It really is of importance, not only what men do, but also what manner of men they are that do it. Among the works of man, which human life is rightly employed in perfecting and beautifying, the first in importance surely is man himself. Supposing it were possible to get houses built, corn grown, battles fought, causes tried, and even churches erected and prayers said, by machinery—by automatons in human form—it would be a considerable loss to exchange for these automatons even the men and women who at present inhabit the more civilized parts of the world, and who assuredly are but starved specimens of what nature can and will produce. Human nature is not a machine to be built after a model, and set to do exactly the work prescribed for it, but a tree, which requires to grow and develope itself on all sides, according to the tendency of the inward forces which make it a living thing. John Stuart Mill [1]

I don’t want to sound too melodramatic, but sometimes I think that technological progress [2] is either our salvation or our damnation, but I can’t figure out which. More on topic with Thoreau and my previous posts [3], how do you simplify when the world around you is getting more technologically interconnected and complex?

As someone who both has a tree tattoo based on the above passage from Mr. Mill and works in the Hi-tech industry, this is something I’ve wrestled with a bit, especially while going through my minimalist journey [3]. When thinking about the impact of technology on quote-unquote “advanced society,” I can’t help but think of the opening scene of The Gods Must Be Crazy [4]. I’d highly recommend the movie for the hilarity that ensues after this, but the film opens with a very unsettling observation about civilization. A narrator begins by comparing the native pygmies of the Kalahari desert with the “civilized man” a few hundred miles away in some, unspecified city. The narrator notes how civilized man has invented all sorts of labor saving devices–tools, running water, computers, etc.–but that the complexity of these labor saving devices kept increasing so that now civilized man must spend many more hours working in school learning how to use all these work-saving devices as to render them counterproductive. I’ve written on this phenomenon elsewhere in this blog [5]. The narrator places this in stark contrast to the natives of the Kalahari who’s needs are simple and do not want because they have never had [6].

In some ways, The Gods Must be Crazy doesn’t even consider what I think are some of the most important effects of technological progress.  Namely, they don’t consider that labor saving devices increase expectations surrounding these actions that are now easier to do. Laundry makes a perfect example: laundry used to be extremely time consuming and difficult, so people didn’t do it very often. Then we invented the washing machine, and laundry became very easy to do (relatively speaking; I still hate it). Think of all the time we’ll save! However, because it’s so much easier, we started changing our habits and expectations. Now, society has decided that a T-Shirt should be washed after every individual use [7], so we may spend less time per laundry load, but we do a lot more laundry loads and the net change is pretty well moot. Now don’t get me wrong. The Gods Must be Crazy, takes a very romanticized view of things. It doesn’t note things like increased life expectancy or the opportunities for self-actualization that come with higher material standards of living that come along with civilization. Nevertheless, it’s hard to argue that an increase in material wealth is fundamentally any less absurd than Thoreau’s notion that we could make a home in a toolbox with an airhole in it [8]. So even if technology is neither salvation nor damnation, then at best it’s still a double-edged sword.

I want to go through an example of how technology can cut both ways, then share some thoughts about how we as individuals–even if not as a society–can collect more on the benefits of technology while mitigating some of the potential damage it can do to us. To the surprise of no one who knows me, I want to use Healthcare as my example. It’s my passion, but it’s also the epitome of technology being salvation and damnation at the same time.

It’s considered common knowledge among healthcare economists that technology is driver behind the exorbitant increases in expenditure relative to the overall economy [9]. But there are also plenty of news stories (at least on NRP, which is my primary source of news) about fancy new diagnostic tests that purport to give the same results as the old test but at a fraction of the cost, which all seems to suggest that technology is how we’re going to decrease our 17% of GDP expenditure on healthcare. How can the same pressure or force do both?

Let’s unpack this a little bit more. The economic definition of technology–The purposeful application of information in the design, production, and utilization of goods and services, and in the organization of human activities–says that technology increases production. Going back to Econ 101, if production increases, then price falls. If things cost less, we consume more of them, all else equal. This includes things like Order Sets and Computerized Physician Order Entry (CPOE). Order sets are groups of orders that evidence suggests should be ordered together in a given context. For example, a patient presents with a possible stroke, you order a barrage of antithrombotics, a brain MRI, and an X1 Lipid profile (among other things) [11]. Order sets were an improvement in technology over a provider remembering everything the patient needs [12], and CPOE has taken that to the next level by providing more flexibility by specific patient contexts (you can only have so many paper order sets on hand, but the computer can store one for every ICD code we’ll ever make). So, I would venture a guess–for which research has provided corroboration–that CPOE has increased the number of orders physicians place [13]. Defensive medicine and over-ordering in a Fee-for-service model aside, Electronic Health Records (EHRs) and better testing technology (esp. laboratory automation) will increase the number of tests we do. Because it’s easier (read: cheaper).  (Note that interoperability also makes it easier to not perform certain tests and preliminary research has shown decreased ordering as a result of record sharing, but since even the best vendors are still pretty basic in their true interoperability capabilities, I’m going to table this for now.)

More importantly, physicians are now easily ordering tests that didn’t exist 50, 20, even 10 years ago. Where a doctor used to take a guess or a “wait and see” approach, she can now order a test. This is what’s called “induced demand,” where the more tests we have available, the more tests we seem to want. This is distinct from just ordering more because they’re cheaper; we actually have a drive to invent more tests after creating more tests. Imagine the first urine analysis that detected endocrine problems. That was great. It got used because it was useful. But it wasn’t perfect. Physicians wouldn’t have dreamed of needing this before, but now they can’t live without more precision in the test. My doc doesn’t just want to know if something is wrong with my endocrine system, she wants to know if something is wrong with the kidneys or the thalamus. The creation of a test created demand for creating new tests. This is clearly useful, but it’s not without cost. Furthermore, it slights (but doesn’t destroy) the notion that cheaper tests (e.g. Point of Care Tests that are now fully automated [14]) will ever be the source of a decrease in expenditure, even if it mitigates the increases.

I haven’t even scratched the vast, vast surface of healthcare’s relationship with technology and the resultant complexity. Within that complexity, is there any hope–or should there even be desire–for simplicity? After all, the human body is indubitably complex, why shouldn’t our apparatus for maintaining it be equally complex and nuanced? But as this is a series on Simple Elegance, I think there’s still something to be gleaned from the old tautologies in medicine. Not leaches or bleeding, but Occam’s Razor and the Hippocratic oath. Pointed, direct ideas that aren’t flippant about complexity, but  aren’t lauding extremely complex research and technology because it’s “cool” in its complexity. The humble checklist, for all the thought that goes into it, is simply elegant, and it has saved more lives than robotic surgical arms [12].

Or take social media, which has increased social interaction, almost by definition. Increased social interaction has increased complexity [15] because there’s more to grab out attention [16]. Like I said. This is kind of a double-edged sword. On the one hand, we have many new opportunities, but on the other, we have too many opportunities. Think of that friend (you know you have one) who posts everything on facebook (or linkdin or twitter) and just floods your news feed or whatever it’s called now. Is keeping up with that friend worth it? Is de-friending that friend worth it? These are both fine questions that are worth asking, but the undeniable truth is that being this person’s friend (on or off facebook) requires time and energy.

Technology lets us do more, and that’s the key takeaway from this. We can either do more things and thereby do less of any of them, or we can do more of a few things to the exclusion of others. Technology allows us to simplify complex problems, but also complicate otherwise simple problems through distraction [16]. So what are we to do?

Here’s my (maybe, barely) humble proposal: specialize, augment, and let go.

Specialize
At the end of the day, what do you want to do? What do you want to do with your life? Your energy? Your health? Hint: you can’t do everything, so figure out what it is you want to do when you grow up. Then find what tools are available to help you get there. Then buy them. Within reason, buy the best, most top-of-the-line, latest-and-greatest gadget or software package out there to help you succeed in your goal. I wanted to get organized, so (with the blessing of my wife, who let me buy this for Christmas) I bought OmniFocus. Was it expensive? Yeah, kinda (relative to the free solutions I had been using), but technology increases production, and this increased my production of personal organization dramatically.

Augment

Technology doesn’t create; it expands. It enhances. It augments. OmniFocus didn’t make me get organized. I have to work at that; every day I have to push myself to stay organized. But technology takes the man out of manual labor: it automates what can be automated and frees up our energy for things technology can’t do. I tell OmniFocus to do an extremely simple task, but one that I am very bad at and it is very good at: remembering what I need to do this week. I can remember what I need to do, but that requires mental resources. My iPhone just requires electronics, which are very abundant, and it can specialize in remembering while I specialize in thinking.

Let Go

Two paragraphs ago, I recommended you shell out some hard-earned money for the best software suite you can. But only in a specific area. I like playing guitar and recording, but I’m not about to go buy Logic. I would like it, don’t get me wrong, but my focus is on learning, economics, data, and healthcare. So I’m going to spend my money on Coursera, and continue using garageband to record myself and shudder in horror when I sing. But I need to let go and not let cool stuff absorb me. Going into the Apple store is a dangerous venture, because there’s all this cool new shit around that I’d love to buy. But very little of it augments me in the ways in which I’ve chosen to specialize. If technology isn’t moving you forward, then let go of it. Find something that will.

I feel like this is a longer and denser post than I try to write, so thank you for bearing with me. Up next: what’s in my software pockets? There are lots of blogs out there about what people carry with them. I think it’s supposed to be a sort of personality test, but I’m not entirely sure. In any case, I’ve just gone on for 3 paragraphs about how I think you should use technology, and for several before about what I think technology is. So next I’m going to lighten it up a bit and share a bit about the software and hardware I use to augment my specializations, as well as the things I’ve used, but let go of over the years.

Thanks, and I hope you enjoyed this.

References

[1] On Liberty, John Stuart Mill; http://www.bartleby.com/130/3.html

[2] For the purposes of this post, I’d like to operationally define ‘technology’ as the use of information to automate or obviate human tasks. This includes the simple text message that reduces the overhead of calling someone and exchanging pleasantries to the complex ‘big data’ marketing analysis of finding out what people want to buy without having to go through the trouble of asking them.

[3] See https://tattooedeconomist.wordpress.com/2015/01/23/simple-elegance-my-minimalist-journey/ and https://tattooedeconomist.wordpress.com/2015/01/13/simple-elegance-what-is-minimalism/

[4] http://www.imdb.com/title/tt0080801/ for the movie, and the clip in question is here: https://www.youtube.com/watch?v=Qgs528eZXSs

[5] I wrote a series of posts about what I call “aggregation.” The first post focuses on the inevitability of progress and how marginal effects and result in a fundamentally different gross effect.
https://tattooedeconomist.wordpress.com/2012/12/04/on-the-margin-in-the-aggregate-part-1-the-inevitability/

[6] According to Buddhism, the second noble truth is that suffering is brought about by want and desire for material possessions and physical comforts. http://www.buddhanet.net/e-learning/buddhism/bs-s04.htm

[7] “Im Ready” by Jack’s Mannequin; http://www.metrolyrics.com/im-ready-lyrics-jacks-mannequin.html

[8] “I used to see a large box by the railroad, six feet long by three wide, in which the laborers locked up their tools at night; and it suggested to me that every man who was hard pushed might get such a one for a dollar, and, having bored a few auger holes in it, to admit the air at least, get into it when it rained and at night, and hook down the lid, and so have freedom in his love, and in his soul be free. This did not appear the worst, nor by any means a despicable alternative. You could sit up as late as you pleased, and, whenever you got up, go abroad without any landlord or house-lord dogging you for rent. Many a man is harassed to death to pay the rent of a larger and more luxurious box who would not have frozen to death in such a box as this.” http://www.gutenberg.org/files/205/205-h/205-h.htm

[9] http://www.rand.org/pubs/commercial_books/CB199.html

[10] Find an econ textbook to quote http://www.businessdictionary.com/definition/technology.html

[11] Example pulled from http://clinfowiki.org/wiki/index.php/Order_set

[12] Atul Gawande, Checklist Manifesto; 16. http://www.amazon.com/The-Checklist-Manifesto-Things-Right/dp/0312430000

[13] The National Center for Biotechnology Information has done some preliminary research on the behavior changes accompanying EHR adoption here:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181982/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3243295/

[14] for example, http://www.healthcare.siemens.com/point-of-care/urinalysis/clinitek-advantus-urine-chemistry-analyzer

[15] Revolution Analytics made a very revealing plot of Facebook friends, available at http://blog.revolutionanalytics.com/2010/12/facebooks-social-network-graph.html
Also, Southpark did an excellent parady of the complexity created by social networks http://en.wikipedia.org/wiki/You_Have_0_Friends.

[16] http://www.theguardian.com/science/2015/jan/18/modern-world-bad-for-brain-daniel-j-levitin-organized-mind-information-overload

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