Matthew Holt is the eccentric Co-Chairman of the Health 2.0 Conference. Before helping launch the Health 2.0 movement, Matt was a survey researcher at Harris Interactive, as well as being involved with the Institute for the Future. In 2003, he started The Health Care Blog, one of the first blogs of its kind to specifically address the trials and tribulations of health care. Matt has an undergraduate degree from the University of Cambridge and a Master of Science degree in Health Services Research from Stanford University.
1) Often great innovation is figuring out what will not change over time (in contrast to being “disruptive”). In that spirit, what are three commonalities of companies/innovators that you have seen have successful longevity in the health technology space?
One, companies that have developed for the inpatient side of the hospital and grow from there. Put more broadly, you need to get embedded properly in an organization, which does not change dramatically over time and is willing to adopt you. The two obvious examples are Neil Patterson with Cerner and Judy Faulkner with Epic. The industry on this side of things does not move that fast, so if you are lucky enough to get your foot in the door, your company is inherently going to have longevity. Getting the timing right is very important as well.
Two, the need for care is not going away, so companies that make care more accessible. I believe telehealth will have longevity for this reason. Teladoc has been around 15 years, MDLive has been around at least a decade. These companies have longevity because they have an expansive model, which works for health plans, pharmacy chains, providers as well as direct-to-consumer. Provide a solution to a long-standing problem, and you should do relatively well.
Three, companies that build broad-based platforms. Additionally, you need to figure out your user interface and experience so it is good enough that a lot of people adopt it. Companies that build quality technology to track activity, diet and other lifestyle choices [like the companies Under Armour scooped up in this space] are good examples.
2) Insurers are starting to fund the tracking of consumer consumption of healthy activities that support personal well-being (e.g. United/Fitbit, Aetna/Apple, etc). How do you see this flow of capital effecting consumer health technology in the foreseeable future?
The good and bad reality of this situation is that as a consumer product good, health wearables are getting so cheap they are becoming ubiquitous; however, they are also getting commoditized. The commitment is low — similar to a gym membership — and like a gym membership, you see a lot of drop off after the initial purchase.
Insurers are getting involved because the costs of entry are lower and they are looking for any way to motivate us — if even by a nudge — toward healthier behaviors. There is discourse in the wellness space if this stuff actually makes a difference. That said, this trend is a win for most in the chain. Manufacturers sell more devices, payers are not investing much and get to see if this moves the needle, employers get to say they are doing something, and employees get these devices for next to nothing. In short, I agree it’s a trend. I think that we’ll see more of this kind of stuff as we try to figure it out whether there are real rewards to tracking behavior beyond professional athletes and peak performers and condition-specific wearables, where I believe there is enough evidence to make the assertion that wearables add a lot of value.
3) Currently, there are unprecedented health technology advancements (e.g. CRISPR) that have the potential to significantly accelerate human evolution. In this context, how do you believe health technology will redefine what it means to be human over the next generation?
This is a question better suited for Daniel Kraft, but I’ll give it a try. I always used to joke that I thought that the future of health care was when most people could email their doctor, which many of us still cannot do effectively yet we want to move on to cure Cancer and using Big Data.
Let’s start that we know that if we exercise and eat better, that’s half the battle. I have little doubt that eventually technology is going to make that easier, better, faster and make it more effortless. In that sense, the construct of willpower might change.
It is important to consider how this technology is affecting our environments, too. It is changing how we think about providing service to people. Something as simple as improving food portability could help change our eating habits for the better. Maybe CRISPR can change your genetics so that sugar tastes bad. Who knows?
The next generation will see us aiming at improving the impact and efficacy of drugs on diseases by manipulating the drugs and/or the genome to improve outcomes. At some point we might start designing humans to avoid disease all together and to live longer, but that will be a while. For those interested in that, I recommend checking out Aubrey de Grey’s stuff. He outlines eight things we need to fix to make this happen. It is worth watching if this topic interests you.
4) There have been a lot of digital health products that purport they can change user behavior. However, history suggests that many of these products and services have overpromised and under-delivered on their claims. What is a good example of a company getting it right in the “behavior change” genre, and what can we learn from them?
Companies that are doing this well have pervasive mechanisms for compliance. Medisafe is one that I like in this area. Good companies look at deliberately getting you from X to Y. However, some areas are hard. For instance, nutrition is particularly hard, and even with great technology, the truth is people just do not keep up with that type of change because technology has not solved the problem that some behavior change is hard.
That said, technology around cognitive behavior therapy treatments — treating things like anxiety, depression, PTSD and insomnia — seem to be making headway. A British company called Big Health has come out with a program called Sleepio that is really interesting.
Canary Health is also another interesting example. They have created technology to bring Kate Lorig’s work on self-management to a broader audience, and that has helped people with diabetes change their lives for the better — so there are examples of success in this space.
5) What is the last thing you remember regarding Health 2.0 that made you sincerely say to yourself, “this changes everything” and why?
Okay, I am going to steal my answer here from Indu Subaiya. It is the advancements in Google Home and Amazon’s Alexa in combination with FHIR. This is really exciting her.
If you split up the various layers of interoperability — and say maybe voice is the first layer — FHIR can then get into the data and stick it in to any functional layer you want. In fact, FHIR (if it works), may actually change how we deliver care and how patients experience care.
That’s the big picture excitement. Small picture, there’s a real cool company called Medal we had on last year, which figured out how you get data out of a EMR by basically printing it using the print driver from a standard computer. Super clever idea, totally bypassing the need for APIs. One more, which was shown this year, is a company called Suggestic. They have got this super cool augmented reality, where you hold your phone up over a menu and it makes you aware of the things you can and cannot have based on your dietary restrictions.
Steven Groves is the CIO of GoodLife Fitness, the largest fitness provider in Canada (and the fifth-largest fitness provider in the world). In addition to this role, Steve also spent more than 11 years on the Board of Directors of London Bridge Child Care Services, recognized throughout North America as a leader in the area of non-profit early childhood education. He was recently recognized by Forbes as one of the Top 20 Social CIOs.
1) If you had a magic wand and could improve a way technology is being misused in health clubs today, what would it be and why?
I think at this point, my perception is that we are not focused enough on a holistic view of the member beyond the four walls of our own clubs. I do not think we are necessarily misusing technology. Rather, the focus has been too much on technology that can be used exclusively to advance our clubs’ agenda, which is different than looking at technology for the betterment of our members — whether or not they choose to do some of their activities inside of our clubs or outside of our clubs.
When some of the first wearables came into our industry, things like the bodybugg — back whenever that was — bodybugg was intend to be worn predominantly outside of the club. Ironically, many probably took it off to work out because it was clunky. It seems to me as though — we as an industry —are not really focused enough on the overall outcomes that our members are looking for. We could be better at helping them with the selection of the right technology to get the results they’re paying us for. The truth is this technology is not necessarily going to be specifically aligned with improving what is happening within the four walls of our club.
2) There is a growing acknowledgement in our industry that we need to be better at catering to a wider spectrum of consumer types, e.g. age groups, aspiration types, gender differences, etc. This is in contrast to prescribing a “one size fits all”offering. How have you seen technology most amply and effectively applied to help support this effort?
One example is ResMed. They are a medical company. My understanding is they are one of the largest manufacturers of CPAP devices. They have also created bedside devices. Being the experts in sleep, they have created this bedside device that uses sonar-style technology, and the device passively monitors your sleep activity. Previous versions of sleep monitoring devices were either uncomfortable or [the new ones] do not work that well. So what ResMed did is devised this device that sits there and it monitors your sleep: it monitors your breathing, it monitors the temperature of the room, it monitors sound levels in the room … it can basically see your body in the dark. The signal from the device is bouncing off the water in your body and can pass through everything else, so it can actually see right through your blankets, any material you might have on top of you. I could not believe how accurate this thing is … from your phone you get this wave pattern that is reflective of exactly your breathing pattern.
So ResMed, having such a massive data set that they have collected about how people sleep, by their claim, can accurately predict when you’re in light sleep, when you’re in deep sleep, when you’re in REM sleep, when you’re actually awake. And then the device picks up on a whole bunch of other pieces of information around the environment that you are sleeping in. So there’s the noise level, and room temperature, and maybe one or two more data points. From a personalization standpoint, coming back to your question, what I found was most interesting is that after it learned about your sleep patterns for a week, it starts to get prescriptive. It asks you an eight-question survey each day. How much caffeine did you have today? How much alcohol did you have today? Etc. Then it starts to prescribe ways to improve.For instance, it started creating for me — clearly, very unique to my own personal situation — it was the first true prescription that I have seen that was catering to my own personal unique needs. This is circumventing the spectrum all together; this is catered to the individual.
3) What can United States club operators learn from our Neighbors to the North? Where are areas of difference that Canadian clubs get right and the United Statesmaybe could do better?
It may be a naïve perspective, because honestly I do not spend a lot of time within U.S. club operations, but my sense is that U.S. operators have the luxury of having so many other competitors and peers within the country — in other words, the sheer number of clubs is massive — that I don’t think U.S. operators necessarily feel the need to look outside of the Americas, or let’s say North America even, for ideas and new ways of doing things. I get a sense that your market is very insulated in that way.
Whereas in Canada, we are small — especially here at GoodLife — we do not really have any peers in the country. The second-largest club chain in the country is also ours, Fit4Less. What we do, and I think we do quite well, is work with a lot of club operators globally. We have really benefited from some of the learnings that we have gathered from people in Europe and Asia — in particular Australia.
This may be an unfair assessment — a naïve assessment. However, I get the sense the U.S. market is a bit of an echo chamber.There is a lot that we can learn from other operators from the East, and from others in the West. I get the sense in the United States there is a feeling that you do not need to necessarily go outside your country’s boundaries for ideas. If true, that is limiting.
4) Discourse about data “interoperability”in the health club industry has almost boiled over, and the concept of data interoperability means different things to different operators and CIOs. What does it mean to you and why (or why not) is interoperability in our industry important?
I want to deal with technology I can plugin to a system and have it functionally do what I want. I like the software IFTTT. I think in the case of IFTTT, they call this type of flow “channels.” I want to be able to take hardware and software — ranging for IoT and SaaS platforms — and feel confident anything that will be useful to the clubs and/or our members can be channeled, plugging into a workflow management system I control.
I want the same easeI use IFTTT to get my Nest thermostat to report that my living room is over 80 degrees through a text message sent to my mobile phone — I want this ease of integration with the technology I use to run our clubs.
So when people say to me, “What does interoperabilitymean to you?” I use that as an example just to get them thinking about it. If a new member rides a piece of Life Fitness cardio equipment — they jump on one of our bikes — and it is the first time that they’ve been on that bike, and they’ve tapped their RFID to acknowledge they’re on the bike (so we know it’s them) I want to be able to have that trigger fire an event somewhere. For example, the trigger goes to a CRM platform that fires off a quick email giving them tips on that particular piece of equipment, and how they should be using it properly and safely … a simple recipe to enhance the member experience.
If I can start to get you to understand IFTTT, then I can start talking to you about and Enterprise Services Bus, and the integration of APIs, and having an open API architecture. So many of the APIs in our industry do not expose even 30 percent of the features and functionality of the actual UX of the system. This is frustrating, because I do not always want to have to use the UX of the platform that we purchase, and in many cases we as technology experts arrogantly think we can do better, and so we really want to write something ourselves. The current state of affairs is limiting. We end up having to write our own APIs in a lot of cases, just to create an abstraction layer. Salesforce and Amazon Web Services built their products with an API integration strategy top of mind, then theyadded the UX/UI layer. The fact that much of the technology in our industry was built the opposite way just shows a level of immaturity that our industry still has.
5) In your opinion, what is your favorite underappreciated and/or unknown health club technological addition? An uncommon product or service that almost always results in a significant return on investment for the club that adopts it.
ShapeLog is intriguing for me in this regard. I found out about ShapeLog through the Fitness Industry Technology Council podcast that Josh Trent does. I had never heard of it before, and quite frankly I have not heard of anybody else talk about it since. It is a fairly simple technology in that it is a device that you mount on the cable of selector equipment — the pulley equipment that we all have in our clubs — and what it does is it is able to measure the tension that’s being applied to the cable as the weight is being lifted off by the user.
It’s able to measure the tension, and from that it is able to calculate how much weight you’re lifting. Which in and of itself is kind of cool, then wirelessly they can send that information, so that it displays on your device. They are effectively able to record your workout. The part that really intrigued me was the fact that how you and I lift weight is unique to each of us, and apparently is almost as unique as our own fingerprints. What this product is doing is capturing 100 pieces of data per second — I believe that is the number they had given us in the demo — through native accelerometers and tension monitoring. The device creates a unique pattern of my lifting and lowering of the weight and stores this information in its database. Now, the next time I sit down and I do my next set of reps, it knows that that was me, and so it is actually able to track my workouts without me having to go up and log in, or tap an RFID chip onto the equipment. It eliminates a set in the identification process, making the ability to track less invasive and more passive.
If you read my newsletter, you are aware that the past two years have been a bit challenging for me in some respects. I have gone from being an avid long distance runner to now walking with a limp. My care up until recently was with one of the biggest integrated managed care consortiums in the United States. Unfortunately, in my case, working with them has been a disaster, and I am now shopping for a better way to treat my condition. However, that is not what this post is about. I am sharing it because my personal trials and tribulations treating a painful hip created the impetus for exploring a direr situation — a situation on which I believe my eclectic professional experience with UX and healthcare gives me a unique point of view.
There are pros and cons, strengthens and weak points, within any complex system — the healthcare system is no exception. When weak points are not looked at critically, that is when we can run into serious problems.
A National Emergency
In 2013, a group of scientists from the Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Stanford University and Mayo Foundation for Medical Education and Research provided hard evidence that something was not right with the opioid prescription rates in the United States. When they analyzed the prescription rates of opioid and non-opioid therapy for non-cancer pain in the period between 2000 and 2010, their data revealed some interesting trends. Although patients’ reports of pain remained unchanged in this period (pain was the main cause for one fifth of all visits to a doctor), opioid use nearly doubled (it went from 11.3 percent to 19.6 percent). Just as intriguing was their finding that the use of non-opioid pharmaceuticals did not follow the same trend. Only opioids were on the rise. Researchers struggled to find any association with patient, physician or practice characteristics that could explain the increase (Daubresse et al., 2013).
Leonard Paulozzi and his colleagues from the Centers for Disease Control and Prevention (CDC) cite even gloomier figures. They report that the sale of prescription opioid drugs keeps increasing; in fact, they quadrupled in the period between 1999 and 2010. In 2010, enough opioids were prescribed to medicate every adult American for a month (Paulozzi, Jones, Mack, & Rudd, 2011). To the best of my knowledge, this data has not improved in the past couple of years. The issue became so widely recognized that in 2014, a White House Summit was held to address the impact of opioids on American society (Clarke, Skoufalos, & Scranton, 2016), and just a couple weeks ago President Trump acknowledged that the opioid crisis is a national emergency.
Furthermore, the opioid epidemic has led to a significant increase in addictions, drug overdoses and deaths among Americans. To put this in perspective, the number of deaths from drug overdoses is now approaching the number of road deaths per annum. More people are dying of opioid poisoning than “street drugs,” drugs like cocaine and heroin (Paulozzi, Budnitz,& Xi, 2006). Many health experts are warning that this epidemic is worsening. The current state of affairs is having a grave impact on public health and safety, not to mention the financial burden it is putting on health insurance (estimated at $72.5 billion per year as reported by the National Drug Intelligence Centre).
Many health professionals offer strategies on how to better manage pain and minimize the risks of opioid overuse and misuse. However, we should not forget the fact that the number of patients experiencing pain has remained about the same over the past decade. Nonetheless, opioid prescriptions have been increasing. Why is that?
Hard Pill to Swallow: Is Patient-centered Design Part of the Problem?
I have built a reputation for my expertise on user experience and healthcare. A significant portion of my working hours is spent innovating ways to improve the satisfaction, engagement and fun end users have with digital health products and various fitness consumption modalities. While getting my Ph.D., I also did a lot of practicum work assisting physicians with employee burnout protocols (through an affiliation with a hospital group in the Bay Area; important to note, it is not the same group mentioned at the beginning of this post). During my work as a doctoral candidate on physician burnout, after malpractice lawsuits, the number one thing I heard that contributed to physician burnout was the cognitive burden a company called Press Ganey put on this particular physician group. If you are not familiar with Press Ganey, they are one of largest companies in the “patient satisfaction” business and their purported “mission” is to “support health care providers in understanding and improving the entire patient experience.” Simply put, they collect patient feedback data on doctors, and many times these assessments are tied to a physician’s livelihood.
More and more doctors and health experts have been recognizing that the increase in opioid use is correlating with the increasing emphasis on patient satisfaction. This might seem paradoxical at first (it did to me; after all, design thinking and great UX is about empathy and making the end user happy, right?), but it actually makes a lot of sense once you look at the facts at a macro level. Jenice Clark and Alexis Skoufalos of Thomas Jefferson University, Philadephia, and Dr. Richard Scranton of Pacira Pharmaceuticals conclude their article on the opioid epidemic in America with an insightful opinion from an expert panel:
It takes mere seconds for a primary care physician to write a prescription for an opiate; it takes 30 minutes to explain why he/she is unwilling to do so. (Clark, Skoufalos, & Scranton, 2016, p. S-7)
After digging further, I found patient satisfaction data now also gets reported via the HCAHPS survey. This is becoming a widely used healthcare quality metric. In fact, it is becoming the national standard for collecting the “patient experience” — so much so, scores from these surveys are starting to be incorporated into calculating reimbursements. In other words, in these cases, happy, drugged up patients indirectly mean more resources for a physician’s practice. Although patient satisfaction is a very subjective metric, it is used quantitatively to evaluate and compare physicians and determine financial compensation, job retention and promotions.
Are There Cases Where Grading UX Should Not Be Measured by the User?
Some experts warn that the “positive patient experience” is not necessarily linked to better health outcomes either. For example, in an article titled The Cost of Satisfaction, Joshua Fenton of University of California, Davis and his colleagues found that patient satisfaction was linked to:
Their nationally representative sample showed that satisfied patients did not necessarily fare better when compared to those that left their doctor’s office less satisfied. The rub: they are actually more likely to die!
Furthermore, studies show that patients often ask for services that are not clinically indicated. For instance, Kravitz et al. (2005) found that patients’ requests have a big effect on physicians prescribing antidepressants. Also, physicians whose patient rating affects their livelihood are more likely to budge and agree to patient requests (Pham et al., 2009). Patients expect their demands to be met. If unsatisfied, patients often now have a direct lever to affect a physician’s livelihood.
I Would Like the Credit, but I am Not the First to Stumble Upon This
Aleksandra Zgierska, Michael Miller and David Rabago of the University of Wisconsin-Madison, Madison (2012) believe that patient satisfaction surveys are generally a helpful initiative and can be a driver of positive change. However, they can also contribute to the prescription of addictive medications such as opioids.
When looking at these “patient satisfaction” instruments critically, you will often find the first question on the survey is an enquiry if you were satisfied with the way your doctor treated your pain. Since modern day primary care physicians experience time pressures, time-consuming discussions on alternatives to opioids are not necessarily promoted (for more on the burdens of modern healthcare, see my interview with Matthew Heineman about healthcare in America). When faced with high patient volumes and demands for interventions, it can be easier for doctors to simply write a prescription. In this way, the patient often leaves the (brief) office visit initially happy.
After working with burnt out physicians for several years now, I have an immense amount of empathy for this employee group. As such, it is very important to note that the harm here is not just to patients. As Zgierska, Miller and Rabago warn, these practices also can leave clinicians in emotional and moral distress. In fact, it is likely that the opioid epidemic is a silent yet significant factor in the explosion of cases of physician burnout. When you peel it back, it really is becoming a no-win situation for everyone.
When Great UX Gets in the Way of Great Outcomes
In my case, I likely need a hip replacement, but the integrated managed care consortium I was a part of does not like to perform replacements on people under 50 — especially males. Why? Although younger candidates have better surgical outcomes, this group (my strata) also has higher readmission outcomes. Having to get a second hip replacement is a more complex procedure and often has much graver outcomes than an initial replacement.
The most egregious aspect for me was that even though this consortium was impeding my effort to get better, the medical staff would still ask about my activity level during every office visit (by way of the worn out script of their rudimentary health risk assessment, affirming to me there was no real understanding of my condition). I’d have to inform them every time I was there because I would love to be more active. Instead of ever really developing a path forward, I’d routinely leave with a prescription for NSAIDs and/or opioids. It was more advantageous for them to keep their costs down and alleviate my symptoms than address the problem.
When I started to complain to other colleagues in healthcare, I quickly realized this is the elephant in the room. The over-prescribing of opioids is additionally concerning when many suggest that long-term use for chronic, non-malignant pain has more cons than pros. It brings many side effects, including gastrointestinal issues, confusion, respiratory problems and increased risk of infections and tumor growth (Clarke, Skoufalos, & Scranton, 2016). Inappropriate prescribing also means that more drugs become available to the general public through black markets, leading to further abuse and addictions. Ultimately, I have now stopped taking all prescribed painkillers and just suffer through the pain until I can treat the condition and not the symptoms. My current UX is terrible but at least I’m not a dope.
Do You Want Great UX, Or Do You Want Great Healthcare?
When it comes to improving the quality of care in our hospitals, I am not attempting to marginalize that pain assessment and pain management are two important standards. However, patient satisfaction — originally designed to promote quality of care — has in some cases undermined the principles of good medicine. This may sound contrarian from someone who generally advocates for patients to become the smartest person in the room about their particular condition, but maybe some decisions should be left to the people most qualified to make them. We need to foster systems that afford doctors the luxury of treating conditions and not simply addressing symptoms.
Instant gratification has its place, and it is natural to want to avoid discomfort. However, in this particular narrative, it is not a good replacement for legitimate treatment options. The current system is rigged to make you sicker. That has got to change, especially in cases like mine where there are better treatment options. Great UX is not always in the user’s best interest. In fact, as this post outlines, it can lead to many ill effects — on a personal, national and global level.
I hope your summer is off to a great start and you are finding your way to having tons of fun. I am starting to really enjoy further deconstructing the topic of fun. Seneca said, “we suffer more in imagination than in reality,” which is likely true. However, I believe we can make a case that we enjoy more contentment in imagination than in reality, too. So, if it is true that contentment is subjective (academics acknowledge this by measuring happiness through subjective well-being instruments), then a strong case can be made for the benefits of architecting a life through positional economics and taking measures to increase one’s prospects to engage in fun opportunities. In an attempt to practice what I preach, the family and I have made the decision to move from California to North Carolina — freeing up some resources for more life experience and (hopefully) more fun. Time will tell if we feel like the reward (opportunities for fun) outweighed the risk (loss of existing support systems).
More on that in future editions; for now, here are some more great interviews with two modern pioneers in digital health.
Business, Innovation and Entrepreneurship: This quarter, we look at the entrepreneurial side of digital health with Ryan Tarzy. Ryan is the current director of the Incubation Studio at CoverMyMeds. Before this position, he served as SVP of Business Development for PokitDok and has co-founded two companies, Medikeeper and Playful Bee. The interview with Ryan Tarzy about digital health can be found here.
Health and Wellness: This quarter’s health and wellness interview is with Daniel Freedman about virtual fitness. Daniel originally co-founded CyecureBox, a successful cyber security tool. He has since gone on to focus his efforts on the development of his new company BurnAlong — a virtual fitness startup that aims to help people find the time to exercise. The interview with Daniel Freedman about virtual fitness can be found here.
Life Experience: This quarter, I got to experience Lightning in a Bottle. It is an unbelievable festival with stunning art, good music, and lots of great educational sessions. I got to meet and learn from Dr. Jack Kreindler (@drjackUK) and Dr. Adam Gazzaley (@adamgazz) while partaking in some shenanigans with good friends and enjoying the scenic setting of California’s Central Coast.
Contribution: I was able to donate time, as well as money, this quarter. Through TECHquality, I helped improve the gender gap in digital health by mentoring a co-founder of the company Cleanopy. I also donated to former interviewee Jeff Atkinson’s son during his Tour de Pier effort, as well as donated a car to the East Bay SPCA.
It is the anniversary of my brother’s passing. Brian left a legacy through amazing memories with quality friends — a testament to the value of making time to enjoy and experience life. I believe he would be proud of the direction I have taken this endeavor and the directive to focus on fun for a while. His life is certainly a reminder to make the most of the time we have. My hope is to honor him by making sure I maximize people’s ability to have fun with the short time we have been given. The next edition will mark 10 years of this project. It has been quite a journey so far, and I look forward to it being a lot more fun as we continue on. I’m grateful that you are a part of it.
Daniel Freedman graduated from the London School of Economics (LSE). He started his career as a journalist and worked for several publications, including the Wall Street Journal and Forbes. He contributed to the bestseller “The Black Banners,” a book about Sept. 11 and the United States’ war with al-Qaeda that was published in 2012. Freedman later shifted his interest to the technology sector, working at tech startup Apploi and co-founding CyecureBox, a cyber security tool. After transitioning from Manhattan to Baltimore, he has been focusing on the development of BurnAlong, a startup that aims to help people find the time to exercise. During his eclectic career, Freedman has also held posts at the United Nations and the U.S. Senate.
1) What currently excites you about virtual fitness? How have things evolved from the days of Jane Fonda VHS tapes to the virtual fitness experience a user can consume today?
I think what’s really changed today is virtual fitness is allowing people to bridge the online and the offline fitness experience. New ways of delivering virtual fitness can finally bring people the “real” experience that they want, as opposed to having disconnected, lonely experiences with static content.
If you look at video games, the virtual world bridges that divide. If I go back to when I was a kid, if I wanted to play video games with a friend, I had to travel to their home. Today, my nieces can play with one another and/or their friends online, from their respective homes in different cities. They can see and speak to each other no matter where they are in the world. It’s the same in the business world where work tools like Skype and Google Hangouts have connected us.
What’s exciting to me in the fitness space is being able to bridge the divide and give everyone access to the experiences they want, when they want them. Fitness is about relationships, purpose and motivation. New advances in virtual fitness now allow us to do that at scale, with your workout buddies wherever they might be.
2) What are the limitations of delivering virtual fitness, and how have you seen this effectively mitigated?
If you go into any gym or studio, anywhere in the world, and ask, “Who is the most popular instructor here?” And then you ask them, “When was the last time someone said they can’t make a class, or was away for the summer, or traveling for work, and so could you film the class?” Odds are the instructor will say it was within the last two to three days. This reflects a massive lost opportunity for gyms and studios, because their members would prefer to choose a virtual experience with their favorite instructor, rather than strangers, if given that option.
BurnAlong does that, bridging that divide, giving people the connection to their favorite instructors/their friends, at a time and/or place convenient for them. And instructors can gain an insight into what people are doing outside of the gym, and help keep them on track.
3) Throughout the process of your product development, what has surprised you about virtual fitness delivery and consumption while building BurnAlong?
One big surprise is the willingness of people to try something different from home, or get started on their fitness journey. We see with companies, that often people have heard about top local instructors, they’re very curious to try them out, they’ve just never had the time, or confidence, or motivation, to actually take the class. But being able to experience it at home, from the comfort of their own home, makes a big difference.
We see this especially with companies and their employees. Right now, for many, five percent of employees participate in wellness programming. What we’ve found is that it’s not that the other 95 percent of the company isn’t interested. On the contrary, there are just a lot of barriers to attend (e.g. schedule, family commitments, aversion to working out with co-workers in an open setting, etc.). We found that virtual fitness is great for those who do not like exercising in front of others (especially colleagues and/or strangers).
For instance, yoga can be intimidating if you do not understand it. Virtual fitness allows someone who wants to be a little more confident before they subject themselves to other peers seeing them engage in activity [to get some practice]. They can get accustomed to movements, gain familiarity before engaging in the activity in a group setting.
For an instructor, this can be quite eye opening. Big personalities can be intimidating. Virtual fitness allows participants to understand the instructor, the class, they get to know the routines — a relationship is built before having to step in an unfamiliar setting. Through this process, a user can take steps to understand group dynamics before leaning in.
Virtual fitness is a great way to onboard new entrants into fitness who would have been too intimidated to ever get started otherwise.
4) Exergaming is a facet of virtual fitness that has had a lot of press but seemingly always falls flat after the initial hype (i.e. Wii Fit, Pokemon Go, etc.). Why do you think gamification has ultimately not lived up to the hype, and do you see this changing in the future?
Anything can get boring, unless it’s changed up. It’s the same limitation of the old way of delivering virtual fitness — where you’ve only got the same 10 options and the expectation is you are meant to keep going through that same 10 classes over and over again. Most people who buy fitness DVDs don’t buy only one; these folks have got piles of them. They want choice and variety. If there were only 10 books that everyone wanted to read, there wouldn’t be a need for Amazon, right? So too for fitness, there’s not just 10 ways of working out; the rise of boutiques reflects the desire for so many different people to work out in so many different ways.
The appeal of attending fitness classes in person with friends is that while the workout may be similar, the instructor will change things up, and your friends will chat about different things. The conversation is going to be different every week. What virtual fitness can now do is bring that variety to you in your home, with your friends, with fresh content from instructors, when you can’t make it in-person.
5) How do you see fitness evolving over the next five to ten years? How will virtual fitness change the way people currently consume fitness?
What we believe in at BurnAlong, and what our product is based on, is that people increasingly want unique experiences. I think virtual fitness has got the power of bringing fitness to people wherever they are — that specific type of experience that they want whenever and wherever they want it. We believe the virtual compliments the in-person experience, rather than replacing it (which most online companies believe).
The virtual can also bring special classes to places where previously people didn’t have that experience. People talk to friends across the country and all over the world about their favorite instructors; now those friends can experience those classes with that friend. Geography no longer needs to be a limitation.
In five years, I might wake up planning to attend my favorite cardio class at eight o’clock in the morning, but I wake up and Amazon’s Alexa or Google Home or another connected device will say to me, “Daniel, your noon meeting has just been moved, and you do not have time to physically attend your eight o’clock class. However, I’ve notified your instructor that you’re going to be joining online rather than in person.”
My co-worker Harry who takes the class with me is in London for work, and will be taking the same class virtually since it is his favorite, too. We choose to take the class live together. I log in at eight o’clock, wave to Harry and the instructor, who sees me and says, “Thanks for joining Daniel. Sorry you couldn’t come in person. You know I see your heart rate is already at 140, good run earlier … Daniel, you are already ready to go!”
It’s an experience where, just because you cannot do something in person, you are no longer limited. The virtual world bridges that divide, makes people more efficient, and allows them to use their time more effectively without sacrificing quality. This will only continue to improve in the years ahead
You should never be in a situation where just because you are traveling this week, or just because you can’t get a babysitter, or just because you had to work late … you can’t get the type of fitness experience and expert guidance you value and deserve.
Ryan Tarzy received his B.A. in Economics and Applied Mathematics from Northwestern University. Early in his career, he realized that his talents involved combining the role of an entrepreneur with that of an advisor. Since then, Ryan has been passionately working on moving healthcare forward and has founded or led several digital health startups. In 2003, he co-founded MediKeeper, one of the earliest digital health startups. He later served as CEO of Personal Health Labs, a lab focused on R&D in areas such as health gaming and interoperability. He now serves as Director of the Incubation Studio at CoverMyMeds. Prior to CoverMyMeds, he served as Co-Founder of Playful Bee and SVP of Business Development for PokitDok. He has recently begun to angel invest in digital health startups.
1) Many have attributed the impressive evolution and expansion of digital health to a move towards human-centered design, suggesting that a lot of previous health technology was engineered in a such a way that user experience was an afterthought. In your opinion, to be a success in digital health is user experience more important than utility? And why?
I think it is absolutely accurate that in the past, user-centered design has arguably been an afterthought. However, as we evolve into this next wave of digital health beyond Health 2.0, I think it is unfortunately still true that neither utility nor user-centered design is the most important factor of success. I would say at this point, success relies primarily on a solid business model. You can have fantastic user-centered design, you can have some utility, but if you have not figured out the way you’re going to get reimbursed, the way you’re going to get paid, or have a compelling value proposition for the direct consumer, then you are still going to struggle to be successful in digital health.
That said, I do believe user-centered design is driving some really exciting things coming out of the new wave of companies in digital health. I’m really encouraged by that, and I hope that it continues. I think that it does become a differentiating factor when you compare multiple companies, all of which have the reimbursement model and/or revenue model figured out.
2) As an investor in digital health startups, what do you look for in early stage companies trying to make it in health tech? And, what is a common flaw of new entrants that you feel could be easily avoided?
First and foremost, I look at the founders. Founders, to me, are the No. 1 determinant for success. I look for founders that, if they haven’t done this before, have deep domain expertise. They have dealt with the business problem before, they understand it, and they’re now trying to solve it through their own company.
I also look for founders that have a combination of passion and hustle that makes me confident that they’re going to be able to get past the inevitable roadblocks and hiccups that are going to take place when you’re trying to tackle an industry like health care. Those are the top two things I look for.
Lastly, I look for companies that I feel like I can provide an unfair advantage (while advising them). I want to feel like I can bring a lot more to the table than just monetary value as an investor.
In terms of things that I think are common mistakes … ultimately the sales cycles in health care are just really long. What I see is most new entrants will come in vastly underestimating the sale cycle and struggle. When you have these long sales cycles, what kills you is waiting on those maybes. You really have to aggressively develop process to manage the pipeline and be able to move beyond that first LOI, or unpaid pilot, and get yourself more quickly to a proven revenue model — a robust pipeline that is bringing in recurring revenue.
Another common mistake is a great idea, with a lack of domain expertise. It sounds self-serving as a healthcare investor with deep domain expertise to say this, but it is always good to have someone with healthcare expertise as an investor and/or advisor in the group. You need an advisor with specific knowledge in the area that you’re trying to tackle.
For example, a lot of people lump life science investors in with health IT and digital health investors — these are completely different businesses. One is dealing with long development cycles and a completely different type of regulation. The other is more about reimbursement cycles and enterprise sales and understanding the intricate players in the space. They are just different animals. You need someone, depending on which area you’re tackling, with that specific type of healthcare domain expertise. Very few can do both.
This is very personal to me because the first company I co-founded was one of the early personal health record companies. My co-founders and I built the company on the premise that there is this need, this obvious need, for a more central place for individuals to manage their health information. Back then we called it personal health records (PHRs), now you might call it a health portal. It just still feels like something that should exist but, I agree, at this point there has not been a huge success in this space yet.
What’s really interesting about this is there’s information leaking out that both Google and Apple are now attacking this space with new technologies. The ubiquity of smartphones, or even now through smartwatches, might potentially be a new opportunity for this to take hold.
I’ve always believed that the ideal health information exchange is the “HIE of One,” where the individual is the conduit of their own health information. The panacea of interoperability to create a universal portal, whether it’s Google Health or Microsoft HealthVault, is the wrong way to think about it. We need the ability for an individual to easily be able to take control of their health information and have control of the back and forth. Then, consume their data in whatever portal they want. I hope this is where things are going and I’m excited to see Apple coming into the market and Google seemingly retrying to attack this market. I’m really intrigued to see what they come up with.
4) What is your take on the longevity of today’s wearables? There are numerous articles with click-bait titles indicating the smartphone is dead within five years. One could argue that might be the same fate for most wearables today. Where do you see the puck heading for wearables?
I feel like five years is too aggressive to say the smartphone will die, but I may be wrong. I think that I’m much more pessimistic about the future of wearables as they exist today. We are seeing the early stages of these devices; they have passionate followers; they literally have millions of users out there. If you believe that wearables are going to become a more ubiquitous thing — I will say today’s wearables will likely be starkly different five years from now. Looks at Apple’s AirPods, those will change the smartphone and are technically a wearable. Wearables will evolve in ways we cannot predict.
It comes down to, what do you define as a wearable? Staying with the AirPods example, this is a sign that we’ll be utilizing voice for data entry … speech will be integrated into our car, which is integrated into our watch and into our AirPods. And really, the cloud becomes more and more the world we live in versus having our nose in our smartphone.
So although I am pessimistic that devices like the Fitbit will have legs five years from now, I am optimist about the future of computing being more integrated into all parts of our life in a, hopefully, more user-centric way without having to have our nose buried in our smartphone all the time. As voice gets more and more compelling, we will not need to physical interact with devices, limiting the need to “wear” anything.
5) In your opinion, what are two underrated and/or little-known companies right now in digital health that you believe are positioned to make a huge impact (in the future) and why?
1) LeapCure: This is a company that has really cracked the code on recruiting patients for clinical trials. It is fascinating to me that over 60 percent of clinical trials fail due to patient recruitment issues. That’s just staggering to me and just seems like such a big problem that we haven’t been able to crack.
This company has been able to use techniques that have been utilized in other non-health care markets to micro-target individuals — even for very rare diseases. One of their customers specifically specializes in rare diseases for children. So, truly the needle in the haystack kind of problem: how do you find the less than 20 patients in the country that would qualify for this clinic trial?
They are able to do that, and will likely make a huge impact. They are reducing the cost of patient recruitment and increasing the success rate of clinical trials. That could have a far-reaching impact on the industry. So, I’m really bullish on that and what they’re doing and excited to work with their team as an investor and board observer.
2) Paubox: Sometimes seemingly boring companies on the surface are in the best position to make an impact. Paubox operates in the area of email and disaster recovery. Sounds incredibly boring for healthcare but, what they’ve done is, they have cracked the code of how to deliver HIPAA-secure email — and they do that in a way that is user-friendly. You can finally simply use your Gmail account as a doctor, and they’re able to make that HIPAA secure for communication with patients. All the friction created by email alerts that push you to a portal, only to hassle with additional passwords and clunky communication channels. Paubox solves all that. Finally, you can simply email your doctor … like you email the rest of the world.
What is Fun? The Oxford English Dictionary (O.E.D) defines fun as “amusement, especially lively or playful.” As an adjective, the word is described as “amusing, entertaining, enjoyable.” “For fun” or “for the fun of it” means “not for a serious purpose.”
The standard definition of fun suggests some overlap with the concept of play. In fact, these two words are often mentioned together (e.g. fun and games). However, play often appears to be the overarching term, where fun is more specific to experiencing enjoyment. For example, when defining play, play researcher Scott Eberle, Ph.D., writes that fun is one of the basic elements of play. He also observes that we play because the act of play promises fun. If there were no fun in play, we would likely not play (Eberle, 2014). This suggests a relationship between the concepts of fun and play, a possible causality perhaps: fun is a natural byproduct of play — fun is intrinsic to play. Eberle also argues that although there are many ways to develop knowledge, self-assurance and vigor, none of them are as fun as play.
Another academic concept that is used when discussing fun is “flow.” When Gayle Privette of the University of West Florida attempted to distinguish between peak experience, peak performance and flow, she defined peak experience as mystic and transpersonal, peak performance as transactive and flow as having fun (Privette, 1983).
Casual and Academic References to Fun
Definitions of fun are generally discussed as a result of an act and/or engaging in activity. Some authors focus on the fun side of things/activities and talk about the hedonic aspects of certain activities. As such, in academic writing, fun is often equated with hedonism. For instance, Barry Babin, William Darden, and Mitch Griffin (1994) took the hedonistic value of shopping (e.g. shopping for fun) and contrasted it with shopping’s utilitarian value, which is more concerned with usefulness and task completion. Utilitarian shopping can almost be regarded as work. Shopping for fun, on the other hand, is personal, subjective to the shopper and often entails playfulness. The participant values the experience itself because the endeavor is entertaining. In short, many activities can be analyzed for their ability to induce fun — emphasizing entertainment and enjoyment of the process rather than its practical value.
When activity is done for fun, it often involves increased arousal, perceived freedom, fantasy fulfillment and escapism (Hirscham, 1983). The saying “time flies when you’re having fun” indicates that the concept is also connected with our perceptions of temporality and can influence the subjective component of time. This popular anecdote is a cultural artifact that further alludes that flow and fun are related social constructs.
People sometimes also talk about “short-term fun” and contrast it with “long-term gains,” suggesting that fun could obliterate the lasting success of an individual. Fun and play often get negative press, especially when adults engage in fun activities excessively. It sometimes gets implied that people’s efficiency and productivity could decline if they overtly prioritized fun. Modern research, however, does not support that negative proposition of fun (e.g. R. Fluegge-Woolf, 2014).
Can Fun Be Universally Defined?
Although fun is often connected with play, few would argue play is the only time we have fun. For instance, for many, work can be fun as well. A task like gardening can be perceived as monotonous to one person while being perceived as fun by another. But, does work cease to be work if we have fun? Actually, fun in the workplace is increasingly being researched. Researchers are exploring strategies that help make our work lives more fun. For instance, there are evolving applications of gamification. Gamifying work involves creating strategic tactics in an attempt to make arduous tasks more fun. New studies have confirmed that a fun work environment creates more productive and creative employees, therefore showing that both parts of the “work hard, play hard” phrase can actually coexist (R. Fluegge-Woolf, 2014).
Your perception of whether something is fun depends on your mindset, ability and skills, the environment as well as those around you (your relationships). For example, taking public transportation can be a tedious, mind-numbing activity. If you’re headed to a concert with a group of friends, though, it can be the ride of a lifetime: spending time together, chatting while excitedly anticipating the show — in laymen terms, “a ton of fun.”
What is clear is that fun is a subjective construct. What seems fun to one person might be perceived differently by somebody else. Therefore, perhaps the most relevant question is: How do you define fun? What is fun to you?
OK, to all you non-parents out there … I am going to go out on a limb here and share a secret held by us on the other side — misery loves company, so when one of us tells you, “My children are the best thing that has ever happened to me,” or some similar thinly veiled ploy to have you come join us in Suckville — don’t you believe it! The reality is we likely miss you dearly, yet there is no reasonable escape from the trap of our new reality, and our only hope is to trick you to come along. Like someone drowning — clinging on for dear life — we are ready to take you down with us. Therefore, it should be no surprise that a recent study out of the Indiana University—Purdue University Indianapolis by Leslie Ashburn-Nardo suggests child-free adults consistently face moral outrage by their childbearing counterparts. The hard truth is, many of us dream about our prior lives sans kids. Often kids aren’t fun and many of us long for pieces from our previous autonomous lives.
Joking aside, I love my kids. There are moments when it is really fun being a parent. My kids bring me occasional joy; they most certainly give my life a sense of meaning and purpose that was not there before. Like many other parents, I do my best to juggle priorities and sacrifice my own needs for theirs. Being a psychology geek, I truly enjoy watching them develop and thrive. Parenthood gives me a sense of accomplishment; there is no question I love my kids. Surely, I must be happier with two little bundles of joy in my life. Right? Right?!?
The Parenting Happiness Gap
Not according to science; research studies from different parts of the developed world have been suggesting for some time now that people with kids are less happy than their non-parent counterparts. So if you have been struggling with the self-actualization that your new life parenting is not as fun as you thought it would be … don’t stress, you are in good company. Those who have read Dan Gilbert’s Stumbling on Happiness or All Joy and No Fun by Jennifer Senior are probably already familiar with some of the previous science. Important to note, this does not mean that parents are (necessarily) unhappy. It just verifies that there is a happiness gap between the two groups. To put it more bluntly, when your ex-drinking buddy tells you, “My kids make me so happy,” they’re probably full of shit. This is especially true here in the United States. More than other countries in the world, there appears to be a strong link between parenthood and lower emotional well-being in the United States.
I’m not trying to be a polemicist. As I previously suggested, there is an abundance of research to support this claim (see Glass, Simon, & Andersson, 2016 for a comprehensive list of studies). For example, research published in 2005 in the Journal of Health and Social Behavior suggests that having children is associated with decreased mental health. This work also suggests parents reporting significantly higher levels of depression than their childfree counterparts.
There is a gender bias to these statistics due to hormonal issues associated with postpartum phenomena. However, these effects are observed in both men and women (Evenson & Simon, 2005). Cohabiting with dependent children is a period of parenthood that has been associated with the highest degree of stress levels (this goes for both genders); of this group, parents with minor children are the ones who usually experience the highest time and energy demands (Evenson & Simon, 2005).
“Don’t Worry, it Gets Better” Might Be a Lie, Too
According to Ranae Evenson of Vanderbilt University and Robin Simon of Florida State University, even empty-nesters have trouble reaching the levels of happiness experienced by non-parents. This is unfortunate interesting since many people believe that once their children are all grown, parenthood is more enjoyable. A meta-analytic review published in the Journal of Marriage and Family suggests that, after having children, couples actually report being less satisfied with their marital relationship compared with non-parents (Twenge, Campbell, & Foster, 2003). Twenge, Campbell and Foster conclude that lower marital satisfaction might be due to new role conflicts from the change in family dynamics, as well as the increased autonomy that comes with the empty nest. In other words, you wake up from Suckville and realize you still want to go to Burning Man, only to discover your partner would now rather watch “The Good Wife” reruns.
In a nutshell, science shows us (once again) what we already know but for some reason decided to kid ourselves about: being a parent is hard fucking work. While fantasizing about the birth of a child, we usually look forward to personal gratification, meaning and purpose, but these positive emotions are fleeting and ultimately get eclipsed by the vast variety of stressors associated with childcare. These underestimated stressors can often lead to a poorer sense of well-being (Umberson & Gove, 1998).
United States + Kids = Suck
From all over the globe, those who romanticize parenthood still acknowledge the stressors connected with parenting, but it seems like parenting is especially hard here in the United States. I have dug into the research, and stress theory has failed to explain why American parents feel worse than their counterparts in other countries (Glass, Simon, & Andersson, 2016). Many experts agree that the reason American parents report less happiness than parents in other countries is a lack of parenting support (when compared to collectivist cultures) and the lack of support offered by governmental programs (e.g. family leave, significant tax breaks, etc.). While in some developed countries, childbearing brings a number of social and financial benefits — well, let’s face it, the United States simply fails miserably here.
A group of researchers looked into resources provided to parents in different countries and examined whether the happiness gap between parents and non-parents was smaller in countries that provided more family assistance. They confirmed that the (distal) source of parenting stress generally originated in the respective countries’ social, economic and policy constraints. They referred to this as the macro-level cause for parental negative emotions. Their analysis showed that out of 22 OECD countries, the greatest happiness gap between parents and non-parents was experienced in the United States.
In fact, us American parents report being 12 percent less happy than those without children. In contrast, countries that provided more resources and social support for parents (paid work leave, work flexibility, subsidized childcare) generally had a smaller disparity in happiness between parents and non-parents. Truth be told, in some countries (e.g. Spain, Portugal, Sweden and Russia), parents actually reported being as happy (even slightly happier sometimes) as their non-parent counterparts (Glass, Simon, & Andersson, 2016).
Another factor is parenting does not have the social value and esteem attached to it that it did 50 years ago. We can now decide for ourselves when to have children. That is why some social scientists argue that when we compare people with children to non-parents, we are in fact comparing two groups of people who made different choices and have different attributes and preferences. Admittedly, the science here is as messy. It might, therefore, be more relevant to compare people’s happiness before and after they have had kids.
Professor Andrew Clark of the Paris School of Economics and his team are currently working on the book The Origins of Happiness, which is looking at the determinants of well-being in four countries: the United States, Germany, Australia and the U.K. They presented some of their findings at the Wellbeing Conference 2016 which was held last December and was organized by the OECD and the London School of Economics (LSE). After four years of following new parents, their preliminary findings reaffirm that parenthood does not improve subjective well-being in the long run. The positive effects only last for the first 12 months after the baby is born. Unfortunately, after that, the well-being score of parents starts to decline.
Is Being a Happy Parent Possible?
OK, so parenting can suck … but here we are … and we love our kids … so WTF should we do? The good news is parenthood does offer many opportunities for some of the most worthwhile moments of your life. We lose a lot of autonomy as parents, but we can choose to bring more joy into our lives through our children. A study led by Katherine Nelson, a psychologist from the University of California, Riverside, shows us again what we already intuitively know — that the relationship between parenthood and well-being is very complex. It is influenced by so many factors, including: parenting style, emotional bonds between the parents, the child’s temperament and age…
When evaluating parental happiness, we should look at the whole context; it is important to observe why and how we, as parents, become more or less happy. If we have “bought in,” we can experience positive emotions through our enhanced social roles (Nelson, Kushlev, & Lyubomirsky, 2014).
Moreover, to counter the somewhat negative research on parenthood, Nelson and her colleagues demonstrated (in three studies) that parents (especially fathers — go dads!) can be happier and experience more meaning in life compared to non-parents (Nelson, Kushlev, English, Dunn & Lyubomirsky, 2013). So, being a happy parent is in the cards, if you are ready to work.
Let’s explore how:
Allow Time for Unstructured Play
Play is a source of happiness for kids, as well as adults. It is baffling to me that kids seem like they’re continually being deprived of free play. We’ve become too dystopian. Some of the silliest fights I have with my wife are about my kids going outside because they might get dirty. “Yeah, no shit, that is part of the fun of going outside.”
Statistics show American children (as well as children in other developed nations) have less and less free time to engage in free play activities. Our kids’ lives are increasingly highly structured and controlled. There are reasons for this, sure, but I want you to think about some of your favorite childhood memories for a moment … they probably involve at least some images of unstructured play, shenanigans with friends, moments of a carefree existence … moments when you were not directed, because you were a kid!
How does this make me happier? If we are always helicoptering over our kids (more on that later), we have less autonomy. Autonomy makes us happy. Furthermore, Professor Peter Gray argues that the decline of free play importantly contributes to an increase in different psychopathologies among young people, including: anxiety, depression, narcissism and difficulty focusing (Gray, 2011). In his writing, Gray (2014) suggests that children need to be allowed time to play freely, with other children, and away from adults. So when we eliminate the autonomy out of our lives, and the lives of our children, we create a perpetual death spiral. It is a bitter pill to swallow, but your parenting style might be part of the problem.
We need to give children some space to express their personality, learn, develop their skills and build social interactions. In his book, Free to Learn, Gray further explores these concepts and looks for ways to improve children’s happiness and the potential to learn.
The first rule of being happy (and raising a happy person) appears to be giving your kid some space. Let them play freely and get absorbed in some self-directed activity that has not been organized for them. It is good to have fun with your kids, but if one or both of you are not having fun anymore, it is counterproductive. Letting your kid free play also helps you recharge and have more fun during the time you do share experiences.
Don’t Make Play Your Duty
When you do play with your kids, avoid engaging in it as a sense of obligation. Play should be fun for everyone involved. Otherwise, it is not play. Hey … I get it, singing “Frozen” karaoke for the nth time isn’t your idea of fun.
Our interests, energy, humor are different than our children … you don’t need a Ph.D. behind your name to observe that. This makes it difficult to bridge the age gap in parent-child play, but you can get creative if you try. Gray (2014) suggests finding ways that fit the abilities and interests of the parent and the child. This strategy is going to be specific to your family. For me, I have gotten my 5-year-old into rock climbing and running. Do what works for yours.
Consider the Implications of Helicopter Parenting on Well-Being
Terri LeMoyne and Tom Buchanan of the University of Tennessee at Chattanooga explored the style of “helicopter parenting” on a sample of college students. They found that helicopter parenting can have a negative effect on children; lowering their levels of well-being and making them feel more negative about themselves. Children of helicopter parents are also more likely to take medications for anxiety and/or depression (LeMoyne & Buchanan, 2011). Ill effects of over-parenting were also shown in other studies. For instance, one led by Chris Segrin of the University of Arizona, Tucson, highlighted that helicopter parenting can lead to child having difficulty in relating to others (Segrin et al., 2014). Science shows us that although a caring and genuine relationship is essential for our children’s well-being, they (and we) will probably be happier if we give them less direction. Again, make sure your parenting style is not the culprit. When the time is right to play with your kids, let them guide you and generally only intervene for reasons of safety and security.
Don’t Take Life Too Seriously, No One Gets Out Alive Anyways
If you constantly strive to be a flawless parent, then my guess is you are probably not having much fun anyway. Having parental standards is important, but try your best not to turn this into perfectionism. There are rewards for being a flexible parent. Studies show that authoritarian parents who are high on demands and low on responsiveness tend to have children who have low self-esteem and are overly worried about making mistakes (Hibbard & Walton, 2014). Nicholas Affrunti and Janet Woodruff-Borden from the Department of Psychological and Brain Sciences at the University of Louisville also suggest that parental perfectionism and over-control can be risk factors for the development of child anxiety (Affrunti & Woodruff-Borden, 2015). So embrace your silly side.
Deploy a little healthy code-switching and become a kid yourself during play. The practice can be healthy for all involved. There is inherent fun in getting silly and laughing with someone. You both release oxytocin, which in turn creates strong bonds with each other, which in turn makes you feel good — plus a host of other benefits that contribute to the well-being of both parent and child.
Create Fun Rituals
This is one I have borrowed from my best friend Micah and his family. I am trying to get better at this one, but it the spirit of authenticity I must admit I have failed a bit here. The recognition that routine “family time” is important for family relations and well-being is well-established. Weekends play an important and beneficial role in the lives of many families in this regard — they give us more time to do things together. Rosalina Pisco Costa, a sociologist working at the University of Évora in Portugal, writes about the creation of “special time and space” and family rituals. Family rituals can center around different things (celebrations, greetings, trips) and involve the stages of anticipation, experience as well as conclusion (Costa, 2014). Costa also cites the work of Imber-Black and Roberts (1998) who suggested that “rituals give us places to be playful, to explore the meaning of our lives, and to rework and rebuild family relationship” (p.4). Fun rituals are something we can consider including in our family life to experience the emotional benefits they bring. Circling back to Micah and his family, they invested in a boat knowing that the significant cost would ensure that maritime activities, such as weekly sleepovers on the new boat, would become the norm and create endearing memories for all.
I am not suggesting you go out and buy a boat. I am suggesting you make family time a habit by engaging in a family ritual the whole family enjoys.
Invest in Experience, not Things
I feel like this has been covered well recently by others (see: Buy Experiences, Not Things or The Science Behind Why You Should Spend Money on Family Holidays Instead of Toys) and is almost a cliché topic now, but it is still worth a mention. Investing in experience over things builds memories that all parties can relish. Furthermore, since you likely have some control of your family’s resources, choosing an experience over buying another toy interjects some autonomy back in your life. We know the benefits from experience last longer than the gratification derived from most tangible things. Moreover, you don’t have to succumb to the pressure of going to a child-centered destination like Disneyland for your family vacation. What is an experience that would create an enjoyable, lasting memory for all involved? If you plan your vacations accordingly, you can mitigate the ill-conceived adage: children make a family, but destroy the marriage. Pick a location where the tips from 1-5 (above) are baked in. For instance, you could choose an all-inclusive resort that has a kid’s club so there are opportunities for family fun, as well as intimate time with your partner while your kid is at play. Fun for all!
The Days Are Long, But The Years Are Short
If you are lucky enough to find unwavering fun in being a parent … I am happy to hear that unicorns exist … something for me to strive for. For the rest of us, we tell our friends, “Don’t worry, it gets better,” because it can … especially if we are able to parent mindfully. Life is about moments, and as parents we have committed to a lot of those moments being with our kids. Either by choice or lack of family planning, these moments are not just ours anymore; however, we still hold a few cards and we can influence our environment and our family time to maximize our ability to have fun and be happy (along with our kids).
Parenthood can easily become a shitshow at times, but we have more control over that than we think. The days are long, but the years are short — we might as well stack the deck in our favor, so in our final days we have a lifetime of fun memories and we can relish in a family life lived happily.
I live on the island of Alameda, California — here on the island there is a place that has begun to wear on me. It’s called Pump It Up, a favorite among local parents for children’s birthday parties, and there is nothing inherently bad about this place. I suppose selfishly I do not like it because I have not connected with many people in the parent circle of my kids … and this type of event is solely for our kids. It is boring and no longer novel (because of the amount of times we’ve all been there), and I find myself questioning my existence every time it is my turn on the rotation to take one (or both) of my children to one of these parties. (I wonder if my parents had a similar disdain for Chuck E. Cheese?)
Since I am a psychology geek, I do take solace that these parties provide fertile ground to ponder the value of friendships. One, because it is a fascinating place to watch the storming, norming, forming marvels of childhood. Two, since my children are preoccupied, the experience gives me the space to mindfully explore my own loneliness and my lack of sensibilities in building rapport with strangers (i.e. the other care givers that somehow pulled the short straw that day). The recent resurgence and virality of Harvard’s Grant and Glueck study (which, in part, indicates that men with happier childhoods likely have stronger relationships in old age) has had me recently pondering these subjects more deeply than usual.
Please do not get me wrong. It’s not that I don’t want to be friends with the parents of my kid’s friends. On the contrary, science backs up the notion that good friends can be one of life’s greatest gifts. Alas, I suspect at least half of you reading this are better at building and preserving close relationships than me. If one’s ability to acquire friends has a standard distribution, I am for certain on the losing end of the bell curve. I have always been an odd ball. My psyche is staffed by Tim Burton characters — witty, funny, yet flawed and weird looking. These characters don’t stay in the cage long during cocktail conversations, and they get apathetic easily — they’re looking for wit and humor on the other end, not another conversation about child rearing and my day job. I do have a script for the latter, but it is long and boring. Once this script is triggered, I have literally had parents simply walk away as I meekly fade out my dialogue, embarrassed that I have killed yet another one.
At the risk of doing that to you here, let me get on with it. I know I have to try harder. In her book Friendships Don’t Just Happen, Shasta Nelson points out that making, keeping and changing friends is perhaps one of our most important skills. In reality, I think there are a lot of people like me that feel “developing” friends can be a messy proposition. I, for one, remember reading the book How to Win Friends and Influence People by Dale Carnegie and then putting it down feeling almost as dirty as I did when completing The 48 Laws of Power by Robert Greene. Authenticity is a personal value of mine, so I don’t want to boil down making friends to a “system” — so at these parties I have stopped trying and instead navel gaze while watching the kids play…
Parents have a significant influence on who our kids will be friends with
Different aspects of a child’s personality can be assessed simply by observation (e.g. self-control, self-esteem, mood, relationships with others and self-reliance). I personally look for self-reliance in my kids since it correlates with success. Self-reliance has been defined by Diana Baumrind, a researcher of human development from the University of California, Berkeley, as ‘the ability of the child to handle his[/her] affairs in an independent fashion relative to other children his [or her] age.’ Things to foster in kids in this regard are: ease of separation from you, willingness to be alone at times, leadership interest and ability, as well as pleasure in learning new tasks. Research by Baumrind (1967) shows that the parenting style that resulted in well-developed self-reliance includes being firm, loving, demanding and understanding. I think my wife and I are doing the best we can here, and building this self-reliance will hopefully lead our kids to more secure friendships.
Less is known about the influence friends and peers have on our child’s development
We know as our kids move through developmental stages, they become increasingly dependent on peer relationships and peer communication. There is little doubt we also influence this. Salient connections have been found between the relationship we have with our kids when compared to their later relationships with friends, as well as with their future romantic partners (Farley & Kim-Spoon, 2014). For instance, one longitudinal study found that adolescents who were insecurely attached to their fathers were more likely to develop an insecure attachment to their best friends. Similarly, insecure attachment to mothers led to more insecure attachments to romantic partners later in life (Doyle, Lawford, & Markiewicz, 2009). Clearly, building strong bonds with our kids is important, because ultimately they get the final decision who they keep as friends.
Why does friendship matter for our kids?
How our children evolve getting along with their peers can be an important predictor of their academic success. North American studies show that children who have a better relationship with their classmates perform better in school, and peer acceptance and attachment have been linked to academic achievement (Kingery, Erdley, & Marshall, 2011). Kids with a bigger social network have more opportunities for engagement, encouragement and support. An extensive literature review by Burack and colleagues showed that children with more positive peer relations also show more prosocial behavior, self-esteem and perceived support, and are less likely to develop depression, aggression and anxiety (Burack et al., 2013). Close relationships with peers have been found to provide children with a safe base from which he or she can explore and develop (Laible, Carlo, & Raffaelli, 2000).
Why does friendship matter for us?
I am in my 40s now. Unfortunately, a simple truth is that once parenthood hits it gets more difficult to connect with others. There is a really good 2012 New York Times article by Alex Williams where he examines the topic of making friends as an adult. Williams points out to make close friends three conditions need to be fulfilled: proximity; repeated, unplanned interactions; and a setting that encourages interactions that can be confidential. Unfortunately, these conditions are often difficult to fulfill once we have a job, a partner and/or a family.
Do I work too hard to have friends?
Some authors wonder if becoming successful results in having less contact with family and friends, which could create a sense of loneliness – ‘the top is not a crowded place’ (Reinking, & Bell, 1991). However, various scientific studies contradict the notion it is lonely at the top. Those who hustle actually have reported less loneliness compared to those that work fewer hours in comparison (Bell et al., 1990), and another study from the 1990s looked at people’s position in organizational hierarchy (which was interpreted as a level of success) and their corresponding loneliness. The findings support the premise that employees working at higher levels of an organizational hierarchy are not lonelier when compared to those working at lower levels (Reinking, & Bell, 1991). This is further supported by a recent Harvard Business Review article currently making the rounds: Does Work Make You Happy? Evidence from the World Happiness Report.
Conclusion: True friendships are invaluable
The final act of a Pump It Up party is the cutting of the cake. It is at this point I generally find myself pinching my leg until it is time to leave. The uneasiness reminds me I miss adult parties with my own friends; but the truth is this is self-inflicted misery — merely a by-product of not prioritizing pre-existing relationships accordingly. I can do better. Kid’s parties, whether I like them or not, are also important for developing good social habits in my children. The influence I yield about viewpoints on friendship influences my children’s behaviors and characteristics. It will develop how they relate to their peers. Science tells me children with more secure attachments, develop more secure friendships. My children’s ability to connect with their peers will likely influence their academic achievement since being accepted by your peers is correlated with academic success. I also know that the simple truth I am mindful of all of this means no matter how bad I fuck up (and I will), they’ll probably turn out okay.
As we grow older, for many (myself included) it is simply difficult to meet new people who become close friends, so we revere early relationships which provide us the positive support and encouragement we need to continue to develop and grow. Those that get my newsletter know my little brother recently passed away. If it was not for the support of my best friend from college, Micah, I don’t think I would have made it. If you are familiar with Dunbar’s work, then you already know science says we can only have five close friends anyway; if true, I’m truly a lucky man Micah is one of them.
We need the bonds of friendship to flourish. The presumption that people who work more become detached from their family and friends has not been supported by science, so this cannot be used as an excuse. We can, however, do a better job staying connected to old friends no matter what the distance and circumstances. As the findings from the Grant and Glueck study suggest, it might be one of the best things we can do for our well-being.
So … maybe it’s time to get the gang back together, tap a keg, and rent a bounce house suitable for adults? We won’t let the kids in, they can sit outside, bored; let them talk about how silly and annoying we are for a change.
Last quarter I mentioned I wanted to start exploring fun and play more deeply. Certainly I have mastered the art of work, but somehow I have found fun increasingly elusive. Being the nerd I am, simply observing the benefits of fun from my daughter’s delightful play was not enough. I had to dig into the science. As such, I wrote the post: Why You Need More Fun in Your Life, According to Science. It was a self-serving assignment — something to work on, because heaven forbid I spend the time having more fun. I discovered I am not alone in experiencing the elusiveness of fun, because it was my first post to truly go viral with 100s of likes and shares. Since then I have been digging into fun, and … well … it’s been fun. There is a lot to unpack: fun; play; happiness; autonomy; flow — science reveals to us these are not tangible puzzle pieces that each have their respective place. Instead, for each of us, they are unique parts of a complex quilt that when aptly patched together making our lives more fulfilling and helping us build resilience against the bad stuff.
The truth is, sometimes life is not fun. I was thrown another curve-ball recently. I was diagnosed with osteoarthritis and had to have corrective hip surgery. I was told until science catches up with my condition, I am no longer a runner. Even just typing that out — I am no longer a runner — creates internal cognitive dissonance (i.e. it’s sucky). I can choose to let this identity change get me down, or I can adjust to new forms of fun and play. To know if change is beneficial, it is important to understand how to make personal assessments and gauge whether new adaptations are working for you (or not). This quarter, I reached out to two thought leaders in the space of self-evaluation: one a best-selling author, the other one of the leading psychological researchers at Harvard.
Business, Innovation and Entrepreneurship: The interview this quarter is with Cathy Presland about tracking progress. Cathy is considered an expert on leadership, drawing her knowledge from over 20 years of experience working with governments and international organizations. She is also an international bestseller and runs the World-Changers’ Circle program from her office in the UK. My interview with Cathy Presland is available here.
Health and Wellness: This quarter’s interview is with Matthew Nock, Ph.D., about assessing an intervention using only a single individual (i.e. n=1, self-experimentation). Matthew is a leading expert in single-case experimental design. He received the MacArthur “Genius” Award in 2011 and is currently a psychology professor at Harvard University, where he also runs the Nock Lab. My interview with Dr. Matthew Nock is available here.
Life Experience: This quarter, I traveled to Houston for Super Bowl LI. I also had hip surgery, which I alluded to earlier. Both significant life experiences — however, Houston was notably more fun than surgery, so it gets the photographic evidence.
Contribution: This quarter, I made donations to Tour de Cure again, as well as Little Kids Rock. More importantly, I made time to share the gift of contribution with my daughter. Sloane and I spend an afternoon at Crab Cove in Alameda, California, helping to clean up the beach there with a host of other local volunteers.
Lastly, this quarter Charlie Hoehn, author of the book “Play It Away,” found my website. When we were able to connect, it made my day. I am a fan of Charlie’s work so I wanted to finish this newsletter paying it forward and plugging a new book he is working on: Play for a Living. I am hopeful I will be able to coax him into an interview sometime in the future.
Until next time, wishing you all the fun you can handle!