http://www.mikesimonds.com/blogs/willis/ en Fri, 30 Jul 2010 23:30:51 GMT vBulletin 60 http://www.mikesimonds.com/images/EloquentBlue/misc/rss.jpg http://www.mikesimonds.com/blogs/willis/ http://www.mikesimonds.com/blogs/willis/27-velluvial-matrix.html Thu, 01 Jul 2010 21:38:49 GMT This entry is accredited to Dr. Atul Gawande and was given at the commencement speech at Stanford's School of Medicine for the graduating class of 2010. Here is what he told the graduating class.

Many of you have worked for four solid years—or five, or six, or nine—and we are here to declare that, as of today, you officially know enough stuff to be called a graduate of the Stanford School of Medicine. You are Doctors of Medicine, Doctors of Philosophy, Masters of Science. It’s been certified. Each of you is now an expert. Congratulations.

So why—in your heart of hearts—do you not quite feel that way?

The experience of a medical and scientific education is transformational. It is like moving to a new country. At first, you don’t know the language, let alone the customs and concepts. But then, almost imperceptibly, that changes. Half the words you now routinely use you did not know existed when you started: words like arterial-blood gas, nasogastric tube, microarray, logistic regression, NMDA receptor, velluvial matrix.

O.K., I made that last one up. But the velluvial matrix sounds like something you should know about, doesn’t it? And that’s the problem. I will let you in on a little secret. You never stop wondering if there is a velluvial matrix you should know about.

Since I graduated from medical school, my family and friends have had their share of medical issues, just as you and your family will. And, inevitably, they turn to the medical graduate in the house for advice and explanation.

I remember one time when a friend came with a question. “You’re a doctor now,” he said. “So tell me: where exactly is the solar plexus?”

I was stumped. The information was not anywhere in the textbooks.

“I don’t know,” I finally confessed.

“What kind of doctor are you?” he said.

I didn’t feel much better equipped when my wife had two miscarriages, or when our first child was born with part of his aorta missing, or when my daughter had a fall and dislocated her elbow, and I failed to recognize it, or when my wife tore a ligament in her wrist that I’d never heard of—her velluvial matrix, I think it was.

This is a deeper, more fundamental problem than we acknowledge. The truth is that the volume and complexity of the knowledge that we need to master has grown exponentially beyond our capacity as individuals. Worse, the fear is that the knowledge has grown beyond our capacity as a society. When we talk about the uncontrollable explosion in the costs of health care in America, for instance—about the reality that we in medicine are gradually bankrupting the country—we’re not talking about a problem rooted in economics. We’re talking about a problem rooted in scientific complexity.

Half a century ago, medicine was neither costly nor effective. Since then, however, science has combatted our ignorance. It has enumerated and identified, according to the international disease-classification system, more than 13,600 diagnoses—13,600 different ways our bodies can fail. And for each one we’ve discovered beneficial remedies—remedies that can reduce suffering, extend lives, and sometimes stop a disease altogether. But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures. Our job in medicine is to make sure that all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive. And we’re struggling. There is no industry in the world with 13,600 different service lines to deliver.

It should be no wonder that you have not mastered the understanding of them all. No one ever will. That’s why we as doctors and scientists have become ever more finely specialized. If I can’t handle 13,600 diagnoses, well, maybe there are fifty that I can handle—or just one that I might focus on in my research. The result, however, is that we find ourselves to be specialists, worried almost exclusively about our particular niche, and not the larger question of whether we as a group are making the whole system of care better for people. I think we were fooled by penicillin. When penicillin was discovered, in 1929, it suggested that treatment of disease could be simple—an injection that could miraculously cure a breathtaking range of infectious diseases. Maybe there’d be an injection for cancer and another one for heart disease. It made us believe that discovery was the only hard part. Execution would be easy.

But this could not be further from the truth. Diagnosis and treatment of most conditions require complex steps and considerations, and often multiple people and technologies. The result is that more than forty per cent of patients with common conditions like coronary artery disease, stroke, or asthma receive incomplete or inappropriate care in our communities. And the country is also struggling mightily with the costs. By the end of the decade, at the present rate of cost growth, the price of a family insurance plan will rise to $27,000. Health care will go from ten per cent to seventeen per cent of labor costs for business, and workers’ wages will have to fall. State budgets will have to double to maintain current health programs. And then there is the frightening federal debt we will face. By 2025, we will owe more money than our economy produces. One side says war spending is the problem, the other says it’s the economic bailout plan. But take both away and you’ve made almost no difference. Our deficit problem—far and away—is the soaring and seemingly unstoppable cost of health care.

We in medicine have watched all this mainly with bafflement, even indifference. This is just what good medicine is like, we’re tempted to say. But we’d be ignoring the evidence. For health care is not practiced the same way across the country. There is remarkable variability in the cost and quality of care. Two communities in the same state with the same levels of poverty and health can differ by more than fifty per cent in their Medicare costs. There is a bell curve for cost and quality, and it is frustrating—but also hopeful. For those getting the best results—the hospitals and doctors measured at the top of the curve for patient outcomes—are not the most expensive. They are sometimes among the least.
Like politics, all medicine is local. Medicine requires the successful function of systems—of people and of technologies. Among our most profound difficulties is making them work together. If I want to give my patients the best care possible, not only must I do a good job, but a whole collection of diverse components must somehow mesh effectively.

Having great components is not enough. We’ve been obsessed in medicine with having the best drugs, the best devices, the best specialists—but we’ve paid little attention to how to make them fit together well. Don Berwick, of the Institute for Healthcare Improvement, has noted how wrongheaded this is. “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,” he says. He gives the example of a famous thought experiment in which an attempt is made to build the world’s greatest car by assembling the world’s greatest car parts. We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo: “What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.” Nonetheless, in medicine, that’s exactly what we have done.

Earlier this year, I received a letter from a patient named Duane Smith. He was a thirty-four-year-old assistant grocery-store manager when he had a terrible head-on car collision that left him with a broken leg, a broken pelvis, and a broken arm, two collapsed lungs, and uncontrolled internal bleeding. The members of his hospital’s trauma team went swiftly into action. They stabilized his fractured leg and pelvis. They put tubes in both sides of his chest to reëxpand his lungs. They gave him blood and got him to an operating room fast enough to remove the ruptured spleen that was the source of his bleeding. He required intensive care and three weeks of hospital recovery to get through all this. The clinicians did almost every single thing right. Smith told me that to this day he remains deeply grateful to the people who saved him.

But they missed one small step. They forgot to give him the vaccines that every patient who has his spleen removed requires, vaccines against three bacteria that the spleen usually fights off. Maybe the surgeons thought the critical-care doctors were going to give the vaccines, and maybe the critical-care doctors thought the primary-care physician was going to give them, and maybe the primary-care physician thought the surgeons already had. Or maybe they all forgot. Whatever the case, two years later, Duane Smith was on a beach vacation when he picked up an ordinary strep infection. Because he hadn’t had those vaccines, the infection spread rapidly throughout his body. He survived—but it cost him all his fingers and all his toes. It was, as he summed it up in his note, the worst vacation ever.

When Duane Smith’s car crashed, he was cared for by good, hardworking people. They had every technology available, but they did not have an actual system of care. And the most damning thing is that no one learned a thing from Duane Smith. For we have since had the exact same story occur in Boston, with an even worse outcome. Indeed, I would bet you that, across this country, we miss the basic, unglamorous step of vaccination in probably half of emergency splenectomy patients.

Why does anyone receive suboptimal care? After all, society could not have given us people with more talent, more dedication, and more training than the people in medical science have—than you have. I think the answer is that we have not grappled with the fact that the complexity of science has changed medicine fundamentally. This can no longer be a profession of craftsmen individually brewing plans for whatever patient comes through the door. We have to be more like engineers building a mechanism whose parts actually fit together, whose workings are ever more finely tuned and tweaked for ever better performance in providing aid and comfort to human beings.

You come into medicine and science at a time of radical transition. You have met the older doctors and scientists who tell the pollsters that they wouldn’t choose their profession if they were given the choice all over again. But you are the generation that was wise enough to ignore them: for what you are hearing is the pain of people experiencing an utter transformation of their world. Doctors and scientists are now being asked to accept a new understanding of what great medicine requires. It is not just the focus of an individual artisan-specialist, however skilled and caring. And it is not just the discovery of a new drug or operation, however effective it may seem in an isolated trial. Great medicine requires the innovation of entire packages of care—with medicines and technologies and clinicians designed to fit together seamlessly, monitored carefully, adjusted perpetually, and shown to produce ever better service and results for people at the lowest possible cost for society.

When you are sick, this is what you want from medicine. When you are a taxpayer, this is what you want from medicine. And when you are a doctor or a medical scientist this is the work you want to do. It is work with a different set of values from the ones that medicine traditionally has had: values of teamwork instead of individual autonomy, ambition for the right process rather than the right technology, and, perhaps above all, humility—for we need the humility to recognize that, under conditions of complexity, no technology will be infallible. No individual will be, either. There is always a velluvial matrix to know about.

You are joining a special profession. Doctors and scientists, we are all in the survival business, but we are also in the mortality business. Our successes will always be restricted by the limits of knowledge and human capability, by the inevitability of suffering and death. Meaning comes from each of us finding ways to help people and communities make the most of what is known and cope with what is not.
This will take science. It will take art. It will take innovation. It will take ambition. And it will take humility. But the fantastic thing is: This is what you get to do. ]]> Willis http://www.mikesimonds.com/blogs/willis/27-velluvial-matrix.html http://www.mikesimonds.com/blogs/willis/24-salesforce-dev-531-classes-triggers-and-syntax-oh-my.html Sun, 20 Jun 2010 21:22:12 GMT Mike and I completed a rousing week of training at the Salesforce.com DEV-531 class this past Friday. You can read about the details of the class in... Mike and I completed a rousing week of training at the Salesforce.com DEV-531 class this past Friday. You can read about the details of the class in Mike's blog so I'll skip the what's and why's and go straight to the wtf.

Ironically, I'd written a pretty meaty trigger prior to attending the class to handle Chatter feed post updates from the Opportunity line item. After the class, I'll have to say that it makes more sense but as a gal named Debbie in the class put it, "put a blank piece of paper in front of me and ask me to write code from scratch and I'm lost."

I think that's the general sense of what everyone got from that class. To be honest, I don't know what it is about Salesforc.ecom's courses that are so confusing. I contend that it's been the stupid recruiting app that they somehow insist on using that boggles everyone's mind. Or maybe it's the 2 days of making analogies to Dogs of all things instead of something normal... like accounts... or contacts.

The abstract nature of the introduction thoroughly confused me. Not saying I'm the sharpest tool in the shed, but I'm sure a lot of people found little to now value in it. Mike asked a question about updating a Contact based on an update to the Account tables on the last day of class. That one day of instruction was probably the most valuable out of the whole week as it was concret and familiar. Maybe that's a piece of information to take back to Salesforce.com.

The one thing I will say about the whole experience is that we are not alone out there in the Salesforce.com world. As Mike has shown us, there are many of us out there with the same questions; many of which have already been answered. What I encourage everyone to do is make friends, share ideas and contribute to each others' successes. If we can't talk amongst ourselves, how are we ever going to move forward.... Or in my case, how am I going to keep looking like I know something :)

Ready to get back to California and (for once this week) not be in heat above 95 degrees or humidity in the 50% range. Oy!

Football Non Sequitor - GO USA! ]]> Willis http://www.mikesimonds.com/blogs/willis/24-salesforce-dev-531-classes-triggers-and-syntax-oh-my.html http://www.mikesimonds.com/blogs/willis/22-sleepy-little-town.html Mon, 10 May 2010 03:45:23 GMT It's kind of strange to see my hometown in the news over such a non-issue. The little town I speak of is Morgan Hill, CA at a little school called Live Oak High School. A little personal history on the place:

I graduated from Live Oak High School in 1999. At the time, the school was housing roughly 3,000 students on a campus built for less than 2,000. A few years after I graduated, they built another high school across town which relieved some of that overcrowding however, I don't know what the population of the school is now but I'm pretty sure it's still overcrowded. I remember my 3 years there (yes, it was 3-year high school for population reasons) as ones filled with fun and their fair share of controversy.

I recall one year in the theater plaza, we had a gang fight. It was Mexicans versus a generally white group of students over (you guessed it) Cinco de Mayo. The school administration took very strong action at that point and a police presence was also apparent for weeks to follow. I also recall a bomb threat at the school where we were all evacuated for an hour or so while bomb sniffing dogs and police combed the school. The threat was determined to be false and we were allowed back into the classrooms. Our bags (every single one) had been rifled through.

This brings me to the recent events of 4 kids wearing American flag oriented clothing on this year's Cinco de Mayo. If the details are correct, most of these kids were Hispanic and were simply showing American Patriotism. As I also understand it, the school had a policy that no flags of any kind would be tolerated on campus on Cinco de Mayo.

What amazes me most is that such a non-issue has been turned into a racially charged one. I'm a war refugee (please refer to my previous posts). I love this country with every fiber of my being and I will proudly, without hesitation stand to protect her. I think anyone and everyone who is living in this country and uses her resources should fly the American flag and respect what it represents irrespective of national origins. The flag represents a nation that grants the opportunity for success through determination and work ethic. It promotes collaboration and free discourse. It drives the ingenuity that has allowed America to rise and continue to firmly exist as a powerhouse in economics, justice, and politics.

I mentioned earlier that during our bomb scare, our bags were all searched and placed on our desks when we returned. In our civics course later in the day, we discussed this. "Was this illegal search in violation of our Constitutional rights?" asked the teacher.

Many in the class responded in the affirmative; others in the negative. The teacher then went on to explain that a school during this time opened itself to what is called an "exigent circumstance." This says that "exigent circumstances arise when the law enforcement officers have reasonable grounds to believe that there is an immediate need to protect their lives, the lives of others, their property, or that of others, the search is not motivated by an intent to arrest and seize evidence, and there is some reasonable basis, to associate an emergency with the area or place to be searched such as this bomb scare." (United States v. Smith, 797 F.2d 836, 840 (10th Cir.1986))

In this case, it seems that the exigency rules also applied to not only the Fourth but the First Amendment. I'll probably get some flack but I think the administration was correct in their actions. I think policy was enforced the way any flag would have been dealt with on that day. Exigency circumstances existed to suspend the Freedom of Speech Amendment. The students were in violation of a policy and were given the option of compliance and refused. They were properly reprimanded. Had there been a riot or a fight like we had in my day, they probably would have been hanged for not responding as they did.

My consternation is with the politicos who have capitalized on this for their own gain. The parents of the kids who pro-actively contacted the media have given the tea party a reason to come down onto my sleepy little town with their right-wing rhetoric flung into my face as I drive down our downtown streets.

The Left is no better citing this as a race issue instead of what it was, poor judgment of some kids who had nothing better to do with their time than try to instigate trouble on a campus I have such fond memories of.

My only solace is that our memories are short term and as a dear adoptive grandmother of mine would say "this too shall pass." I look forward to having my sleepy little town back. ]]> Willis http://www.mikesimonds.com/blogs/willis/22-sleepy-little-town.html http://www.mikesimonds.com/blogs/willis/20-singin-rain.html Mon, 19 Apr 2010 15:26:27 GMT My fiancé and I went to see this yesterday at the Montngomery Theater in San Jose. Sometimes, it's really hard to remember just how good these men and women (and kids!) are on that stage. The talent it takes to memorize the lines, the finance that goes into props/sets, and the enjoyment that a live audience can bring will always amaze me.

This show in particular had more than a few great moments. During the scene where Gene Kelly sings in the street and hangs onto the lampost, they actually had a mechanism to make it rain on stage which was brilliant!

Good Mornin' was also a great piece especially since they used tap as part of the scene. You can see a little bit of that performance at the end of this video.

Unfortunately, it's an art that most people don't really appreciate or see anymore. If you've ever been to a live performance, you'll understand. Please support your local performing arts centers! ]]> Willis http://www.mikesimonds.com/blogs/willis/20-singin-rain.html http://www.mikesimonds.com/blogs/willis/18-education.html Mon, 12 Apr 2010 23:34:59 GMT My parents were refugees from Cambodia in the early 1980s. When we fled the country, I was the ripe old age of 6 months and I couldn't possibly realize what was going on. My mom tells me of nights when we would crawl through the jungles in abject fear that I would cry and a Khmer Rouge guerrilla would find and kill us without thinking twice. She tells me of nights where she would forget where she was due to fatigue, stress, and exhaustion only to come back to ensure that the guide they hired wouldn't throw me by the way-side like garbage because I was a burden to the group. The protection of a mother's love was never more evident.

Though the reign of Pol Pot existed until about the 1980s, his supporters were in full force for years thereafter. My dad tells me of the labor camps where we would be given (by his estimates) 2 cups of rice to feed 3 adults and 2 children for an entire week. He tells me that he and my uncle hunted field mice, crickets and various other forms of food that we would cringe in fear us just so that we could survive. They risked everything and decided to dare to leave the country. They thought it was with full understanding that our guide had papers to allow us not only in Thailand but into the UN refugee camp there; not the case.

When we arrived at the border, he left us. My mom, dad, uncle, 6 year-old sister and myself with nowhere to go and not any clue as to what to do. The Thai authorities had built trenches at the borders and put large spiked poles in them to deter people from crossing into their country because of the number of refugees. My dad and uncle found a place to navigate through the death traps and my sister and I were lifted to safety. My mom was caught in a flash flood and the waters started to rise rapidly. Through the panic, they were able to pull her to safety.

We hiked up behind the refugee camp and smuggled into the camp through a hole in the wall under cover of darkness. After a while, we simply became one of the refugees and acquired papers when we said we had lost them.

After about 2 years, we were notified that we had been sponsored by a church in the US to come live as refugees. My parents had no idea what it all meant. They only knew that it was a way to get out of a situation that saw no possibility of improvement so they were happy to take it. With literally the clothes on our backs, we were met by the Red Cross organizing the transport and were flown to Washington state.

My mom watched the kids as my uncle and my dad were put into vocational schooling. During the nights my dad would wash dishes at a local restaurant to earn some cash and my mom would sew clothing for $1 per shirt; a good day was 10 shirts. Whatever time my dad had during the day between working and going to school, he studied with the local pastor to gain basic math and English skills that were non-existent in Cambodia's educational system.

The one thing that my parents embedded in my and my sister's psyche has been education. Without it, they saw zero chances of success not just here but anywhere. Perhaps it was the persecution of the educated that they saw in Cambodia. Maybe it was because they themselves never had a chance to learn. Whatever the reason, I am thankful to them for pushing me to succeed and not to accept anything less than absolute drive to be better.

I'm taking classes in the coming weeks to further educate myself not because I am being forced to, but because I have lost some of that drive in the daily grind. Some would cringe at the possibility of continuing to learn in such a structured environment. I am grateful. ]]> Willis http://www.mikesimonds.com/blogs/willis/18-education.html http://www.mikesimonds.com/blogs/willis/14-chatter-enabled-my-salesforce-developer-instance.html Mon, 05 Apr 2010 23:04:43 GMT Initially, they dubbed this the "Facebook of the Enterprise" but then they realized that the word "Facebook" is synonymous with the word "productivity killer" in the corporate world. I've had a chance to mess around with this feature in the development instances and I have to say, it's interesting. Essentially as I understand it, the application (Salesforce.com) will now speak to the user. The user dictates what they want to follow and as those records become updated, the application "tweets" updates to the user's chatter feed.

This chatter feed has a summary chatter feed on the users' homepages that will show all the chatter tweets across all objects. Each record (opportunity, account, etc.) also has it's own chatter history. The system administrator really defines what field changes will trigger a Chatter feed update so it's customizable to whatever extent people see as pertinent.

The biggest downside I see is that unless I'm missing something, the parent-child relationship doesn't work quite just right. Any updates made to the child do not trigger a chatter feed to the parent or the main chatter feed. This is huge given that some business thrive on the opportunity line item detail at times having those changes supersede the opportunity in importance.

I've actually spoken to one of the project managers and he says that my use case isn't currently supported. Speaking on personal experiences only, Salesforce.com has a pretty firm grasp on what they need to do in order to improve a product and I can't imagine that this isn't on their roadmap.

Overall, a very interesting tool. Like Mike says, I'll be looking forward to see how companies will utilize this social type technology in business day applications. ]]> Willis http://www.mikesimonds.com/blogs/willis/14-chatter-enabled-my-salesforce-developer-instance.html http://www.mikesimonds.com/blogs/willis/8-want-ride-my-bicycle.html Tue, 23 Feb 2010 19:15:49 GMT Mike will get a good laugh at this but I'm hoping that the weather out here in California starts to improve soon. It's been raining off and on for about 3 days now and my peddling feet are getting itchy. I weighed myself a couple of weeks ago and I'm running at 220lbs @ 6'3". According to the doctoring world, that puts my BMI smack dab in the middle of "Overweight."

Theoretically, I should lose 40lbs to put me in the middle of the "Normal" range. I don't know what great F***ing doctors made these numbers up but that's nuts. At 180lbs, I somehow I think I'd look emaciated. No wonder girls in this country have a ridiculous expectation of height and weight to be "attractive." That being said, my goal is to hit 200 this spring season. 20 pounds would be a good place for me and to be honest, I don't think I've gained or lost weight for about 5 years. I could sit on my duff or exercise pretty much every day but my weight is alwyas +/- 5 lbs of 220.

Kinda makes you wonder doesn't it? ]]> Willis http://www.mikesimonds.com/blogs/willis/8-want-ride-my-bicycle.html http://www.mikesimonds.com/blogs/willis/7-content-its-whats-dinner.html Wed, 17 Feb 2010 16:22:58 GMT Just got back from a week in Dallas and let me tell you, a foot of snow when you're unprepared for it sucks. I know it's only a foot and the East Coasters on this site are probably laughing at me but I'm a California guy... I get weird when I don't see the sun for 4 days let alone have to wake up to 26 degree weather. Good and productive week nonetheless and I gotter' done (hey when in Rome right?)

While in the Lone Star State, I got an e-mail from someone at my company asking me to make Salesforce.com's content offering the new gold standard for documentation. Personally, I like the features that content has but I'll be damned if their permissions aren't a web of Whiskey Tango Foxtrot. I haven't had a lot of chance to work with it yet, but I'm envisioning the rights management and access restrictions as the most time consuming thing out there. Apparently, we're not only looking to replace current existing document storage systems but we're also looking to it for a Dreamforce type shindig coming up in a few months. My boss has asked us to make sure that all the content is available to specific users within specific groups that (surprise) do not follow or respect the groups that we have built in our org.

If any of you have suggestions, best practices, or know of any gotchas with Content, let me know.

As much as I complain about it, I find myself looking forward to it. It's something new for me to learn, to fumble through and ultimately to figure out and that makes the day go much much faster.

Cheers,
~Will ]]> Willis http://www.mikesimonds.com/blogs/willis/7-content-its-whats-dinner.html http://www.mikesimonds.com/blogs/willis/6-mikes-brain-im-ugly.html Tue, 02 Feb 2010 20:44:46 GMT Mike and I have known each other on a professional level for a few years now and I've had the good fortune of calling him a friend as of late. He's asked me to come to his website to think and write about the Salesforce System Admin role and see what questions of the world I could possibly help answer. I was hesitant, the stuff that I've seen on these forums is way over my head 90% of the time but I figure I'd take a shot to see what was out there.

My experiences in the role have been comprehensive to say the least. Mike tends to agree that the level of architecture work that I do far exceeds what a system admin's typical role is defined as; this is all conjecture of course because I've never had the same role at any other company.

I wanted to invite questions and comments from the user community. What do you want to hear about? What problems are bugging you? How can I help?

Hopefully through my idle ramblings, I can help shed some light on some problems that you are or will have. ]]> Willis http://www.mikesimonds.com/blogs/willis/6-mikes-brain-im-ugly.html