The Georgetown waterfront is great for airplane watching, although the residents may not be too happy about that. I don’t think this one would have turned out as well as it did had the glare not been so intense.

To convince myself that I am not completely clueless in the ways of medicine, I occasionally turn to my few diagnostic successes. ⊕ To be clear: this is cherry-picking, and I make no claim for being a master diagnostician. Yes, a bunch of my colleagues had missed the first patient’s friction rub that was to me so evident; but say “friction rub” to a third-year medical student and they will know immediately the differential diagnosis and the treatment. How many friction rubs have I missed actually hearing? Plenty, I am sure! Like this one time when a 20-something year old man who languished in the hospital for days with severe but mysterious chest pain. Our first encounter was on a Saturday, when I saw him as the covering weekend resident; he was discharged Sunday, 24 hours after I started treatment for the acute pericarditis he so obviously had.

Once, during a mandatory ER rotation, I figured out that a patient who came in complaining of nausea and vomiting actually had an eye problem: bilateral acute angle closure glaucoma. I pestered the skeptical ophthalmology resident to come in on a Sunday afternoon, confirm the diagnosis, treat the glaucoma, likely save the patient’s vision, and get a case report for a conference out of it.

And I will never forget the case of the patient who was in the steaming hospital room shower whenever I saw him; he had come in for kidney failure from severe vomiting and insisted he never used drugs, illicit or otherwise. Still, it was obvious with anyone with a sense of smell that he had cannabinoid hyperemesis syndrome and would have to quit.

Superficial commonalities aside — all three were men with an acute health problem — what ties these together is that I had to use senses other than sight to figure them out: ⊕ This being the 21st century taste is no longer allowed, but I will leave to your imagination how doctors of old could tell apart the “sweet” diabetes (mellitus) from the “flavorless” one (insipidus). hearing the friction rub, feeling the rock-hard eyeballs, smelling the pungent aroma of cannabis. And all three cases came to mind when I read a tweet an X about ChatGPT’s great diagnostic acument.

I can’t embed it — and wouldn’t even if I could — but the gist of Luca Dellanna’s extended post is that he:

1. Had a “bump” on the inside of his eyelid that was misdiagnosed by three different doctors.
2. Saw the fourth doctor, who made the correct diagnosis of conjunctival lymphoma.
3. Got the same, correct diagnosis from ChatGPT on his/its first try.

A slam-dunk case for LLMs replacing doctors, right? Well, not quite: the words Luca used to describe the lesion, “a salmon-pink mass on the conjunctiva”, will give you the correct response even when using a plain old search engine. And he only got those words from the fourth doctor, who was able to convert what they saw into something they could search for, whether in their own mind palace or online.

Our mind’s ability to have seamless two-way interactions with the environment is taken for granted so much that it has become our water. This is the link to the complete audio and full text of David Foster Wallace’s commencement speech that became the “This is Water” essay, and if you haven’t read it yet, please do so now. But it is an incredibly high hurdle to jump over, and one that is in no danger of being passed just yet. It is the biggest reason I am skeptical of any high proclamations that “AI” will replace doctors, and why I question the critical reasoning skills and/or medical knowledge of the people who make them.

In fact, the last two years of American medical education could be seen as simply a way of honing this skill: to convert the physical exam findings into a recognizable pattern. A course in shark tooth-finding, if you will. This is, alarmingly, also the part of medical education that is most in danger of being replaced by courses on fine arts, behavioral psychology, business administration, medical billing, paper-pushing, box-checking, etc. But I digress.

Which is not to say that LLMs could not be a wonderful tool in the physician’s arsenal, a spellcheck for the mind. But you know what? Between UpToDate, PubMed, and just plain online search doctors already have plenty of tools. What they don’t have is time to use them, overburdened as they are with administrative BS. And that is a problem where LLMs can and will do more harm than good.

There are graceful, majestic sports played almost every week at the Capital One Arena; and then there is Monster Jam. Oof!

The five or so regulars readers of this blog may have noticed a pattern of promises made and not kept of things I will, may, or should discuss at some future, unspecified point. These were usually somewhere in the margin notes, but sometimes I would end with a cliffhanger. The topics included mental models, notable microblogs, and ABIM’s financial shenenigans; in my head, the list was significantly longer, and the items expanded into 1,000+ word posts that would be a slog to reference, a nightmare to edit, and which no one would ultimately read.

Up until last year, whatever I thought about those topics would stay in my head, waiting for the stars to align and for the Gods of chaos and time Also known as my children. to smile upon their humble servant. Which is a net good for the reading public — who needs to read the unbaked thoughts of an oncologist? — but as Cory Doctorow wrote, having one’s thoughts written down is good practice both for developing them and for future reference. I was, in a way, depriving my future self of the benefit of knowing how big of a fool my past self was.

But ever since learning of the micro.blog/MarsEdit combination This is Miraz Jordan’s brief YouTube introduction to the two; 15 minutes of time well spent if you have even a tiny bit of interest., I’ve maintained a daily log of thoughts, readings, viewings, and writings. The low friction of the tools begs for scattered non-sequiturs and word salads — think of an unkempt Obsidian database — but the semi-social veneer that micro.blog provides tempers my worst instincts and makes the posts better overall for everyone exposed, including my future self. Sure, those longer texts still don’t get written — although, just watch this one grow! — but for personal use the snippets are even more valuable (and easier to skim).

Not everyone should be a capital-b Blogger — or have a gated newsletter for that matter — but many more people could benefit from a small-p personal blog of the commonplace type. The reason I bristle at overproduced “content” and at statements that anyone who writes must give it their all, strive to perfect everything they write above the 80%-done good-enough-for-government-work standard that is close to my heart, is that they create the wrong impression of what blogging could/should/would be if it hadn’t been for the Huffington Posts and the Gawkers of the peak-blog internet that equated blogging with monetization. And also why I took an initial dislike of The Curator’s Code despite its obvious usefulness. Why should personal blogging be standardized? It’s Personal!

And if you want to find some of these to read, for instruction, inspiration, or just plain enjoyment? Outside of the great micro.blog blogs — check out the Discover page for a daily sampling — there is Dave Winer’s scripting.com, John Naughton’s Memex, Ian Betteridge’s Technovia, Reader John’s Tipsy Teetotaler, Jerry Coyne’s Why Evolution is True, and oh so many more.

Being stuck at an airport doesn’t have to be bad. Nashville, for example, has more than one airport restaurant with live music at all hours of the day (and night). Last year we spent a few hours waiting for a delayed flight at Ole Red.

Continuing the daily cadence of one photo followed by a complaint about America’s most hated board of medicine, ABIM has once again shown its complete deafness of tone. With almost 10% of its customers — for we are not members of this private club — rebelling against its practices, it still sent out an automated extortion reminder threatening to remove certification if you don’t pay up. Well, I don’t think I shall.

As a prolific child fabulist, I very much appreciated @ayjay’s reminiscence. Most people are, in fact, reflexive embellishers, but not everyone can recognize it in themselves or turn it into a healthy skepticism. At least that’s what I tell myself!

I am reasonably quick at making decisions, and people occasionally ask me for input when they need to make theirs. This is either when they have already decided — and there are good and not so good ways of soliciting feedback then, but that is for a different time — or when they haven’t a clue about what to do. This latter situation is usually because:

• The problem is not clear (“I am unhappy at my job, please help.")
• The problem is clear but the options are not (yet) well-defined (“I am medical student who wants to be involved in clinical trials, please help.")
• Both the problem and the options are clear, but the correct choice is not (“I have 4 good job offers with different salaries, geographic locations, and prospects for advancement, please help.")

My favorite part of the process, and the part I consider the most difficult, is defining the problem, figuring out the options, and mapping out — to the extent possible — the Markov chain for each; i.e. the first two items on the list. But once you do that, shouldn’t the choice be clear? Well, for some (many?) apparently not!

Wild problems aside, ⊕ This is admittedly a very big aside, but most issues people ask me about are not, in fact, wild, just ill-defined. once you know the choices and their consequences, shouldn’t it be easy to pick the one that fits best with your priorities?

Well, not unless you rank them! Which is so banal I’m a bit embarrassed to waste even two minutes of your time for it, but seriously, for every 10 people I ask about their top priority (singular), nine will start giving me an unordered list of them, and start hemming and hawing about my follow-up, which is to pick just one. Because there can be only one: it’s right there in the name! And if only one choice fits, well, there you have it! If there are several, you go down your ordered list one by one and prune.

Of course, it is not always that easy. But the decisions people get paralyzed about are seldom in the Sophie’s Choice category; and for those that are, there are usually many more degrees of freedom to reframe the problem, the choices, or both, than poor Sophie had. For everything else, the choice is difficult because people haven’t figured out the priority, i.e. what they actually want.

NB: the list of priorities can be all-encompassing (“values”, but remember, at the end of the day it’s really just one “value”) or context-specific (“first, do no (net) harm” for doctors, etc.) I am sure there are whole industries ready to sell you their lists of priorities, or, um, empower you to make your own. I am by nature skeptical of anyone who too readily shares theirs. Caveat lector, as they say.