Two podcasts, three doctors, one good show

In the last two months, two of my must-listen podcasts, Systematic and Mac Power User, have had medical professionals on as guests. I don’t usually listen to medical podcasts—Twitter and saved PubMed searches are big enough firehoses—so I thought it would be interesting to hear how my more experienced colleagues use technology. Two of the three episodes were underwhelming, one was stellar.

It started with Brett Terprstra and Dr. Pamela Peeke on Systematic. She has several books targeted towards lay public, and the episode went in the same vein—broad advice on nutrition, well-being, etc. I cringed more than once, but that was to be expected—public health information relies on overplaying the risks and simplifying facts to the point of absurdity1. The one thing I could agree with was how important meditation can be, as mindful meditation might decrease physician burnout. Negative points for not mentioning Mindfulness in Plain English as essential reading, though I haven’t read Dr. Peeke’s own recommendation, The Miracle of Mindfulness.

I had higher hopes for Episode 169 of MPU, since Katie Floyd’s and David Sparks’s guest, Dr. Jeffrey Taekman, has an excellent productivity blog. Alas, McSparky spent more than half of the show being fascinated by the minutiae of what doctors do. Which is better than what followed—long periods of uncomfortable silence while the unprepared guest clicked through every app in his menu bar to see if there is anything worth mentioning2. There wasn’t.

Then another episode of Systematic came on, with Dr. Don Schaffner, a microbiologist3. It was outstanding. Brett was a better interviewer than David, and avoided getting too side-tracked by his guest’s interesting work. But ultimately, the show was good because Dr. Schaffner had useful tips and app recommendations that did not simply regurgitate the latest round of MPU/Mactories/Macdrifter/etc. sponsors. His paper review workflow gave me several ideas I will work on during the holiday downtime. He also suggested a promising contender in my quest to find headphones that will survive more than 8-12 months of intensive use.

One more thing for me to do during the downtime: promote Zotero. Between the developers fumbling Papers 3 and Mendeley being taken over by an evil corporation, Zotero coupled with a few extensions is the best reference manager on any platform. Coming in 2014.


  1. Much like weather forecasts

  2. OK, it was not total silence. You could hear Katie fuming in the background. 

  3. PhD, not MD. Wonder if that explains why the show was better. 

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Ten common residency idioms and phrases

  • 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.
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As a one-time interviewer and two-time interviewee…

…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?

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USMLE, ponovo

Dve i po godine od mog prvog teksta o polaganju USMLE-a, malo toga se promenilo. Goljan je i dalje odličan za patologiju (i više od pola Stepa 1), ali se u međuvremenu pojavila i Patoma. Potpuno su eliminisali dvocifreni skor jer je zbunjivao ljude. Zbog sve boljih prosečnih rezultata minimalni prolazni trocifreni će od Januara 2014. biti 192 umesto 1884.

Centralni deo pripreme i dalje bi trebalo da budu fleš kartice. Android tableti i telefoni su sada mnogo dostupniji3. Anki je i dalje prvi izbor, ali ne i jedini. Proces je jednostavan:

  • Pročitajte ovlaš poglavlje iz First Aid-a.
  • Za oblasti za koje je preporučen još neki (opširniji) udžbenik, pročitajte samo one oblasti iz tog udžbenika koji se spominju u First Aid-u2.
  • Pročitajte još jednom sekundarni udžbenik, dopisujući u First Aid stvari koje mislite da treba zapamtiti
  • Pročitajte još jednom First Aid, podvlačeći stvari koje mislite da treba da idu na fleš kartice1.
  • Napravite fleš kartice od svih podvučenih stvari iz First Aid-a, i svih stvari koje ste iz sekundarnog udžbenika ubacili u Frist Aid.

Ako ste sve uradili kako treba, na to poglavlje First Aid-a ne bi trebalo ni da se vraćate. Već ste ga prešli tri puta, a sve što još niste zapamtili je u karticama. Proveravajte se karticama svaki dan, u prevozu, dok čekate u redu, na dosadnim predavanjima. Zato je bitno imati telefon ili tablet.

Dva-tri meseca pred ispit, uplatite USMLE World, i počnite sa tim pitanjima. Kad sam poslednji put gledao, bilo ih je oko 3.000 za Step 1 i 1.800 za Step 2 CK. Mesec dana pred ispit uplatite neki od NBME testova, vidite gde ste i na šta bi trebalo da obratite više pažnje.

Sâm proces prijave za specijalizaciju se nije promenio5. Zbog novih medicinskih fakulteta sve više Amerikanaca bira internu medicinu, ali nema ništa manje FMG-eva. Neki programi će uvek pre izabrati Amerikanca sa lošijim skorovima od nekoga na J1 vizi sa 260 na oba stepa, ali ne svi, čak ne ni većina. Uvek je dobro znati nekoga u bolnici u kojoj se prijavljujete.

Da li uopšte vredi dolaziti ovde, kada ima toliko problema sa primenom ACA? Apsolutno.


  1. To su obično suve činjenie do kojih ne možete brzo doći povezivanjem stvari koje već znate. Ako ste imalo pazili na faksu, to nikako ne bi trebalo da bude ceo First Aid, pošto bi dobar deo tih činjenica trebalo da vam je već ugraviran u pamćenje. 

  2. Najbolji primer za ovo je mikrobiologija i Microbiology Made Ridiculously Simple. Čitajte samo o onim organizmima koji se nalaze i u First Aid-u, što je manje od pola knjige. 

  3. Iako su Apple uređaji bolji izbor za lekare, u Srbiji su i dalje preskupi i nedovoljno podržani. 

  4. Naravno, efektivni minimum za strance je i dalje oko 220 ± 10. 

  5. Ove godine i ja intervjuišem gomilu kandidata. Više o tome čim se završi ceo proces, sredinom marta. 

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30 iPad apps I use almost every day

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

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Peti oktobar 2013

Jutros sam ustao kad i Dora. Nije mogla da spava—zubi, valjda—pa sam je sinoć oko 11 smestio kod sebe u krevet. Ivana se tada još nije bila vratila sa posla, a kada smo se probudili već je bila otišla. Tako to ide sa dežurstvima.

Skajp uz doručak. Dora demonstrira svoj novostečeni ataksični hod (pra)bakama i dekama. Između poziva bacim pogled na Blic: imovinske karte ministara. Toma Jovanović je ministar?! Pre devet godina polagao sam kod njega fiziologiju. Ispit sam spremao četiri meseca. Posle pet minuta: Može devet? Može! Više vremena je proveo pričajući o tome kako je upoznao svoju suprugu. I ona je kod njega odgovarala, ako se dobro sećam.

Toma Jovanović je ministar? Prosvete?!

Idemo u šetnju parkom, na hibridnom trotinetu/kolicima, poklon od strica. Stric sad radi u Roterdamu. Otišao je kad je izgubio posao—ili je beše dao ostavku?—u Novom Sadu. U parku se sprema neko venčanje. Na jednom od travnjaka razapet šator. Izlaze dve devojke u sariju.

Dora je posle šetnje umorna. Dok drema instaliram kapiju za stepenište, dečije brave za fioke i ormariće. Ne sećam se da su moji roditelji to nameštali kad smo brat i ja prohodali. Opet, na sudskoj smo pričali koliko je kod nas skučajeva dece koja gutaju kaustične rastvore.

Nismo imali ni sedište za auto. Doduše, nismo imali ni auto dok nisam napunio 8-9 godina.

Sad imam auto koji sam plato manje od iPad-a na kome ovo kucam. Mobilni telefon mi čita otisak prsta. Od kuće mogu da pogledam MRI pacijenta koji sam naručio pre manje od 12 sati.

Nego, peti oktobar. Ovo je najbolji tekst koji ćete o tome pročitati. Ako još uvek imate sumnji, zamislite svet u kome se 11. septembar desio pre 5. oktobra.

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Šta se dešava u Vašingtonu

Napomena: američku političku scenu pratim koliko i kriket—znam šta je, čujem kolege kako pričaju o tome, i vidim poneki prilog na CNN-u, jedinom kanalu na TV-u u lekarskoj prostoriji.

Republikanci su se preračunali. Obamaker1 je izglasan dva puta—jednom u Kongresu, drugi put kada je Obama dobio drugi mandat a demokrate povećale većinu u Senatu. Sada misle da državnu upravu mogu držati kao taoca, dok se ne desi šta? Obama odloži sprovođenje zakona na godinu dana? Ha ha ha.

Valjda su se nadali da će novo individualno zdravstveno osiguranje biti spektakularan promašaj, i da će desetine miliona razočaranih i još uvek neosiguranih Amerikanaca vilama i bakljama krenuti na Belu kuću. Onda bi Bejner, Rajan i Bahmanova2 zajedno stali pred mikrofon i rekli U-ta-ta dok se demokrate ritualno samo-spaljuju isped Kapitola.

Na njihovu žalost, nešto je u glavama ljudi uvek bolje nego ništa, vesti su pune naslova o deci sa rakom koja ne mogu da počnu hemoterapiju jer je državni NIH zatvoren, tik iznad članaka o siromašnim invalidima koji prvi put posle 20 godina mogu da se osiguraju, a utisak koji republikanci sami potvrđuju je da su baš oni odgovorni za zatvaranje federalnih ustanova kako bi zaštitili zemlju od zlog i nedopečenog Obamakera.

Bejner verovatno proklinje dan kada su braća Koch rešila da sponzorišu/oforme ultra-desne Tea Party republikance. Za par dana ili nedelja skupiće dovoljno umerenih republikanskih kongresmena da se odblokira budžet i podigne granicu zaduživanja, i možda dobiti neki minimalni ustupak u vidu ukidanja nekog minornog poreza na medicinsku opremu. Obama 3, GOP 0.


  1. Affordable Care Act—ACA—je zakon koji, između ostalog, propisuje obavezno zdravstveno osiguranje za sve Amerikance. Onima koji do sada nisu mogli da ga dobiju, jer im ga poslodavac ne omogućuje a suviše su mladi za državno osiguranje i suviše bolesni za individualno privatno, obezbeđene su povoljne polise koje delom subvencioniše federalna vlada a delom pojedinačne države. Što se mene kao interniste i budućeg onkologa tiče, ovo je sjajno. Više osiguranih znači manje glavobolja za nas i pacijente, manje uplakanih morbidno gojaznih sredovečnih žena koje ne mogu da priušte zamenu kolena, i možda malo više posla za socijalne radnike koji će sada umesto sleganja ramenima moći da pomognu ljudima da nađu kakvo-takvo osiguranje. 

  2. Za neupućene u američku političku scenu—prvi je nakvarcovani, umereni i potpuno impotentni Speaker of the House, iliti predsednik donjeg doma Kongresa koji nema nikakvu kontrolu nad ultra-desnim krilom; Pol Rajan im je mlada nada koja pokušava da ima dobre odnose sa svima i bude glas razuma—dok ne otvori usta i pokaže da nema pojma o čemu govori; Mišel Bahman je njihova Nataša Jovanović, samo za dlaku fotogeničnija. 

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On RVUs, sort of

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.


  1. Relative Value Units

  2. Not his actual words. Actually, he sounded very apologetic when explaining it. Still stung though. 

  3. Hello, observation status. 

  4. At the same time? — a thought will come to them, to be quickly dismissed. 

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On patient notes and busy interns

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?


  1. Or in my program, six months ago. 

  2. They would be the ones calling the patient “a poor historian”, and were usually correct, although not in the way they intended. Patients are the ones giving a (hi)story, the physician is the historian. 

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Attending APDIM Chief Residents’ Meeting

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.


  1. Despite this, there have been worryingly few sightings of Mickey so far, and zero of Donald. 

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