What I learned and unlearned on bone marrow transplants

The average heme/onc fellowship program doesn’t have many “tough” rotations. The one that is universally feared is the erroneously named Bone marrow transplant service2. After spending six weeks on such rotation fresh out of (Chief) residency, I think I can understand—-though not agree with—-the reasons why.

It is not easy. The patients are either already, or about to become, extraordinarily sick, with little outward signs or symptoms to show it. Having cancer while not having an immune system is not a good combination, even if it is temporary. The ones who are months or years out from a successful transplant and still need to be hospitalized are usually miserable from longstanding severe graft versus host disease1. It makes for a tough bunch of humans to deal with day-to-day.

Then again, being on transplant service in an academic center can be the apex of your inpatient career. Months of residency spent on acute care floors and in intensive care units should have given you all the skills you need to do well. These are, in no particular order:

  • Clarifying ambiguity: The rounds are over, attendings and consultants have dispersed, and you have just heard more facts about T-cell activation than you realized existed. But—-do you know if that febrile-but-not-neutropenic patient should get an antibiotic? What’s that other patient’s target Tacro level? Send CSF for flow, or just give intrathecal Methotrexate? If those aren’t clear, you should have asked more questions, and not of the “Which cells have IL-6 receptors?” kind.
  • Identify attending priority: This is often the biggest cause of ambiguity. Between the floor attending, the study PI, staff ID consultant, and various other consulting services, whose advice do you heed? Not always the same person’s, and not even in the same order. Not much you can do, except be aware of it, and not follow everyone’s advice as soon as you hear it.
  • Asserting your autonomy: With all this asking and following, you may rightly ask if you were anything more than a glorified intern. In the field of hematology, oncology, and infections that affect this population, you most certainly are—-you are, after all, still in training. Not so for most other matters of internal medicine. Blood pressures, fingerstick, TSH levels—-if you are comfortable managing them, let the team know.
  • Being there early: An important trait often forgotten by senior IM residents. Just getting there an hour earlier than anyone else to get the work done makes you look like a superstar. One hour in the early morning save three in the late afternoon.
  • Dictating right away: Like, pronto. The answer to “How many pending dictations do you have” should always be “Zero”. It’s easier for you, and is just good patient care. No excuses.
  • Writing everything down: This is How to be an intern 101, but being at least two years removed from internship can make you stupid. Carry the patient list and a good pen with you at all times. Yes, that includes the restroom.

Nothing here is particular to transplants—-it is just good inpatient medicine. Which may be why so many oncology fellows loathe it—-it is, after all, an outpatient specialty. Then again, stem cell transplants are one of the few therapies we have that can cure cancer.


  1. Which is not to say that everyone who had a stem cell transplant is miserable—-a mistaken belief many oncology fellows have after the rotation, and a clear example of selection bias. 

  2. Most stem cells used for transplants are now harvested from the peripheral blood, not the bone marrow. 

more ...

What is the evidence for that?

This has become the mantra of every medical student, intern, and resident wanting to appear smart on rounds and conferences, of every attending intent on shooting down a team member’s suggestion. Five, ten years ago it might have have signaled genuine interest. Now it means, usually, “I don’t know anything about the subject, but I’m still calling you out on (what I think is) your BS. Here, look at me! I am evidence-based!”

No, nobody has posed me that question in quite a while, and I don’t remember ever asking it in any context1. But, honestly, except for a few very well-known examples listed in this excellent post, you can find “evidence” in the medical literature to back up any claim. Off-the-cuff conversations during lectures and rounds are not the best place to dissect them, especially when one side has seniority.


  1. Although I understand asking questions means showing interest, I’ve always preferred looking things up myself. This would make me appear either very smart or very dumb, depending on whatever subcontious impression I made on the person in the first few minutes of us meeting. Try to use the halo effect to your advantage. 

more ...

Moj prvi dan na poslu

Između spremanja Stepova i iscrpljujućih unutrašnjih monologa o smislu USMLE-a, univerzuma, i svega ostalog, različite tehnike vizualizacije konačnog ishoda mogu vam pomoći da savladavate unutrašnji otpor prema uspehu.

Vizualizujte ovo: veliki metalni čekić koji vam ritmički razbija lobanju u komadiće—-frontalna kost na jednu stranu, zigomatična na drugu, gle, delići sive materije lete ka plafonu; sumo rvač koji vitla tim čekićem dok vam sedi na leđima koristi svoju drugu, slobodnu ruku da vas golica ispod pazuha, dok na raskrvavljeno uvo šapuće stihove Bodlera—-na latinskom; kolega čiji je čekić stoji pored vas i preti da će vas tužiti ako mu odmah—-Odmah!—-ne vratite isti; a vama se piški.

Dakle, moj prvi dan.

Hteo sam da dođem bar jedan sat pre početka smene, ali sam se izgubio, lutao bolnicom, i jedva stigao na vreme. Poneo sam mantil, ali ne i stetoskop. Čekalo me je devetoro pacijenata koje je trebalo da upoznam, pregledam, dokumentujem, itd. za nepunih sat i po. Bili su raštrkani na tri zgrade i četiri sprata, skoro svi na kontaktnoj izolaciji1.

Od tih devetoro, najduži boravak imala je pacijentkinja sa već trideset i nešto dana bolničkog staža. Za dodatnih dvadeset koliko sam je ja pratio, završila je na dijalizi, dobila manji infarkt, dva stenta, masivni šlog, i napustila bolnicu sa balom na bradi i cevčicom u stomaku. Diktiranje njene otpusne liste trajalo je dva sata.

Desetog pacijenta primio sam istog dana oko četiri popodne. Bio je mršav, žut, sa transplantiranom jetrom koja otkazuje i ženom koja radi u bolnici. Skoro dve nedelje ležao je u sobi 6012—-da, još uvek pamtim broj—-da bi sâm kraj života proveo u hospisu. Ovo tada nisam znao: ako ste u bolnici, dve stvari koje vam nikako ne trebaju su loša jetra i rodbinske veze. Još nešto što nisam znao: šta je kog đavola hospis?

Dan koji je počeo u 5:30 ujutru završio se nešto posle 11 uveče. Do odlaska kući počeo sam da mrzim: pejdžere, kontaktnu izolaciju, kompjuterski sistem, papirnu dokumentaciju. Zavoleo sam: …

Ništa. Prvog, a ni sledećeg, ni onog posle. Doručak je bio u 5 ujutru, večera u 10, ručak sam preskakao. Vikend je bio dan za pranje veša, kupovinu hrane, i spavanje. Srećom, samo prvih par nedelja.

U jednom trenutku—negde oko 4. jula, kada se zbog praznika smanjio broj pacijenata—shvatio sam da imam vremena za kafu pre vizite2, pa i za podnevna predavanja uz—-besplatan!—-ručak. Počeo sam da pronalazim prečice između spratova, naučio da nikada ne treba koristiti lift. Na trogodišnjoj specijalizaciji, dve-tri nedelje za upoznavanje sistema i nije tako mnogo. Ne bi bilo ni dva-tri meseca.

Zato, ne dozvolite da vas spremanje USMLE-a previše potrese. Najgore tek sledi.


  1. U vreme kad sam ja bio student—-ne znam da li je tako i sada—-neki hirurzi su zaboravljali da operu ruke i navuku sterilne rukavice pre postavljanja centralne linije. Gel-odora-rukavice pre ulaska u svaku sobu bio je kulturološki šok sa jedne strane, gubljenje dragocenih sekundi sa druge. 

  2. Vizita = “rounds”, možda, valjda. I da, “imati vremena za kafu” znači 5 minuta za kupovinu kafe za poneti, ne pola sata-sat za divanjenje uz cigarete. 

more ...

Farewell, Squarespace.

Starting tomorrow, miljko.org will no longer be on Squarespace. Instead, it will be a Pelican-generated static site hosted free of charge on GitHub Pages.

Squarespace is an excellent service, for those who don’t have the knowledge, time, or ambition to muck around with self-hosted websites, but have enough readers to justify the $8/month subscription. My long commute gives me more time to play with Python, git, vim, etc, and the $96 renewal charge was due this month. It was an easy decision to make.

Having most of my posts saved as markdown files payed off, as it is currently impossible to get a clean conversion of old Squarespace articles to Pelican. Some links will be dead, some images temporarily unavailable, and the three of you reading this via RSS will need to resubscribe.

That is all.

more ...

Research during residency

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.

more ...

Down the vim rabithole

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 (nay, three) 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 Spring. That is probably for the best.

more ...

June 2014, final tally

  • 4 books read: Ocean at the End of the Lane, Tenth of December, The Golem and the Jinn, Ubiq
  • 2 books re-read: Getting Things Done, Mindfulness in Plain English
  • 1 book half-way through: Embassytown
  • 2 computer games completed: To the Moon, Bastion
  • 3 tabletop games played: Dixit (3 sessions), Pandemic (2), Eldritch Horror (4)
  • 1 used minivan purchased
  • 1 article, 1 abstract submitted
  • 61 km ran
  • 1000+ toddler photos taken
  • 0 tedious field trips made

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.

more ...

Goodbye, Sinai

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.

more ...

Three tech tips for new interns

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.

more ...

Managing photos with Transporter, Hazel, Picturelife, and Backblaze

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.


  1. Backblaze will back up the Transporter Library folder, since it doesn’t count as network-attached storage. It doesn’t back up NAS drives. 

  2. We keep RAW files in a separate folder, one that’s not on Picturelife’s monitor list 

  3. Which is why this post has affiliate links. 

  4. That being said, Picturelife is the best of its kind and I strongly recommend it. 

  5. I thought about illustrating it with a diagram of a Rube Goldberg machine. 

more ...