It took me a while, but I finally got it: The Road Not Taken is not about individualism and thinking different(ly), but rather about the narrative fallacy, hindsight bias, and contemplation of the counterfactuals. Brilliant.

Pre-weekend reading: How to nurture a personal library. Just lovely.

Miško (Mouser) the cat, living up to his name.

A brief experiment with Drummer reminded me how fun it was to write short, untitled, tweet-like posts throughout the day without having to be exposed to social networks. Drummer itself was too high-maintenance for the 2020s me, but Micro.blog is a (paid) service whose focus is — and the name does give it away — short, untitled, tweet-like posts with a light layer of social networking.

Which is to say, my old domain is now resurrected as a micro blog with a snazy Edward Tufte-inspired design. The RSS you get there should include updates from this blog, so subscribe to either but not both.

Drummer is an online outliner that enables quick, easy, and near real-time posting of text both long form and short — what we used to call blogs back in the good old days of two years ago. Dave Winer created it for his own purposes, but it works beautifuly with just your Twitter account as a login. Here is my page.

As things are still very much in progress, Dave recommended doing daily backups. Sadly, I didn’t, and as of today’s updates a few weeks' worth of half-baked notes are wiped out from the Drummer server (but thankfully not from the website they helped create). That’ll teach me.

Since posting to that page is on hold until everything is back in order, expect more — dare I say daily — updates here. Managing markdown files is not nearly as intutitive or pleasant to use as Dave’s outliner, but he seemes to be working on an OPML to markdown converter. That will be well worth the wait.

• 1994: Fifth grade; I am charged with editing the school newspaper. There is an Intel 386 PC at home that is about to be upgraded to a 486 and do something more than run Lands of Lore.
• 1996: Seventh grade; I typeset a book of poems¹. The school newspaper becomes the school magazine — in layout only; the publishing schedule remains haphazard — as I upgrade from Word 6.0 to QuarkXPress
• 2000: High school starts again after a freshman year interrupted by NATO bombing. I make the town library’s official website. It is a php hack job laid out in tables instead of the newfangled and to me unknown CSS; it still wins an award.
• 2002-2008: Med school; I typeset a book here and there and occasionally help out with the library website.
• 2009: Teaching assistant, Institute for histology and embryology, Belgrade School of Medicine.
• 2010: Resident, Internal medicine, JHU/Sinai, Baltimore MD.
• 2013: Chief resident, Internal medicine, as above; I understand the benefits of not being invited to a meeting.
• 2014: Clinical fellow, hematology/oncology, National Cancer Institute, Bethesda MD.
• 2016: As above, but also Chief fellow ex tempore for the joint NCI/NHLBI fellowship; my hatred of poorly-run meetings intensifies.
• 2017: Staff clinician, later to be renamed Assistant research physician, Clinical Trials Team, Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda MD; the 1994 me marvels at the word salad trailing the title.
• 2021: Chief Medical Officer, Cartesian Therapeutics.

It is easier than ever to organize and attend a meeting, which should scare the living daylights out of anyone who doesn’t organize or attend meetings for a living. It used to be that only middle management had to deal with a series of 90-minute meetings all 15 minutes apart in which they had no specific role, which had no effect on their task list, and which left them no better off than they’d be if they had just read the minutes.

We are all middle management now.

My own experience with middle management was during chief residency and I learned quickly that the more administrative aspects of it just weren’t for me. But I also learned a few coping strategies, modified below for the video conferencing age.

• A short ad-hoc meeting is better than a long email thread. Email is a brilliant technology, but it just wasn’t meant for frequent back and forth between any number of people. It always amazes me when someone sends an email with five direct recipients and ten more addresses cc’ed, and then expects to have a productive conversation. ⊕ I believe Cal Newport wrote a whole book about this issue which is in my ever-growing To Read pile so this will remain just a belief for the foreseeable future. Pre-2020 the excuse would have been that everyone was too far apart to attend a meeting, whether in another time zone or in a different building on campus. No longer.
• A short standing meeting is even better than an ad-hoc one. Few things in any line of work need someone’s immediate and undivided attention. Issues can usually wait: if one project is on hold because a decision needs to be made, there will be others to work on. If they can wait a full week, why not batch them and bring them up with your boss/employees/co-workers/contractors at a weekly meeting. If they can’t wait for more than a day, make it into a short daily meeting held at a set time. We have these meetings all the time in medicine — we call them rounds, and they have worked well for more than a century.
• Frequent short meetings are better than infrequent long ones. Setting one up used to be hard logistically: from booking the right sized room on time to making sure the timing works out for everyone — not to mention having to include a buffer for getting to the conference room and setting up AV. With that much overhead for a meeting of any length, of course the default was at least 60 minutes, if not a full hour and a half. Now even a 90-year-old can tap a link on their oversized phone to log onto that Zoom meeting while quarantining at home. The negligible cost of starting a meeting may mean they are more frequent, but it should also make them shorter. Much shorter.
• One day full of meetings is better than all five weekdays broken up with just a few per day. When in meeting mode, it takes me at least 30 minutes to get my bearings back to doing other work. Mode switching is a fixed cost and it’s best done infrequently. I therefore have a day dedicated to meetings, and if I have any say whatsoever in when a meeting will be held I try to do it then. Wednesdays. If you need to have a meeting on a different day, try to have it as a bookend — morning and afternoon rounds are a good example of this.
• Finish off a meeting with a task list and the designated person(s) for each task. You will probably have missed something, but that’s OK since you’re still at the meeting and others can fill in the gaps. Send off that list as an email to all attendees. Congratulations: you are now the meeting’s Most Valuable Attendee. If the meeting ends without anyone being able to come up with a single task, it should not have taken place. ⊕ This excludes staff meetings mandated by this or that accreditation agency, which turn into venting venues by design — though even then the tasks should be to set up smaller, more meaningful meetings to deal with concrete issues that may be brought up.This is an important lesson. Take note of whomever called the meeting and try to avoid attending their meetings in the future.
• Bonus tip: If you are setting up a one-on-one meeting with me, and you are the one sending out a calendar invite, do enter both of our names ⊕ My default name for those kinds of meetings is just “Milos <-> Person 2”. in the meeting title. I have too many meetings with myself on the calendar and it’s getting hard to keep track.

If you liked this, you may also enjoy my lukewarm take on handling email.

There is a crisis in medicine, but not the one you think: ⊕ And not only in medicine, of course.

I have a folder called Articles for them on my desktop. Which never gets opened. It is a like a black hole.

— Venkatraman Radhakrishnan (Venky) (@venkymd) November 15, 2020

90% of what I do on Twitter is email myself interesting articles I see Tweeted only to never be read.

— Aaron Goodman - “Papa Heme” (@AaronGoodman33) February 25, 2021

Reading primary literature is superior to press releases and tweets — it sounds so obvious, but not many physicians act on it. There no prizes to be won for not just following the KOLs[^kol], ⊕ Key Opinion Leaders, the influencers of medicine before influencer became a real noun. Note that unlike the influencers of social media KOLs don’t use the #sponsored hashtag, though there is a hashtag equivalent. nor do you save any time. Quite the opposite: instead of a promoted tweet about the me-too drug de jour falling into your lap, you need to find a way to identify what’s worth your time reading, and also find time to actually read it — not a small achievement, as highlighted by the above tweets.

But then what? Sure, there is profit at the end of the rainbow in the form of useful knowledge, but merely reading a PDF may not result in any knowledge at all, let alone knowledge you can use. Or, as the [underpants gnomes][gnomes] would put it:

I too had a backlog of unread PDFs once, spent so much time organizing files and folders, using this and that program to store the metadata, ⊕ NB: if you write any sort of scholarly texts you will still need a reference manager, no matter what system of organizing PDFs themselves you choose. I recommend Zotero, lest your institution has a requirement for Endnote (which must have quite a salesforce, to so thoroughly insert their buggy, laggy, slob of a program into every academic crevice). trying out plain paper, a Kindle, an iPad or two, thinking it is how I was reading them that mattered and oh if only I could find the perfect setting, under the shade of an old oak tree perhaps, with some peace and quiet, a pen in one hand and a cup of coffe in the other, well, then the unread pile would melt away and all would be good in the world.

But reading is easy, if what you read is useful, entertaining, or both. For most people without visual impairments or dyslexia, the log jam is at Step 2. We don’t want to read our pile of PDFs because, in most post-GME circumstances, there isn’t a clear goal to reading them (lest you have superhuman memory). The clear exception here being board exam and MOC prep, where the goal is obvious and the sources of information are all spelled out. This is particularly true early on in your carreer, when you have nothing to hang your hat on mentally, and few connections to make between what you are reading and what you already know. Sure, you don’t need to keep track of the articles you’ve read if the only reason for reading is to pan them on Twitter. You do, however, want to summarize what you’ve read and save it for future use, be it in a lecture, article, grant proposal or a blog post. So if and when you find a fairly obscure but potentially important fact about this or that cellular pathway in a supplemental figure from a CNS-adjacent journal, and you memorize the fact for later use, and then a year or so later you do use it to make a figure for the background section of a clinical trial protocol, well, what you do not want happening in that case is to spend hours of your life trying to retrace your steps and figure out the original source when a fellow ⊕ Yes, this has happened to me. We do have good fellows. asks where you got the data.

I wouldn’t be admitting to all that if I didn’t think I’ve found a solution. A few years ago, I replaced the unsustainable routine of just-in-time literature reviews for whatever I needed done with a robust knowledge management system — a GTD® © David Allen Co. 2001. It is a good system though. for ideas, if you will. It got to a point where I can read at least one article every day and skim a few more, get the useful information out and into my app of choice ⊕ The app of choice before DEVONthink was Roam, which is a web service and a marvelous one at that, but unfortunately not much into encryption, privacy, and other things people dealing with confidential information like to have in the tools they use., and have all the information I need to write an editorial like this in a morning or two.

As with most of the things I do it is too personal and Rube Goldberg-y to be of use to anyone else, but it started with a forum post and a book, and if you’d like to turn your plate full of PDFs into something more usable may I recommend that you start with one or both of those and see how it goes. Could it be any worse than what you’re doing now?

Everyone loves Ted Lasso, both the character and the show, in great part because he manages to be funny without being sarcastic. It reminds me of what made Frasier so good: that the writers never took the easy jokes. Smart humor is hard, smart humor without sarcasm is even harder.¹

The past few years have made me sarcarsm-intolerant. I can still appreciate professionally done satire — Stephen Colbert of the Colbert Report years comes to mind — but you, my Twitter friend, are no Stephen Colbert. Good satire takes some effort to create, but is easily understood. Casual sarcasm is the opposite: it is easy to say or write what you don’t mean, but recognizing sarcasm requires knowledge of the context, the author’s prior writings, the subject in question, and even then, often, it is missed. Queue the author’s indignation and musings on how the Twitter sheeple can’t recognize a joke, though sometimes the indignation itself can be self-consciously funny.

Uh oh, I guess I better be able to prove real fast that I was doing work on bats a few years back.... pic.twitter.com/abkBX2z0Xl

— Vinay Prasad MD MPH (@VPrasadMDMPH) May 17, 2020

The exchange above was notable for erecting a barrier between people who some time ago would have considered themselves part of the same ingroup. ⊕ Yes, ingroups of days past still had factions and civil wars, but what used to be confined to the university cafeteria or the sparsely attended conference session is now right there for the world to see, and pile onto. Somewhat paradoxically, meatspace barriers are as ephemeral as an academic’s memory; online barriers, while not set in stone, are quite a bit more solid. The algorithm remembers. If there is one thing sarcasm does well, it is to erect barriers between smaller and smaller groups until everyone is at a war of wits with everyone else. It turns a tool of communication capable of spreading great knowledge quickly into a French court-style spectacle for the masses, fueled by the algorithm.

Dropping sarcasm would not make the internet excruciatingly boring. Note @10kdiver of the Markov chain thread from the paragraph above, or @wrathofgnon, @Gwern, @craigmod, @BCiechaowski… all brilliant, not an ounce of sarcasm between them (half an ounce from Gwern, perhaps). There is in fact an infinite number of ways to be interesting online without being sarcastic, and sarcasm itself permeates the online life so much that it is, well, boring.

Offline, the distinction blurs between being sarcastic and having plausible deniability. Sarcasm may be the highest form of intellect in teenage years, where plausible deniability helps save face, but before the end of adolescence saving face quickly turns into gaslighting. Small wonder that the most sarcastic character on Friends was also the one to catfish a woman. This is also one of many reasons why Friends will never be in contention for the best of anything, except maybe the best show to reveal the 90s to be the backwards decade it truly was. So if there ever was a quick and easy litmus test, it is this: after the horrible year we’ve had, and a decade that was not much better, whom would you rather hang out with and who would you rather be: Ted Lasso or Chandler Bing.

The decade in which one’s three children are born will have to rank among the best ones ever, no matter what else happened. But then add marriage, a move to America, completing 25 years of training, Thats 8 years of elementary school, 4 years of high school, 6 years of medical school, 4 years of residency — Chief year included — and 3 years of fellowship. getting a dream job, becoming an uncle — twice — and not to forget, starting this blog, and, well, it is hard to imagine things getting any better.

So yes, it has been a good ten years. Certainly better than any other ten-year span I’ve had. A good test would be imagining the ten-year-ago me learning the outcome of the single decision he’s made back in 2008 to go for residency training in the US of A instead of a PhD in Germany, and I’m not one to pee their pants from excitement but I do imagine myself coming close, even without knowing the counterfactual.

Is America the greatest country in the world? It was for me, at the time, even as a visitor Or rather a nonimmigrant alien of extraordinary ability, for now.. And it may continue being so for decades to come; I don’t see any competitors coming close. ⊕ And I’m looking.