Yes, but why?

This website is:

  • a public repository of articles, lectures, and other original works I authored or co-authored;
  • a place to repost comments, reviews, and recommendations I wrote on other sites (like Quora, Amazon, etc);
  • a place where my half-baked ideas and philosophizings go if I think them interesting enough for general consumption.

This last one is what gives me trouble. Ideally, if I think a topic is worth writing about, I should make the extra 3-day effort to gather references, edit it nicely, and have it published. But like the character in “The bridge on the Drina” who means to be the town chronicler but can never find an event worthy enough to write about, most subjects have me less excited the more I think about them. By the time I finish a blog post, then, I have no intention to revisit the matter.

This is an excellent filter against appearing foolish in print, but horrible for productivity.

Two solutions come to mind readily, with equal chances of failing—either stop posting the third category of articles altogether and start writing everything with an intention of publishing; or start writing even more with the hope that at least a small percentage of that will turn into something a journal would accept for publication.

The former is a set-up for procrastination, the latter—doing extra work in a hope to create material for even more work—oxymoronic . I will try both and see where I end up.

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Locked in

Two years ago, I haplessly expressed excitement about my task list manager of choice being updated soon.

It hasn’t yet. Two iterations of iOS and an Apple Watch later, Things 3 is still not available, and I am becoming increasingly annoyed. Inside my mind, two kinds of costs—Ms. Sunken and Mr. Opportunity—are battling it out.

Mr. O has me thinking about time wasted on not being able to turn a next action into a project; or having to make too many taps to edit anything in the iOS app. And then I stress out even more contemplating all the features I don’t even know I’m missing out on—not wanting to find out about those is why I not dare read reviews of the competition.

Ms. S, meanwhile, is raising dread whenever I thinking about moving to Omnifocus, Taskpaper, or whatever the GTD app du jour is—knowing that I would be trading a set of known deficiencies for a potentially grater set of unfamiliar ones.

The mister and missus are irrational beings—even though Things 3 remains vaporware, there have been a few 2.x updates that iOS7-fied the experience—from going flat to adding extensions and notification center widgets. All that considered, I should not spend so much time thinking about an app.

And yet, it is 6pm on January 2, 2016, and instead of writing about getting back to the lab, finally finishing the PhD thesis, or being a haughty gastro-tourist in unseasonably warm New Orleans, I am being much too first-worldly for my Balkano-Serbian comfort.

Which I will add to the pile of absurd reasons for why I dislike Cultured Code.

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Sve se vraća

Brzo: koje su još uvek profitabilne izvozne industrije u Srbiji?

Poljoprivreda, OK.

Ljudi, naravno.

Još nešto?

Uopšte nije teško.

Ovakvi naslovi:

Vučić i Dinkić spremaju izvoz oružja Arapima!

se brzo zaborave. A onda vam ljudi sa progrešnog kraja nišana koji ste prodali u trideset i petom poslovnom poduhvatu stoleća zakucaju na vrata.

Zatim pročitate gde evropski teroristi nabavljaju oružje (za nestrpljive: u Briselu), i spisak najvećih uvoznika srpskih rukotvorina vam postane jasniji (Belgija je bila na četvrtom mestu).

Ovo nije problem samo sadašnje vlasti—i prethodnici su se ponosili dostignućima srpske metalurgije.

Zato mi je drago što se Srbija—i ljudi i državne strukture—prema izbeglicama ophodi bolje nego komšije. Ali, nemojmo se pretvarati da je država samo nedužni posmatrač onoga što se dešava na Bliskom Istoku.

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Can you post to a Pelican blog from iOS?

It looks like you can, provided you have a server running somewhere. Mine is a 2013 MacBook Pro with a dying battery.

This one I’m writing in Drafts, which will then copy the post to a Dropbox folder monitored by Hazel. This should trigger a simple bash script that processes the markdown file and pushes the newly created html files to github.

Very Rube Goldberg-y, I know. I’ll try doing it from Editorial next.

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High-dose cyclophosphamide for GVHD prophylaxis

That high-dose cyclophosphamide is being used for haploidentical donor transplants is well-known in circles that know what haploidentical transplants are. When I saw that Hopkins transplanters used it as single-agent prophylaxis in HLA-matched related donor transplants, I was intrigued enough to do a full literature review. This is the result, presented as a slightly-too-long fellow lecture, all 100+ slides of it.

Since I have a hard time remembering facts unless I know the history behind them, the section about the works of Dr. George Santos is rather long. It was also important to show that crude animal models can be both helpful (in telling you that higher doses of cyclophosphamide work better for GVHD prophylaxis that lower) and misleading (in making you think high-dose Cy is toxic to hematopoietic stem cells, thus changing your clinical trial design).

Error: Embedded data could not be displayed.

You can view a full-screen version of the slideshow here.

As this may be incomprehensible without someone explaining the slides, I may one day upload a version with a voice-over.

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Programming, meet medicine

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?

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Lečenje u NIH-u

Jedna od mnogih stvari po kojima se NIH razlikuje od ostalih zdravstvenih ustanova je da pacijenti ne plaćaju ništa. Zdravstveno osiguranje nije potrebno, lekovi—od kojih mnogi koštaju $1.000 po dozi—se samo pokupe u apoteci, a ako živite daleko od Betezde platiće vam (domaći) let, voz, gorivo. Do pre 10-15 godina plaćali su i hotele, sada je tu samo dnevnica od $50.

I meni najzanimljivije—ne leče samo državljane. Štaviše, na nekim protokolima ima više legalnih i ilegalnih imigranata iz Centralne i Južne Amerike nego Amerikanaca. Ko god se pojavi na pragu instituta i ispunjava uslove za upis na studiju može da računa na američke poreske obveznike. A niko neće oterati nekoga ko je veoma bolestan ali ne ispunjava uslove, naročito ako standardnu terapiju ne može primiti kod kuće.

Zato svaki put kada čujem da se u Srbiji skuplja desetine i stotine hiljada evra da bi se neko poslao na lečenje u Italiju, Rusiju, ili Nemačku, pomislim na stvari koje se rade ovde i da li bi one pomogle. Ima ih previše za nabrajanje, tako da je najbolje otići na—sajt koji ima podatke o svim aktivnim studijama koje finansira NIH—i pogledati da li postoji nešto što se izvodi (ne samo finansira) ovde. Ono što sam video u poslednjih godinu dana, bez nekog reda:

  • aplastična anemija
  • srpasta anemija
  • B-ćelijski limfom
  • primarni CNS limfom
  • transplantacija koštane srži/stem ćelija za mijelodisplastični sindrom, akutne leukemije, limfome
  • Kapoši sarkom
  • hairy cell leukemija
  • hronična limfocitna leukemija
  • primarni efuzioni limfom
  • limfogranulocitoza
  • LGL leukemija
  • metastatski ili neresektabilni rak pankreasa
  • hepatocelularni karcinom
  • holangiokarcinom
  • metastatski rak debelog creva
  • metastatski rak jajnika
  • trostruko-negativni metastatski rak dojke
  • metastatski rak grlića materice
  • rak bešike
  • rak prostate rezistentan na hormonsku terapiju
  • metastatski rak pluća
  • mezoteliom pleure i/ili peritoneuma
  • timom
  • adrenokortikalni karcinom
  • metastatski melanom

Ovo ne uključuje pedijatrijska oboljenja, kojih ima još toliko. I ne uključuje bolesti koje sam video van Instituta, pošto vam u drugim akademskim centrima u Americi računi stižu iako ste na studiji.

U većini slučajeva se nekome iz Srbije sa metastatskim rakom ne bi isplatilo da prelazi okean kako bi primio eksperimentalnu terapiju čija se efikasnost još istražuje. Ali, treba se raspitati—mogu da zamislim situaciju u kojoj bi itekako vredelo.

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A yearly welcome

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.

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The overhead

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.

  1. Some speculation on my end there. They might have been on LSD

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