• I don’t feel comfortable doing that.—I don’t know what you’re asking me to do (nurse to intern); I’m too lazy to do it (intern to resident); I think it’s a stupid idea and there’s no way you can make me do it (resident to attending); You’re not paying me enough to do this crap (attending to administration).
• It’s a light elective—You don’t need to show up.
• Needs to read more. (on a written evaluation)—I have no idea how much medicine this person knows. I barely know any myself.
• The family is reasonable.—Family members don’t ask too many questions and will agree with anything you say.
• The patient has xyz.—I’ve read in an old discharge summary that the patient has xyz, but have no idea how they established the diagnosis, what stage it is in, or what the hell xyz even is.
• The head is normocephalic, atraumatic. Pupils are equal, round and reactive to light and accommodation. Sclearae are nonicteric.—If I were to report the physical exam I actually did it would take five nanoseconds, so take these fillers to make it seem like I’ve put in some effort.
• Thank you for the thorough presentation.—Why did you waste my time with all that useless information?
• That’s an outpatient work-up.—Administration is already breathing down my neck because of this patient’s length of stay and you’re worried about a mild anemia and a positive hemoccult!?
• That’s her new baseline.—Her disease is worse and we don’t know why, so I guess she’s stuck with it.
• Please let me know if you have any more questions.—This is the end of our conversation, so please stop talking. I shall now leave.

…to me, this looks flaky. Yes, Scott Adams (of-Dilbert-fame) is right in saying your best bet for success in life is being pretty good in several skills rather than trying to be the best ever in only one. So, a plan like this:

1. Step one: become a decent entrepreneur
2. Step two: become a decent MD
3. Step three: ???
4. Step four: profit!

might indeed be a good idea. However:

• Medicine implies altruism. Entrepreneurship implies greed.
• Programs want their residents to be 100% dedicated to medicine in general and the program in particular. Can you do that with a small business on the side?
• Physicians in academia, i.e. those who conduct residency interviews, forgo 300k+ salaries so they could dedicate themselves to research and education. Are you sure telling them about your latest money-making scheme is a good idea?
• As a resident, do you look at each patient as an opportunity to help them and learn from them, or to figure out how to build a business around them?

Residency programs exist to train physicians, not CEOs. Residency slots are already in short supply. Would program directors give a position to someone who is more likely to end up not practicing medicine at all?

After 18 months of intensive use, here are some of the apps left standing on my iPad 3, sorted by category. I like to think I’m a semi-advanced user, so for some of them I have also listed simpler alternatives. It goes without saying that you should download all the free iWork and iLife apps.

Medicine

MKSAP 16

• For: all medicine residents
• Recommendation: strong
• Price: free (if you bought online MKSAP access)

MKSAP question bank. No-brainer if you are studying for your internal medicine board or MOC exam. Less page-flipping and instant gratification. Unfortunately, it doesn’t allow you to highlighting or annotate the explanations. Also, it can’t make custom quizzes, can’t review unanswered/wrong questions, and doesn’t allow you to copy any of the text to your notes. Lot’s of cants, but it’s the only MKSAP app available. Free if you purchase the electronic version of MKSAP 16.

Download MKSAP 16 from the app store here.

ACP Guidelines

• For: all interns
• Recommendation: ok, sort of
• Price: free

It seems like a good idea, and the content is great, but it is more of a branded PDF reader than anything else. Doesn’t have search or favorites, and you have to download each recommendation one by one. The download is fast, but good luck getting what you need without internet access. So, good for night-time reading, particularly if you’re an intern, but not a good POC tool.

Download ACP Guidelines from the app store here.

Stanford 25

• For: everyone
• Recommendation: just OK
• Price: free

If you haven’t heard of Stanford 25 before, see this TED talk and see the blog. It’s another good, if ugly, night table app.

Download Stanford 25 from the app store here.

Productivity

Things for iPad (or Omnifocus)

• For: everyone
• Recommendation: strong
• Price: $19.99 for Things, $39.99 for OmniFocus

Whether you’re a GTD fan or not, this or it’s more powerful and more expensive sibling OmniFocus are a must-have for anyone shuffling between more than two areas of responsibility. It still hasn’t been updated for iOS 7, but is very functional. Only two missing features for me, really: there are no nested tasks/dependencies, and you can’t filter by more than one tag.

I’ve been thinking about switching to OmniFocus, but this works well enough for me that the hassle of complete overhauling my system wouldn’t be worth it. Not to mention the >100$ price tag.

Download Things for iPad from the app store here. You can find OmniFocus for iPad here.

Boxer

• For: everyone who gets more than 5 emails/day
• Recommendation: strong
• Price: $0.99

The best mail client on the iPad. Apple’s Mail.app was OK until I realized I spent way too much time scrolling through my list of 20 IMAP folders whenever I wanted to move an email. Boxer works with Gmail, IMAP and Exchange accounts, has smart email sorting, and integrates with Sanebox.

Download Boxer here

Dropbox

• For: everyone
• Recommendation: strong
• Price: free

If you use Dropbox on your PC—and you must—then this is a no-brainer.

Download Dropbox for iOS from the app store here

iThoughts HD

• For: nerds
• Recommendation: OK
• Price: $9.99 for either

I found Tony Buzan’s book on mind mapping as a first-year medical student and used the hell out of it for my biophysics, chemistry and genetics coursers. As the material got more complicated, shuffling huge stacks of A3 paper became unwieldy, so I went back to plain old Cornell notes for biochemistry et al. This app is what got me back to making maps, this time when writing review articles and planning out other research. Also good when contemplating the GTD 50,000 ft view.

Download iThoughts HD for iPad from the app store here. It’s prettier new cousin Mindnode 3 is available here

Calendars 5

• For: all busy overachievers
• Recommendation: ok
• Price: $6.99

The default calendar used to be ugly and impractical. With iOS 7 it’s just the latter. This is a good replacement. Fantastical for iPad would be nice, though.

Download Calendars 5 from the app store here.

Drafts

• For: advanced users
• Recommendation: strong
• Price: $3.99

Quick note-taking and automation rolled into one. I use it as the default inbox for anything and everything, mainly by appending a dump.txt file in my Dropbox. There is a separate iPhone version that is just as useful.

Download Drafts for iPad from the app store here.

Pinner

• For: pack-rats
• Recommendation: ok
• Price: $1.99

Pinboard is an excellent almost-free bookmarking and discovery service. There are plenty of iPad clients available, but Pinner seemed to be the most cost-effective. I haven’t regretted the purchase.

Download Pinner from the app store here.

GW Mail

• For: anyone who is forced to use GroupWise
• Recommendation: meh
• Price: $9.99

I have to use GroupWise email for work. This is the only decent client I found for iOS. Stopped looking for a replacement since my last day of residency is less than six months away.

Download GW Mail here

Reading

Reeder 2

• For: serious feed readers
• Recommendation: strong
• Price: $4.99

I’ve been using RSS feeds since the days of Bloglines (circa 2001) and switched to Google reader after the first big redesign. It’s sad that Google decided to murder it instead developing its potential as a social service. Feed wrangler is a good replacement, Feedly is a free one. Reeder 2 is the best iPad feed reader there is, and works well with both.

Download Reeder for iPad from the app store here.

Instapaper

• For: everyone who reads
• Recommendation: strong
• Price: $3.99

If you read any text that’s longer than 500 words with any regularity, you need a service that will keep track of the articles and remove all the annoying cruft surrounding the text. Instapaper is the first one of its kind, and the best way to read articles on it is on an iPad.

Download Instapaper for iOS from the app store here.

NextDraft

• For: everyone
• Recommendation: strong
• Price: free

Ten good articles hand-picked by an expert hand-picker and delivered (almost) every weekday. My only source of news for the past six months.

Download NextDraft from the app store here

ReadQuick

• For: dabblers
• Recommendation: ok
• Price: $4.99

The second book from Tony Buzan that I read was on speed reading. This app will flash words from any article you find online or in your Instapaper/Pocket queue one-by-one at a set rate. Good for those who are too lazy to swipe.

Download ReadQuick from the app store here

Writing

Day One

• For: everyone
• Recommendation: strong
• Price: $4.99

A journaling app. I don’t use it for the Dear-Diary types of texts—though I have no doubt it would be perfect for that. Instead, I use it to keep an archive of meeting and lecture notes (usually started in Drafts and sent to Day One), with an occasional milestone in between. Feature request: multiple journals.

Download Day One for iOS from the app store here

Byword

• For: beginner iPad writers
• Recommendation: ok
• Price: $4.99

If you want to write a long text on an iPad and don’t need automation, text expansion et al. then this is the app for you.

Download Byword for iOS from the app store here

Editorial

• For: advanced users
• Recommendation: strong
• Price: $4.99

If you want to write a long text on an iPad and like mucking about with workflows, text snippets and Python scripts—which I most certainly do—this is your only choice on any platform. This will become essential next July when I start my long commute.

Download Editorial from the app store here

Social

Twitterific 5 or Tweetbot

• For: everyone
• Recommendation: meh… you might want to wait for the newest version of Tweetbot to come out
• Price: $2.99 for Twitterrific, $2.99 for Tweetbot

If you are on Twitter—and if you are a physician you really should be—please get a decent iOS client. The official one is definitely not it. Tweetbot used to be until iOS 7 came and made it look and feel ancient. Twitterrific is a good—if slightly annoying—substitute, with the added benefit of being universal (i.e. iPhone and iPad with the same purchase). I’m using the old version of Tweetbot and waiting for the new one, since Twitterific tended to make a mess of my position in the stream.

Download Twitterrific 5 here and Tweetbot for iPad here

Facebook

• For: everyone who uses Facebook (why?)
• Recommendation: my wife likes it
• Price: free

OK, I guess, if you’re into that sort of thing.

Download Facebook for iOS here

Skype

• For: everyone away from family
• Recommendation: OK
• Price: free

This is the international default for long-distance communication, I guess. It gets choppy and drains the battery, but it’s the only thing my mom knows how to use so I’m stuck with it.

Download Skype for iPad here

Games

Letterpress

• For: everyone who can spell
• Recommendation: strong
• Price: free (with in-app purchase)

An excellent turn-based word game. The only multiplayer game I play with any regularity. You need an in-app purchase if you want to play more than two games at the same time, but it’s well worth it. I have five going on right now.

Download Letterpress here

10000000

• For: nerds
• Recommendation: strong
• Price: $1.99

Bejeweled meets a 2D RPG. Hours of fun, even when you get to 100000000000 or however many points.

Download 100000000 here

Aquaria

• For: adventure gamers
• Recommendation: strong
• Price: $4.99

A 2D side-scrolling action-adventure game set under the sea. At my pace I will finish it in about two years, but it’s great even in 15-minute increments.

Download Aquaria for iOS here

Shopping

Deliveries

• For: serious shoppers
• Recommendation: strong
• Price: $4.99

Forward an email containing a tracking number to a special email address. Boom, you can now track your package through this app, with push notifications if you’re into being interrupted whenever a case of -diapers- Wild Turkey is delivered to your front door.

Download Deliveries for iOS here

Eat24

• For: serious eaters
• Recommendation: OK
• Price: free

Good app for ordering food in the Baltimore area. Don’t know about rest of the country.

Download Eat24 for iPad here

Hipmunk

• For: world travelers
• Recommendation: strong
• Price: free (you pay for the plane ticket, though)

The best flight comparison engine there is. Find the most affordable and least annoying plane route. Also does hotel rooms, which I haven’t tried.

Download Hipmunk for iOS here

Entertainment

Netflix

• For: everyone with a Netflix subscription
• Recommendation: OK
• Price: free

I have used this app exactly once, to watch a couple of episodes of Buffy the Vampire Slayer while waiting for an Amtrak train. Well worth it, though.

Download Netflix for iOS here

AppleTV Remote

• For: everyone with an Apple TV
• Recommendation: strong
• Price: free

I don’t have my original remote any more. We assume Dora ate it. This app is even better, since you don’t have to muck around with the tiny remote buttons when entering your wifi password or searching Netflix.

Download AppleTV Remote here

comiXology

• For: everyone who reads comics
• Recommendation: strong
• Price: free (the app, not the comics)

The only way to read comics on an iPad.

Download comiXology here

They let us peek into the sausage factory last week.

Nominally, the lecture was about RVUs¹. An accountant type in a pinstripe suit explained why the government came up with the concept and how more RVUs translate to mo’ money for the hospital. Then he showed us a table. This is how much RVUs an average ophthalmologist makes in an hour. Here is an orthopedic surgeon. See here at the bottom? That’s an internist. This is how much you’re worth to us, scum².

Then there was a chart. This is the last fiscal year. This solid line here are monthly RVUs for an average hospitalist. The dotted line is for a single physician in the practice. See how it’s always above the solid line? That’s good. We love that person.

We had medical students and interns just three months into training listen to this. It was blood-curdling.

Not because the hospital organized the lecture, mind you. It is a very good thing they did it, and it is good for doctors in training to realize as early as possible in what kind of a healtcare system they are expected to work. What is frightening is that there needs to be an entity, let’s call it administration, which views the hospital as a production plant and physicians as line workers who need to maximize outputs, optimize efficiencies and do other newspeak claptrap.

Administration usually lies—appropriately—on the ground floor, far removed from that other sausage factory of actual patient care. It looks at pie charts and histograms and RVU tables and keeps coming up with new and exciting ways to increase production while wondering why those bumbling doctors at the bottom of the list can’t do whatever the top performing docs are doing to keep the hospital in the black.

It’s modern medicine, it’s complex, it’s expensive, it requires that level of organization and detachment—you might be tempted to say. Yes, you could indeed say that, if not for the lonely example of every other country in the developed world which does it differently than the US.

But never mind that. With all the shenanigans the Congress has been up to this week, that end of the equation is unlikely to change. What administrators should do—and I understand the banality of the following advice—is see real physicians interacting with real patients for at least and hour each week. Interns being bombarded by page after page—from critical to comical—while trying to figure out a 15-minute window to eat, get coffee and use the restroom⁴. Residents finishing a 24+ hour ICU shift that started with three codes and ended with a difficult end-of-life care discussion, with central lines placements and intern supervision—but no sleep—sprinkled in between. Attendings getting yelled at while trying to explain to family members why they need to pay for the medications out of pocket or bring their own³.

One hour. Each week. Mandatory. To put things in perspective.

Electronic patient notes, the way they stand now, are dangerous. As physicians wiser and more experienced than myself have noted, they are made for billing, not story-telling and communication between healthcare professionals; and as anyone with even basic literacy in the English language will notice as soon as they read one, they are a barely comprehensible, intelligible, muddled word salad that looks computer generated because, well, in most cases it is.

Why?

For one, they are ridiculously easy to create. Click on a checkbox and every admission note you start will come pre-populated with what the EMR thinks are the patient’s current home medications, prior surgical procedures and such. Have trouble accurately documenting the dozen medications your 72-year-old with systolic heart failure, diabetes, CKD and vascular dementia has? No big deal—the e-patient has at least something listed from an ER visit 9 months ago. You’ll make sure to go back to the admission note later and append it with the correct list when you get it from the family member tomorrow, right? Right.

They also save you from having to type. Click click click, and the review of systems is done. Too much clicking? There is a solution: spend 5 minutes to create a macro, and you will have all your common questions pre-answered as No on all the notes, shaving of seconds of additional clicking. Because asking all your patients the same questions and expecting identical answers is just plain common sense, amiright? Oh, and of course tachycardia is a symptom. It’s right there on the ROS list, waiting to be clicked.

Most of all, electronic notes are the one cure for writer’s block. While in the distant past¹ you had to spend agonizing minutes staring at a blank admission note trying to form a coherent story on why the patient came to be seen, and then try putting it down on paper down without feeling ashamed, you learn from EMR that it is OK to sign a medico-legal document that contains this brilliant turn of phrase:

The reason for visit is: pt missed hd, high bp, n/v. The course was: constant. The exacerbating factor was: none. The alleviating factor was: none.

But why? Medicine residents are, in general, all moderately-to-ridiculosuly smart and ambitious people who should know better.

Well, for starters, some of them don’t. Even in the olden days¹ you had a couple of interns who weren’t the best ever history-takers² and wrote poor-quality notes. Electronic notes, unfortunately, help them obfuscate their deficiencies. It is very easy to see in a one-page note how much useful information the resident has actually obtained. Not so much with computer-generated six-pagers.

Then there is your typical smart intern just finishing putting in orders for her fourth admission admission that day after discussing each one with the supervising resident, all while answering a barrage of pages about the 30 patients she is cross-covering. The first two admission notes are almost done—she has to updated the plan after talking with the resident—but the other two will have to wait until she updates the sign-out and hands off all the patients to the night float. This is arguably much more important than notes as it directly affects the care those newly admitted patients will get overnight, while the admission note is not really needed until the following day during morning rounds. She’s smart enough to prioritize.

She’s also smart enough to know what is expected of her. What she know about writing admission notes during residency she learned from her peers, particularly seniors—who concentrated on efficiency —and that lady at the billing department who gave a noon conference talk on the importance of complete documentation for coding. So The Man wants me to be efficient-yet-thorough, and then he gives me this electronic tool with auto-population, templates, macros and such. Hmmmmm…

Yes, she might get in trouble if her notes are so horrendously bad to significantly impede patient care. From my very limited experience this just does not happen. Or rather, if it does, appropriate documentation is a single bullet in the long list of areas of improvement during an M&M.

What to do?

No regular programming here, but had there been any it would now have been interrupted due to my attending this year’s chief resident meeting. Which is in Disney World, of all places¹.

You can always follow me on twitter for the latest smart-ass comments.

I don’t care much for spelling or grammar. My native language, Serbian, has no concept of the former thanks to its being phonetic. As for the latter, few people in my home town and the surrounding area cared too much about it, flinging tenses, forms and declinations around carelessly. I proudly continue this tradition.

What gets to me is semantics. Misspelling tachypnoeic is unfortunate; saying that the patient’s head is normocephalic means either that it had grown a head of its own, or that the speaker had no idea what the word they were using signified¹.

So anyway, lots of big words and a sizable footnote just to introduce something I’ll likely be doing on a weekly basis—-complaining about today’s youth and their improper use of medical verbiage².

Carry on.