Naked Medicine

Let's Face It: Medicine is Business

Psychology of Money and Expertise

A consultant who helps client make changes in their work and lives* is struggling to setting a price of her expertise. She likes to work strategically — and solve her clients’ problems as efficiently as possible.

Unfortunately, she is so efficient, that her clients perceive her services as a waste of time because “I must not need your help if you can solve my problem so easily in such a short amount of time”! Yet if it takes too long, then “I don’t have enough money in my budget for your services” — catch-22 of “damned if you’re too good, damned if you’re not good enough” at what you do!

Image by Svilen MilevI work in the knowledge field (also consulting but more like management consulting and leadership development) and see the exact same problems. I also tend to cut through crap, avoid page fillers in reports, and just give people the most important points they need to know since, you know, they all say how busy they are.

But I have realized that some people perceive value based on VOLUME.

Those who are experts will suffer from their expertise because of the perception paradox. Thus they WANT to get the 300 pages of worthless crap for $5000 (some industry reports cost this much esp. when it comes from “professional consultants”), because it makes them feel like they paid good money for it, versus the 10 pages that describe the heart of the problem and the pertinent actions to take, because suddenly – “hey, you are charging me $500 a page?” — er, no, I am charging you $500 for each mistake you don’t have to make that is going to cost you $50,000 to fix.

Thus for consultants in private practice, I suggest a hybrid of expertise and perception needs: you have to draw out the sessions so that you build a lot of “extra work” around the actual work, in order for the clients to FEEL like they’ve gotten their money’s worth and BELIEVE in the fairness of the exchange.

If you are a wizard and you can solve their decades-long emotional issues in 60 minutes, chunk this up into 6 sessions where 10 minutes is part of the actual work and 50 minutes is all the “nice to do but not critical work”.

Is this deceptive? I used to think so — until I learned the hard way, that part of working with any customer is meeting them where their perceptions are.

There will be customers who say, “cut through the crap and give me the 1 session for this price, I know enough to know what expertise look like”. For these customers I work with them in my preferred way of working: efficient and effective.

There will be customers who say, “no, I need you to hold my hand, I want the 6 session deal.” Both customers are RIGHT because they are the persons buying. People want to feel good and justified in their investment, you are giving the same important service, only you are also working with a perception problem around the value of that service.

If you’re a consultant struggling with setting fees, you can try your own experiment. Charge the same amount for 2 options, only label the 6-session option “for regular people” and the other 1-session option “for CEOs who have no time”. They’re priced the same, only now you’re working with each person’s perception of the value of their own time.

Danger of Safety Deafness to Pharma DTC Ads

Pharma ads are a relatively “new” phenomenon. In the late 1990s, the FDA allowed pharma companies to advertise directly to consumers (DTC). These DTC campaigns were reviled by physicians who believe that the ads would create pressure on them from the patients and disrupt that physician patient relationship.

Pharma companies do not have “free speech” because they operate under “commercial speech”. They are therefore dictated by the Food and Drug Administration (FDA) on what they are allowed to say and they are required to provide the information about the safety of the drug as part of “fair-balance”.

This is why you will see the disclaimers built into the ad, as the narrator smoothly go from talking about how the drug works and to ask your doctor about the drug to the standard —

“…WonderDrug is not for everyone. Women who are pregnant or nursing should not take WonderDrug. Your doctor may do routine liver testing when you are on WonderDrug. Do not take WonderDrug if you are also taking IncrediblePill. Patients who experience big toe palpitations should stop WonderDrug immediately and call their doctor….”

From an industry perspective, one of the arguments *for* DTC is that diseases and conditions become educational opportunities.

For example, depression is a stigmatized condition — then Pfizers happy little marshmallow cartoon (or pill? or cloud? I don’t know what that Zoloft character was meant to be) showed up on screen and it was a way to encourage consumers to talk to their doctors about conditions they may otherwise not discuss. For erectile dysfunction, it used to be an uncomfortable topic, but it is one of the side effects of diabetes and patients care about sexual function (compliance on meds) — so you have ads that break the ice of conversation that patients need to have so that doctors can work with them on adhering with medication regimen for best outcomes.

So there are definitely positives as a result of DTC.

On the other hand, when a DTC for restless leg syndrome came out, I didn’t like that campaign very much. I felt this was such a specialized population of patients, that having a DTC campaign may cause patients to start diagnosing themselves, erroneously, based on seconds of soundbite.

In the past when pharma companies have been sued for not disclosing safety risks and full side effect profile, their DTC ads have usually been part of the lawsuit where the charges would be that patients have not been properly informed of the full risks of the drug and that the time spent on effectiveness tips the fair balance to make the drug appear “safer than it should appear”.

Image by of the concerns I have is that over time, patients may begin to ignore those safety statements. This can be a real danger.

It’s not unlike how many of us have grown “blind” to online ads. We go to the website and our eyes are hit by ads all over the place, but we’ve trained ourselves to selectively ignore them. Ad-blindness is a real phenomenon and internet marketers talk about this and how to bypass or overcome them.

In pharma DTC, we may become so used to those safety disclaimers that we may become selectively deaf to those statements. Many of those statements are also repetitive and similar — such that we may begin to downplay the real risks that “need for liver monitoring” may pose.

Here’s an example from real life:

We’ve all seen various statin drug commercials — these are widely used blockbuster drugs. There are always safety statements about muscle weakness — sign of serious adverse event that can result in death.

One of my relatives was on a statin drug and he watches a lot of TV, he no doubt has seen ads for these statin drug commercials including the one he was taking. One afternoon when he visited and we were sitting at a picnic table he casually mentioned that he had trouble walking very far because he seems to have very low energy.

I knew he must be on a statin drug but he’s been on several drugs for several years: this person is a chronic smoker who still wouldn’t give up smoking or horrible fat-laden diet after multiple surgeries including a quadruple bypass (I am not kidding! Quadruple bypass! One of the most serious heart surgeries you can get). He’s always complaining of aches and pains — but still:

I asked him if he had switched meds recently and sure enough, he had been taken off an old statin in favor of “a newer” statin. I told him that he needed to call his doctor immediately and make sure that his “weakness” isn’t due to a serious adverse event like rhabdomyolysis, which can cause fatalities because of kidney over-burden.

He called his doctor and was taken off that statin to another statin and his “weakness” improved dramatically.

In other words, patients who are watching these commercials may grow deaf to these statements that sound very clinical but they don’t know what this looks like in real life. We aren’t thinking “oh I’m feeling this way because the drug is causing my muscle fibers to massively break down” — we think “I’m feeling really weak.”

“I saw a nurse – Where’s the doctor?”

You went to see the doctor and then realized that you talked to the nurse practitioner who ordered some tests — but you never saw the doctor! What’s going on?

In some states, a nurse practitioner (NP) has the same prescribing authority as the doctor, and may even act as a patient’s primary care “doctor” — thus I wouldn’t rule this out as a case of negligence, but more a prevailing norm of healthcare in a particular geographic area.

That said, you should absolutely be comfortable with the care you are receiving. If you want to see an MD instead of an NP, that is within your right as a patient!

I’ve heard of patients complain about their doctors not scheduling enough tests to rule out possible conditions associated with their complaint, so “test ordering” may depend on the context of the appointment. Often, physicians are not financially rewarded for ordering tests (costs the insurance companies too much) when compared to prescribing a drug (cheaper for insurance companies to pay for pills than an expensive scan).

For example, I had an acquaintance whose doctor was writing prescription drugs for her diabetic elderly father without doing any blood tests or monitoring. Her father began vomiting on a regular basis, and this doctor simply switched to writing other prescription drugs without figuring out why the patient was vomiting and becoming increasingly lethargic. She took her father to another doctor, who promptly ordered a series of tests to look at what was happening, and determined that the vomiting was mostly likely a serious adverse reaction to one of the diabetes medication. This doctor used the results of the tests to make a more informed clinical decision on which drug may keep the patient’s diabetes under control while minimizing the side effects that would prevent the patient from taking the drug regularly to keep symptoms at bay.

How you can still coach with compassion in pharma biotech

Most people in the pharmaceutical industry want to play by the rules and meet all compliance standards. I haven’t ever met any employee or managerial leader who has told me, “I want to bend the rules as much as possible then get the hell out of here, I can’t care less what happens to patients.”

However, where behavior and ideals collide, is when people observe inconsistencies with preached rules and prevailing behaviors that are rewarded.

Thus, pharma managers and executives must coach their teams on at least 2 levels:

Level 1 Tap into the Ideal Self

Coaching with compassion level may be done by tapping into the person’s ideal of how he and she wants to work in the role and in industry; that person’s vision of why s/he matters in the job s/he is doing.

Many people in industry do this for personal reasons, whether they’ve been a patient themselves or have had family and friends go through a health crisis that propelled them to want to get into the industry. Connecting with these ideals and catalytic events can rekindle that vision the employees held when they entered the industry.

Level 2 Navigate those risky gray areas

Discussing the inconsistencies that arise, and from the person’s positive emotional attractor state, to look at these inconsistencies and ask that person what s/he think is happening and then what s/he thinks about it.

This creates concrete examples that the leader/coach and team member can discuss, rather than generalities about “what we should and shouldn’t do, what we could and couldn’t do.”

Giving Customer Less Choices Drives Up Business

I often marvel at how good business seems to be at “In N Out” burger, a popular burger “restaurant” in California.

In N Out is branching into other states – the company is private and doing extremely well, and the secret lies in it giving customers “less” choices than rival burger joints.

In N Out has a very simple menu and serves up “hamburger” “cheeseburger” “double cheeseburger” (called the “Double Double”). When you go there, you don’t have to guess what you’re going to get, you already know you’ll get a burger of some kind, or fries.

However, what In N Out appears to limit customers in menu choices, it compensates with a loyalty-inducing strategy: by positioning customer choices in the customization of the burger via a “hidden” or secret menu.

The customizations are often in “code” – like 3 by 3 or 4 by 4 (# of patties, # of slices of cheese) or “animal style” (extra sauce, extra pickles).

Having a simple menu that streamline operations as well as buying choices yet customizable “code-based” menu that creates a sense of “membership” among those In-n-Out patrons is ingenious.

This “The Variation of the Number of Choices” is a strategy in many markets and in companies like In N Out, is a key competitive advantage.

p.s. the double-double’s are also super yummy, I don’t care if it’s over 800 calories.

Why Consumers aren’t Buying “High Cost-of-Developing Drugs” Argument

The Economist recently published an article on the government of India denying Novartis the patent for its cancer drug, Glivec (in the U.S. marketed as Gleevec).

In reading the reader comments, it is obvious that a sense of fairness violation was perceived by readers who felt that the government was correct in denying Novartis this patent, given that the readers perceived the company should have “made back its R&D losses” in developing this drug and beyond.
Image by Chris Holder
Pharma companies cite R&D development costs as well as the pitiful yield in its success rate in developing novel drugs as the reason why drugs cost so much. Thus patent is given as a way for companies to recover overall losses in this risk-intensive business as well as remain sustainable over the long term.

Yet companies are also known to go for patent extension strategies that do not represent truly novel contribution to market, by creating slightly different forms – or formulations of the drug – and then gaining patent on that slightly different form. Then companies use their sales and marketing arms to then keep patients on the “newer” (in patients’ mind, “better”?) version of the drug instead of the cheaper generic.

Those who argue for patent protection speaks about the risk and astronomical costs in bringing a drug to market. This is true, especially during human clinical trials, which consumers are rarely given the full picture of just how much “each patient” in a clinical trial actually costs the company to run the complete trial, especially when there is tremendous overhead in setting up these trials across different clinical settings within the country.

But consumers also perceive the unfairness of the pricing and when it comes to healthcare and medicine, emotions run high and it is common to conclude that pharma companies are greedy and being unfair given that they should have had already recuperated on their fixed costs and now they are using strategies to boost their bottom-line when they aren’t really investing in that drug (but they have to keep investing in their pipelines of drugs, many of which will fail, rendering huge losses to the companies).

Drug companies try, and its advocacy arm (PhRMA in the u.s.) tries, but the approach and message don’t seem effective. These messages are often very abstract and statistics-driven, which do not lend well to personalization. Statistics aren’t stories the average consumer can relate to.

Expensive Weddings: A Problem of Irrational Behavior Economics

Image by Con Mani (Austria)Weddings formally celebrate the nuptial partnership between two people. However, the cost of wedding parties can significantly impact the new couple’s financial health. Wedding parties can grow into major productions from catering (food) to entertainment (music). Each spending category comes with upgrade options, which quickly escalates overall wedding cost. According to a wedding website that surveyed 17500 couples, the average cost for a wedding was $28,427 in 2012 in the United States. In the United Kingdom, a similar survey by You & Your Wedding Magazine showed that a wedding cost couples £22,000 in 2012.

Expensive Weddings: A Problem of Irrational Behavior Economics
When I attended weddings as a little girl, I remember the wedding highlight was the banquet that followed the wedding ceremony, when bride and groom would toast guests at each table and we kids finally get to eat! Now? We have grown used to televised, extravagant wedding parties that shifts our perception of what we should “normally expect” from weddings: we have learned to expect multimedia productions with slide shows, choreographed dances, and exotic parting gifts for guests.

Image by Allie HyltonWhen it comes to weddings, we experience pressures from social norms: we attend our peers’ weddings and begin to form arbitrary ideas about what we should be willing to pay for a wedding. We are further colored by our emotions toward what should be “the happiest day in a couple’s life” (next to becoming parents).

Scale of Problem Behavior
When we consider that:
(1) Money is a cause of many arguments between married couples,
(2) Debt is a precursor to additional, vicious cycling financial problems, and
(3) Young people often already hold education debt (student loans) and may be unemployed or underemployed

— We can appreciate how the happiest day of a newly married couple’s life may quickly transform into heavy financial burdens for the young couple if they paid for the wedding — or for their elderly parents if they had to borrow money (assume new debt) or withdraw from retirement funds to pay for a wedding production.

A Research-Based Wedding Financial Protection Plan
First, use both credit cards and cash — but strategically. Since credit cards remove our “pain of payment”, we may be more likely to deviate from the wedding financial plan and engage in impulse purchases, just as shoppers using credit cards bought junk food on impulse [Thomas et al. (2011). How Credit Card Payments Increase Unhealthy Food Purchases: Visceral Regulation of Vices. Journal of Consumer Research, 38(1), 126-139.] Existing experimental research relevant to psychological intensity have shown that we may be more willing to say “yes” to a $1000 upgrade when we are already paying $10000 for a wedding party. If we are reminded of what other uses we may assign to this $1000, such as saving toward the down payment for a house, we may avoid such opportunity cost neglect [Frederick et al. (2009). Opportunity Cost Neglect. Journal of Consumer Research, 36(4), 553-561.]

Therefore, use credit card to pay for basics like renting a location and buying the dress, but use cash for any upgrades that are offered by wedding service providers.

Image by Allie HyltonSecond, create a personal arbitrary anchor around wedding cost. Engaged couples may be familiar with the marketing tactic of jewelers that say “a wedding ring should cost 3 times a monthly salary”. They can use the same logic to create a new anchor for their wedding budget, for example, by deciding that the wedding should cost 5 times – and not more – the couple’s monthly salary. Existing experimental research has shown that people tend to assign arbitrary values of how much they are willing to pay for something [Ariely & Norton. (2008). How actions create-not just reveal-preferences. Trends in Cognitive Sciences, 12(1).] — therefore, setting their own arbitrary anchor allows engaged couples to have a framework to make financial decisions around the wedding party.

Third, create a “memorable ending”, not a “memorable wedding”! This is perhaps the most powerful research-based strategy. Several studies have shown that how an event ends is more important than the entire duration of the event in people’s minds [Tetlock & Mellers. (2002). The great rationality debate. Psychological Science, 13(1), 94-99]. When you create a memorable “ending”, the guests will be more inclined to remember your entire wedding as “memorable”!

In conclusion, I don’t expect that couples will elope like I did (I was a poor graduate student when I got married), but these 3 research-based ideas may help a young couple have a memorable wedding event within their wedding budget.
Image by Allie Hylton

Medical Decision Making and Conflicts of Interest

Dr. Peter Ubel is a professor at Duke University and gave a guest lecture for Dan Ariely’s (also a professor at Duke) Coursera class on Irrational Behavior economics. Ubel’s lecture talks about a colleague who told a leukemia patient that the patient’s chance of recovery if he undergoes chemotherapy was 20%, which was an overstatement of the 5% benefit of chemotherapy for leukemia, especially considering the side effects:

“In Mr. Andrews case, a 5% chance that his leukemia would respond to chemotherapy and yet the oncologist told him that it was 20% odds. Is that a lie? Well here I want just tell you. It’s not just patients who are prone to strange decisions in medical contexts. We physicians are prone to those too. And I don’t think that that oncologist lied. I think that oncologist when asked straight up front what are my odds of getting benefit from the chemo had that 5% number in her head. And immediately started recalculating because it’s so hard to give someone such dismal news.” [Source: Coursera week 3 on Dishonesty

One of the students in the course was outraged that Dr. Ubel did not come right out and confront his colleague as well as tell the patient that his colleague “had lied.” I was troubled that Dr. Ubel did not have a conversation with his colleague about his concerns, because this must happen not just with this one oncologist, but many others who pull numbers out of their own “clinical judgment” hats. However, Dr. Ubel did go back to challenge the patient’s decision, but in a way that also elicited the patient to reveal why he had chosen to go with the most aggressive treatment (the patient revealed that his partner had passed away of AIDS and was a fighter and that his partner would have wanted the patient to fight as well).

I believe that if Dr. Ubel had learned that the patient was swayed primarily by the oncologist’s judgment and nothing else, then he would make sure that the patient understands the “true statistics” and what aggressive chemotherapy or radiation therapy entails. This is the reason why Dr. Ubel did have that follow-up conversation with the patient, and based on the patient’s own explanation, knew that the patient was truly making an informed decision that respects the patient’s own wishes, not just relying on what the oncologist claims.

It is indeed true that the medical profession upholds a certain “code of brotherhood” where physicians don’t call out each other’s biases, and that this poses a major problem in deciding in the “best” interest of patients. However, I personally didn’t perceive this to have happened in Dr. Ubel’s example. I perceived that he felt as troubled by the oncologist’s claim as we all did when we knew the conflict of interest in the oncologist’s claim.

Part of the office hour video, which I wasn’t able to watch completely, included Dr. Ubel talk about how “hope” is important to patients and therefore physicians must also take into consideration the effect of hope and not necessarily give patients false hope, but also not to dash hope by quoting death statistics. Yet this oncologist who had overstated the chemotherapy’s benefit of 20% instead of the truthful 5%, had done so by calculating her own biases of hope (these may not necessarily be false hope, it may very well reflect her own hope for the patient).

We don’t like physicians to give us cold, clinically calculated statistics that may or may not be true for us as individual patients. But we also don’t like physicians to overstate and give us false hope. This is the kind of balance that makes medicine more an “art” than science even when we have all this scientific data at our fingertips.

More from Dr. Ubel

Golden Handcuffs

Professor Dan Ariely in his “LEGO experiment” (source: Ariely, D., Kamenica, E. & Prelec, D. (2008). Man’s Search for Meaning: The Case of Legos. Journal of Economic Behavior and Organization, 67, 671-677.) tried to assess the effect of “meaning” in people’s work, by offering people less and less money to build LEGO toys until it was no longer worthwhile for them to build LEGO toys for pay.

Limit of LEGO Experiment
One of the limitations of this approach is that you may be dealing with “building fatigue” — people starting to get physically and mentally tired after a certain # of builds, and this would be a contributor to their refusal — not so much the decrease in money.

What if you let people rest for an hour (the duration of the average lunch break) and continue building for lower $? Would the lowest $ point change?

What About the Golden Handcuffs effect?
Image by question that is related to this lecture is what I’ve heard as the golden handcuffs: you no longer find meaning in your job but the money is just too good. Thus you keep doing a job you hate, because you don’t want to give up the money, even as other factors relating to motivation (intrinsic rewards) are at a all-time low.

How would you test this using an experiment? I’m just curious how we’d design an experiment around this. Should we have people build LEGOs for $3, $3.07, $4 etc… while someone yells into their ear saying “you suck!” to simulate demoralizing work condition?

I think a rational way to weigh the benefits and risks of golden handcuffs – based on my personal experience (yes, I have been there), goes something like this:


$$ Salary
$$ Health benefits
$ Bonuses, paid vacations, holidays
$ Stability, feeling of security however illusory


-$$ Work-related stress, depression requiring therapy
-$$ Personal strife due to work stress
-$ General negative health effects due to stress
-$ Having to pretend like I’m “Leaning In” when I feel like “Checking Out”

For the most part, I’m highly self-motivated, thus the “golden handcuff” effect has come largely due to demoralizing conditions due to work-related politics that appear well beyond my control, yet the consequences of these affect how well I am able to perform my work.

Give and Take and Why I’m Still Looking for a Role Model I Can Relate To

I am reading “Give and Take” by Adam Grant. Basically, Grant writes a treatise suggesting that people who are “givers” (the nice guys) may appear to end up last in the short run, but they end up winners in the long run. More promotions, more advancement, more opportunities, more friends, more money.

I highly anticipated reading this book after first learning about Grant from the New York Times write-up. I really wanted to like this book. I appreciated the numerous studies cited, but was disappointed by the superficial treatment of the givers. Specifically, I did not find what differentiates those who “give and (eventually) win” and those who “give and simply became exhausted”.

Grant’s selection of “takers who suffered crises of creativity”? Frank Lloyd Wright and Jonas Salk.

These were 2 examples early in the book about famous people who weren’t good collaborators and who took too much credit for the collaborative work of others.

I don’t know much about architecture but I’ve heard of Frank Lloyd Wright. The wikipedia entry about Jonas Salk says nothing of Salk’s “hogging the limelight” around polio vaccine work and I never came across a negative impression about Salk in my readings until now. Are these the best examples of what negative effects come if you act more like a “taker” or even a “matcher” versus a true “giver”?

I *REALLY* want to believe in what Grant is proposing.

But I’m having a hard time being convinced.

Surely there are some who didn’t make the bell curve of giving super-stardom: people who were generous and eschewed credit and still ended up in the bottom of the barrel. An early chapter in the book talks about those groups of engineers and professionals who were at the top and bottom of the ladders – and both groups ironically were givers. What made one group ascend to the top, and one group trapped at the bottom? Was it a matter of time – that givers become recognized but this recognition require longer time frames to manifest? Or was it something else? Addressing this first “elephant in the room” would make the book more balanced and persuasive. At least, it would not lead well-meaning but exhausted givers to wonder if their plight stems from them “not giving enough.”

I first read about Grant from this NYT piece and while intrigued enough to preorder his book, I can’t help but wonder if he can give as much as he does if he doesn’t have a spouse who basically handles the domestic affairs while Grant “gives of himself to his students and colleagues”. Because it reads like this guy is at the beck and call of everyone, in addition to (maybe?) his family:

Children. It must be said that in the middle of a national debate about flexible hours and telecommuting, there is precious little in Grant’s book about work and family balance. The division of labor in Grant’s own marriage is very traditional; his wife, who has a degree in psychiatric nursing, does not work outside the home, devoting her time to the care of their two young daughters and their home. Grant would be an extraordinary giver under any circumstances; but it can only help that he doesn’t have to worry about running to the grocery store or renewing the car registration.

“Sometimes I tell him, ‘Adam — just say no,’ ” his wife, Allison, told me, referring to the hundreds of requests he gets every day. “But he can’t say no. That’s what he is. That’s his way.”

Grant is devoted to his family — he has dinner most nights at home and takes his daughter to a preschool activity on many afternoons. But he also works at least one full day on the weekend, as well as six evenings a week, often well past 11. Once, when Grant was asked to give a talk on productivity, he confessed to a mentor that for all his research, he was still not sure what he did that was any different from anyone else. It wasn’t exactly a mystery, his mentor told him: He worked more. “I made a commitment to talk about that more,” Grant said. He did not mean to suggest that everyone should work on weekends; he wanted them to be aware that they were making a choice, maybe even one they felt good about.”

The book suggests that givers gain by expanding the pie, which made logical sense. However, we may expand the pie, but we can’t expand the unit time we have to sustain the increasing demands of a bigger pie. Expanding the pie does not necessarily mean all relationships demand the same effort at the same time, but still: increased influence increases demands over the same units of time. The book’s examples did not describe how givers who expanded the pie evolved to sustain their giving while balancing their personal commitments (to family, for example).

Several chapters in, and I still struggled with how the author proposes to balance “giving” across both personal and professional boundaries. I kept looking for an in-depth example of givers who exemplified such balanced giving across personal and professional circles. If some of the “role models” in the book exemplified this balance, it was not treated in depth… then the book ended. Even though I knew buying the book I shouldn’t find anything about family and domestic partnerships with children, surely these dynamic individuals have vibrant personal lives, and personal relationships that may rival the demands of their time and effort.

Yet personal relationship aspects of these profile were mentioned only in passing to illustrate the story, without delving into the effects of “expanding the pie type of giving” on their personal relationships. Maybe these don’t negatively affect personal and family relationships – maybe this positively affect family relationships – but whatever the effect, it was overlooked or deliberately omitted. I saw this omission as the second “elephant in the room” and the book’s Achilles’ heel. It leaves too many questions unanswered, questions that are important for people who may not always be in the position of “designated career spouse”.

As a woman and a parent who has “domestic policy/domestic affairs” as my major responsibility, I can’t help but wonder how feasible it would be for “me” (and those like me, whether male or female) to put these principles in action.

This is the problem with these “leaning in” type of articles and proposals.

Show me someone who can do this on top of balanced family responsibilities, give me a role model I can RELATE to!

Our culture and companies celebrate “visibility”. Not really “takers” per se, but visibility. People who appear like they’re movers and shakers and who can haul out lots of accomplishments and credits to their name. The NYT article comment section is most telling. There was one person who said she had given selflessly to students and colleagues but she saw who “got ahead”.

I wonder if there is a gender difference: whether women are expected to be givers so if they give, it doesn’t shake anybody’s world. Men on the other hand, are not expected traditionally to be givers, when they give, they get invited to speak at Google and write a book that gets written up on NYT to help preorders (it worked, I bought a copy, but I’ve read several chapters of this book and I’m still trying to figure out — what is that ‘balanced’ giving). What I mean by balanced giving is not “matching” (give to gain) but — give to others while also giving to people who need me the most (my family).

I think I’d have a more rewarding life and sleep best at night when I think I have my personal relationships intact and I have given when I can give and be honest when I can’t. I’d like to have a livelihood too, but I haven’t figured that part out in this Give and Take book.

This book read like a carefully curated collection of confirmation biases, superficially supporting the hypothesis that givers are the true movers and shakers at the workplace and beyond. For all my anticipation and aspiration for this book, I was left uninspired.
A quick browsing of the comments that DON’T call into question the professor’s anxiety and desire for approval revealed this woman’s comment that I found pertinent:

Comment states: This is my husband. Very giving of his time to others, the office door always open, everyone who works for him adoring him. While I did not have the fortune of being a stay at home wife, and while my husband did do his fair share at home, our home life did and is still suffering. My number one complaint in our marriage and family life is that he is available and accessible to others but is not here at home to deal with some very important issues especially now that our last child is in his teens and needs lots of male guidance. The other thing is that his devotion to face time with people at his work takes time from his duties at his desk. Thus, he works Saturdays and Sundays in his office catching up on those duties. I, on the other hand, learned that if anything was going to be done at home, couldn’t meet with my students way past school hours nor go to my students’ sporting events or competitions as some of my male colleagues are able to do because they have a wife at home. My point is that giving is wonderful, but unless one is single or married to a supportive partner who enjoys the burden of being alone a lot with the home responsibilities, people near and dear to you are suffering because of your lack of giving them what they need- the time and attention you so generously give to strangers!

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