Evolving Medical Education for a Digital Future

Three major technology trends—mobile phone–enabled platforms, big data, and artificial intelligence (AI)—exemplify how new technologies are transforming conventional modes of healthcare delivery. Mobile applications are replacing activities previously requiring in-person visits, computers are using vast new data streams to personalize treatment approaches, and AI is augmenting disease diagnosis.

Physicians have an important role in deciding where and how these new tools might be best utilized in diagnosing, treating, and managing health conditions. As medicine undergoes a “digital transformation,” a foundational review of medical education spanning medical school, residency, and continuing medical education (CME) is needed to ensure that physicians at all stages of practice are equipped to integrate emerging technologies into their daily practice. By evolving medical education today, we can prepare physicians for medicine’s digital future.

Computers algorithmically diagnosing diabetes from retinal scans[1]; chatbots providing automated mental health counseling[2]; smartphone applications using activity, location, and social data to help patients achieve lifestyle changes[3]; mobile applications delivering surgical follow-up care[4]; and smartwatches passively detecting atrial fibrillation[5] are just a few examples in which technology is being used to augment conventional modes of healthcare delivery.

Many proposals to evolve medical training in a world of continuous technology transformation have focused on specific technologies, such as incorporating telemedicine into existing Accreditation Council for Graduate Medical Education (ACGME) competencies,[6] creating a new specialty of “medical virtualists,”[7] or better integrating data science into healthcare.[8]

Emerging Technologies Transforming Medicine

Looking beyond legacy health information technology platforms like electronic health records (EHRs), active venture capital funding provides a vision for where the community is placing its bets for emerging technologies. We highlight three areas drawing significant investor interest: mobile health ($1.3 billion raised in 2016),[9] big data enabling precision medicine ($679 million),[10] and AI ($794 million).[11]

Mobile health. In a 2015 national survey, 58.2% of smartphone owners reported having downloaded a health-related mobile application[12] from an estimated 259,000 available health-related applications.[13] These applications frequently help patients self-manage their health conditions by providing education, tracking tools, and community support between clinic visits.

Big data enabling precision medicine. Phone-based sensors, wearable devices, social media, EHRs, and genomics are just a few of the many new technologies collecting and transmitting clinical, environmental, and behavioral information. These new contextual data streams are facilitating personalized medical decision-making with treatments tailored to each individual patient.

AI. New computational methods such as AI, machine learning, and neural networks are augmenting clinical decisions via algorithmic interpretation of huge data sets that exceed human cognitive capacities. These new computational technologies hold great potential to assist with diagnosis (interpretation of ECGs, radiology, pathology), personalized treatment (tailoring treatment regimens for individual tumor genotypes), and population health (risk prediction and stratification), though for now they remain software innovations reliant on human clinician hardware to guide appropriate use.[14]

Knowledge Domains

Physicians have an important role in deciding where and how new tools might be best utilized in diagnosing, treating, and managing health conditions. A recent study by the American Medical Association (AMA) found significant physician interest in digital health tools, with 85% of physicians reporting that they perceived at least some benefit from new digital tools in improving their ability to care for patients.[15]

Integrating emerging technologies such as mobile applications, big data, and AI into regular practice will require providers to acquire new knowledge across ACGME educational domains such as Professionalism, Interpersonal & Communication Skills, and Systems-Based Practice.

From a foundational perspective, it is important that physicians understand their role and potential liability as related to these new technologies. This includes but is not limited to:

  • Understanding relevant laws, particularly state-based regulations concerning remote practice of medicine (ie, telemedicine). (Systems-Based Practice)
  • Compliance with HIPAA and other key privacy regulations when interacting with patient-generated data outside the bounds of the EHR. (Systems-Based Practice)
  • Evaluating potential malpractice implications, including assessing coverage scope. (Systems-Based Practice)
  • Awareness of emerging reimbursement codes for time allocated to new technology–enabled practice models. (Systems-Based Practice)

Outstanding questions remain regarding the clinical efficacy of many new technologies. With formal clinical trials still underway, physicians may feel unable to speak definitively regarding a specific technology’s potential risks and benefits. Yet, the increasingly broad use of these tools requires that physicians use their clinical expertise to help their patients understand the limitations of such technologies and steer them toward appropriate tools. Essential skills and roles that modern physicians must now adopt include:

  • Teaching patients how to identify trusted tools—those using evidence-based guidelines or created in conjunction with credible physicians, scientists, and hospitals (Medical Knowledge)
  • Setting clear expectations upfront about the extent of physician involvement in reviewing patient-generated data (particularly if there is no anticipated involvement) (Patient Care)
  • Assessing technology literacy in the social history and adapting patient education on the basis of digital attainment, including recommending websites, online video, and mobile apps when appropriate (Patient Care)
  • Advancing clinical knowledge by referring select patients to enroll in digital remote clinical trials (Systems-Based Practice)

Taking into account the rapidly increasing amounts of data inputs in clinical decisions, physicians must augment their statistical knowledge to become generally familiar with new data science methods:

  • Leverage data science tools such as visualization to more efficiently review large amounts of patient data, including identification of outliers and trends (Medical Knowledge)
  • Seek to understand the inputs and assumptions of advanced computational algorithms and not allow them to become a black box. Recognize that although deep-learning algorithms can deduce important patterns and relationships, physicians remain necessary as a critical lens in deciding how to apply findings to each individual patient. (Patient Care)

Implications for Physicians

For current medical students and trainees, many of whom are digital natives themselves, the educational domains outlined above may seem intuitive or obvious. In contrast, physicians currently practicing today are already burdened with countless administrative tasks that may make these future technologies feel overwhelming or irrelevant. Yet, the frustration and feelings of burnout that many physicians have as related to the use of EHRs exactly illustrates why it is critically important that physicians engage early in the dissemination of new technologies.

The first step for providers in the digital transformation of medicine is awareness. While providers may not be aware of, or are dismissive of, new technologies, these tools are already being used avidly by millions of patients around the world.[11] Mobile health, big data, and AI soon will become an integral part of medicine, much like EHRs (and stethoscopes).

The second step is for physicians to familiarize themselves with general categories of new digital tools. New journals such as the Journal of Medical Internet Research offer peer-reviewed manuscripts focused on “eHealth and healthcare in the Internet age.” Physicians may benefit from downloading and signing up for test accounts of new applications or connected health devices. Organizations should consider allowing physicians to spend a portion of their CME budgets on such “digital transformation” learning activities.

The third step is for physician leadership organizations to work with regulatory agencies like the FDA to help identify the most robust tools for physicians to adopt and recommend. A positive example of this is the AMA’s recently issued guidelines on the appropriate use of digital medical devices.[16]

By evolving medical education today, we can prepare physicians for medicine’s digital future. In the face of complex and rapid change, we may all be trainees in a world of ever-accelerating technological evolution.


10 amazing and helpful apps that will inspire you

There are millions of mobile applications available to smartphone users today, and that number will only keep growing as it becomes easier to build and deploy apps. Some apps are for amusement, but others are specifically designed to improve the lives of their users or the world at large.

10 amazing and helpful apps that will inspire you

We asked a panel of Young Entrepreneur Council members the following question about some of the most innovative apps they’ve encountered that were created to help people:

What’s one innovative app you‘ve seen that’s designed to help people, and what can leaders learn from apps like it?

Their best answers are below:

1. Be My Eyes

Be My Eyes is an app that provides blind and low-vision people with visual assistance by connecting them with volunteers and company representatives. What leaders can learn from this app is that basic tasks, like picking out the correct can of soup, can be challenging and humbling and that asking for help is nothing to be ashamed of. If you don’t have the right answer, someone else will. – Duran InciOptimum7

2. Charity Miles

Charity Miles is an app that motivates you to hit your fitness goals by donating money to your favorite charity. For every mile that you run, walk or bike, you earn money from corporate sponsors that is then donated to the charity of your choice. Leaders should take notice and see how they can combine charity with business in a more innovative approach. – Syed BalkhiWPBeginner
3. Chummy

Chummy aims to make the world better by paying it forward. Users can request help for everything from moving furniture to finding a lost pet. This should trigger entrepreneurs to think about achieving socially responsible goals by helping other businesses solve their problems. It may require unique thinking to find solutions that are financially sound and socially conscious. – Blair ThomaseMerchantBroker

4. Aaptiv

The best app I’ve seen recently is Aaptiv. It’s like having a personal trainer without having to pay the high fees. Aaptiv is a fitness app that has thousands of workouts involving activities like running, using the elliptical and strength training. When you start your workout session, the trainer will give you the exercises to perform via audio. I think leaders can learn that fitness can be done whenever, even with busy schedules. – Jean GinzburgJeanGinzburg.com

5. Pacifica

The Pacifica app provides a way for people to deal with daily anxiety and stress. It provides audio lessons to help deal with stress, mood trackers and mindfulness meditations. When work gets too stressful, apps like this can help calm your mind, which is important if you want employees to perform their best. – Chris ChristoffMonsterInsights

6. Speak & Translate 

Speak & Translate is an amazing app that allows you to communicate verbally with people who speak different languages. One of my passions is creating connections, and breaking down the boundary of language entirely with an app is absolutely groundbreaking. This app teaches us as leaders that there are no excuses for not making connections. – Stanley MeytinTrue Film Production

7. Voice Access

Voice Access is a new Android accessibility app from Google. It helps people with limited mobility navigate their phones by voice, helping them with opening apps, scrolling, editing text and other common interactions. It’s a well-designed accessibility app, and it should inspire app developers to think about creating user experiences that don’t exclude people with restricted mobility and other disabilities. – Vik PatelFuture Hosting

8. Samaritan

Samaritan gives you the stories behind some of the homeless people you may see every day and allows you to donate money ($1 or more). These funds go toward needed services and expenses like clothing, groceries or gas. Leaders can learn from it because giving back to the community is the right thing to do. – Andrew SchrageMoney Crashers

9. Red Stripe

Red Stripe is an app for people with red-green colorblindness. It uses a smartphone camera to identify these colors and highlights them on the screen with stripe patterns. It’s a simple but useful app that shows how, with a little imagination, the built-in capabilities of mobile devices can be used to enhance people‘s lives. – Justin BlanchardServerMania Inc.

10. Budge

Budge is an app that lets you challenge your friends in the name of giving to charity. You can challenge a friend to things like quitting smoking, losing weight, running 10 miles etc., and whoever loses has to make a donation to charity. Leaders can learn how to make giving to charity a fun team activity with this app

Apple Releases Mysterious iOS 12.1.2 Update After Just ONE Beta

Ios 12 1 21

Apple has released iOS 12.1.2 to the public, just about a week after the first beta became available for developers and software testers.

The update is a relatively light one. According to Apple’s release notes..

It fixes a bug impacting eSIM activation for the iPhone XS, iPhone XS Max and iPhone XR.

It also addresses an issue that affected cellular connectivity in specific regions.

eSIM activations are now available from AT&T, Verizon and T-Mobile as of the writing of this article. Once users download iOS 12.1.2, they shouldn’t experience any bugs with eSIM activations.

But while iOS 12.1.2 is a minor update, it is fairly unusual. Apple typically doesn’t rush a software update out after just one beta version.

Presumably, iOS 12.1.2 contains a fix that Apple opted not to wait to address.

As far as what that might be, it could be anyone’s guess. But it’s worth noting that iOS 12.1.2 lines up with a previously planned software update from Apple.

What’s Really Going on Here?

Last week, Chinese courts placed an import ban on certain iPhones due to an alleged violation of two Qualcomm patents.

Apple, in response, said it would release a software update that addresses any concerns about its devices violating those patents.

While iOS 12.1.2’s release notes don’t mention anything, its launch on Monday does certainly correlate with that timing.

Interestingly, the iOS 12.1.2 update is only available on iPhone — not on iPad or iPod touch. That further suggests that it could be related to the previously announced update.

But it’s also a bit confusing since reports suggested that iOS 12.1.2 also fixed a bug on iPad Pro. That could hint that an iPad and iPod touch version of the software may be on its way, or that the bug fix will be implemented in a future update.

How Do I Get It?

iPhone users can download it over-the-air by going to Settings > General > Software Update.

Is Smart Technology Making Us Dumb?

Yes and no: there are reasonable arguments on both sides of the question

Is Smart Technology Making Us Dumb?

We still haven’t grappled with the deep questions Nicholas Carr brought to public attention in his seminal book, The Shallows: What the Internet Is Doing to Our Brains (2010). Is the internet making us dumb? Is the technology causing us cognitive loss or debilitation? Carr focused on the internet, which is, by design, a dumb technology—a general-purpose digital communication infrastructure that pushed “intelligence” to the ends of the network.

Since my own book Re-Engineering Humanity, co-authored by Evan Sellinger, was published, I’m often asked: Is smart technology making us dumb? My first reaction is to bounce a few questions back. Can technology really be smart? Is your question whether our use of certain technologies is making us dumb? Or is your question about technology companies?

Eventually, I return to the original question and respond like a lawyer: It depends. It’s yes, in some ways and no in others. Before addressing it, we must acknowledge the conceptual mistake of boiling intelligence down to a binary—smart versus dumb—as if it exists on a single dimension. There are many different types of intelligence that matter, and how technology affects different types also varies considerably.

Once I’m done meandering, however I answer yes. I believe we may be making ourselves dumber when we outsource thinking and rely on supposedly smart tech to micromanage our daily lives for the sake of cheap convenience.

The internet provides us with seemingly limitless data, prose, images, video and other raw materials that could in theory enhance our intelligence and enable us to become more knowledgeable, to be more skillful or to otherwise use actionable intelligence. Maybe we could improve our decision-making, reflect on our beliefs, interrogate our own biases, and so on.

But do we? Who does? Who exactly is made smarter? And how? And with respect to what? Are you and I, and our siblings and children, engaging with the seemingly limitless raw materials in a manner that makes us more capable, more intelligent? Or do we find ourselves outsourcing more and more? Do we find ourselves mindlessly following scripts written or designed by others?

We’re easily led to believe that we’re extending our minds and becoming more intelligent with a little help from the digital tech tools, when in reality, those are often just illusions, sales pitches optimized to pave the path of least resistance. Every time someone suggests they’ve extended their mind with their smartphone, that they are thinking through and with their phones, I respond by asking them about who’s doing what thinking.

Are they extending their mind or extending the reach of others into their mind? When you rely on GPS, who’s doing the route planning? Who is gaining what intelligence? Are you smarter because of GPS? What impact does outsourcing navigation and awareness of your surroundings have on your capabilities? Certainly, Waze or Google gain intelligence about you, your surroundings and even others around you. That could be good or bad, but it’s not really extending your mind or expanding your intelligence.

As everyone knows by now, many digital tech companies know a lot about each of us. Advertisers, Cambridge Analytica–like firms, large platforms and so on. They’ve gained considerable intelligence and, as a result, power. But note that for the most part, they feed on different raw materials. They don’t get smart by consuming the same materials that we’re fed.

They gain actionable intelligence by collecting treasure troves of data, gleaned from digital networked technologies. Everything that occurs on the internet—every interaction, transaction, communication, etc.—everything is data, strings of 0s and 1s. And all of our activities generate data. Digital tech companies gain actionable intelligence by collecting and processing data, mostly about how we behave in response to different stimuli—what we’re fed. This empowers those companies. They may, for example, personalize their services to induce desirable behaviors, such as sustained engagement. Or they may develop new salable insights about consumers. I could go on. But the bottom line is that digital tech companies get smarter, more capable, more powerful.

But what about you and me? Do we also get smarter? Do we extend our minds and thereby gain intelligence and increased capabilities? What actual capabilities are extended or enhanced? Are they in fact practiced? If so, to what end? What actionable intelligence improves the quality of your life?


Upon reflection, I remain uncertain. Again, the lawyer in me emerges, and I can reach no definitive evaluation. Does that say something about me and my reflective capacity, the ambiguity of empirical evidence, or something else?

The internet promised the library of Alexandria at our fingertips, delivered instantaneously wherever and whenever we like. It delivered that and much, much more. One might describe the exchange in Faustian terms, as trading one’s soul for knowledge. Putting aside concerns about what’s been lost (our soul, humanity, etc.), it’s not even clear that the promised knowledge was delivered. To make matters worse, evaluating the Faustian bargain is even more difficult when the intellectual capabilities required to do so seem to be waning, at least for many of us.

A New Apple Patent Offers a Radically New Vision for Future Smartphones

Apple will likely stick with its signature smartphone notch for the foreseeable future, but the company is looking to shake up the display design in years to come. With Samsung and a few upstarts hard at work developing an ecosystem around “foldable” multiple-display handsets, a new patent suggests that Apple’s looking in a slightly different direction.

It’s actually series of new Apple patents, and together they suggest the iPhone’s successors will be more of an all-in-one gaming platform that can make better use of the augmented reality and gaming features the company touted this year.

The bevy of 37 new patents the U.S. Patent and Trademark Office approved and released Tuesday detail the designs for an iPhone with a screen that wraps all the way around it, almost like a smartphone crepe. Its internals would be completely encased in a flexible display, making it completely bezel-less and giving users access to screen real-estate on the rear and sides of the phone. The patents were first reported by Patently Apple.

The filings also explain how the device could use an accelerometer to detect tilt motions, as well as how users could use the rear screen to interact with the front screen. This design would make it an ideal gaming phone. Tilt controls could be used for racing or dogfighting games and the rear touch interface could serve as bumpers like the ones found on all gaming console controllers. In short, the findings suggest that a gaming-focused iPhone could be in Apple’s future.

apple iphone patent
A flexible screen would wrap around the phone’s internals, creating a sort of smartphone crepe.

Sections of the documentation obtained by Patently Apple describe the theoretical device:

“A transparent display cover structure that wraps around an axis of the electronic device…The control circuitry comprises an accelerometer that gathers tilt data…The electronic device has a front face and a rear face and wherein the flexible display layer is configured to display content on the front face based on touch input gathered using the touch sensor on the rear face.”

This design corresponds with Apple’s push towards AR and gaming applications with the 2018 releases of the iPhone XS, XS Max, and iPad Pro. A wraparound display could convert iPhones into gaming controllers for iPad Pros or standalone mobile gaming platforms.

iphone patent concept gaming apple
View of a user interacting with the back of the device to control the front display.

While this design could make Apple’s push into gaming more viable, the documentation doesn’t address where it would put its cameras. That much display would also take a big toll on battery life.

Patents, while they are a good way to see what concepts companies are spitballing, are not dependable gauges of product launches. If Apple does choose to move forward with this idea it probably wouldn’t be for at least a few more years.

But who knows, maybe the iPhone and iPad will be bundled together as a gaming console within the next decade.

Samsung Galaxy F: Likely Release Date, Features for the Foldable Smartphone

Samsung is looking to set the next generation of smartphone trends with the upcoming release of its Galaxy F, a foldable smartphone. The handset will tout an ambitious design that the Korean tech company flexed during its recent developer’s conference, set a new bar for phone prices, and barely anyone is expected to buy it. But according to a recent smartphone industry analysis, a more gradual rollout could be exactly what Samsung wants.

Tech industry market intelligence firm, TrendForce, published a report ahead of its December 19 The Future of Smartphone Era Webinar asserting that Samsung doesn’t plan to sell millions of Galaxy F models, it just wants to establish its foldable phone dominance. The analysis expects the smartphone will account for 0.1 percent of the global smartphone market in 2019 and it expects that to grow to 1.5 percent in 2021.

The gist of the report is that current phablet designs are getting stale and consumers are looking for fresh handset designs, but that won’t happen overnight. However, if Samsung gets ahead of the curve the company could have a top-tier foldable phone if the concept ever eclipses traditional smartphone designs.

The Galaxy F will pack an extra screen and pack features that seem targeted to on-the-go multitaskers. Samsung said it’ll be able to run three apps side-by-side using a feature dubbed “multi-active window.” But is this ambitious smartphone design worth the price of a fully suited-up, 2018 MacBook Pro?

Here’s everything else we know about Samsung’s foldable smartphones so far.

samsung foldable phone teaser
Samsung’s newly uploaded profile photo ahead of its developer conference. 

Samsung Galaxy F Launch Date

Samsung hasn’t yet announced a clear launch date but expect updates and even a full-fletched unveiling as early as next spring. The Yonhap News Agency in South Korea recently reported that the company will launch its flagship foldable phone in March of next year, citing industry sources.

When he teased the foldable phone at its developer’s conference, Justin Denison, SVP of mobile product marketing also strongly implied that we should be ready for a March announcement.

“We hope we’ve inspired you until the next UNPACKED where you’ll see more of this technology in action,” he said.

samsung foldable phone
The foldable phone when it is closed.

Samsung always hosts an UNPACKED event early in the year to announce new Galaxy S phones. The S9 and S9+ were both announced late in February and released in early March. This means the upcoming S10 releases might be accompanied by a massive foldable phone reveal.

Samsung Galaxy F Price

The Galaxy F might be a tablet you can fold into a smartphone, but it might cost as much as a state-of-the-art laptop. Once it hits shelves it could run consumers anywhere from $1,900 to $2,500, according to an anonymous tipster interviewed by Gizmodo. This is new heights for its forecasted price.

That would potentially add another $130 or even $730 to its already astronomical price tag. The Yonhap report says the device could cost as much as $1,770 and that Samsung will aim to ship 1 million of them.

The Galaxy F was never expected to be cheap. An anonymous Samsung official told Reuters: “Unlike our flagship products,” the source told the wire service, “the foldable phone is a completely new concept in terms of design and user experience, which requires a different approach.” Usually when companies roll out trend-setting features, they come at a hefty cost.

samsung foldable phone
Possible dimensions of the two screens.

Expect a slight departure in the pricing strategy. Currently, Samsung’s most expensive flagship — the Galaxy Note 9 — starts at $999. It’s possible the company could make a play for rapid growth by trying for an accessible price point, but more likely the new phone will be priced higher since there aren’t any formidable competitors.

The competitors that Samsung does have, however, are also pricing high. A lesser-known company called the Royole Corporation recently debuted its take on the foldable phone, the FlexPai, on October 31 that starts at 8,999 Chinese yuan (roughly $1,300). It was a little bit janky, and Royole isn’t a big name, so it seems reasonable to presume that Samsung’s foldable phone could cost even more.

What Carriers Will the Samsung Foldable Phone be Available On?

Not only could it be incredibly expensive, but it could be a hassle to get anywhere other than the U.K.

A recent Gizmodo report states that the Galaxy F might only be available on the British mobile network, EE. That means that everyone else would need to purchase an unlocked version of the device and slide in their own SIM card.

There’s hasn’t been word about carrier deals in the United States at the time of writing.

What Will the Samsung Foldable Phone Be Called?

Yonhap referred to the foldable phone by its “Galaxy F” moniker, a name that was given to the device by the countless rumor cycle stories. The “Galaxy X” nickname has also emerged during coverage.

It’s unclear if the news service was confirming that this is what the phone would be called or if they were just referring to it by its widely adopted nickname.

Samsung Galaxy F Design Specs

Blueprints of the device have begun making the rounds online and they look like Samsung has glued three displays together. The United States Patent and Trademark Office published blueprints the Galaxy F on November 15 revealing that it would fold up a lot like a brochure.

Instead of opening up like a booklet, the sketches display a device that can be opened twice. Once to reveal what appears to be the camera and a second time to turn it into a tablet.

Its cover display has been said to be 4.58-inches and its tablet display 7.3-inches. The bottom edge of the blueprints shows the outline of a USB Type C charging port and a headphone jack.

To give people a better, less confusing visual, the Dutch Blog LetsGoDigital translated these mockups into a few 3D renders. The results were stunning, and much sleeker than what Denison held up on stage.

Samsung Galaxy F: Will Its Screen Be Oled?

Denison explained that these new smartphone booklets needed to completely overhaul previous display designs.

Instead of a glass outer layer, the foldable phone will use an “advanced composite polymer that is both flexible and tough,” he said. This will be complemented by a “foldable adhesive” that would allow the display to be folded “hundreds of thousands of times” without warping or cracking.

FDA Approves First Digital Inhaler With Tracking App

The US Food and Drug Administration (FDA) has approved the first and only digital inhaler with a built-in sensor that connects to a companion mobile application that can monitor usage as well as strength of the user’s inhalation.

The ProAir Digihaler, from Teva Pharmaceutical Industries, contains albuterol sulfate 117 µg powder for inhalation.

The new inhaler is approved for use in people aged 4 years and older to treat or prevent bronchospasm in individuals with reversible obstructive airway disease and to prevent exercise-induced bronchospasm. The approval is based on review of a supplemental new drug application submitted by Teva to the FDA.

“The digital technology built into ProAir Digihaler provides patients with data on their inhaler use, which may help them to have a more informed dialogue with their healthcare provider regarding their asthma or COPD [chronic obstructive pulmonary disease] management,” Sven Dethlefs, Teva executive vice president, global marketing and portfolio, said in a news release.

“There are 25 million Americans living with asthma, many of whom use inhalers as part of their treatment regimen. Despite advancements in care over the years, we know that many are using their rescue medications incorrectly or too often,” Tonya Winders, president and CEO of the Allergy and Asthma Network, said in the release.

“The FDA approval of ProAir Digihaler is significant because it may help patients track their inhaler usage and provide data that can be used to work more closely with their HCPs [healthcare providers] on their asthma management. This approval is a major step forward and is indicative of how medications are evolving through technological innovations,” Winders said.

Teva said the ProAir Digihaler will be available in 2019 through a small number of “early experience” programs, which will be conducted in partnership with healthcare systems in limited geographic areas, in order to gather real-world experience.

A national launch is planned for 2020.

Doctors in UK sceptical that Artificial Intelligence will replace them: Survey


This is How Google will Collapse

Reporting from the very near, post-Google future

Google made almost all its money from ads. It was a booming business — until it wasn’t. Here’s how things looked right before the most spectacular crash the technology industry had ever seen.

The crumbling of Google’s cornerstone

Search was Google’s only unambiguous win, as well as its primary source of revenue, so when Amazon rapidly surpassed Google as the top product search destination, Google’s foundations began to falter. As many noted at the time, the online advertising industry experienced a major shift from search to discovery in the mid-2010s.

While Google protected its monopoly on the dying search advertising market, Facebook — Google’s biggest competitor in the online advertising space — got on the right side of the trend and dominated online advertising with its in-feed native display advertising.

The people who turned to Amazon over Google? The 18–29 crowd led the way.

In late 2015, Apple — Google’s main competitor in the mobile space — added a feature to their phones and tablets that allowed users to block ads.

Devices running iOS were responsible for an estimated 75% of Google’s revenue from mobile search ads, so by making this move, Apple was simultaneously weighing in decisively on the great ad blocking debate of the 2010s and dealing a substantial blow to the future of online advertising.

The rising number of users blocking ads on mobile showed no signs of slowing down

A year later, as the internet went mobile, so too did ad blocking. The number of people blocking ads on a mobile device grew 102% from 2015 to 2016; by the end of 2016, an estimated 16% of smartphone users globally were blocking ads when browsing the internet on a mobile device. The number was as high as 25% for desktop and laptop users in the United States, a country that accounted for 47% of Google’s revenue.

The people most likely to block ads were also the most valuable demographic: millennials and high earners.

Young users are a good indicator for the future of technology, and they were heavy users of ad blocking software

Internet users had spoken, and they hated ads.

In early 2017, Google announced its plans to build an ad blocker into its popular Google Chrome browser. Google’s ad blocker would only block ads that were deemed unacceptable by the Coalition For Better Ads, effectively allowing the company to use its dominant web browser to strengthen its already dominant advertising business.

Even after making this desperate and legally questionable move, it would quickly become clear to Google that even though ads were getting better, ad blocking numbers would continue to rise. Google had given even more people a small taste of what an ad-free internet experience could look like.

The company discovered that it wasn’t just annoying ads that people didn’t like; it was ads in general.

The advertising industry trying to figure out why people hated ads so much

A key platform where Google served ads was YouTube, which it bought in 2006 and quickly turned into one of its biggest entities. But even with a sixth of the world visiting this video-sharing behemoth every month, YouTube never became profitable. In an attempt to combat the effect of ad blockers, YouTube launched an ad-free subscription model in late 2015, but the subscription numbers were underwhelming.

YouTube’s already insurmountable problems multiplied in early 2017 as advertisers began to pull out amid ad placement controversies, and huge revenue generators began to leave the site.

Even those who weren’t blocking ads had trained themselves to ignore them entirely. Researchers dubbed this phenomenon “banner blindness”. The average banner ad was clicked on by a dismal 0.06% of viewers, and of those clicks, roughly 50% were accidental.

Research showed that 54% of users reported a lack of trust as their reason for not clicking banner ads and 33% found them completely intolerable. These figures painted a pretty grim picture for the sustainability of online advertising, but especially for Google’s position within the industry.

Google’s mighty engine had started to sputter.

A chance to pivot, and how Google missed it

If losing a major portion of their audience and annoying the rest wasn’t bad enough, Google also failed to get ahead of one of the biggest shifts in technology’s history. They recognized the importance of artificial intelligence but their approach missed the mark. Since Google’s search pillar had become unstable, a lot was riding on the company’s strategy for artificial intelligence.

“We will move from mobile first to an AI first world.”

Google’s then-CEO Sundar Pichai famously predicted in 2016 that “the next big step will be for the very concept of the ‘device’ to fade away” and that “over time, the computer itself — whatever its form factor — will be an intelligent assistant helping you through your day. We will move from mobile first to an AI first world.”

Google’s ability to acknowledge the coming trend and still fail to land in front of it reminded many observers of its catastrophic failures in the booming industries of social media and instant messaging.

Sundar Pichai wondering how to monetize a virtual assistant

Google vs. Amazon

Meanwhile, in 2014, Amazon released a product called Amazon Echo, a small speaker that could sit in your home and answer questions, perform tasks, and buy things online for you. The Echo was a smash success. Google released its copycat product, Google Home, two years later, but it was already too late to catch up, and had no clear revenue strategy.

Alexa — the assistant that lived inside the Echo — on the other hand, was quickly integrated into several products and services, and its monetization model was clear, viable, and most importantly future-friendly. The Echo made it easy to order products through Amazon, and every time someone used an Echo to purchase something, Amazon made money.

Google extended the reach of their virtual assistant by building it into Android, but doing so still didn’t provide an answer for how the technology would generate enough revenue to sustain Google’s expanding repertoire of expensive innovations.

Google’s ads relied on screens, yet voice interaction subverted screens entirely. Google briefly tried playing audio ads with the Google Home, but consumers were far from receptive. Investors started to voice their concerns in 2017, but Sundar Pichai told them not to worry, leaving them to assume that Google would use their age-old strategy and analyze users’ voice searches so that users could be shown more suitable ads on devices with screens.

Alexa celebrating its victory over Google

Headlines in early 2017 proclaimed that “Alexa Just Conquered CES. The World is Next.” Amazon then made their technology available to third party manufacturers, putting even more distance between the two companies. Amazon had already beaten Google once before, holding 54% of the cloud computing market (compared to Google’s 3%) in 2016, and they were just getting started.

By early 2017, Amazon had begun closing in on the entire retail industry.

Ads weren’t forever

At its peak, Google had a massive and loyal user-base across a staggering number of products, but advertising revenue was the glue that held everything together. As the numbers waned, Google’s core began to buckle under the weight of its vast empire.

Google was a driving force in the technology industry ever since its disruptive entry in 1998. But in a world where people despised ads, Google’s business model was not innovation-friendly, and they missed several opportunities to pivot, ultimately rendering their numerous grand and ambitious projects unsustainable. Innovation costs money, and Google’s main stream of revenue had started to dry up.

In a few short years, Google had gone from a fun, commonplace verb to a reminder of how quickly a giant can fall.

How Technology is Hijacking Your Mind — from a Magician and Google Design Ethicist

“It’s easier to fool people than to convince them that they’ve been fooled.” — Unknown.

I’m an expert on how technology hijacks our psychological vulnerabilities. That’s why I spent the last three years as a Design Ethicist at Google caring about how to design things in a way that defends a billion people’s minds from getting hijacked.

When using technology, we often focus optimistically on all the things it does for us. But I want to show you where it might do the opposite.

Where does technology exploit our minds’ weaknesses?

I learned to think this way when I was a magician. Magicians start by looking for blind spots, edges, vulnerabilities and limits of people’s perception, so they can influence what people do without them even realizing it. Once you know how to push people’s buttons, you can play them like a piano.

That’s me performing sleight of hand magic at my mother’s birthday party

And this is exactly what product designers do to your mind. They play your psychological vulnerabilities (consciously and unconsciously) against you in the race to grab your attention.

I want to show you how they do it.

Hijack #1: If You Control the Menu, You Control the Choices

Western Culture is built around ideals of individual choice and freedom. Millions of us fiercely defend our right to make “free” choices, while we ignore how those choices are manipulated upstream by menus we didn’t choose in the first place.

This is exactly what magicians do. They give people the illusion of free choice while architecting the menu so that they win, no matter what you choose. I can’t emphasize enough how deep this insight is.

When people are given a menu of choices, they rarely ask:

  • “what’s not on the menu?”
  • “why am I being given these options and not others?”
  • “do I know the menu provider’s goals?”
  • “is this menu empowering for my original need, or are the choices actually a distraction?” (e.g. an overwhelmingly array of toothpastes)
How empowering is this menu of choices for the need, “I ran out of toothpaste”?

For example, imagine you’re out with friends on a Tuesday night and want to keep the conversation going. You open Yelp to find nearby recommendations and see a list of bars. The group turns into a huddle of faces staring down at their phones comparing bars. They scrutinize the photos of each, comparing cocktail drinks. Is this menu still relevant to the original desire of the group?

It’s not that bars aren’t a good choice, it’s that Yelp substituted the group’s original question (“where can we go to keep talking?”) with a different question (“what’s a bar with good photos of cocktails?”) all by shaping the menu.

Moreover, the group falls for the illusion that Yelp’s menu represents a complete set of choices for where to go. While looking down at their phones, they don’t see the park across the street with a band playing live music. They miss the pop-up gallery on the other side of the street serving crepes and coffee. Neither of those show up on Yelp’s menu.

Yelp subtly reframes the group’s need “where can we go to keep talking?” in terms of photos of cocktails served.

The more choices technology gives us in nearly every domain of our lives (information, events, places to go, friends, dating, jobs) — the more we assume that our phone is always the most empowering and useful menu to pick from. Is it?

The “most empowering” menu is different than the menu that has the most choices. But when we blindly surrender to the menus we’re given, it’s easy to lose track of the difference:

  • “Who’s free tonight to hang out?” becomes a menu of most recent people who texted us (who we could ping).
  • “What’s happening in the world?” becomes a menu of news feed stories.
  • “Who’s single to go on a date?” becomes a menu of faces to swipe on Tinder (instead of local events with friends, or urban adventures nearby).
  • “I have to respond to this email.” becomes a menu of keys to type a response (instead of empowering ways to communicate with a person).
All user interfaces are menus. What if your email client gave you empowering choices of ways to respond, instead of “what message do you want to type back?” (Design by Tristan Harris)

When we wake up in the morning and turn our phone over to see a list of notifications — it frames the experience of “waking up in the morning” around a menu of “all the things I’ve missed since yesterday.” (for more examples, see Joe Edelman’s Empowering Design talk)

A list of notifications when we wake up in the morning — how empowering is this menu of choices when we wake up? Does it reflect what we care about? (from Joe Edelman’s Empowering Design Talk)

By shaping the menus we pick from, technology hijacks the way we perceive our choices and replaces them with new ones. But the closer we pay attention to the options we’re given, the more we’ll notice when they don’t actually align with our true needs.

Hijack #2: Put a Slot Machine In a Billion Pockets

If you’re an app, how do you keep people hooked? Turn yourself into a slot machine.

The average person checks their phone 150 times a day. Why do we do this? Are we making 150 conscious choices?

How often do you check your email per day?

One major reason why is the #1 psychological ingredient in slot machines: intermittent variable rewards.

If you want to maximize addictiveness, all tech designers need to do is link a user’s action (like pulling a lever) with a variable reward. You pull a lever and immediately receive either an enticing reward (a match, a prize!) or nothing. Addictiveness is maximized when the rate of reward is most variable.

Does this effect really work on people? Yes. Slot machines make more money in the United States than baseball, movies, and theme parks combined. Relative to other kinds of gambling, people get ‘problematically involved’ with slot machines 3–4x faster according to NYU professor Natasha Dow Schull, author of Addiction by Design.

Image courtesy of Jopwell

But here’s the unfortunate truth — several billion people have a slot machine their pocket:

  • When we pull our phone out of our pocket, we’re playing a slot machine to see what notifications we got.
  • When we pull to refresh our email, we’re playing a slot machine to see what new email we got.
  • When we swipe down our finger to scroll the Instagram feed, we’re playing a slot machine to see what photo comes next.
  • When we swipe faces left/right on dating apps like Tinder, we’re playing a slot machine to see if we got a match.
  • When we tap the # of red notifications, we’re playing a slot machine to what’s underneath.

Apps and websites sprinkle intermittent variable rewards all over their products because it’s good for business.

But in other cases, slot machines emerge by accident. For example, there is no malicious corporation behind all of email who consciously chose to make it a slot machine. No one profits when millions check their email and nothing’s there. Neither did Apple and Google’s designers want phones to work like slot machines. It emerged by accident.

But now companies like Apple and Google have a responsibility to reduce these effects by converting intermittent variable rewards into less addictive, more predictable ones with better design. For example, they could empower people to set predictable times during the day or week for when they want to check “slot machine” apps, and correspondingly adjust when new messages are delivered to align with those times.

Hijack #3: Fear of Missing Something Important (FOMSI)

Another way apps and websites hijack people’s minds is by inducing a “1% chance you could be missing something important.”

If I convince you that I’m a channel for important information, messages, friendships, or potential sexual opportunities — it will be hard for you to turn me off, unsubscribe, or remove your account — because (aha, I win) you might miss something important:

  • This keeps us subscribed to newsletters even after they haven’t delivered recent benefits (“what if I miss a future announcement?”)
  • This keeps us “friended” to people with whom we haven’t spoke in ages (“what if I miss something important from them?”)
  • This keeps us swiping faces on dating apps, even when we haven’t even met up with anyone in a while (“what if I miss that one hot match who likes me?”)
  • This keeps us using social media (“what if I miss that important news story or fall behind what my friends are talking about?”)

But if we zoom into that fear, we’ll discover that it’s unbounded: we’ll always miss something important at any point when we stop using something.

  • There are magic moments on Facebook we’ll miss by not using it for the 6th hour (e.g. an old friend who’s visiting town right now).
  • There are magic moments we’ll miss on Tinder (e.g. our dream romantic partner) by not swiping our 700th match.
  • There are emergency phone calls we’ll miss if we’re not connected 24/7.

But living moment to moment with the fear of missing something isn’t how we’re built to live.

And it’s amazing how quickly, once we let go of that fear, we wake up from the illusion. When we unplug for more than a day, unsubscribe from those notifications, or go to Camp Grounded — the concerns we thought we’d have don’t actually happen.

We don’t miss what we don’t see.

The thought, “what if I miss something important?” is generated in advance of unplugging, unsubscribing, or turning off — not after. Imagine if tech companies recognized that, and helped us proactively tune our relationships with friends and businesses in terms of what we define as “time well spent” for our lives, instead of in terms of what we might miss.

Hijack #4: Social Approval

Easily one of the most persuasive things a human being can receive.

We’re all vulnerable to social approval. The need to belong, to be approved or appreciated by our peers is among the highest human motivations. But now our social approval is in the hands of tech companies.

When I get tagged by my friend Marc, I imagine him making a conscious choice to tag me. But I don’t see how a company like Facebook orchestrated his doing that in the first place.

Facebook, Instagram or SnapChat can manipulate how often people get tagged in photos by automatically suggesting all the faces people should tag (e.g. by showing a box with a 1-click confirmation, “Tag Tristan in this photo?”).

So when Marc tags me, he’s actually responding to Facebook’s suggestion, not making an independent choice. But through design choices like this, Facebook controls the multiplier for how often millions of people experience their social approval on the line.

Facebook uses automatic suggestions like this to get people to tag more people, creating more social externalities and interruptions.

The same happens when we change our main profile photo — Facebook knows that’s a moment when we’re vulnerable to social approval: “what do my friends think of my new pic?” Facebook can rank this higher in the news feed, so it sticks around for longer and more friends will like or comment on it. Each time they like or comment on it, we’ll get pulled right back.

Everyone innately responds to social approval, but some demographics (teenagers) are more vulnerable to it than others. That’s why it’s so important to recognize how powerful designers are when they exploit this vulnerability.

Hijack #5: Social Reciprocity (Tit-for-tat)

  • You do me a favor — I owe you one next time.
  • You say, “thank you”— I have to say “you’re welcome.”
  • You send me an email— it’s rude not to get back to you.
  • You follow me — it’s rude not to follow you back. (especially for teenagers)

We are vulnerable to needing to reciprocate others’ gestures. But as with Social Approval, tech companies now manipulate how often we experience it.

In some cases, it’s by accident. Email, texting and messaging apps are social reciprocity factories. But in other cases, companies exploit this vulnerability on purpose.

LinkedIn is the most obvious offender. LinkedIn wants as many people creating social obligations for each other as possible, because each time they reciprocate (by accepting a connection, responding to a message, or endorsing someone back for a skill) they have to come back to linkedin.com where they can get people to spend more time.

Like Facebook, LinkedIn exploits an asymmetry in perception. When you receive an invitation from someone to connect, you imagine that person making a conscious choice to invite you, when in reality, they likely unconsciously responded to LinkedIn’s list of suggested contacts. In other words, LinkedIn turns your unconscious impulses (to “add” a person) into new social obligations that millions of people feel obligated to repay. All while they profit from the time people spend doing it.

Imagine millions of people getting interrupted like this throughout their day, running around like chickens with their heads cut off, reciprocating each other — all designed by companies who profit from it.

Welcome to social media.

After accepting an endorsement, LinkedIn takes advantage of your bias to reciprocate by offering *four* additional people for you to endorse in return.

Imagine if technology companies had a responsibility to minimize social reciprocity. Or if there was an independent organization that represented the public’s interests — an industry consortium or an FDA for tech — that monitored when technology companies abused these biases?

Hijack #6: Bottomless bowls, Infinite Feeds, and Autoplay

YouTube autoplays the next video after a countdown

Another way to hijack people is to keep them consuming things, even when they aren’t hungry anymore.

How? Easy. Take an experience that was bounded and finite, and turn it into a bottomless flow that keeps going.

Cornell professor Brian Wansink demonstrated this in his study showing you can trick people into keep eating soup by giving them a bottomless bowl that automatically refills as they eat. With bottomless bowls, people eat 73% more calories than those with normal bowls and underestimate how many calories they ate by 140 calories.

Tech companies exploit the same principle. News feeds are purposely designed to auto-refill with reasons to keep you scrolling, and purposely eliminate any reason for you to pause, reconsider or leave.

It’s also why video and social media sites like Netflix, YouTube or Facebook autoplay the next video after a countdown instead of waiting for you to make a conscious choice (in case you won’t). A huge portion of traffic on these websites is driven by autoplaying the next thing.

Facebook autoplays the next video after a countdown

Tech companies often claim that “we’re just making it easier for users to see the video they want to watch” when they are actually serving their business interests. And you can’t blame them, because increasing “time spent” is the currency they compete for.

Instead, imagine if technology companies empowered you to consciously bound your experience to align with what would be “time well spent” for you. Not just bounding the quantity of time you spend, but the qualities of what would be “time well spent.”

Hijack #7: Instant Interruption vs. “Respectful” Delivery

Companies know that messages that interrupt people immediately are more persuasive at getting people to respond than messages delivered asynchronously (like email or any deferred inbox).

Given the choice, Facebook Messenger (or WhatsApp, WeChat or SnapChat for that matter) would prefer to design their messaging system to interrupt recipients immediately (and show a chat box) instead of helping users respect each other’s attention.

In other words, interruption is good for business.

It’s also in their interest to heighten the feeling of urgency and social reciprocity. For example, Facebook automatically tells the sender when you “saw” their message, instead of letting you avoid disclosing whether you read it (“now that you know I’ve seen the message, I feel even more obligated to respond.”)

By contrast, Apple more respectfully lets users toggle “Read Receipts” on or off.

The problem is, maximizing interruptions in the name of business creates a tragedy of the commons, ruining global attention spans and causing billions of unnecessary interruptions each day. This is a huge problem we need to fix with shared design standards (potentially, as part of Time Well Spent).

Hijack #8: Bundling Your Reasons with Their Reasons

Another way apps hijack you is by taking your reasons for visiting the app (to perform a task) and make them inseparable from the app’s business reasons (maximizing how much we consume once we’re there).

For example, in the physical world of grocery stores, the #1 and #2 most popular reasons to visit are pharmacy refills and buying milk. But grocery stores want to maximize how much people buy, so they put the pharmacy and the milk at the back of the store.

In other words, they make the thing customers want (milk, pharmacy) inseparable from what the business wants. If stores were truly organized to support people, they would put the most popular items in the front.

Tech companies design their websites the same way. For example, when you you want to look up a Facebook event happening tonight (your reason) the Facebook app doesn’t allow you to access it without first landing on the news feed (their reasons), and that’s on purpose. Facebook wants to convert every reason you have for using Facebook, into their reason which is to maximize the time you spend consuming things.

Instead, imagine if …

  • Twitter gave you a separate way to post a tweet than having to see their news feed.
  • Facebook gave a separate way to look up Facebook Events going on tonight, without being forced to use their news feed.
  • Facebook gave you a separate way to use Facebook Connect as a passport for creating new accounts on 3rd party apps and websites, without being forced to install Facebook’s entire app, news feed and notifications.

In a Time Well Spent world, there is always a direct way to get what you want separately from what businesses want. Imagine a digital “bill of rights” outlining design standards that forced the products used by billions of people to let them navigate directly to what they want without needing to go through intentionally placed distractions.

Imagine if web browsers empowered you to navigate directly to what you want — especially for sites that intentionally detour you toward their reasons.

Hijack #9: Inconvenient Choices

We’re told that it’s enough for businesses to “make choices available.”

  • “If you don’t like it you can always use a different product.”
  • “If you don’t like it, you can always unsubscribe.”
  • “If you’re addicted to our app, you can always uninstall it from your phone.”

Businesses naturally want to make the choices they want you to make easier, and the choices they don’t want you to make harder. Magicians do the same thing. You make it easier for a spectator to pick the thing you want them to pick, and harder to pick the thing you don’t.

For example, NYTimes.com lets you “make a free choice” to cancel your digital subscription. But instead of just doing it when you hit “Cancel Subscription,” they send you an email with information on how to cancel your account by calling a phone number that’s only open at certain times.

NYTimes claims it’s giving a free choice to cancel your account

Instead of viewing the world in terms of availability of choices, we should view the world in terms of friction required to enact choices. Imagine a world where choices were labeled with how difficult they were to fulfill (like coefficients of friction) and there was an independent entity — an industry consortium or non-profit — that labeled these difficulties and set standards for how easy navigation should be.

Hijack #10: Forecasting Errors, “Foot in the Door” strategies

Facebook promises an easy choice to “See Photo.” Would we still click if it gave the true price tag?

Lastly, apps can exploit people’s inability to forecast the consequences of a click.

People don’t intuitively forecast the true cost of a click when it’s presented to them. Sales people use “foot in the door” techniques by asking for a small innocuous request to begin with (“just one click to see which tweet got retweeted”) and escalate from there (“why don’t you stay awhile?”). Virtually all engagement websites use this trick.

Imagine if web browsers and smartphones, the gateways through which people make these choices, were truly watching out for people and helped them forecast the consequences of clicks (based on real data about what benefits and costs it actually had?).

That’s why I add “Estimated reading time” to the top of my posts. When you put the “true cost” of a choice in front of people, you’re treating your users or audience with dignity and respect. In a Time Well Spent internet, choices could be framed in terms of projected cost and benefit, so people were empowered to make informed choices by default, not by doing extra work.

TripAdvisor uses a “foot in the door” technique by asking for a single click review (“How many stars?”) while hiding the three page survey of questions behind the click.

Summary And How We Can Fix This

Are you upset that technology hijacks your agency? I am too. I’ve listed a few techniques but there are literally thousands. Imagine whole bookshelves, seminars, workshops and trainings that teach aspiring tech entrepreneurs techniques like these. Imagine hundreds of engineers whose job every day is to invent new ways to keep you hooked.

The ultimate freedom is a free mind, and we need technology that’s on our team to help us live, feel, think and act freely.

We need our smartphones, notifications screens and web browsers to be exoskeletons for our minds and interpersonal relationships that put our values, not our impulses, first. People’s time is valuable. And we should protect it with the same rigor as privacy and other digital rights.

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