More Tales of American Health Care

I periodically post here, on Facebook, or elsewhere about confounding health care experiences. I’m relatively young, relatively healthy, and have very simple care needs. The failures I experience worry me because they imply that people with more complex or urgent needs are likely being even more poorly served. All of my experiences are with managed care providers. The most recent is with Kaiser Permanente.

I had symptoms that presented as a simple stomach ailment. I won’t go into the details because, as you might expect, they are not fun. After 96 hours of being barely able to eat, and having lost over 6 pounds of body weight, I decided it might be worthwhile to call the Kaiser consultation line and get an expert opinion as to whether I should take any further action or simply let it run its course. I was specifically concerned because I was going to need to travel for work, so I thought talking to a nurse would help me decide if the trip should be cancelled.

The phone tree was mystifying, as always. I kept being transferred to the wrong place, but after talking to three people I landed on a pre-screener who asked a few simple questions and, based on the answers, determined that I had no use for a phone nurse but instead needed an in-person appointment. He transferred me to appointments. They told me that none were available, and I should go to urgent care instead. And so off I went.

After the expected hour or so of waiting around and repeating my symptoms to three different people, the doctor gave me a cursory exam and confirmed that it was, indeed, a simple stomach virus which would run its course. He offered to do additional blood work, which I declined, and prescribed some medication to help with symptoms.

This is all fine, I suppose. If someone could make a cheap home combination blood pressure cuff, pulse/ox, and stethoscope that plugs into an iPhone, that would probably eliminate 20% of routine office visits. It’s the 21st century, where’s my telemedicine?

Anyway, the interesting bit is the prescription. You see, modern pharmacies have complex software to check for possible drug interactions. That’s in addition to the job of the doctor and the pharmacist, of course. I’m no expert, but reading the printout that came with the prescription immediately raised alarm bells. Dr. Internet suggests that taking this stuff could be a Very Bad Idea as in some cases it interacts with something I’m already taking to cause fun symptoms like coma. Now, I’m no expert, and I may be wrong about whether this is really dangerous. But yikes!

So I called Kaiser. The pharmacist I spoke to suggested tapering off the other medication while taking this one. I suggested that seemed ridiculous given the other med’s long biological half-life. He stumbled around a bit, and said he would have my doctor follow up. Right. In the meantime? Unclear.

Maybe it’s fine. But I’m sufficiently freaked out/miffed that I’m not touching the new stuff, and am just going to have to suffer the old-fashioned way. And I’m concerned about Kaiser’s capacity to effectively treat me while keeping me safe from iatrogenic effects.

Update (2017-05-04): I never received the promised follow-up call.

The internet is weird. While trolling through YouTube I stumbled upon a “related” video by a channel called SourceFedNERD. The hosts were hilarious and the content enjoyable, so I clicked over to subscribe. The very next video of theirs I watched turned out to be an announcement that the channel was shutting down. It was posted last week. I could have found this channel at any point since early 2012, subscribed, participated and enjoyed their content. But instead I found it today.

How Subtle Class Cues Can Backfire on Your Resume

This study of hiring practices by top-tier law firms comes to unsurprising conclusions. But the methodology and specifics are interesting. For example, “even though all educational and work-related histories were the same, employers overwhelmingly favored the higher-class man. He had a callback rate more than four times of other applicants and received more invitations to interview than all other applicants in our study combined. But most strikingly, he did significantly better than the higher-class woman, whose resume was identical to his, other than the first name.”

Spit and polish

My grandfather, Ralph Silverman, trained as a chemist at Indiana University on the GI Bill after serving in the Army Air Corps during World War II. In 1960 he uprooted his family and moved to California to form his own business manufacturing cleaning chemicals. Through grit, hard work, determination, and a little luck, he built a successful enterprise and gave his family a better life. It is a classic American Dream story, and fifty-seven years later, Maintex is a thriving facilities solutions company.

As a child I would go into work with my dad and help grandpa open the mail: checks in one pile, bills in another. As a teenager I worked part of my summers on the company’s catalog and web site. My first major programming accomplishment was designing a content management system for Maintex at age 14. While in college I helped maintain the servers that ran the web site, email, and FileMaker database.

While some employees assumed I would move into the family business, my parents and grandparents encouraged me to pursue my own dreams. I had the privilege of graduating from university with no debt thanks to my grandparents’ generosity, and I was able to successfully pursue a career in information technology.

The rest is well documented on this blog. I built a life in Boston, forming friendships, getting married, buying a house, and working in tech. I moved between several jobs, advancing my career but never quite satisfied with my role and level of responsibility.

All along, Maintex kept gnawing at the back of my mind — the amazing opportunity and awesome responsibility of potentially stewarding a multi-generational company. A company with a mission and purpose. A company that provides for the livelihoods of hundreds of employees.

It was a massively difficult decision. Meghan and I eventually came to the conclusion that I needed to give it a serious try. I plan to spend the next six months learning the ins and outs of the business, and contributing as much as I can. As I do so, I am very cognizant of the risks and potential pitfalls of coming into a family business in the third generation. To that end, my aim is to observe as much as possible and ask a million questions, especially in the areas where I know the least. I think I’m in a good position to do this — I have never been afraid to expose my ignorance!

Once this insight is offered, it must be said, everything else begins to fall in order. The recent Super Bowl, for instance. […I]t is exactly what you expect to happen when a teen-ager and his middle-aged father exchange controllers in the EA Sports video-game version: the father stabs and pushes the buttons desperately while the kid makes one play after another, and twenty-five-point leads are erased in minutes, and in just that way — with ridiculous ease on the one side and chicken-with-its-head-cut-off panic infecting the other.

Adam Gopnick, “Did the Oscars Just Prove That We Are Living in a Computer Simulation?”

Another Final Day

Friday was my last day as an employee of Brightcove. It has been a whirlwind 2 years and 8 months. After so much time in higher ed, a stint at a product-driven technology company was a breath of fresh air. I got to work with some incredibly talented people, and was given the opportunity to expand my knowledge and experience in exciting new ways.

In terms of buzzword compliance, Brightcove does pretty well. The majority of the company’s product suite is run on top of cloud computing providers like Amazon and Google. The technology stack utilizes a distributed, service-oriented architecture, with the microservices exposed via public APIs.

As a complex online video platform, Brightcove’s stack includes workflows for ingesting and transcoding video and other assets, centralized content management, pipelines for packaging assets and generating video players, global distribution using content delivery networks, and complex analytics using tracking beacons. In total over 100 distinct deployable services contribute to a seamless end-user experience that can reliably accommodate hundreds of millions of daily video views around the world.

Brightcove occupies the third and fourth floors of the Atlantic Wharf complex on the Boston waterfront

I joined the Systems Engineering team, and worked as a Senior and then Principal engineer, focusing on both operational execution and, increasingly, designing and building complex core infrastructure projects. I was pushed to create elegant and reliable solutions, but also to evangelize technologies and approaches across development teams.

Brightcove’s engineering organization is composed of many independent teams, each of which makes its own decisions about how software is built, deployed, and managed. The advantage of this approach is in agility and speed. The trade-off is that it can lead to a plethora of different languages, tools, solutions, and techniques — in short, an accumulation of technical debt.

Much of my challenge was in convincing disparate teams of the advantages of adopting common tools and techniques and standardizing deployment and service management. This task was at times enjoyable, but often frustrating. The incentives for teams are to deliver on product commitments, and this often leaves little time for work that is not customer-visible.

This challenge is common in my realm; some companies solve it by creating a Site Reliability Engineering team, although this typically bifurcates operational responsibility for services from engineering responsibility. On the whole, I like Brightcove’s approach of keeping engineering teams responsible for running their own services. I hope that the pendulum moves a bit, and the Systems Engineering team’s unique role become more valued and supported over time.

The thing I will miss the most about Brightcove is the community of people, both in person and on chat, who made every day a chance to learn, grow, and have fun. I’m not sure I’ve ever laughed so much at work before, or had so many interesting in-depth technical discussions. Culture is a hard thing to cultivate. Brightcove’s senior management and the supporting cast, like our amazing office services team and our HR business partners, work really hard on this, to their credit.

I’m leaving Brightcove for a unique opportunity outside of technology that involves a management component. I never thought I wanted to be on a management path, but now I’m giving it a try, in part due to my experiences at Brightcove. More on the new gig in a future post.

Geeking Out

A month with the Touch Bar, and that’s enough

I purchased a new Apple laptop because I needed one, not because of any particular advertised feature. The Touch Bar models were better specced, so I grudgingly ended up with one. Today I finally turned off the Touch Bar’s “App Controls”, returning it to the standard function layout.

I don’t know how other people use computers, but I expect I’m in the majority as someone who keeps my eyes and attention focused on the display while typing. The term “touch typing” refers to the skill of being able to type by touch without needing to look at the keyboard. Thus, creating a “Touch Bar” — a flat capacitance screen with constantly shifting tap targets and no physical cues as to button location — is the exact opposite of a touch typing innovation.

The Touch Bar is very clever in the way that it dynamically updates with buttons relevant to each app. But we already have a mechanism for that functionality — a massive backlit screen that updates 60 times per second. I’m not sure that a touch screen laptop is useful, but being able to touch a target where I’m looking makes a lot more sense to me than having to change my focus away from the massive display screen I spend all my time working on in order to glance down at a tiny set of touch targets in a location where I have trained myself to never look.

Is the Touch Bar an innovation? Reviews are mixed, mostly taking a wait-and-see attitude. But I’m willing to call it now — the Touch Bar is a step backwards. Before, I had trained myself to know by touch how to change volume, brightness, and music. Now those buttons have no tactility. Just because something is new does not make it innovative. Just because you can create a whiz-bang bit of gadgetry does not mean you should.

Geeking Out

Update on 2016 tools and productivity enhancements

Last year this time I wrote about changes to the tools and processes I use for personal productivity. This is just a brief update on where things ended up.

Document storage

Switching from Neat to Doxie was a failure, the multi-step scanning process and poor software integration made it a non-starter. I am still stuck with a Neat scanner that works less and less reliably with each Mac OS update, and a software suite that is now officially unsupported and unmaintained. I still have not found a better solution for scanning and keeping track of the small quantity of critical paper documents that I receive.

Note taking

I have abandoned Evernote as bloated and unworkable, as planned, but found Ulysses too be overly focused on writing long-form documents, whereas I need a general note-taking application. I have been using Quiver, a notebook focused on programmers who want to store code snippets, and found it to work reasonably well for all types of notes. I frequently get into trouble due to the lack of a full-featured iOS app.

I have been playing with Bear, a late entrant that is also a plain text/Markdown note taking app, and I’m generally pleased with it. But the import from Evernote is poor, and there are a few important features that are still missing.

Bookmarks and reading

Instapaper is still my favorite app for offline reading. Using Pinboard for shared/social bookmarking, however, was a bust — if the bookmark is not in my browser, I am not going to find it or see it. Instead I have switched to using Chrome on iOS so that my bookmarks and browsing history stay in sync between platforms.

Task management

Abandoning Things for 2Do was an overwhelming success. The features of 2Do work much better for me. But the lack of integration with other tools and/or a cloud component continue to hold it back from true excellence.

For more complex project management I have taken a look at a variety of tools including the venerable Basecamp (too opinionated, too wordy) as well as Asana (poor iOS app) and Flow, but I’ve fallen back to the trusty and flexible Trello.

Conclusion

Well, it’s good to try new things. With the plethora of tools and apps available, there should be something that fits everyone, but I still haven’t found the perfect set of apps for me. In particular, the Neat hardware/software is an (expensive) disaster, and there doesn’t seem to be a better tool for simply scanning, OCRing, and searching receipts and documents. But I will keep looking in 2017!

I have been moving more of my writing to Markdown format, and that makes it much easier to switch between apps. It would be easier still if every app supported the same set of Markdown formatting options.

On Charter Schools and State Ballot Initiatives

There is intense debate in Massachusetts right now around Question 2, a ballot initiative aimed at raising the cap on public charter schools. I am generally of the opinion that legislating through ballot initiatives is a poor idea (with all the normal downsides of direct democracy). This being New England, we experience the flaws of direct democracy perennially at our horrible “town meetings,” which is apparently not enough to discourage proponents of ballot initiatives.

Which leaves us with Question 2, and the requirement for a simple “yes” or “no” vote. I have been a big believer in public charter schools ever since attending Santiago Charter Middle School in Orange County, California. Before that I attended a magnet program that was also excellent. Both were formative experiences that I believe profoundly affected who I would grow up to become.

I have no experience with privately run charters. I was in a very diverse environment, but as a student on an accelerated learning track my classmates often looked like me, and my experience has no relevance when discussing the needs of underserved populations. My school district was run at the county level, with over 20 elementary schools. My middle school of approximately 1000 students is roughly the same size as the entire enrollment of the school district of Hull, where I currently reside.

Santiago has 42 credentialed educators providing a diverse range of programs including wood shop, theater, dance, Chinese, and various other additions to standard, remedial, and honors curriculums. Hull’s Memorial Middle School has a quarter of the students but almost half the teachers, spends vastly more per pupil, and offers far fewer programs. Economies of scale cannot be achieved unless towns are willing to regionalize their school systems, which seems extremely unlikely to occur.

Which is all to say, educational policy and funding is extremely complex. A yes/no ballot question on charter caps is a very coarse instrument for making policy improvements. And based on my education, experience, and research, I cannot offer a concrete conclusion on whether passing Question 2 will improve things in aggregate, or not. From what I have read, the impacts of Question 2 in the first few years will be primarily in Massachusetts’ larger cities, while the majority of the opposition comes from its smaller suburbs. I don’t want to see public school districts anywhere suffer from decreased enrollment to competing charters if it negatively impacts educational outcomes. But I’m also not sure there is a better policy prescription than charters for continuing to experiment with new programs and approaches for education.

On balance, I think the benefits of more charters at least slightly outweighs the potential downsides.

White Trash Triptych

As a student of American civilization, I continue to work to understand what drives supporters of Donald Trump’s presidential candidacy. The many media narratives to choose from are universally simplistic and self-reinforcing. The more I read, the more muddled my thoughts become.

The people I know who support Trump do not fit the narratives being peddled, and the people I know who should fit those narratives are not Trump supporters. One thing I know for sure is that the simplistic characterization of Trump followers as rural working-class white “trash” is an easy crutch for urban elites, but a false one.

I have been thinking about this and reading about it for months, for years, if you go back to the rise of the Tea Party movement, but even still I cannot form my thoughts into prose. I will delete the many paragraphs I have spent so long writing and instead simply link to a few of the stories I have found most compelling and enlightening. They don’t all agree with each other, but they are all good food for thought.

As I write this the odds are somewhere in the 90% range that Hillary Clinton will be the next president. But even if she wins, and even if the Democrats take back control of one or both houses of Congress, the Trump supporters are not going to disappear, and the problems of rural whites are not going to magically get better.

Two perspectives of the urban vs rural divide and the plight of the white working class, the first more irreverent than the second:

A long read that discusses the social science around white nationalism and traces its roots and effects around the world, going back to World War II:

And finally, two articles discussing recent books on the subject, Strangers In Their Own Land, about the Tea Party movement, and Hillbilly Elegy, a memoir of growing up in an Ohio steel town:

Ahmad Khan Rahami Is Arrested in Manhattan and New Jersey Bombings

I do not want to see bombings become a normal part of American life. But, much like homicides, robberies, and drunk driving, we cannot let individual incidents of violence terrify us or change how we go about our lives. Informed, engaged communities; committed, dedicated police and investigators; trust in the power of a democratic society to bring justice — this is how we remain resilient and free.