It's Not Possible To Be Fully Human If You Are Being Surveilled 24/7

Groklaw has now shut down it's operations to avoid exposing all of it's email to government surveillance.

Groklaw is a site that provided deep analysis of the legal system, providing explanations of ongoing court cases. Now it's joined other online services like Lavabit that have closed down in order to protect their users privacy.

You can read the entire story here but the following I found especially compelling:

...What I do know is it's not possible to be fully human if you are being surveilled 24/7.

Harvard's Berkman Center had an online class on cybersecurity and internet privacy some years ago, and the resources of the class are still online. It was about how to enhance privacy in an online world, speaking of quaint, with titles of articles like, "Is Big Brother Listening?"

And how.

You'll find all the laws in the US related to privacy and surveillance there. Not that anyone seems to follow any laws that get in their way these days. Or if they find they need a law to make conduct lawful, they just write a new law or reinterpret an old one and keep on going. That's not the rule of law as I understood the term.

Anyway, one resource was excerpts from a book by Janna Malamud Smith,"Private Matters: In Defense of the Personal Life", and I encourage you to read it. I encourage the President and the NSA to read it too. I know. They aren't listening to me. Not that way, anyhow. But it's important, because the point of the book is that privacy is vital to being human, which is why one of the worst punishments there is is total surveillance:

One way of beginning to understand privacy is by looking at what happens to people in extreme situations where it is absent. Recalling his time in Auschwitz, Primo Levi observed that "solitude in a Camp is more precious and rare than bread." Solitude is one state of privacy, and even amidst the overwhelming death, starvation, and horror of the camps, Levi knew he missed it.... Levi spent much of his life finding words for his camp experience. How, he wonders aloud in Survival in Auschwitz, do you describe "the demolition of a man," an offense for which "our language lacks words."...

One function of privacy is to provide a safe space away from terror or other assaultive experiences. When you remove a person's ability to sequester herself, or intimate information about herself, you make her extremely vulnerable....

The totalitarian state watches everyone, but keeps its own plans secret. Privacy is seen as dangerous because it enhances resistance. Constantly spying and then confronting people with what are often petty transgressions is a way of maintaining social control and unnerving and disempowering opposition....

And even when one shakes real pursuers, it is often hard to rid oneself of the feeling of being watched -- which is why surveillance is an extremely powerful way to control people. The mind's tendency to still feel observed when alone... can be inhibiting. ... Feeling watched, but not knowing for sure, nor knowing if, when, or how the hostile surveyor may strike, people often become fearful, constricted, and distracted.

I've quoted from that book before, back when the CNET reporters' emails were read by HP. We thought that was awful. And it was. HP ended up giving them money to try to make it up to them. Little did we know.

Ms. Smith continues:

Safe privacy is an important component of autonomy, freedom, and thus psychological well-being, in any society that values individuals. ... Summed up briefly, a statement of "how not to dehumanize people" might read: Don't terrorize or humiliate. Don't starve, freeze, exhaust. Don't demean or impose degrading submission. Don't force separation from loved ones. Don't make demands in an incomprehensible language. Don't refuse to listen closely. Don't destroy privacy. Terrorists of all sorts destroy privacy both by corrupting it into secrecy and by using hostile surveillance to undo its useful sanctuary.

But if we describe a standard for treating people humanely, why does stripping privacy violate it? And what is privacy? In his landmark book, Privacy and Freemom, Alan Westin names four states of privacy: solitude, anonymity, reserve, and intimacy. The reasons for valuing privacy become more apparent as we explore these states....

The essence of solitude, and all privacy, is a sense of choice and control. You control who watches or learns about you. You choose to leave and return. ...

Intimacy is a private state because in it people relax their public front either physically or emotionally or, occasionally, both. They tell personal stories, exchange looks, or touch privately. They may ignore each other without offending. They may have sex. They may speak frankly using words they would not use in front of others, expressing ideas and feelings -- positive or negative -- that are unacceptable in public. (I don't think I ever got over his death. She seems unable to stop lying to her mother. He looks flabby in those running shorts. I feel horny. In spite of everything, I still long to see them. I am so angry at you I could scream. That joke is disgusting, but it's really funny.) Shielded from forced exposure, a person often feels more able to expose himself.

I hope that makes it clear why I can't continue. There is now no shield from forced exposure. Nothing in that parenthetical thought list is terrorism-related, but no one can feel protected enough from forced exposure any more to say anything the least bit like that to anyone in an email, particularly from the US out or to the US in, but really anywhere. You don't expect a stranger to read your private communications to a friend. And once you know they can, what is there to say? Constricted and distracted. That's it exactly. That's how I feel.

Floating Doctors + Humanitarian Medicine

The Floating Doctors Mission is to reduce the present and future burden of disease in the developing world, and to promote improvements in health care delivery worldwide.

• Providing free acute and preventative health care services and delivering donated medical supplies to isolated areas.
• Reducing child and maternal mortality through food safety/prenatal education, nutritional counseling and clean water solutions.
• Studying and documenting local systems of health care delivery and identifying what progress have been made, what challenges remain, and what solutions exist to improve health care delivery worldwide.
• Using the latest communications technologies to bring specialist medical knowledge to the developing world, and to share our experiences with the global community and promote cooperation in resolving world health care issues.

Sound like something that you might be intrested in helping out? (Freelance MD is already making a small monthly payment to help foot some of the bills.)

You can help Floating Doctors with a donation of any size.

Volunteer medical providers?

Doctors, nurses, PAs, NPs, dentists, optometrists, physiotherapists, occupational therapists, medical students, public health researchers, educators, engineers, and anyone with a pair of willing hands and the desire to help out in this world are welcome to participate in our project.

Everyone has some special talent or characteristic that can be used in the service of others. We pride ourselves on maximizing the experience of our volunteers to express their particular talent in a way that brings the most help to our patients.

We have no minimum or maximum length of stay and a reputation for working hard and being easy to work with. It is impossible to know exactly what kinds of cases we will see, or what situations we will encounter. All we know is that it will be an adventure of the heart—at some point, there will be a moment where your presence can mean a tremendous change in a person’s life.

Here is a typical experience for a volunteer…a surgeon from Austria vacationing in Panama decides to joining Floating Doctors for a one-day mobile clinic to a remote island indigenous village.

“Life is not about seeing what you want and how to get it but rather is about seeing what you have and how to give it.” Frank Baxter

Keep Your Goals To Yourself

Finding Your Lifesytle Niche As An MD

ZDoggMD (AKA Zubin Damania MD) is a hospitalist who's kickin'it his own way.

ZDogg's interview with TechCrunch TV discussing finding your niche and being happy as a physician.

ZDogg is a genuine doctor who uses YouTube as a creativity outlet to teach people about things like safe sex, delivering bad news, stayin’ healthy on vacation and hemorrhoids. When Hsieh asked how the world of being a doctor was going for him, ZDogg answered that he loved it but was frustrated with the fact that he couldn’t be himself. He told Tony that he’d love an outlet to share the raps he composes with a wider audience, hopefully to give people a good laugh but also to teach them a medical thing or two. Tony, being the zen like guy that he is, responded, “Why don’t you do it then?”. And so he did. The results are in the links above.

Movin' On: The Path Not Taken

Last week I got an email from a former physician colleague. He still works at a health care organization that I left years ago. The re-connection got me thinking about what I would have missed in my life and career had I remained at that organization. Now that I'm about three months away from leaving ACPE after three and half years as CEO, I've been in a reflective mood.  

First, leaving the traditional health care organization, with its typical hospital-physician-insurer tugs of war over reimbursement, culture, and authority dynamics, was a breath of fresh air for me. Never comfortable with the status quo, I wanted to get out and find new approaches to improving health care. 

Freed from the constraints of orthodoxy, I signed on to join a small start up company focused on changing consumer behavior in the workplace to reduce health care costs, and create a healthier workforce. I learned how to find investors. I learned how to assemble office furniture from IKEA because frugality, functionality, and teamwork was required of everyone on the senior team. I liked the idea that our work and execution of strategy would determine whether the business concept would succeed. When a couple of senior professionals left, I understood that I would have to take over some of their responsibilities of consumer research. I enjoyed doing that. Even though the company eventually closed its doors (like most start ups), the experience was a good one.  

Next, I joined a couple of system safety engineers in their growing consulting group to learn about how aviation, nuclear power, manufacturing, and other industries had become highly reliable. It required learning new concepts and language, then translating that to health care. It was exciting to work with health systems, physicians, and nurses who were committed to being pioneers in adapting the safety science of engineering to health care. I soon discovered that several other physicians were intrigued by the same concepts. We could talk the same language, and see a path to improving performance and patient safety. The consulting work was part-time, which allowed me to travel, and get a major stonemasonry project moving along. Could life be any more interesting or satisfying?

When ACPE's founder and CEO announced his retirement in 2008, the opportunity came to build on everything in my background. I found the new challenge that made my life more interesting and satisfying. I'm convinced that having worked in the insurance, hospital, medical practice, consulting, and entrepreneurial sectors of health care was attractive to the ACPE Board. I viewed the College more as a nimble, creative start-up opportunity than a thirty-five year old professional association. The strategic thinking and business plan execution required of start-ups was far more important than having a background in association management.  

Learning how to listen to the staff, which includes journalists, artists, educators, and professionals in marketing, IT, and finance, was key to surviving the recession, and rebounding from it. I asked our creative artists and journalists how they would redesign our journal - pej - to give it a more contemporary look and feel.  Who would have thought that changing to small case, big blocky letters would have such an impact?  The quality of writing - both from physicians and free lance journalists - increased.  

From my private equity market experience, I paraphrased a quote from Malcomb Forbes with my Board about their role and my role:

"There are but two questions a board should ask at each meeting.  The first question is always the same: 'Should we fire the CEO today?'. If the answer to the first question is "yes", then the second question is, "Then who among us shall serve on the search committee?". If the answer to the first question is "No", then the second question is, 'Then how can we support the CEO and the staff to be successful?'

Some said that was "too harsh" a way to look at the governance-management issue. Not for me, nor for the great board chairs I had the privilege to work with. All are great friends - but we all understood the harsh reality and consequences of running a business.  

I was left thinking that if I'd stayed with my previous organization, I would have had a nice salary, important title, pension plan, and nice people as colleagues. But I most certainly would not have found my way to ACPE, learned how to lead and manage through the recession, or have the opportunity to work with talented people outside of health care, who have a lot to offer to those of us working in the health care industry. I'm looking at my next transition at the end of the year as adventursome, exciting, and fulfilling. One way or another, I'm "leaving the tribe" again - a topic I'll be speaking on in Las Vegas at the Medical Fusion Conference in November.

Physician = God Complex?

By Dr. Anthony Youn

"I Am God!" proclaimed Alec Baldwin’s Dr. Jed Hill in the 1993 movie Malice. When he revealed his Doctor-God complex, most non-medical viewers were shocked. Doctors and nurses... not so much.

Why do some doctors think they are on par with God?

One night as a third year medical student I was assigned to work with a grizzled, veteran Ob-Gyn doctor for a night of call. At 2 am I went up to the doctor and asked the typical medical student question, "Is there anything I can help you with?" In front of the entire nursing staff he set his face 6 inches from mine, pointed his finger at my face, and said, "There is absolutely nothing, I repeat, nothing you can and ever will be able to help me with." He turned and stormed down the hall. As a medical student, events like this were not uncommon, as there were always certain doctors who took perverse pleasure in making their subordinates feel useless and inferior.

Well, I earned my M.D. and thought that things would change. Now I was a real doctor and other physicians would respect me. Boy, was I wrong. Even with an M.D. after my name I was still a resident, a peon in the eyes of real attending physicians. This was never any more apparent than in the weekly M&M conferences. M&M’s had nothing to do with the tasty candies and everything to do with attending physicians verbally pummeling residents for any complications or deaths that occurred over the last month. Never mind that the patients were the ultimate responsibility of the attendings, or that many of the attendings approved the treatment decisions at the time. Many a time my colleagues entered M&M’s confident resident physicians and exited quivering lumps of self-doubt.

So what causes some doctors to think they are on par with God? Quite possibly the power to make life or death decisions for their patients gets to some doctors’ heads. Physicians are the ones that, with a pen, can write an order for a patient that saves his or her life. However, while we doctors may have the knowledge of what medication may save a life, do we have the ability to administer that medication? Doctors need secretaries to enter the order into the computer, pharmacists to prepare the proper dosage, and nurses to place the IV and administer the medication. Although we often forget it, we physicians do not exist in a health care bubble. We can’t do it alone. Many doctors still type with one finger at a time, have never used a mortar and pestle, and couldn’t successfully place an IV into a vein the size of a pencil. Yes, I’m talking about me.

I have a message to my fellow physicians. We need to lighten up. Laughter, they say, is the best medicine. I’d love to write a prescription for "Laughter" for the many doctors who take themselves too seriously. While the act of completing four years of college, four years of medical school, and surviving 3-8 years of brutal residency training is something to take pride in, it doesn’t give us carte blanche to treat others as inferior to us. As a plastic surgeon I am reminded every time I operate that I can’t do it alone. I need someone to gown me, plug in the cautery machine, arrange my surgical instruments and supplies, hold the retractors, and even work my iPod. I try to make an effort to thank the staff who support me each day, but admit that there are times I get frustrated and do not treat my support staff the way they should be treated.

The best compliment I ever received from a nurse had nothing to do with surgical skill or knowledge, but was when she said, "Dr. Youn, you’re one of the only doctors who is one of us". I hope I can continue to live up to that statement.

Signature: Anthony Youn, MD, FACS is a board-certified plastic surgeon and author of IN STITCHES, a humorous memoir about becoming a doctor. Dr. Youn's site is at www.institchesbook.com.

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Are You Resilient?

We like to think we are ... but how well do you really "bounce back" from life's stressful events?

I recently heard a wonderful interview with a woman who is 109 years old, and who continues to live independently, "with all her marbles and profoundly engaged with the world around her", as the interviewer noted.

A gerontologist, the interviewer noted that while the woman most likely has a gene that contributes to her unusual longevity, she also exhibits a powerful trait that professionals in his field call "adaptive competence".  In other words, from his experience with thousands of patients, his opinion is that the key to living to a long and healthy old age is the ability to keep moving forward after life's inevitable setbacks.  It's about being resilient.

It made me start thinking about the physicians I work with in a coaching capacity.  Many of them, I've noticed, are somewhat low on the resilience scale.  Why?  Maybe you can help me understand it.

Is it a function of highly intelligent people,  linear thinkers, who spend too much time thinking about the "what could happens", and the "likely probabilities"...?.  Is resilience, or "hardiness" as talked about in the psychological literature, something that's beaten out of you in medical school and residency, with a myriad of difficult experiences feeding off of each other in some kind of a closed loop?  Are physicians highly trained, with deep but narrow skills that tend to create a feeling of insecurity around their "other" abilities, and a sensitivity to rejection, hardship, or perceived failure?  What keeps docs from having an easy time "bouncing back"?  And what, if any, are the bigger ramifications of this, either for them personally, for their practice of medicine, or for their professional fulfillment?

What we do know is that resilience is one of those psychological traits that really matters both personally and professionally ... it affects how much stress you feel, how well you keep perspective on difficulties, how able you are to maintain healthy coping skills.  People low on the resilience scale tend to dwell on things, feel victimized, get overwhelmed and turn to unhealthy coping mechanisms such as avoidance of issues and escapism (such as substance abuse).  Conversely, people high on the resilience scale have higher levels of trust, tolerance for ambiguity, optimism and adaptability - all things associated with strong leadership and higher degrees of personal and professional success.

The APA (American Psychological Association) specifies a combination of factors that contribute to a person's resilience.  They include:

• The capacity to make realistic plans and take steps to carry them out
• A positive view of yourself and confidence in your strengths and abilities
• Skills in communication and problem-solving
• The capacity to manage strong feelings and impulses

How do you rate yourself?  How well do you:

• View problems as opportunities?
• Learn from your mistakes (and accept that you make them)?
• Seek out new and challenging experiences?
• Have a sense of humor and realistic optimism under stress?
• Succeed despite hardships?

In today's practice environment, the need for resilience is stronger than ever.  In order to thrive in an atmosphere of uncertainty, increased performance demands, rapid change, and a growing feeling of loss of control, many physicians are forced to either "bounce" or flounder.

The good news is that even if you are one of those docs that tends towards the low end of the resilience scale, you can develop these skills ... even if they aren't second nature to you.  Here are 10 tips for building your resilience (thanks to the APA):

• Make connections. Good relationships with close family members, friends, or others are important. Accepting help and support from those who care about you and will listen to you strengthens resilience. 
• Avoid seeing crises as insurmountable problems. You can't change the fact that highly stressful events happen, but you can change how you interpret and respond to these events. Try looking beyond the present to how future circumstances may be a little better. Note any subtle ways in which you might already feel somewhat better as you deal with difficult situations.
• Accept that change is a part of living. Certain goals may no longer be attainable as a result of adverse situations. Accepting circumstances that cannot be changed can help you focus on circumstances that you can alter.
• Move toward your goals. Develop some realistic goals. Do something regularly -- even if it seems like a small accomplishment -- that enables you to move toward your goals. Instead of focusing on tasks that seem unachievable, ask yourself, "What's one thing I know I can accomplish today that helps me move in the direction I want to go?"
• Take decisive actions. Act on adverse situations as much as you can. Take decisive actions, rather than detaching completely from problems and stresses and wishing they would just go away.
• Look for opportunities for self-discovery. People often learn something about themselves and may find that they have grown in some respect as a result of their struggle with loss. Many people who have experienced tragedies and hardship have reported better relationships, greater sense of strength even while feeling vulnerable, increased sense of self-worth, a more developed spirituality, and heightened appreciation for life.
• Nurture a positive view of yourself. Developing confidence in your ability to solve problems and trusting your instincts helps build resilience.
• Keep things in perspective. Even when facing very painful events, try to consider the stressful situation in a broader context and keep a long-term perspective. Avoid blowing the event out of proportion.
• Maintain a hopeful outlook. An optimistic outlook enables you to expect that good things will happen in your life. Try visualizing what you want, rather than worrying about what you fear.
• Take care of yourself. Pay attention to your own needs and feelings. Engage in activities that you enjoy and find relaxing. Exercise regularly. Taking care of yourself helps to keep your mind and body primed to deal with situations that require resilience.

I encourage all of you to think about how your degree of resilience may be affecting your ability to attain personal or professional fulfillment or make positive changes in your life.  When there isn't much you can control, this is the one thing you do have a say in.  If that horse knocks you off, are you likely get right back in the saddle?  Or do you wait a while, nursing your wounds ... or not get back on at all?  It's worth exploring, for your sake and for those who you come into contact with every day.

Especially if you want to live to be 109.