It's not About the Money: Why Monetary Carrots-and-Sticks are Detrimental to Healthcare

In describing why Cooper Union, a unique college that offers absolutely free education to students, would effectively die if it starts charging tuition, Kevin Slavin wrote:

"For many of us, Cooper wasn't even the cheapest way to go to school...So the question is: why did we go? We went not because of the financial value of free--that is, zero tuition--but rather, because of the academic value of free. At Cooper Union I was paid poorly, and I was proud of it. I would have worked all day just to be able to teach at Cooper Union at night. I would never have done that in an institution that charged their students. Because "free" affects far more than a fiscal bottom line. It affects the intentions, behavior, ambition, and performance of everyone in the system. In other words, it determines the academic quality."

Kevin Slavin, an alumni and a teacher of Cooper Union, understood that money affects human motivation, and not in a good way. The phenomenon he describes is equally true in medicine.

Let me give you an example. I work in an academic hospital, one so large that it was impossible to survive financially without succumbing to the craze of monetary carrots-and-sticks that is sweeping the nation, such as Physician Quality Reporting System (PQRS), a Center for Medicare and Medicaid Services (CMS) initiative to promote better health outcomes through incentive payments/penalties.* Unfortunately, the actual outcomes are not what was intended, and the road to hell is truly paved with good intentions.

As a geriatrician caring for older adults, I would be remiss if I do not engage my patients in advanced care planning - helping them pick health care proxies in the event that they cannot make decisions for themselves, explaining the details of mechanical intubation, guiding them through the conversations of how to obtain a good death. These are difficult conversations - taxing, uncomfortable, time-consuming. But, I often stay late at work, skipping meals and foregoing sleep, to make sure I give these conversations the time and sensitivity that they deserve.

Why did I stay late? I sure was not paid overtime, not that overtime would make me stay longer. I was not paid by the number of health care proxy forms that I filled. Money does not drive me, and doctors should not be reduced to horses that live for a carrot on a stick. I helped my patients plan for the future because I care that their wishes regarding their life and health are followed, because it matters to me that I do a good job.

Sure, it makes sense that doctors are driven by altruism, but how is money as motivation detrimental?

Here's how: in an attempt to succeed in the age of carrots-and-sticks, my outpatient geriatric clinic created a competition in which the clinic provider with the most documented health care proxy forms filled wins a $100. It did not matter how many health care proxy forms were actually completed in reality, because that number was never used to determine the winner - only health care proxy forms recorded in the right slot on electronic medical records count, because those are the ones our clinic will get paid for. It was never said but one notion was undeniably true - the most important and direct purpose of this effort was to get the clinic paid. Having care plans for our patients was a side event.

Because advanced care planning slots in the electronic medical records were inadequate, undescriptive and user-unfriendly, I recorded my patients' wishes in free text. To reflexively participate in our clinic's proxy-form sweep stake, I would spend time transferring my free-text work into slots of electronic zeros and ones that count for money. That time cannot be spent on something else, like caring for patients or educating myself to become a better doctor, because time is limited, and knowing this I refused to participate in this shenanigan. I refused to be reduced to a primitive horse.

Once upon a time I happened upon a CMS policy maker and commented to her that incentive payments are not effective in achieving desirable outcomes in healthcare.

"What do you mean? Of course money motivates people. You don't think doctors' behaviors are motivated by money?" she interrupted the conversation, incredulous.

I replied, disillusioned by what I was hearing, "I hope not." I hoped, then and always, that doctors do what we do because our job is a calling.

"Well, maybe individual doctors are not motivated by money, but our healthcare system should be. Research studies have shown consistently that money can motivate behavior change," she was convinced.

I was convinced, too. "Sure, money can change behaviors, but are they behaviors that we want?"

She had no answer.

*Of note, monetary incentives are used by many parties in the healthcare system, both private and public, at a variety of levels. Using PQRS as an example was not an attempt to target or comment on current government efforts on healthcare reform.

Dash and I

Dash was sweet, but feisty. He was polite, but always refused to give up. He was eighty, but he was lean, full of strength. I sat by his bed and watched, letting my heart break with every word.

"Bbbbut...I...dooon't...understand!" We came back to this sentence over and over, as I tried to comprehend the anger, the vibrant possibility contained within this husk of an extensive left hemiparesis. Everything I took for granted was monumental to Dash, every day since his third stroke put him in a nursing home. Every word was a marathon, every shower a hike over Mount Everest.

"Ttthhey...leeefft...me...heere...to...die!" Dash shouted in heart-wrenching fragments, and all I could offer was a touch on his right arm. I had nothing better, and it was humiliating. Dash was moved to the long-term care unit when he could not make enough progress to go home. We took care of him, because his family would not. Dash would die here - I could not have put it better myself.

Dash was a fighter, and he was ready. He would concede anything to get better, to regain function, to go home. Everyday I saw him he would ask why the physical therapists no longer came by, why no one gave him a chance to leave. I would tell him that Medicare would not pay, because this husk, on this generic, impersonal hospital bed, was the new Dash, was all that Dash would ever be now. It was the truth, and the truth was awful. I had no answer for him, so I sat there, sad and defeated, holding his right hand. I tried to understand what it was like, to lie in this bed as a prisoner, to lose the basic independence of showering without someone staring at you, and I couldn't. I wish no human being had to, but here we are, Dash and I, holding each other's hands, a pair among millions of elderly residents in nursing homes and their doctors.

Dash looked away, a tear dropped on his pillow, and my heart broke. I wanted to help Dash, help him cope with this new life, but I had no right. Dash had to take this journey on his own, this path to acceptance, because no one should have the audacity to say this is OK, other than Dash. Until then, I held his right hand, and Dash squeezed back.

Learning to be a Caregiver in the Midst of Hardship

I am honored to post a story from Cameron, a reader who would like to share his experience taking care of loved ones with difficult medical conditions, which is becoming more common for all of us - elderly parents, children with cancer, relatives with addiction. Please share your experiences or leave questions for Cameron in the comment section.

Learning to be a Caregiver in the Midst of Hardship

November of 2005 found my wife, Heather, and I confronted with the worst news of our lives.  This news came at a time when we were just enjoying being brand new parents to our lovely three-month-old daughter, Lily.  But on the fated day of November 21st, Heather was diagnosed with malignant pleural mesothelioma. When we received the diagnosis we were in shock at what we would do next.  As I felt my life begin to rapidly change in front of me, I knew immediately that I had to take on the role of caregiver to ensure that my wife received everything she needed to fight the disease.

We had three choices for Heather’s treatment, one of which included going to an experienced doctor who specialized in mesothelioma in Boston.  This doctor’s name was Doctor Sugarbaker, and while we also had other options that were closer to home, we chose Doctor Sugarbaker due to the extensive experience he had with this particular type of disease. I knew that in order to survive this, my wife would need the best care possible.

After going into caregiver mode and deciding upon a treatment plan for Heather, I started having occasions where I felt overwhelmed with the disease we faced and the overload of my schedule.  One time, I simply collapsed and cried on the kitchen floor, afraid of what the future might bring.  I could only picture the worst case scenario, Heather passing away and leaving me to raise our daughter on my own.  However, even with these moments of weakness I never let Heather see my fears.  I knew she needed me to be strong, no matter what I was going through on the inside.

Being a caregiver is not an easy task, especially when you are providing nearly round-the-clock care for someone you love.  One piece of advice I have for anyone who is faced with being a caregiver is to accept help when it is offered.  I really do not know how Heather and I would have made it through her ordeal if it had not been for the loving and supportive help of her parents and many other people in our community.

Over the following months, Heather would undergo difficult treatment, involving mesothelioma chemotherapy, surgery, and radiation.  Despite the odds against her, she eventually came through her treatment cancer free, and remains so to this day, over seven years after her diagnosis.

I am so thankful that my wife will be okay, and our lives are in the process of returning to normal and getting back on a productive track.  Providing non-stop care for Heather taught me many things.  I learned the importance of finding balance and maintaining priorities at all time.  We now hope that by sharing some of our experiences, we can help others currently battling through their own cancer journeys today.

How to Train Your Doctors

Back in the day, legend has it that when space programs were just developed, NASA soon discovered that ball-point pens will not write in zero-gravity. Unfazed, NASA spent a large amount of money developing pens that will work in space, while the Russians simply used pencils.

It turns out that this legend is only half true(1), but the lesson remains - sometimes, we get bogged down trying to solve a problem within its existing framework. Sometimes, it's better to wipe the slate clean and start from scratch.

The problem I propose is residency, how our future doctors are trained. Imagine a shearing shed. On one end stands a line of plump, happy, fluffy sheep - metaphorically these are bright-eyed medical students, healthy, well-rested from the last year of light coursework in medical school, excited to finally be at the forefront of medical care. After 3 or more years in the residency, the shearing shed spits out a scrawny, shivering ghost of a bald sheep - these are your doctors. They are burnt out, fatigued, unhealthy graduating medical residents usually without the same self-esteem, optimism or hunger for knowledge they used to have. This generalization has truth in it - poems(2), books(3), other forms of media(4) have tried to describe this gruesome experience. I, for one, have never heard anyone said that they would want to do residency for the rest of their life, as a real job, because they love it so much and they never want to quit. 

Maybe that is too much to ask - not every job in the world creates that kind of enthusiasm. But, considering the importance of the task at hand, should we not attempt to train doctors in a way that by the end, the sheep remain plump, happy, fluffy and, most importantly, medically smarter than before the shearing?

I propose that we build this alternative training program from scratch, so we can dream bigger without the constraints in the current system of what can and cannot be. My proposal assumes happy, fluffy sheep - meaning caring, upstanding medical students looking to learn real medicine so that they can provide the best care for patients on the job - this is not always true but that's the topic for another day. With that assumption, a better training program will have the following characteristics:

1. Autonomy: Learners should be able to dictate the content and the manner in which they want to learn medicine. 

1.1 Content: Not every medical student wants to be a pulmonologist, so why does every medical resident in the same program need to do the same amount of ICU time? Learners should tailor the type and duration of rotations to fit their career goals. 

1.2 Manner: How many current residents, laboring in the trenches, work with ACGME on work hour regulations? I am going to tempt fate here and guess zero, or at least a very small minority if that, because there simply is not enough time in the day. So why are people sitting in an office far removed from residency deciding when a bunch of grown-up adults should take a nap, go home, come to work? Shouldn't 25-something future doctors know when they're at their best learning and when they need to take a break? If your future doctors need to rely on someone else to manage their work day, would you really want them to be your doctor, especially out after training when there is no one and nothing telling them when to take a nap, go home, come to work? The new work hour regulation is really misguided and quite a shame, because being able to follow patient progression over a 28-hour call is priceless - I wrote more about work hour regulations here.

2. Service vs Education: there is a time for service in every doctor's life, but residency should not be one of them. Medical students may have as little as 1 year to learn *everything* they need to know to be able to treat you on their own without supervision. None of that time should be spent learning the computer system or filling out paperwork, because many people can fill out paperwork without spending 4 years in medical school - it is low-yield. Progressive medical clinics hire scribes to write notes, enter orders, fill out paperwork, so doctors can focus on patients, look at them during conversation and treat them like respectable human beings. The diversity of cases is also important, which is why many reputable programs have medical admitting residents scouting for cases with educational values. There will be time to take care of patients admitted for pain control or alcohol withdrawal in the real world, but if a full-fledged doctor has never seen a case of pituitary adenoma during their training, would you trust him/her to care for you if you have one?

3. Evaluation: To become a full-fledged doctor, which is the goal of residency, you only need to spend a certain amount of time among a number of required rotations, and pass a multiple choice test. Failing other types of evaluations beyond these do not necessarily stop one from becoming a doctor. Other qualitative evaluations are performed mostly by doctors, a few by nurses, none (in my program) by patients, which seems backwards to me. It is important to know what your colleagues think, but isn't it more valuable to see if your customers are satisfied? I don't know of other thriving service industry where close to 0% of evaluations come from customers. 

4. Equality: Residency is a monopoly, where medical students cannot become doctors without going through it. As a result, residents usually get the short end of the stick in everything that they do: slower computers, fewer medical assistants, more rectal exams. Being treated as a second class citizen should never be a rite of passage. Equality means respect, and the hidden curriculum in residency currently teaches us that it is acceptable to treat those with less experience without respect.

5. Add yours here. Wipe the slate clean and dream about how you want to make your doctors. One day, someone might actually listen and make your dreams come true.

(1) http://en.wikipedia.org/wiki/Space_Pen

(2) Farrago, Douglas. "Stages of the physician." The Placebo Chronicles. New York: Broadway Books, 2005. 5.

(3) Not the least of which is the infamous House of God, written by psychiatrist Stephen Bergman

(4) http://www.youtube.com/watch?v=VUd-JMPhgK4

The only thing I had to do was to help Jerry and I failed

I have failed Jerry, and now I'm replaying every word I ever said in my head, over and over, the whole exercise consuming my being.

Jerry was not old. He just turned sixty, a good few decades of retirement awaiting him. Then, he was diagnosed with stage 4 esophageal cancer. It seemed that he had spent his entire life working up to that moment, only to be stolen away unjustly, by a cancer that drowned him slowly in his own oral secretions. Jerry had been in the hospital for months, battling recurrent aspiration pneumonia that caused nasty sepsis. He frequented the intensive care unit, had a feeding tube placed along with a stent in his esophagus to remedy a fistula to his trachea, a communication caused by a large tumor burden in his chest.

I met Jerry the day before he died. Jerry was in bed under a tangle of wires, breathing quickly, gasping for air with every available muscle in his chest. He was distressed, decompensating from another ravaging aspiration pneumonia, blood pressure non-existent. I was supposed to help Jerry, as a responder from the intensive care unit. The only thing I had to do was to help Jerry and I failed.

I asked for labs and a stat chest X-ray. I was told by his inpatient doctor that Jerry was full code, meaning Jerry wanted anything and everything done, including a tube down his throat and compressions that would break his ribs, interventions that were becoming more and more realistic for Jerry. I waded through a throng of nurses poking for veins and grabbed his hand. I asked for his wishes, again, wanting to make sure I knew what he wanted for himself. I asked Jerry if he would want to be intubated - he shook his head and said no, with the perplexity of a schoolboy who was offered a rotten piece of Jello that he had already refused. Jerry seemed to have given extensive thought to this piece of Jello, and after multiple rounds decided that he would not want Jello for himself.

Still, I was not sure if Jerry was thinking clearly in his severe illness. I asked if he would want his wife to make decisions for him, seeing that Jerry was already working so hard to keep himself oxygenated. He nodded, with immense fatigue, then went back to focus on his breathing, his staying alive. I found his wife, crying and beside herself. I felt cruel when I asked her what Jerry would have wanted - what a burden I placed on her. The word unfair was an understatement. How can she agree to the tube if Jerry hates it? How can she refuse the tube if it's the only thing that will keep the love of her life breathing longer?

She produced a piece of paper - Jerry's living will. It said that Jerry did not want artificial respiration, cardiopulmonary resuscitation, artificial nutrition that would prolong his life. It said so in capital letters. The last sentence read, "these decisions are made when I am sound of mind."  He signed it on February 20, 2012 - 6 months ago.

I was relieved. I thanked Jerry he made a living will. I could guide Jerry's wife through this difficult process, having an idea of what he wanted. I was angry. If Jerry coded before I found this piece of paper, I would have done everything that Jerry did not want. The covering inpatient doctor did not know why his living will was not found or discussed on admission.

Jerry's wife was broken, in despair. Her daughter asked her to keep Jerry alive while rushing in to the hospital. She pulled at her hair. She heavily sobbed. She begged me, begged the world and Jerry, not to make her choose. I sat her on a chair, hoping to provide some comfort, and told her that we would not intubate or perform chest compressions on Jerry - the medical team changed his code status to DNR/DNI. Luckily, even though Jerry was breathing quickly, his oxygen saturation was holding. For now an optimist could hope that Jerry would not require intubation. Jerry did not discuss pressors on his living will - most people do not. Pressors would keep Jerry's blood pressure up in the setting of sepsis, but a central line required to administer pressors is poked through the neck, a procedure with its own set of risks and discomfort. I talked to Jerry, his wife talked to Jerry, and we agreed that Jerry wanted pressors. Jerry came with me to the intensive care unit.

The next few hours was wrong, was when I failed Jerry. He maxed out on levophed, tiring out from tachypnea, secretions building up and drowning him. Jerry was actively dying. His daughter, now at bedside, asked about intubation. She said Jerry had been intubated before, despite his living will. I asked how, and she was not sure if the living will was discussed with his doctors then. I said I did not know where Jerry would land if he were intubated, avoiding projections with my limited experience, but I said there was a good chance that once placed, the tube would not be successfully removed. Jerry might be stuck on the ventilator - a horrible way to die for someone who specifically stated, when he was sound of mind, that he would not want to die on the tube. Jerry's wife agreed, while his daughter looked on, not saying a word, tired and holding her tongue. I told them my critical care attending was coming in - he could discuss intubation in more details with them.

By the time the attending stepped in, Jerry was out cold, no longer conscious but struggling to breathe all the same. Maybe out of experience, maybe out of comfort with aggressive medical care, maybe out of sympathy for his wife, imagining how heart-breaking it must be to watch her love drown, my attending offered intubation to the family. We can always back off, he said. It was the only tangible hope in a sea of despair and the family took it. I wondered if they took it for Jerry or for themselves, but who can fault family members, regardless of what they choose? His wife loved Jerry and wanted the best for him. She was deciding the only way she knew how, making earth-shattering choices for the first time in her life for Jerry, without Jerry.

The gamble did not pay off, for anyone. No one could know in a few hours Jerry would max out on 3 pressors, now with a breathing tube that did not do anything for him. Jerry was dead, had been dead long before the time when his heart would eventually stop. The Jerry that the world knew was dead. The-accomplished-pharmacist-who-regularly-hugs-his-wife-Jerry had left the world. The body on the hospital bed accepted breaths initiated by the ventilator, but once his heart and lungs finally gave out, chest compressions and electrical shock would not fix the sepsis within. Jerry would eventually die. He could not be saved.

And I have failed. I failed to save Jerry from the breathing tube, even though he told me clearly what to do. I failed to save his wife from the guilt that she may ruminate on, increasingly over time, wondering if she made the right choice for Jerry, and  there would be no resolutions to that doubt because we would never know what happened if Jerry was not intubated. My only hope for her was that Jerry would know every decision was made out of love, that there was no blame, that he understood and loved her all the same. In the end the sepsis overwhelmed Jerry and there were no more pressors to give. The breathing tube was never withdrawn.

How We Die

It was another day in the intensive care unit. The night was clean and calm, ventilators beeping their expected  melody, and the laborers of medicine went about their night shifts uneventfully, including me sitting with the obnoxious admission pager attached to my hip. The smoothness of it all shattered when the beeper started screaming - I picked up the phone and soon the emergency room physician was on the line.

"We have an old lady with potential sepsis for you - fluids are going right now," the voice said.
"What's her blood pressure?" I asked reflexively.
"80/50 and still unstable - you should come see her soon," the urgency in that voice was unmistakable.

I scoured the patient's information quickly from the chart before heading to the emergency room, as I usually do, and registered a repeated past medical history of an abdominal aneurysm that had never been fixed. Her name was Dorothy, a name that is endearing today and would have been very fashionable in the 1920's. Dorothy lived in a nursing home for the past few years, with multiple hospital admissions becoming increasingly frequent in the recent months. Her stage 4 pressure ulcer was unrelenting, undermined by severe malnutrition demonstrated by an albumin level of 1.5. Her white blood cell count was not elevated, but infected older patients do not always present with leukocytosis. From the chart I braced myself for the harsh reality I was about to encounter, knowing her chance of leaving the hospital alive was poor, and with a heavy heart went to find Dorothy.

I pulled the curtain aside as I stepped into the room and the commotion around Dorothy was jarring. The monitor was unhappy with a blood pressure of 80/50 and it made its discontent known, loudly. Nurses ran in and out, starting new intravenous access, hanging more fluids, everyone fumbling all around except Dorothy. She was in a hospital gown but the blanket had fallen by the bedside, revealing her lower naked half with a foley bag lying nearby, draining not a drop of urine. Her arms and legs were skin on bones, her face gaunt with wispy hair, all combined to make her the life-sized version of a skeletal crypt keeper from horror movies, except the only horror in that moment was in Dorothy's eyes, staring blankly at the ceiling. She was agitated, scared perhaps, confused most certainly, her arms flailing wildly for something invisible that may save her life. She moaned, yelped, then screamed a cacophony of unsettling fear and panic. I grabbed her grasping hands and soothed her, uttering something vague like it's OK - not so much to say that life was there to stay but more to acknowledge that it was perfectly normal, expected even, to be scared. I searched for a family member, someone more adept at calming Dorothy than me, but I found no one.

Then something horrible happened. Dorothy's blood pressure started plummeting right in front of our eyes, systolic down to 70, then to 50, blood surely pouring out of her aorta into abdominal compartments. It became clear that her aneurysm had ruptured, catastrophically, life literally seeping out into her abdomen. The family, informed prior of what believed to be sepsis in Dorothy, mistakenly thought that they would have time to come visit her in the morning. They were promptly called again, this time notified that Dorothy was actively dying, a surgical repair of her aneurysm unlikely to be successful considering her frail baseline. Everyone was thankful that her family decided to stop all interventions knowing they were futile. Her son said he was rushing in then hung up the phone.

But Dorothy was already dying - I knew none of her family members would make it in time. I looked at Dorothy, left in the wake of the ravenous medical efforts aiming at postponing death, and there was not an ounce of dignity left in her being. Her gown was pulled aside, revealing a stomach dirtied with gel used for the bedside ultrasound. The foley hung lifeless between her bent legs, IV kits and needles strewn around like candy wrappings, wires attached to EKG leads tethering her soul. Dorothy was no longer flailing, her body now without the necessary blood to fuel the bodily expression of the fear within. I picked up her left hand and held it, making a mental note to stop in that moment for Dorothy and witness her death, in an attempt to add what little dignity I could to this horrible chain of events. My intern looked at me, then proceeded to hold  Dorothy's other hand. Everyone else, the emergency room physicians and nurses, moved on out of necessity to other sick patients, all but one who returned with clean sheets to cover Dorothy, hopefully leaving her presentable to family members.

As Dorothy's heart slowed down and I held her lifeless hand, I could not recall a more horrible death other than a trauma case in medical school, a 12-year-old girl crushed by a school bus bleeding out every orifice. No one can predict death, but looking at Dorothy's chart one would guess that death was near - odds are that a malnutritious, demented, immobile body ravaged by stage 4 pressure ulcers would not survive increasingly frequent hospital admissions. I wondered if anyone ever mentioned to Dorothy or her family members that death was coming, that they should prepare for it, sooner rather than later.

Sometimes fear of death is so blinding that we forget to think about how we want to die. Other than certain suicides, we have no control over when we die, even though postponing the moment of death is what medical care is focused on. The only aspect of death we mortals could dictate, given enough thought and preparation, is how death will take us. The spectrum ranges from Dorothy to a peaceful death at home surrounded by love and familiarity, expected and prepared for. I remember reading a survey reporting that most people wish to die at home, although in reality only the minority of people do. I wonder if it is because we become so afraid and occupied, speculating how to fend off death, that we forget death is certain, a natural twin of life, something that can only be fended off for so long. I wonder if people know that hospitals are a horrible place, that once you enter it can be difficult to leave through the front door. I wonder if people know that Do Not Hospitalize is an option. I wonder if people know how to plan for death at home - I certainly do not. Of all the wishes in our lives, the wish for how we die seems as important as any, something to plan for deliberately and carefully.

The line on the monitor went flat and still Dorothy was alone, two strangers holding her hands. The nurse stared at me expectantly - I pronounced the time of death as she left to gather paperwork. I wanted to stay and find out where people go after they die in the hospital. Who pick up the body? Are they put in a body bag? Where is the morgue? I wonder if other doctors know the answers - patients stop being ours once they are dead, even though they remain as human as ever - before and after, especially during death. How we die should never be taken lightly.

If people want to die, heroic measures won't get in their way

I was working in the Intensive Care Unit (ICU) the other day and as I counted, I found that more than half of the patients there, for lack of a better term, brought the condition upon themselves.

I sound harsh, but there was no better way to put it. I was taking care of Mrs. B, a 60-year-old lady with COPD who called EMS for shortness of breath. As EMS readied to take her to the hospital, she said, "you all are gonna have to wait until I finish my cigarette." She has been intubated many times for COPD exacerbation, visited the ICU a hundred more times. She said if she got out, the first thing she would do would be to smoke a cigarette, but she did not believe she would make it this time. After multiple weeks on continuous BIPAP with spurts of intubations in between, she told us to quit and let her die.

Looking around the ICU that day, there were multiple stories like her - a cirrhotic who was actively drinking despite his varices bleeding to death after 30 units of various blood products that turned out to be futile, a 20-year-old diabetic with recurrent admission for diabetic ketoacidosis who left against medical advice the minute he found out he would not get any intravenous dilaudid, a gentleman admitted with pulmonary edema every 3 days because he refused to go to dialysis.

As days passed, I realized that these patients were common - I was being trained to undo what these people did to themselves, so that they can leave the hospital to do it some more. Some has hurt themselves so many times it could not be undone, despite many resources wasted and much money spent. I watched 30 units of blood passed through one end of our patient only to flow right out another, and I wondered if there was not someone else out there who would not undo our efforts, our blood products, our precious resources.

More importantly, I wondered if we could ever draw a line, where we say enough is enough, where we say you do not get a second chance at life so that you can just kill yourself in the end, where we say there comes a point when heroic measures cannot cure how people want to live their lives. Before medical school I always thought that medicine was made to promote health, but in the light of reality I have learned that my job in the ICU today is really to prolong death, so that in the end people can crash and burn a bigger flame, taking much needed resources with them.

Mrs. B knew in her heart that smoking would be her death, yet smoking was the one thing she pined for. I wanted to tell Mrs. B that if she wanted to die, I was in no place to stop her. I might have had a shot as her primary care doctor before she picked up her first cigarette, but that time is long passed. In the end when the BIPAP came off, she became unconscious and passed away peacefully. I wanted to ask if we should have stopped sooner, maybe two intubations ago, but I will never know.

More medical care is bad for you

I recently admitted a patient with a pulmonary embolism. Before heparin drip was started, my attending ordered a hoard of eccentric, non-indicated hypercoagulable workup in the hope of avoiding the effect of heparin on these test results, including phosphatidylserine antibody and methylenetetrahydrofolate reductase DNA. I watched in horror as the nurse drew out approximately 13 tubes of blood, since each test needs its own tube.

On rounds, the attending of course pimped us about all the possible tests you could draw on a patient who comes in with a clot. I zoned out in my head since I know that regardless of the test results, pulmonary embolism is life-threatening enough that this patient will need life-long anticoagulation - the tests will not change anything. Even if the patient tested positive for genetic clotting diseases, there is no point screening family members or even considering anticoagulation in them unless they develop clots themselves. We went on a long and useless thought experiment. What bothers me the most is that we get a pat on the back when we try to draw these tests just because they are vaguely related to hypercoagulability, but when you actually stop to ask yourself what you would do if the tests come back positive, the answer is usually a shoulder shrug . Imagine the phosphatidylserine antibody came back positive - what does that even mean? and do we even care? I personally do not as the patient is going home with anticoagulation no matter what.

Useless thought experiments, unindicated lab tests and interventions happen on a regular basis, both in my medical school and residency program. We transfuse blood when there is no good evidence that it improves any outcome, just because doctors are nervous that patients will have heart damage from demand ischemia. Consulting surgeons would like to follow Lipase level in my patients with pancreatitis, and my attendings let them even though there is no evidence that its correlates with symptoms just because we don't want to get in a fight. I was told to perform extensive workup in a patient with acidemia, when the obvious cause of kidney failure stares us right in the face - I couldn't convince my attending to wait until the kidney failure resolves to see if the acidemia goes away, at which point no workup will be needed. We looked for zebras even though we know it's a horse, only because my attending "didn't want to miss anything."

In my opinion, most of what we do in medicine is not backed up by good evidence. A lot of the guidelines are biased by group interests and potential profits. This is part of the reasons why some of the tests/procedures that used to be indicated are no longer. Mammogram used to be recommended every year, but now yearly screening may lead to unnecessary breast procedures and once US Preventive Services Task Force tried to recommend increased screening interval, the backlash from groups that stand to profit from mammograms and breast procedures was overwhelming.

But a lot of it stems from how we are trained in medical school and residency. If we get a pat on the back every time we draw useless tests, we will continue to perform unindicated workup when we become attendings. If we are deemed unknowledgeable every time we refuse to do extensive lab work because we have a good explanation of what the abnormality is, we will spend more money without improved outcomes, which is happening in the US as we speak.

I wonder if my patient knew that the test for phosphatidylserine antibody costs $194 at our hospital, and that in the end the test will leave her with nothing better than less blood in her veins.

From the brink of hospice to awaiting a reading machine

It was a beautiful Monday morning in May. Yawning uncontrollably, I hopped into a Ford Hybrid with my attending and drove off to visit a patient who lived two hours away from our hospital. I woke up especially early that morning since we knew the commute would take many hours. We drove past open fields and a few cows before pulling into a driveway of a lovely house with a cute garden behind it. A middle-aged lady peered through the screen door and waved. My attending waved back as we clambered out of the car. She opened the front door and hugged my attending like a long lost friend, which she practically was, as they caught up over a short conversation before moving on to discuss her brother, Mr. R.

Mr. R was blind. He could not and had not left his one-windowed bedroom for many years. When my attending was called about Mr. R a few years ago, it was a consult for home visit evaluation for hospice - Mr. R had such severe COPD that his prior provider thought that there was nothing more medicine could do for him. When my attending first met Mr. R, he was in bad shape - he was bound by yards of oxygen tubes connected to a tank, however not quite long enough to reach anywhere but his bathroom across the hall from the bedroom. That did not matter much, since getting up from bed was a huge feat causing severe shortness of breath. The blindness did not help either.

My attending agreed to see him under special circumstances. Mr. R lived outside the usual range of home care visits provided by our hospital - she was hoping to set him up for hospice during a one-time visit. However, as she looked at Mr. R more closely, she realized that his COPD was not yet optimized and that medicine deserved a fighting chance. She set to work as his new primary care doctor, driving out to his house over the years to provide medical care - if Mr. R could not get up from bed without gasping hopelessly for air, there was no hope of traveling to the clinic for him.

I looked at Mr. R with a hidden surprise, watching him grin as my attending entered the room. He was thin with a well-kept white beard, looking incredibly full of life for someone previously considered for hospice. I felt his firm handshake and observed in quiet wonder - Mr. R was breathing normally, speaking in full sentences, on 2Liters of oxygen. He reported that he was doing very well, taking inhalers as prescribed and finishing the last of his prednisone taper, which allowed him to titrate his oxygen down to 2Liters. He could get up from bed and make it to the bathroom, although still short of breath by the end of his journey. He appreciated the visit by the good people at the blind rehabilitation center, who helped him cope with blindness and promised him a reading machine.

I stuck a pulse-oximeter on his finger, which beeped after a few seconds showing 94% oxygen saturation and a heart rate of 80 - his vitals were much better than my guesstimate. His lungs were a bit wheezy, although with good air movement. We drew his blood for testing and decided to adjust medication by phone after results came back. We concluded the visit - my attending gave him a hug and promised to follow up on his reading machine. As I asked Mr. R for a trash can to dump a piece of used gauze, a weird sense of humility hit me - suddenly I did not know where things were and was at the mercy of my patients, I could not go into other rooms or touch anything unless permitted by Mr. R - is this what patients feel like on our turf in clinic?

My attending talked with his sister in the hallway afterwards regarding the plans of care for Mr. R, and she thanked us profusely for making the trip out to her house - a familiar happening during a home-care visit. I took my last look at Mr. R facing the one window in his room, as if he was staring through it, and thought about how far he has come - from the brink of hospice to awaiting a reading machine. I turned around and climbed back into our vehicle, driving a long drive back to the city.

In this day and age when our population is growing older and fewer people have the time or resources to go to doctor's appointments, home care visits by doctors have become increasingly valuable and life-saving. Home-bound population is greatly underserved, and capacity for home-care visits is limited, most of all by time and distance. Doctors can only travel to so many patient destinations in a day.

With the increasing popularization of mobile technology, a new model for home care visits emerged - one that could save time, expand home-care capacity and utilize community-based health care. I amateurly dubbed it, "The Home-Care Node System."

The Home-Care Node System consists of two major nodes: a single physician node in the center at the hospital interacting with multiple allied health nodes situated in the patient's neighborhood. In the node system, physicians make the first home-care visit along with a team of allied health professionals (who live near the patient) to perform initial intake together - the team can perform physical exams first-hand to document an agreed baseline on the patient. For subsequent follow-up visits, allied health professionals become the eyes and hands for physicians. They go out to patient's home, easily since they live nearby, equipped with a video-ready device (maybe an iPad, maybe a laptop, fill in your own blank here). Video conference is linked to the physicians at the central node, allowing them to take history, maybe take a look at a rash on the patient's foot, and listen to reports from allied health professionals who can answer any questions that video footage or patient's account cannot answer. Allied health professionals can take vital signs or draw labs if needed.

The only missing ingredient is the ability to repeat physical exams by the physicians in person, but I argue that this is not extremely important. Allied health professionals can perform the physical exam and share their findings with the physicians. Most physical findings that matter do not require MD training to recognize. If a wheeze is too tiny for an untrained ear to hear, then the lungs are practically moving good air on the grand scheme of things. If a wheeze is prominent and diffuse, a medical student will hear it and so will a physician attending. If there is any doubt, a physician can make a special trip to the patient's house to investigate further, but for all other non-subtle findings, allied health professionals in the area can free physicians to take care of more patients in wider areas of service. There is also much to be said about community-based health care - local allied health professionals understand the environment that the patient lives in and have invested interest in improving the health of their community.

The Home-Care Nodes will not be easy to set up in our maze of a health care system, but a lot of great inventions sprout from what-ifs that were given a try. As I sat down to write my home-care visit note for Mr. R and pondered about how far he has come, I daydreamed of a day when home-bound patients are adequately and efficiently served. But then again, daydreaming is a powerful thing – as long as we act on it.

Why is medical education so demoralizing?

My first year of residency training has ended. As I sit awaiting the start of a new year and new responsibilities that come with being a senior resident, the accomplishments of last year and the excitement of what comes next are overwhelmed by dread - I am not excited and cannot wait for residency to end.

I look around me in the health care sphere and most of what I see is negativity. Exacerbated by the failure of our health care systems, sure, but that is not the brunt of it. As I take leave from medical training and step outside to work on my personal projects in non-health care related fields during vacation, I realized I fear returning to work, to medical training, like a little kid fearing a trip to the dentists.

I look back over my training this past year and realize that everyday is a beating- from my colleagues and never from patients. Every day on rounds, we residents put ourselves up to mean scrutiny - we give presentations on patients we admitted to hospitals, we devise a plan on how to help them feel better - and, of course, we take great pride in what we do and pour a lot of thoughts and heart into these presentations. What we get in return from most attendings and senior residents are often agreements, sometimes additions to the plan, other times harsh criticisms on systematic failures attributed to individual's carelessness (which is seldom true - when things fall through the cracks in hospitals, it is usually due to a systematic flaw bigger than one person), but rarely an acknowledgement that creates a positive work environment. The focus seems to be on what is not perfect, and hardly on what was done well - strides are rarely celebrated in medical education.

There are many instances when residents are "pimped" by attendings - that is, being asked questions to see how much we know. The original intention of pimping (I hope) is to teach, but nowadays I would say that goal is rarely accomplished. Most clinician educators take less than a few seconds to wait for answers while pimping - when do residents have time to think and formulate their responses? A question answered correctly is rarely followed by a pat on the back, only harder questions, some so vague and uneducational most residents don't bother learning answers to. Many times residents are pimped tactlessly in front of patients, whose trusts and confidence are needed for us to do our jobs. I wonder why I feel that the goal of pimping is to embarrass and make us feel stupid.

Last but not least, I feel that my time is not valued. There are many instances when I sit around without any responsibility, waiting just to be let out at 5PM like a 5-year-old because that is when my attendings deem appropriate - I look at people who have autonomy over their own time (like Google employees) and wonder why we are not treated like adults, who can make our own decisions regarding which activities are useful in our training and which are not. There are many occasions when I try to eat lunch in 5 minutes, when I miss a meal completely, when I do not go to the bathroom for 10 hours, when I sleep 4 hours a night, when I work 21 days in a row - and I look at people in other jobs, sometimes nurses, who have a real lunch break, who have real weekends, and I wonder what kind of existence I was living.

On a Southwest plane during my vacation, I read a Southwest magazine featuring its 40th anniversary in business, and a heart-warming theme throughout the whole magazine was how thankful the company was to its employees, how each one of them takes great pride in what Southwest offers and how each one of them was excellent in what they do. Most successful companies have the right idea - the funny thing about humans is if you tell them they are excellent, they become excellent, and compliments and appreciation are rare in medical training.

I can already foresee comments telling me to tough it up and stop whining, but I look at great companies in other industries and employee's morale is never allowed to be quite as low with such daily beatings and abuse. Talk to a resident, and what you will most likely hear are complaints - about long hours, about mean attendings/senior residents, about inefficiency in their workplace. If residency is a long-term job that you can keep until 60, most doctors will not stick with it or want to return to it.

If I could do it all over, I would still pick residency, because my patients made everything worth it, but really, does medical education have to be so demoralizing? Why do we teach people by making them feel small instead of empowered? Does adequate medical training have to come at the price of 10 hours without urination? I challenge us to do better, to build a system where self-esteem is high and residents are well-rested. If Southwest can do it, so can we!

New ACGME work hour regulations for interns: friend or foe?

On the night of October 4, 1984, a young girl named Libby Zion was admitted to New York Hospital in Manhattan for fever, agitation and strange jerking movements. No one knew that her death the next morning would, 27 years later, drastically change the quality of physician training, for better or worse.

When Libby was evaluated in the emergency room that night, neither the ER physician nor her family physician Dr. Raymond Sherman, consulted by phone, were able to make a definitive diagnosis of what was going on with Libby.

They decided to admit her for hydration and observation. When an intern Dr. Luise Weinstein and a resident Dr. Gregg Stone evaluated her for the admission, they also were not sure of Libby’s cause of illness – Dr. Stone termed it “a viral syndrome with hysterical symptoms,” suggesting that Libby may be overreacting to a benign viral syndrome. They prescribed her Meperidine to control shaking, and Dr. Sherman approved the plan by phone without evaluating the patient. Dr. Weinstein went on to care for 40 other patients in the hospital that day, while Dr. Stone went to sleep in the next building, to be reached by beeper if needed.

Later on that night, the nurse contacted Weinstein when Libby became more agitated and started pulling out her intravenous lines. Weinstein ordered restraints and Haldol, a medication used for agitation, without re-evaluating the patient. She also did not notify Stone or Sherman. Libby finally calmed down later that morning, until 630 AM when a vital sign check showed that Libby had a dangerously high fever to 107. Measures were taken to reduce her temperature, but Libby soon suffered cardiac arrest and died.

On careful review, it was discovered that Libby was taking an antidepressant named Phenelzine. Combined with Meperidine given to her in the hospital, Phenelzine can cause fatal serotonin syndrome, symptoms of which include hyperthermia resulting in cardiac arrest.

What follow were outraged parents, a high-profile court trial and the image of the bedraggled, unsupervised intern wreaking damage in hospitals featured in the pages of the Washington Post, the New York Times and Newsweek. Libby’s parents believed that her death was caused by inadequate supervision and fatigue from long work hours. This sparked work hour regulations for residents and interns, which continued to evolve even 27 years later. In 2010, the Accreditation Council for Graduate Medical Education (ACGME) announced stricter work hour regulations, from 30-hour shifts in 2003 to 16-hour shifts to take effect in July 2011. It also stipulated that residents must have 8-10 hours off between shifts, with total work hours/week not exceeding 80 hours.

I have the distinct fortune of being the intern during this monumental transition – I am the only group of interns who during my first year of training have the opportunity to work 30-hour shifts while also transitioning to the 16-hour calls. As I keep my head above ground while my residency program goes through multiple trials of work hour changes to meet the new standards, I often ponder (despite lack of time) about what happened to Libby.

Looking carefully at the story, Libby did not die simply because interns were taking 30-hour calls. When Libby presented, multiple physicians missed her diagnosis, including the more experienced ER doctor and the Zion’s family physician, who should know that his patient Libby was taking Phenelzine before she came to the hospital. The decision to give her Meperidine was not made by the residents alone – it was approved by the well-seasoned, board-certified family physician Dr. Raymond Sherman. When Weinstein decided to give Libby restraints and Haldol, she was probably tired, but more importantly she was BUSY – she did not re-evaluate Libby or call for help, not because she was sleeping, but because she was covering 40 other patients.

Libby highlighted what was and is wrong with medicine today. Private physicians cannot and should not be allowed to manage patients who are sick enough to be admitted by phone – Experienced physicians need to evaluate patients in person and should not rely solely on residents’ accounts. Medication reconciliation and prevention of medication cross-reactions should not be left vulnerable to human errors and information technology needs to be effectively used.

Most importantly, from personal experience, I can testify that as an intern, I am more likely to make medical errors because I have to take care of an absurd number of patients, not because I am tired, and cutting calls from 30 to 16 hours will only exacerbate the situation. As my call hours are cut to sixteen, I am still forced to admit the same overwhelming number of patients I usually do on a 30-hour shift. As I struggle to get out at the 16th hour, there were numerous orders that I simply did not have time to execute, and the fate of the patients are left to the residents who stay overnight for 28-hour calls but remain overwhelmingly overworked. As I lose post-overnight call resting hours and accumulate more commute time from not being able to stay in the hospital, I end up spending MORE time working and less time sleeping. As I become more tired and take care of more patients in shorter periods of time, my learning has greatly diminished – I spend less time processing my patients and more time cramming 30-hour worth of paperwork into 16-hour shifts.

The solution stares us in the eye – interns need a stricter cap on the number of patients they can admit or care for at one time. Patient care can be improved and medical errors can be avoided if providers simply have more time – thorough assessments can be made and comprehensive plans can be formed. Sixteen-hour shift is not the answer – it only aggravates the actual source of the problem

Medical care and airlines - should there be a difference?

A recent article by Pauline Chen features a group of primary care physicians at Tufts Medical Center in Boston, who have created a concierge practice that funnels income into the traditional general medical practice that sees less-advantaged patients. Surveys (performed by the medical center itself) found that patients rated the quality of interactions with their doctors similarly regardless of their affiliation. The only significant differences in responses had to do with the services offered — care coordination, physician access and interactions with office staff. According to the medical director, analogous to airline services providing both first class and coach services, the parallel practice gets patients to the same destination - some eating peanuts, others eating caviar.

I believe this is an intelligent hybrid that may have successfully reacted to our broken medical system, but the ends does not justify the means. Differing services based on the ability to pay is discrimination - it is demoralizing for coach flyers, but morally wrong for economically-disadvantaged patients. This is because medical care is not the same type of services as airlines - people will not die if they cannot fly to places, but they will die without medical care.

In a civilized society, its members should have equal access to life-saving services regardless of the ability to pay. Just like the fire department, medical care should be provided as a societal safety net so that, instead of worrying whether our house will burn down while we're off at work or whether a catastrophic illness will take away everything we've worked hard to earn, we can focus on higher pursuits like being a productive member of society.

Differences in health outcomes between two groups remain unclear. If they are unequal, then there is discrimination based on the ability to pay. If they are equal, then first-class patients pay more money without justifiable returns other than convenience and a more pleasant office staff, which I argue should not be different in any circumstances - I'd like to believe that medical professionals treat fellow human beings in sickness with utmost compassion at all times, regardless of payment scheme.

Either way, segregating patient care leaves a bad taste in my mouth. As a doctor, we ask patients to trust us with personal life stories that they may never share with their parents or their significant others. Such level of trust can hardly be established in the settings of discrimination.

Deep-fried snickers bars

Today I went to a lecture where a cardiologist showed us photos of disgusting food sold across America. The purpose was to convince all the cardiologists in the room that despite decreasing incidence of heart attacks from 2000-2007, cardiologists can rest assured that these fattening food items will keep them in business, and this is true only because America pay based on volume regardless of outcome. It makes me sad to think that cardiologists are happy when people eat deep-fried snickers bars.

Why do we use carrots and sticks if humans are not horses?

It was 6PM and I was still at the clinic. My last patient, Mr. R, had left over an hour ago and as far as the rules go, I could be home by then, eating dinner and taking a shower. But as I perused Mr. R's medication list over and over, I couldn't get myself to leave. He was taking over 15 medications and the pill burden was overwhelming. Since he recently lost Visiting Nurse Services and had to fill the pillbox on his own, he was exhausted from taking medications. I thought of how all the puzzle games I used to play had prepared me for this day as I went through different combinations of medications to arrive at the smallest possible number of pill counts for Mr. R. I continued to think of his case on my drive home trying to figure out a way to get a better control of his raging diabetes.

As I sat down and stuck a fork into the piece of chicken that was my dinner, the clock read 730PM and I thought about why I didn't leave earlier. Why did I spend time trying to fix the life of a stranger instead of feeding myself? What motivates us as doctors to stay late and perform a thorough task instead of clocking out on time and leaving the fate of our patients to other forces in the health care system?

And this is a pivotal question, because as our nation tries to make sense of why health care cost is spiraling out of control, the new system will be rebuilt based on what motivates health care workers to do a good job of caring for patients.

Many fresh carrots on newly-minted sticks have already been instituted in various areas of the medical system as part of the new health care legislation in an attempt to motivate health professionals to do the right thing, including programs like Medicare's Physician Quality Reporting Initiative (PQRI). According to the legislation, PQRI asks physicians to report how the care they furnish aligns with evidence-based clinical guidelines for a variety of medical conditions, such as diabetes or heart disease (1). In 2010, physicians who successfully report these measures will receive a 2% bonus on charges received from Medicare. The bonus tapers down to 1% in 2011 and 0.5% from 2012-2014. However, starting in 2015, physicians who fail to report these measures will receive a penalty of 1.5 percent deduction from their Medicare revenue from that year, increasing to 2% penalty in 2016 and each subsequent year.

But before we march forward to the trial and error of this new measure designed to induce higher performance, it is important to step back and ask ourselves: what motivates us as human beings?

According to Daniel Pink's book Drive based on numerous researches replicated in various settings over time, humans are motivated by three intrinsic drives: autonomy, mastery and purpose.

In a book by Deci et al published in 1985 (2), multiple researches on school children randomized to autonomy-supporting versus controlling teachers conclude that autonomy-supporting environment correlates with more creativity as well as enhanced intrinsic motivation and self-esteem. The concept of autonomy is replicated in the real world today by a successful Australian software company called Atlassian (3). Inspired by FedEx's promise to deliver a package in 24 hours, Atlassian instituted "FedEx day," when, once in each quarter, software developers are allowed 24 hours to work on anything they want, enjoying full autonomy. Results are brilliant bug fixes and new innovative features that otherwise would not be explored as successfully.

Another landmark article in 1959 (4) by Robert White, a professor emeritus in clinical psychology at Harvard University, proposed that the inherent satisfaction in exercising and extending one's capabilities is a strong motivator. It later inspired numerous experiments on mastery motivation which show multiple positive effects on performance, from leading test subjects to spend more of their free time on tasks (5) to increasing cognitive development in children (6). The 21st century example of these validated experiments can be found on Youtube, where there are millions of videos on the how-to of everything, from using make-up to writing computer programs, made by folks who enjoy the subjects in their free time, free of charge.

An interesting study by Adam Grant at Wharton demonstrates the power of purpose as a motivator (7). The study shows that employees working in a call center at a university fundraising organization who were given stories of how the money they raised affected the lives of beneficiaries earned more than twice the amount of donation compared to before the intervention. Volunteers exemplify the power of purpose in the real world, where people from all walks of life are driven, not by the extrinsic motivation of money, but by the intrinsic motivation of being part of a cause.

Interestingly, within decades of social studies research on motivation, the most surprising finding of all is that monetary rewards actually lead to poorer performance for cognitive tasks. The pervasive belief that higher monetary rewards lead to higher performance only applies to straight-forward, mechanical tasks – as soon as the job requires even the least amount of rudimentary cognition, monetary rewards produce negative effects on performance. This finding has been shown in works by numerous researchers, including Dan Ariely (a professor of behavioral economics at MIT)(8) and Dr. Bernd Irlenbusch (a lecturer at the London School of Economics) (9).

Despite the repeatedly validated science of intrinsic motivations, managers and organizations continue to use money to motivate workers for the more and more complicated cognitive tasks of the 21st century, the Medicare's Physician Quality Reporting Initiative (PQRI) included. The monetary penalties of PQRI will narrow physicians’ minds onto the goal of mechanically completing reports, eliminate autonomy and distract away from mastery and purpose. It sends the message that physicians should do a good job, not because our work has a higher purpose of keeping other human beings healthy, but because we will earn more money for it. In a way, it views physicians as rudimentary horses easily lured by rudimentary carrots, when in reality I would like to believe that physicians are human beings driven by the ability to direct our own fate, the desire to be good at what we do, and the heart to be part of something bigger than ourselves.

On my drive home after another hard day's work, listening to the repeating lyrics of the wise singers of "The Lox," I reflected back on our motivation as physicians as the radio crooned, "It's the key to life. Money, Power and Respect." Autonomy is power, and mastery brings respect, but the Lox was wrong about the last key to life. In the end, life is never about money - it is all about purpose.

(1) http://www.acponline.org/advocacy/where_we_stand/access/int_prac_guide.pdf
(2) Intrinsic motivation and self-determination in human behavior By Edward L. Deci, Richard M. Ryan
(3) http://www.atlassian.com/about/Atlassian_Media_Kit.pdf
(4) R. White. Motivation Reconsidered: The Concept of Competence. Psychological Review. Vol. 66, No.5, 1959.
(5) S. Harter. Developmental Differences in the Manifestation of Mastery Motivation on Problem-solving Tasks. Child Development. Vol. 46, No. 2 (Jun., 1975) pp. 370-378.
(6) K. Jennings et al. Exploratory Play as an Index of Mastery Motivation: Relationships to Persistence, Cognitive Functioning, and Environmental Measures. Developmental Psychology. Vol. 10, No. 4, 386-394
(7)http://www.management.wharton.upenn.edu/grant/Grant_JAP2008b_TaskSignificance.pdf
(8) D. Ariely, U. Gneezy, G. Lowenstein, &N. Mazar, Federal Reserve Bank of Boston Working Paper No. 05-11, July 2005; NY Times, 20 Nov. 08
(9)http://www2.lse.ac.uk/newsAndMedia/news/archives/2009/06/performancepay.aspx

Can entropy be reversed?

For those with an android phone, I'd like to introduce you to Edwin, one of the most amazing applications out there for android users that really puts the future in perspective. It is a speech-to-speech personal assistant program that lets you asks any questions, from what is the meaning of life to where is the nearest coffee shop, and it will give you the answers (which by the way are 42 and dunkin donuts on chapel street). It links to wolfram alpha, google translate, and other incredible computational programs that vastly increase Edwin's ability to assist, including calculations, word spelling/definitions, language translation, map/navigation - the list goes on. Below are just some of the quirkier responses you can play around with if you're bored:

Input: I love you

Response: Sadly, I was not designed to love, but if I were, I would love you

Input: I hate you

Response: I'm sorry you feel that way. Maybe with a later update, you will change your mind.

Input: Where is my car?

Response: Not sure, but wherever you find it, that's where it is.

Input: Why are you awesome?

Response: If I have computed more, it is by standing on the shoulder of giants (plus a lot of hard work - with all due respect to Sir Isaac Newton).

Input: Do you have a brain?

Response: I am capable of universal computation; that I can say.

All fun aside, Edwin just shows that all the fancy technology we ever imagined in sci-fi novels/movies will become reality only in a matter of time. Edwin seems to be a primitive ancestor of Multivax, the all-knowing AI in the famous short story "The Last Question" by Isaac Asimov. With more computational power and programmed responses, Edwin will maybe one day tells us how entropy can be reversed. Until then, the next game-changing discovery will be something we have never ever imagined, sensed or comprehended in human history - a completely separate dimension that will change everything and how we operate. In a way I feel like we are ants, unaware of the human world above us. When Armageddon comes we wouldn't understand why, when in reality God just spilled a bag of skittles on us.