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.

This is all about work email. I have succeeded in transferring most personal communication to Slack, iMessage, and WhatsApp, with a sprinkling of Skype for the grandparents. The sole holdout is Dad, who insists on emailing me links to Serbian tabloid news, child rearing advice, and recipes.

Inbox Zero is a great idea in its original form: live you life and write your emails in a way that solicits as few return emails to you as possible. It means giving some thought to what you put in your responses, and being clear and definitive about them. It doesn’t mean mindlessly deleting or archiving everything or, even worse, sending out half-baked replies just to pass on the baton when you’ll get a dozen of them in return.

I only check email twice a week day and once on a weekend, and with the explicit intent to clean out the inbox (unless when on service or when I’m the primary attending for a sick inpatient). Never check email “just to see what’s there” unless you have the time and the means to do something about whatever you’ll find. More than once in the past I was left to sour over an unexpected administrative roadblock or a non-urgent patient care calamity during a family event, when I could have just as easily waited for Monday morning.

When scheduling meetings: Doodle (or your preferred equivalent) for more than three people, email is fine for 1 or 2. If using email and I’m scheduling, proposed times, location, and a tentative agenda are all in the initial email. If I’m responding to a meeting request I try to put all of those in my reply, but that also depends on who’s requesting.

I thank in advance, not after the fact, and rarely send emails whose sole purpose is to give thanks.

If I get an unsolicited and unexpected email from someone I don’t know but that’s not obviously a mass posting, I wait for the second one. Most times it never arrives.

If the email looks like it came from a template it gets deleted without being read.

If I am cc’d on an email chain with many recipients and not directly called out, I archive and wait it out. The only exception is when I know that one or two replies from me would be able to end the game of email chicken that these chains tend to become.

The few times that I didn’t follow these guidelines, I came to regret it (confirmation bias warning!). I’m sure plenty of people don’t give it a second thought and go by just fine. But they probably don’t work in health care.

Update: Out of Office messages are equally important, and covered well here. My own recent OoO message was as explicit as it could get without using profanity, and hopefully conveyed the sentiment that no, I won’t be checking messages at all.

Also, this is happening:

Or it may happen, eventually, when I get to it. Probably close to the trial expiration date, if ever.

Sigh.

This website is:

• a public repository of articles, lectures, and other original works I authored or co-authored;
• a place to repost comments, reviews, and recommendations I wrote on other sites (like Quora, Amazon, etc);
• a place where my half-baked ideas and philosophizings go if I think them interesting enough for general consumption.

This last one is what gives me trouble. Ideally, if I think a topic is worth writing about, I should make the extra 3-day effort to gather references, edit it nicely, and have it published. But like the character in “The bridge on the Drina” who means to be the town chronicler but can never find an event worthy enough to write about, most subjects have me less excited the more I think about them. By the time I finish a blog post, then, I have no intention to revisit the matter.

This is an excellent filter against appearing foolish in print, but horrible for productivity.

Two solutions come to mind readily, with equal chances of failing—either stop posting the third category of articles altogether and start writing everything with an intention of publishing; or start writing even more with the hope that at least a small percentage of that will turn into something a journal would accept for publication.

The former is a set-up for procrastination, the latter—doing extra work in a hope to create material for even more work—oxymoronic. I will try both and see where I end up.

Two years ago, I haplessly expressed excitement about my task list manager of choice being updated soon.

Speaking of @culturedcode, looks like Things 3 is progressing nicely. Hope “more structure” is code for dependencies. pic.twitter.com/ctwycDyL1e

— Miloš Miljković (@Miljko) February 2, 2014

It hasn’t yet. Two iterations of iOS and an Apple Watch later, Things 3 is still not available, and I am becoming increasingly annoyed. Inside my mind, two kinds of costs—Ms. Sunken and Mr. Opportunity—are battling it out.

Mr. O has me thinking about time wasted on not being able to turn a next action into a project; or having to make too many taps to edit anything in the iOS app. And then I stress out even more contemplating all the features I don’t even know I’m missing out on—not wanting to find out about those is why I not dare read reviews of the competition.

Ms. S, meanwhile, is raising dread whenever I thinking about moving to Omnifocus, Taskpaper, or whatever the GTD app du jour is—knowing that I would be trading a set of known deficiencies for a potentially grater set of unfamiliar ones.

The mister and missus are irrational beings—even though Things 3 remains vaporware, there have been a few 2.x updates that iOS7-fied the experience—from going flat to adding extensions and notification center widgets. All that considered, I should not spend so much time thinking about an app.

And yet, it is 6pm on January 2, 2016, and instead of writing about getting back to the lab, finally finishing the PhD thesis, or being a haughty gastro-tourist in unseasonably warm New Orleans, I am being much too first-worldly for my Balkano-Serbian comfort.

Which I will add to the pile of absurd reasons for why I dislike Cultured Code.

Shonda Rhimes on work:

Work will happen 24 hours a day, 365 days of the year, if you let it. We are all in that place where we are all letting it for some reason, and I don’t know why.

Via Cal Newport’s blog.

Helping out Georgetown University fellows with their oncology consult service for a few days reminded me of how important it was to have at least three good pens with you at all times. By that, I don’t mean grabbing a handful of disposable Bics from a Staples shelf just because you know you will lose a lot—though you should certainly plan for theft and absent-mindedness. There are at least three different use cases you will face daily, and no pen will be ideal for all of them. I’ve tried out enough, and listened to plenty of podcasts on the topic, to be happy with my choices.

Role 1: The task keeper

• My choice: Zebra Sarasa Push Clip Gel Ink Pen, 0.4 mm black
• First runner-up: Uni Jetstream Standard Ballpoint Pen, 0.5 mm black
• Honorable mention: Zebra Sarasa 3 Color Gel Ink Multi Pen, 0.5 mm

Intern or fellow, this will be your most-used pen—the one you pull out to quickly jot and check off to-dos, make note of pertinent lab values and vital signs, and write down other important bits of information. If you are anything like me or my colleagues, you will be doing this on the signout, or some other piece of paper packed with information you might need.

This is why your pen should be:

• as thin as possible, since you’ll likely write on the margins, but
• not too faint, so it wouldn’t blend in with the rest of the text,
• quick to use, since you’ll have to pull it out during rounds, patient encounters, and other situations in which fiddling with the cap would lead to losing both time and the cap, and
• affordable, since you will misplace one every couple of months.

For the first two, the Uni Jetstream wins hands-down. The tip is as smooth as a 0.5 mm can be. It doesn’t skip, spill, sploch, or splat. The price is right—just $2.99 on jetpens.com. It is the best-in-class for every thing save one.

Zebra Sarasa Push Clip is not too thin, but thin enough to be scratchy and slightly annoying. Even with that small flaw, I choose it before the Jetstream. Because of the clip. The wonderful, magical clip.

You see, after four years of rounding, the act of pulling out a pen becomes a reflex. You hear something important, you have a thought, you blink, and you have a pen in one hand and your Very Important Paper in the other. You write something down, you blink, and your hands are free again. You are one with the sign out, and the pen.

To do that, you must at all times know where those two things are. The Very Important Paper is hard to miss, but the pen needs to be not just in the same pocket, but in the same spot in your pocket at all times. For me, the whitecoat-less fellow, that’s the inside of my left front pants pocket. This requirement rules out any clipless pens—goodbye, disposable Bics—but the regular clips don’t fare too well either. Too tight a clip, and you spend too much time fiddling it into the spot you want. Too loose, and it’s easy to put in, and easy to lose.

Which is why the clip is magical. You open it wide on entrance, and clamp it shut once you have the pen where you want it. It won’t budge after hours of walking up and down the hospital stairs. And, unlike one of my Jetstreams, it will be very difficult to break.

Alas, it only comes in one color. This is enough for the mild-to-moderate inpatient workload of a fellow, but during internship I needed the typical gunner pen to stay organized. Zebra Sarasa 3 is the high-end guner pen—one color fewer, but with the Zebra clip. For me today, it is just too bulky, I default to black anyway, and I’d just get annoyed with it running out way before the other two. But for me four year ago, it would have been perfect.

Role 2: The note writer

• My choice: Ohto Graphic Liner Needle Point Drawing Pen - 02, 0.5 mm black
• Runner-up: Pilot Petit1 Mini Fountain Pen - Fine Nib, any colour

As much as I appreciate the ammount of writing I can cram onto a sign out with a thin pen, using one to write in paper charts, or for making notes on an old H&P while seeing a patient, creates an unreadable mess. The faint black lines of your pen blend in with the small type and the gray ruled lines of the progress note. Also, you don’t need as quick an access—a morning note-writing session may seem hectic, but you are the one who initiates the process. A couple of seconds looking for the pen or opening the cap won’t make you lose any information.

The Ohto liner leaves a consistent, dark line, lasts for ages, and is the right size for me. The ink is water-proof and archival safe—which is what you want for a medico-legal document. There’s a cap you need to worry about, but I’ve yet to lose one. And at $2.50 it won’t be the end of the world if I do.

This role can also be filled by a nice fountain pen—and you’ll see some attendings using one. I have had horrible luck finding a fountain pen that I won’t be afraid spilling in my bag or pocket, and most cost too much to carry around the hospital while sleep-deprived. The Pilot Petit1 pens have the right price, nice nib, and are easy enough to use. But I’m still too scared to put it in my pocket.

Role 3: The backup

• My choice: Uni-ball Signo DX UM-151 Gel Ink Pen

This is the one you sprinkle around the house to be there just in case. The one you give out to friends and colleagues. And the one you use if you lose any of the others. If you needed to have just one pen, this would be the one, since it’s both thin and dark. Not perfect for either notes or task lists, but good enough.

At slightly less than $2 per pen it is afordable enough, though if you just want something to give out to others—and don’t care about them or their fingers—you can get a box of 60 horrible little stick for the price of three Signos. I guess you can give those out to your enemies and watch them writhe in pain and frustration.

Bonus: A pencil case

My choice: Kokuyo Will Stationery Actic Mini Pencil Case

This is entirely optional, but it saved me a surprising amount of time. It comfortably fits 4-5 pens and refills, and has good build quality. If your bag is small or you don’t mind fishing around for the pen you want, you can certainly do without it.