Posts in: tech

And the day is off to a great start!

I have heard nothing but good things about the Playdate, save for the screen not being viewable under direct sunlight. Good thing it will be a wet, cold October in DC.

Playdate: your order is on the way!

Orange tabby cat wearing a crown: Stable Diffusion running on a meager M1 versus Midjourney running on who knows what. Either way, the visual arts will never be the same.

Goodbye, Drummer (for now)

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.

Blogroll

I, for one, am glad that blogs are making a comeback. Here are a few I’ve been reading for at least a few months, many of them for years, some for decades.

Applied philosophers

The only true philosophers of our time.

The new scientists

People without major academic credentials who have interesting ideas about science.

The old scientists

People with major academic credentials and interesting ideas, something to teach, or both.

The ludites

People against modernity of one sort or another.

People doing their own thing

Unclassifiable but exhilarating.

Apple enthusiasts

Some tips, a few tricks, many opinions.

Finance-adjacent

Economists and investors, for the most part.

Journalist-cum-substackers

Former or current journalists who now earn some or all of their living by writing newsletters via Substack, which is slowly reinventing blogs (in the sense of reinventing the wheel, not actually making them better and in fact in many was making them much worse).

Company blogs

For when I really want to know when the next update is coming.

How I handle email (which is not how everyone should, but you may find some of these useful)

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.

A few unpopular (in certain circles) opinions from a person who has no rights having them

For better or worse, the American system of government is strong. Those who say otherwise have a financial interest in people thinking the opposite.

Culturally, US has more similarities with Iran than with Saudi Arabia, even if you count religion and religiosity as part of culture. The Christian right is working hard to make them even more similar.

Though still quite hard, it’s easier for a high-skilled immigrant to come to America than to any other country in the world. Comparison is even more favorable for low-skilled and unskilled immigrants. For all of them, quality of life, acceptance, and protection they get are better than anywhere else.

The randomness of the Green Card lottery process is a feature not a bug.

Reading the non-fiction sections of The New Yorker, The Atlantic, and whatever their conservative equivalents are, is good for generating fake insight but ultimately pointless. The Economist is useful for a tiny segment of the population but lets be real: if you’re reading this you are not it.

The only useful section in the daily newspapers is Local. Maybe Sports, if you are into that sort of thing, but professional and college sports are a scam so stick with the amateur leagues.

TSA agents and airline personnel are nice people but some passengers check out their brains at the curb and make everyone’s lives less pleasant.

Apple hardware products are underpriced for what you get but do you actually need what they offer? This doesn’t include the AirPods, which are the best thing Apple has made in the last 20 years and still underpriced; though they unfortunately resemble in both name and appearance a mind control method from Doctor Who S2 and paired with a smart phone are not far from it.

The world doesn’t need another IPA. America needs more tripels.

This is all coming from a non-immigrant resident alien with no expertise in politics, international law, transportation, or technology. I do know beer though.

Apple’s App Store rules, Dosegate edition

Now they are coming for the doctors (see What’s New in Version 3.0.5). The makers of MedCalc, the best medical calculator app out there, explained what happend in detail. Seeing that URL made me appreciate the developers even more. This was the rule they were supposedly infringing:

22.9 Apps that calculate medicinal dosages must be submitted by the manufacturer of those medications or recognized institutions such as hospitals, insurance companies, and universities.

Nevermind that many doctors view themselves as institutions—this is an idiotic rule. Is University of Baltimore, which has no biomedical science courses or programs, allowed to publish a drug dose calculator? Is GEICO?

The FDA has issued guidance for mobile medical apps. It specificaly allows calculators that use generally available formulas, and forbids apps which calculate radiation dosage, but does not mention drugs. Where, then, did this rule come from?

It is, of course, the same App store rules that allowed these pearls of quackery.

It’s madness, and it’s maddening.

Three tech tips for new interns

The new intern class starts in less than a month. It’s easy enough to find advice on how to be well-organized, efficient, and likable. Here are some more tech-oriented tips I wish I knew back when I started.

Take photos and videos, with permission

Get an iPhone. Turn off Photo stream, or download a camera app that doesn’t automatically upload to it, like VSCOcam. When a physical exam finding is rare, stumps you, or is just cool to see, ask the patient about recording it. If you see an interesting or rare radiography image, save it. But please remove all personally identifiable information.

Useful for: appearing smart on rounds, observing disease course, creating informative slides, posters, and written case reports.

Keep track of things you are interested in

Your EMR will have a way to create custom patient lists. Use it. If you are into hematologic malignancies, eosinophilic esophagitis, MODY—or anything, really—keep track of all your patients who have it. If you don’t yet know what it is, keep a list of all the patients you found interesting and try to find a pattern.

Useful for: getting ideas for research and quality improvement projects, figuring out your career path.

Do not copy forward, copy/paste, or use templates and macros

I started my internship in 2010 so I can’t believe I’ll write this, but—back in the day before EMRs, we wrote our progress notes and H&Ps by hand. This meant reviewing the med list, vital signs, and labs each morning and writing down only the important stuff; completing and recording just those parts of the physical exam that had to be done; and writing a new assessment and plan each day. Well duh, isn’t that what interns should do?—you might naively ask, until your second or third day on the job when a helpful senior resident shows you how to shave minutes—minutes!—off your note-writing time by using some variant of copying forward, templates, or macros.

These tricks are a mental crutch, and a known cause of documentation errors. They might help your handicapped intern self the first few months on the job, but will then prevent you from thinking about what you are doing and writing. A thoughtful daily review of everyone’s medications and labs will turn into a quick glance over a two-page long list of 10-point single-spaced Courier New. Also, your typing speed will never improve if you only document by clicking.

Useful for: being a good, thoughtful doctor.

If you have a Google+ account—and you might not be aware that you do—anyone using Gmail can now email you without knowing your address. You can disable this “feature” in the settings, but having it be opt-out shows yet again how little Google cares about privacy.

Not that there’s anything wrong with that—privacy is a relatively modern invention that younger generations might not care for as much as we do. But you should understand the implications of patients and random strangers being able to leave messages in your personal inbox. Suing doctors is not a modern invention.

This is why I stopped using all Google services—search included—years ago. The company has become so large, with so many users, that it doesn’t need to cater to fringe interests. And for a business with billions of users, doctors are a fringe group—one that hates change-for-change’s-sake, having to re-learn an interface “just because”, and not being the true customer. This one in particular, as it keeps reminding me that doctors are second-class citizens in the tech world. Electronic health records are made with the billing departments in mind—we are there to provide content. Google services are created to sell adds—we are there to provide eyeballs.

Also, the number of people at Google who may access my data is huge. FastMail Yes, it’s an affiliate link., my email provider of choice, has fewer than 10 employees. Gmail alone has hundreds. Not that anyone would be interested in me in particular, but if I ever inadvertently send or receive private patient information through my personal account, I’d rather as few people as possible see it.

Email is fine, but why abandon search? First, I have googled enough ailments and substances, common and obscure, that the add network thought I was an elderly female recovering heroin addict with more than one paraphilia. The adds I would get were in that sense appropriate. Second, because of SEO the only valuable page-one results I would get were Wikipedia entries. Everything else was a hodgepodge of useless Livestrong, Huffington post and five-pages-per-500-word-article-AND-behind-a-login-wall Medscape links. Duckduckgo and, yes, Bing at least help with the first problem while not making the second one any worse.

Google calendar is the only service I would consider using. It is fast, reliable, omnipresent and easy to use. There is, however, that constant nagging fear that they will find some way to integrate it with Google+ and yet again sacrifice functionality to force people into its circle. This is why I use Apple’s iCloud calendar, its horrendous web interface and all.

Also: Reader. I use FeedWrangler now, but man.

Doctors' concerns aside, Google is all set to become the network TV Or Microsoft. of the internet—large, bland, and largely not relevant to the people who are. It is already two-thirds of the way there.

Two podcasts, three doctors, one good show

In the last two months, two of my must-listen podcasts, Systematic and Mac Power User, have had medical professionals on as guests. I don’t usually listen to medical podcasts—Twitter and saved PubMed searches are big enough firehoses—so I thought it would be interesting to hear how my more experienced colleagues use technology. Two of the three episodes were underwhelming, one was stellar.

It started with Brett Terprstra and Dr. Pamela Peeke on Systematic. She has several books targeted towards lay public, and the episode went in the same vein—broad advice on nutrition, well-being, etc. I cringed more than once, but that was to be expected—public health information relies on overplaying the risks and simplifying facts to the point of absurdity. Much like weather forecasts. The one thing I could agree with was how important meditation can be, as mindful meditation might decrease physician burnout. Negative points for not mentioning Mindfulness in Plain English as essential reading, though I haven’t read Dr. Peeke’s own recommendation, The Miracle of Mindfulness.

I had higher hopes for Episode 169 of MPU, since Katie Floyd’s and David Sparks’s guest, Dr. Jeffrey Taekman, has an excellent productivity blog. Alas, McSparky spent more than half of the show being fascinated by the minutiae of what doctors do. Which is better than what followed—long periods of uncomfortable silence while the unprepared guest clicked through every app in his menu bar to see if there is anything worth mentioning. OK, it was not total silence. You could hear Katie fuming in the background. There wasn’t.

Then another episode of Systematic came on, with Dr. Don Schaffner, a microbiologist. PhD, not MD. Wonder if that explains why the show was better. It was outstanding. Brett was a better interviewer than David, and avoided getting too side-tracked by his guest’s interesting work. But ultimately, the show was good because Dr. Schaffner had useful tips and app recommendations that did not simply regurgitate the latest round of MPU/Mactories/Macdrifter/etc. sponsors. His paper review workflow gave me several ideas I will work on during the holiday downtime. He also suggested a promising contender in my quest to find headphones that will survive more than 8-12 months of intensive use.

One more thing for me to do during the downtime: promote Zotero. Between the developers fumbling Papers 3 and Mendeley being taken over by an evil corporation, Zotero coupled with a few extensions is the best reference manager on any platform. Coming in 2014.