Tech

Reality-Based Policy and the Digital Doctor: An Interview with Mark Smith

Mark Smith

Mark Smith, MD, MBA, was the founding CEO of the California HealthCare Foundation; he served in that role for 17 years before stepping down last year. I’ve known Mark since we were residents together at UCSF in the mid-1980s, and both of us were influenced by training at the epicenter of the AIDS epidemic. Mark continues to see AIDS patients at San Francisco General Hospital one day each week. He was the lead author of Best Care at Lower Cost, a major Institute of Medicine report, published in 2012. Mark is one of those rare people who can take complex and politically charged concepts and distill them into sensible nuggets – while managing to be hilarious and profound at the same time.

In the continuing series of interviews I conducted for my upcoming book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Agehere are excerpts of my interview with Mark Smith, conducted on July 24, 2014.

Bob Wachter: Put yourself back about 10 or 15 years ago when you were thinking about the promise of healthcare IT. As you’ve watched the last 15 years play out, what’s been surprising to you?

Mark Smith: As with most of life, it’s a lot harder in fact than in theory. My first hint of this came with the implementation of computerized order entry at Cedars-Sinai in 2002. [In a story I tell in the book, Cedars’ physicians all but threatened to go on strike after they turned on the clunky system. Within a month, they pulled the plug on the system, a hiccup that cost the organization $34 million in 2002 dollars.] That was my first window into the gap between what sounds lovely in a policy paper, and what it means in practice to implement this stuff.

Some of the issue is generational. As it turns out, a lot of other things that older doctors find troubling and resist – such as protocol-based care and quality reporting – track nicely with the tools through which they are supposed to do these things, namely IT.

When I talk to groups of docs, I always start by saying there are at least three groups of you here. There are younger docs who find all this stuff completely rational – it’s part of your vision of medicine. There are older docs who, depending on the state of your Roth IRA, are basically done. You’re not going to change a lot, and when you are finally forced to… fuck it, you’re done.

Then there’s a fairly big group in the middle that is caught between their expectations and the reality. That is where the grumpiest and the most scared people are. That is the group we’ve got to concentrate on. My sense is trying to get every single doc to use the technology or to feel comfortable with it is a lost cause. They will eventually retire, move off the stage, or be in practices that will eventually wither and die.

BW: I wonder whether that middle group is angry at technology because it has invaded their space. There it is, and you can pound it with your fist. It’s easier to be pissed off at your computer than at the National Quality Forum, Medicare, the Joint Commission, etc.

MS: Yes. It’s a little more visible and a little more understandable for people.  If you’re a practicing doc, the RUC and Meaningful Use and the SGR – these are abstractions. But when someone says the ergonomics of your everyday practice are going to change in the following way, that becomes the focal point for a lot of your anger and resistance.

BW: Do you have any theories as to why, in this industry that represents one-sixth of our economy, the information technology systems are so bad?

MS: I think a lot of it is in the economics. In healthcare, the reimbursement policies are at best neutral and often are inimical to IT adoption. There’s a wonderful article on the adoption of EMRs in Hawaii, at Kaiser. It turns out they had a lovely before-and-after natural experiment. When they implemented their EMR, patient satisfaction went up; provider satisfaction went up; quality measures went up; visits dropped by 27%. Now, at Kaiser that’s a good thing. But for most of American medicine, that’s an economic disaster. To the extent that the world is still largely driven by volume, and one of the first effects of consumer-oriented IT is to decrease the volume of traditional visits – well, it’s no secret why that doesn’t happen naturally.

The second is that if you think about a company’s motivation to make easier, more intuitive, more beautiful IT for your phone, it’s because if they put it out there, people will gravitate to it and they will make a bunch of money. That’s not the way the IT in healthcare gets adopted or sold. It’s largely one corporate executive selling to another corporate executive, and the docs and the nurses have no say. The instant market gratification of putting out something that people really like, something that’s easy to use – that feedback loop doesn’t exist, because health IT is still largely a B2B [business to business] phenomenon.

BW: If you were in Washington in 2008 and somebody gave you $30 billion to spend on health IT, would you have spent it the way the government did?

MS: My sense is that they missed an opportunity to impose or to bring about standards, which would have let the IT people compete on the interface. In other words, if the backbone of the data were standardized, then you could have IT companies not competing on standards, but competing on the beauty of their interface, the intuitiveness of their interaction with providers. What we have instead is competition all up and down the vertical, and that I think is the tragedy.

That’s the magic of HTML, right? Most people have Windows, some people have Macs, some people have Linux – you can choose whatever interface you like. Companies compete on the intuitiveness, the attractiveness, and the beauty of the interface.  Whoever does that well will win.

Smith’s California HealthCare Foundation was the major funder, to the tune of $10 million, of one of the first efforts to build a regional health information exchange, in Santa Barbara, California. After a few years, it failed. I asked him to reflect on that experience.

MS: The central lesson was that, despite all the rhetoric about what happens if your patient was in an emergency room across town, there was no convincing business model about why people should spend private money for this public place.

The reality then, and I believe now, is that if your objective is to improve care, that has much more to do with improving communication within the clinical ecology in which most patients get most of their care than with having some universal communication between ecologies.

At a recent talk, somebody asked me, “Well what if the patient is in an ER across town?” I said, when I was a resident, if they were in an ER across town, you picked up the damn phone and called them.

It’s not that that a robust information exchange wouldn’t be a good thing, but, given what it takes to create that kind of public good compared to how often that happens and its impact on day-to-day quality of care – it just wouldn’t be my first priority.

But that was then, this is now. Part of what’s happening is that those docs who were semi-independent 10 years ago are now in an ACO or have been bought. With consolidation comes a greater opportunity for a unitary system, within an ecology. These ecologies are getting better and better, and more and more sharply defined all the time.

The other thing is, the technology’s a lot better. At the time you didn’t have the easy possibility of data sharing and interchangeability without people actually all giving their data to one big database. Now you do.

We turned to the question of patient portals. I asked Smith how important patient access to their own data is, and where he sees this area heading. Both of us were on the Google Health advisory board, an effort by the company to create an early consumer-facing healthcare portal. It failed miserably, and Google pulled the plug on it in 2012. He began by discussing another corporate effort to provide data to patients.

MS: I was also on the Qualcomm Life Advisory Committee. Of course, they’re pushing to allow everybody to have access to their data, 24/7, anywhere in the world. I remember one meeting where somebody said, “You know, it’s like your credit score, you can hit a button and get your score!” I asked him, “How often do you check your credit score?” Once every six or eight months, you don’t do it five times a day. I would argue if you’re checking your blood pressure every hour, then you’re a self-monitoring narcissist. Not an average human patient.

But it’s clear that patients do want access to their health system, they want engagement and co-management, they want co-production of their care.

I remember five years ago, when George Halverson [CEO of Kaiser Permanente at the time] would talk about Kaiser’s EHR, he would talk about it in Washington policy-wonk terms – how it was improving quality, how they can quickly detect side effects of new medications. Now, when I drive to the Oakland airport, I see a big sign that says, “Talk to us your way. In person, on the phone, online.”

From a patient standpoint this is less about monitoring your information, and more about electronic interaction with your healthcare system. I think within a few years if your organization can’t do that, it’s dead in the market. Once you get used to checking your lab results on your phone the day the blood was drawn, you’re never going back to, “Come in next week and we’ll talk about it.”

I turned to the ever-present question of the role of doctors in a future IT-enabled healthcare system.

MS: I’m old enough and perhaps stodgy enough to believe that, to many patients, a personal relationship with someone (often, though not always, a doctor) is an important part of the co-production of their health. That will never be replaced by a computer.

BW: Never?

MS: Yes, never.

BW: Okay.

MS: At the same time, it is neither economically sustainable nor socially necessary to have doctors doing low-value tasks. You and I both know that doctors generally overvalue the relationship with their patients – they think they are more important in their patients’ lives than their patients do. They think they spent more time with them than they did. They think they explained things to them that they didn’t. They think that their patients are more loyal to them than they actually turn out to be.

Look, all of us had to learn how to be doctors given the systems in which we worked and the technology that was available. At the time when a stethoscope was the best way to discern an S3, we learned how to use a stethoscope. That has now become not just a tool but part of our nostalgia about what it means to be a doctor.  But it’s no longer the best way to figure out if a patient has a failing ventricle.

If we lament the passage of the stethoscope, and say that the iPhone is evil technology that somehow interferes with the doctor-patient relationship, that’s just silly. It is possible for you to have your patients’ data at hand and still look that patient in the eye. You may have to rearrange your workday. You may have to rearrange your office. You may have to re-jigger the order in which you do things in your visits, but that’s adapting to new technology. At one point the stethoscope was new technology.

I am fundamentally excited by all this. Just as I am fundamentally excited by the technological advancements in drugs and devices. When I speak now, I almost always end with the story of my 71-year-old patient who has AIDS; who just had his hip replaced; who walks his grandchildren to school every day; who takes one pill once a day for his HIV. It’s a miracle.

BW: Unbelievable.

MS: I take more medicine than he does. You can’t help but be excited about what we can do for patients.

All right, so you’re going to have to incorporate these new technologies into what you do, and you’re going to have to figure out what there is that’s essential about your communication with this individual. People always resort to bemoaning the threat to the doctor-patient relationship – it’s the last refuge of scoundrels.

In my practice at San Francisco General, I’ve had the experience… I don’t know if it’s a good thing or not, but I think it’s a good thing so I’m going to keep doing it. When a patient asks me a question, I sometimes say, “You know, I don’t know the answer, let’s look it up.”

“What are your chances of developing liver cancer with hepatitis C? I want to say it’s about 14%, but I don’t know, let’s look it up.” I’ll turn the screen around and type in the search and go to a curated and reliable website, and we’ll read the answer together.

This is contrary to everything I was taught about the importance of instilling confidence in my patients by showing that I knew these things. I’m actually much more comfortable now saying, “You know, that’s a number I don’t keep in my head. And I don’t have to – let’s look it up.”

In some ways that is a marker for the issues we’re talking about. What is the essential role of the doctor, and what are roles that are better played by other people, or by technology? My forte, as a physician, is understanding what question you’re asking and trying to get you the answer, as opposed to trying to pretend that I remember all these things.

Robert Wachter 

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25 replies »

  1. “I came away with some sympathy for David Blumenthal’s point of view (I’ll post his interview in a week or two): that getting computers into hospitals and doctors’ offices was the crucial first step, a necessarily precondition before we focused on getting the machines to talk to each other. In retrospect, that may have been a policy error, but – given the facts on he ground at the time – it was a reasonable path for the feds to take.”

    This absolutely was a policy error. And there were PLENTY of people advising him (and Farzhad) that this was the case.

    HITECH implementation was focused around showy illusory progress (look – lots of adoption!) and the related issue of not forcing vendors to re-architect their system to be interoperable (and usable) from the start (which would have taken time / delayed said illusory progress).

    Ron

  2. He mentions one example that EHR reduces patient visits….(“one of the first effects of consumer-oriented IT is to decrease the volume of traditional visits”). I very much doubt this is generally true…..it may be part the “vision” of what EHRs might do…..always the promise that the wonderful results are just around the corner. I would be interested if you have any references that support his assertion.

  3. correct: had to hire a bunch of quality care nurses who did massage the data to make me look great on paper……….now i have to pay for them as well.

  4. Your group obviously doesn’t have a Kaiser-quality Dept. of Metric Massage and Manipulation.

  5. “When they implemented their EMR, patient satisfaction went up; provider satisfaction went up; quality measures went up; visits dropped by 27%.”

    unfortunately when we adopted the emr: visits dropped 25%, our 80 doc physician owned group went belly up, bought by hospital, placed on volume driven model, visits went back up, patient sats went down, compensation tied to patient sats went down, visits had to go up again, quality measures went down, comp tied to quality went down, visits had to go up…..rinse and repeat.

  6. “And the vibrancy of the Silicon Valley healthcare ecosystem (with investment dollars flooding into health IT) is another secondary effect of healthcare finally hitting its digital tipping point”

    And that’s why I’m a doctor: so I can send dollars to Silicon Valley.

  7. After interviewing nearly 100 people for my book (including 4 of the 5 ONC directors), I came away with some sympathy for David Blumenthal’s point of view (I’ll post his interview in a week or two): that getting computers into hospitals and doctors’ offices was the crucial first step, a necessarily precondition before we focused on getting the machines to talk to each other. In retrospect, that may have been a policy error, but – given the facts on he ground at the time – it was a reasonable path for the feds to take.

    And, when you look at the sharp uptick in the adoption curve for health IT over the past five years (now up to 70% penetration of EHRs in hospitals and doctors’ offices, up from 10% in 2008), HITECH met its primary goal: transforming the healthcare industry from a mostly analog business into a largely digital one. The focus on interoperability today is welcome and, to me, represents a predictable second-order phenomenon. And the vibrancy of the Silicon Valley healthcare ecosystem (with investment dollars flooding into health IT) is another secondary effect of healthcare finally hitting its digital tipping point.

  8. That’s what was on my statement. Of course, my high-deduct piece was $121. I’m sure the “$436” is akin to a “chargemaster” accounting fiction. I have no way to know what Muir actually got paid.

  9. Why in the world does BC/BS have a $436 office visit in their approved fee schedule?

  10. “Once you get used to checking your lab results on your phone the day the blood was drawn, you’re never going back to, “Come in next week and we’ll talk about it.”
    __

    Yeah.

    From my 2015 WinterTech post: ( http://tinyurl.com/oshbaeu )

    “…I am effectively without a Primary these days. After I retired from the REC, sold the house in Vegas in September 2013, and moved over to Contra Costa County, I ended up in the Muir system. My new doc there is a nice young Internal Med D.O. whose answer to everything is to refer me to a specialist — even to get a dad-gumbed scrip refilled! e.g., from one of my TCHB comments:

    [png screen snip]…

    It’s Tramadol 50 mg. I have some bulging disks and pinched nerves (“cervical and lumbar spondylosis with myelopathy”), in part the upshot of too many years of getting the crap knocked out of me while pursuing my absurd decades-long full-court Hoop Dreams, (I have the attestational eyebrow suture scars, and torn meniscal and MCL vestiges), followed by too many recent years of too much sitting, reading, and blogging for hours and days on end.

    I usually took one Tramadol a day, in the early morning upon arising (even though the scrip said ‘one every 4-6 hours as needed’). On bad days, I’d drop a 2nd one mid-day. They helped. Materially.

    Given that DEA recently “rescheduled” Tramadol, I can’t help but wonder whether my young doc wants to keep his fingerprints off the Rx. I’d given him my entire longitudinal Hx from my Vegas Primary, dumped from the EHR. I fail to see the point of doing an expensive encounter with yet another physician — one who doesn’t know me, and who will have to redundantly (and expensively) read the chart, listen to (or blow off) my CC Subjective, and either bless or deny the simple Rx request.

    I note on the EOB that Muir charged me and my BC/BS $436 for each primary care visit (Cheryl and I are now on high-deductible HSA). I dutifully underwent the PT regimen he wrote me for (it helped a bit). I dutifully do my exercises. My cut of the nearly $3k for that was just shy of $1,200. My paid OOP for 2014 came to about $3,600 (welcome to the ACA). For a lot of people, that might be extremely painful in its own right.

    Knowing that I would have another annual visit coming up, I went into Muir’s portal to schedule it and request a lab draw order (blood and UA panels) to avoid another $436 charge for a pleasant (MU-compliant) 30 minute 99213 chat just to essentially pick up a lab slip and incur yet another charge for the f/up.

    He refused. Had some Muir employee call me the following week with the news. Didn’t respond (for the record?) to my portal email.

    I told the caller to just cancel my appointment request.

    Maybe Doctor on Demand won’t be able to help me. The cost of finding out will be nil. I’ll pay by credit card.

    Had I the right iPhone apps (suitably QC vetted, of course, for clinical accuracy and precision), I’d prick my finger, pee in a cup, and run the specimens for my own labwork. Maybe most patients aren’t competent to evaluate them. That is not the case with me. I know what to look for, what safely seems negligible, and what needs MD attention.

    Dr. Topol:
    Patients are intrinsically remarkably smart—they know their own bodies and the context of their lives—and no one has a bigger interest in their own health. That doesn’t mean, however, that they do all (or any of) the right things to stay healthy, but when things do go wrong, they are pretty darn good at detecting a problem. But we’ve learned that, in general, doctors don’t like smart patients. In fact, a recent study of physician attitudes found that: “patients who have in-depth knowledge of their condition encounter problems when their expertise is seen as inappropriate in standard healthcare interactions.”

    Those attitudes won’t be enough to hold back a whole new generation of even smarter patients and hopefully more supportive and smarter doctors. Indeed, they’re already all around us. [ibid, pg 8]…”

  11. “I’ll turn the screen around and type in the search and go to a curated and reliable website, and we’ll read the answer together.

    This is contrary to everything I was taught about the importance of instilling confidence in my patients by showing that I knew these things. I’m actually much more comfortable now saying, “You know, that’s a number I don’t keep in my head. And I don’t have to – let’s look it up.”
    ___

    Lawrence Weed 101.

  12. “BW: If you were in Washington in 2008 and somebody gave you $30 billion to spend on health IT, would you have spent it the way the government did?

    MS: My sense is that they missed an opportunity to impose or to bring about standards, which would have let the IT people compete on the interface. In other words, if the backbone of the data were standardized, then you could have IT companies not competing on standards, but competing on the beauty of their interface, the intuitiveness of their interaction with providers. What we have instead is competition all up and down the vertical, and that I think is the tragedy.

    That’s the magic of HTML, right? Most people have Windows, some people have Macs, some people have Linux – you can choose whatever interface you like. Companies compete on the intuitiveness, the attractiveness, and the beauty of the interface. Whoever does that well will win.”
    __

    I’ve been arguing that point FOREVER. e.g.,

    “One.Single.Core.Comphrehensive.Data.Dictionary.Standard

    One. That’s what the word “Standard” means — er, should mean. To the extent that you have a plethora of contending “standards” around a single topic, you effectively have none. You have simply a no-value-add “standards promulgation” blindered busywork industry frenetically shoveling sand in the Health IT gears under the illusory guise of doing something goalworthy.

    One. Then stand back and watch the private HIT market work its creative, innovative, utilitarian magic in terms of features, functionality, and usability. Let a Thousand RDBMS Schema and Workflow Logic Paths Bloom. Let a Thousand Certified Health IT Systems compete to survive on customer value (including, most importantly, seamless patient data interchange for that most important customer). You need not specify by federal regulation (other than regs pertaining to ePHI security and privacy) any additional substantive “regulation” of the “means” for achieving the ends that we all agree are necessary and desirable. There are, after all, only three fundamental data types at issue: text (structured, e.g., ICD9, those within other normative vocabulary code sets, and unstructured, e.g., open-ended free-form SOAP note narratives), numbers (integer and floating-point decimal), and images. All things above that are mere “representations” of the basic data (e.g., text lengths, datetime formats, Boolean/logical, .pngs, bmps, .tiffs, .jpegs etc)…

    From my February 2014 post “We should not prescribe specific functionality for the EHR other than interoperability and security.”
- John Halamka

    http://tinyurl.com/kebjk4u

  13. Great interview, useful insights. I like especially the discussion of the market reasons for such terrible EMRs: It’s a B2B decision that leaves the actual users out; there is no standardized backbone; and well-designed EMRs actually drive down utilization, which in a code-driven fee-for-service system is your bread and butter. From the point of view of the actual buyer (the institution) there are few or no economic incentives to get it right, and actually some incentives to get it wrong.

  14. “ My sense is that they missed an opportunity to impose or to bring about standards, which would have let the IT people compete on the interface. In other words, if the backbone of the data were standardized, then you could have IT companies not competing on standards, but competing on the beauty of their interface, the intuitiveness of their interaction with providers.”

    Mark Smith, my initial thought was that your statement was an excellent summary. I still feel that way, but believe it is dependent upon what the bureaucracy believes need be contained in the standardized backbone of the data. We generally see some standardization in industry without such a backbone as designers compete with one another. Can you give us an idea of what that backbone should be?

  15. “At one point the stethoscope was new technology.”

    It’s a matter of functional use. One doesn’t need a stethoscope to examine an ingrown toenail and there was no mandate to use one. Physicians are some of the first to jump on new technology that improves their care and sets them apart from others in their field.

  16. Barry, if you feel something is necessary for the hospital and doctors to know place the information on the back of your Medicare or insurance card. In some areas with high senior populations the paramedics know to look on the refrigerator for this information.

    The physician doesn’t need much to go on. Among the most important are meds, allergies, physicians, important diseases, and DNR if that is what one wants.

  17. Excellent points Dr. Palmer.

    In my experience as a patient, especially in emergency rooms, one thing the doctors and nurses always want to know is what drugs I’m taking. If I’m conscious and not disoriented, I can usually tell them. I also have them registered with Medic Alert and my wife carries a copy in her purse. However, many patients can’t tell the docs what drugs they take because they can’t speak, don’t know or can’t remember. Do you have a preferred solution to this issue such as, perhaps, a registry only accessible to providers on a need to know basis but not employers or other non-medical people?

  18. A couple of excellent comments from the piece:

    “the gap between what sounds lovely in a policy paper, and what it means in practice to implement this stuff”

    and “The second is that if you think about a company’s motivation to make easier, more intuitive, more beautiful IT for your phone, it’s because if they put it out there, people will gravitate to it and they will make a bunch of money. That’s not the way the IT in healthcare gets adopted”

    No one wants to acknowledge the reality is that the EHR inducements/mandates/penalties are a windfall for the software developers and even more so for the consultants who help install this stuff…..and in aggregate a significant degradation to quality of care, physician productivity and the quality of the patient physician relationship……..

    In order to fulfill the promise of healthcare IT we need to remove the mandates and inducements…..that lead us to try and cram all this down the healthcare systems throats…..and let the systems evolve to the point that the benefits lead medical practices and systems buy the stuff because the multiple benefits are compelling (in terms of quality of care, productivity and patient satisfaction).

  19. Great interview.

    Mark Smith seems endowed with abundant common sense, a missing ingredient in healthcare fixers these days.

    I think he is spot on about patient’s engaging with their records.

    I’m curious what he thinks about ICD 10.

  20. You fellows feel that there is poor communication in health care. Or inefficient communication? Something is amiss? Are we not communicating with the patient well? Or the patient with us? Or, are the providers not communicating with the administrations of our hospitals or clinics or nursing homes or community health services? Or vice versa? Or is it the billing communication, back and forth, provider to biller? to insurer? Or the government agencies? Which way is faulty? Agency to provider? Provider to Agency?

    I don’t see these problems. I have heard shibboleths of these problems. Are they in the literature? Erroneous prescriptions were the canary in the mine. Has this been a big problem that HI has fixed? Don’t we need proof for a few of these allegations?

    You use this phrase “coordination of care”. This has to mean “does every provider know what every other provider is doing and thinking?” Is this important? Why is it not good for fresh minds to wonder about old diagnoses and dated lab work? We all know about the (CV) coefficient of variation in lab data. Maybe it is good to repeat lab work? Maybe we have too much knowledge of what the other guy is thinking so that we make too many identical diagnoses? and we are group-thinking?

    Just because computers are new and we are all in love with them does not mean that they are proper for every data handling chore in health care. If you were Oppenheimer beginning the Manhattan project today, I bet there are discussions that you would not put in digital form, at least one with a TCP/IP structure and a banal OS on a WAN.

    Back up a bit. Start with mental health. You know that this does not fit well with an EHR. Then go to drugs and rehab. Ibid and ditto. Then STDs and gynecology and urology. Then go to job seekers. What do they want kept secret? BMI and diabetes for one and two, I bet. Then there are people running for office. Would JFK want folks to know about Addison’s disease? Even dentists. How many movie stars want others to know about dental veneer? Do you want a kid to know that it is impossible that his father is biologic?

    You can’t just root for EHRs without thinking. You need a patient directed vault for utter secrecy. Maybe a two-tier system will survive with handwriting for some things and your beloved binary data for other things.

    When you think of it, hand- writing was pretty good security. Few could read it and it was tough to find the chart in the dark at midnight if you were a robber. But it was there. I don’t recall any hackers selling hand-written patient charts.

    Before more Sony’s and Anthem’s we need to think of a hybrid system backup….I think.

  21. Great interview, Bob

    I would have been interested to have heard Mark’s thoughts on Healthcare.gov and the exchanges after the first two years. Was this the same sort of “We’ll build it, things will work themselves out” thinking on the part of policy makers?

    This does seem to be the trend when policy people sit down to solve real world problems using technology. There’s a real theme here.

  22. The money quote —

    I was also on the Qualcomm Life Advisory Committee. Of course, they’re pushing to allow everybody to have access to their data, 24/7, anywhere in the world. I remember one meeting where somebody said, “You know, it’s like your credit score, you can hit a button and get your score!” I asked him, “How often do you check your credit score?” Once every six or eight months, you don’t do it five times a day

    “How often do you check your credit score?” Once every six or eight months, you don’t do it five times a day. I would argue if you’re checking your blood pressure every hour, then you’re a self-monitoring narcissist. Not an average human patient …

    Brilliant.

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