It is easier than ever to organize and attend a meeting, which should scare the living daylights out of anyone who doesn’t organize or attend meetings for a living. It used to be that only middle management had to deal with a series of 90-minute meetings all 15 minutes apart in which they had no specific role, which had no effect on their task list, and which left them no better off than they’d be if they had just read the minutes.

We are all middle management now.

My own experience with middle management was during chief residency and I learned quickly that the more administrative aspects of it just weren’t for me. But I also learned a few coping strategies, modified below for the video conferencing age.

• A short ad-hoc meeting is better than a long email thread. Email is a brilliant technology, but it just wasn’t meant for frequent back and forth between any number of people. It always amazes me when someone sends an email with five direct recipients and ten more addresses cc’ed, and then expects to have a productive conversation. Pre-2020 the excuse would have been that everyone was too far apart to attend a meeting, whether in another time zone or in a different building on campus. No longer.¹
• A short standing meeting is even better than an ad-hoc one. Few things in any line of work need someone’s immediate and undivided attention. Issues can usually wait: if one project is on hold because a decision needs to be made, there will be others to work on. If they can wait a full week, why not batch them and bring them up with your boss/employees/co-workers/contractors at a weekly meeting. If they can’t wait for more than a day, make it into a short daily meeting held at a set time. We have these meetings all the time in medicine — we call them rounds, and they have worked well for more than a century.
• Frequent short meetings are better than infrequent long ones. Setting one up used to be hard logistically: from booking the right sized room on time to making sure the timing works out for everyone — not to mention having to include a buffer for getting to the conference room and setting up AV. With that much overhead for a meeting of any length, of course the default was at least 60 minutes, if not a full hour and a half. Now even a 90-year-old can tap a link on their oversized phone to log onto that Zoom meeting while quarantining at home. The negligible cost of starting a meeting may mean they are more frequent, but it should also make them shorter. Much shorter.
• One day full of meetings is better than all five weekdays broken up with just a few per day. When in meeting mode, it takes me at least 30 minutes to get my bearings back to doing other work. Mode switching is a fixed cost and it’s best done infrequently. I therefore have a day dedicated to meetings, and if I have any say whatsoever in when a meeting will be held I try to do it then.² If you need to have a meeting on a different day, try to have it as a bookend — morning and afternoon rounds are a good example of this.
• Finish off a meeting with a task list and the designated person(s) for each task. You will probably have missed something, but that’s OK since you’re still at the meeting and others can fill in the gaps. Send off that list as an email to all attendees. Congratulations: you are now the meeting’s Most Valuable Attendee. If the meeting ends without anyone being able to come up with a single task, it should not have taken place. This is an important lesson. Take note of whomever called the meeting and try to avoid attending their meetings in the future.³
• Bonus tip: If you are setting up a one-on-one meeting with me, and you are the one sending out a calendar invite, do enter both of our names in the meeting title. I have too many meetings with myself on the calendar and it’s getting hard to keep track.⁴

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If you liked this, you may also enjoy my lukewarm take on handling email.

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.

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.

Many times during residency I looked for a table like this online. There weren’t any, so I decided to create one.

Ye’r welcome.

Source: Induru RR, et al. Managing Cancer Pain: Frequently Asked Questions. Cleveland Clinic Journal Of Medicine. 2011;78(7).

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.

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.

In the olden days, back when I could keep all my photos on Facebook, photo management was simple. I didn’t have that many to begin with; the ones I did have were grouped around events—birthdays, vacations, etc—and easily organized into albums. I also didn’t care much for privacy, or backups.

Then two things happened: iPhone 4S, and Dora. Every day became a photo-op, with two cameras in our pockets ready to shoot. The DSLR was still there for big trips and Dora’s modeling yet another outrageously expensive dress. This gave us:

• hundred of new photos and hours of video each month coming from four different sources (our two iPhones, a Nikon DSLR, and friends with their own cameras);
• no time to sort them;
• more respect for privacy, but at the same time a need to share baby photos with everyone;
• panic attacks whenever I thought about having to organize the mess of file names, formats, storage, and backup solutions.

We needed a good method to collect all the photos, organize them for easy access, retrieve them quickly for show-off purposes, and back them up both locally and in the cloud.

Having children usually comes at a point in your life when you care less about money and more about your time—though your progeny will do their best to relinquish you of both. The willpower-depleting effects of a toddler’s tantrum are also well-documented. No surprise then that many of the tools listed below have at some point sponsored a certain Mac-centric podcast that has destroyed many family budgets³. No regrets, though—it all works.

Collecting, with Transporter Sync

For simplicity’s sake, I like systems with multiple inputs to have one central gathering node. Unfortunately, our only desktop computer is a ridiculously noisy four-year-old Windows PC which sits in a usually occupied guest bedroom. The fans that buzz with the sound of a thousand bumblebees instantly disqualify it from a job as a media server, so I had to use my Macbook Pro. Thanks to Transporter Sync, that was easier than I thought possible for an SSD-only machine.

Transporter, similarly to Dropbox, has an iOS app that automatically uploads new photos to a predetermined folder. Unlike Dropbox, there is no monthly subscription—you pay once for the device, and keep using it as long as the hard drive is working. It can also act as a NAS-lite—having access to the folders kept only on the remote hard drive without them occupying the limited space of an SSD, through a Transporter Library folder.

Organizing, with Hazel

A folder full of unsorted cryptically named JPEGs and RAWs is less than useful when your parents want to see all the photos from that trip to Naples back in January.

Enter Hazel, the Swiss army knife of file automation. With the rules I’ve set up, it renames photos based on the date and time taken, tags them according to the device that took them, and moves them to the proper Year/Month subfolder. It does the same with our DSLR’s RAW files, placing them in a separate folder. Since the laptop only has 256 Gb, it moves any files older that three months to Transporter Library, the “special” folder kept only on the external hard drive.

We therefore have the last three months’ worth of photos and videos organized by year and month on the laptop, and our entire collection on the external Transporter hard drive.

Access, with Picturelife

In theory, we could get to all those photos using the Transporter iOS app, but we’re not a masochists. It’s slow, ugly, and not meant for browsing media.

Thank FSM for Picturelife! It sucks up all our new photos and videos from the Transporter—though we’ve excluded RAW files since we do have to pay for all that data²—presents them in a nice web and mobile app interface whenever we want it, and can pass them on to Facebook, Shutterfly, Flickr, or wherever else we choose. It will also, from time to time, send you a “this day in the past” email, with photos taken years ago. When you have as many unprocessed photos as we do, it is a great discovery mechanism.

Did I mention it can send photos to Shutterfly with just a couple of clicks? I still have flashbacks of the last holiday season, progress bar dragging glacially, the upload finishing just in time for me to miss the shipping deadline. Good times.

Backup, with Backblaze and SuperDuper!

Keeping everything on the Transporter and Picturelife as on-site/off-site backups would probably be enough for some. Unfortunately, counting on a VC-backed company that might at any point pull an Everpix to hold all our photos does not seem optimal⁴.

Which is way Backblaze and SuperDuper! keep copies of all those photos as a part of my general backup system¹. If you have a Mac and an extra external hard drive, you should also turn on Time Machine. This way, there are three local copies of all the photos, RAWs, and videos (Transporter, SuperDuper! image, Time Machine), a cloud backup of the same (Backblaze), and an easily-accessible collection of JPGs and videos (Picturelife).

Setting this up is neither cheap nor simple⁵, but it gives you quick and easy access to all your photos, has several levels of backup, and—most importantly—requires little effort to maintain.

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.

You can download the workflow here.