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Interview with John Gengarella about Fitness Technology

John Gengarella is known for his extensive experience in global operations, customer-centric design and application development. He has been connected with highly successful enterprise software businesses for over 25 years. However, John began his career in the fitness industry. Outside of the fitness industry, John has held executive roles including vice president of C3 Energy, Chief Revenue Officer for 24/7 Customer and CEO of Voxify. In 2015, John was appointed the CEO of Netpulse, a company that has been viewed as one of the market leaders in mobile technology for the fitness industry. In addition to his professional work, John is the lead mentor in the non-profit organization StartX, which focuses on the development of Stanford’s top entrepreneurs through experiential education. He is also an angel investor and advisor to various early stage technology ventures.


1) One thing that consistently surprises me is that it usually takes a while for emerging tech companies — ones that specifically focus on health clubs — to realize that the total addressable market (TAM) regarding health clubs is actually fairly modest. In this regard, what lessons can you pass down to anyone thinking about creating technology that caters to health clubs?

I do not agree that it is a small total addressable market. I actually believe it’s enormous.  I think if you look at what’s out there today, you’ve got a handful of groups doing over a billion dollars in sales. If you look at the spend over the entire industry, there are testaments of over a $70 billion TAM. Folks are investing serious money to engage their members. I believe there are 185,000 clubs globally, that’s an enormous market. MINDBODY got a $450 million evaluation, a company that’s focusing on a niche segment of the market — studios.

You can easily build a $100 million company in this space. But it depends on how you define the market. Thirty years ago or so, I had a few clubs. We had index cards that had member’s names on them and you stuffed envelopes with monthly invoices that looked like the things you get at Denny’s. So, if you were assessing the fitness market at that time as an entrepreneur, did you say, “Hey, I’m going to make money on index cards and envelopes,” or did you say, “Hey, I can build a CRM solution, or automated billing system, and completely change the dynamics in a new set of investments in that segment?” I think you have got to look at the market overall and how we’re solving problems. I think if you look at IT spend, for example, that might be a small number. That might only be a billion dollars. But what does an average club spend on marketing? It’s 10x that spend. I bet worldwide clubs spend close to 10 billion annually on member acquisition. I think there is an enormous opportunity for the right entrepreneur in this space. The challenge is you have to go solve a problem. What do I do to engage members? What do I do to attract new members? What do I do to increase my retention? …the same core tenets exist from 30 years ago.

So my assessment is I think the market’s huge. And then, where do you draw the line? Is it Fitbit? Is it Under Armour? I mean the lines are blurring every day, there are tens of billions invested annually in fitness. As a software guy, I’m not as interested in treadmills and those kind of things. The Precors and the Matrixes will make their money selling equipment. 30 years ago, we talked about what was inside our four walls. Today, now we are talking about engagement with members outside of those four walls, as well. The club brand is still alive and well… on your app… on your T-shirt — but the market is changing. It is no longer necessarily simply what is happening in those three hours a week inside the club anymore.

2) As the head of a company that makes a great fitness mobile app — specifically regarding fitness — what is the role of activity trackers as they exist today, when the modern smartphone often rivals the internal hardware of commercial fitness devices?

That’s interesting. There is no question that the Apples and the Samsungs are going to be battling the Fitbits of the world very soon in terms of tracking. You have a few pieces that you’re solving for in this space:

  1. You need a form factor that works
  2. You want as complete of a data set as possible
  3. You want accuracy

I think the biggest challenge for smartphones is form factor. Especially since phones are getting bigger as they also are turning into mini entertainment centers. Also, women often leave their phone in their purse, so it is not constantly tracking activity. I think form factor is a challenge for phones today. What this means is you are also not getting a complete data set. For those who want all their activity tracked, you need to have your phone glued to you 24/7. Accuracy is also an issue. Without separate peripherals you are not going to get heartrate information, at least not accurately. There is still skepticism, even if smartwatches take, that they can accurately track heartrate. 

Phones do have a phenomenal advantage in that they are ubiquitous, and adoption is exceptional. I don’t know anybody that does not have a smartphone today. But what do I get out of that? Do I get the accuracy of my heart rate? Do I get other capabilities that I want to see… capabilities I can get from a wearable that I am in touch with the entire time. Given what we are trying to solve for, it will prove to be an interesting battle.

3) Looking past current wearables on the market today, where do you see digital health taking the health club industry five years from now?

That’s a really interesting question because the potential has become enormous, but just as it has been for the last 30 years, the next five will still be about relationships. What’s the relationship that I have today with my club (as a member)? What’s the relationship that I have with the other members? What’s the relationship that I have with my employer? What’s the relationship I have with my healthcare provider? My doctor? My coach? My team? I think when you look at the evolving way we engage in relationships through technology, you’ll see the digital aspect of that becoming more pervasive. I am not addressing just the customer relations concerns here, but also the relationship an employee has with their employer —  a financial relationship that plays a role in the person’s well-being. The big challenge is going to be the exchange of value. To me, there is a two-way value exchange. For instance, I (employee) let you see my steps on a daily basis, you (employer) give me $300 towards my monthly insurance bill. People love to discuss privacy concerns, but quickly forget it was only a few years ago they were hesitant to store credit card information with Amazon.com. Privacy issues aside, annual healthcare spend is the largest line item on our country’s P & L! Follow the money — over the next five years there will be enormous energy around a digital understanding of each consumer, each member, each employee. I see this evolving into some greater level of personalization that simply does not exist today. How do I get to know a specific person in a meaningful way and understand their needs, provide them value for that exchange, and capitalize on the value associated with that understanding in an ethical way? We’ll answer that question.

4) There is a modern-day narrative that fitness delivery is well-positioned, better than ever, to be on the forefront of the continuum of health care. However, this discussion has been going on for a few years now (e.g. Exercise is Medicine, Exercise is a Vital Sign, etc). In your opinion, do you believe technology has helped, or hindered, progress in this area? 

The challenge is the complexity around data privacy. What are the responsibilities around those that are in charge of the data? How do I protect the consumers’ willingness to share? What level of privacy should I expect in terms of dealing with any manufactured insight, i.e. new personal information generated about me that could effect my livelihood (e.g. credit score)? This problem doesn’t get solved with one “ah-ha” moment. There are going to be step-changes that go along with this because we are a cautious nation when it comes to privacy. There are credit card breaches all the time with little consequence. But, if I let somebody know what your blood pressure is, I can still go to jail. So, I think that we are cautious as a society about health data, but I believe you will see that loosen over time. What are the true risks if I share this information? Truth is, you probably have a great interaction with your doctor and she becomes wonderfully more insightful about your health.

There are valid, historic concerns about the consequences of having a preexisting condition. There’s a scare about how that data can be used and possible negative impacts that could come as a result of someone having that information. Again, fair value exchange becomes important. I’m willing to share, if there is limited risk and I get something in return. Few are going to share data for the fun of it. If people get better care, get a lower rate on insurance, get more personalized programs that are really consistent with their health, they will come around. You can see that today, in the volume of opt-in consumer apps that are out in the market. There will be dissection among the population: those that are willing to share health data and those that are not. There is always a sub-segment that’s going to believe in some conspiracy theory that, “data will always be used against me.” They are not going to participate willingly. Luckily there are many that have a willingness to take that risk. I think the more challenging issues are not around, “Can I collect data and generate insights around this woman’s health and well-being?” The challenges are more going to be around policies and protections that allow the consumers of that information to use it appropriately and ethically. To me it’s not technology that has hindered us so much… people have.  

5) The last couple of questions I have asked you what you think might be different in the future regarding fitness technology, a harder question might be the one I will conclude with: what is going to remain the same five years from now?

Five years from now, mobile will still be the center of our lives. It is the communication mechanism for any audience, whether you are talking about a health club member, you are a member of an airline, a hotel guest, or an Uber rider. Mobile will remain the primary platform for customer interaction in the near future. This bears repeating from my previous answer… thirty years ago, I used to have a few health clubs and the same mandates exist today: a need to acquire new members, a need to retain those members, and a desire to increase the contribution/benefit made to the member base. That’ll be the same in five years… probably for as long as health clubs exist.

With the pervasiveness of availability of information available to the consumer, the fitness industry, like any other mature industry, is becoming more and more competitive. So, the drivers of asset performance will be the same in five years. Mechanisms for personalization will evolve. There will be this quest for personalization. Whether I have a big box or a small box, I will be able to use technology to have the capability to differentiate my offering with personalization, but that is only filling the need that has always been there …building a meaningful connection with your member. 

Interview with Jill Gilbert about Health Technology

Jill Gilbert is a lifelong entrepreneur and the producer of the Digital Health Summit. Jill worked in the film industry for 15 years before moving on to health and technology. After leaving Los Angeles, her initial focus was the crossroads of aging and technology. She created the first comprehensive online directory and resource for senior care, the Gilbert Guide, for which she was praised as the champion of positive change in the aging services industry. In 2015, she launched another event at CES, Robots on the Runway, which focuses on the world of robotics. Her latest project is called Discover Baby Tech, a website and blog that will aim to bring together products and technology for new parents.


1) Behavior change and wearables are two buzz terms often talked about in the same conversation, yet many devices don’t truly deliver on the promise of actively helping someone change their behavior. What’s a favorite example of a digital health product that actively assists the user in building a desired habit?

Activity trackers have become synonymous with the word “wearables.” These devices (activity trackers) will certainly change some people’s behavior, primarily through awareness. Oftentimes, though, they fall short when it comes to behavior change. I’m more excited about closed-loop wearables, devices that are often condition-specific that trigger — or better yet, assist — with the desired next action to treat a particular condition. When you can engineer the need for “change” out of the usage loop, you immediately get a lift with regards to device efficacy. Most behavior change — when it comes to wearables — is going to be as good as the prompt and/or stimulus. The closer we can get the stimulus to inspire (or be) the next desired action in the loop, the closer we get to behavior change being a non-factor. Until activity trackers move our feet for us, I believe they won’t be as successful as other innovations I have seen recently in digital health.

2) It’s clear that the industry is on the verge of some significant breakthroughs. In your opinion, what’s currently being underreported regarding health technology that deserves greater attention?

Mental health is an area where digital health really can play an important role. For instance, pharmaceutical adherence is a huge issue in mental health. Many people with mental health issues suffer when they are not regimented about taking their medication. We are also making strides with regards to digital therapeutics. Cost is a major factor in treating mental health, and advances in the way we can treat people through behavioral modification platforms that are scalable — made possible because of digital health — is exciting. Telemedicine is also making an impact, by allowing patients to benefit from doctors that have excess capacity. Health technology is allowing people to get treatment who are so unwell they cannot leave the house. It is opening up treatment options for those worried about stigma. There are a lot of great things happening here, but it is not getting as much attention as one would think. Look what Lantern is doing, look what Iodine is doing, this is great stuff and not talked about enough. There is also a lot of promising technology to help with addiction as well.

3) Digital health is well-positioned as a valuable tool to help people with their entire continuum of care, with the potential of assisting people in lessening the frequency of doctor visits. What needs to happen so that consumers can have a better coalesced health experience through digital technology?

Interoperability is key. It is so important, and its lack of existence creates so much friction. Because the problem is so complex, we see people design around it (data operability), and what you are left with is disparate solutions. Literally, digital health in a lot of ways is the Wild, Wild West. Yet, on the other side you have hospital systems with antiquated legacy systems that often don’t even have APIs. We are finally making some strides though… Cisco and UCSF have partnered to engineer an integrated health platform that will hopefully get us closer, but the problem is mammoth. We need smart minds and a lot of resources to solve this problem.

4) Technology is inherently always changing. That said, what have been the constants since 2010 that are facets and/or indicators of successful digital health products? In other words, what is foundational for innovators to get right, or avoid getting wrong, in order to be successful in this space?

This sort of piggybacks off my Wild, Wild West comment. This space is inherently complex, and so in a lot of cases processes that work for pure tech start-ups — like creating a minimal viable product (MVP) — fail in this space. Especially if you hope to get FDA approval, there is a lot to navigate and that’s why we always stress strong partnerships. That said, companies still need to be bold. True innovation and breakthroughs come from mavericks who accomplish what others say cannot be done. There is a balance. The good news for innovators is that it is hard for bigger companies to take risks, so often through the “right” type of partnerships a start-up can get significant help from a larger organization. Obviously, there will be unique considerations that depend on the product. A reimbursable product is probably going to have to rely more on outside help than a consumer box product. The good news is there are great partners out there, like Ximedica, whose primary purpose is to help these types of products figure out a proper strategic path and wade through the intricacies of regulation.

5) You have set your sights on baby tech. Why baby tech? And what benefits do you hope to deliver with this next endeavor?

My ideas around baby tech came about from CES, and getting a lot of products sent my way that were meant for babies, new moms, fertility, post-pregnancy, etc. There was/are enough interesting digital baby products out there, and it was clear this is a distinct category worth addressing. Also, I got enthusiastic about it because I was about to become a new mom myself when I first saw this category get exciting. There is so much amazing stuff out there. Moms can go it alone, we have for decades, but [digital products] might help ease some of the burdens. I am creating DiscoverBabyTech.com to share what I know, create a space for product reviews, report new developments in this space and generally create a resource for moms interested in this topic. The plan is to launch next month sometime. We hope to attract people like ourselves to the site, new moms who love tech.

The Interesting History of Workplace Wellness

The Interesting History of Workplace Wellness
The history of workplace wellness starts with the Italian physician Bernardini Ramazzini (1633-1714) who is believed to be one of the first to write about the effects of work exposure on workers (occupational diseases) and was interested in the possibilities of taking preventative measures (Gainer, 2008) to help improve employee well-being. Half a century after Ramazzini’s death, the Industrial Revolution brought with it many new health problems and injuries due to the way work was reformulated and systematized.

In 1810, Welsh social reformer Robert Marcus Owen proposed a 10-hour work day to help protect the well-being of workforces. By 1817, he purposed a more aggressive measure — the 8-hour work day — and coined the phrase “eight hours labor, eight hours recreation, eight hours rest” (Donnachie, 2000). One of the first organizations to implement Owen’s ideal on a wide scale in the United States was the Ford Motor Company in 1914 ([Ford] Gives $10,000,000, 1914; Chalmers, 2013).

In 1832, Charles Turner Thackrah is credited for having created the first written account of the health problems of industrial workers (Gainer, 2008). Accordingly, Thackrah’s book is considered a pioneering work in the pursuit of improving employee well-being. In his book Thackrah wrote, “The evil of the employ is the incidental one of intemperance (Thackrah, 1832, p.18).” In context, I believe this quote from Thackrah is likely highlighting that employers often operate their organizations with disregard for moderating or restraining their employees’ working conditions.

These notable milestones notwithstanding, workplace wellness was generally an afterthought for organizations up until the advent of Employee Assistance Programs (EAPs) in the 1950s, when companies began to offer wellness interventions primarily focused on alcoholism and mental health issues (Owens, 2006). According to Reardon (1998), true workplace wellness programs did not really begin to exist until the mid-1970s. During this timeframe, there was a perceived shift in financial responsibility for health care, from government to employer. The development of worksite wellness was motivated primarily by cost containment (Reardon, 1998). It was also linked with the activities of the occupational safety and health movement (OSH) and the worksite health promotion movement (WHP), which developed in the late 1970s (DeJoy & Southern, 1993). Greiner (1987) cites the following reasons behind the emergence of worksite wellness during this period:

  • A general culture shift that promoted fitness
  • Emerging research findings that showed the cost of employees’ unhealthy habits
  • Newly formed workplace health promotion groups such as the Washington Business Group on Health and the Wellness Councils of America.

Furthermore, in 1974, the Employee Retirement Income Security Act (ERISA) was established, which was a further signal of the increased concern for employee health. It set the minimum standards for most voluntarily established pension and health care plans in private industry to provide protection for the individuals in these plans (Call, Gerdes, & Robinson, 2009).

The Johnson & Johnson’s Live for Life program, which became known as the prototype for big corporate worksite wellness programs, was started in 1979. The program included a questionnaire and a physical assessment with the purpose of collecting information on each person’s activity levels and body fat measurements. The company then provided support to control risk behaviors — weight control, nutrition, and stress management (Pencak, 1991). 

In 1980, with the arrival of a new political administration in the United States, health promotion focus was lost at the federal level (Greiner, 1987). However, workplace wellness programs began appearing in academic literature in the early 1980s. The articles of this time were mainly discussions of the effects of physical fitness efforts on workers’ health and performance (Call, Gerdes, & Robinson, 2009). In 1982, the Journal of Occupational Health started featuring articles that looked at how workplace wellness programs could reduce absenteeism and other costs related to illness, as well as a few articles that discussed how fitness centers could potentially attract top talent (Call, Gerdes, & Robinson, 2009).

Outside EAPs, workplace wellness programs in the United States during the 1980s seem to have primarily focused on the physical aspect of health, while ignoring other health dimensions. In the late 1980s, companies started addressing issues of psychological well-being as part of a more encompassing workplace wellness strategy. In 1986, the OSH started an initiative that emphasized workers’ mental health. Its aim was addressing the issue of work-related mental health disorders (mainly focused on stress-related illness). This was followed in 1991 with another initiative, Managing Depression in the Workplace, which was launched by The National Institute of Mental Health (Reardon, 1998).

In the 1990s, the federal government launched an initiative called Healthy People 2000 that proposed that 75% of employers with 50 or more workers should offer health promotion services as a benefit (Reardon, 1998). The evidence for the advantages of worksite wellness was scarce; nonetheless, the belief that workplace health promotion brings benefits to a company by having a positive impact on employees was becoming a popular concept among managers who started supporting such programs more widely (Pencak, 1991). During this period, wellness and health promotion programs were generally divided into three levels (Pencak, 1991):

  1. Level one addressed awareness (e.g. classes, posters, health fairs)
  2. Level two was concerned with lifestyle and behavioral change (education to support habit change — these programs generally lasted up to 12 weeks)
  3. Level three targeted the environment (these programs had no time limit and encouraged the work environment to support the changes through organizational structure and increased knowledge)

In 1994, The National Survey of Worksite Health Promotion Activities found that 80% of enterprises were offering educational activities to raise their employees’ health awareness, 44% had facilities for fitness and were encouraging activities, and 30% were doing HRAs of their employees (Reardon, 1998). In 1996, Pender’s Health Promotion Model provided guidance for the development of worksite wellness programs (Reardon, 1998). The Pender Model adopted a holistic view of an individual and went beyond the physical dimension of health. It targeted reversible behaviors and gave organizations a framework to work with.

In 2000, the U.S. Department of Health and Human Services published a new version of the program Healthy People 2000Healthy People 2010. The new program had a similar goal to its predecessor: it aimed for 75% of worksites with 50 or more employees to have a comprehensive health promotion plan (Hughes, Patrick, Hannon, Harris, & Ghosh, 2011) consisting of 5 key elements: (a) health education, (b) supportive social and physical work environment, (c) integration of the program into the administrative structure, (d) related programs (e.g. assistance for workers), and (e) screening programs.

Over the past fifteen years, workplace wellness programs have seemingly taken off. These programs have moved from providing health information, counseling, and fitness delivery to using monetary rewards to incentivize employees to stay well (Wieczner, 2013). In particular, the United States has made significant strides toward ensuring the well-being of employees. With this increase in exposure, there has been an increase in attention paid by big businesses to the efficacy and cost-effectiveness of wellness programs, yet very little research exists for small and mid-sized business. Unfortunately, much of the data from large-sized organizations regarding workplace wellness cannot be generalized to SMBs due to SMBs’ smaller budgets, different business strategies and different employee considerations (Hughes, Patrick, Hannon, Harris, & Ghosh, 2011). Furthermore, barriers still exist with SMBs to be able to offer these types of programs at scale. Small companies seem particularly challenged in offering wellness programs (McPeck, Ryan, & Chapman, 2009). According to one study, less than 7% of small businesses offer wellness programs (Carter, Gaskins, & Shaw, 2005). Hughes, Patrick, Hannon, Harris and Ghosh (2011) describe several factors that hinder health promotion programs in small and mid-sized companies. First, there is the additional cost such programs impose on a company that might already be financially overburdened. Mandatory health and safety regulations generally take priority over voluntary health promotion programs, and as such any ideas of participatory workplace wellness programs fall by the wayside. Small companies often lack a health and safety department, which tends to be the initiator of workplace wellness programs in many larger companies. Another factor is that small companies might not offer health insurance and employee benefits that would often be the motivation for preventative programs (Hughes, Patrick, Hannon, Harris, & Ghosh, 2011). Burke (2006) also suggests that there is generally a lack of awareness and understanding about worksite wellness in smaller companies.

There are, however, other characteristics that perhaps make wellness programs in small companies easier to deploy than they would be in large corporations. These include reduced bureaucratic demands, which give easier access to health promotion vendors; better connections between the management and workers, easier communication and, possibly, more empathy towards workers who are seen as “a part of the family” (Divine, 2005).

Little, if any, research has been done on the topic of the decision-making process in relation to the adoption of wellness programs in SMBs (Hughes, Patrick, Hannon, Harris, & Ghosh, 2011). Hughes, Patrick, Hannon, Harris, and Ghosh (2011) conducted a qualitative study that explored some of the factors (structural, cultural, work factors) that support the development of wellness programs in small and mid-sized companies. The participants in the study stated that they rely on brokers or health insurers for health promotion education. The main criterion for a SMB adopting a wellness program was its cost and cost-effectiveness (program cost-benefit). The employers in that study expressed that they desire information on the cost-effectiveness of the program, as well as data showing that the programs will bring the benefits they sought (e.g. reduced absenteeism). Simply summarized, high program cost and low program cost-benefit may be barriers to adopting these programs with SMBs. Employers in the study considered both direct and indirect costs (such as the cost associated with employees taking time off work to participate in the program).

According to Hughes, Patrick, Hannon, Harris and Ghosh (2011) there are three key tactics that need to be considered when working with SMBs:

  1. Health promotion needs to be related to overall company success-related factors (usually financial success). Some of these factors include employee productivity, recruitment, and retention. These factors are more convincing to small businesses than the actual quantifiable health care cost savings.
  2. Insurers and benefits brokers should be the potential channel for expanding health promotion.
  3. Senior management and human resources should be the targets. The members of senior management are often the final decision makers, so they need to be presented with the relevant health promotion information.

More research is required on the subject of optimal design and funding of health promotion and preventive care benefits for small to mid-sized businesses. There is a lack of knowledge of the impact of workplace health promotion on small to mid-sized businesses’ bottom line, employee retention rates, and productivity levels (Hughes, Patrick, Hannon, Harris, & Ghosh, 2011). These findings need to be conveyed to insurers, brokers, and workplace health promotion vendors and could help build the business case for worksite wellness programs.

It is important to note at least one study contradicts the findings of Hughes, Patrick, Hannon, Harris, and Ghosh (2011). Divine (2005) found that humanitarian reasons and employee-relation goals prevail over financial motives when trying to inspire SMBs to take up workplace wellness. Putting aside a SMB’s motives for workplace wellness, the available literature does generally support that SMBs rely on benefits brokers and health insurers for wellness solutions (Marquis and Long, 2000). A national study by Marquis and Long (2000) supports the assertion that SMBs generally use outside experts to pick their programs. Studies by McPeck, Ryan, and Chapman (2009) and Goetzel and Ozminkowski (2008) also support the reliance on outside vendors and the role of senior management.

Sources:
Burke, B. (2006). Public policy options for small employer health insurance. North Carolina Medical Journal, 67(3), 222–224.
Call, C., Gerdes, R., & Robinson, K. (2009). Health and wellness research study: Corporate and worksite wellness programs: A research review focused on individuals with disabilities (Government Contract Number: DOLU089428186). Gaithersburg, MD: Social Dynamics, LLC. Retrieved from http://www.dol.gov/odep/research/CorporateWellnessResearchLiteratureReview.pdf
Carter, M., Gaskins, S., & Shaw, L. (2005). Employee wellness program in a small rural industry: Employee evaluation. AAOHN Journal, 53(6), 244–248.
Chalmers, W. D. (2013). America’s vacation deficit disorder: Who stole your vacation? Bloomington, IN: iUniverse.
Chapman, L. (2004). Expert opinions on “best practices” in worksite health promotion (WHP). American Journal of Health Promotion, 18(6), 1–6.
DeJoy, M., & Southern, J. (1993). An integrative perspective on worksite health promotion. Journal of Occupational Medicine, 35(12), 1221–1229.
Divine, R. L. (2005). Determinants of small business interest in offering a wellness program to their employees. Health Marketing Quarterly, 22(3), 43–58.
Donnachie, I. (2000). Robert Owen: Owen of New Lanark and New Harmony. Edinburgh: Tuckwell Press.
[Ford] gives $10,000,000 to 26,000 employees. (1914, January 5). The New York Times. Retrieved from http://www.nytimes.com/learning/general/onthisday/big/0105.html
Gainer, R. D. (2008). History of ergonomics and occupational therapy. Work, 31(1), 5–9.
Goetzel, R. Z., & Ozminkowski, R. J. (2008). The health and cost benefits of work site health-promotion programs. Annual Review of Public Health, 29, 303–323.
Greiner, P. (1987). Nursing and worksite wellness: Missing the boat. Holistic Nursing Practice, 2(1), 53–60.
Hughes, M. C., Patrick, D. L., Hannon, P. A., Harris, J. R., & Ghosh, D. L. (2011). Understanding the decision-making process for health promotion programming at small to midsized businesses. Health Promotion Practice, 12(4), 512. doi:10.1177/1524839909349162
Marquis, M. S., & Long, S. H. (2000). Who helps employers design their health insurance benefits? Health Affairs, 19, 133–138.
McPeck, W., Ryan, M., & Chapman, L. S. (2009). Bringing wellness to the small employer. American Journal of Health Promotion, 23(5), 1–10.
Owens, D. M. (2006). EAPs for a diverse world: Employers that provide culturally competent employee assistance programs show employees they care. HR Magazine, 51(10), 91–96.
Pencak, M. (1991). Workplace health promotion programs: An overview. The Nursing Clinics of North America, 26(1), 233–240.
Reardon, J. (1998). The history and impact of worksite wellness. Nursing Economics, 16(3), 117–121.
Thackrah, C. T. (1832). The effects of the principal arts, trades, and professions, and of civic states and habits of living, on health and longevity: With a particular reference to the trades and manufacturers of Leeds, and suggestions for the removal of many of the agents, which produce diseases, and shorten the duration of life. From the London ed., with improvements. London: Porter.
Wieczner J. (2013, April 8). Your company wants to make you healthy. The Wall Street Journal. Retrieved from http://www.wsj.com/articles/SB10001424127887323393304578360252284151378

Interview with Edgar Schein about Organizational Culture

Dr. Edgar Schein is one of the most prominent organizational development figureheads alive. He earned his Ph.D. in social psychology from Harvard University and went on to teach at the MIT Sloan School of Management reaching Professor Emeritus distinction. Along with numerous academic publications, Dr. Schein has a long list of books that cover various organizational topics such as group process consultation, career development, and of course, organizational culture. His titles include Organizational Culture and Leadership, Helping, Career Anchors and Humble Inquiry.


1) You have stated recently that the concepts of organizational culture that are often disseminated from your original work on culture need to now be viewed differently. What is one of the biggest misconceptions — regarding the way your work is used today — that you would like to see better aligned with our current understanding of organizational culture?

From the beginning, I have argued that culture covers everything a group learns in its evolution. That includes external understanding of the environment so that you can survive and grow. Internally, that includes figuring out how to get along. I think today’s usage of the word culture is almost exclusively number two. It’s discussed in terms of workplace culture and how to get better engagement; how to get people to work in teams; how to be more service oriented. People use the word, culture, as almost exclusively geared at how to make employees happier and behave differently according to some notion of what management thinks might be better. What gets ignored is the role of culture in defining strategy, and mission, and how we’re going to get organized. All these concepts are also part of culture, and they are almost never really referred to now in most of the current, popular managerial literature.

2) Few (if any) would question the merit of your ideas around leaders needing to be more helpful and the concepts of humble inquiry. In environments that are inherently fast-paced (ex. medicine) what are a couple useful strategies to utilize these methods where time is scarce? 

One misconception is that humble inquiry is a slow, tedious and long-running process. I can see how it could easily be interpreted that way. But, my experience has been that, if a leader — whether it’s a doctor or whoever — who has time constraints, still wants to be a humble inquirer, you can do that by being more personal. So, my best example is, I’ve recently talked to several doctors and they complained bitterly about the degree to which they only have a few minutes with a patient because of all the other stuff they have to do. So, recently, whenever I’ve been with a doctor and we get into this discussion I coach them to lean over, touch the patient on the shoulder, and say in effect to this person, “As you may know, in the present system, I only have ten minutes. So, let’s make those ten minutes count.” My hunch is that, if you say something like that, it would immediately relieve some of the pressure and would enable both of them to be more open and personal — saying what’s really on their mind. So, it’s use of time, rather than the absolute amount of time that I think makes the difference. What I want to teach leaders is to see how they can very quickly personalize their relationship with their subordinate, or client. When successful, what then transpires is good, open communication rather than a formal dance of do I trust the other person, etc., etc. That may take a lot of time in some instances, but there’s nothing arbitrary that says it’s got to take at least an hour, or a day, or whatever. It’s really how you do it that matters.

3) Previewing my own research a bit, I have found during the process of my dissertation — contrary to popular advice that effective workplace wellness requires leadership actively architect “positive” company culture — successful wellness programs in small to mid-size businesses flourish when leadership is not evolved. Successful programs instead seemingly share the commonality of beginning as an internal well-being movement, spearheaded by (what is perceived as) a neutral advocate. You have discussed previously that “concepts” do not have cultures, groups do. A working theory of mine (in this context) is that well-being is better supported by an organization when employees do not feel coerced by tactics pushing them towards a preconceived definition of “wellness.” If that’s true, are there any tactics leadership can use to inspire a healthy culture other than giving this cohort autonomy?

The leader doesn’t have to participate, but they have to believe that whatever is going on at that middle level is worthy of support. So the distinction you have to make is not that leaders have to be involved, but that leaders have to be aware of what’s going on and be supportive. I can give you lots of examples of that. An interesting example (in regards to your question) would be, if you found some middle-level-generated programs that succeed where the leader is indifferent.

There are a lot of touch-feely programs out there. The leader comes in and discovers for the first time you are engaging in one of these type of programs and says, “What? You’re meeting in this group? No more of that.” There are plenty of examples where good programs are being killed that way. The problem is that middle managers and/or their staff do not explain well enough to leaders what they were actually doing. If they learn that the employees really like this stuff, they are generally not going to kill it — unless it really violates some of their own assumptions about what employees should be doing. The programs that I’ve seen killed, for example, are where employees will get into a T-group program sponsored by HR, and then an executive takes notice and sees them engaging in various kinds of emotionally charged feedback activities. The executive gets horrified, and says, “Who launched this program? I’m not going to have any more of that in my company.” That’s the kind of thing that can happen if leaders aren’t well-oriented to what the program will actually involve.

4) In your extensive look at the role culture plays within organizations, what are your thoughts on the impact culture can have on influencing and/or impacting personal well-being (outside of what we discuss above)?

My basic view is that culture covers everything that goes on in the organization unless it’s a brand-new organization and no culture is yet formed. But, assuming that the group or the company has some history, the culture will determine both what people regard to be the right way to work and how to feel about it. So, you can have a culture, which we used to have a lot of in the auto industry and so on, where what the person expects is a fair day’s work for a fair day’s pay. As long as I get my pay and I have reasonable working conditions, I don’t expect my company to make me happy. I expect my company to give me a living. And, if that’s the cultural norm, as it was in many organizations in the past, then you can’t say this is a bad culture because employees aren’t happy. It is what it is and employees have accepted it. Now, what seems to have happened is, in the last 25 years, is employees are beginning to say, “A fair day’s work for a fair day’s pay isn’t good enough for me. If I spend all this time at work, I want to feel better.” That spawned organizations like Great Place to Work. Organizations like Great Place to Work make their money because a lot of employees think this stuff makes a difference. They believe, “How I feel at work is important.” If the boss gets concerned and says, “Gee, I want to be an organization that makes my employees happy because there’s some evidence, at least in some industries, that safety and quality actually is better if employees feel healthier and happier.” There’s enough research now that bosses are beginning to believe that this is real. So, suddenly, they want to change their culture. But, if they’ve spent 25 years building a fair day’s pay for a fair day’s work kind of culture, you can’t just now say, “OK. I’m going to bring in a couple of consultants and we’ll create a healthy culture.” It doesn’t work that way because you’ve trained all your supervisors and all your managers to be impersonal, and bureaucratic, and that’s the way the place has worked forever. So, now suddenly, you discover the employees aren’t happy… so what are you doing to do? Well, you might from the very top have to start treating your own subordinates differently because your own subordinates are also part of that cultural system. So, when people say, “I now want healthy and happy employees,” they generally don’t realize that whether or not they can get there depends very much on the culture that’s already there, the culture they have built over however many generations. Therefore, they can slowly begin to evolve their culture in a new direction, but that also means changing your reward system, changing the way people are managed, changing all the fundamentals of the organization.

5) You have recently focused some of your work around humble consulting looking at intimacy as it applies to working relationships. Sheryl Sandberg has discussed that it is the fear of perceived intimacy that holds men back from creating strong professional bonds with female counterparts. Have you unearthed anything in your recent work that might mitigate this risk (other than common sense)?

When my Humble Consulting book comes out, which will be shortly, you will see that I make a big distinction between three levels of relationship. One is sort of the bureaucratic “stranger” relationship. Level two is what I’m calling a more “personal” relationship. Then, level three is what I’m calling “intimate” relationships. So, the question is, are we using intimate in the same way as Sheryl Sandberg? I’m arguing that level two relationships, which are always appropriate, is what you would call a personal relationship. I know you as a whole person… I am responding to you as a whole person. The question of what is appropriate in the workplace between men and women, I think it’s totally appropriate for both to get more personal around the tasks that they have to perform. But, that should not imply they need any more intimacy, sexual or otherwise.

The definition of intimate becomes crucial in this discussion. In U.S. culture, one might think that the word immediately implies this deeper male-female kind of stuff. And, that would certainly be a misuse of a working relationship. Therapists and lawyers aren’t supposed to be intimate with their patients and clients, but they can be very personal in how they structure the relationship so that good information and trust is built up. So, that’s the distinction, but I cannot specifically answer this question because I do not know how Sandberg has defined the word for her work.

The trick is to be aware that society’s rules always apply. What society decides as inappropriate intimacy applies across the board. You can’t say, “Well, in my company, we’re going to use different rules.” The key is for you, or me, or anybody to play by cultural rules because those rules apply to all these situations. Then, within that say, “Okay. I can’t be intimate, but as a boss I can sure have a better relationship with my subordinates by at least getting more personal.”

Interview with Mitesh Patel about Health Incentives

Mitesh Patel is a practicing physician, as well as a faculty member at both the Penn Medicine Center for Health Care Innovation and Penn’s Center for Health Incentives and Behavioral Economics.  Dr. Patel is also an Assistant Professor of Medicine and Health Care Management at the Perelman School of Medicine and The Wharton School at the University of Pennsylvania. He is well known for his research on behavioral economics where he and his colleagues are discovering ways to improve and elicit healthy behavior.  Dr. Patel’s thought leadership has been featured on CNN, NPR and in The New York Times, and his scientific findings have been published in several prestigious journals including the Annals of Internal Medicine, the New England Journal of Medicine, and the Journal of the American Medical Association.


1) As a physician interested in health, what do you make of the recent UCLA study that suggests BMI is a poor performance indicator? Although the extremely high recidivism rates we hear in lay media are generally inflated, programs that focus solely on weight loss programs seem to be falling out of favor. Is there a better approach to gauging and influencing toward behavior that contributes to wellness?

The challenge with using BMI is akin to the challenge of using any kind of score or metric for a population of people. There is always going to be a gray area. For instance, someone with a BMI of 29.9 is overweight, but someone with a BMI of 30 is obese. Even though there is a very, very small amount of difference between the two, when you categorize someone through this lens it can be classified as a significant difference. So this challenge I just described with BMI will be comparable with a lot of other standard measures.

So what many companies, employers and insurers are trying to do is find more holistic ways of looking at people’s health.  That is where it gets complicated, someone might have a low BMI, but have diabetes, and the right intervention is weight loss. This is an example of why using any metric in isolation is challenging. I do believe outside the context of the BMI measure, losing weight for overweight individuals is generally known to be beneficial. There is generally never harm in getting your BMI down to a lower range if you are above 25. However, that said, you certainly can find people with a BMI of say 32 that live to be over a hundred, but on average people in our current population are healthier if they lose weight.

A common problem with some wellness programs is they are often one-size-fits-all. For instance, lose 10 pounds and get a reward, but really we need to do a better job at personalizing to the individual. This highlights the importance of paying attention to how these programs are designed. We are facing complex problems, and oftentimes we are meeting these problems with solutions that are frankly too simple.

2) Outside of monetary incentives, what do you believe is most important for a company/organization to get right to best set themselves up for positively supporting employee well-being?

This brings us back to the importance of the overall design of the program. Is the program designed in a way that it will produce the results the company is expecting to get? Let’s say the goal is to increase everyone’s activity level, so the company gives everyone a free Fitbit, sets up a leaderboard to see how much everybody is doing and then creates a competition because competition can drive people to change behavior. The problem with this hypothetical solution is the program will motivate the people who are the top of the leaderboard — the people that tend to be already motivated — and demotivate the 95 percent of people that are not at the top of the leaderboard. I don’t think this is the right approach because it excludes the people you want to reach the most. We have done a couple studies where instead of setting a high bar, we set a threshold instead. For instance, in one study we set the threshold at 7,000 steps. The average American gets 5,000 steps, so the goal (in this particular study) is about a 40 percent increase in steps for most users. What this does is create a program that will reach more sedentary people than simply people who are already highly motivated to begin with.

3) What excites you the most about how technology is being used today to influence healthy behavior? And, where is it failing?

I think technology possess great potential to help us change behavior. One of the main reasons is that we could not measure these behaviors up until [roughly] 5 or 10 years ago. We didn’t know how many steps people took, we didn’t know if they took their medication (we can now with connected pill bottles), weight measurements were self-reported and often inaccurate. Technology has given us the opportunity to passively monitor, and we can now do that at a large scale. We can measure thousands of people with very low manpower because it can all be automated through technology.  The greatest promise of technology is being able to, on a large scale, automate this idea of passively hovering and get a rich data set so that we can see what is working (and what is not). Furthermore, we can do this while the only expectation for the participant is to continue doing what they are doing, which if you think about it is a big deal.

Where technology is failing is we have not taken the step beyond measuring. How do we actually get people to change their behavior using technology? I call this the “technology delusion.” People sometimes think that you can take someone who is overweight — who is inactive — give them a wearable device and all of a sudden they are going to be a new person. This might work for me or you who are engaged with this stuff, or Quantified Selfers, but it will not be true for people that have an inherent lack of motivation. These devices have not been shown to increase motivation in at-risk populations. That is why the studies I am a part of couple a behavioral change strategy with a technology. The technology is good for recording, maybe helping with feedback loops, but the behavior change component is what is often missing from organizational workplace wellness strategies.

4) There is research to suggest that extrinsic rewards are episodic, and in some cases extrinsic rewards can alter motivation in ways that are counterproductive. Most of this research is based on carrots (incentives) opposed to sticks (penalties), does using the fear of loss mitigate any of the risks generally associated with extrinsic motivation? Besides proving to be more effective, are there other attributes to penalties that position it as a better choice than rewards?

Intrinsic motivation is of course desired, if we can get people to increase that kind of motivation it is where we would start. The problem is it is fairly hard to influence intrinsic motivation, and then sustain that increase. The person really needs a good reason, many times that reason relates to a family event, or a life-changing event; whatever it is, the intrinsic motivation has to come from within the individual.

Extrinsic motivation, giving somebody some type of reward, is generally meant to jump start new habits and then hopefully we can remove the extrinsic motivators. There are some that believe you have to leave the reward in place to see sustainable behavior change. We have found evidence that people who get extrinsic motivation that’s well-designed get better results than our control groups. Furthermore, in some instances we have removed extrinsic motivation and we don’t really see that those people do worse than the control group either. We performed one study where we positioned the reward as a loss, allocated the money up front, and then took it away if the participant did not meet their goal. What is important here is that the lever was not a penalty — no one lost money out of their pockets. So this was not a stick per se but more like a “frozen carrot.” We told all three groups in that study at the end of the month they will get a check in the mail, and they could earn about $42 (a month). The reward was the same among the two non-control groups, but for one group the incentive was framed you get something for your behavior, the other group it was framed you start with a reward but it can be taken away. What was nice about that was it was a reward kind of masked as a penalty, and it made people feel like the money was theirs, a concept called the endowment effect. We find time and time again when people have skin in the game they are more likely to change their behavior.

5) Addressing the potential negative aspects of penalties, how do you coalesce your findings of successfully using the fear of loss to elicit behavior change, with the ethical notion that people should not be (or at least feel) penalized for personal choice?

Certainly there are ethical things to think about when one group is going to get something and another group is not. Those concerns should be discussed and addressed. One way to determine if the reward is causing harm is asking the question, “Do people disengage?” People are generally concerned about framing a reward as a loss, the belief being a group (subjected to the loss) is not going to like it or consider it punitive. We found in our study that even with a frozen carrot, 96 percent of people finished the study and stayed actively involved even 3 months after we turned off the incentive. This engagement is much higher than you would see in many wellness programs currently in use. If the incentive was perceived in a way so punitive that it made participants drop out that might give us pause. However, because of the success of the study it makes us believe that this method is scalable. I am not saying it will be for everybody. We still need a way to make these incentives more personalized. Some people will respond better to losses, some to gains. What we learned at the population level is it appears more respond more favorably to losses, but at the individual level a patient-centered approach will help us further by identifying the right incentive for a particular person, which in turn will increase efficacy.