John Siracusa is a programmer. Merlin Man is a lifehack guru-cum-internet personality. If you are in a medical field, there is no particular reason you would know them.

They co-host a podcast that modestly has themselves as the subject matter. It is one of the best new podcasts this year, second only to CGP Grey’s (though with Road Work coming out this week, it may be a three-way tie). In this week’s episode, Siracusa had this to say about programmers (link to the audio here—it sounds better than it reads):

Plenty of people can espouse information telling some younger programmer “make sure you always call ‘srand’ before you call ‘rand’”, and they can easily tell you “don’t listen to that guy, you should not call ‘srand’ before you call ‘rand’”.

Neither one of them really understands it, because they can’t explain it. If that young programmer is saying “But why? But why? Why? How do these things work together? Explain it to me.” and they realize “Oh, I can’t explain it. All I have is this…”—it’s not a cargo cult, but it’s more like—”I have this practice that I’ve learned through supposed bitter experience that if I didn’t do this one time and something didn’t work, then I did do it, then it did work.” Very often in programming you can sort of learn that way where basically “I tried this one thing and it didn’t work, or this bug happened, then (I did) this other thing, and the bug was fixed”, and come away from that with a rule, or a heuristic, or something you think is an unwritten law without actually understanding the underlying…

Remind you of anything? In medicine, “cargo cult” is exactly
the term I would use. Programming’s saving grace is that it is a finite system created by humans, and—at least in theory—knowable. The human body is as black a box as it ever was—the only difference between now and the 1800s being a stronger flashlight.

So, programming clearly shares this with medicine: most of its practitioners don’t have a firm grasp of what they are doing, and don’t understand the underlying principles of their craft. Why, then, do we fool ourselves that adding programmers’ idiosyncracies to physicians’ by the way of electronic medical records, clinical decision support systems, and ultimately AI-run e-doctors, will somehow “fix” medicine instead of making it bad in a different way?

July 1st is when most US residency programs let their new interns loose after a week of corporate compliance training and ACGME-mandated talks about burnout.

If you are a medical student or a new intern, read this.

And this short post of mine still applies.

In addition, remember that it is easy to become very cynical very quickly. That is not the best of defense mechanisms, but it is better than substance abuse, domestic violence, or suicidal ideation. So, if you have to be cynical, do it up the chain of command, not down or laterally. That way you will avoid preconditioning medical students, observers, and your fellow interns. The senior residents will either support you in your jadedness, or will get to feel smug when they tell you that you are too young for that much cynicism. Your attendings should, ideally, teach you why you are wrong—though the younger they are the more likely it is they will behave like senior residents. So it’s a win for everyone, really, unless someone dings you for lack of professionalism.

Also, please remember to eat.

There are many misnomers in American medical English. Patients walk into your clinic (from Greek kline, bed) to learn whether their scan was negative (good) or positive (bad). Those who have severe chronic pain may ask for their pain medicine (that relieve pain, not cause it), usually opioids. Some physicians would call them pain-seeking (though what they are seeking is relief). If they don’t get a prescription, they may rate their doctor poorly on a patient satisfaction survey, which is a big thing if you are into quality improvement. Quality improvement. There’s a misnomer.

Quality improvement in medicine is by definition limited to improving things you can measure, i.e. quantify, i.e. judge by criteria that are the ying to quality’s yang. Those measures may be valid or not, and may improve patients’ lives, longevity, etc. (or not) but they are not quality. Because they are measures. Numbers. You know, quantities.

The movement is dangerous in at least three ways. Firstly and most obviously, many of the things being measured haven’t been validated in prospective trials. They are either (poor) conjecture—like tight glycemic control for type II diabetics assumed to help because of good outcomes in type ones (since, you know, a skinny teenager and a morbidly obese 60-year-old are similar that way.) Or they came out of a corporate think-tank cocaine-fueled outside-the-box brainstorming session, like patient satisfaction scores¹.

Secondly, even if they were the best measures in the world, tying them to promotion and compensation would have the unintended consequence of having practitioners loose sight of all other aspects of medicine, including the patient. There are many accounts of how it can happen—this one from Dr. Centor comes readily to mind—but since (1) identifying and (2) addressing the patient’s actual problem is difficult to measure objectively, it is not one of the benchmarks.

And finally, wherever there are numbers and money, techniques will evolve to game the system. David Simon’s account of how this happens in law enforcement is applicable. Want fewer central line infections? Enact a policy not to draw blood cultures from central lines! Too many nosocomial urinary tract infections? Urinalyses on admission for everyone! Hospitals create teams with dozens of people whose only job is to find new and better ways to do this. And they have to—because everyone else is doing it. A depressing amount of time, money, and effort wasted because of pointless exercises of anonymous pencil-pushers.

This is how you get to a near 3000% increase in the number of hospital administrators over 30 years. I am sure they are all good people, with good salaries, but they are, for the most part, insignificant. An epiphenomenon induced by someone’s desire to turn healthcare into an industry, forgetting that the six sigma ideology that works so well for toaster ovens can’t be forced onto moist, squishy, and fragile humans.

Which is also a good working definition of quality improvement.

“She makes the mistake of talking to patients.”

— Overheard from a fellow discussing the consult attending’s rounding habits

Is there such a thing as spending too much time with a patient? The question seems preposterous, when recent time motion studies showed that physicians in general, and residents in particular, clock embarrassingly few face-to-face minutes. The quote above was said with a wink and a nudge, but there are situations when it can be true, particularly if you talk to a patient—or get talked to—instead of having a conversation.

Two groups are at highest risk of talking too much—trainees and consultants. Many an internist remembers having to pick up the pieces after a consulting physician flew by the bedside to throw an unasked for opinion bomb. Think hematologists talking about insulin regimens, cardiologists about causes and treatment of back pain, or orthopedic surgeons about code status. “But one doctor said…” and a perplexed look is the usual outcome, more so if the consultant debated him or herself out loud.

Fellows are even more efficient sowers of confusion. Unlike some of their superiors, they still remember other fields well enough to a) have a valid opinion, and b) keep it to themselves. Where they are at highest risk for foot-in-mouth is the area of their future expertise—picking up just enough from the attendings to sound knowledgeable, yet not knowing enough to tell the patient what they don’t know. Even at later stages of training, a fellow’s best plan shared with the patient may tumble down when the attending gives a diametrically opposed recommendation. The common scenario is one in which there is no evidence, and clinical judgment rules. You can either not share your own view, or punctuate every conversation with “But we’ll see what my attending says.” More time wasted, and for nothing.

Patients themselves can be talkative, sometimes to their detriment. The reasons are many, and understandable: they have much to say about themselves—relevant to why they are in the hospital and not so much, they might not have anyone at home listening, they may have some level of delirium, dementia, or other cognitive disorder. Being able to identify such a person, and then knowing how to direct the conversation, is an unknown skill for most trainees and goes against today’s dogma of giving patients time to talk. No harm done to the chatty ones, but there are only so many hours in the day, and some of them should be spent thinking.

To be clear, we don’t have an epidemic of young doctors staying in the hospital until 2am while demented World War II veterans regail them with half-made up stories from Normandy. If only. But more isn’t always better, and physicians need to know when to speak up (to get their patient back on the topic), and when to stay quiet (not to overwhelm them with half-baked ideas).

First they came for the nerds.

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 detail¹. 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.

Another week, another Quora question.

What is an online resource for learning statistics needed for clinicians explained in a language that could be understood by doctors?

There are many biostatistics courses available on Coursera. Living in Baltimore, I’m biased towards JHU’s offerings. “Case-Based Introduction to Biostatistics” by Dr. Scott Zeger is a good one. If you prefer text to video, here are three good resources:

• An article: “A Review of Basic Biostatistics” by Kimberly Dukes and Lisa Sullivan (free PDF)
• A short book: “The Science of the Art of Medicine” by Dr. John Brush (free, iBooks only)
• A textbook: “Statistical Inference for Everyone” by Brian Blais (also free)

If I had to pick one, it would be Dr. Brush’s book. He is a cardiologist writing for other physicians in a language they can understand. Also, Dr. Lehman recommended it, which is more than good enough for me.

For the first time since joining Quora, I found a question to which I can meaningfuly contribute. Thought you might like to see my answer.

Why would someone choose to be a chief resident (in internal medicine)?

Why indeed.

The cynical answers would be “out of a misguided sense of loyalty to your program”. The correct and not very useful answer is—it depends.

Most positions entail primarily administrative responsibilities, with some teaching and clinical duties, and a salary just slightly higher than that of a PGY-3. So, you can expect your patient care skills to languish unless you work on maintaining them, your teaching skills to be slightly improved—or at least no worse if you’ve had some prior experience—and your knowledge of hospital administration, people management, dealing with email, and making the most out of seemingly pointless meetings to go through the roof. If you have any interest in academic medicine, as a generalist and sub-specialist alike, this last skill set will be invaluable. It is also a stamp of approval of sorts for any fellowship program director looking at your CV if and when you apply.

You also have much more free time. Depending on how many chiefs your program has, it will be most or all weekends, and almost all federal holidays. This is a good time to study for the boards if you haven’t taken them already, write up the research you’ve been working on, or spend some time with your family (the chief’s maternity/paternity leave is usually more flexible, but that’s program-dependent).

The downsides: you will have one fewer year of attending-level salary, so if you have a large debt or other financial responsibilities think twice before saying yes; some friendships you made with the junior residents will be undone or temporarily put on hold, unless you are very careful about not playing favorites; you may lose some respect for your higher-ups, as it goes whenever you peek behind the curtain; you will need to develop a thick skin, if you don’t have one already. Some would say these last two are actually pluses. It depends.

Visa issues complicate the matter, but I won’t go into details—bureaucracy shouldn’t play a role in determining a career choice, and when there is will (your own as well as the program’s) there is a way to bypass any obstacles.

Hope this helps.

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.

A key skill to have during oral exams back in med school was never to admit not knowing. Avoid the areas you’re uncertain of, dodge the examiner’s field of expertise as much as you can, and never ever say “I don’t know”.

These sage words were passed on from generation to generation, propagated by everyone, including me. Only, this wasn’t what I or any of my friends actually thought. It was a poke at the climate of intellectual dishonesty at our school, not a guide to success in medicine.

Starting residency, though, flips the sarcasm switch somewhere and the funny guidelines become instructions to be followed verbatim. The knowledge in question is different—patient data instead of textbook medicine—but the idea is the same. Observe the modern American intern’s vocabulary:

• Not that I know of (means I don’t know).
• I wasn’t aware of that (means I didn’t know).
• I don’t think it is (means I don’t know if it is).
• I belive so (means I have no idea, but yeah, maybe).
• It probably was (means I don’t have a clue but I did a D6 roll in my head and it was a 5).

I used all of the above, and more, during internship, but still get frustrated hearing it from others¹. If you are an intern, or anyone reporting patient data to a person above you in the pecking order, try using “I don’t know, but I can find out in a second” instead. Then start practicing your EMR skills to trully make it a second.

Observe George Carlin discussing how euphemisms are invading the English language:

I first heard a version of this years ago, back in Serbia, while I was still a med student. It hadn’t left much of an impression, but I can imagine myself nodding my head and thinking ha ha, yes, stupid Americans, ruining their own language, or something comparably obnoxious.

Well, I’ve, erm, matured since then. True, some euphemisms now inspire rage instead of vague amusement, like my two favorites:

• “I just wanted to let you know” instead of “I’m telling you”, and its relatives “Please let me know”, and “Thank you for letting me know”. Physicians are particularly fond of this, for we are the gatekeepers of knowledge, and the only reason you know something is because we are letting you. Don’t worry though, it’s not just you, we say that to each other all the time.

• “I don’t feel comfortable doing xyz” instead of “I don’t want to do xyz”, as mentioned here.

Most of them, though—particularly ones we use with patients—have a good reason to exist. The Radiolab segment which inspired this post made fun of “making someone comfortable” being used for dying ICU patients. Instead of… what, exactly? Euthanasia? There is a difference between giving someone drugs usualy meant for comfort—opioids, primarily—in order to kill them, and giving them opioids for pain and comfort knowing it may shorten their life.

Then there are turns of phrase used because they are euphemisms. “You should get your affairs in order”, “your time is becoming limited”, “at this point we should concentrate on quality of life, not quantity” are all ways of saying “I don’t know when you’ll die, but it will be soon, so start planning the funeral”. I am sure Mr. Carlin would appreciate getting it straight, but not every patient is as stoic. We can easily be more blunt if asked to do so, but you cannot un-hit a patient with a sledgehammer like that. So the default is to err on the side of softness.

Then again, most of the euphemisms we use with patients also make us more comfortable with the sitation. What I wrote above may then just be my rationalizing it away with a convenient it’s-best-for-the-patient mantra. In truth—to use another common phrase—euphemisitis is a multifactorial condition (as in, I have no idea what the reasons are, but it’s probably a little bit of everything).