from my high school volleyball coach – Bob Miller.  In pre-season practices we would spend literally 2 or 3 weeks (which is an eternity for high school age boys), on the fundamentals before we were allowed to hit.  Passing, setting, blocking, footwork, endurance.  The theory was to set the fundamentals and the rest will follow.  And, by and large, it worked for his teams through 3 decades and many regional and state titles.  Flashy hitting only gets a team so far – the message was clear and we saw the proof – fundamentals win championships.

Much the same way, the fundamentals of business lie in this passion philosophy.  Developing and maturing your own personal business and life passion and continually honing and reflecting on it gives you the foundation not only to succeed, but to lead and win.  It gives you the tools to inspire others and create real, lasting change and success.  What’s more inspiring? To crush the blogging competition – or to create an open platform that enables and encourages freedom of expression?  And, I don’t think the latter necessarily replaces the former.  I think that the desire to aim to that larger goal can actually lead a company to defeat the competition, which in turn creates more economic value and overall human creativity and creation.

Coach Wooden - the champion of character and fundamentals

Such a fundamental mission also creates a foundation for your character.  As the going gets tough, your fundamental passion can help motivate and drive past the hard times.  I haven’t sorted through it completely, but my general guess is that the type of life passion you develop is directly reflective of your character – another key component of success.  One of my favorite quotes is from the late John Wooden, “Hard times do not create character – they reveal it.” (thanks @kevinthau for reminding me of this quote).  Understanding your fundamentals, and what drives you, enables you to stay true to that character, inspire others and continue through tough times.  Many thanks to @photomatt for helping me to refocus on my essential passion.

I recently had the odd feeling of talking with one of my wife’s co-workers, who I also follow on Twitter.  Or, rather, she’s in my twitter stream and she’s fairly prolific and often entertaining.  The conversation, while itself wasn’t odd, but I had an odd feeling because as we were talking I realized that I know a disproportionate amount about her, relative to what she knew about me.  I almost felt like a stalker.

Clearly, people on Twitter understand that everything they say is public – or at least they should.  And we read what they write, so there’s a quid-pro-quo.  However, given traditional social norms I still at least feel a bit like a stalker when I talk to people I follow on Twitter.  A couple of friends, friends who are in social media, also concur – they should be most comfortable, but they still admit a slight feeling of stalker-itis.  If you google “twitter manners” or “twitter etiquette” you tend to get blog posts about how to properly post on Twitter (how to reply, DM and thank people for RT-ing) and be a good Twitter citizen – almost none advise what to do with the info you gather about people you follow on Twitter and how to most effectively use that social info.

I’m meeting with a person on Monday who I’d really like to impress, and as it turns out I also follow him on Twitter.  How do I let him know that I follow him out of interest rather than stalking?  If I come across as too familiar it might seem like I’m stalking him or just might be plainly weird.  I suppose this post is more about asking the question – what do you do with the information you gather about people on Twitter while you’re in a social or business situation with those very same people?

I asked my PR-pro wife and she had a great suggestion – just prior to remarking on their Twitter updates, preface your comments that “I saw on Twitter you did ………” or “I saw on Twitter you headed to Disneyland last week – how was it?”  Potentially, you could even engineer the conversation some – for example they may have tweeted that the trip was sunny and fantastic – and you therefore have an easy conversation starter that gets things off on the right foot.  Either way, it shows that you’re interested in what that person does – I wouldn’t rehash their entire Twitter history, but commenting on one or two status updates might be a good ice breaker and convo starter.  I thought it was a brilliant thought and wanted to pass it along!

So, that’s a start in thinking about how to productively use all the updates you read on Twitter without feeling too much like a member of the stalkerazzi.  I’m open to any other ideas – thoughts as to ways to more effectively mine and use the information you gather on Twitter?  Drop me a comment!

I read Michael Pollan’s In Defense of Food a couple months ago and it’s really changed the way that I think about and approach food.  In an odd way, I’m actually more willing to spend time shopping and preparing food and it seems to be sticking.  I’m feeling healthier and plan on using it as a foundation for how I think about food – or at least a bit of a start.

However, one fascinating aspect that he didn’t address are the neurobiology and behavior that is created by the food that we eat.  In other words – how does the food we eat affect us neurologically, particularly regarding eating unhealthily as a population.  The brain is relatively straight forward – deep within the brain there are ‘reward’ centers – areas that are responsible for us feeling good after we accomplish something.  These areas light up when we eat, bathe, have sex and are really stimulated by certain recreational drugs – heroin comes to mind.  Interestingly, since heroin stimulates this reward area so much more than food or bathing does, drug addicts often fall in to bodily disrepair because they no longer receive the right reward stimulation.

This is something that I studied while in undergraduate classes at Emory – behavior and its link to the brain reward areas.  Specifically, after reading Pollan’s book I began wondering about different types of food, how they stimulate the body and also stimulate the reward centers in the brain.  For instance, most folks who eat a daily donut, or make a trip to McDonalds every day – they tend to crave that type of food. The more they eat, the more they want to eat.  To take that one step further, I’ve often wondered about the fat and sugar content of foods and whether the amount of fats and sugars in foods are relative to the reward and sensory feedback in the brain.  It made me wonder whether people can actually become addicted to junk food and whether that is one of the problems (not necessarily the problem) that underscores our obesity epidemic.

Some interesting research has been coming out of UT Southwestern in Dallas and the Rudd Center for Food Policy and Research at Yale.  Specifically, I’m thinking directly about research done by Deborah Clegg’s research at UTSouthwestern – her group has shown that saturated fats can cross the blood brain barrier (no real surprise there) and have an effect on the internal workings of our brains and affect satiety.  A great down-to-earth article was written in the NYTimes that captures the essence of her research.  Essentially, her research shows that saturated fats block the effects of Leptin, which is a hormone that works on the brain and make it feel satiated.  And, they showed that those effects can last for days.  In other words, the more saturated fat that you eat, the harder it is for you to feel satiated and therefore the more you eat.  You have to eat more to feel full.  Among the common population this seems counter intuitive – more fat should make you feel full, right? But that’s what is so important about this work – it has the chance to help counter those perceptions.  David Kessler’s appearance on The Colbert Report back in April sums this point up pretty nicely (and humorously), too.

The same can be said about sugars.  Recently, a movement to levy tax on soft drinks has taken flight.  The logic goes like this – the more sugary drinks you eat, the fatter you get, the more you cost the healthcare system.  So, then, why don’t we just tax you for the money that you’re going to coast the system?  I’m not here to debate the merits of this proposed policy, but it’s important to acknowledge that sugary drinks are affecting our population.  Not only that, but diet drinks as well!  A paper in Behavioral Neuroscience illustrates that rats who were given artificial sweeteners tended to actually gain weight.  The same has been shown by UCSD researchers in humans – real sugar actually has a much more profound effect on the brain, causing the person to feel more satiated.  A good, basic article by CBS News illustrates a few more of those points.  Jonah Lehrer also has a great summary on diet soda in his blog The Frontal Cortex.

While I am definitely not blaming our obesity epidemic on these findings or giving people an excuse for why they’re obese, I am saying that we need to better understand the neuro and behavioral implications of this type of research to better address the issues facing this country.  It helps to explain why people have a very hard time staying on diets and staying away from the fatty foods they crave.  This is important as we strive for reform and savings in our healthcare system.  Sugar and pop taxes aren’t the answer, but at least we’re beginning to target a core reason why people have so many health issues, which translates into the massive spending (and economic productivity loss)we see in healthcare.  Without getting people off the bad foods and drinks they consume, we’ll never lose the weight our society so desperately needs to lose.  The argument is much more profound than “just stop eating.”  I’m glad to see that it’s starting to hit the main stream, like in my friend Ramit Sethi’s I Will Teach You to Be Rich blog – “Ugh, why don’t fat people just eat less?” If we want true reforms, we need to better understand why people eat and act the way they do – without understanding this we’re doomed to repeat our mistakes and repeatedly fail.  Real reform has to start at the basics – the way we live our daily lives and what we eat.

With the passing of Senator Kennedy last week, cancer has made its way back in to the news – particularly the “War on Cancer” begun almost 40 years ago by President Nixon (and Kennedy, btw).  Kennedy’s struggle with glioblastoma, a particularly tough brain cancer, was highlighted in the NYTimes last week.  From diagnoses to death, it was a little over a year for Kennedy, which led some to question the effectiveness of the War on Cancer and some stats even show that death rates for cancer have barely budged, despite billions upon billions invested.

But, I’d like to suggest that we have actually benefitted tremendously from this research and investments – in some cancers survival is up and life is often prolonged.  This is mostly due to improvements in radiation oncology and chemotherapeutics and there is a large pipeline of drugs in the works.  However, I’d like to suggest that the most important advance is that all of the invested research dollars have helped us to “know that which we don’t know.”

What do I mean by this?  Cancer and molecular biology have turned out to be much bigger and complex areas than we thought back in 1971.  We now have the advantage of knowing about tumor suppressor genes, apoptosis issues, and oncogenes.  And, as noted by Susan Love in this NYTimes piece, we have now begun to think about cancers in a much more helpful way – even if two cancer cases have the same specific diagnosis (say, breast cancer), at a genetic level  those two cancers could be completely different.  This has massive implications for treatment and other options.  For example, if we knew the exact set of genetic mutations that led to a person’s cancer we’d be able to more accurately target therapies that are specific to their cancer.  Ideally, this would lead to better outcomes and many lives saved – at present the community is calling this personalized medicine.

Companies like Genomic Health are now developing tests to examine the genotypes of individual cancers and help highlight optimum therapies.  This technology is still very, very novel and not well tested – there are many miles to go until they become standard of therapy.  But until then, these new paradigms of thinking about cancer and oncology are direct decendants of the War on Cancer.  To some this effort may seem like a failure or waste of research dollars, but it has yielded invaluable insights, showed us just how large the battle really is and has illuminated the path we’re going to have to take.

Knowing what we don’t know is the victory.

Clearly, the title of this post is something that has been talked about for quite some time.  There’s even an X-Prize for the first team to do 100 whole genomes in 10 days for under $10K per genome.  I don’t think that I’m revealing any big shocks here – this type of sequencing will radically open up doors.  That is, until it shows us that which we as of yet don’t know we don’t know.

There are a number of companies, as mentioned in my last post – Complete Genomics, Pacific Biosciences, 454, etc – who are pushing new concepts to old technologies.  Who knows, maybe their approaches will become the standard, but the reason I think not is that despite their high technology (which, don’t get me wrong – they’re brilliant), I think it’s going to have to take a complete shift in how sequencing is done – away from Sanger sequencing.  Now, my bet is that these are going to be marvelously successful companies while the next generation technologies come about.  That is, these companies will bring down the cost of sequencing, which will dramatically promote more research, which will beget more research, and on and on.

That research will lead us to begin to truly understand genomics and its relevance to medicine and mainstream science.  For example, we might actually begin to understand which genes and epigenetic/metagenetic factors combine to produce cancer.  We’re just now discovering the genetic profiles of cancers, and that work will only pick up as whole genome sequencing becomes more readily available.  But it’s going to take a dynamic shift in thinking and sequencing techniques to quickly and effectively sequence the genome.  New technologies from companies like Halcyon will have base sequence reads in the hundreds of thousands to millions – instead of in the hundreds as we see today.  When you do the math, there are significant gains of several magnitudes in speeds, reliability and accuracy of these next generation technologies.  For now, though, they all remain very rusty – I’ve seen them myself – but I really think they’ll come along and continue to change the market.

For now, we’re stuck with current technologies – which should come on line by the end of 2009 or at least by the middle of 2010.  As research performs its work using these more expensive technologies, the findings will pour in and advances in medicine and other areas will be discovered.  By the time all this happens, the next generation of even cheaper sequencing will be available and be ready to go mainstream.  The current, more expensive technologies are setting the stage for tomorrow’s cheaper, more reliable technology.  Kinda reminds me of the computer industry and Moore’s Law.  And, much like microchips and then hardware, DNA sequencing will be subject to commodification – decreasing margins and altering business.  Hopefully this will lead to improvements in sequencing and cost – we all benefit from this type of competition.

But, the commodification of DNA sequencing will lead to mountains of data, which will have to be dealt with.  And it will be . . . in my next post.

There is an interesting story brewing in the whole healthcare debate.  Now that we’re past the nice-ities and the pie-in-the-sky promises of the election cycles, we’re starting to get in to the meat of the healthcare debate and ecosystem.   And in that I mean that we’re starting to see the self-interests of the insurance companies (payers) and providers (docs, nurses, special interest groups, etc) and politicians converge in all the glory that is the healthcare debate.

A great example of this was written in the NYTimes today in an article entitiled “Health Care Spending Disparities Stir a Fight.”  In it the authors detail (at a pretty high-level) the debate over healthcare quality versus spending.  Particularly they focus on a long-standing project called the Dartmouth Atlas (DA), which is based out of Dartmouth’s medical School and headed by a doc named Elliott Fisher.  The DA is essentially an impressive data mining project where medicare data is crunched by rooms full of computing power up in Hanover, NH.  Their findings, funded largely by federal grants, are freely and readily available for download at their site.  I’ve actually had the pleasure of working with Dr Fisher in the past and a number of his colleagues on a couple of projects for Mercer Health.

In those projects we specifically dissected the DA by metropolitan service area.  Here’s where the rub and disingenuous aspect to the politicians and providers arguments – and, yes, I’m singling out the comment from Cedars Sinai here – the DA pulls the raw claims data from the complete Medicare database.  It shows which patients have received what type of care and for how much.  True, there are definitely statistical errors and some methodology issues, but those are pretty much the same across all providers.

What we found was that in 10 different US metropolitan areas you could easily break down and detail which hospitals were delivering high quality care for the least cost.  Mind you, this is the same care/procedures/tests as the more expensive hospitals, but for much less moolah.  And, to boot, research has shown (still searching for the right citation here, but it exists) that those high quality indicators lead to better outcomes AND less spending over the long term.  It’s pretty much a win-win type of situation.

What I’m suggesting is this, rather than looking for miracle cures for healthcare spending, such as healthcare IT, and begin to look at how we practice and the right practice behaviors that lead to better outcomes and, ultimately, savings.  Michael Porter, yes, that same 5-forces guy, published an interesting piece in the New England Journal on June 3rd.  While I don’t necessarily agree with all of his points, I do believe that he’s hitting on the fundamental notion that we need to look deeper than just cutting costs and fully examine and question the way medicine is practiced and the way healthcare is administered.

The Dartmouth Atlas, if you take and dissect its data, details that some hospitals perform as well or better than their more expensive counterparts, indicating that we can do this for less and that all starts in the fundamentals of how we practice medicine and healthcare.  To me this means all players being open, willing to look deeply at their own practices and business behaviors and make alterations that are realistic and friendly to the market.  Without being honest with themselves, it might just come down to legislators making the rules, and that’s something that none of us really want.

For a while now I’ve been keeping an eye on the whole healthcare IT thing and have found just an incredible number of errors in the way we (as a country) approach the use of healthcare IT in our system.  I’ve published academic articles and a white paper on the subject of health information exchange, detailing one of the best cautionary tales for this time of uber-stimulus potential.

There’s lots of talk in publications like the Wall Street Journal that doubt the value of electronic health records/IT in practice, while there’s tons of governmental and industry press that tries to sell healthcare IT, it’s hard to tell who’s telling the truth.  And, if you’re a newbie to healthcare IT, John Halamka, one of the more rational leaders of the effort has a good blog and a great post that details the basic terminology. 

One of the lessons I learned through my research time at UCSF is to really dive in and check where publications proclaiming the value of healthcare IT come from – most articles cite a source they believe to be credible.  But, ultimately, if you trace those citations back, even the best sources of “data” on healthcare IT value are based on experts opinions. These “facts” have gained validity over time through being unintentionally “laundered” through citations in publications.  While some of these estimates and opinions are the best that we have, that doesn’t mean they’re accurate – both sides of the argument are using “proof” of dubious origination.

I have to admit, I’m burned out on the healthcare IT argument, but what does intrigue me about it is the business case around healthcare IT and the mistakes I think people are making with regards to finding a value-based argument for healthcare IT adoption.  Most of the public expects to never again fill out forms in doctor’s offices or tell an emergency room doc their history, and interestingly enough to me is that is enough for people to back hundreds of millions to billions worth of healthcare IT investment.  Guess what – you’re still going to have to do those forms.  Sorry to break the bad news – those forms are more of a CYA for docs in this overly litigious medical profession. Until that changes, you’re still going to have to fill out those forms.

The real value comes in as more and more docs and hospitals adopt healthcare IT – it’s the same value proposition as seen in the internet – it’s all about the number of nodes on a network that give it value.  Metcalfe’s argument, while more of a metaphor than a fact is a good place to start regarding the argument for widespread healthcare adoption.  Therefore, the first step in healthcare adoption needs to be the actual adoption of healthcare IT.  This has less to do with preventing errors or creating other efficiencies through IT adoption, rather it’s about digitizing and therefore “net-enabling” healthcare information broadly.  Which leads then to the second step – networking all that information in a meaningful manner.  It’s not until that step that the real, significant savings realized by healthcare IT adoption.

Here’s the rub – it’ll cost tens of billions of dollars to properly digitize a physicians’ practice or a hospital’s infrastructure.  That investment comes in the first wave of healthcare IT adoption when the ROI for the investment is low.  Healthcare IT adoption has been slow over the years, so it’s not going to speed up fast enough to really get to that second step of networking the data while the argument and passion for healthcare IT adoption is still high.  We need a solid plan now that understands this paradox in healthcare IT adoption and that looks toward long term success and makes the necessary funds available to ensure long-term success.  Otherwise, we’ll find ourselves creating a patchy system that is optimized for no-one and even more inertia that prevents true healthcare IT adoption.

Once we get to the point where we have the nodes on the network and information flows more freely, the ROI will become very apparent and innovations that we cannot visualize or conceive of today will become reality.  I hope we can get to that point.  Until then, just remember Metcalfe’s law of nodes as a guiding principle – I think an argument rooted in that tradition will help drive the necessary adoption.