Is Gold Destined for Summer Doldrums in 2019?

Every summer gold traders tremble in fear of “the summer doldrums.”Newcomers to the gold scene might be asking whether the summer doldrums are a real thing?  While old-timers might ask: “Does it look like we’ll get those this year?”

Here’s a 1-year chart of GLD – guess for yourself on each question, then your friendly Gold Enthusiast will weigh in.

spdr trust gld 2019











As you can see the recent gold rally is no joke.  It almost looks more like a Bitcoin rally in miniature — haha. (Longtime readers will know The Gold Enthusiast is not a true Bitcoin fan.)

But first let’s examine this whole mythological summer doldrums idea.  The summer doldrums are called that because all the big retail news about gold happens in other times of the year.  In the Fall it’s India buying gold preparing for marriage season.  In the Winter and Spring it’s marriage season itself, along with Christmas and New Year holidays in the West.  Then in Spring there’s gold gifting season in India and parts of the Middle East. And for some reason Russia always seems to be buying gold for their central bank reserves in December.  Then in January there’s a burst of New Year optimism, with manufacturers projecting their gold use for the year.

But in summer there’s – just not much.  Not much news, other than July earnings season in US markets, which is a snore-fest by US earnings season standards. That’s where the idea of summer doldrums comes from.  It is a thing – it’s when the gold market kinda goes news-cold.  Not that nothing’s going on, just that relatively there’s not much to put gold on the front page.  On a known, repeating basis.

Which brings us to this year.  This year we have some geopolitics!  And as we all know, geopolitical uncertainty is a big driver of gold prices.  The 1-year chart of gold above shows a dip from July through August, then a slow gradual sideways move until December.  That was owning to a lack of good news from the retail markets as well as a lack of uncertainty in geopolitical terms.

Then came December when the picture for gold brighted up. A lot.

Now as we head into this summer we have quite a bit of uncertainty.  Yes, it looks like we have a truce in the US-China trade war.  But in the meantime, Iran rattled a few modern sabers, with some actual missile firing and ship-attacking.  And the US responding more with words and economics than with shooting.  So while this-all gets sorted out we have – geopolitical instability.

And we’re into summer this year from a much higher price level.  Which either adds to the upside potential, or to the size of the downside slump, depending on which way you want to call it from here.

So the answers to our original questions were Yes and No.  Yes, the summer doldrums in gold are a real thing.  And No, it doesn’t look like we’ll have those this year.


The Gold Enthusiast

DISCLAIMER: The author is long the gold sector via small positions in NUGT, JNUG, a few junior miners, and covered calls on part of the NUGT position. He has no plans to trade these in the next 24 hours.



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Fog of (Trade) War

After a rollercoaster two months of headlines about trade wars and tariffs, once again the market finds itself in the familiar position of not knowing what to think about the long-term effects of the U.S.-China trade dispute. But it does recognize this: that substantial progress on trade requires much more than an agreement on how many soybeans China purchases from the U.S. Muddling the issue – and further inflaming investor anxieties — is the U.S. government’s threatened use of tariffs to address non-trade related issues like immigration at the Mexican border.

In our view, trade uncertainty now represents the key macro (and as we will argue, micro) risks to the outlook.

How trade affects the Fed…

Fed Chair Jerome Powell best summed up the central bank’s view on the trade talk situation at the June 4th Chicago Fed Economic Outlook Symposium: “We do not know how or when these issues will be resolved.”

Regardless of any near-term movement in trade negotiations, however, expectations of significant cuts in Fed policy rates this year reflect the market’s belief that accumulation of trade-related risks will continue to weigh negatively. The near-term debate is over the timing and magnitude of the easing, not whether an easing occurs. The market already appears to be pricing in these rate cuts (see graphic below).

What underlies the chart is that the Fed and the markets are currently engaged in a complex dynamic, in which central bank “accommodation” is less about transmitting more favorable borrowing costs (as is the traditional textbook explanation) and more about increasing confidence in the outlook for continued economic growth.

In this dynamic, the more the trade war undermines such confidence – and thus dampens consumption, hiring and investment – the more the market believes the Fed will cuts rates to increase confidence and in turn stimulate economic activity.

…and what the stock market said

Finally, given the uncertainty around trade, what are we to make of the stock market rally since Powell’s June 4th remarks? As the table below shows, the S&P 500 Index gained 5%, on the heels of a steep drop triggered by the May 6th breakdown in talks. Digging deeper, we observe two things: first, that the rally was fueled by a rotation into high-quality stocks; and second, that quality stocks with the strongest balance sheets – i.e., those least likely to default – also declined less.

In other words, amid the trade “fog” of May and June, stock investors thought more like bond investors, seeking more defensive companies that could better weather a trade war.

What’s the difference between quality as measured by a company’s balance sheet versus their income statement? Classic equity investors tend to look at income statement measurements of a company’s fundamentals, such as earnings variability or return on equity, which tends to be more forward-looking and growth-oriented. Overall, equity investors focus on the upside potential of a stock.  Creditors, or those that own the bonds of a company, tend to look at a company differently. As a holder of a bond you have less ability to benefit from growth in the company’s earnings but have more downside potential in the case of a default.  Consequently, you look at balance sheet centric measures like interest rate coverage or debt to equity ratio that are more defensive in nature, because you are more concerned about limiting downside.

The silver lining for investors

 The performance differences between high quality stocks as measured by traditional income statement vs. balance sheet metrics highlights the unique nature of risks posed by trade uncertainty. Traditionally, the Fed can help alleviate macro pressures and reduce recession risk. However, macro policy can do little to offset the micro risks: trade disruption of critical supply chains to individual companies. Companies with stronger balance sheets have more resilience to margin compression–and stronger buffers against the winds of war.

However, a silver lining for investors is that trade uncertainty increases the dispersion of returns (bigger winners and bigger losers), a benefit to alternative long/short investment strategies.

Jeffrey Rosenberg, CFA, is a senior portfolio manager for BlackRock’s Systematic Fixed Income (“SFI”) team and a regular contributor to The Blog.

Investing involves risks, including possible loss of principal.

This material is not intended to be relied upon as a forecast, research or investment advice, and is not a recommendation, offer or solicitation to buy or sell any securities or to adopt any investment strategy. The opinions expressed are as of July 2019 and may change as subsequent conditions vary. The information and opinions contained in this post are derived from proprietary and non-proprietary sources deemed by BlackRock to be reliable, are not necessarily all-inclusive and are not guaranteed as to accuracy. As such, no warranty of accuracy or reliability is given and no responsibility arising in any other way for errors and omissions (including responsibility to any person by reason of negligence) is accepted by BlackRock, its officers, employees or agents. This post may contain “forward-looking” information that is not purely historical in nature. Such information may include, among other things, projections and forecasts. There is no guarantee that any forecasts made will come to pass. Reliance upon information in this post is at the sole discretion of the reader. Past performance is no guarantee of future results. Index performance is shown for illustrative purposes only. You cannot invest directly in an index.

©2019 BlackRock, Inc. All rights reserved. BLACKROCK is a registered trademark of BlackRock, Inc., or its subsidiaries in the United States and elsewhere. All other marks are the property of their respective owners.


Book Review & Summary: The Behavioral Investor by Daniel Crosby

This was an excellent book about behavioral investing that should help you improve your investing process.

Too many investors neglect their process and get overly excited by a stock pick they read about on their favorite financial website, or, probably worse, that they hear about from a friend or someone they respect. They don’t do their own full diligence and wind up getting lucky or burned. (“You can be right and still be a moron” for making a poorly thought-through decision, according to Crosby.)

Dr. Daniel Crosby, a psychologist and behavioral finance expert, is here to explain all the ways you can consciously and unconsciously subvert yourself and torpedo your attempts at achieving your investing goals. He offers good advice for building a resilient process for avoiding most mistakes.

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Review: Great Content, Mediocre Structure

The content is important, which is why I’m writing this synopsis. He pulls insights for investing and investors from dozens, if not hundreds, of studies and meta-analyses from people like Kahneman and Tversky, among many others. I’ll cover those insights below.

My main issue with the book is its structure. A well-structured book would either build an argument successively, piece by piece in each chapter, or it would map out its content so that each main and supporting idea would be discussed independently, yet taken together, the ideas would collectively cover the whole space. (Consultants call this being Mutually Exclusive and Collectively Exhaustive, or “MECE,” — pronounced “mee-see.”)

This book should have used the latter strategy, but instead suffered from some serious repetitiveness. Chapters 4-7 cover the main psychological biases investors face. Crosby then repeats a lot of those concepts — while introducing new aspects of them, as well — in the subsequent four chapters that are supposed to discuss how to overcome those biases.

When you keep shifting between the problem statement(s) with their resolutions, your ideas get confused and the takeaways become less apparent.

The final 5 chapters are a mess, structurally. There is repetitive content from the first 8 chapters that goes beyond making connections for the reader. It is a heap of thoughts about risk, active vs. passive investing, bubbles, value and momentum factors, building a rules-based process, etc. Again, it’s good content, just put together in a suboptimal way.

I do like how most chapters include synthesized bullet points at the end. There were a few chapters where I thought those synopses didn’t quite adequately cover the meat of the chapter, though, so you can’t rely just on reading those. It should also come as no surprise that the final 5 chapters, where Crosby loses the plot the most, have no end-of-chapter summary.

Anyway, rather than write a typical summary of the book, I’m going to re-structure the key points of the book into a more cogent storyline, but I’ll mostly use quotes from the book in doing so.

Book Notes/Synopsis

The basic premise of the book is: markets are made up of people, so to understand and profit from markets, we must understand human nature.

Sociologically, we’re wired to not be good at investing:

“Trusting in common myths is what makes you human. But learning not to is what will make you a successful investor.”

Neurologically, it’s the same. Our brains are outdated, impatient, and hungry:

“Your brain is constantly searching for ways to go into energy saver mode and not work quite so hard.”

“Important information is almost of necessity hard to digest. Our mental fatigue ensures that we leave relevant new information to the side and rely instead on well-trodden paths of dubious quality.”

“Our ability to control our short-term impulses toward greed is limited and that we are more or less wired for immediacy.”

“Money … is so important that we eschew reason, ignoring what is economically best in favor of what is emotionally satisfying.”

“Market conditions are constantly in flux and can lead us to learn the wrong lessons.”

“The anticipation of reward releases a flood of dopamine, which primes us to become sloppy and undisciplined; success begets failure.”

Physiologically, we are set up for failure:

“Physical states can impact emotion just as surely as the reverse is true.”

“Loss aversion kept our ancestors alive. It keeps you from becoming a successful investor.”

There are 4 Types of Behavioral Risk: Ego, Conservatism, Attention, and Emotion. Each Requires Different Strategies to Overcome Them.


“We look for supporting evidence, we congratulate ourselves for believing as we do, and we react violently against attacks to our worldview.”

“Our need to view ourselves as competent and maintain ego lives somewhere so deep within us that not even cognitive impairment can touch it.”

“Paradoxically, the more ambiguous a situation, the more certain we become.”

Crosby identifies three types of overconfidence to watch out for: overprecision (excessive certainty), overplacement (elevated belief in personal skill), overestimation (unrealistic optimism).

“When self-esteem is threatened, … people lose their ability to self-regulate. Arrogant people in particular … rush to prove their critics wrong, even if it means taking big risks.”

“It is egoistic in the extreme to assume that you can predict the future, but nihilistic in the extreme to assume that nothing can be known.”

Overcoming Ego

Be rules-based instead of using discretionary processes:

“The behavioral investor realizes that course-correcting bad ideas is nearly impossible and that designing a system inoculated against untruth is the far better one.”

“Bubbles are a natural, recurring feature of capital markets… Have a rules-based system for avoiding catastrophic loss that is infrequently (i.e., every few years) activated.”

Diversify (but still have conviction):

“Diversification is a concrete nod to the luck and uncertainty inherent in money management and an admission that the future is unknowable.”

“Put in place a plan that diversifies across geographies and asset classes, both familiar and foreign.”

Be honest with yourself about what you don’t know, and force yourself to explain your beliefs/assertions using facts & data:

“‘I don’t know’ is a profitable if seldom uttered sentiment.”

“The next time you feel as though you must buy or sell a security, or that you are certain of where the financial markets are headed, take a moment to explain, in detail, the factual reasons why this is so.”

Ask “How do I know I’m right?” or “How might I be wrong?”

Gain greater knowledge using Richard Feynman’s 3 part process:

  1. Figure out what you don’t know
  2. Educate yourself
  3. Teach it to a child or novice

Check your level of certainty:

“Everyone thinks that they are a contrarian… True contrarianism is painful and should cause considerable self-doubt. If your brand of swimming upstream doesn’t hurt, it’s unlikely to work.”

Or, to paraphrase Crosby: if you feel overly passionate about one of your investing ideas, you probably haven’t thought about it enough.


“All paths to conservatism, it would seem, run through some form of loss aversion.”

“Individuals feel stronger regret for bad outcomes that are the consequence of new actions taken than for similar bad consequences resulting from inaction… Put simply, if you’re going to make a mistake, your brain would rather you make a mistake by doing nothing.”

“The sunk cost fallacy, as it is known, means that the larger the past resource invested in a decision, the greater the inclination to continue the commitment in subsequent decisions.”

“The implications for investing are clear: we tend to overvalue what we own and undervalue unowned alternatives.”

“Our conservative nature already means that we see less risk in the familiar and so are likely already overweight what we know.”

Overcoming conservatism

Have a long-term orientation:

“By privileging today over tomorrow and certain mediocrity over possible greatness, fearful investors provide behavioral investors with an equity risk premium that is improbably large. This premium can be earned by doing the opposite: by privileging tomorrow over today.”

“Behavioral investing must be long-term to be effective.”

Procrastinate (a little):

“So, when tasked with making an important investing decision, take time to reconsider your immediate choice and see if you still think the same after more thought.”

Use heuristics/rules of thumb:

“Risky situations, where probabilities are understood, lend themselves to logical and statistical thinking. Uncertain situations like capital markets, where ‘unknown unknowns’ run rampant, require looser controls in the form of rules of thumb.” (Heuristics)


“The availability heuristic, which simply means that we predict the likelihood of an event based on how easily we can call it to mind rather than how probable it is.”

Storytelling bypasses many of the critical filters we apply to other forms of information gathering… For this reason, stories are the enemy of the behavioral investor.”

Salience is the psychological term for prominence, meaning that our attention can be hijacked by low-probability-high-scariness things like shark attacks while ignoring high-probability-low-scariness dangers like taking a selfie near a busy street.”

Honing Attention

Avoid telling yourself stories, or listening to others’:

“To manage risk in any meaningful sense means stepping outside of the stories we tell ourselves and considering information in an emotionless a manner as possible.”

Evaluate investment media: evaluate the source, question the drama, examine the tone, consider the motive, check the facts.

“Complicated macro narratives should be scrupulously ignored.”

Focus your attention on what matters:

“A part of any sensible approach to security selection is determining what matters most and a focus on those variables to the exclusion of the cacophony all around. If everything matter, nothing does.

“Behavioral investors, as the sworn enemy of noise traders, must do just the opposite: 1. Revel in principled contrarianism and 2. Cultivate an understanding of the empirical and psychological markers of signal.”


“Low levels of emotion give rise to a high dispersion of ideas and behaviors, but strong emotion has a decided homogenizing effect that can harm the investor with even the best intentions. Emotion makes you a stranger to your rules.

“They were simply unable to predict the degree to which passion would change them.”

“All too often we confuse the intensity of our longing with the probability of our winning… We tend to conflate our desire for an outcome with its likelihood.”

“Even the most educated professional investor suffers from what is commonly known as restraint bias, or the tendency to overestimate our ability to control impulsive behavior in the moment.”

Any strong emotion has the impact of shortening time horizons and increasing impatience, two of the worst things an evidence-based investor could ever hope to do.”

“Emotional distress (the kind caused by market volatility) leads to a failure to consider all options and shifts people in favor of high-risk, high-reward payoffs, even if they are objectively poor choices.”

Managing Emotion

“Good investing, tedious as it can be, is inappropriately labeled as risky when it is really just boring.”

“It can be tempting to want to stop emotion in its tracks, but oftentimes, the most adaptive approach is to repurpose it for more favorable outcomes.”


“Emotion in and around financial markets is often lumped into one of two categories: fear or greed. Meditation, it would seem, is well positioned to tame both…. Both show evidence of being tamed by the simple act of mindfulness meditation.”

“At their core, mindfulness and meditation are all about focusing on present thoughts and actions in a non-judgmental way.”

“Ideally, investment managers would work somewhere between 4 and 12 days per year and spend the other 361 days a year in the pursuit of ideas that challenge their existing beliefs.”

HALT – hungry, angry, lonely, tired – “abstain from making important decisions in any of these emotional states.”

“Avoid emotion-inducing situations like watching financial news and frequently checking account balances.”

“Build a model and follow it slavishly.”

Building behaviorally sound portfolios

Systems Trump Discretion

Discretion and intuition don’t work:

“The following [are] the criteria for making good discretionary decisions: predictable outcomes, static stimuli and the availability of good feedback. Capital markets, in which human behavior is absolutely central, meet none of these conditions.”

“In the absence of a certain level of predictability and rapid feedback, neither of which are present in financial markets, intuition lacks soil fertile enough to take root.”

Therefore, you need to use a rules-based system that you evaluate not on the outcomes but on the quality of the process:

“Learning to score you investment wins and losses based on the quality of your decisions and not on the quality of the outcome is the key to managing your emotions, appropriately measuring your own performance and living to fight another day.”

“A behavioral investor begins by doing no harm and screening out any stocks that appear to be fraudulent, at risk for bankruptcy, or otherwise sick.”

Diversification and Conviction Can Coexist

We use diversification to overcome ego, but this doesn’t mean you should own 100 stocks. Most gurus from Buffett and Graham to Klarman recommend 6-30 holdings that you know well and believe in.

“We believe that a policy of portfolio concentration may well decrease risk if it raises, as it should, both the intensity with which an investor thinks about a business and the comfort-level he must feel with its economic characteristics before buying into it.”

Buffett 1993 shareholder letter

“Even inexpensive, high quality stocks with a catalyst have an uncertain fate. By bundling risk (i.e., diversifying), the likelihood increases that doing the right thing for the right reasons will pay off.”

On thinking about catalysts as part of gaining conviction:

“Take the probability of loss times the amount of possible loss from the probability of gain times the amount of possible gain. That is what we’re trying to do. It’s imperfect, but that’s what it’s all about.”


“A low likelihood event with great upside or downside may be well worth attending to.”

Prepare for Bursting Bubbles Without Being Too Fine-Tuned to Them

“The default state of a strategy should be bullishness [markets usually go up], but ought to include a contingency for low-likelihood-high-intensity events.”

“But there are two things that begin to give investors pause and would warrant taking a more defensive position. The first is flagging momentum, which increases the probability that the market will fall in value. The second is steep valuations, which increase the intensity of the potential crash.”

“Thus, the behavioral investor has the default position of being aggressively invested until such time as momentum begins to slacken (probability) and valuations are extreme (intensity).”

“The behavioral investor knows market timing is typically ineffectual, but is also aware of times in history when broad market levels have become obviously and grossly disconnected from any measure of fundamental value.”

Less is More When it Comes to Information

This is largely covered in the “Honing Attention” section. Don’t succumb to storytime, focus on what matters, don’t watch “Mad Money.”

I won’t repeat myself even though the book does!

Validate Investing Strategies by Looking for Evidence, Theory and Roots in Behavior

“Arbitraging emotionality seems to be an enduring form of investing advantage – one that may actually be increasing.”

3 Tests of an Investable Idea:

1. It’s supported by the data

“The first hurdle an idea must clear to be considered worthy of a behavioral investor is that it has a rich history of empirical support. The data must support your assertion, period.”

2. There’s a strong causal theory behind it

“If there is no good reason for a data point to correlate with outsized returns, it probably doesn’t.”

3. It’s behaviorally difficult to stick with

“Smart people discover truths about the market, share them with the world, and return-hungry arbitrageurs ensure that those truths don’t stay true for long.”

“But what calendar effects, and many other market anomalies, lack is the third and final trait that behavioral investors require: it must owe to an enduring psychological tendency. There is no psychic pain in arbitraging calendar effects… For a factor to be worthwhile to a behavioral investor it must be empirically supported, theoretically sound, and behaviorally intransigent.

Active vs. Passive. vs. Rules-Based Behvioral Investing

Rules-based behavioral investing is: low fee, diversified, has the potential to outperform, has low turnover, and manages bias. Passive investing cannot outperform and does not manage behavioral biases. Active investing is not low fee, low turnover, and also does not manage behavioral biases.

There are many reasons to be a passive investor:

“Passive investing should be the de facto choice of those uninterested in the art and science of investment management.”

Know-nothing investors … are likely to beat more than 90% of active managers and have time to focus on pursuits more meaningful than compounding wealth.

The rise of passive investing yields more opportunities for other investors, however.

“The very inclusion of a company in an index leads to an immediate increase in the price-to-earnings and price-to-book ratios of the stock.”

“Increasingly, large swaths of a corporation are being bought and sold out of habit and not conviction, meaning that prices are less and less reflective of true value.”

“The behavioral investor understands and seeks to mimic the best parts of passive investing — low turnover, rock bottom fees, and appropriate diversification — without succumbing to absentminded buying and selling.”

Value and Momentum: The Behavioral Investment Factors


“Value stocks tend to provide greater returns with lower volatility and incredible consistency.”

“Value investing is sensible, empirically robust and has behavioral roots that make it psychologically and physically hard to execute, passing all 3 hurdles of a sound behavioral investment idea.”

Theoretical/behavioral sources

You need sound theory.

“All else being equal, we look to price as the foremost determinant of quality.”

“The relationship between cost and value is more tenuous than ever and in capital markets it can be accurately said to be inverse. The more you pay, the less you get.”

What You See Is All There Is (WYSIATI), coined by Daniel Kahneman, tells us that humans basically take at face value a stock’s price, return distribution, and fundamentals, and project that forward as-is.

“For many investors, their mental representation of a stock is given by the the distribution of the stock’s past returns… People adopt this representation because they believe the past return distribution to be a good and easily accessible proxy for the object they are truly interested in, namely the distribution of the stock’s future returns.”

-Barberis, Mukherjee & Wang, “Prospect Theory and Stock Returns: An Empirical Test” as quoted in “The Behavioral Investor”

Value investing is physically painful. Being the odd contrarian leads to feelings of social exclusion that generate brain activity in the same parts as real, physical pain.


“It is innate tendency of humankind to project the present state of things into the future indefinitely. In so doing, we create one of the most important exploitable market anomalies – momentum.”

Theoretical/behavioral source: overconfidence and self-attribution.

“This overconfidence becomes paired with self-attribution in the sense that investors attribute the rising prices to their own stock picking genius and not some combination of luck and skill, which is more likely the truth.”

Or is it confirmation bias and representativeness?

“People make a purchase believing what they believe, do not want to be disabused of those notions, and look at recent price moves as being indicative of future moves.”

“The premier market anomaly is momentum. Stocks with low returns over the past year tend to have low returns for the next few months, and stocks with high past returns tend to have high future returns.”

Value and Momentum Factor Premia Are Durable

Crosby shares a chart originally produced by Ben Carlson that shows the annualized premia for value, size, beta, and momentum factors from 1927-2014:

Value 5.0%
Size 3.4%
Beta 8.4%
Momentum 9.5%

The Value and Momentum factors do seem to pass Crosby’s test for a go-forward investing strategy. I would’ve loved for him to investigate the Beta factor, as well.

Final random tidbits

“Behavioral investors take a middle path, understanding that the question is not ‘Is the price right?’ but ‘Where is the price headed?’”

“Invest in a basket of stocks that imperfect subjective appraisal has unfairly punished, but that a positive feedback loop will soon reward with a push toward fair value.”

“Whatever success you achieve as a result of having read this book will come, not as a result of personal genius, but through acceptance of personal mediocrity.”

I hope you enjoyed my synopsis of The Behavioral Investor and are now ready to incorporate what you’ve learned into your own investing process.

The post Book Review & Summary: The Behavioral Investor by Daniel Crosby appeared first on The Value Investing Blog of Old School Value.

The importance of checking in

Last week was a rough week.

I can be a pretty open book when it comes to my personal and professional life (though I’m not going to delve into the details here). As I shared what I went through, the kindness and encouragement from family, friends, and colleagues helped tremendously.

I proactively sought support from those closest to me. But every other connection spun out from an unrelated call or conversation. Many of you reached out for some other reason, and I felt compelled to share what I was going through before we dove into discussing the intended topic. After all, I wanted to give some context as to what was shaping my current perspective. And the outcome of sharing was helpful: by being honest, I felt supported and “safe” to do work without judgment.

Though what I’ve come to realize is that while I’m open, not everyone is. It’s natural to feel embarrassed and many don’t feel free to bring their personal lives into the workplace because we don’t want to burden others or feel like it’s not “productive.”

However, this is far from the case. In my experience, sharing my story with colleagues brought a deeper connection. I was open about what was going on and we were able to move forward within that context.

This got me thinking about an instance where the board of directors of one of our portfolio companies was disappointed that the CEO was not prioritizing the right things.  What they didn’t realize, and what I found out, was that the CEO was overwhelmed… going through a break up and family illness at the same time. Had there been a “check in”, we could have had productive discussions on how to support the CEO.

Over the past few years, I try to start every conversation with a personal check-in before discussing business. The organizations that we are building and are a part of, are only as strong as the people who are in it.

Perhaps this is a no-brainer given that our business is so relationship driven, but it might serve as a great reminder to all of us. In fact, as Boris wrote earlier this year while inspired by Bill Campbell, great leaders show empathy. So, really ask yourself: when’s the last time that you asked your investor, your portfolio company, your colleague, your partner, your manager, your employees how are they actually doing?

It’s not prying… it’s human touch which can really lift spirits and make someone’s day better (more than you’ll ever know), and inspire productivity. The more we share (regardless of power dynamic: investor-founder, manager-employee, etc.), the more context and perspective we have around the business and better understand why things are moving in a certain direction. And if this exercise seems awkward, you can try personal check-ins with a concept like “Red, Yellow, Green” as indicators of mood (i.e. red = hypersensitive; yellow = a bit on edge; green = calm).

So think about checking in with others, and being open to share your own experiences. And thanks to everyone who put work on hold for a few minutes last week – I really appreciate it.

The post The importance of checking in appeared first on Version One.

These Numbers Show OPEC Is Stuck In A No-Win Downward Spiral

Crude oil prices eased after Wednesday’s surge, as OPEC’s latest forecasts showed it will produce more than needed next year despite extending an agreement with Russia to cut back.


In 2020, demand for OPEC’s oil will average 29.27 million barrels per day, a decline of 1.34 million bpd from 2019’s expected level, the Organization of the Petroleum Exporting Countries said in a monthly report published Thursday.

But OPEC is producing about 29.83 million bpd, even as it significantly outperforms on its pledge to curb output. Earlier this month, OPEC and Russia agreed to extend their agreement to cut by 1.2 million bpd for another nine months, to the end of March 2020. They’ve also been cutting supply by about 700,000 barrels a day more than agreed.

Meanwhile, non-OPEC crude oil supply would rise by 2.4 million bpd next year, as U.S. shale firms pump more due in part to OPEC and Russia’s own efforts to prop up crude oil prices.

OPEC Vs. U.S. Shale

The projected 2020 surplus of OPEC oil could leave the group stuck between two bad choices: keeping output (and in turn governmental revenues low) or pumping more to weaken crude oil prices and try to force U.S. shale players out of the market.

The former strategy could continue to encourage U.S. shale companies to keep pumping, further eroding OPEC’s market share and influence, not to mention government coffers. The latter strategy could also challenge OPEC revenues, while pushing U.S. shale producers to boost efficiency.

When OPEC pushed crude oil prices lower in 2014 to force U.S. shale to cut back, companies used new technologies and techniques to emerge from the downturn as more efficient producers.

Maintaining production cuts with Russia also risks reviving U.S. antitrust action. A House of Representatives panel in February approved a bill that would open up OPEC to antitrust lawsuits over its coordination with Russia on output and crude oil prices.

For now, OPEC members are shielded by sovereign immunity from U.S. lawsuits. The legislation would change antitrust law to allow the U.S. attorney general to sue the oil group or any of its members on grounds of price collusion.

Crude Oil Prices Pull Back

U.S. crude oil prices dipped 0.4% to settle at $60.20 a barrel. Brent crude oil prices lost 0.4% to $66.73 a barrel.

On Wednesday, U.S. crude oil prices spiked to top $60 for the first time in nearly two months, as official U.S. data showed a big decrease in inventories, while a new tropical storm in the Gulf of Mexico threatened to temporarily halt production there.

Exxon Mobil (XOM) stock nudged up 0.1% on the stock market today. Chevron (CVX) stock ended flat, BP (BP) gained 0.1% and Royal Dutch Shell (RDSA) added 0.2%.


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Take-Two Downgraded, Activision Called 'Top Pick' In Video Game Stocks

Take-Two Interactive Software (TTWO) stock fell Thursday after a brokerage firm downgraded the game publisher. The same firm also named Activision stock as its “top pick” among video game stocks.


Jefferies analyst Alex Giaimo downgraded Take-Two stock to hold from buy as he assumed coverage of video game stocks for the firm. He also cut his firm’s price target on the Grand Theft Auto publisher to 115 from 135. Take-Two stock dropped 0.5% to 116.53 on the stock market today.

The valuation for Take-Two stock “feels full,” based on earnings growth forecasts, Giaimo said in a note to clients.

“Despite the undeniable success of Grand Theft Auto and Red Dead Redemption and the long-tail revenue contribution, we believe Take-Two is now in a ‘soft spot’ when considering the timing of the next major release,” he said.

Take-Two faces tough comparisons later this year vs. last fall’s release of Red Dead Redemption 2. The Sept. 13 launch of Borderlands 3 could provide some relief, he said. Meanwhile, he doesn’t anticipate the rumored Grand Theft Auto 6 until fiscal 2022.

New Call Of Duty Game Could Boost Activision Stock

Giaimo named Activision Blizzard (ATVI) his “top pick” in video game stocks. He rates Activision stock as buy with a price target of 56, down from the firm’s prior target of 60. Activision stock rose 1.1% to 47.34 on Thursday.

He sees the release of Call of Duty: Modern Warfare on Oct. 25 as the next big catalyst for Activision stock. The company’s BlizzCon 2019 convention on Nov. 1-2 also could lift shares, he said.

Giaimo also likes social and mobile game publisher Zynga (ZNGA). He rates Zynga stock as buy and raised the firm’s price target to 7.50 from 7.

Conversely, he is down on Electronic Arts (EA). He rates EA stock as hold with a price target of 100.

“While EA’s leading portfolio of sports titles helps provide a degree of stickiness and recurring revenue, the company has struggled in developing consistent non-sports breakout content,” Giaimo said. For instance, season two of Apex Legends has underwhelmed, he said.

Follow Patrick Seitz on Twitter at @IBD_PSeitz for more stories on consumer technology, software and semiconductor companies.


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Natural Gas – The important support level that’s now resistance

  • Inventories continue to build during the injection season
  • The price falls to the lowest level since 2016
  • A new record in stockpiles is possible before the 2019/2020 withdrawal season gets underway- Support is now resistance


Natural gas is one of the most volatile commodities futures markets. Since 1990, the price of the energy commodity traded in a range from $1.02 to $11.65 per MMBtu. 


Many changes have occurred over the almost three decades since the New York Mercantile Exchange introduced futures on the natural gas market. Massive discoveries of quadrillions of cubic feet of reserves in the Marcellus and Utica Shale regions of the United States have expanded the supply side of the fundamental equation. 


Meanwhile, since necessity is the mother of invention, the switch from coal to natural gas-fired power generation and technology have increased the demand for natural gas. 


Technological innovation when it comes to extracting the gas from the crust of the earth and liquifying gas for shipment beyond the pipelines and to destinations around the globe have lowered production costs and increased the addressable market for US gas. 


One of the critical data points that market participants watch each week is the Energy Information Administration’s data on inventories in storage around the US. Inventories build each year from March through November and fall during the winter months, which is the peak season for demand. Prices typically move higher and lower based on the weekly data. 


Inventories continue to build during the injection season


At the end of the most recent withdrawal season in March, the amount of natural gas in storage declined to a low at 1.107 billion cubic feet of the energy commodity.


We were around fourteen weeks into the injection season at the end of June, and stocks were at the 2.39 trillion cubic feet level. The average injection over the period has been 91.64 billion cubic feet. With approximately nineteen weeks to go until November when inventories begin to decline, if injections continue at the same pace, there would be 4.131 trillion cubic feet at the start of the winter season. Last year, stocks peaked at 3.247 trillion, and the previous record came in 2017 at 4.047 trillion cubic feet. Therefore, the rate of injections weighed on the price of natural gas over the past weeks and months. 


The price falls to the lowest level since 2016


In March 2016, the price of nearby natural gas futures fell to the lowest level since the 1990s when it found a bottom at $1.611 per MMBtu. In 2017 and 2018, the low was at just above the $2.50 level, and at the start of the last peak season in November 2018, the price rose to $4.929 the highest price since 2014 when natural gas found a peak at just below $6.50 per MMBtu.


The increases in stockpiles and record production over the recent months caused the price to fall below technical support at the $2.50 per MMBtu level.

Source: CQG


As the monthly chart illustrates, the price broke below $2.50 for the first time since 2016 in April and reached a low at $2.159 per MMBtu on the active month NYMEX futures contract. As the price fell, the EIA reported six consecutive weeks of triple-digit injections into storage. However, over the past two weeks, injections have been below that level at 98 bcf during the week ending June 21, and 89 bcf at the end of the final week of June. It is likely that the report as of the first week of July will also come in below the 100 bcf level when the EIA releases the data on Thursday, July 11. 

After falling below the $2.20 level, the price of natural gas futures turned higher and were over $2.40 per MMBtu as of the close of business on Friday, July 5. 


A new record in stockpiles is possible before the 2019/2020 withdrawal season gets underway- Support is now resistance


If injections keep pace with the average levels since March, we will see a new record going into the 2019/2020 peak season for demand. Even if production and inventory increases slow, the chances of an end of season peak at the four trillion cubic feet level have, grown which took the price to a three year low. 


Meanwhile, the latest EIA data that ended the streak of injections of over 100 billion cubic feet caused a price recovery. However, the support level that developed in 2017 and 2018 is now technical resistance on the upside, which could limit gains in the price of the energy commodity. Natural gas tends to attract many speculators because of its history of wide percentage price moves. Given the price action since March, shorts who took profits when the price was below the $2.20 level are likely to come back on the short side of the market as it approaches what could be significant technical resistance at just over $2.50 per MMBtu. 



About the Author 

Andy Hecht is a sought-after commodity and futures trader, an options expert and analyst. He is a top ranked author on Seeking Alpha in various categories.  Andy spent nearly 35 years on Wall Street, including two decades on the trading desk of Phillip Brothers, which became Salomon Brothers and ultimately part of Citigroup.  Over the past decades, he has researched, structured and executed some of the largest trades ever made, involving massive quantities of precious metals and bulk commodities. Aside from contributing to a variety of sites, Andy is the Editor-in-Chief at Option Hotline.


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Humanitarian Medical Mission — A Cure For Burnout?

I had the opportunity recently to spend a week in Honduras doing humanitarian work, aka medical missionary work. Like alternative medicine, this is something I had a lot of interest in during medical school but as time went on, never did as much of as I thought I might. I spent a month during residency in a rural Mayan village in Guatemala and I went to Chile with the Air Force after their big earthquake in 2010, but that’s about it.

medical mission

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This opportunity came up through the Making a Difference Foundation. This foundation was started by CHG Healthcare, a local company here in Salt Lake City, one of this website’s long-time sponsors, and the company behind locum tenens services you’ve heard of such as CompHealth, Weatherby, and Global Medical Staffing as well as

Like many companies, including ours, CHG decided they wanted to do some good in the world. They had been donating to other organizations for years but basically decided to bring their charitable mission in-house and the Making a Difference Foundation was born. They’ve been lining up a half dozen humanitarian trips a year and invited me to come along on one and even offered to pay my program fee and airfare. Yes, of course, they’re hoping for a little publicity, but I told them that of course if I went on a humanitarian trip I was going to write about it on my blog.

I took a look at the dates, locations, needs, and opportunities and decided to go on a one week trip to Honduras with them. I had two conditions though:

  1. I wanted to make sure they could actually use an emergency doctor. Obviously different organizations go different places with different needs. If the purpose of the trip was to repair cleft palates, that probably wasn’t the right trip for me.
  2. I wanted my daughter Whitney to be able to go along and I wanted her to have something to do. I didn’t care if it was cleaning the floors and stocking the shelves, but I wanted her to have some meaningful work there.

I don’t know that in the end that either of those conditions was really fulfilled all that well, but we still had a great experience and an enjoyable time.

Medical Mission Preparation

medical mission

Showing up to work at the ED

Over the course of four or five months before the trip, there were a few things that needed to happen. The Making A Difference Foundation partnered with A Broader View Volunteers to handle a lot of the details. There was some paperwork to fill out. There was a list of immunizations that were recommended, so we went to a travel medicine clinic. I got my tetanus shot updated and we both took the oral, attenuated typhoid vaccine (which needs to be attenuated quite a bit more in my opinion given how ill I was the day after my first dose). We also picked up some malaria pills. I had to pay $15 for a background check. I had to send them a copy of our passports and my medical license. We had to buy Whitney some scrubs. They also recommended we get some gifts for our host family. And they recommended we bring “at least one bag of medical supplies” and provided a list of needed supplies including the following:

  • Anesthesia — masks, breathing circuits, LMA’s, hyperinflation bags, epidural kits
  • Casting Materials — undercast padding, plaster wrap, casting tape
  • Drainage/Irrigation — irrigation trays, suction catheters, yankauers, wound evacuators
  • Drapes — surgical, exam, single and drape packs
  • Dressings — gauze pads/rolls, elastic, bandages, wound dressings, dressing kits, medical tape
  • Electrodes — EKG/ECG, ESU, EMS, defibrillation, needles/blades
  • Endo/Laparoscopic — staplers, trocars, obturators, graspers, dissectors
  • Feeding — nasogastric tubes, enteral administration sets, gravity bags – NO SOLUTION
  • Gloves — surgical and exam
  • Gowns — surgical & patient
  • Infant — bottles, newborn caps, diapers, birthing blankets
  • IV — administration sets, IV catheters, winged infusion sets, epidural supplies, ext. sets
  • Lab — specimen collection, vacutainers, test tubes/bottles, pipettes, culture media
  • Medical Apparel — scrubs, masks, caps, shoe covers, aprons
  • Mobility Aids — wheel chairs crutches, walkers, canes
  • Monitoring — leads, temp probes, BP cuffs, pulse ox/O2 sensors
  • Needles/Syringes — all types and varieties, sharps disposal containers
  • Nursing Aids — dressing aids, underpads, restraints, anti-embolism stockings, diapers
  • OB/GYN — umbilical catheters, speculums, maternity briefs/pads, umbilical clamps
  • Operating Room — surgical packs, table covers, surgical instruments , towels
  • Orthopedic — post op boots/shoes, braces, slings, undercast padding, splints
  • Ostomy — pouches/bags, barriers, stoma powder/deodorizer
  • Personal Hygiene — body wash/shampoo, toothpaste, combs/brushes, washcloths (all unused)
  • medical tourism

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    Respiratory — nasopharyngeal, ambu bags/resuscitators, nasal cannulas,  endo/trach/bronchial tubes

  • Skin Prep — alcohol pads, iodine applicators, soap, scrub brushes, lubricating jelly
  • Sutures — all types and varieties, wound closure devices
  • Urinary — catheters, catheter trays, drainage bags, skin prep items, specimen containers
  • Medications including:
    • Hypertension: (Enalapril, propranolol, atenolol, aspirin, hydrochlorothiazide)
    • Diabetes: (Glibenclamide, Metformin)
    • Epilepsy: (Phenytoin, phenobarbital, phenotypic)
    • Migraine or headache: (migradorixina, avamigram)
    • Muscle aches: (doceplex, diclofenac, carbaflex, ultradoceplex, dexaneurobion, doloneurobion)
    • Pregnancy control: (Prenatal and folic acid)
    • Constipation: (Fiber)
    • Stomach: (Ranitidine, neogel, famotidine, sertal compound)
    • Antitussives: (Salbutamol spray 0.2% and Beclomethasone spray 0.1.% Tylenol)
    • Antibiotics: (ciprofloxacin, amoxicillin, tetracycline, dicloxacillin)
    • Fevers: (Acetaminophen, ibuprofen)
    • Allergies: (diphenhydramine, Allegra (fexofenadine), brenadryl)
    • INJECTIONS:: (Thiamine, dipyrone, ampicillin, Ceftreaxone, gentaminicin, lisagil sertal compound, Alergil, novalgina, procainic penicillin, benzathilica, distilled water)
    • Cures: (Povidine, gauze, clinical alcohol, hydrogen peroxide, bandaids, bandages, cotton) * Ophthalmic solution

I simply went to the two ED directors where I worked, gave them the list and took what they gave me. Since I packed in about 20 minutes, I’m not really sure what I actually took down there, but it ended up being two large duffle bags of stuff. I’m sure they threw half of it away, which is fine. Take what’s useful and leave the rest, right?

Whitney was in charge of gifts and I also went by the library and picked up a few books on Honduras to read on the plane. It was a good thing we left early for the airport, as I discovered at the counter that I had brought an old, expired passport instead of my current one. My neighbor ran my current down to me and we checked in with four minutes to spare.


The Honduran flag has five stars on it, to signify that they are in the middle of the five main Central American countries (Guatemala, El Salvador, Honduras, Nicaragua, and Costa Rica) that many Central Americans would still like to see united. (Apparently, Belize and Panama are always excluded from that list for some reason.) Honduras is the second poorest in Central America (behind Nicaragua) and has the second highest homicide rate in the world (behind El Salvador).

As we were arriving in Honduras, the front page article in the newspaper was about how the US Embassy in the capital had been firebombed the day before. All of the teachers and most of the health care workers in the country had already been on strike for a couple of weeks because they hadn’t been paid in months and the government was talking about privatizing both industries. While we were there, the Dole Fruit Company had dozens of its vehicles attacked, burned, and looted. Most Americans are aware of the “caravans” showing up at the Southern border. Guess where they all started?

Honduras Medical Tourism

Whitney shares a coke and a moment with a Garifuna boy

Honduran Medical System

Fortunately for us, we were hours away from the capital in a city on the Caribbean coast called La Ceiba. The on-the-ground folks for A Broader View had arranged for us to assist and observe in the public hospital in this city of 3/4 of a million people. There were several reasonably well-equipped private hospitals in town, but I was told that about 70% of the people in Honduras can only afford to go to the public hospital. It was an interesting lesson in socialized medicine and two-tier health care systems.

Medical tourism

Wrestling drunks in the ED, just like at home

There was obviously a fairly inefficient bureaucracy in place. Given my prior military experience, I’m no stranger to large bureaucracies trying to run a health care system, but this was a whole other level. This hospital had a supply budget the year before of about a million dollars. Yes, just one million. However, the administrator had only spent $200,000 for whatever reason. So in classic bureaucratic “use it or lose it” fashion, the new budget was $200,000, leaving them woefully undersupplied.

This isn’t a little rinky-dink hospital either. There would be 30-50 people in the waiting room for the EDs (adult medicine, adult surgery, peds, gyn) every morning when I walked in. It received ambulances with GSWs to the head and multiple motorcycle accidents per day, patients were transferred there from outlying hospitals for a higher level of care, and it had inpatient pediatrics, medical and surgical wards, L&D, and ICU. Orthopedics, neurosurgery, gynecology, and general surgery were all available.

Despite this high-volume, high-acuity patient population, capabilities were severely limited compared to what you and I are used to. I didn’t see a computer in the entire facility. Now, before you laud the elimination of an EMR from your practice, consider the difficulty of practicing without any old records and having to handwrite all your notes and orders.

There were no electronic x-rays, in fact, the only x-rays you could even get were hand x-rays due to limitations of the machine. That’s right, they were running a trauma center without a functioning x-ray machine. Forget bedside ultrasound. Even radiology didn’t have an ultrasound, only L&D did. So if you needed an x-ray, you wrote a prescription for it and gave it to the patient’s family member. They went out and raised the money for the x-ray, raised the money for an ambulance transport, and called the ambulance to come get the patient, take them to a radiology center (usually associated with the private hospitals) and bring them back for further care. As you might expect, this process could take most of the day.

medical tourism

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There was a CT scanner in the hospital, but due to limited parts (a filter of some kind that they only had one of) they only fired it up once or twice a week and batched any CTs they needed to do. Any other CT scans were sent out. Forget MRI. Imagine being a neurosurgeon without an MRI.

If you need labs, the nurses would draw them and give the vial to the family. If it was a lab that could be done at the hospital, they would take it to the lab and pay to have it done. If it could not be done at the hospital, like a troponin, for instance, they took it to an outside lab, waited for it to be run, and returned with the results.

If the patient needed a splint or a cast or an operation and the hospital did not have the supplies needed to do it, the family was given a list of needed supplies (like OR drapes and towels) and sent out to purchase them and bring them back before the procedure would be done. The suture cart had only 0 and 2-0 sutures. Facial lac? Yup, that got closed with 2-0.

Food, bedding, clothing, etc were all provided by family members. Needless to say, if you didn’t have a family member you could be in a world of hurt here. In order to deal with the reality of this inefficient bureaucracy, a black market had sprung up in kiosks outside the hospital selling most of the supplies a patient might need. Capitalism to the rescue!

Medical mission emergency department

Whitney putting on her first cast

It was interesting that there was no shortage of labor. Despite the strike, at any given moment there were dozens of workers in this ED. Granted, most of them were nursing students and the hospital was primarily run by 22-23-year-old interns, but it was interesting that the largest expense in the hospital was not highly specialized labor like in the US, it was supplies.

The pathway to becoming a doctor starts at 16-17 with an 8 eight-year program. 60-70% of medical students are women. There are six years of school followed by an intern year and then a social service year. The social service year was required whether you went to the public medical school or one of the two private medical schools. Your assignment came via a lottery, although if you scored a highly desirable position you might be able to exchange it for something you’d rather do. Those who were sent into a bush village in Moskitania were simply out of luck.

Following those eight years, you were a generalist and could try to get a job or hang out a shingle if you like. You could also apply to do a residency. Both medicine and surgery are three-year residencies. The interns were paid $220/month. The social service docs made $300/month. A resident would make closer to $1000/month and a typical attending would make $2000-3000/month.  Here’s a video where I interviewed one of our hosting docs/translators, Dr. Annette Dyan.  She was just finishing up her social service year.



It was interesting that the doctors knew what the patients needed, they simply did not have it available. For instance, there was one ventilator in the hospital. So a key discussion on rounds each morning was who to put on the vent and who to take off the vent. There was an option to transfer patients to the next larger city, but the family had to arrange and pay for the transfer. They often chose not to, usually for financial reasons. It was interesting to round each morning on a patient with a PCO2 of 110 who wasn’t put on the ventilator until the fifth day of hospitalization. I did her intubation without paralytics. Despite a chip-shot view and a heavy dose of valium, it still proved fairly challenging.

The ingenuity of the staff was impressive. For instance, instead of an EKG machine with little stickers that get thrown away each time, the EKG machine used suction cups. It worked fine. And clearly had been working fine for a long, long time given the state of the wires on the machine, all of which were covered in electrical tape by the time we left. I watched a paracentesis done, quite effectively, with an 18 gauge needle, IV tubing, and a bucket.

It was appalling to compare the air-conditioned mall where you could watch the newest movies, buy motorcycles and big screen TVs and any cell phone you wanted to the state of the hospital. It was really quite a testimony to me of the value of capitalism for solving problems. On the other side of the political spectrum, it was also a testimony of what an inadequately funded Medicaid/county hospital system could look like.

Medical Tourism

Having done humanitarian work in the past, I know it often becomes what I call “medical tourism.” There will always be an element of that. As discussed in the previous section, just seeing how other doctors do things has value and is certainly interesting. But the real goal of humanitarian work is usually to make a difference in the lives of those you are serving. The problem is that medical tourism is relatively easy to arrange and do. Making a real difference requires a lot more time and effort.

For instance, our group included five emergency doctors. We went to assist in an ED in a country where emergency medicine doesn’t exist. There is a medical side and a surgical side. 90% of the time, there is no attending in the department at all, just the interns and perhaps a social service doc. The internist rounds a couple of times a day and the surgeons come when called.

The arrangements of the trip were for the five of us to be in the ED for a few hours a day for five days. But there were no US docs the week before and there weren’t going to be any US docs the week after. So how were they supposed to incorporate us into their system? It was an impossible task.

It becomes even more impossible when you consider the language, cultural, and system knowledge barriers. I mean, how many shifts does it take to get you up to speed in a new hospital in your country? Now imagine that in another country. I speak pretty good Spanish. I studied it in high school, spent two years full-time as a missionary speaking mostly Spanish, minored in Spanish in college, worked as a Spanish translator in a clinic to help prepare for medical school, did a residency 40 miles from the Mexican border and have continued to speak Spanish every week of my career. But I’m not a native speaker and many of the docs spoke even less than I did.

medical tourism

All Work and No Play is a pretty rare humanitarian project

The ideal experience for the “medical tourist” would have been to have come down, been plugged right into their system–teaching, seeing patients etc, have a translator who happened to be a physician who had worked in their system at your side the entire time, and then somehow magically been able to detach from the system, get on the plane and go home a few days later. It just wasn’t going to happen.

So I knew this particular experience was going to lean far more toward the medical tourism side than the “making a huge difference” side of the spectrum. Having done an experience in Guatemala that was much closer to the other side, this wasn’t a surprise to me from the very beginning.

medical tourism

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A “medical tourism” trip is usually pretty short, is fairly vague on the medical work you will actually be doing, and usually focuses on some of the cultural and scenic experiences you will have. The people running the trip usually have a significant focus on you having a good trip and getting the experience you are looking for.

If you are interested in avoiding being a medical tourist, here are five tips I have for you:

  1. Go for a long time. There is a reason that Doctors Without Borders requires a 6-month commitment from most of its doctors. It just takes a long time to make a big difference. It can’t be done in a day or two.
  2. Have a defined project. My neighbor takes his general contracting company to an underdeveloped country every other year and builds them a building like a school or a library. There is a very defined goal and it is clear when it is completed. They take everything they need and leave their tools behind. Many surgical specialties are capable of doing similar work, with perhaps the classic example being the repair of cleft lips and palates, but it is entirely possible to do something similar with vaccines, pulling teeth, or a deworming project. Maybe it is teaching PALS or ATLS or ventilator management. But it is much more likely with a short trip that you will make a difference by having a defined project rather than trying to “help in any way we can.”
  3. Go multiple times. It is pretty difficult to know how you can best help prior to sending qualified personnel who speak the local language and understand the local culture and medical system to check things out. But a second, third, and tenth trip? That is much easier to design to make a big difference.
  4. Make sure you’ll be plugged into the system. As a doc, you’re a specialized labor component. If you want to be part of the system, you need to replace somebody when you arrive and someone needs to replace you when you leave. If you’re an “extra” component, you’re going to find yourself doing a lot more observing and a lot less helping. Sure, you did an appendectomy or a C-section today, but who’s going to do it next week?
  5. Forget yourself and go to work. Don’t focus on your “experience,” but instead on the best way to make a difference and you’ll be more likely to have both a meaningful experience and make a difference.

You might find that you get some pushback when you tell people what you’re doing. This surprised me a bit. It didn’t come from the locals, who were either very grateful for our assistance or at least put on a good show of being grateful. It came from people back home. Apparently, some people find the idea of being a medical missionary as being racist or colonialist or something. Here’s an example of a tweet sent my way:

medical tourism

So be prepared for that.

A couple of parts of the experience that I was looking forward to was living with a host family and going out to a rural area. Unfortunately, both of those portions of the program had been eliminated when I arrived. We stayed in a hotel (air conditioning and a shower every night) and rode an air-conditioned bus to the air-conditioned hospital each day. Medium-adventure at best there. The “medical brigade” to a rural area was also canceled, in part due to the political unrest but mostly just due to the fact that the vaccines we were going to give there never arrived.

We did some touristy stuff too–a barbecue at the beach, a visit to a chocolate farm, and a snorkeling trip on the last day. It was fun, of course, but not the main reason I went on the trip. I think that’s pretty typical for most week-long humanitarian trips.

We made some great friends, both with the people on the trip with us and our local hosts and translators. It was amazing how close you can get to people in such a short time period.

Don’t Forget Your Deduction

Remember that your travel expenses to do humanitarian work and donations are tax-deductible as long as it is run through a US 501(c)3. You can’t deduct the value of your time, but you can deduct your airfare, program fees, mileage, etc.

Busting Physician Burnout

I think humanitarian work can be an excellent antidote to burnout. Spending time in an underdeveloped country always makes you grateful for what you have. Inserting yourself into their medical system makes you grateful for your wonderful job.

In my first shift home, we had a trauma patient come in. How grateful I was to have an x-ray tech, a CT tech, experienced nurses, lab techs, and a respiratory therapist at my side to greet them! An hour later, the patient had been given medications and I had results from CTs and x-rays and was ready to disposition the patient. The nurses were complaining about not having baby wipes in the ED and having to call central supply for them. I was just happy to have all the disposable gloves I wanted to use.

Doing some humanitarian work, even if it ends up being mostly medical tourism, is a great way to remind yourself of why you went into medicine in the first place. You will probably find that just like you wrote on your admissions essay that you really do “like science and want to help people.”

Now, I can’t say I have any significant amount of burnout from my clinical work. It’s hard to get burned out working eight, 8-hour, day/evening shifts a month. If I have burnout from anything, it’s from WCI work. But I left my computer home on this trip and didn’t do a thing with WCI for 8 1/2 days, the longest period I’ve gone since starting 8 years ago. It sure was nice to have a siesta and not feel like I should be checking email, creating content, or promoting the business.

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As mentioned earlier, one of the main reasons I went was to have a great shared experience with my daughter. I wanted her to be exposed to a foreign culture and language, medicine (her expressed career interest), and economic hardship like she has never known. I think it was a success in that regard and hopefully, she’ll write up a column about her experience that we can publish soon.

What do you think? Have you done any humanitarian work? Why or why not? What tips do you have for someone considering a trip like this? Comment below!

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“Tax reform is a crucial component of the @UniteThePoor campaign for three key reasons” says @shaillybarnes @Kairos_Center

✅Current system is unsound
✅Fair-share taxes fund needed investments
✅Morally right thing to do

#TaxTheTop #TaxTheRich

Watching keynote inspire19 talking about tippingpoints and how education investments done like creation of a soccer team make a much bigger positive impact. Total contrast to basketball

RT @LisaMartinTV: Watching @Gladwell keynote @Coupa #inspire19 talking about #tippingpoints and how #education investments done like creation of a #soccer team make a much bigger positive impact. Total contrast to #basketball