Where Telemedicine Falls Short

by David Blumenthal - June 30, 2020

Telehealth use has surged during the coronavirus pandemic, with the technology spreading far and fast. Doctors and patients alike must be wondering if this is the beginning of a whole new kind of doctor –patient relationship, one that might totally transform our health care system.

I’m not convinced, and Americans may not be either as the initial telehealth surge appears to be leveling off.

I am not skeptical because of the technology: I am a strong supporter of health information technology and believe new IT holds huge benefits for patients and their caregivers. Years ago, I helped lead the federal government’s effort to get hospitals and doctors to adopt electronic health records. Indeed, virtual care would be much less valuable if it weren’t for electronic records that enable doctors to access patients’ health histories remotely.

But I am also a primary care physician. I know that trusting relationships between patients and clinicians can be a boon to giving and receiving care. And that trust - the kind that lets anxious patients return to sleep at night, the kind that settles the stomach of a new mother with a sick baby - grows fastest and strongest through in-person relationships.

I also know that well-trained clinicians use all their senses - not just hearing and vision. They appraise the whole patient: Is there a new limp, a shift in posture, a new pallor? Often, it’s what patients don’t notice or complain about that is essential. And there is no diagnostic test more cost-effective than the laying on of hands. I have found treatable cancers multiple times in routine exams that would be impossible to replicate in the virtual world. Could a Zoom visit detect a lymph node too firm, a spleen or liver too large, or an unexpected prostate nodule (with a normal PSA)?

Trust and face-to-face encounters are even more important for patients with complex and intertwined problems. Five percent of the American population accounts for 50% of health care spending. These are sick, fragile individuals who often have multiple conditions - diabetes, heart disease, hypertension, arthritis, dementia, depression - that are tangled and difficult to manage under the best of circumstances, and even more so on a screen. The key to helping these patients can be keeping them away from hospitals when a symptom pops up. But for doctors and patients to have enough confidence to wait and watch depends on having a history together, one based on familiarity and trust.

There are times and places where virtual care makes perfect sense. During the pandemic, when in-person exposure has to be limited, it has been crucial for keeping doctors and patients connected. And in parts of America where no alternatives exist, telehealth has been a lifesaver - especially in enabling the delivery of scarce specialty services to support family physicians in remote areas.

There are also situations where virtual connections deliver excellent care with greater convenience and lower cost than in-person visits. Examples include routine and repetitive issues like monitoring blood pressure or mild respiratory symptoms (Covid-19 notwithstanding). There is growing evidence that virtual care for some mental health conditions works well, too. And virtual care likely works better for the young and healthy than the elderly and sick. Technologies for remote monitoring of certain key health parameters - heart rhythm, blood sugar, weight, respiratory rate - may help people control their chronic conditions better and assist clinicians with diagnosis and treatment. Combine this with artificial intelligence and a new world of possibilities opens up.

The past few months represent a crash course in telehealth for doctors and their patients, and this exposure will undoubtedly leave us better positioned to use the technology moving forward. But telecare will work best when it is adapted to humans and their needs rather than the reverse. It should be one more tool that builds upon, and promotes, the human relationships and caring clinical eyes, ears, and hands that have always sustained us when we are sick.

David Blumenthal, MD, is president of the Commonwealth Fund. He previously served as the National Coordinator for Health IT in the Obama Administration.

 How One Boston Hospital Built a Covid-19 Forecasting System

by Jennifer P. Stevens , Steven Horng , Ashley O’Donoghue , Sarah Moravick and Anthony Weiss - June 29, 2020

The Covid-19 pandemic created an unprecedented strain on healthcare systems across the globe. Beyond the clinical, financial, and emotional impact of this crisis, the logistical implications have been daunting, with crippled supply chains, diminished capacity for elective procedures and outpatient care, and a vulnerable labor force. Among the most challenging aspects of the pandemic has been predicting its spread. The healthcare delivery infrastructure in much of the United States has faced the equivalent of an impending hurricane but without a national weather service to warn us where and when it will hit, and how hard.

To build a forecasting model that works at the local level – within a hospital’s service area, for example - the Beth Israel Deaconess Medical Center (BIDMC), relied on an embedded research group, the Center for Healthcare Delivery Science, that reports to the CMO and is dedicated to applying rigorous research methods to study healthcare delivery questions. We used a series of methods derived from epidemiology, machine learning, and causal inference, to take a locally focused approach to predicting the timing and magnitude of Covid-19 clinical demands for our hospital. This forecasting serves as an example of a new opportunity in healthcare operations that is particularly useful in times of extreme uncertainty.

In early February, as the U.S. was grappling with the rapid spread of SARS-COV-2, the virus that causes Covid-19, the healthcare community in Boston began to brace for the months ahead. Later that month, participants in a biotechnology conference and other residents returning from overseas travel were diagnosed with the new disease.

It was the start of a public health emergency. To understand how to respond, our hospital needed a Covid-warning system, just as coastal towns need hurricane warning systems. Our hospital is an academic medical center with over 670 licensed beds, of which 77 are intensive care beds. We knew it was hurricane season, but when would the storm arrive, and how hard would it hit? We were uncertain about what lay ahead.

Hurricane season - but where is the storm?

Lesson 1: National forecasting models broke down when predicting hospital capacity for Covid-19 patients because no local variables were included.

Our institution turned first to national models. The most widely used national model applied curve-fitting methods (which draw a best-fit curve on a series of data points) on earlier Covid-19 data from other countries to predict future developments in the United States. National models did not consider local hospital decision-making or local-level socioeconomic factors which dramatically impact key variables like population density, pre-existing health status, and reliance on public transportation. For example, social media data showed many student-dense neighborhoods in Boston emptying after colleges canceled in-person classes at the beginning of March, which meant fewer people were in Boston to contract the virus. Another critical variable in hospital capacity forecasting, the rate of hospitalization for people with Covid-19, varied as the weeks went on, even though national models held this variable constant. For example, early on our hospital was choosing to admit rather than send home many SARS-COV-2 positive patients, even with mild infections, because the clinical trajectory of the disease was so uncertain. Thus we needed a dynamic hyper-local model.

Building our storm alert system

Lesson 2: Local infection modeling required a range of different research methods, and the trust and commitment of operational leaders who recognized the value of the work.

The hospital turned to our research center to achieve these goals. The center, which is embedded in the hospital and reports to the Chief Medical Officer (Dr. Weiss), brought applied machine learning and epidemiological approaches to construct a hyper-local alert system.

To demonstrate the feasibility of forecasting local hospital-capacity needs for managing Covid-19 patients, we built a preliminary SIR model (a traditional epidemiological framework that models the number of Susceptible, Infected and Recovered people in a population), which was integrated into our institution’s incident command structure, an ad hoc team created with members of the hospital and disaster management leadership to respond to the pandemic. However, the accuracy of SIR models depends on the accuracy of estimates of disease characteristics such as incubation time, infectious period, and transmissibility, variables that are still not well understood. Therefore, we turned to machine learning approaches, harnessing real-time data from our electronic medical record to determine these variables directly from real patients. We also gathered Covid-patient census data from multiple hospitals simultaneously, using a common machine-learning technique called multi-task learning to capitalize on limited data. These methods allowed us to estimate when the demand for hospital capacity to treat Covid-19 patients would peak and plateau - predicting the timing to within five days of the true peak and more accurately modeling the slope of the peak and decline than national models did.

Had leadership relied on national models, they would have expected a sharper peak and decline, and a peak two weeks earlier than the actual peak. Our modeling affected key decisions, including the need to bolster personal protective equipment (PPE) supplies; to gauge the necessity of even urgent procedures, and postpone them if necessary in order assure we had the capacity to absorb the peak; and to establish staffing schedules that continued farther into the future than those originally planned.

Predicting the next hurricane

Lesson 3: Effective modeling in confusing times may require rapidly developing new methods for predicting the next storm.  

Hospitals now face a difficult challenge. We need to open our doors to the patients without Covid-19 who didn’t seek care or whose care was deferred. But how do we make sure to have enough protective equipment for safely bringing back outpatient procedures? And when can nurses who had been redeployed to our ICUs return to the floors and interventional areas such as the endoscopy suite and cardiac catheterization lab? Complicating these questions is whether we will see another rise in infections with changes in state-wide policies, reopening of schools and businesses, or a coming influenza season.

In this new phase, we now need to develop methods for understanding how people will move within a community (going to school and visiting stores, for instance) and how much they will interact with one another and, therefore, affect the risk of infection over time. To this end, we constructed a risk index for local businesses by comparing pre-pandemic traffic to traffic as they reopen, and whether they are indoors or partly or entirely outdoors. Businesses where visitors are densely packed in indoor spaces, especially for longer periods, have a higher risk index - meaning they are more likely to be the site of infection spread. Using our risk index, we created and validated a model for identifying such potential “super-spreader” businesses in our service area. This analysis is part of another body of research that will undergo peer review and publication and, therefore, its results are provisional. Meanwhile, we can use our work with businesses to further inform our forecasting model by examining traffic in business locations we have identified as high-risk and assessing whether incorporating these data improves the ability of our model to predict the demand on hospital capacity.

Integrating rigorous research methods into hospital operations

Lesson 4: Given the profound future uncertainty in healthcare, small investments in trusted internal research groups that can answer operational questions with new methods can yield substantial returns.

Our institution made a prescient investment in creating an embedded and trusted research group made up of clinicians, economists, and epidemiologists studying healthcare operations. The team has brought specialized machine learning methods and expertise in extracting conclusions from messy data to quickly and accurately solve emerging real-world problems - capabilities that traditional business analytics groups are less likely to have. Other organizations can similarly unite the rigor and flexibility of methodological experts with the need to rapidly answer operational questions in dynamic and even chaotic environments.

The authors would like to thank Manu Tandon, Venkat Jegadeesan, Lawrence Markson, Tenzin Dechen, Karla Pollick and Joseph Wright for their valuable contributions to this work. 

Jennifer P. Stevens, MD, MS is the Director of the Center for Healthcare Delivery Science at the Beth Israel Deaconess Medical Center and an Assistant Professor of Medicine at Harvard Medical School.

Steven Horng, MD, is the Clinical Lead for Machine Learning at the Center for Healthcare Delivery Science at the Beth Israel Deaconess Medical Center and an Instructor of Emergency Medicine at Harvard Medical School.

Ashley O’Donoghue, PhD, is an economist at the Center for Healthcare Delivery Science at the Beth Israel Deaconess Medical Center.

Sarah Moravick, MBA, is the Vice President of Organizational Planning and Improvement at the Beth Israel Deaconess Medical Center.

Anthony Weiss, MD, MBA, is the Chief Medical Officer at the Beth Israel Deaconess Medical Center and an Associate Professor of Psychiatry at Harvard Medical School.

 Have Your Privacy Policies Kept Up with Your Digital Transformation?

by Cillian Kieran - June 29, 2020

For companies everywhere, Covid-19 has expedited digital transformation at almost unimaginable speed. In an effort to survive and get back to business safely, companies have rapidly adopted services such as contactless payment, click-and-collect applications, and enhanced customer relationship management. These transitions are vital for business to continue, but each also introduces new risks. For every business that shifts operations online, there are potential privacy pitfalls that will prove very damaging if mismanaged, and as new regulations are set to go into force in the United States, the stakes for getting this pivot right are higher than ever before.

Across industries, teams with expertise in real-world spaces are rushing into digital ones where they’re novices and pumping huge amounts of user data into new systems. In the restaurant industry, establishments are scrambling to build new online ordering and delivery infrastructure or to partner with companies who already offer those services. In higher education, institutions faced with missing out on a year’s tuition fees are rapidly migrating their entire curriculum online, and rushing to digitize everything from online teaching to student health records. In the live events space, production veterans are being asked to migrate their well-established processes online and into new cloud technologies. In each case, these changes carry the risk that reams of personal data will be mismanaged and vulnerable to exposure.

This situation raises two major challenges for many businesses: First, they need to make quick decisions on procuring new technology: building online storefronts, implementing communications platforms that process customers’ personal data, and more. Second, they lack experience with data processing infrastructure, or even technology in general. That adds up to teams making quick decisions on the use of technology systems they don’t know much about. There might be an understandable temptation to treat privacy concerns as a secondary issue - one that can be addressed after the immediate crisis - but that would be a mistake, and one which would place companies at elevated risk of monetary fines, class-action lawsuits, and PR headaches.

There’s been growing regulatory pressure on both sides of the Atlantic. The General Data Protection Regulation (GDPR) in Europe, which was implemented in May 2018, and the California Consumer Privacy Act (CCPA) in the United States, which becomes enforceable by law on July 1 (impacting any company with a presence in California and over $25 million in annual revenue), contain stringent protocols for the management of user data, and both threaten steep fines for businesses that get data wrong. Particularly in the United States, there’s little reason to think that regulators will meaningfully relax standards because of the pandemic. California Attorney General Xavier Becerra has been unambiguous in his intent to press forward on implementing CCPA, stating: “We’re committed to enforcing the law starting July 1. We encourage businesses to be particularly mindful of data security in this time of emergency.”

The good news is that managing privacy concerns doesn’t have to be yet another daunting task on top of the already Herculean feat of moving large parts of your business online. There are a number of simple, meaningful steps you can take to minimize the risk of a privacy breach. To make your rapid digital transformation as safe as reasonably possible in the coming months, consider implementing these privacy-focused measures. Each can be done independently, but if your business can tick all four of these boxes, you’ll greatly mitigate privacy risk:

1) Be Mindful of How Your Vendors and Partners Use Customer Data

Businesses may be tempted to rush into contracts with third-party vendors who promise “plug-and-play” solutions to a number of digital transformation challenges. And while companies may be aware that they must review any Data Processing Agreements (DPA) during procurement, there is a tendency to underestimate the consequences of skipping this step. Under CCPA and GDPR, a business can be held financially liable for failure to perform due diligence on third parties that process customer data - in fact, this was the scenario that led to Marriott Hotel Group being fined $123 million by ICO in 2019.

Your key focus when reviewing vendor DPAs should be ensuring they’re privacy compliant and that their data policies align with your business’s stated data policies - otherwise a business runs the risk of violating their own privacy policy. Additionally, check the language about subcontractors in any vendor DPA. There should be assurance that vendors won’t subcontract to another processor unless explicitly instructed by your business to do so. This ensures your business is legally protected if a vendor unilaterally offloads data duties to a non-compliant third party.

2)  When Processing Data, Perform Impact Assessments To Monitor Risk

Impact assessments for data processing are required in many cases by GDPR, but not required by the CCPA. However in times of frenetic change, implementing basic risk assessments for data activities - however tedious - forces businesses to think critically before making a potentially damaging decision on issues like data storage, subcontracting, and more. Furthermore, in the event of being charged with a privacy violation, a paper trail demonstrating proactive steps to mitigate risk reads favorably to regulators.

The UK’s Information Commissioner’s Office provides a free data protection impact assessment template that will set your business on the right track to accurately assessing privacy risk, whether you’re based there or not.

3) Strive for Clarity in Your Privacy Policies

As key stakeholders reevaluate privacy policies ahead of CCPA enforcement, consider how the document reads. Your goal is to make this policy accessible to all of your customers - not just those fluent in legalese. You might think you’re covering yourself by including phrases wide open to interpretation to prepare for any future regulatory requirement, but your priority should be to help your increasingly privacy-savvy customers understand your policy and trust your company. Slack’s privacy policy shows that thoroughness doesn’t have to come at the expense of clarity for readers.

4) Designate a Data Protection Officer (DPO)

No matter a business’s size, centralizing responsibility for data decisions is preferable to diffusing responsibility across multiple departments. That is truer than ever during times of rapid change. DPOs serve as a focal point for privacy concerns within an organization and a vital liaison to regulatory bodies while the character of privacy law enforcement remains ambiguous. Even if the person lacks privacy experience, empowering a single set of eyes to focus on privacy is a quick, cost-conscious way to de-risk.

As stated at the outset, managing rapid digital transformation well can require taking risky action. But in the current climate, depending on regulatory largesse is an unnecessary risk for businesses when they can take simple, process-driven steps to shore up privacy.

Data privacy implementation exhibits many features of the economist’s “time inconsistency” dilemma – it’s too soon to do it until it’s too late. And as we’ve seen in the last few weeks, “too late” can mean a serious stumble at a critical business juncture.

Cillian Kieran is the CEO and founder of privacy company Ethyca. A background in software engineering and two decades spent leading large-scale data programs for Heineken, Sony, Dell, and Pepsi convinced him there was a better way to build privacy deep into large technology systems. Now, Ethyca powers privacy for global brands like Away, Slice, and AspireIQ.

 Office Reentry Plans Must Account for Medically Vulnerable Employees

by Rebecca Zucker - June 29, 2020

After a few months of sheltering in place, states are beginning to open up and employers are starting to consider what a potential “back-to-the-office” plan might look like. Many people are feeling anxious about how safe the office will actually be - especially those who are at higher risk for Covid-19. This anxiety also extends to employees who might not be high-risk themselves but live with someone who is. (For brevity, I’ll refer to these two groups collectively as those who are high-risk.) How your organization supports these employees needs to be a key part of your reopening plan.

It is not a question of if, but how many of, your employees will fall into this high-risk group, given the wide range of pre-existing conditions identified by the CDC that make someone more susceptible to adverse outcomes. While it’s important to create a safe workplace for all employees, it is especially important to think about how you will support this specific, high-risk employee population. Below are several recommendations.

Have a process in place for fielding questions and concerns.

HR leaders I have been talking to in various sectors have been addressing a wide range of employee questions throughout the crisis. This will only accelerate when the organization gets ready to reopen its offices, and there will be many questions and concerns specifically from this subset of employees.

Irene Bassock, an employment attorney and Of Counsel at the law firm Cohen & Buckmann, says, “There has to be some type of planning, knowing that these requests will be coming in fast and furious. It’s important that employees know where to go. That there are people on the front line, whether it be their managers or HR. That questions are getting to people who understand how to respond to those questions, so you don’t get knee-jerk reactions.” Having a clear process in place will help create greater alignment and mitigate conflicting messages.

Support their ability to continue working from home, if possible.

A silver lining of this pandemic is that it might normalize remote work. While working at home is not ideal for everyone, we have all learned over the last few months that it is doable when necessary - and even beneficial. Allowing high-risk employees to work from home will not only help them feel safe but will also reduce the number of people in the office, giving those who are physically present more space to socially distance themselves. Studies have shown that, in student populations, fearing for one’s physical safety negatively impacts performance, and the same relationship can be inferred for working adults.

Make sure they feel included on the team.

There are a number of ways to do this. For example, don’t make them the only one calling into meetings. One organization I worked with, prior to the pandemic had a policy that if one person calls into a meeting, everyone calls into the meeting in order to level the playing field.

Another way to prevent these employees from feeling marginalized, while also mitigating risk of infection to your other employees is to create A and B teams (or possibly more). Here, project teams are comprised of both A and B team members (note: A and B do not indicate any difference in employee performance). A and B team members alternate weeks in the office. This provides multiple benefits: High-risk employees are not singled out as the only people working from home; there is even more space at the office and therefore, more social distancing; and if an employee does become sick, an entire project team is not affected and disruption to the project is minimized.

Provide training for managers.

This training needs to include two elements. The first is to train managers on how to respond to inbound requests, whether it’s how to answer them directly or how to convey the organization’s process for handling them (if someone like HR needs to get involved). The second is to train managers on how to be more attuned to how others are feeling and how to express empathy. Essential coaching skills should also be taught. These include engaged listening skills and inquiry skills to better understand each individual’s situation, as well as how to probe beyond superficial answers to understand how a colleague is really doing.

While the pandemic has greatly increased the complexity of our world, it’s clear that the ongoing safety and welfare of your employees needs to be at the top of your priority list. This is especially important for those who are at higher risk. The strategies above can help you best support this employee population and should be a key part of your reopening plan.

Rebecca Zucker is an executive coach and a founding Partner at Next Step Partners, a boutique leadership development firm. Her clients include Amazon, Clorox, Morrison Foerster, the James Irvine Foundation, Skoll Foundation, and high-growth technology companies like DocuSign and Dropbox. You can follow her on Twitter: @rszucker.

 Let Yourself Be Unproductive. At Least for a Little While.

by Peter Bregman - June 26, 2020

Recently, my father died of lymphoma he could no longer fight.

“There are few people in this world who leave an indelible mark,” a friend wrote to me, “such that when you reflect upon their essence you can actually see their smile, hear their voice, and feel their presence as though they are there with you in the moment. Your father is among those few.” Every single encounter with him always left you feeling better about yourself.

The world has changed; it’s a lesser place without him.

I find myself a little lost. I’m scattered. Unfocused. Struggling to be productive. To move forward on anything in a meaningful way.

I’m experiencing a very personal loss and sadness right now. But I’m hearing other people describe similar struggles as we all experience this pandemic, this economic collapse, this awakening to the depth of racial injustice. That’s personal too.

I really don’t like feeling all this. It makes me anxious.

My instinctive drive to push past it kicks in. To plan and to-do list and schedule my way to productivity and achievement and forward progress. That, I know how to do. It’s my comfort during uncertainty.

But I also have an opposing impulse, a quieter voice, one that feels deeper, more profound, and even scarier: Stay unproductive.

At least for a little while. Feel the sadness, the loss, the change. Sink into the discomfort of not moving forward, not getting things done. In a strange way, not progressing may be its own form of productivity. Something fruitful is happening, we’re just not controlling it.

In this moment, being unproductive seems important. I think it’s what I must feel - maybe what we must feel - to allow for growth. To allow ourselves to pause in the liminal space, to linger with a question that this moment begs us to ask:

How can I allow myself to be changed?

Not, how should I change. Or how must I change to keep up with a changing world. And certainly not, how can I not change and preserve the way things have always been.

Those questions come from a habit of relentless productivity and achievement. But they miss what can be magical and transformational about this moment - our real opportunity.

Can you allow this change in your world - deeply personal and vastly global - to wash over you, shift your worldview, change you? Not with your discipline or drive, not from a self-directed, strategic, goal-oriented place, but from a place of openness and vulnerability. Not from willfulness but from willingness.

And in that pause and openness and vulnerability, can you listen - without defense - to the voices you hear and the nudges you feel? Can you find the emotional courage to follow your inklings, step by step, toward what, even just maybe, feels right?

For me, I long to be willing, to be molded by the loss I feel from my father’s death and the grace with which he lived his life. I feel sadness that I will never see his smile again or feel his strong, tender hands on my back. And I also feel excited that when I miss him, I feel him even more, and I can begin - in small ways - to feel my own smile, my own hands, showing up in new ways, more generously, more tenderly, more strongly.

We all need emotional courage because being willing to be changed means we must accept and admit that we are not in control and we don’t know. Two things many of us spend our lives scrambling and acquiring and competing and succeeding and workaholic-ing to avoid admitting. It’s disorienting to let go. To realize - to admit - that our control is really only a sense of control.

Which is why to slow down rather than speed up, to pause and feel, to approach this moment, with an openness and willingness to be changed, is really, really hard.

So what can we do to support ourselves through this moment?

That’s actually the wrong question. I have read - and followed - lots of advice about things we can do to slow down and leave space for change: meditation, poetry, walks, journaling, dream-work, and more. But these things can also get in the way because they reflect more doing. It’s trying to solve the problem with the same thinking that created it.

Here’s an alternative that has been working for me: Not doing. Or at least, less-doing. There are a few ways I’ve been entering not-doing space that you may want to try. Consider relaxing pressure on:

Your time

Walk away from your calendar. Leave that space for, literally, nothing. Not a thing. It’s not your writing time or even focused work time. Don’t fill those moments with the busy work of email and to-do lists. Allow yourself time out of time. Allow yourself to dawdle. I went food shopping with one of my daughters and she asked to take a certain road home. “But it will take twice as long!” I protested. “Who cares?” She answered, “It’s a beautiful drive.” And, in every way, it was.

Your thinking

Let your mind wander. When you go for a run, don’t listen to a podcast or even music, just run. When you fold the laundry, just fold the laundry. I’m not suggesting “mindfulness,” focusing on each fold as you fold. The opposite, actually. Don’t be mindful - that’s just more control, more pressure, more demand. Instead, let your mind go wherever it goes and, maybe, notice where it goes.

Your relationships

If you need a break from seeing people, allow for that. I have lovely, caring friends who have offered runs and conversations and I tell them the truth: I love them but, right now, I want to go running by myself. They understand. And if you do want to be with people, try doing it with curiosity and vulnerability, without wasting effort performing. If you’re listening, don’t judge or solve or offer advice. Just trust that your presence is enough. And if you’re speaking, ask only for an ear. “I don’t want advice,” you can tell them, “I just want to share what’s going on for me.” You’ll be doing them a favor too because you’re releasing them from having to know anything or perform.

When you relax the demand on your time, your thinking, and your relationships, you’re slowing down, reducing the load, and leaving space for feelings to come up. Maybe tears, maybe laughter, maybe boredom or annoyance. Maybe you’ll feel the stress of not getting things done, or the fear of missing out as people around you produce and network and market. Maybe you’ll feel joy and that might be scary too.

Courageously feel everything without running or repressing or denying or distracting yourself by doing. Give room for your body, your mind, your spirit, to reorganize. Trust that something important is happening - that there is something good on the other side - even if you don’t know what. You can’t force it.

But you can sabotage it. It’s hard to trust not-doing when we’re all suffering loss right now. It feels risky. Our doing habits are so strong.

I feel the instinct to cling to what I have known and what has kept me safe in the past. But I can also feel myself gingerly loosen my grip on the security of what has been, leaving my hands free, open, reaching for what’s to come.

I hope you can be here, with me, in this space for a little while, as we allow ourselves the time and grace to discover who we are and who we are becoming.

Peter Bregman is the CEO of Bregman Partners, a company that helps successful people become better leaders, create more effective teams, and inspire their organizations to produce great results. Best-selling author of 18 Minutes, his most recent book is Leading with Emotional Courage. He is also the host of the Bregman Leadership Podcast. To identify your leadership gap, take Peter’s free assessment.

 The Agile Family Meeting

by Bruce Feiler - June 26, 2020

At a moment when many families around the world are confined to home, climbing the walls, and are searching desperately for fresh techniques for managing their household chaos, one proven solution that my family, along with many others, uses comes from an unlikely source: agile development.

It’s no secret that working parents face enormous pressures. Ellen Galinsky, of the Families and Work Institute, asked a thousand children, “If you were granted one wish about your parents, what would it be?” When she asked parents to predict what their children would say, the parents said: “Spending more time with us.” They were wrong.  The kids’ number 1 wish: that their parents were less tired and less stressed.

So how can we reduce that stress and help families to become happier?

I spent the last 15 years trying to answer that question, meeting families, scholars, and experts ranging from a founder of the Harvard Negotiation Project to online game designers to Warren Buffett’s bankers. I published my finding in the bestselling book The Secrets of Happy Families and have found myself doubling down on many of those ideas in this time of flux of stress. The single best solution I found may be the simplest of all: hold regular family meetings to discuss how you’re managing your family.

Meet the First Agile Family

A few years ago, my research brought me to the Starr family home in Hidden Springs, Idaho. The Starrs are an ordinary American family with their share of ordinary American family issues. David is a software developer; Eleanor is a stay-at-home mom. At the time, their four children ranged in age from 10 to 15.

Like many parents, the Starrs were trapped in that endless tension between the sunny, smooth-running household they aspired to be living in and the exhausting, ear-splitting one they were actually living in. “I tried the whole ‘love them and everything will work out’ philosophy,” Eleanor said. “but it wasn’t working. ‘For the love God,’ I said, ‘I can’t take this anymore.’”

What the Starrs did next, though, was surprising. Instead of turning to their parents, their peers, or even a professional, they looked to David’s workplace. Specifically, to a philosophy of business problem solving that David had studied and taught: agile development. The techniques worked so well for their family that David wrote a white paper about it, and the idea spread from there.

When my wife, Linda, and I adopted this blueprint into our home, weekly family meetings quickly became the single most impactful idea we introduced into our lives since the birth of our children.

The Three Questions

The idea of agile was invented in the 1980s in large measure through the leadership of Jeff Sutherland. A former fighter pilot in Vietnam, Sutherland was chief technologist at a financial firm in New England when he began noticing how dysfunctional software development was. Companies followed the “waterfall model,” in which executives issued ambitious orders from above that then flowed down to harried programmers below. “Eighty-three percent of projects came in late, over budget, or failed entirely,” Sutherland told me.

Sutherland designed a new system, in which ideas flowed not just down from the top but up from the bottom and groups were designed to react to changes in real time. The centerpiece is the weekly meeting that’s built around shared decision making, open communication, and constant adaptability.

Such meetings are easy to replicate in families. In my home, we started when our twin daughters were five and chose Sunday afternoons. Everyone gathers around the breakfast table; we open with a short, ritualistic drum tapping on the table; then, following the agile model, we ask three questions.

1. What worked well in our family this week?
2. What didn’t work well in our family this week?
3. What will we agree to work on this week?

From the very beginning, the most amazing things started coming out of our daughters’ mouths. What worked well in our family this week? “Getting over our fears of riding a bike,” “We’ve been doing much better making our beds.” What went wrong? “Doing our math sheets,” “Greeting visitors at the door.”

Like most parents, we found our children to be something of a Bermuda Triangle: words and thoughts would go in, but few ever came out. Their emotional lives were invisible to us. The family meeting provided that rare window into their innermost thoughts.

The most satisfying moments came when we turned to the topic of what we would work on during the coming week. The girls loved this part of the process, particularly selecting their own rewards and punishments. Say hello to five people this week, get an extra 10 minutes of reading before bed. Kick someone, lose dessert for a month. Turns out they were little Stalins.

Naturally, there was a gap between the girls’ off-the-charts maturity during theses 20-minute sessions and their behavior the rest of the week, but that didn’t seem to matter. It felt to us as if we were laying massive underground cables that wouldn’t fully light up their world for many years to come. Ten years later, we still holding these family meetings every Sunday. Linda counts them as among her most-treasured moments as a mom.

So what did we learn?

1. Empower the children. Our instinct as parents is to issue orders to our children. We think we know best; it’s easier; who has time to argue? And besides, we’re usually right! There’s a reason few systems have been more “waterfall” than the family. But as all parents quickly discover, telling your kids the same thing over and over is not necessarily the best tactic. The single biggest lesson we learned from our experience with agile practices is to reverse the waterfall as often as possible. Enlist the children whenever possible in their own upbringing.

Brain research backs up this conclusion. Scientists at the University of California and elsewhere found kids who plan their own time, set weekly goals, and evaluate their own work build up their prefrontal cortex and other parts of the brain that help them exert greater cognitive control over their lives. These so-called “executive skills” aid children with self-discipline, avoiding distraction, and weighing the pros and cons of their choices.  By participating in their own rewards and punishment, children become more intrinsically motivated.

2. Parents aren’t infallible. Another instinct we have as parents is to build ourselves up, to be Mr. or Ms. Fix-it. But abundant evidence suggests type of leadership is no longer the best model. Researchers have found that the most effective business teams are not dominated by a charismatic leader. Rather, members of particularly effective teams spend as much time talking to one another as to the leader, meet face to face regularly, and everyone speaks in equal measure.

Sound familiar? “One thing that works in family meetings,” David Starr told me, “is the kids are allowed to say whatever they want, even about the grownups. If I’ve come back from a trip and am having trouble reentering the routine, or if mom hasn’t been nice that week, this is a safe venue to express their frustration.”

3. Build in flexibility. Another assumption parents often make is that we have to create a few overarching rules and stick to them indefinitely. This philosophy presumes we can anticipate every problem that will arise over many years. We can’t. A central tenet of the tech sector is if you’re doing the same thing today you were doing six months ago, you’re doing something wrong. Parents can learn a lot from that idea.

The agile family philosophy accepts and embraces the ever-changing nature of family life. It’s certainly not lax; think of all the public accountability. And it’s not anything goes. But it anticipates that even the best designed system will need to be re-engineered midstream.

As I was leaving the Starrs’ home, I asked Eleanor what’s the most important lesson I should learn from the first agile family.

“In the media, families just are,” she said. “But that’s misleading. You have your job; you work on that. You have your garden, your hobbies, you work on those. Your family requires just as much work. The most important thing agile taught me is that you have to make a commitment to always keep working to improve your family.”

What’s the secret to a happy family, in whatever situation you find yourself and whatever kind of stress you face?

Try.

Bruce Feiler is the author of six consecutive New York Times bestsellers, including Council of Dads, which inspired the NBC television series, and The Secrets of Happy Families. His latest book is Life Is in the Transitions: Mastering Change at Any Age.

 Will the Pandemic Reshape Notions of Female Leadership?

by Tomas Chamorro-Premuzic and Avivah Wittenberg-Cox - June 26, 2020

Countries with women in leadership have suffered six times fewer confirmed deaths from Covid-19 than countries with governments led by men. Unsurprisingly, the media has swelled with stories of their pragmatism, prowess - and humanity. Will these positive outcomes influence our collective readiness to elect and promote more women into power?

In both business and politics, leaders of the world have spent the past few months facing a real-time leadership test, played out in the full view of an impatient global audience. A huge crisis, unlike anything seen in our lifetimes, renders experience and expertise irrelevant. Leaders today must learn to lockdown and reopen countries while walking the tightrope between balancing the health of their populations with that of their economies. Their evaluations will be as public as their performances. Instantaneous, global, social-media-documented scrutiny puts their every action and every communication in full view. Whatever the future brings, one thing is certain: those in charge will be judged on how they manage this crisis - and nowhere are the stakes higher than in government.

Heads of states are reluctant participants in this leadership contest, subjected to daily reviews of virus statistics, with journalists as judges. The best way to evaluate leaders’ performance has always been to look at how their teams and followers are performing, especially compared to others. But the pandemic and its grim count of death tolls introduces entirely new pressures: standardized, data-driven global metrics invite people everywhere to easily compare, at the click of a mouse, the relative effectiveness of their elected officials.

In this competition, few comments have received more attention than the stellar performance of female leaders. An avalanche of articles have highlighted the female-led countries managing the crisis better. It is claimed their superior performance reflects well-established gender differences in leadership potential. Numerous pieces have dug into individual strengths, celebrating Angela Merkel’s data-driven trustworthiness, Jacinda Ardern’s empathetic rationality, and Tsai Ing-wen’s quiet resilience.

We are aware of the (many) nuances and limitations of the data under debate. Generalizations stoking the “gender wars” are an easy way to attract popular debate and discussion. Many people have (very) strong opinions about whether women are managing the pandemic better, and everyone is entitled to their own opinions - but not to their own data.

For those who wish to poke holes at the “women are better leaders” arguments, here’s a menu of legitimate qualifiers.

Too Few to Tell (sample size): There are not (yet) enough women running countries to legitimately examine gender effects. Women only govern 18 countries or 545 million people globally. That’s 7% of the world’s population - an achievement, nonetheless statistically insignificant.

It Wasn’t Her (conflating factors): Scientific studies show leaders typically account for around 30% of the variability in a group’s (including a nation’s) performance. This is not trivial but suggests a range of things determine outcomes unrelated to the leader. Every nation confronted this crisis with its own mix of advantages and disadvantages (e.g., educational level, income, income inequality, weather conditions, density, general demographic profile, etc.). Incumbents inherited existing contexts with consequences. They were dealt a hand and have limited credit and blame for how it turned out. This is less true when a leader has been in charge for a long time and has influenced the starting conditions.

It’s the Culture (or, correlation isn’t causality): Correlations can be caused by other factors. Even if you agree that women-led countries are handling the crisis better, there are (at least) two other elements to consider. First, countries do better because they have women in charge. Second, countries have women in charge because they were already doing better (less sexism, more inclusivity, removal of glass ceilings blocking competent women from reaching the top in the first place). You don’t have to be a math whiz to see that if a country (consciously or unconsciously) rejects 50% of its talent for leadership roles, it ends up with less - and lesser - talent.

Only the Best (selection bias): One of the paradoxical consequences of sexism is that it elevates the quality of female leaders. Because women need to work harder to persuade others that they have the leadership talent it takes, they end up being more qualified and more talented when they are selected for leadership roles. As a consequence, our high-performing covid-response countries may simply be enjoying the fruits of their higher standards for women, rather than that women are, in themselves, superior. One could then argue, from a fairness standpoint, we should make it easier for less competent women to get to the top. That’s what a Frenchwoman, Françoise Giroud argued 30 years ago. A better solution for the challenges facing us in 2020 would be to make it harder for incompetent men to become leaders.

Regardless of how robust the evidence might be, or how logical and data-driven the arguments, add to the mix a change in receptivity of the zeitgeist. A small number of female leaders have emerged as a benchmark for what competent leadership looks like - and been applauded for it.

Could this be the moment, then, to replace our old, obsolete leadership archetypes with more pragmatic and meritocratic models?

A crisis is often defined as the time between the old being not-ready-to-die, and the new not-quite-ready-to-move-in. Will our post-covid world say goodbye to our persistent preference for tough, bold, and reckless leaders, primarily male and obsessed with themselves? Will we be mature enough to adopt a more balanced perception of leadership talent, one based more on increasing group welfare than on individual showmanship?

The roller-coaster ride of gender equality over the past few decades may be depressing to some. But this moment, unlike any we’ve ever known, opens new options for the future - millions of them, in fact. This group of talented leaders may become the first visible wave of role models for the generations to come, redefining the way we pick leaders in politics and business. In short, tales of strong female leaders succeeding through this crisis could lead to a change in the overarching narrative of what a strong leader looks like. Society at large may become less surprised and more accepting of leaders (s)elected on their expertise, intelligence, curiosity, humility, empathy, and integrity. Though only time will tell if this new narrative survives the crisis, we hope it will. It would not just elevate the overall quality of our leaders - it would likely increase our trust in the result of our choices.

The world didn’t need a pandemic to realize that people are generally better off when their leaders are smart, honest, and modest. But we are glad to see the public, and especially the media, fall in love with the leaders who display these qualities - daily and publicly - while keeping their nations safe at the same time. It’s a lesson we think will bear fruit, and multiply.

Tomas Chamorro-Premuzic is the Chief Talent Scientist at ManpowerGroup, a professor of business psychology at University College London and at Columbia University, and an associate at Harvard’s Entrepreneurial Finance Lab. He is the author of Why Do So Many Incompetent Men Become Leaders? (and How to Fix It), upon which his TEDx talk was based. Find him on Twitter: @drtcp or at www.drtomas.com.   

Avivah Wittenberg-Cox is CEO of 20-first, one of the world’s leading gender consulting firms, and author of Seven Steps to Leading a Gender-Balanced Business.