City of Angels
“It’s working!” Rimsha messages.
“I can’t believe it!” I text back.
“So cool” thumbs up [Emoji]
“Yay,” I say.
It occurs to me that a founder of a health software company should not be surprised when the product he has spent two years building works. This may be more an issue of organization than confidence— I think. Just yesterday, Arif, my partner and WD’s programmer in Indonesia messaged, “Look there is going to be bugs. We haven’t had enough time to test!” My response was rhetorical:
We have been meeting for two hours every night for two months
Rimsha and I are only in L.A. for five days
Our App is managing medicines not hotcakes
Whitten Heights has been charting on paper for ten years
The first impression we leave will be the last
Within a two-minute pause wherein I imagined Arif comforting his one-year-old son; eating a bowl Kway Tiao Noodles; or hurling a computer terminal across the room, my phone flashed:
Oke.
What’s hotcakes?
Arif is among the smartest, hardest working, excellent people I know. I met him in 2019, when he built the back end of a clinical education App called Walking Doctors that I thought would change medical practice in the world. While my thirty
subscribers failed to meet this goal, Arif was the only team member out of artist, product manager and front-end programmer (in charge of what a user sees and does) who ever seemed to get it. That App should have taken two months and two thousand dollars to make. It ended up taking a year, six thousand dollars, and a quarter of my hair. In 2022 when the Walking Doctors App began to fail due to lack of upkeep, Arif was able to work with the previous product manager, who had since moved on to subway ticketing machines, to fix the problem, take over the code and move all of the software components to his company server. I was so relieved. Regardless of its minuscule user base, I always felt the App represented me – reliable, useful, evidence-based, elegant? When bored or in need of a morale boost, it is not uncommon for me to flip through the Walking Doctors tool kit or images. In the emergency room I use the App checklists to process most of my decisions and yell at my residents for not doing the same. One doesn’t have to be old to forget.
Arif and me in Bandung, Indonesia last summer.
Within this context, Arif and I got to talking. I asked him about his work when he wasn’t doing small side projects like Walking Doctors. He told me about Apps he had developed in oil, real estate, fin-tech and government. I told him about my interests in health software, most recently with older persons requiring caregiver support. To this Arif declared, “I used to be caregiver to pay for my university tuition when I was in Australia!” And like that, a friendship was born.
WD-MedView objectives are this: 1) Show MedTechs (Caregivers with CPR training) the drugs that residents in assisted living, dementia and hospice areas take across four medication periods, 2) Quickly process medicines as given, held or refused with inputs recorded into an electronic health record, and 3) Report medicines prescribed that don’t conform to the evidence-base for elimination or substitution with alternatives named, to insurers for reconciliation.
This is what 1) and 2) look like:
This is what 3) looks like
To me, changing residents’ meds for the better is less a technical challenge than one requiring respect and love. Angie, Gel, Leticia and Roger— Whitten Heights four MedTechs— make between $17-$21 dollars an hour. From the pictures you see that money is not the reason they work. Nor is it freedom of scheduling as they all have second jobs. When pressed, Gel will say things like, who will look after the residents if we leave; or Roger will say, most residents don’t have visitors besides us; or Leticia will say, I don’t have anything better to do after twenty years at Whitten; or Angie will say, the MedTechs will be lost without me. But I do plan to quit!
Angie, Gel, Leticia and Roger’s comments run counter to every management course I have ever taught. Results measurement and financial incentives—not moral compass, determine employee retention. But pretend you know that 40% of the drugs your mom takes are unnecessary and that two medicines will statistically and unnecessarily land her in the hospital within a year. Wouldn’t you do anything to ensure her safety? Angie, Gel, Leticia and Roger, I’ve decided, essentially consider themselves the grown children of the residents at Whitten Heights. To this end, they attend to them naturally, patiently and reliably day after day.
There are challenges. “Twenty-one drugs prescribed to one person can’t be ok, can it?” I am working alongside Angie in memory care, a.k.a. lock-down unit housing individuals with moderate to severe dementia. She is pulling out small paper containers prefilled with an individual’s medicines, 5-10 colorful tablets, capsules and pills deep.
“We have no choice but to follow doctors’ orders,” Angie replies without looking up. An older man in argyle sweater and bright blue slacks suddenly appears beside us.
Mr. X, are you ready for your medicines?”
“Ready as I’ll ever be, Darling,” Mr. X boasts, “especially if you give me a glass of that ice-cold water.” Mr. X chuckles because he knows the water from the plastic jug next to a teetering tower of plastic cups atop the medication cart, is warm. Angie hands him his container of medicines and he flips the contents deftly into his mouth, followed by loud slurps of water. “Ah, just what the Angie ordered.” He chuckles again.
One of Angie’s many admirers
“But Ms. Y is getting four times a day ibuprofen and daily Ambien,” I continue. “These drugs alone can give her upper GI bleed or cause a fall, right?”
“We are not doctors,” Angie says, “even if were to call the doctors they would just yell at us to remind us that we are not doctors.”
I stop haranguing Angie. The morning shift is now buzzing and there’s no time. Multiple older persons are in line, some tapping their toes impatiently. Anyway, Angie doesn’t need me goading her for things out of her control. She moves fast: Medicine tray, colorful candy like drugs, confirmation of person, ingestion, drink, thank you, then out. The whole process is abnormally normal. I realize that medication time is the primary social activity for most in this place. As such, residents look forward to it and dutifully take their medicines. Not one single person resists.
My feelings are mixed. With each resident, Angie registers on her I-Phone medications taken on the MedView App. Given, Given, Given, Held - stockout, Given, Given. Angie pokes in coordination to her whispers puffed at the screen. I am so proud watching her. Two days ago there were no buttons on the App. Three days ago the team had only entered 100 of Whitten’s 555 prescriptions. Ten days ago, there was no WD-MedView.
I have been around long enough, failed enough, been humbled enough to know how important a person is like Angie. If she uses WD MedView, the other MedTechs will follow. I therefore do whatever I can to support Angie’s interest in the technology. I compliment her. I ask how she is doing. I make sure we listen to her inputs, showing changes to the software twelve hours later. What company does that? I give her chocolate. It helps Angie is usually right: She wanted room numbers on each residents’ name plate; for there to be a print option for refill requests; for the system to calculate opiate stock relative to number of pills dispensed and expected count. Each change goes to Arif on WhatsApp as a collection of sketches made on power point usually at 1 a.m. Upon receipt, Arif, twelve hours ahead in Bandung, answers
fast but never immediately, allowing my imagination to run wild: I can see Arif eating, hugging, or crying.
“Let’s go!” is the usual response. Arif, I conclude, is God.
To this point, Arif on this trip, responds to reports and queries on the LA-WhatsApp group we set up. Rimsha after working with Leticia in general assisted living is with me in the Med-Room. She remarks looking at the chat, “I can’t believe how fast Arif is. He programs non-stop.”
“The benefit of a 12-hour time difference,” I say, “we go to sleep and by the time we wake up, the changes are done. It doesn’t get better than that, baby.”
Sometimes I forget that Rimsha is an NYU MPH graduate student and that I am her Professor. I regret use of the word baby and hope that she understands I am just playing around. If she were American, I would already be cancelled. Before I can apologize, Rimsha says, “Maybe we should not change the App so much and just watch it work like it is. This will allow Arif to spend more time with his baby.”
After seven months of working together I still can’t tell if Rimsha is serious or sarcastic. “I am a pediatrician. That baby will be ok,” I say.
“I mean if we change the App all the time, it might confuse the MedTech’s,” she explains. Rimsha having gone to Dental school and then practiced as a Dentist for a couple of years in India speaks with an English accent. This gives her experience and logic even more weight. But it’s a balance too. In my view, there’s no need to wait for feedback for that which we know to be deficient. If it isn’t working for us, it isn’t going to work for others. Steve Jobs described this idea as empathy. All Apple products are made as if the designer were feeling what the user feels—both joy and frustration. Another Apple characteristic is imputation. Any product defect implies the existence of other defects. Even if hidden, product function and customer faith are compromised. It does occur to me that Jobs died an unloved and lonely man. It occurs to me that even beautiful babies emerge wrinkled and stained.
“You are right,” I declare, “tonight’s changes will be our last.”
“But we’re going back to New York City tomorrow,” Rimsha states.
“But didn’t we have a grand time in L.A.—the city of dreams?” I ask.
“We did,” Rimsha declares. She repeats, because she knows my hearing has become increasingly selective on this trip, “we did.”
Heart attack breakfast before work - Newport, CA
