Of the three pillars of medicine, research is the most ellusive. Unless you are in an MD/PhD program—not an option for most Europeans—you will have other priorities in medical school. And unless your residency program has a built-in research year, the way most surgical residencies do, you will either be way too busy in a university or a large community program to do any research, or have plenty of free time in a lower volume community hospital that doesn’t have many research opportunities.
When I interviewed residents-to-be last year, my first thought on seeing a non-PhD applicant having 18 publications on his or her CV wasn’t “Wow, she is a research machine, we gotta have her”, but rather doubt that anyone could be that productive during medical school. More points subtracted for thinking the interviewers would be so gullible.
I graduated six years ago, far enough not to be able to give advice on how to do research as a medical student. The hows and whys are institution-specific, so anything I wrote would have to be in Serbian anyway. Residencies, though, are similar enough to each other that I do have some words of advice for new residents wanting to do Research! in a community hospital, university-affiliated or not.
Patient care trumps research. Unless you have already worked as an attending in another country before coming to the US for residency, don’t waltz in to your PDs office on day one asking about research opportunities. Prove yourself on the field first, then six months later, when you’re comfortable managing DVT prophylaxis, septic shock, and what not, start asking questions.
Get your own idea? Common wisdom says it is better to come up with your own question and start your own projects, since you will be more invested in the outcome. Well, yes, sort of. Unless it is a quick-and-dirty chart review you can do over a two-week vacation—and even then there are IRB hoops you’d need to jump through to get anything done—you will get your inexperienced self into the murky world of project management. Many brilliant ideas have died on the field of required signatures, ambiguous data points, and impossible-to-coordinate meetings. Which is why this next advice is important.
Find good mentors. Surrounding yourself with a few good people is orders of magnitude better than having many good ideas. Research topics come and go, as does our interest in different fields of medicine (yesterday’s apoptosis is today’s epigenetics is tomorrow’s something or other). It is unlikely that the research your started in residency will continue onward into fellowship, but the knowledge, skills, and general wisdom you pick up from your mentors should serve you well into your career. NB: don’t wait for someone to be “assigned” to you—although that’s what many residency programs will do. Seek out people who match your character and who would be able to give you advice in at least three fields: patient care, research methodology, and research topics. This can be one person, or five. And if you find an awesome mentor who just isn’t doing any research right then, you can always write a review.
Is it Science! or quality improvement? ACGME is big on Quality! and Patient Safety! this year. Programs take notice. If you can present your interest as a quality improvement project rather than small-s-science, consider doing it. Not only does showing interest in quality improvement look good on a CV, your institution might have special funds for resident QI projects. A dedicated QI mentor is also a good resource, if you want a carreer as a Sith lor—erm, hospital administrator.
Interest in research goes from I just want something on my CV so I could get a fellowship to When I grow up, I’ll have my own lab, but this applies to most people in most circumstances.
Spending two hours each day on the train, offline and without distractions, gives me an excuse to go down various rabbit holes that a couple of months ago I would’ve thought nothing but time wasters. Starting to read the Dark Tower series—I’m almost done with the Gunslinger—is one of them. Re-learning vim—if dabbling with it in high school 15 years ago counts as having learned it—is another.
This episode of the Technical Difficulties podcast is what started it, followed by a blog post or two on the perfect setup. Now, I may or may not continue using vim as my primary writting tool—I would have to figure out how to integrate it into my workflow—but several things I picked up will always be useful:
git is an amazing tool for tracking changes that researchers should use more
don’t blindly edit stuff—dotfiles in this particular case—on your computer without understanding what those edits mean
Solarized should be your default color theme for anything
use your macro/keyboard shortcut app of choice (mine is Keyboard Maestro, you can just as easily—but not as prettily—use Better Touch Tools) to quickly position windows into quadrants, halves, thirds, etc.
there might not be much difference between bash and zsh if you are a beginner, but zsh has the cool customizable prompts
Yes, I am writing this in vim, previewing and exporting in Marked, then posting it manually to Squarespace. The only thing standing between me and a fancy-pants static website engine powering this blog is there being no internet access on MARC trains, and me being too cheap to get a $20-a-month personal hotspot from Sprint. That is probably for the best.
NIH orientation started today. My commute is 90-plus minutes each way, and the first four months are mostly inpatient. I will have to wait until retirement for another run like this.
Four years ago today was my first day as an intern at Sinai. Yesterday was my last on Sinai’s payroll. I will miss it.
Won’t miss the fake flash mobs of Lifebridge Health, though.
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.
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.
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.
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.
A combination of heavy rain, bad infrastructure, and even worse emergency preparedness No surprise there. This guy is the head of Serbia’s department for emergency response. resulted in Serbia and Bosnia having the worst floods in more than a century.
Dozens are dead, and tens of thousands misplaced. Government officials are having nervous breakdowns on live TV, calling the flood “a Biblical catastrophe”—since touting vast water resources as your country’s main asset isn’t a hint as to what big disaster you should prepare for. In case you’re wondering, the Netherlands' last big flood was in 1953.
And of course a high priest of the Serbian Orthodox Church blamed it on Gay Pride. Because religion. Though I shouldn’t be that sarcastic, since the Orthodox Church is, in fact, trying to help. By praying for the rain to stop.
If you have a couple of minutes, please use PayPal to donate to floodrelief@gov.rs, the official account of the Serbian diplomatic mission in Brussels. If your bank allows international wire transfers, you can give directly to the Serbian Red Cross. While no one we know is affected, my grandparents had to leave their home twice over the past 50 years because of floods. The support they and their neighbors received from the Red Cross on both occasions was invaluable.
Fun fact: The average Maryland to DC commute is the second longest in the US, right after New York. I should know. Mine will be 90+ minutes, come July 1st. Last week, while I was finishing paperwork at my new employer’s Bethesda offices, the looks people gave me went from incredulity to pity on seeing the Baltimore address on my driver’s license and hearing my explanation that no, since my wife is still at Sinai and usually just walks to work, we won’t move. It’s better for me to take one for the team, I’d say, than have both of us suffer hellish beltway traffic from some midway point.
I could write an essay on how taking one for the team is not entirely true, but the title of this post says “podcast”, and it’s already the second paragraph, so here is my point: My commute will be long. I will need to fill that time with something. Sometimes, that will be strangers talking into my ear about things I don’t understand. Here is my list of strangers, carefully curated after ten years of listening.
Comes out every Monday morning, like clockwork. Great for learning about new hardware, productivity apps, etc. but podcasts are not the best medium for going into the minutia of somebody’s workflow.
Go read this. Having Merlin Mann talk for an hour all by himself would be good enough, but Dan Benjamin—the other half of BTW—is the best podcast host in the business. By using a simple formula, it is easy to mathematically prove that their show is the best podcast ever created.
The first 30 or so minutes are laden with inside jokes and obscure references, but even that is fun after you are several episodes in.
It airs each Saturday, but I like alliteration, and there is nothing else good on Wednesdays. I was in Chicago once while it was being taped, but was too late to get a ticket. Now that Carl Kasell is retiring, it’s unlikely I’ll ever be at a live show. So it goes…
Daring Fireball is a better blog than TTS is a podcast—John Gruber and some of his guests tend to ramble—but you can get good insights on baseball and bourbon.
One word: Siracusa. There are two other co-hosts, whose main job is not to screw up too badly. They do it well.
The John Siracusa-slash-Bret Terpstra of food. Yes, Alton Brown is a national treasure.
This is the time for irregular shows, or ones that don’t always have something of interest. In order of preference:
Finishing up our world tour/airplane passenger torture project The torture device being our 19-month-old girl—or rather, her vocal cords. was a trip from Baltimore to Havana, via Cancun. Before you scream Embargo!, neither my wife nor I are American citizens. Our daughter is, but it is fortunately not illegal for US citizens to visit Cuba as long as they don’t spend any money there, at least according to America’s most esteemed journal of law, medicine and gastronomy.
If for whatever reason you want to travel to Cuba from the East coast, you might find our experience helpful.
We took the United flight from Dulles to Cancun, went through Mexican customs and immigration, then took the Cubana flight to Havana after checking in again. Inbound, layover time was more than 3 hours so we could have comfortably checked a bag or two for those large bottles of sunscreen and other essential liquids. The trip back, however, was tight at 1h 55min, so we decided not to risk waisting time at baggage claim, and only brought carry-ons.
In retrospect, it was half of a good move. On the way back, going through customs, immigration, then walking from Cancun’s Terminal 2 to Terminal 3 and checking in for the flight to Dulles is barely manageable in those 90-ish minutes after leaving the plane. However, we could—and should—have checked one of the carry-ons on the inbound flight, as sunscreen, diaper cream, and other toiletries are ridiculously expensive in Havana.
NB: You can easily walk from Cancun’s Terminal 2 Arrivals to Terminal 3 Departures (or 3 -> 2 inbound). There is a shuttle that leaves every 30 minutes and goes Parking -> T1 -> T2 -> T3 -> Parking. The Cancun airport staff told us it would take us 25 minutes to walk from T2 to T3—and that it would take the shuttle at least as much since it makes those other stops—but hey! there’s this van that magically appeared which would drive us to T3 for the low low price of $20. Google maps said it’s less than a kilometer between terminals 2 and 3 so we smiled politely and walked away. It took us—three adults with a carry-on and a large shoulder bag each, plus a toddler in tow—less than 10 minutes. Kudos to United for letting us skip the long check-in line and making it to our flight without issues.
Serbian citizens don’t require a visa, but Dora had only her US passport. We got her a visa in Cancun at check-in for 20 euros.
Cuban entry stamp is bright pink. They asked us before putting one in Dora’s passport, so I can only assume they occasionally get US citizens who’d rather not have their passports stamped for whatever reason (cough, cough). The visa also gets stamped, so there is still proof of entry.
There were no issues going back through Dulles. The customs form asks you which countries you visited on the trip, so we did write we were in Cuba. The immigration officer at Dulles just asked if we were bringing any cigars back with us—of course not, we hadn’t even smoked any while there!—and finished the fingerprinting in record time.
Bring euros, and bring more than you expect. You can convert USD to convertible pesos (CUC) in any exchange office, but with their rates it’s better to change dollars to euros in your own bank, then change euros to CUC once in Cuba. Also, convert some CUC to the peso nacional (CUP), if only for the ridiculously cheap ice cream you can buy on the street.
As for how much to bring, count on at least $20/person/day, not including the room or the 25 CUC exit tax. This would cover lunch, dinner, and a daily trip to the beach or a visit to a museum, monument, etc. Since you cannot use American credit/debit cards anywhere on the island, it pays to take more than you think you would need.
The highlight of the trip! We booked this room on homestay.com, and could not be happier with how it turned out. Centro Habana, the neighborhood it’s in, is definitely not for everyone—very safe, like the rest of Cuba, but also with dog poop and open trash cans everywhere you turn. I could say the same about the part of Naples we stayed in this January. In fact, with laundry out in the open and being able to peek into people’s living rooms from ground level it looked very much like Naples, just with wider streets. Our casa particular was the opposite—clean, well-maintained, gaudy, but cute. Between our large air-conditioned room, the patio, and the open rooftop terrace, we could easily have spent a couple of days just hanging out there chatting with the friendly hosts.
Don’t count on being able to get online at any point. We tried checking in online a day before the trip back, but none of the Havana Vieja hotels we tried had any prepaid cards available. Even if they had, there are no printers to print a boarding pass. Unless you’re staying in a hotel, don’t even think about wi-fi. Just bring a good book or two.
So, if someone’s vacations response email tells you they’re going to Cuba, don’t count on them having any access, no matter what some self-important douche bag tells you.
The only resource we used—and we used it multiple times per day—was the Havana Good Time iPhone app. Some of the information on working hours and prices is slightly outdated, but it is all still relevant, and it comes with an offline map of Havana that is—duh—much easier to carry around than the paper version.
It is always a pain clicking on a link to a journal article only to hit a paywall. It’s doubly painful when I know I have institutional access via my library’s proxy server, but have to jump through hoops to get it: go to the library website, log in, copy and paste the article name or PMID into its PubMed search box, and finally download the PDF. Arduous, and—turns out—unnecessary.
Enter Alfred 2 workflows. Here’s a nice article I found on Twitter today. The NEJM link in the top right corner leads to an abstract, but I need a special archive subscription for the full PDF. No matter—I can just highlight the PMID and hit my special Alfred 2 keyboard combo:
Since I’m not already logged into the Welch library proxy, I hit a login wall. It’s nothing 1Password can’t solve, but you can also just type in your username and password yourself, like an animal.
And Bam! The ugly but magic button is where it should be. Your institution might have a prettier one.
To make it clear—this simple workflow will do a PubMed search of any selected text anywhere in OS X, all through your institutional proxy server. Finding an interesting reference while reading an article, highlighting its title, and hitting ^⎇⌘P to get to the PDF always feels like magic.
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.
