It’s well-known that most common knowledge is false

Did you hear the one about not prescribing angiotensin receptor blockers to patients with ACE inhibitor-induced angioedema? I’ve had heated debates with residents in my old clinic who did not want to even consider ARBs for a patient with worsening diabetic nephropathy who’s had lip swelling while on an ACE-I ten years ago.

Or the one about not giving these patients amlodipine, since there are two—yes, two—case reports on amlodipine-associated angioedema? Should we also stop giving them water?

Then there are shellfish allergies and iodine contrast, fever and atelectasis, morbid obesity and hypothyroidism… No matter how many studies show these associations to be too weak to be clinicaly significant, or just plain false, there will always be an attending somewhere giving them as his or her pearl of the day.

We need some medical mythbusting for physicians, not just the lay public.

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How to spend a Monday morning train ride

The GTD weekly review does a good of job keeping my task list managable, but not all tasks and projects are equal. It’s good to have a sense of when you might have time for deep thinking versus mindless task processing—-something GTD doesn’t trully account for. I had been doing a variant of weekly planning since high school, until internship destroyed any hope of having a daily, let alone weekly plan. It’s time to start again.

And if you are not following Cal Newport’s blog already, you should. The man is a machine.

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No, there’s nothing wrong with your attention span

After skimming through the fifth long-form article about the increase in bite-sized consumable writing made for the short-attention-span—-dare I say “millennial”—-crowd, I became scared for my own tenacity. Would the 15-year-old me, the one who had read the LotR cover to cover, be horrified by this balding humunculus with twice the age and—-if you’d believe the articles—-half the attention span?

No, he would not. I can write that with confidence of a man who has just burned through the first two Dark Tower books exclusively while riding the subway. Get in at Union Station, actually sit down to read at Gallery Place, blink and I’m done with a chapter or two and arriving at Bethesda.

Stephen King is a hell of a writer, you see, and most of what you can find online—-this blog post included—-is derivative crap at worst, well-written nonsense at best. My brain jumping from text to text was its way of saying Dude, why are you punishing me with this drivel? Just get us a good book. So I did, and the percieved length of my metro commute has decreased by two orders of magnitude. Which is a convoluted way of saying that time flies when you’re having fun1.

But if you’ve never read a book in your life and are now devouring Buzzfeed like a horsefly in a manure factory—-sorry, there is no help. It is you.

  1. See above re: quality of online writing. 

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Which opioids are safe in kidney and liver failure?

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).

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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. 

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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. 

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Farewell, Squarespace.

Starting tomorrow, 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.

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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.

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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.

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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.

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