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Interview with Matthew Nock about N-of-1 Experiments

Matthew Nock, Ph.D. is one of the leading experts on n-of-1 experiments and single-case experimental designs. Matthew became MacArthur Fellow in 2011 receiving the MacArthur “Genius” Award. He studied at Yale and now is a professor at Harvard where he also runs the Nock Lab. In addition to his research interests, Dr. Nock has been counsel to the World Health Organization’s World Mental Health Survey Initiative, the National Institutes of Health, the American Psychological Association, as well as other prestigious health organizations.


1) Assuming I have captured the basic methods of single-case experimental design (SCED):

  1. Identification of specific target behavior
  2. Continuous and valid measurements
  3. A baseline period (data is gathered before the intervention is applied)
  4. Stability of the specific target behavior (target behavior changes only when the intervention is applied)
  5. Systematic application of intervention

What are the considerations, risks and advantages for someone partaking in self-experimentation — someone who wants to use these methods to help determine the efficacy of a new habit or practice (e.g. determining the effect of meditation on mood)?

These are the basic methods, but it is important to note there are some variations in how you would apply different types of single-case experiments. Once the intervention is applied, then something else is going to happen next, right? For instance, there is “AB-AB design” also known as “withdrawal design.” In this application, you apply the intervention, you then remove the intervention and examine whether the behavior/condition reverts to the baseline level. You then reapply the intervention — so the A state stays as baseline, the B state stays as an intervention — so you do AB, AB and measure the change.

For instance, if you wanted to see if a reward program for not smoking cigarettes worked for you. You start with cigarette smoking as your baseline. Let’s say you smoke two packs a day. Now you apply the reward (intervention). After the reward you now smoke half a pack a day. You then remove the reward (intervention), going back to baseline (smoking without a reward for not smoking), and you see if you go back to two packs a day. You then reapply the intervention (in this case the reward) in an attempt to determine that it is when, and only when, the intervention is applied that your behavior changes. This method helps you rule out alternative explanations. For instance, in this hypothetical example you rule out that you stopped smoking because of some historical event, or your wife told you she’s going to leave you if you don’t stop smoking at the exact time you started the intervention.

What you are trying to accomplish is identifying the result from the experiment is from the intervention and nothing else. You can do an AB-AB design as described, or, if you have access to other participants, you can do a multiple baseline design. In this example, the first person, they would have a one-week baseline and then you apply the intervention; the second person would have a two-week baseline, then you apply the intervention; for the third person, a three-week baseline then you apply the intervention. Again, if you can show when, and only when, you apply the intervention something has changed, you have evidence that your intervention causes change in people.

A single person can also use a multiple-baseline approach across behaviors. For instance, I am trying to change my smoking and drinking and eating. I could apply the intervention to my smoking, then apply it to my eating, and then apply it to my drinking. If I see that when, and only when, I apply the intervention my target behavior changes, it provides evidence that my intervention is effective. You can apply the multiple baseline approach across people or across behaviors.

If someone is self-experimenting, they will want to do their best to collect their own data objectively. Using these methods on yourself, you run the risk of tricking yourself into seeing something that is not there or failing to see something that is there. When it is a clinician or a researcher observing you, they are going to be, with their own objective eyes, carefully measuring some behavior of interest. If you are not carefully measuring objectively what it is you want to change, again, you might see change that is not there or fail to see change that is there. It is important to do your best to objectively measure.

The benefit of this approach is you are the one following the data. You have a real-world answer to whether or not your intervention is working. It can be just a little bit of extra work to do something like this, to quantitatively, objectively measure your own behavior. However, in my opinion, that is also a benefit: knowing what’s effective; knowing what can change your behavior at a fairly minimal cost.

2) For many, “lifestyle design” is about optimization. For example, using meditation as the hypothetical again, it appears that many find benefit from only minimal exposure (Creswell, Pacilio, Lindsay, & Brown, 2014), but one could posit the effective duration is unique to the individual. Since interventions generally come with an opportunity cost, reducing this cost has a benefit. What are some good strategies for expediting the determination of the minimum effective dose (MED) of any given intervention?

In my mind, there are two philosophies about this. One is start small, and measure carefully the effects of the small dose/intervention, and then increase, increase, increase, until you see maximum benefit(s) and then you might know how much is needed. The other is the opposite; start with the maximum dose and then work down from there. Each has pros and cons, right? It certainly depends on what it is you’re using as an intervention. If there is any toxicity associated with the intervention — drugs are an obvious example — if there are toxic side effects to an experimental drug, you would want to start very small and work up to see what is the needed dose to cause change. The benefit here is you are not exposing the subject to toxicity; the downside is it could take longer for an effect and the person could be engaging their harmful behavior, or suffer from disease, for longer intervals of time than giving them more from the onset. On the flip side, if you start with the maximum dose, you generally will know right away whether it has an effect and then you can work down from the initial amount. The downside is you are now exposing the subject to any toxic side effects from potential overdose. If you are certain the intervention does not have any toxicity and/or limited risk, I think the best thing to do is start with the maximum amount and then work down from there to see how much is needed to maintain the effect.

3) Technology is making the recording and analysis of self-experimentation more accessible. There are an abundance of consumer and condition-specific wearables for collecting data, ecological momentary assessment (EMA) protocols are accessible to anyone with a smartphone, the statistical package R is free to use — enabling anyone willing to take on the learning curve the ability to crunch their own numbers. What technology and innovation excites you in this area? And, is there anything that is currently helping democratize one’s ability to run these types of experiments?

There are a lot of tools at the ready now with smartphones and other wearable devices, so people can collect and analyze their own data quite easily. The big bridge is people often are not going to want to learn something like an open-source statistical program. Learning a statistical program like R, even though it is free, is not a minor endeavor. People want ready-made solutions to problems, so they want an app that is turnkey and ready to go. Technology that is going to monitor their behavior, apply the intervention, whatever it is … to the extent that we can create applications that bridge that gap for people, that are easy to use, people will likely use them.

So yes, there is some great open-source stuff out there, but getting someone to figure out how to collect their own data effectively, then create and apply their own intervention, learn statistics (even if it is free to do), analyze their data; wow, this basically requires an intervention in and of itself to get someone to do that.

The thing that excites me most right now is using wearable devices and smartphones to collect data about people and apply interventions that are beyond their own awareness. There are apps available now that allow us to collect data from people’s smartphones passively. We can monitor their GPS, we can monitor their sleep, we can monitor their activity level, who they’re calling, who they’re texting, who’s calling them, who’s texting them, and we may pick up information that can predict future behavior that people are not aware of themselves.

For instance, if a person’s activity level is decreasing, they have outgoing calls and texts and none are getting returned, and their sleep becomes more irregular, we might predict this person is becoming more depressed. So a condition a person may not even realize they have themselves — we can use information from their phone to help identify potential problems and deploy an intervention remotely before the condition can cause any negative effects. We now have e-interventions, smartphone interventions, where people can engage in a little quick, game-like app that they can play to try and change their behavior. The old model of going to a doctor, the doctor does an assessment and tells me I have a problem, then gives me some kind of treatment — this model is changing. We can now go out and find people who are in need of help before they know they need it, and send interventions out to them that they can use and apply themselves. We can deploy this on demand, 24 hours a day, 7 days a week, whenever it works for the individual.

4) You are a Harvard psychologist. You are also one of the leading experts on destructive behavior. There seems to be a resurgence of William James’ ideas lately, specifically that if we master our free will and make ourselves 100 percent accountable for our actions, this process will increase our chance of positive outcomes. Do you believe in the validity of this assertion? And, given your expertise working with people where this process might pose difficulties, what are some strategies to assist one to increase their ability to be accountable in this area?

My department resides in a building called William James Hall, so the spirit of William James is still present. The idea of holding ourselves 100 percent accountable, as it pertains to the way I am interpreting your question, comes down to the rewards and the costs of a behavior. If we want to change our own behavior, we need to accurately understand to what extent the behavior in which we are engaging is rewarding or beneficial. We also want to accurately understand what the costs involved are. We have to seriously evaluate both the rewards and cost. For instance, if I am smoking cigarettes, I probably feel good after I smoke. In this case, what are the rewards and costs of smoking? It means realizing there are benefits, but there are also significant costs engaging in the behavior. I need to weigh both, but to do so I need to accurately consider present and future elements of the behavior.

So for me, holding ourselves accountable means realistically realizing the cost and benefits of our behavior and weighing those carefully. If the costs are going to ultimately outweigh the benefits, then I think we have a chance of decreasing risky behavior. If the benefits are perceived as outweighing the costs, it is much tougher to change someone’s behavior. For instance, take a self-destructive behavior like cutting oneself or burning oneself, why would someone do that? It turns out that cutting yourself or burning yourself, for many people, removes aversive thoughts and feelings. This behavior has a benefit for them. For these people, the reward of removing these thoughts appear to outweigh the costs of seeing tissue damage, and so they engage in the behavior. Getting people to stop engaging in this behavior is a lot about figuring out other ways to get the existing benefit for alternative behaviors that do not carry such a heavy cost.

I think the same is true with smoking, drinking and overeating — as well as other problematic behaviors. These behaviors have associated rewards, but they also can come with significant costs. To make good choices, we need people to understand and appropriately weight the costs and the benefits. An important part of the process of behavior chance is to figure out ways to have people find similar benefits that do not carry the same costs of the behavior one hopes to change. The challenge is how to get yourself to feel good and/or distract yourself from aversive psychological states, without doing harm to your mind and/or body. If the spirit of your question is, “How do we increase our chance of positive outcomes?” then you can look at it as benefit-cost=outcome. To do this, you need accurate information about the behavior’s costs so you are not discounting and/or ignoring these. Then look at the behavior’s benefits and find suitable alternatives that offer comparable benefits without the associated costs of the behavior you are trying to change.

5) A young student has walked into your office and proclaimed they want to become the leading expert on self-experimentation. What are three rabbit holes you suggest they explore (i.e. ideas, concepts, models)?

Three rabbit holes they should explore …

1) Read up on the decades of research that people have done on single-case experiments and N of 1 designs. There are a lot of well-worked out-methods and approaches to measuring behavior and carefully, systematically applying an intervention to change behavior, as well as observing the effect of the intervention. When you really understand these validated methods, then you are aware when you are truly doing experimentation. We have existing study designs where one can carefully observe the outcome of self-experimentation in an empirical manner — opposed to reinventing the wheel, there are decades of existing work that one can build on, so mastering the current available literature in this area is a big one.

2) Mastering new technology. As we discussed earlier, there have been significant, recent advances in technology available to people interested in experimentation in the form of smartphones, wearable devices, the Internet and free access to educational information. We have easy access to data at our fingertips now. Through technology we can easily measure our real-world behaviors. Mastering new technology will allow a person to tap into a huge new source of objective data on our behavior.

3) Once you master experimental design and you master the latest technology, the last rabbit hole I’d suggest is how to engage and measurement your experiments. You need to figure out how you can use advances in technology to develop new interventions based on what we already know works. Questions like, “Are we effectively using carrots and/or sticks? Are there ways that we can use computers, the Internet, smartphones, wearable devices, to try and apply new interventions?” The new frontier regarding behavior change is to master the way that we try and modify people’s behavior (or modify our own behavior?). With the right creativity — coupled with an existing mastery of the first and second rabbit holes — there is a lot that can be done using the new tools that we have at our disposal. We now have the ability to apply personalized behavior-change interventions, in real-time, at scale.

There is a downside to this third rabbit hole, too, though, especially if you are building tools that help others self-experiment. There are now thousands of thousands of apps out there that are purported to improve health and well-being. However, by my reading, there is very little data to support that most of these apps are actually effective in any meaningful way. Moreover, there is little evidence to suggest that most of these apps will actually change anyone’s behavior. Worse, there is a financial incentive to create apps and to market to people, “This app will make you healthier and happier.” In my opinion, there is not a good public understanding of how to evaluate scientific evidence. That makes it difficult for most to evaluate claims about effective treatment and/or interventions. It’s the Wild, Wild West out there.

Before scientific medicine, people just created their own methods. They could sell snake oil. They could put anything in a bag or box and sell it to us as effective. Some were and some weren’t, and many times the ones that were effective, weren’t effective for the reasons that people thought. Luckily, now we have a much better infrastructure where, if you are going to sell some kind of FDA-approved medication, you have to know what is in it and show that it is effective in randomized clinical trials. It’s on you, you’ve got to have experimental data. I think of the app world as similar to the Wild, Wild West. People are now deploying things that they say are treatments and there is not a good, systematic infrastructure in place to know which ones are experimentally sound and which ones are not. Similar to the thoughts expressed in the previous question, there needs to be a clear benefit to making experimentally sound apps. This benefit could be a special designation, like FDA approval or FDA approval equivalent. Something that ensures it has been tested, with evidence showing that it works. If the app does not have that, then some kind of repercussion for the makers. Until we have that system in place, I think you will continue to see a market full of snake oil.

Interview with Cathy Presland about Tracking Progress

Cathy Presland, a former economist, runs the program World-Changers’ Circle that takes five action-takers on a 6-month journey of transformation. She is an expert on leadership, both personal and professional, and inspires people to look beyond themselves when they make their life and business decisions. Cathy draws her knowledge from over twenty years of experience working with governments and international organizations on different public policies, programs and regulations. Cathy is a respected motivational speaker, teacher, mentor, facilitator and an author. Her book, Write! Stop Waiting, Start Writing. A Step-by-step Guide to Turn What You Know into a Book, is an international bestseller and is just one of the ways Cathy is supporting people who feel they have an idea that they want to share with the world.


1) If someone is looking to create a system to track their process towards some sort of desired change and/or personal improvement, how would you coach them through building this architecture so they can successfully develop a measuring protocol that assists them with meaningful metrics that assist with experimentation and continual improvement?

I think that at the core of any kind of monitoring is the question: is the process serving the end goal? Sometimes this is just a feeling, and sometimes, it is some kind of a quantified measuring protocol. I’m not so interested in numbers; I’m interested in where we are trying to get — How can we make the process more joyful, therefore, making it easier to get to the goal, regardless of the number? In my experience, if we put a measurement around a goal too early, the number becomes more important than the result we’re aiming for and there is no scope for creativity. We’re then quick to jump to self-criticism about not hitting some made-up target which sets off a cycle of demotivation. Measurements are especially not helpful in the early stages when we are just setting up doing something. Sometimes, you first need to do something to test your theory without having to deal with the danger of negative feedback that can come from creating your own metrics. If you want quantification, do a two-week experiment and see how you feel. You can put some measurement around it later if you feel you want to move it forward. So, very rarely would I rush into measurement from the outset because I think we don’t know what we feel inspired to do on a daily basis.

I’ve got a client at the moment, for example, who’s applied for a number of jobs, and she’s not getting the results she wants. So, we had a conversation about what else could she be spending that time doing? It transpired that it wasn’t working for her because she wasn’t really inspired by the job she was applying for. This was the start of an honest conversation. I’m interested in what is going on in our minds that is creating good or bad feelings. When my client has an insight, and she realizes that she wants to be doing something differently, she should just be able to go off and do it. She doesn’t necessarily need to monitor it. Too much measurement can strain your results I think. It may be just about how honest we’re being with ourselves about the things we are doing, whether the things that we’re doing are going to give us the results that we want.

2) When someone is faced with assessing a life change where the present state/status quo is comfortable and satisfactory, and the future state being evaluated is high risk but high reward (i.e. the change requires deviating from an existing desirable state) — what effective strategies, processes and/or frameworks have you found useful for individuals to use to increase the likelihood of making a successful decision?

Life is never a low-risk, high-risk situation in my experience. The future is always unknown. None of us literally knows what we’re going to be hit with personally, professionally, so to me, that is never what it’s about. The actual situation is less important. The only thing that really matters is how we’re thinking about the current situation and what moves we’re making.

I don’t have a framework I could prescribe. What I do have is a philosophy. I do think there is a place that we can come from, because, as individuals, we’re so tiny and meaningless. And, the less consideration I give to me, the more contribution I’ve got to make – to one person, to my children, to my family. I try to have a discussion around what is important to the person in that coaching conversation. What is it that they feel in this moment is the right thing for them to do. It’s about removing you personally and your ego as much as possible, so you can analyze your decision in terms of these questions:

  • Am I doing this because I think I’m going to be happier in some way, which is a red flag because our feelings don’t come from our circumstances?
  • What is the greater good in this situation? What feels ‘right’?

And, at the same time, I also think that the right thing is something that we create in our imaginations. So, I don’t see that as a fixed thing; I see that as a drive, a movement, an action at this point in time.

3) In contrast to the previous question, it is my opinion (given the immense amount of advice currently available about improving performance) that people often get stuck consumed by integrating seemingly endless methods (e.g. life hacks, productivity approaches, etc.) that either act as distractions and/or worse — impede progress towards what really is desired. What is your opinion on this assertion and do you have a process with your clients on making strategic decisions on what not to do? Lastly, in this regard are there commonalities that lend themselves to general advice that would benefit most people about what not to do?

I certainly see lifehacks as distractions. And, I think that they can impede progress when people give them an importance that they don’t have. A lot of life hacks, especially in the personal development world, are designed to try to create some kind of space. Meditation, or anything in that zone, is designed to try to create some space so we can get some clarity. But, the process often becomes an end in itself, like, “I’ve got to meditate”. And we forget that we have access to that space in our heads at any moment. Some people have found life hacks helpful, but the reality is that we don’t need them.

We’re very good at making up things that we think we want and then trying to think our way there.  We go into this cycle of over-thinking, whereas, if we actually just gave ourselves mental space, we’d probably already know what it is that we want to do. But, we just don’t accept it, or we don’t see it, or we don’t think this is it; we kind of don’t know what it looks like. So we spend a lot of time chasing things that we don’t really want to do, or things that other people have, which are completely pointless wastes of time.

People that have enough perspective to know that something is not real or is going to pass, do better in life. We need to distinguish between what’s real and what isn’t. Generally, there are some things that look more real than others to people. Money is a typical example here. Many of us think money will create a feeling of security — but the security comes from within us, not from something external. Similarly, doing something because it’s going to lead to something else — taking an action or a path “so that…” or because there is an ulterior motive beyond the immediate is generally a wrong decision, too, and you are fooling yourselves if you are taking intermediate steps to something. If there’s something that you want to create, there’s always a more direct way to do it. “If I make lots of money, then I can create a foundation to do good in the world.” It’s like, why not just do good in the world now?

The other kind of big general thing that I will comment on is that people seem to think there is somewhere to get to. However, there’s no forward motion. It’s a real trap to believe that there is forward motion because then we’re always trying to get somewhere that we’re never going to get to. It’s just motion, in all sorts of directions and, often, that can be hard for people to conceptualize because we are so conditioned that there is a timeline in life, a journey from A to B. That’s a myth, there is only where we are now.

4) What are good indicators that it might be time to give up on a big idea/plan/goal? Using my own goal as the example, the Boston Marathon has always been a stretch goal, albeit an achievable pursuit — until recently where I was advised never to run long distances again. The Web is cluttered with advice to never give up on your dream, but science suggests this “inspirational” messaging has had some significant negative consequences. What is a suitable gauge and process for determining a goal has realistically fallen out of reach?

For me, this comes down to removing the ego from the decisions that we make. It is about heading in a certain direction and making the most of the opportunities we have rather than regretting those that are not open to us right now. It’s kind of direction versus outcome. And what is important for me is the direction and coming from a higher self. It can be difficult for us to create that separation between what we feel and what we actually decide to do. So, the higher the perspective we get on this, the easier it is to take those clear decisions. That’s where I would work with somebody. We feel what we feel; it’s not for me to tell somebody that what they’re feeling isn’t valid, because that’s what’s coming up for them. But, I will work with them in a way to show them that this isn’t meaningful in the way that they think it might be.

When a big goal falls out of reach, it doesn’t take away from you that direction that you’re heading in. For you, for example, it’s not in the cards to do the Boston Marathon anymore. Or, maybe it is. Or, maybe you can explore something else and get another route for experimentation or exploration. But, if you stay attached to the Boston Marathon, you’re going to lose the creativity to try out lots of different things on route to getting there. The reality is that we have very little control over what happens. We don’t know what’s around the corner; we don’t know who we’re going to meet. And, the more open and positive we are to the possibilities that are in front of us, the more fantastic things happen.

5) You run a program called World-Changers Circle. Although daring big might not be for everyone, what are some of the undervalued intangible rewards you have witnessed from those that succeed at big things?

I think that it is human nature to want to do something that goes beyond ourselves. People come to me because they want to do something meaningful, and this doesn’t have to be grandiose. Amazing things can happen when we get our egos out of the way, and these things happen faster than we expect. You take bigger actions and make bigger asks when you’re not coming from a place of ego. There are a lot of benefits from taking a different perspective and looking differently at the world: you get calmer, have better relationships. You realize that it is actually more about how you’re looking at things rather than anything that other people have done. You realize that the world is driven internally more than externally. And the byproduct of peace is increased happiness which comes with more clarity.

Interview with Raj Raghunathan about Happiness

Professor Raj Raghunathan specializes in psychology, marketing, as well as the philosophy of happiness and decision making. He graduated from Birla Institute of Technology and Science and completed his MBA at the Indian Institute of Management. In 2000, he earned his Ph.D. at the Stern School of Business, New York University. He is a Professor of Marketing at the McCombs School of Business at the University of Texas at Austin. Prof. Raghunathan developed an online course called A Life of Happiness and Fulfillmenta 6-week course on Coursera platform. The course includes knowledge from the fields of psychology, neuroscience and behavioral decision theory. It has had over 75,000 enrollments and has been featured as a Top 10 course offered by Coursera. In 2016, Raghunathan also published the book, If You Are So Smart, Why Aren’t You Happy? Raj’s book explores how to become happy and draws on the concepts Prof. Raj calls ‘happiness habits’ and ‘happiness sins’. Raj has received several National Science Foundation Career Grant Awards. He is an associate editor at the Journal of Consumer Psychology, guest associate editor at the Journal of Marketing Research and is on the editorial boards of the Journal of Marketing and the Journal of Consumer Research.


1) The mechanisms of a happy and fulfilling life can now be explained using science. How do you define happiness as an academic? Does it have quantifiable components or is it truly a subjective measure?

Somewhat surprisingly, happiness is both a subjective experience and measurable. The subjective part comes in two ways — the things that make different people happy, and the types of emotions with which people implicitly equate the term “happiness”. The idea that different things make different people happy is, of course, straightforward. Going sailing may reliably make some  person happy, while for others, it won’t float their boat (so to speak).

The idea that different people equate happiness with different terms is a little more subtle. Prof. Barbara Frederickson of the University of North Carolina finds and suggests (based on work by Dacher Keltner, a researcher at UC Berkeley) that “positivity” comes in 10 main varieties including joy, love, serenity, hope, awe, gratitude, laughter and interest. To me, happiness is the same thing as what Prof. Frederickson calls “positivity.” In other words, in my book, you are happy so long as you are experiencing one or more of these (and other) positive emotions.

What is really interesting about all of this is that, as Prof. Ed Diener and his colleagues have found, the simplest way to measure happiness is essentially by asking people how happy they are across a few items (like, “all things considered, would you consider yourself happy right now?”). This is a highly reliable and valid method. For instance, people’s subjective reports of happiness are highly correlated with some objective correlates of happiness, like serotonin (positive correlation) or cortisol (negative correlation) levels. Likewise, people who report higher levels of happiness tend to have a thicker left pre-frontal cortex, and also tend to be thought of as being happier by their close friends, etc.

So, in a nutshell, what might appear at first blush to be a problem for happiness research, namely, that happiness is too subjective, turns out to be not such a big problem after all.

2) In your work, you suggest that being creative and having fun are habits that should be cultivated to reach higher levels of happiness. Since fun is a very subjective concept (i.e. what is fun for one person, is not necessarily fun for somebody else) how do you suggest fun might be studied more rigorously?

As I mentioned in my response to the previous question, while it is true that what is fun for one may not be fun for another, what we subjectively experience when we say we are having fun is more similar than dissimilar across people. So, for example, even if my idea of fun (say, going on a hike) is quite different from that of yours (cuddling up with a book), you will understand what I mean when I say, “Going on a hike is really fun.” You might say, “that’s not what I would call fun, but hey — different strokes for different folks!”

The point is that it’s important to have fun — in whichever way that works for you. Why? Because you are likely to be more creative, more healthy, more productive and more altruistic when you are having fun (more generally, when you are happy) than when you are not.

3) Your work points out that people who are more educated and successful are not necessarily happier. However, one could argue that with expanded education comes broader knowledge and awareness of critical issues (e.g. global warming, poverty, discrimination, injustice, the division of people), and this insight could have a negative effect on one’s sense of happiness. Can one have a thirst for universal knowledge and increase their happiness at the same time? What, in your opinion, is the relationship between seeking truth and happiness?

It is true that more knowledge and more awareness can lower happiness levels. There was a study that a few of my marketing colleagues (including Ziv Carmon and Klaus Wertenbroch) conducted in which they showed that those who spend more effort and thought in coming to a decision about which product to buy are generally less satisfied with the product than those who make it based on lower levels of effort. A main reason for this is that, when you know more, the more you know what else is possible; so, you are less happy with what you have.

The mechanism to which you allude in your question (to conclude why better informed people may be less happy) is a related one. You suggest that being informed and knowledgeable about all of the ways in which the world is screwed up may be a buzz kill. True. And this certainly seems like an important reason why the smart-and the-successful are not so happy. But I also think that there’s merit to the argument that some of the very things that make us smart or successful — like a need to be superior, the desire to control others or outcomes, or that of engaging in elaborate analyses — when taken to unhealthily high levels, can also undermine happiness levels.

A final reason why success lowers happiness has to do with how access to the yardsticks of success — fame, money, power, etc. — can make us more self-centered and materialistic. Several findings show that being self-centered and materialistic are not good form for obtaining happiness.

4) From the perspective of neuroscience, emotions are important for our decision-making processes. In a Business Insider article, you warn ‘mind addiction’ can make us ignore our gut instincts and feelings (see: ‘Mind addiction’ could help explain why smart people aren’t as happy as they could be). From your research, why do you think we have found ways to short-circuit our intuition?

Great question. It’s not that thinking through problems and overcoming emotions is always bad. Clearly, we have all experienced situations where our emotions have hijacked — or at least derailed — our decision-making process. Impulsive consumption behaviors (e.g., overeating) are all examples of this. So, one big reason why many of us become suspicious of emotions is because we do not want to commit this mistake again. But in an attempting to avoid the mistake of being too impulsive, many of us run the risk of becoming “mind-addicted”.

I think society too plays a big role in instilling mind addiction. Take schooling. Children almost never get to learn about how emotions and instincts can be useful in decision-making. That is, pre-college education almost exclusively encourages the “mind” route to solving problems and making decisions.

On top of that, most of the goals we are encouraged to pursue, from individual ones (e.g., saving enough for retirement, losing a certain amount of weight) to societal ones (e.g., increasing GDP) are quantitative in nature. So, we end up never pursuing qualitative goals (like being happy, or enhancing levels of trust in society). This overly quantitative (vs. qualitative) focus also makes us more prone to relying on the mind to solve problems, getting us increasingly out of touch with our instincts and feelings.

A final reason for mind addiction may be that women are not as well-represented in positions of leadership. So, to the extent that listening to, understanding, acknowledging, and utilizing emotions is a more feminine trait than a masculine trait, society reinforces mind addiction.

5) Mindfulness has become a very popular concept recently, and you often mention it in your work as being a habit that can support happiness. Purportedly, Maslow never published the final version of his hierarchy of needs pyramid in which self-actualization is followed by self-transcendence. Do you think that mindfulness practice might ultimately prove to be a useful tool towards self-transcendence? Or, alternatively, do you see this practice as more a simple, yet very effective, evidence-based cognitive technique to help identify that a lot of what makes us unhappy is merely a waterfall of mindless thoughts and we have more power over these than most believe?

Good question again. I personally think mindfulness has the potential to both offer the “lower order” benefit of reducing stress and enhancing happiness and the “higher order” benefit of self-transcendence. What I mean by self-transcendence (and I imagine you do too) is not something that is necessarily mystical or spiritual. Rather, it’s just the subjective experience of not perceiving oneself as separate from something that we would “normally” consider external. So, for example, when we are so involved in an activity that we lose track of time, or do not feel self-conscious (the critical voice in the back of the head is gone), we merge with the activity to experience a state that Prof. Mihaly Csikszentmihalyi has famously called “flow.” Flow is a transcendental experience in the sense that there is a subjective feeling that one has merged with the activity in which one is involved.

Likewise, being in love is self-transcendental, because one feels this sense of merging with the object of one’s love.

In a similar way, mindfulness can provide a transcendental experience — providing one is able to do it correctly, which may require practice. By “doing it correctly,” I mean doing what is often considered the main aim of mindfulness — “being aware without judgment”. Being aware without judgment means being aware from the perspective of what might be called “bare attention”. Bare attention is very different from mind attention. Mind attention is what leads us to judge, categorize, comment, etc. on whatever is going on. Bare attention, on the other hand, means just being aware of the object of one’s attention without the accompanying commentary. It is difficult to do, but can be learned through practice. Once one is able to successfully take the stance of bare attention, one experiences this transcendental sense of being merged with the object of observation, resulting in what Douglas Harding called a “headless experience”. Sam Harris describes this experience very well in his book, Waking Up, as well.

Interview with Chip Conley about Creating Joy

Chip Conley began his journey in creating “joy” by transforming a seedy motel in the Tenderloin District of San Francisco into the legendary Phoenix hotel. Under the umbrella Joie de Vivre (translated to mean: the exuberant enjoyment of life), the endeavor grew to 40 unique hotels spread across California. He has authored several books, including Emotional Equations, PEAK and The Rebel Rules. Currently Chip serves as the Head of Global Hospitality & Strategy at Airbnb and the Chief Strategy Officer of Everfest, a company that connects the festival community online.


1) Now that you have immersed yourself in the world of festivals, what are the commonalities that make these experiences so impactful and life changing? For instance, there are elements that distinguish the Rise Festival from say, an Outside Lands. What are the essential elements of exceptional festivals that set them apart from a run-of-the-mill collective experience?

There is a French sociologist named Émile Durkheim, and in 1912 he wrote about the nature of pilgrimages. He coined the expression “collective effervescence” that really describes what makes a festival different. He used this term in the context of religious pilgrimages, but I actually think a festival where you become part of the installation — in an environment where people are somewhat out of their customary social environment — that is where transformation tends to happen. When you go to a concert, generally you go there for the day and then you go somewhere else. Collective effervescence happens when your sense of ego almost evaporates and what it is replaced with is a sense of common mission, and a common connection, with other people — that’s the beauty of a festival. The more digital we get, the more ritual we need. In this context, ritual is the IRL experience vs. the URL experience. The URL experience is what we do online, IRL is “in real life,” and I think that the more we are possessed by our gadgets, the more we need to have opportunities for connection in real life. Furthermore, there is no doubt that habitat influences our behavior and what we are willing to accept. A particular festival may have a set of guiding principles (e.g. Burning Man’s 10 Principles). What is really great when a festival does have principles — and they are well-advertised and promoted — is as an attendee you know what you are getting yourself into and also what is expected of you to participate.

2) You are well known for creating physical space and visceral experiences that create joy. Like any good master, you have pulled elements from other disciplines ranging from positive psychology to physical art. What is one of the most profound lessons you have learned along the way? Perhaps one you found the most surprising about the craft of creating joy?

I have always loved throwing parties. I throw the grand opening parties for my hotels, and every five years I throw a party somewhere in the world for just my friends. I did this last year in Baja with 125 friends. It was great. I just threw a party for 20,000 people in Los Angeles for Airbnb. What would normally be considered a conference, we reimagined as a festival and broke conventional rules. This was the third event of this type for Airbnb, and this time we wanted the format to be a bit uncomfortable at first. Not uncomfortable physically, but more like the attendees did not know what they were getting themselves into. A level of curiosity like, “I do not feel like I am in a normal environment.” This level of stress can actually help people to find parts of themselves that they did not know exist. We had the event in a somewhat sketchy area of Los Angeles. There are historic, beautiful theaters that we used as part of the installation. We took over five historic theaters, we took over about seven different retail spaces, and at least three parking lots. We used this environment for workshop spaces, conversation spaces and creative spaces for people to connect. What I believe is that what is remarkable — what creates joy — is when something surprises you and then it delights you. There can be surprise and disappointment or there can be surprise and delight — when it is surprise and delight, it is unexpected. Unexpected delight is memorable. I think interesting juxtapositions do this very well. When juxtaposition is done well, our brain is literally going through a process of having to imagine two things together, for instance, art and spirituality. The blending of ideas can lead to illumination. You see something in a way you never thought of before. The best way to describe someone who is a great festival producer: they are a curator. So, you try to curate an experience, create a habitat for people to have peak experiences. When there is nice mix of unfamiliarity and you push through boundaries — joy comes with that feeling that some level of accomplishment, some level of progress, has taken place. This growth allows you to feel a sense of exhilaration.

3) In your book, The Rebel Rules, you talk about the benefit of sabbaticals to avoid burnout. For many, these opportunities will only manifest a handful of times in a lifetime. As such, in your experience examining both successful “rebels” and those with an affinity for wanderlust, have you identified any strategies for those who embark on soul-searching expeditions to help maximize their outcome?

Creating space (whatever space means in the context of some individual freedom) and seeing what emerges is pretty important. Now, you literally could do that on a weekend. You could say, “Okay, this weekend I am going to put an office message that just says: I’M NOT CHECKING EMAILS THIS WEEKEND.” You hide your phone. For two days you go digital free. You go through a digital detox and maybe you have nothing planned, you literally just allow spontaneity or serendipity to rule those two days. That process might actually start to bring some things up for you, including fear. A lot of us like structure, a lot of us like to have a calendar that is full because it lets us know, “Okay, this is what I accomplished today.” There are a lot of people that need to ‘accomplish’ things to feel alive. So, I think not everyone needs a six-month sabbatical — at least not as a first step. Even if you have the opportunity to take a sabbatical because your life has created a transition, it might be foolish to assume that you know what you are going to get out of a sabbatical. For me, my sabbatical was not really even a true sabbatical, but more along the lines of “what’s juicy for me right now?” For me it was festivals, and I started going on that path, and I went to five festivals in Asia in the winter of 2013 and came back starting Fest300. Then, all of a sudden, out of that emerged the founders of the Airbnb approaching me and saying, “we want to turn our little tech company into a hospitality company, will you help us do it?” I have been doing that for almost four years now. Sometimes you have to make space to grow; I might not have taken the call from Brian Chesky four years ago if I had not taken time for renewal. When you create space, you are in a better place to take the blinders off, which gives you the opportunity to see things you might not have seen otherwise. So making space is one strategy. A second strategy is meditation. I try to meditate twice a day if I can. That experience is my form of a daily sabbatical, because it allows me to decompress and disconnect. It does not have to be meditation — some people like taking afternoon naps, for others it is going for that four-mile run that they do every day. Whatever it is that helps you to break with the linear mind. However, there is not a prescription that is right for everybody. I think for me, knowing my tendencies, having a really open field is probably wise because if I am too prescriptive about what I want at the end of a six-month sabbatical, the end result will be a linear to-do list, which defeats the purpose. With that said, realize your sabbatical probably should be the opposite of what you normally have. For me, I need space to be open to new ideas. For someone else, they may need a sabbatical because they are so lost that the purpose of their sabbatical is more oriented around a mission or some level of achievement.

4) There can be a bit of an underbelly to festival culture, where it is purported that some that identify with this lifestyle and chase experience, do so with hedonistic self-interest. A recent example are some of the complaints coming from Standing Rock (http://www.independent.co.uk/arts-entertainment/music/news/standing-rock-north-dakota-access-pipeline-burning-man-festival-a7443266.html). In consideration that this may exist, how does contribution, responsibility and ethics factor into organizing any collective experience?

I think hedonism in moderation is appropriate, self-interest is not necessarily a bad thing. However, festivals can become an addiction, just like so many other things in life. I think one of the things that Burning Man has done quite brilliantly is creating 10 principles that define this community. The main event and other events around the world that are sanctioned to be Burning Man affiliated help this community to hold ourselves accountable when we see people not living up to them. No one is perfect of course, and the Burning Man principles are not right for every festival. The problem with a lot of festivals is they lack principles. Often when you lack principles what you get is the lowest common denominator. Without an inherent culture, you get something that takes people to their basic instincts. Getting back to your first question, I think the part that is truly beautiful is when you see that collective effervescence happen. Collective effervescence means that people are losing their sense of ego and their sense of identity and, in the process, feeling connected to something bigger than themselves. I think that if principles are articulated well, and these principles are lived out in such a way that they help people move beyond their own selfish needs (in the process of experiencing the festival), then principles have the potential to create a better legacy for the event. If an event is something that is purely hedonistic — and it is important to note that there are festivals that survive and do quite well within that environment — you diminish the ability to somehow feel like there is something bigger than your own personal, hedonistic needs. Great festivals elevate people and help people to transcend their own petty grievances and desires. A great festival is a community of people experiencing something together. So, if it’s a collection of individuals as opposed to a community of like-minded people, the risk is, if you look at Maslow’s hierarchy, pretty low on the pyramid with regards to experience. At these type of events the moment that somebody else is attracting you as an individual to something over here, or a new shiny object there, whimsy just takes you over there because you don’t feel any connection to the purpose of the event. Festivals are at their best when they really do help people to feel connected to something bigger than themselves.

So the issue you have highlighted is not a festival problem — the definition of addiction is using something as a distraction, as a means of not feeling something. Festivals can play this role. If you just constantly go to festivals because you cannot live your normal life, or live in real life and/or you are searching for a utopian experience… festivals always come to an end. If you are going to festivals as a way to vacate in some manner, I think you need to ask yourself, “What could I do in my ‘normal’ life to make it better?”

5) If someone wanted to follow in your footsteps in the pursuit of creating joy, but was at the beginning of their journey and was looking for mentorship, what three pieces of advice would you impart on them to begin acquiring the mastery to be successful in this pursuit?

1) Understanding who you were as a little kid always helps, because weirdly there are clues in your childhood that help you understand what it is that gave you that sense of timeless wonder. Timeless wonder is usually a pretty healthy place to seek out in that Joseph Campbell “follow your bliss” approach to life. So, start by doing a personal archeology project about your childhood. Talk to your friends, talk to your brothers and sisters, your parents, whoever you spent time with as a child. Look at pictures of yourself at childhood and get a sense of what it was that gave you bliss. How can you manifest that in your adult life? I was always fascinated about Walt Disney and how he created Disneyland. I was fascinated by creating experiences for kids in the neighborhood, so… I would do just that. I would create a restaurant in my mom’s dining room for instance. There are clues there — find them.

2) Look at who you admire. Who are the people out there in the world as adults who are living their life in such a way that they could be a model for you? Who is actually having joy in how they experience their life? Who is doing it in a way that gives them a sense that they are living their calling? This does not have to be just in the work world; you could live your calling as a political activist, you could live your calling as an Ironman athlete, you could live your calling as a grandmother. Figuring out what it is that gives you that sense of passion in life and seeing it in other people — this helps you develop a better picture of what life might look like for you.

3) The way to bring joy to people is helping them to feel like they are a kid again. The Celebrity Pool Toss has been going on for 25 years now — a fundraiser we do at my first hotel, The Phoenix. It is a fundraiser for TNDC’s afterschool program for kids. We have created a fundraiser based upon the high bidder getting to toss a celebrity in the swimming pool of the hotel. The reason that it has lived for 25 years now — raising over $7 million for afterschool programs — is because it allows people to act like a kid. Auctions are a bit fun too, but the process of actually throwing someone in the pool is very childlike. I think providing people that sense of being able to break out of their normal formality — helping people feel less contained. Burning Man is a somewhat extreme example. Getting the chance to toss people in the pool is a very simple example, but still effective of reconnecting with a sense of freedom that might have gotten lost in adulthood.

A word of caution for those looking to create an event. Some people find joy in being spectators, others in being participants. Some events are better suited for everybody to be a participant, some are suited for some people to be participants and some to spectate. I think a key to success is to make sure people know what they are opting in for. So, if you are creating an event with the aim of creating joy — if your idea centers around everybody participating, you better make sure the attendees know that in advance.

Interview at the Motionsoft Technology Summit about Big Data

This quarter’s Business, Innovation and Entrepreneurship interview is the compilation of getting to discuss “big data” analytics with four exceptional thought leaders at the Motionsoft Technology Summit this year (2016). These four gentlemen in no particular order are: Jafar Adibi, Ph.D., the President, Co-founder, and CTO of re|unify; Jeffrey Cooper, the Senior Manager of Business Development at Samsung; Mark Newman, the President of Heads Up Analytics, and Keith Catanzano, a Partner at 2River Consulting Group. The answers below are summations of their respective answers, as such they are not represented as verbatim but edited for readability and context.


1) When a company is either building a data model (or working with a third party for this type of service), what considerations should an operator have regarding the crossroad of complexity and usability?  There are scenarios where too many disparate and incomplete data sets can make it difficult to find the signal from the noise; what are the trade-offs as the amount of available business intelligence information continues to increase? And what considerations should we take into account to maximize any investment in mining data?

[Jafar Adibi]: You need to figure out what problem you are trying to solve. Clients will come to me with data, rich sets of data, and say, “Jafar, now go figure out something to do. Find something interesting.” Generally, this is a waste of time. People believe finding correlations (any correlations) are going to help their business, but that is often not the case. When you identify your problem, we are better set up to solve it. There are different analytic methods for classification problems, association problems, and other questions that are not necessarily answered through correlative means. Getting to the right question will help you establish what data sets are important.

Then you need to figure out your budget. There will always be noise in your data, especially data from business intelligence. We can build a model to take the noise into consideration. However, using more data is obviously expensive, so that goes back to what are you trying to solve for. We can exclude data that will not answer your question, which saves you time and money. As such, you want to keep return on investment (ROI) in mind as you think about the question you are asking. Ask yourself, “If I answer this question, how much money with I gain/save?” The answer to the ROI question gives you a ballpark on what it might be worth regarding your investment in a data model.

2) It seems to me that a lot of ad hoc advice about using data for business intelligence is disseminated on broad-based assumptions derived from general population data. However, is this not one of the follies of “Big Data”? Companies are basing important decisions on arguably misleading benchmarks, rather than creating a narrative specific to their population (or at least a sample from their specific population); What are strategies to ensure we are making the best decision based on our company’s unique attributes?

[Mark Newman]: The most important thing is to trust your own expertise. You should intuitively know the customers you are trying to attract. You should have an idea of what strategies you are trying to pursue. You should already know what the important problems are you need to solve. What you don’t want to do is look to data to validate some preconceived answer to your problem. Instead, you want to devote your own educated guesses as to what to do — and then you want to use data to test those rigorously to keep yourself honest.

I think there are two ingredients to doing that. The first is to agree with your colleagues on the definitions of the terms that you are using in your data. If all the stakeholders do not agree on the definition of the numbers, then you all are not going to have an organized lexicon/narrative to work with. You have to agree on key metrics that you are going to use to allow for the monitoring of health and progress within your organization.

The second ingredient that you want to have is to follow an experimental approach that is constantly evolving. Your customers and prospects are going to react differently to your products and services over time. Reasons:

  • They might have more experience with you as your brand matures
  • As consumer groups mature, they change their goals
  • Your previous pitches are now stale, and customers react to them differently
  • Different competitors in the marketplace

What works today does not work tomorrow. Instead of some one-and-done, super solution to what you are trying to accomplish — instead you want to have some kind of innovative, incremental approach in the beginning. If you follow that, then over time, the data is going to have a narrative that reflects who you are, and what you are trying to do, and what works best for you.

3) Until recently, most data aggregation efforts have told a fairly unsophisticated narrative, and inspired relatively unremarkable initiatives in an effort to capitalize on data mining. How can we improve our use of data? And, how can companies do better at making data more actionable?

[Keith Catanzano]: What is the question the company is trying to answer? It is important to not just say, “How do you make data actionable?” We are probably all guilty at some point of looking at a data model and saying, “Look at the results, they’re awesome!” I think intriguing insights can be challenging in terms of making data actionable. There is a ton of data out there. Once you find ways to bring yours together, there is a lot you can see using data by way of insights. At some point you need to do something with the insights. In order to do that, obviously, it’s important to know who your customers are [assuming trying to influence their behavior is your goal], but also why are they customers. However, in this use case the why is more important than the who. The “why” is ultimately what you are going to try to make actionable, because to take action you are going to need to pull some type of lever to influence consumer behavior. There are lots of ways to work with communication or outreach in an attempt to accomplish this, but the effort requires the company to take a deliberate approach regarding how data is used to take action.

It is also important to note that making data actionable is generally not a one-shot deal, and architecting a campaign that changes an entire group’s behavior in some way probably will take a series of events that includes multiple levers I mentioned. So to make data more actionable, an organization should sit down and say, “What is the level of energy I want to put into solving or addressing this problem?” And that’s probably both a financial decision and a brand decision. For instance, a brand manager might ask, “Is this the kind of consumer group that we want to continue to attract? Yes; OK, well … indicators show we may be struggling with this particular group, so let’s double down because from a brand perspective, that’s how we want to be seen.” An alternative scenario here is the data suggests (to the brand manager) that too much effort is being spent focusing on the wrong group. Without asking the right questions, the data just suggests that marketing is ineffective. To finish, a company really needs shared responsibility to make data truly actionable. Ultimately, as an organization you determine what resources you want to put against data analytics, but knowing what question(s) you wanted answered first is important to making data actionable.

4) How will health club and health club member data evolve over the next several years — what will prove to be important signals for our industry in addition to financial, transactional and activity data?

[Jeffery Cooper]: So besides activity data from wearables, there will be a lot of contextual data the health clubs can now potentially get. With corporate wellness taking off you are going to see deep integration with insurance companies and insurance data. I believe, along those lines, health clubs will also be integrated more with the medical industry. As prevention becomes more associated with a basic level of fitness, I believe you will see medical data become relevant.

In that regard, I think prevention of chronic diseases is eventually going to drive a lot of people toward health clubs from the medical side of things. Right now, in most cases, doctors cannot write a prescription for a health club, but that could change as more complex sensors begin to validate the efficacy of fitness interventions.

Genomics data is another revolutionary area. You already have things like 23andMe, but there is a company Helix, which has been recently funded. Their idea is to sequence your genes, and license this data back through health care providers and fitness applications. With genomic data, consumers can make better choices (and health clubs can cater to them better). With this data, people can ask:

  • Am I suited for bodybuilding?
  • Am I suited for endurance?
  • From the limited time I have, where am I going to see the best results?

As science becomes more advanced, these companies will snapshot your genome once, and then as the science learns more and more about the genome — health clubs can take preemptive, proactive actions from that data to keep their members healthier longer, keep them out of the hospital and improve their overall quality of life.

5) Why does “Big Data” often fall short on delivering on its value promise?

[Mark Newman]: Personally, I feel that part of the problem is the way output data get reported. I feel that in data science to deliver a static report, it is potentially a sign that we have not done our job properly. The reason for that is because when we deliver a page of numbers, there is often no context to the end-user. When you are able to create/refine a business question, you generally make the presumptive problem simpler than it first appeared. Before you set off looking to get value from data, your organization should come up with your desired thresholds and metrics. Then instead of looking at static reports that, at best, will give you trailing indicators — build a dashboard that gives you real-time intelligence based on the most important metrics for your business. This dashboard should be something that your employees can always go to — not just some report that gets delivered on your desk — but something that is readily available on an ongoing basis. You also need to evaluate and monitor the efficacy of this dashboard on an ongoing basis. For instance, if you have a forecasting dashboard and there is a forecast your company is trying to meet, is the dashboard valuable and helping you meet your forecast?

I believe both dashboards that monitor things that drive your business forward, as well as insights that are actionable, are at least two things that give you some evaluation of whether “Big Data” is helpful and valuable within the context of your own particular situation. The other thing is that you really want to be doing analyses all the time. You want your data strategy to evolve past sending out graphs and numbers — to actually be working to build a story of what’s going on in your organization — and back up your story with reliable and meaningful communication so every stakeholder is seeing the same thing and you can all agree that your chosen data model(s) is providing value and is meaningful within the context of your particular business.

Interview with Dr. Henry DePhillips about Telemedicine

Dr. Henry DePhillips is the Chief Medical Officer of Teladoc. At Teladoc, Dr. DePhillips is responsible for maintaining the exceptional delivery of clinical care delivered through Teladoc’s telemedicine digital health platform. Prior to Teladoc, Dr. DePhillips held several high-level leadership positions in health care. His positions included a previous role as the Chief Medical Officer at MEDecision, working as the Senior Medical Director at Independence Blue Cross of Pennsylvania, and a role as Head of Business Development, North America for McKinsey’s international Health Systems Institute. Dr. DePhillips is a health technology fanatic who is passionate about telemedicine and shifting health care from a provider-centric model to one that better values the needs of the patient.


1) How do you see telemedicine affecting employee burnout and workplace wellness?

What I am seeing is that telemedicine provides employees quick and inexpensive access to services that contribute to their well-being. Employees also generally perceive the telemedicine experience as more enjoyable than traveling to see a physician. Employees like what we provide, so our service grows as it is better understood by employees. When people get the care they need in a timely manner, this reduces workplace wellness issues — concerns like presenteeism — because employees now have easy access to care rather than “powering through” health conditions that could have unwanted consequences if ignored.  These consequences range from getting other employees sick to compounding personal medical issues by not seeking treatment.

2) What are some of the aspects of American work culture you see uniquely contributing to issues of presenteeism and employees “powering through” illness?

There is a combination of cultural factors here in the United States. One is financial, many American employees can no longer afford to miss a day of work. A second is functional. In many U.S. companies that have downsized staff, if someone misses work then there is no longer anyone to cover their role/position — calling in sick is simply not an option. A third is cultural considerations. In America it is a sign of toughness and/or commitment if an employee powers through their illness. For instance, it can be viewed as a “badge of courage” if you come in with the flu. Lastly, there are logistical considerations. In many cases when someone should see a doctor, they are unable to do so because scheduling is difficult given other considerations. This last factor is where I see services like Teladoc playing an important role. With telemedicine it is no longer a burden to see a doctor. With the traditional approach you generally must take time off work, schedule an appointment, travel from work to see your physician. Now, if an employee is in need of care, it is as close as their keyboard or mobile phone. An experience that used to be three to four hours can now be accomplished in 30 minutes with telemedicine — and unless you need to pick up a prescription, your experience can all take place in a virtual environment of your choosing.

3) How do you see telemedicine playing a role in helping improve the patient experience?

With Teladoc you can update your electronic medical record in minutes, request a board-certified physician to meet with you at a time that works with your schedule, interact with your physician using the digital modality of your choice (phone, video conferencing, digital photos, etc.), and have prescriptions sent to a location that is convenient for you. In my opinion, it is simply a better experience.

4) There are reports that over 15 million people now use telehealth, which is a 50 percent increase in usage from numbers reported in 2013. Who is driving this growth?

Telemedicine is still perceived as a rather new way of receiving care, so we have plenty of early adopters (now) but you are going to see increased utilization blossom as we move into the early majority. Those that would rather take a conservative/traditional approach will likely become more open to telemedicine as the technology matures. “Try it once, and you will like it for life,” really applies to our technology. We see that once users try it once they often return, at least here at Teladoc. In certain populations it is a no brainer — single parents with kids, those that travel for business — again anyone with logistical considerations will likely become lifelong users once they try it once.

5) Why do you think there is a significant proportion of physicians that have an aversion to telemedicine?

It is an evolution. It is a work in progress. Health care as an industry tends to be fairly conservative when it comes to technology. Think back to the Marcus Welby, M.D. days and we have not evolved much since then in regards to care. Health care is still a very provider-centric experience. The provider tells you the times that work for them, you go to the provider’s place of practice, the provider basically makes you adhere to what is convenient for the provider. I see telemedicine as the first major shift towards a consumer-centric approach. Under the current antiquated paradigm, a patient has to say, “I am sick, where must I go to receive care?” However, with telemedicine the patient can now ask, “I am sick, how can I most efficiently get the care I need?” And now, care is as close as the smartphone sitting on the bed stand. The doctor now comes to you, at a time convenient for you. At Teladoc, the average time between requesting a visit and being able to see a physician is 10 minutes. My job as the CMO of Teladoc is to make sure that the quality of care that people expect [from the old model] is the best it possibly can be [in the new model] as we go through this evolution. It is important to note, telemedicine is meant to address a subset of medical problems that has been specifically selected to work with telecare, problems that can be accurately and successfully treated using this form. In most cases I believe telemedicine will provide the end-user a superior experience, but there are going to be some specialties where telemedicine doesn’t make sense, and that is okay too.

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.

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.