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The Science of FOMO and YOLO

I recently went to the French Laundry to celebrate my parents’ 50th wedding anniversary. Those that are connoisseurs of gastronomy are aware that the French Laundry is one of the most exciting culinary experience one can have. Nonetheless, I watched in amazement as many of the tables around me spent a majority of their time one their smartphones.

Before I throw stones at a glass house, let me admit I am one of those people who is persistently switching between my different social media accounts to get that thrill of superficial acknowledgment, or reciprocating in kind by admiring the adventures of my friends through the use of my thumbs.

The Science of FOMO and YOLO

But what happens when never missing an act on the theater of life becomes more important than life itself? A subtle reminder of this happens on any busy metropolitan street, as one can observe the masses walking seemingly aimless of their immediate presence, digitally immersed in the details of someone else’s life. In fact, considering almost everybody uses their smartphone while driving, almost all the time, it would seem many of us are less anxious about dying than missing out on someone else living.

Fear of missing out, or FOMO for short, refers to the persistent worry that others are having rewarding experiences for which we are not included. The origin of the acronym is credited to Patrick McGinnis who used it in his Harbus article Social Theory at HBS: McGinnis’ Two FOs. In our world of constant accessibility of information — through social media and other channels — we are seemingly bombarded with prospection that others are having more fun than we are. The reality, however, is that there are practical restrictions preventing any of us from doing it all. To think otherwise is folly.

Despite this reality, we still want to fool ourselves into believing we live in a world of infinitely obtainable options. If only you are let in on “the secret” the world is full of abundance for the taking. We are hijacking the beauty of situational intimacy for the cheap thrill of vicarious displacement. The desire to be continuously connected with others and see what they are doing is a feature of FOMO. A report by J. Walter Thompson (JWT) showed that Millennials are the most affected by this phenomenon (JWT, 2011). However, Generation Y is feared to be affected at increasing rates, too. With the help of social media, FOMO is pervasive and has the ability to negatively impact us all.

So why does FOMO exist and is there any way for those that suffer from it, to mitigate its effects?

Satisfying Our Desires

The motivation for many behaviors can be explored by tracing them back to our innate needs. Experts suggest that the link between FOMO and psychological needs is quite direct. Experimental psychologist Dr. Andrew Przybylski of the University of Essex in the UK argues that when our basic needs are not satisfied, we are more likely to gravitate towards social media. Digital engagement brings superficial satisfaction regarding some of these needs. For instance, through social media we can feel more in touch and connected with others, as such our subjective social competence increases, and we get more opportunities for perceived action (Przybylski et al., 2013).

However, science is exposing several negative aspects of continuous online engagement. For example, some people engage with social sites to avoid negative emotions and get away from the dissatisfactions of everyday relationships (Ellison, Steinfield, & Lampe, 2007). When this is true, the state of FOMO can act as a habit loop accelerant between the individual’s need to mitigate negative emotional states and excessive social media engagement (Riordan et al., 2015). A study by Przybylski and his colleagues showed that people who are low on autonomy, competence and relatedness (the three basic needs according to the self-determination theory) tend to report higher levels of FOMO (Przybylski et al., 2013).

One hypothesis is those suffering from FOMO might be desperately trying to restore their inner psychological balance. However, any perception of balance is generally short-lived and instead a vicious cycle of comparison and loss of authenticity begins to take hold. Other needs that people, particularly adolescents, might be trying to gratify when excessively relying on social networking sites include the need for popularity and a sense of belonging, A study published last year in the journal Computers in Human Behavior supported this assertion. Their findings suggest adolescents with a stronger need for popularity and affiliation exhibited a higher sense of FOMO and fueled it by using Facebook more intensely (Beyens, Frison, & Eggermont, 2016).

The Dangers of FOMO

Psychologists have anecdotally suggested for some time that those that significantly suffer from FOMO degrade their well-being and happiness over time, and now there is hard science to support this assertion. In one of their studies, Przybylski and his team showed that FOMO is linked to lower mood and life satisfaction (Przybylski et al., 2013).  People who have been overly enchanted by social media are often suffering from a feeling that they have not made good choices. FOMO can hit you from two sides in this regard. On one side, an internal yearning to be connected and elevate your life to that of others on your feed; on the other, indignation and/or envy about the things you might be missing out on and/or that others seem to have. These emotions left unchecked can spiral.

Moreover, a recent study from the University of Otago in New Zealand showed that in college students, FOMO is a factor that can drive this group to riskier behaviors, including alcohol (ab)use. For instance, compared to students who do not worry about “missing out”, those who do are significantly more likely to engage in impulsive acts while drinking that they later regret (Riordan et al., 2015). However, to perhaps justify FOMO another expression has surfaced to justify the negative effects of FOMO. YOLO or ‘you only live once’ is often used to explain the wild things that go on in our lives that when examined ex post facto look like poor decisions.

YOLO — Friend or Foe?

Research shows that FOMO is somewhat linked to a desire for more social engagement and the pursuit of activities that satisfy innate needs. The approach taken by many affected by FOMO is based on an inherent need for extrinsic rewards, where gratification is sought somewhere from the outside oneself (e.g. confirmation by others), while neglecting methods for more sustainable intrinsic motivators. To solve some of the mysteries of FOMO, we might need to look where one can gain positive social experiences, finding happiness from within (instead of experientially).

While YOLO could be frowned upon by those who consider themselves ‘mature and responsible’, the concept does have potential psychological merit. It feels somewhat rebellious. It also emphasizes living in the Present and doing your best to have fun with what life presents you. YOLO brings that allure of authenticity back and challenges you to be you — regardless of the consequences. Often YOLO experiences encourage one to wander from the safety and try something novel. If the YOLO experience is not coerced, the locus of control is moved internally. Moreover, if a YOLO attitude is paired with a dose of prudence it can be expansive, beginning with replacing mindless activity on Facebook and Twitter and for those lucky enough leading to peak experiences.

When we try something new, the almost universal fear of failing is there looming.  Studies show that we are likely more anxious about an unknown outcome than we are about a negative one that is known to us (Arntz & Hopmans, 1998). Yet, when we can get the courage to face the unknown, there is an opportunity for personal growth. An experiment by Arnoud Arntz and Miranda Hopmans of the University of Maastricht, Netherlands, showed that the pain of a new experience (even if it is uncomfortable) is likely to bring us less subjective pain than that of a known negative experience.

To get out of the grips of FOMO completely, we may need to upgrade YOLO and take our adventures to another level. YOLO is a lot about the pleasures of the moment. But science (ever since Aristotle) shows us that to get a sense of genuine purpose and meaning, we need to nurture personal development and feel as though we are living our fullest potential (Huta & Waterman, 2014). YOLO is not just about hedonism, it is great when we can find positive (offline) experiences, but it can be even more positive if these new experiences are seen as worthwhile. New experiences are the best when we feel that we are learning, developing and/or growing.

YOLO Might Be Good for the Soul and Mind

Research from Massachusetts General Hospital and Harvard Medical School shows that unique experiences have the power to activate a part of our brain called the amygdala, which is the part of our brain that helps us with learning (Weierich et al., 2010). When we completely immerse ourselves in something new, other parts of our brain can momentarily become inactive. When this happens the novelty of the experience can complete absorb us and silence our inner critic and the quiet mental space of contentment found in these moments is great way to combat the noisy world of FOMO.

Sources & further reading:

Arntz, A., & Hopmans, M. (1998). Underpredicted pain disrupts more than correctly predicted pain, but does not hurt more. Behaviour Research And Therapy, 36(12), 1121-1129. doi:10.1016/S0005-7967(98)00085-0

Beyens, I., Frison, E.  & Eggermont, S. (2016). “I don’t want to miss a thing”: Adolescents’ fear of missing out and its relationship to adolescents’ social needs, Facebook use, and Facebook related stress. Computers in Human Behavior, 641-8. doi:10.1016/j.chb.2016.05.083

Ellison, N., Steinfield, C., & Lampe, C. (2007). The benefits of Facebook “friends”: Social capital and college students’ use of online social network sites. Journal of Computer-Mediated Communication, 12(4),1143-1168.

Huta, V., & Waterman, A. (2014). Eudaimonia and Its Distinction from Hedonia: Developing a Classification and Terminology for Understanding Conceptual and Operational Definitions. Journal of Happiness Studies, 15(6), 1425-1456.

JWT (2011). Fear of missing out (FOMO). Retrieved from https://www.jwt.com/worldwide/news/fomojwtexploresfearofmissingoutphenomenon

Przybylski, A. K., Murayama, K., DeHaan, C. R., & Gladwell, V. (2013). Motivational, emotional, and behavioral correlates of fear of missing out. Computers in Human Behavior, 291841-1848. doi:10.1016/j.chb.2013.02.014

Riordan, B. C., Flett, J. A. M., Hunter, J. A., Scarf, D. and Conner, T. S. (2015). Fear of missing Out (FoMO): the relationship between FoMO, alcohol use, and alcohol-related consequences in college students. Annals of Neuroscience and Psychology, 2:7.

Weierich, M. R., Wright, C. I., Negreira, A., Dickerson, B. C., & Barrett, L. F. (2010). Novelty as a Dimension in the Affective Brain. NeuroImage, 49(3), 2871.

Interview with Matt Holt about Health 2.0

Matthew Holt is the eccentric Co-Chairman of the Health 2.0 Conference.  Before helping launch the Health 2.0 movement, Matt was a survey researcher at Harris Interactive, as well as being involved with the Institute for the Future.  In 2003, he started The Health Care Blog, one of the first blogs of its kind to specifically address the trials and tribulations of health care. Matt has an undergraduate degree from the University of Cambridge and a Master of Science degree in Health Services Research from Stanford University.


1) Often great innovation is figuring out what will not change over time (in contrast to being “disruptive”). In that spirit, what are three commonalities of companies/innovators that you have seen have successful longevity in the health technology space?

One, companies that have developed for the inpatient side of the hospital and grow from there. Put more broadly, you need to get embedded properly in an organization, which does not change dramatically over time and is willing to adopt you. The two obvious examples are Neil Patterson with Cerner and Judy Faulkner with Epic. The industry on this side of things does not move that fast, so if you are lucky enough to get your foot in the door, your company is inherently going to have longevity. Getting the timing right is very important as well.

Two, the need for care is not going away, so companies that make care more accessible. I believe telehealth will have longevity for this reason. Teladoc has been around 15 years, MDLive has been around at least a decade. These companies have longevity because they have an expansive model, which works for health plans, pharmacy chains, providers as well as direct-to-consumer. Provide a solution to a long-standing problem, and you should do relatively well.

Three, companies that build broad-based platforms. Additionally, you need to figure out your user interface and experience so it is good enough that a lot of people adopt it. Companies that build quality technology to track activity, diet and other lifestyle choices [like the companies Under Armour scooped up in this space] are good examples.

2) Insurers are starting to fund the tracking of consumer consumption of healthy activities that support personal well-being (e.g. United/Fitbit, Aetna/Apple, etc). How do you see this flow of capital effecting consumer health technology in the foreseeable future?

The good and bad reality of this situation is that as a consumer product good, health wearables are getting so cheap they are becoming ubiquitous; however, they are also getting commoditized. The commitment is low — similar to a gym membership — and like a gym membership, you see a lot of drop off after the initial purchase.

Insurers are getting involved because the costs of entry are lower and they are looking for any way to motivate us — if even by a nudge — toward healthier behaviors. There is discourse in the wellness space if this stuff actually makes a difference. That said, this trend is a win for most in the chain. Manufacturers sell more devices, payers are not investing much and get to see if this moves the needle, employers get to say they are doing something, and employees get these devices for next to nothing. In short, I agree it’s a trend. I think that we’ll see more of this kind of stuff as we try to figure it out whether there are real rewards to tracking behavior beyond professional athletes and peak performers and condition-specific wearables, where I believe there is enough evidence to make the assertion that wearables add a lot of value.

3) Currently, there are unprecedented health technology advancements (e.g. CRISPR) that have the potential to significantly accelerate human evolution. In this context, how do you believe health technology will redefine what it means to be human over the next generation?

This is a question better suited for Daniel Kraft, but I’ll give it a try. I always used to joke that I thought that the future of health care was when most people could email their doctor, which many of us still cannot do effectively yet we want to move on to cure Cancer and using Big Data.

Let’s start that we know that if we exercise and eat better, that’s half the battle. I have little doubt that eventually technology is going to make that easier, better, faster and make it more effortless. In that sense, the construct of willpower might change.

It is important to consider how this technology is affecting our environments, too. It is changing how we think about providing service to people. Something as simple as improving food portability could help change our eating habits for the better. Maybe CRISPR can change your genetics so that sugar tastes bad. Who knows?

The next generation will see us aiming at improving the impact and efficacy of drugs on diseases by manipulating the drugs and/or the genome to improve outcomes. At some point we might start designing humans to avoid disease all together and to live longer, but that will be a while. For those interested in that, I recommend checking out Aubrey de Grey’s stuff. He outlines eight things we need to fix to make this happen. It is worth watching if this topic interests you.

4) There have been a lot of digital health products that purport they can change user behavior. However, history suggests that many of these products and services have overpromised and under-delivered on their claims. What is a good example of a company getting it right in the “behavior change” genre, and what can we learn from them?

Companies that are doing this well have pervasive mechanisms for compliance. Medisafe is one that I like in this area. Good companies look at deliberately getting you from X to Y. However, some areas are hard. For instance, nutrition is particularly hard, and even with great technology, the truth is people just do not keep up with that type of change because technology has not solved the problem that some behavior change is hard.

That said, technology around cognitive behavior therapy treatments — treating things like anxiety, depression, PTSD and insomnia — seem to be making headway. A British company called Big Health has come out with a program called Sleepio that is really interesting.

Canary Health is also another interesting example. They have created technology to bring Kate Lorig’s work on self-management to a broader audience, and that has helped people with diabetes change their lives for the better — so there are examples of success in this space.

5) What is the last thing you remember regarding Health 2.0 that made you sincerely say to yourself, “this changes everything” and why?

Okay, I am going to steal my answer here from Indu Subaiya. It is the advancements in Google Home and Amazon’s Alexa in combination with FHIR. This is really exciting her.

If you split up the various layers of interoperability — and say maybe voice is the first layer — FHIR can then get into the data and stick it in to any functional layer you want. In fact, FHIR (if it works), may actually change how we deliver care and how patients experience care.

That’s the big picture excitement. Small picture, there’s a real cool company called Medal we had on last year, which figured out how you get data out of a EMR by basically printing it using the print driver from a standard computer. Super clever idea, totally bypassing the need for APIs. One more, which was shown this year, is a company called Suggestic. They have got this super cool augmented reality, where you hold your phone up over a menu and it makes you aware of the things you can and cannot have based on your dietary restrictions.

 

Interview with Steve Groves about Fitness Technology

Steven Groves is the CIO of GoodLife Fitness, the largest fitness provider in Canada (and the fifth-largest fitness provider in the world). In addition to this role, Steve also spent more than 11 years on the Board of Directors of London Bridge Child Care Services, recognized throughout North America as a leader in the area of non-profit early childhood education. He was recently recognized by Forbes as one of the Top 20 Social CIOs.


1) If you had a magic wand and could improve a way technology is being misused in health clubs today, what would it be and why?

I think at this point, my perception is that we are not focused enough on a holistic view of the member beyond the four walls of our own clubs. I do not think we are necessarily misusing technology. Rather, the focus has been too much on technology that can be used exclusively to advance our clubs’ agenda, which is different than looking at technology for the betterment of our members — whether or not they choose to do some of their activities inside of our clubs or outside of our clubs.

When some of the first wearables came into our industry, things like the bodybugg — back whenever that was — bodybugg was intend to be worn predominantly outside of the club. Ironically, many probably took it off to work out because it was clunky. It seems to me as though — we as an industry —are not really focused enough on the overall outcomes that our members are looking for. We could be better at helping them with the selection of the right technology to get the results they’re paying us for. The truth is this technology is not necessarily going to be specifically aligned with improving what is happening within the four walls of our club.

2) There is a growing acknowledgement in our industry that we need to be better at catering to a wider spectrum of consumer types, e.g. age groups, aspiration types, gender differences, etc. This is in contrast to prescribing a “one size fits all”offering. How have you seen technology most amply and effectively applied to help support this effort?

One example is ResMed. They are a medical company. My understanding is they are one of the largest manufacturers of CPAP devices. They have also created bedside devices. Being the experts in sleep, they have created this bedside device that uses sonar-style technology, and the device passively monitors your sleep activity. Previous versions of sleep monitoring devices were either uncomfortable or [the new ones] do not work that well. So what ResMed did is devised this device that sits there and it monitors your sleep: it monitors your breathing, it monitors the temperature of the room, it monitors sound levels in the room … it can basically see your body in the dark. The signal from the device is bouncing off the water in your body and can pass through everything else, so it can actually see right through your blankets, any material you might have on top of you. I could not believe how accurate this thing is … from your phone you get this wave pattern that is reflective of exactly your breathing pattern.

So ResMed, having such a massive data set that they have collected about how people sleep, by their claim, can accurately predict when you’re in light sleep, when you’re in deep sleep, when you’re in REM sleep, when you’re actually awake. And then the device picks up on a whole bunch of other pieces of information around the environment that you are sleeping in. So there’s the noise level, and room temperature, and maybe one or two more data points. From a personalization standpoint, coming back to your question, what I found was most interesting is that after it learned about your sleep patterns for a week, it starts to get prescriptive. It asks you an eight-question survey each day. How much caffeine did you have today? How much alcohol did you have today? Etc. Then it starts to prescribe ways to improve.For instance, it started creating for me — clearly, very unique to my own personal situation — it was the first true prescription that I have seen that was catering to my own personal unique needs. This is circumventing the spectrum all together; this is catered to the individual.

3) What can United States club operators learn from our Neighbors to the North? Where are areas of difference that Canadian clubs get right and the United Statesmaybe could do better?

It may be a naïve perspective, because honestly I do not spend a lot of time within U.S. club operations, but my sense is that U.S. operators have the luxury of having so many other competitors and peers within the country — in other words, the sheer number of clubs is massive — that I don’t think U.S. operators necessarily feel the need to look outside of the Americas, or let’s say North America even, for ideas and new ways of doing things. I get a sense that your market is very insulated in that way.

Whereas in Canada, we are small — especially here at GoodLife — we do not really have any peers in the country. The second-largest club chain in the country is also ours, Fit4Less. What we do, and I think we do quite well, is work with a lot of club operators globally. We have really benefited from some of the learnings that we have gathered from people in Europe and Asia — in particular Australia.

This may be an unfair assessment — a naïve assessment. However, I get the sense the U.S. market is a bit of an echo chamber.There is a lot that we can learn from other operators from the East, and from others in the West. I get the sense in the United States there is a feeling that you do not need to necessarily go outside your country’s boundaries for ideas. If true, that is limiting.

4) Discourse about data “interoperability”in the health club industry has almost boiled over, and the concept of data interoperability means different things to different operators and CIOs. What does it mean to you and why (or why not) is interoperability in our industry important?

I want to deal with technology I can plugin to a system and have it functionally do what I want. I like the software IFTTT. I think in the case of IFTTT, they call this type of flow “channels.” I want to be able to take hardware and software — ranging for IoT and SaaS platforms — and feel confident anything that will be useful to the clubs and/or our members can be channeled, plugging into a workflow management system I control.

I want the same easeI use IFTTT to get my Nest thermostat to report that my living room is over 80 degrees through a text message sent to my mobile phone — I want this ease of integration with the technology I use to run our clubs.

So when people say to me, “What does interoperabilitymean to you?” I use that as an example just to get them thinking about it. If a new member rides a piece of Life Fitness cardio equipment — they jump on one of our bikes — and it is the first time that they’ve been on that bike, and they’ve tapped their RFID to acknowledge they’re on the bike (so we know it’s them) I want to be able to have that trigger fire an event somewhere. For example, the trigger goes to a CRM platform that fires off a quick email giving them tips on that particular piece of equipment, and how they should be using it properly and safely … a simple recipe to enhance the member experience.

If I can start to get you to understand IFTTT, then I can start talking to you about and Enterprise Services Bus, and the integration of APIs, and having an open API architecture. So many of the APIs in our industry do not expose even 30 percent of the features and functionality of the actual UX of the system. This is frustrating, because I do not always want to have to use the UX of the platform that we purchase, and in many cases we as technology experts arrogantly think we can do better, and so we really want to write something ourselves. The current state of affairs is limiting. We end up having to write our own APIs in a lot of cases, just to create an abstraction layer. Salesforce and Amazon Web Services built their products with an API integration strategy top of mind, then theyadded the UX/UI layer. The fact that much of the technology in our industry was built the opposite way just shows a level of immaturity that our industry still has.

5) In your opinion, what is your favorite underappreciated and/or unknown health club technological addition? An uncommon product or service that almost always results in a significant return on investment for the club that adopts it.

ShapeLog is intriguing for me in this regard. I found out about ShapeLog through the Fitness Industry Technology Council podcast that Josh Trent does. I had never heard of it before, and quite frankly I have not heard of anybody else talk about it since. It is a fairly simple technology in that it is a device that you mount on the cable of selector equipment — the pulley equipment that we all have in our clubs — and what it does is it is able to measure the tension that’s being applied to the cable as the weight is being lifted off by the user.

It’s able to measure the tension, and from that it is able to calculate how much weight you’re lifting. Which in and of itself is kind of cool, then wirelessly they can send that information, so that it displays on your device. They are effectively able to record your workout. The part that really intrigued me was the fact that how you and I lift weight is unique to each of us, and apparently is almost as unique as our own fingerprints. What this product is doing is capturing 100 pieces of data per second — I believe that is the number they had given us in the demo — through native accelerometers and tension monitoring. The device creates a unique pattern of my lifting and lowering of the weight and stores this information in its database. Now, the next time I sit down and I do my next set of reps, it knows that that was me, and so it is actually able to track my workouts without me having to go up and log in, or tap an RFID chip onto the equipment. It eliminates a set in the identification process, making the ability to track less invasive and more passive.

How Great User Experience (UX) Might Be Killing You

If you read my newsletter, you are aware that the past two years have been a bit challenging for me in some respects. I have gone from being an avid long distance runner to now walking with a limp. My care up until recently was with one of the biggest integrated managed care consortiums in the United States. Unfortunately, in my case, working with them has been a disaster, and I am now shopping for a better way to treat my condition. However, that is not what this post is about. I am sharing it because my personal trials and tribulations treating a painful hip created the impetus for exploring a direr situation — a situation on which I believe my eclectic professional experience with UX and healthcare gives me a unique point of view.

How Great UX Might Be Killing You

There are pros and cons, strengthens and weak points, within any complex system — the healthcare system is no exception. When weak points are not looked at critically, that is when we can run into serious problems.

A National Emergency

In 2013, a group of scientists from the Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Stanford University and Mayo Foundation for Medical Education and Research provided hard evidence that something was not right with the opioid prescription rates in the United States. When they analyzed the prescription rates of opioid and non-opioid therapy for non-cancer pain in the period between 2000 and 2010, their data revealed some interesting trends. Although patients’ reports of pain remained unchanged in this period (pain was the main cause for one fifth of all visits to a doctor), opioid use nearly doubled (it went from 11.3 percent to 19.6 percent). Just as intriguing was their finding that the use of non-opioid pharmaceuticals did not follow the same trend. Only opioids were on the rise. Researchers struggled to find any association with patient, physician or practice characteristics that could explain the increase (Daubresse et al., 2013).

Leonard Paulozzi and his colleagues from the Centers for Disease Control and Prevention (CDC) cite even gloomier figures. They report that the sale of prescription opioid drugs keeps increasing; in fact, they quadrupled in the period between 1999 and 2010. In 2010, enough opioids were prescribed to medicate every adult American for a month (Paulozzi, Jones, Mack, & Rudd, 2011). To the best of my knowledge, this data has not improved in the past couple of years. The issue became so widely recognized that in 2014, a White House Summit was held to address the impact of opioids on American society (Clarke, Skoufalos, & Scranton, 2016), and just a couple weeks ago President Trump acknowledged that the opioid crisis is a national emergency.

Furthermore, the opioid epidemic has led to a significant increase in addictions, drug overdoses and deaths among Americans. To put this in perspective, the number of deaths from drug overdoses is now approaching the number of road deaths per annum. More people are dying of opioid poisoning than “street drugs,” drugs like cocaine and heroin (Paulozzi, Budnitz,& Xi, 2006). Many health experts are warning that this epidemic is worsening. The current state of affairs is having a grave impact on public health and safety, not to mention the financial burden it is putting on health insurance (estimated at $72.5 billion per year as reported by the National Drug Intelligence Centre).

Many health professionals offer strategies on how to better manage pain and minimize the risks of opioid overuse and misuse. However, we should not forget the fact that the number of patients experiencing pain has remained about the same over the past decade. Nonetheless, opioid prescriptions have been increasing. Why is that?

Hard Pill to Swallow: Is Patient-centered Design Part of the Problem?

I have built a reputation for my expertise on user experience and healthcare. A significant portion of my working hours is spent innovating ways to improve the satisfaction, engagement and fun end users have with digital health products and various fitness consumption modalities. While getting my Ph.D., I also did a lot of practicum work assisting physicians with employee burnout protocols (through an affiliation with a hospital group in the Bay Area; important to note, it is not the same group mentioned at the beginning of this post). During my work as a doctoral candidate on physician burnout, after malpractice lawsuits, the number one thing I heard that contributed to physician burnout was the cognitive burden a company called Press Ganey put on this particular physician group. If you are not familiar with Press Ganey, they are one of largest companies in the “patient satisfaction” business and their purported “mission” is to “support health care providers in understanding and improving the entire patient experience.” Simply put, they collect patient feedback data on doctors, and many times these assessments are tied to a physician’s livelihood.

More and more doctors and health experts have been recognizing that the increase in opioid use is correlating with the increasing emphasis on patient satisfaction. This might seem paradoxical at first (it did to me; after all, design thinking and great UX is about empathy and making the end user happy, right?), but it actually makes a lot of sense once you look at the facts at a macro level. Jenice Clark and Alexis Skoufalos of Thomas Jefferson University, Philadephia, and Dr. Richard Scranton of Pacira Pharmaceuticals conclude their article on the opioid epidemic in America with an insightful opinion from an expert panel:

It takes mere seconds for a primary care physician to write a prescription for an opiate; it takes 30 minutes to explain why he/she is unwilling to do so. (Clark, Skoufalos, & Scranton, 2016, p. S-7)

After digging further, I found patient satisfaction data now also gets reported via the HCAHPS survey. This is becoming a widely used healthcare quality metric. In fact, it is becoming the national standard for collecting the “patient experience” — so much so, scores from these surveys are starting to be incorporated into calculating reimbursements. In other words, in these cases, happy, drugged up patients indirectly mean more resources for a physician’s practice. Although patient satisfaction is a very subjective metric, it is used quantitatively to evaluate and compare physicians and determine financial compensation, job retention and promotions.

Are There Cases Where Grading UX Should Not Be Measured by the User?

Some experts warn that the “positive patient experience” is not necessarily linked to better health outcomes either. For example, in an article titled The Cost of Satisfaction, Joshua Fenton of University of California, Davis and his colleagues found that patient satisfaction was linked to:

  • higher admission rates,
  • greater overall expenditure,
  • higher prescription drug use and
  • increased mortality rates (Fenton, Jerant, Bertakis, & Franks, 2012).

Their nationally representative sample showed that satisfied patients did not necessarily fare better when compared to those that left their doctor’s office less satisfied. The rub: they are actually more likely to die!

Furthermore, studies show that patients often ask for services that are not clinically indicated. For instance, Kravitz et al. (2005) found that patients’ requests have a big effect on physicians prescribing antidepressants. Also, physicians whose patient rating affects their livelihood are more likely to budge and agree to patient requests (Pham et al., 2009). Patients expect their demands to be met. If unsatisfied, patients often now have a direct lever to affect a physician’s livelihood.

I Would Like the Credit, but I am Not the First to Stumble Upon This

Aleksandra Zgierska, Michael Miller and David Rabago of the University of Wisconsin-Madison, Madison (2012) believe that patient satisfaction surveys are generally a helpful initiative and can be a driver of positive change. However, they can also contribute to the prescription of addictive medications such as opioids.

When looking at these “patient satisfaction” instruments critically, you will often find the first question on the survey is an enquiry if you were satisfied with the way your doctor treated your pain. Since modern day primary care physicians experience time pressures, time-consuming discussions on alternatives to opioids are not necessarily promoted (for more on the burdens of modern healthcare, see my interview with Matthew Heineman about healthcare in America). When faced with high patient volumes and demands for interventions, it can be easier for doctors to simply write a prescription. In this way, the patient often leaves the (brief) office visit initially happy.

After working with burnt out physicians for several years now, I have an immense amount of empathy for this employee group. As such, it is very important to note that the harm here is not just to patients. As Zgierska, Miller and Rabago warn, these practices also can leave clinicians in emotional and moral distress. In fact, it is likely that the opioid epidemic is a silent yet significant factor in the explosion of cases of physician burnout. When you peel it back, it really is becoming a no-win situation for everyone.

When Great UX Gets in the Way of Great Outcomes

In my case, I likely need a hip replacement, but the integrated managed care consortium I was a part of does not like to perform replacements on people under 50 — especially males. Why? Although younger candidates have better surgical outcomes, this group (my strata) also has higher readmission outcomes. Having to get a second hip replacement is a more complex procedure and often has much graver outcomes than an initial replacement.

The most egregious aspect for me was that even though this consortium was impeding my effort to get better, the medical staff would still ask about my activity level during every office visit (by way of the worn out script of their rudimentary health risk assessment, affirming to me there was no real understanding of my condition). I’d have to inform them every time I was there because I would love to be more active. Instead of ever really developing a path forward, I’d routinely leave with a prescription for NSAIDs and/or opioids. It was more advantageous for them to keep their costs down and alleviate my symptoms than address the problem.

When I started to complain to other colleagues in healthcare, I quickly realized this is the elephant in the room. The over-prescribing of opioids is additionally concerning when many suggest that long-term use for chronic, non-malignant pain has more cons than pros. It brings many side effects, including gastrointestinal issues, confusion, respiratory problems and increased risk of infections and tumor growth (Clarke, Skoufalos, & Scranton, 2016). Inappropriate prescribing also means that more drugs become available to the general public through black markets, leading to further abuse and addictions. Ultimately, I have now stopped taking all prescribed painkillers and just suffer through the pain until I can treat the condition and not the symptoms. My current UX is terrible but at least I’m not a dope.

Do You Want Great UX, Or Do You Want Great Healthcare?

When it comes to improving the quality of care in our hospitals, I am not attempting to marginalize that pain assessment and pain management are two important standards. However, patient satisfaction — originally designed to promote quality of care — has in some cases undermined the principles of good medicine. This may sound contrarian from someone who generally advocates for patients to become the smartest person in the room about their particular condition, but maybe some decisions should be left to the people most qualified to make them. We need to foster systems that afford doctors the luxury of treating conditions and not simply addressing symptoms.

Instant gratification has its place, and it is natural to want to avoid discomfort. However, in this particular narrative, it is not a good replacement for legitimate treatment options. The current system is rigged to make you sicker. That has got to change, especially in cases like mine where there are better treatment options. Great UX is not always in the user’s best interest. In fact, as this post outlines, it can lead to many ill effects — on a personal, national and global level.

Sources & further reading:

Clarke, J. L., Skoufalos, A., & Scranton, R. (2016). The American Opioid Epidemic: Population Health Implications and Potential Solutions. Report from the National Stakeholder Panel. Population Health Management, 19 (Suppl 1), S1-S10. doi:10.1089/pop.2015.0144

Daubresse, M., Viswanathan, S., Alexander, G., Yu, Y., Chang, H., Shah, N., & … Kruszewski, S. (2013). Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010. Medical Care, 51(10), 870-878. doi:10.1097/MLR.0b013e3182a95d86

Fenton, J., Jerant, A., Bertakis, K., & Franks, P. (2012). The Cost of Satisfaction A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Archives of Internal Medicine, 172(5), 405-411.

Kravitz, R., Franz, C., Azari, R., Wilkes, M., Hinton, L., Franks, P., & … Feldman, M. (2005). Influence of patients’ requests for direct-to-consumer advertised antidepressants: A randomized controlled trial. Journal of the American Medical Association, 293(16), 1995-2002. doi:10.1001/jama.293.16.1995

Paulozzi, L., Budnitz, D., & Xi, Y. (2006). Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiology and Drug Safety, 15(9), 618-627. doi:10.1002/pds.1276

Paulozzi, L., Jones, C., Mack, K., & Rudd, R. (2011). Vital signs: Overdoses of prescription opioid pain relievers — United States, 1999–2008. Morbidity and Mortality Weekly Report, 60(43), 1487-1492.

Pham, H., Reschovsky, J., Landon, B., Wu, B. & Schrag, D. (2009). Rapidity and modality of imaging for acute low back pain in elderly patients. Archives of Internal Medicine, 169(10), 972-981. doi:10.1001/archinternmed.2009.78

Zgierska, A., Rabago, D., & Miller, M. (2012). Patient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA – Journal of the American Medical Association, 307(13), 1377-1378. doi:10.1001/jama.2012.419

Interview with Daniel Freedman about Virtual Fitness

Daniel Freedman graduated from the London School of Economics (LSE). He started his career as a journalist and worked for several publications, including the Wall Street Journal and Forbes. He contributed to the bestseller “The Black Banners,” a book about Sept. 11 and the United States’ war with al-Qaeda that was published in 2012. Freedman later shifted his interest to the technology sector, working at tech startup Apploi and co-founding CyecureBox, a cyber security tool. After transitioning from Manhattan to Baltimore, he has been focusing on the development of BurnAlong, a startup that aims to help people find the time to exercise. During his eclectic career, Freedman has also held posts at the United Nations and the U.S. Senate.


1) What currently excites you about virtual fitness? How have things evolved from the days of Jane Fonda VHS tapes to the virtual fitness experience a user can consume today?

I think what’s really changed today is virtual fitness is allowing people to bridge the online and the offline fitness experience. New ways of delivering virtual fitness can finally bring people the “real” experience that they want, as opposed to having disconnected, lonely experiences with static content.

If you look at video games, the virtual world bridges that divide. If I go back to when I was a kid, if I wanted to play video games with a friend, I had to travel to their home. Today, my nieces can play with one another and/or their friends online, from their respective homes in different cities. They can see and speak to each other no matter where they are in the world. It’s the same in the business world where work tools like Skype and Google Hangouts have connected us.

What’s exciting to me in the fitness space is being able to bridge the divide and give everyone access to the experiences they want, when they want them. Fitness is about relationships, purpose and motivation. New advances in virtual fitness now allow us to do that at scale, with your workout buddies wherever they might be.

2) What are the limitations of delivering virtual fitness, and how have you seen this effectively mitigated?

If you go into any gym or studio, anywhere in the world, and ask, “Who is the most popular instructor here?” And then you ask them, “When was the last time someone said they can’t make a class, or was away for the summer, or traveling for work, and so could you film the class?” Odds are the instructor will say it was within the last two to three days. This reflects a massive lost opportunity for gyms and studios, because their members would prefer to choose a virtual experience with their favorite instructor, rather than strangers, if given that option.

BurnAlong does that, bridging that divide, giving people the connection to their favorite instructors/their friends, at a time and/or place convenient for them. And instructors can gain an insight into what people are doing outside of the gym, and help keep them on track.

3) Throughout the process of your product development, what has surprised you about virtual fitness delivery and consumption while building BurnAlong?

One big surprise is the willingness of people to try something different from home, or get started on their fitness journey. We see with companies, that often people have heard about top local instructors, they’re very curious to try them out, they’ve just never had the time, or confidence, or motivation, to actually take the class. But being able to experience it at home, from the comfort of their own home, makes a big difference.

We see this especially with companies and their employees. Right now, for many, five percent of employees participate in wellness programming. What we’ve found is that it’s not that the other 95 percent of the company isn’t interested. On the contrary, there are just a lot of barriers to attend (e.g. schedule, family commitments, aversion to working out with co-workers in an open setting, etc.). We found that virtual fitness is great for those who do not like exercising in front of others (especially colleagues and/or strangers).

For instance, yoga can be intimidating if you do not understand it. Virtual fitness allows someone who wants to be a little more confident before they subject themselves to other peers seeing them engage in activity [to get some practice]. They can get accustomed to movements, gain familiarity before engaging in the activity in a group setting.

For an instructor, this can be quite eye opening. Big personalities can be intimidating. Virtual fitness allows participants to understand the instructor, the class, they get to know the routines — a relationship is built before having to step in an unfamiliar setting. Through this process, a user can take steps to understand group dynamics before leaning in.

Virtual fitness is a great way to onboard new entrants into fitness who would have been too intimidated to ever get started otherwise.

4) Exergaming is a facet of virtual fitness that has had a lot of press but seemingly always falls flat after the initial hype (i.e. Wii Fit, Pokemon Go, etc.). Why do you think gamification has ultimately not lived up to the hype, and do you see this changing in the future?

Anything can get boring, unless it’s changed up. It’s the same limitation of the old way of delivering virtual fitness — where you’ve only got the same 10 options and the expectation is you are meant to keep going through that same 10 classes over and over again. Most people who buy fitness DVDs don’t buy only one; these folks have got piles of them. They want choice and variety. If there were only 10 books that everyone wanted to read, there wouldn’t be a need for Amazon, right? So too for fitness, there’s not just 10 ways of working out; the rise of boutiques reflects the desire for so many different people to work out in so many different ways.

The appeal of attending fitness classes in person with friends is that while the workout may be similar, the instructor will change things up, and your friends will chat about different things. The conversation is going to be different every week. What virtual fitness can now do is bring that variety to you in your home, with your friends, with fresh content from instructors, when you can’t make it in-person.

5) How do you see fitness evolving over the next five to ten years? How will virtual fitness change the way people currently consume fitness?

What we believe in at BurnAlong, and what our product is based on, is that people increasingly want unique experiences. I think virtual fitness has got the power of bringing fitness to people wherever they are — that specific type of experience that they want whenever and wherever they want it. We believe the virtual compliments the in-person experience, rather than replacing it (which most online companies believe).

The virtual can also bring special classes to places where previously people didn’t have that experience. People talk to friends across the country and all over the world about their favorite instructors; now those friends can experience those classes with that friend. Geography no longer needs to be a limitation.

In five years, I might wake up planning to attend my favorite cardio class at eight o’clock in the morning, but I wake up and Amazon’s Alexa or Google Home or another connected device will say to me, “Daniel, your noon meeting has just been moved, and you do not have time to physically attend your eight o’clock class. However, I’ve notified your instructor that you’re going to be joining online rather than in person.”

My co-worker Harry who takes the class with me is in London for work, and will be taking the same class virtually since it is his favorite, too. We choose to take the class live together. I log in at eight o’clock, wave to Harry and the instructor, who sees me and says, “Thanks for joining Daniel. Sorry you couldn’t come in person. You know I see your heart rate is already at 140, good run earlier … Daniel, you are already ready to go!”

It’s an experience where, just because you cannot do something in person, you are no longer limited. The virtual world bridges that divide, makes people more efficient, and allows them to use their time more effectively without sacrificing quality. This will only continue to improve in the years ahead

You should never be in a situation where just because you are traveling this week, or just because you can’t get a babysitter, or just because you had to work late … you can’t get the type of fitness experience and expert guidance you value and deserve.