Software is Fragile

yay-689848By now everyone has heard of the Heartbleed bug.  Prior to that Apple had its “Goto Fail” bug.  Magic tricks seem obvious once they have been explained.  In the case of Heartbleed, the programmer forgot to put a limit on the amount of information that could be requested in a packet, thus exposing information that was nearby in memory, which could be the very information that a secure protocol is supposed to hide.  In the case of Goto Fail, the admonition to always enclose blocks of code in braces, even if it is a single statement, was ignored, so that an extraneous goto statement ended up always being called, thus aborting the security checks that the protocol was designed to implement.  These two high-profile software bugs have drawn attention to how the integrity of the Internet depends on some very obscure code written by some very obscure programmers.  The Heartbleed code is in an implementation of the SSL security protocol and it is open source, meaning anyone can view the source code.  This theoretically makes it easier to find bugs, but this is true both for the bad guys who want to exploit the bugs and the good guys who want to squash the bugs.  The system works if there are more good guys looking at the code than bad guys  Despite the immense profits corporations make from the Internet, these companies don’t spend much money to support the development of the underlying code that allows the Internet to function securely.  It took two years for the good guys to find the Heartbleed bug (it’s not clear if or when the bad guys found out about it).  I have a feeling more effort is going to be put into this now.  Don’t be surprised if other similar bugs are discovered.  This would be a good thing, because no complex software is bug-free, and bugs discovered can be fixed.

I had my own mini-Heartbleed bug recently.  I don’t write mission-critical code, but still it is important to me that what I write works properly.  A doctor wrote to me that my EP Mobile app had stopped working.  He had an tablet running Android 4.3 and when he tapped on a item in the main menu, nothing happened.  This was odd because the app worked on my phone and tablet, as well as on the simulators that come with the Android software development kit.  The menu code was one of the first bits of code I had written, several years ago.  I was new to Android programming at the time, and I think I basically copied it from one of my Android programming books.  Reviewing the code, it seemed extremely straight-forward and simple.  At first I couldn’t imagine what the problem could be.

Well, to make a long story short, and not to get too technical (and you can skip this paragraph if you don’t know/care about programming) the problem was in this code:

CharSequence selection = ((TextView) view).getText();
if (selection.equals(getString(R.string.calculator_list_title))) {
}  // etc.

This is code that shouldn’t work, but almost always does.  The error is that selection is a CharSequence, which is not the same as a String.  Thus you shouldn’t be able to compare selection with a String using selection.equals().  According to the Java standard, the results of such a comparison are undefined.  The problem is that this code works — most of the time — even though it is erroneous.   There is no error generated and everything seems to be hunky-dory until you get an email from a user who says that the app isn’t working.  The solution is to convert the CharSequence to a String using the toString() method.  It seems easy in retrospect.  The trick is figuring it out ahead of time.

Software is inherently fragile.  A simple Google search finds lists of epic software fails, such as this one.  The results of software mistakes range from mere embarrassment to the destruction of billion-dollar space missions or the death of patients from overdoses of radiation therapy.  We entrust so much to software nowadays.  All our medical records are in computer databases.  Our financial transactions are online.  Our cars and jets are computer controlled.  It is sobering to think that a misplaced semi-colon or brace buried deep in some systems code somewhere could reveal my credit card information or worse make a plane fall out of the sky.  Software, like a person, is inherently complex.  We have to throw as many resources as possible towards improving it, including improving the tools we have to check for software errors.  But we can’t expect perfection.  We have to do the best we can.

Complexity is never simple.

The Root of All Evil

The Tower of Babel

The Tower of Babel

Imprecise language may not be the root of all evil, but it runs a close second. The ability to communicate may be the most basic characteristic that makes us human. If we lose that capability, all sorts of unintended consequences ensue, à la the Tower of Babel.  Which brings us to the recent US Supreme Court decision, McCutcheon vs FEC, overturning limits on aggregate federal election funding.  Chief Justice John Roberts wrote “The government may no more restrict how many candidates or causes a donor may support than it may tell a newspaper how many candidates it may endorse.”   In this ruling the exchange of money has become synonymous with freedom of speech and of the press.

Imprecise speech is sometimes related to tendencies people have to overgeneralize or to use euphemisms so as not to offend.  But it can also be used to advance an agenda or just plain distort the truth.  Just as atheism is not a religion but the lack thereof, and the fact that there is a theory of gravity does not mean that gravity is just a theory,  so money is not speech.  Speech refers to words coming out of people’s mouths, and, by the slightest stretch, those same words written down. When the Supreme Court in 1989 decided that burning a flag was a form of speech, the floodgates of overgeneralization were opened.  I am not against protecting non-verbal and non-written forms of expression under the law. I think they should be protected. I can understand that it’s a lot of trouble to write a new law saying art or music or flag-burning is a protected form of expression akin to speech and expect it to get passed. It’s a lot easier just to interpret the existing First Amendment to cover these particular cases. But once starting down this path, it’s hard to know where it stops. Language becomes devoid of meaning.  Fuzzy language begets fuzzy math.  One plus one can equal three, a corporation is a person, and the exchange of money is a form of speech, protected under the First Amendment.

In the US Constitution it is apparent the founding fathers understood that money was not the same thing as speech.  The Constitution talks a lot more about money than it does free speech and does so in different contexts.  Words for money (money, commerce, revenue, tax, coin, dollar, treasury) are used 30 times in the Constitution.  Words for speech (speech, debate) are used only 3 times. In fact, the First Amendment is pretty much all the Constitution says about speech:  “Congress shall make no law … abridging the freedom of speech.”  It’s not as if the founding fathers ever confused the two concepts. Perhaps the founding fathers would have responded to this Supreme Court decision equating money and speech with the immortal words of Inigo Montoya: “You keep using that word. I do not think it means what you think it means.”

Now that money and speech are the same, so that giving vast sums of money to politicians is just a form of protected free speech, not implying quid pro quo, I wonder if our beloved politicians, the incorruptible beneficiaries of this largesse, will ease up on the laws that prohibit gifts to others. Maybe we doctors will again be able to receive a free pen from a drug company without the suspicion of quid pro quo.  After this Supreme Court decision, how can the pols make laws regulating any donations of money or goods to any professionals, when they themselves are not subject to such regulation?

It may be that I am not crediting the court with enough guile. There may be method to their madness. Perhaps they came to this decision just to show the reductio ad absurdum of equating money and speech, with the intent to force us finally to change our non-democratic plutocracy into something more equitable.  It would be wonderful if this decision effected changes in campaign financing and lobbying laws. Otherwise we are sliding down a very slippery slope indeed.  If the Court has such an agenda I would be surprised.  It appears this latest decision is just a natural consequence to the logic (or lack thereof) of the Citizens United ruling.

The mechanics of elections are the foundation of how our government works. Why should any 9 people (let alone people like Antonin Scalia and Clarence Thomas) have such an influence on this fundamental mechanism? But where is the impetus to change the system when those who have the ability to change it, our elected officials, have nothing to gain and everything to lose?

So that’s why I would vote for imprecise language as the first runner up in the competition for the root of all evil. The winner? Money, of course.

Thematic Unity in Rachmaninoff’s Second Piano Concerto

Rachmaninoff at the time of the 2nd concerto

Rachmaninoff in 1900, the period the 2nd concerto was composed

Rachmaninoff’s second piano concerto (1901) was written after a course of psychotherapy for depression that the composer suffered following the disastrous premier of his first symphony.  Apparently this treatment worked, for the concerto is one of the most popular ever written for the instrument.  Its popularity stems not only from its lyrical themes but also from its remarkable construction.  Unlike some other works by the composer there is no excess in this concerto.  It was never revised or needed revision, in contrast to his first and fourth concertos which were revised multiple times.  His popular third concerto contains several ossias (alternative passages), including two different versions of the first movement cadenza.  There are several optional cuts in the third concerto, sanctioned and indeed played by the composer, though today these cuts are rarely made in performance.  The second concerto in contrast has no ossia passages, no first movement cadenza, and one can’t conceive of any place where it could be cut.  In particular the first movement of the second concerto is about as tight and economical a piece of music as Rachmaninoff ever wrote.  There is a remarkable thematic unity throughout the concerto that contributes greatly to the impression it makes on the listener.  I would like to focus on this aspect of the concerto.   Some of the observations I make have been noted by others, in particular in the detailed 1990 Rachmaninoff study by Barrie Martyn.   I have read many books on piano concertos and Rachmaninoff in particular as well as many liner notes over the years and so it is difficult to remember exactly where each idea came from.  Keep in mind this is just a blog post and not a scholarly article!   Also note that the concerto, published in 1901, is in the public domain, even under the crazy copyright laws of the United States (incredibly a work published in 1923 will not go into the public domain until 2019, thanks to the Sonny Bono Copyright Extension Act of 1998).   The score is available for download from IMLSP.

The opening of the concerto is announced famously by a series of solo piano chords, clearly a bell-motif similar to the chords that close the famous C sharp minor prelude.  Rachmaninoff was fascinated by the tolling of bells, as is evidenced in many of his works, especially his liturgical pieces (he even wrote a symphonic poem entitled The Bells, after the Edgar Allen Poe poem).  Here is the beginning of the concerto:


Opening chords

The quarter-notes in the last bar, boxed in red, are important, but I will return to them in a moment.  The opening chords are simple but striking.  It takes a large hand to play them unbroken, and it is a little curious that Rachmaninoff himself, despite his double-jointedness from Marfan’s syndrome and hands that could reach a twelfth, breaks the left hand chords, playing the bottom F a moment before the beat in both his recordings.  I suspect he did this for musical rather than mechanical reasons.  Players of his era often rolled chords or otherwise embellished the score to an extent that today’s players rarely do.  In any case, Rachmaninoff’s own performance certainly sanctions the non-simultaneity of all the notes of these chords, for those players who lack the hand span to play them unbroken!

The question arises, did Rachmaninoff reuse these opening chords later on in the concerto, or did he “throw them away,” much as Tchaikovsky threw out the whole opening theme of his 1st concerto, which is never referred to again in the rest of the work?  As it turns out, the same chord sequence (in fact the exact same chords) appear in the orchestra in the beginning of the third movement (in the green box):


Bell theme in 3rd movement

It may not seem too curious that Rachmaninoff would reuse these first movement chords in the third movement. It does seem more curious when one realizes that the first movement of the concerto was actually written last, after the final two movements were written and originally performed.  Almost a year separates the performance of the last two movements and the first performance of the complete concerto.  One could imagine that Rachmaninoff already had the first movement in mind when he composed the last two movements.  Or perhaps some of the first movement themes were drawn from the third movement.  It is also possible that Rachmaninoff further revised the last two movements after composing the first movement, thus introducing the first movement themes.  I don’t know if there are manuscripts extant that would reflect this, but it is an interesting question, especially in light of the multiple shared themes throughout the concerto.

Returning to the opening bars, in the last measure there are four notes (F-A flat-F-G, boxed in red) that at first glance (or hearing) may seem to be just a grand flourish leading to the main theme of the movement, but actually they turn out to be the pervasive theme of the movement, gradually becoming more and more important throughout the development section and eventually usurping the recapitulation of the movement.  The four note theme makes multiple appearances.  For example, it is hidden in the lyrical second theme of the first movement (boxed in red):


1st movement, 2nd theme

During the development, it appears as an accompanying flourish in the woodwinds to the 1st theme in the strings:


1st movement, development

Here the theme is mutating, preceded by two repeated notes, and becoming a little more martial in character.  The piano takes over, with a more scherzando mood, again featuring the four note theme:

1st movement, development, piano

1st movement, development, piano

There is an interplay between this four note theme, the theme of repeated notes and the 2nd theme which builds up to the recapitulation.

1st movement, further development

1st movement, further development

The start of recapitulation has a completely different character from the exposition.  The martial theme is in the piano and the orchestra accompanies with the first theme.

1st movement, recapitulation

1st movement, recapitulation

A lyrical version of the four note theme is present throughout the recapitulation of the second theme, altering its character quite poignantly:

1st movement, recapitulation 2nd theme

1st movement, recapitulation 2nd theme

This leads to some wonderful harmonies (see my post on this) and then the coda.  Not surprisingly, the four note theme is present even here:

1st movement, coda

1st movement, coda

Rachmaninoff is not finished with this four note theme, as he quotes it in the second and third movements too:

2nd movement, bridge

2nd movement, bridge


3rd movement, beginning

3rd movement, beginning

3rd movement, passage-work

3rd movement, passage-work

It is even possible that the famous “Rachmaninoff signature” with which he ends this and also the third concerto is derived from the repeated note martial manifestation of the four note theme:

3rd movement, end

3rd movement, end

This four note theme is not the only theme that pervades the concerto.  For example, consider the transition between the first and second themes of the first movement.  Rachmaninoff prior to the premiere performance of the movement had a relapse of his perennial self-doubt, fearing the transition was too abrupt.  The transition in actuality is quite clever and is a good example of the economy of the whole first movement.  The transition begins with a brief elaboration by the piano of part of the first theme, followed by an accelerando with rapid piano passage work, followed by rhythmic tonic and dominant chords in c minor (a foreshadowing of the martial mood of the recapitulation).  After this there is a rising arpeggio in the orchestra culminating in a tutti chord, some syncopated triads in E flat major, and then the 2nd theme.  The rising arpeggio foreshadows the second theme, as it is based on a similar arpeggio:

1st movement transition to 2nd theme

1st movement transition to 2nd theme

1st movement, start of 2nd theme

1st movement, start of 2nd theme

The second theme of the first movement bears a certain similarity to the famous melody of the third movement.  Both feature a right hand melody in octaves against left hand quavers.  The third movement melody is long and more intricate, rising to a climax which is used to effect in the final orchestral tutti.  The first movement melody is more limited.  Again note the rising figure with which it begins in the blue box.  Now one can see that the third movement melody also quotes this phrase:

3rd movement, 2nd theme

3rd movement, 2nd theme

In case you think this is a coincidence, Rachmaninoff takes pains to quote this rising phrase at the very end of the 2nd movement.  One can’t hear the unexpected A after the G sharp without getting a sense of deja-vu reflecting back on the 2nd theme of the first movement.

2nd movement, close

2nd movement, close

As always with this kind of analysis,  I could go on, though other than to the hard-core enthusiast of deconstructing works of classical music, I probably made my point quite a while ago.  Perhaps some if not most people just want to listen to the music without trying to understand how it is put together.  Musical analysis to some is akin to revealing how a magician does his tricks and thus spoiling the effect.  I suspect though that if you have read this far you actually, like me, find this interesting.

To summarize, it is surprising to find first movement themes in the latter movements of Rachmaninoff’s second piano concerto given that the first movement was composed last. Even more remarkable is the terseness and economy of the first movement.  The development of the tiny four note theme into the dominant theme (I use the term in its non-harmonic sense) of the movement is an example of the composer’s excellent craftsmanship which is underappreciated.  Rachmaninoff was often looked down upon in the 20th century by music critics but he has garnered more respect with the passage of time.  Certainly no work has a more secure place in the repertoire than his second concerto, one of the most remarkable works for piano and orchestra in the musical literature.

The Rent is Too Damn High. Why Does Medical Software Cost So Much?

In an era when Apple gives away its Mavericks OS X operating system for free, when completely free open-source operating systems like Linux and BSD are available, when even Microsoft is considering giving away its Windows operating system for free, one has to ask the question, why is medical software, in particular EHR (Electronic Health Records) systems, so expensive?  The software industry appears to be headed towards a business model of low-cost or free software, with profits generated in other ways.  Linux distributions (“distros”) sell the Linux operating system at no or minimal cost, but generate profits by providing support services.  Apple gives away its software but profits from hardware sales.  Google gives away its software in exchange for advertising revenues.  Of course not all software is free.  Oracle still charges an arm and a leg for its database systems, but viable open-source alternatives such as Postgre, MySql exist.  Many companies have moved to these lower-cost or free alternatives due to this cost.  But even the cost of enterprise software like Oracle pales in comparison to the cost of EHR systems.

Case in point, Epic System’s EPIC EHR.  The costs of this system can only be described as astronomical.  Duke paid $700 million for their system, while UCSF managed a bargain-basement price of $120 million (see this Forbes article).  And what do you get for this price?  As a former user, I am not in the minority in my opinion that EPIC sucks.  The problem is, the other EHR systems suck worse.  EPIC is replete with useless mouse clicking to satisfy bureaucratic ideas of what doctors need to document.  It is the epitome of software written with a total disregard for the end-user.  It is difficult to go into more specifics.  Epic Systems is touchy about their software.  I know from personal experience that EPIC employs full-time staff whose sole responsibility is to scan the Internet for EPIC screenshots and have them removed.  Isn’t it remarkable to spend $700 million and not even get a screenshot to look at?

Medicine is big business, so it attracts the big business types.  I remember a simpler time.  Back in the 1980s, prior to the advent of electrophysiology recording software (like the GE Cardiolab system), I wrote some software (in Turbo Pascal — oh the nostalgia!) that used a graphics tablet to enter measurements such as A1A2 vs A2H2 intervals into an Apple II or IBM PC computer.  The software constructed tables of intervals and graphs, and could calculate such now-a-days neglected functions as the anterograde functional refractory period of an accessory pathway.  Today we don’t measure this value, we destroy it using radiofrequency ablation, but in those days of yore when we were trying to figure out why our patients placed on class I antiarrhythmic drugs for PVCs were dying suddenly, figuring out the effects of these drugs on the electrophysiology of the heart was important.  The software I wrote helped ease the pain of doing these repetitive measurements for the poor EP fellows who were wearing out their calipers otherwise, and they at least were thankful for this early example of medical software.

The American College of Cardiology or the American Heart Association (I don’t remember now which) had an abstract session back then devoted to medical computer software.  I submitted an abstract for the program and it was accepted.   I went to meeting where the ACC or AHA (darn which was it?) provided the hardware and I got to demonstrate my program to the participants milling through the exhibit area.  It was similar to showing a poster, which, if you have not done it, is one of the most fun things you can do at a medical meeting.  People who come by are nice, interested in your work, and ask good questions.  This is diametrically opposed to the nervous tension of presenting an abstract in front of a large group.  So presenting my program at the meeting was a blast.  People came by, both health care workers and from industry, and had a lot of nice things to say.   Of course a few years later the program was obsolete due to the launch of computerized EP systems as mentioned above.  But  I learned a lot from the experience, not the least of which was how to code properly linked lists.

Flash forward to modern times, about 2 years ago.  The Heart Rhythm Society (HRS) at their upcoming meeting planned to showcase medical software relating to electrophysiology.  I had written the mobile app EP Mobile for Android, and somehow HRS had gotten wind of this and invited me to show the app at their meeting.  Distant happy memories of my earlier experience with software and medical meetings came back to me, and so I eagerly replied positively to the HRS email.  Then in a follow-up email came the fine print.  HRS wanted me to pay $3000 to show my app.

A quick email exchange followed.  EP Mobile for Android was a free app.  EP Studios, my little company I set up to try to protect my personal assets from liability, though not technically a non-profit company, was in a very real sense more non-profit than any so-called non-profit company, and I could not afford to contribute $3000 to the Heart Rhythm Society for the honor of displaying my software.  I explained this to the contact at HRS, but he was not able to wrap his head around the concept of free medical software, even in the form of an mobile phone app, so the deal fell through.

Winston Churchill purportedly said:  “You can always count on Americans to do the right thing – after they’ve tried everything else.”  The use of monolithic, proprietary medical software has been foisted on us by our government, at the behest of the multi-billion dollar medical software industry.  Everyone is happy about this except the doctors and their patients.  Is it too late to fix this?  Probably.  However, maybe there is still a way out of the current disastrous situation.  There is little doubt that, if done properly, codifying medical data is good thing.  The problem is the current interfaces are terrible.  There are too few vendors and they don’t care about user feedback.  I would go back to basics.  Medical data is after all just data.  There needs to be a standard data format for medical data.  I know that HL7 exists, but it seems to be pretty messy, and only last year opened itself up as a free standard (it required a license fee before).   If all the energy devoted to making mutually incompatible EHR software systems was instead directed towards defining a good, open, free medical data standard, to be used by all computerized medical hardware, imaging, and so forth, I believe we could break down the medical software oligopoly.  Domain specific languages and APIs (application programming interfaces) could be developed and with these building blocks anyone could create medical software.  It wouldn’t have to free, but it would have to be affordable to sell, unlike the present situation, so costs would go down.   User interface quality should improve.  And Judy Faulkner, billionaire CEO of Epic Systems, might finally have some competition.

Making a MOCkery of Medicine

NotABIMI thought I’d weigh in on the American Board of Internal Medicine (ABIM) recertification process after reading an excellent article on it today. After all, I’ve been through the process several times, most recently enduring it in 2012. I was lucky enough to be “grandfathered” with regard to my Internal Medicine and Cardiology board certifications. Unfortunately no such option exists for my Cardiac Electrophysiology board certification, it having been created in 1992 after the ABIM wised up the fact that life-time certifications were not profitable. Thus there was no option but to renew the certification in 2002 and 2012, which I duly did, much to my distress. I know a few physicians who claim to enjoy taking these tests, even retaking a certification exam that they are grandfathered into. More power to them. There are a few masochists in every crowd. But the ABIM is determined to take away even their fun, by ramping up the Maintenance of Certification (MOC) requirements to the point that even the most committed connoisseur of the painful is bound to cry uncle.

There are two aspects to recertification. First there is the test that one takes for an exorbitant fee every ten years. Note that physicians are already required to take many hours of Continuing Medical Education (CME) courses per year (which is another scam, but I will pass over that for now). All the physicians I know are very interested in keeping as current as possible in their specialty and don’t require external incentives like mandatory CME or board recertification to do so. Even if one is cynical and refuses to believe that physicians do things like this for the sake of delivering the best patient care, one should at least grant that medicine is a business and it is necessary to keep up to stay competitive with other physicians. Nevertheless in addition to mandatory CME the recertification exam pops up every ten years, and one risks being ostracized if it is not taken and passed. Unfortunately I can’t say much about the test itself. Before I took it I signed a form (in blood, I think) that forbad me from revealing anything about the test. I do know something about how the questions are selected. When I was in academics I, like many of my academic colleagues, was asked to submit 4 questions on electrophysiology to the board. These questions and the hundreds of others sent in were reviewed by the ABIM question selection committee (which I believe was also primarily made up of academicians) who then picked out the actual test questions. I remember when I made up my questions I made an effort to come up with something obscure or tricky. Having taken the test before, it seemed that those were the kinds of questions the board liked. Apparently the process hasn’t changed, judging by the types of questions on the most recent test I took in 2012.

I’ve been taking tests my whole life, and, as much as I dislike them, it wasn’t the test so much as the MOC requirements that rankled me. I was told that I should start the MOC a minimum of 1 year prior to the test. Really? (footnote: now the MOC requirements have changed and start within 2 years of the last test. Ugh!) I thought to myself, what could they possibly make me do that would take a whole year? So, when the countdown to recertification reached T – 1 year, I fired up the ABIM website to find out what I had to do.

My first reaction was that I must have pulled up the wrong web page. I was re-certifying in Cardiac Electrophysiology, the subspecialty of cardiology dealing with problems with the rhythm of the heart. The options presented looked like suggestions for a high school science project. Some were so vague as to be meaningless. For example, from the current ABIM website:

Approved Quality Improvement (AQI) Pathway

The Approved Quality Improvement (AQI) pathway offers diplomates the opportunity to earn practice assessment Maintenance of Certification (MOC) points for participating in externally developed quality improvement (QI) activities that have met ABIM’s standards for measuring and improving patient care.

Whatever that means. Some of the more understandable options had to do with collecting data from patients to send to the ABIM. What they wanted this data for or what they would do with it I had no idea. The striking thing though was that NONE of the options had anything to do with the subspecialty I was certifying in, i.e. Cardiac Electrophysiology. No MOC having to do with the heart rhythm. So this was all just a rather large hoop that I had to jump through. I ended up selecting the Hypertension Module because one of my colleagues had done that option before and had managed to complete it.

What the Hypertension Module involved was collecting a huge amount of data on 50 to 100 office patients. Supposedly the patients were to enter this data on their own on the Internet. In Kentucky this just wasn’t going to happen. So as an alternative I ordered 100 questionnaire booklets from the ABIM. I handed these out to the office patients and asked them to answer the questions. There was no IRB consent form or real explanation as to why I wanted this data from them. I told them that the ABIM required me to collect this data from my patients for some unknown reason but participation was voluntary. Most of my patients were nice enough to fill out the forms.

Not having my own staff of dedicated data entry personnel, I had my long-suffering medical assistant enter the data from the forms into the computer. I did pay her for this out of pocket, though not as much as she deserved (Thank you Karen!). Up until this point I really didn’t know what would happen once all the data was in. The ABIM site was very mysterious about where this module was heading. I was still in Step 1, and couldn’t go on to Step 2 until at least 50 sets of patient data were in the computer. So, after several months of data collection (I now saw why it was important to start the process a year ahead of time), the data was in, and the Step 2 button, which had been grayed out and disabled, stood before me in an activated state, ready to be pushed. It reminded me a little of a computer game, in which you try to open a door but it just gives a rattly sound and a text appears that says “you don’t have the key” until you actually find the key. So without further ado I clicked on the button and the computer churned away, analyzing my trove of what was admittedly somewhat sketchy data to begin with. Then after a dramatic pause the ABIM website announced its findings.

I wasn’t sure what it had to do with hypertension (this was the Hypertension Module, wasn’t it?) but the grand analysis revealed that a greater percentage of my patients than was deemed acceptable were failing to meet goals for lowering of serum cholesterol. (Flash forward 2 years: those goals have been thrown out the window anyway in the latest guidelines). Hmm. So my patients referred to me for the most part by other cardiologists for consideration of pacemaker or defibrillator implantation or catheter ablation of arrhythmias were not meeting standards for cholesterol lowering. I thought to myself: whose fault is that? I don’t usually have anything to do with managing lipid levels. I am a subspecialist, which one would think the ABIM would be aware of as they were requiring me to take their subspecialty certification test. As a matter of fact most of the cardiologists who referred patients to me had little to do with managing cholesterol levels either. In Louisville, Kentucky the management of lipid levels is the jealously guarded province of the family practice doctors. But there it was staring me in the face. After several months of effort that completely distracted me from my real job as an electrophysiologist, the answer to the question of Life, the Universe and Everything was a faulty cholesterol level.

So on to Step 3. The ordeal was not over. For the next step in the MOC Holy Quest was to develop a plan to address this dreadful oversight in my clinical practice and implement it. After that there was Step 4, which was to assess the wonderful success of my innovative plan and show how it had revolutionized my clinical practice so that I would be eternally grateful to the ABIM for my enlightenment that was only possibly through the MOC program. And they wanted me to do this assessment by repeating the data collection in another 50 patients after I had put my fool-proof-amazing-cholesterol-lowering plan into effect.

Excuse me, ABIM, but I do have a real job, and is there any way I can get on with it, instead of spending the rest of my life on your science project? Well, reading the proverbial fine print, there was a way. I could, if I so desired and were so lazy (though they would so much prefer the more complete option) only collect the specific data that was identified in the original number crunching and submit that to them. In other words, I could get 50 cholesterol levels (never mind that I virtually never order a cholesterol level in my field of work) and show that they were better than before. Ah, I know an out when I see one.

So I wrote my MASTER PLAN FOR THE LOWERING OF CHOLESTEROL AND THE SALVATION OF THE HUMAN RACE which I think had something to do with asking the patients to exercise more and eat fewer buckets of Kentucky Fried Chicken, and immediately put the plan into effect. Then, after waiting what I thought was a realistic number of months, I resubmitted my data. Wow, the cholesterol levels were much, much better. The plan had worked! I just hope the ABIM is not planning to publish my data. Because… I made it all up!  And I bet I’m not the first to have done so.

As a medical professional and former academic researcher, I never would dream of falsifying data under any normal circumstances, but I was driven to this by the completely unreasonable nature of the MOC requirement. To summarize this unreasonableness:

1) There were no MOC module options that were relevant to my subspecialty.

2) My patients, my staff and I were forced to waste time on a project of no clinical value.

3) There was ZERO educational value to this project.

4) There seemed to be some undisclosed (sinister?) ulterior motive for the ABIM to collect this data from my patients.

5) I was an unpaid data gatherer for the ABIM (No. Worse, I paid them for the privilege).

6) My patients were unwitting participants in a project that was not important to them or me. I’m sure many participated because they trusted me, but by asking them to participate I was violating or abusing that trust.

I’m not sure what else to say. It is unbelievable that physicians have to go through this process. As much as taking a clinically irrelevant test every 10 years irks me, it is still far preferable to the sham that is the MOC. It really has to go.

Fair Use Justification of CPT® Codes in EP Coding

The following is a formal justification for use of a limited number of CPT® codes under the US Copyright law fair use exemption in the soon-to-be-released mobile app EP Coding.

EP Coding icon

EP Coding icon



As CPT® codes are copyrighted by the American Medical Association, it is important to make the case that use of a very small percentage of these codes, with paraphrased descriptions in a mobile app is covered under the Fair Use doctrine of US copyright law. Note that the AMA does acknowledge the possibility of fair use of CPT® codes. Also please note the following:

CPT copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Fair use criteria

Four criteria are used in determining fair use of copyrighted material:

  • The purpose and character of the use, including whether such use is of a commercial nature or is for nonprofit educational purposes.
  • The nature of the copyrighted work.
  • The amount and substantiality of the portion used in relation to the copyrighted work as a whole.
  • The effect of the use upon the potential market for or value of the copyrighted work.

The purpose and character of the use, including whether such use is of a commercial natue or is for nonprofit educational purposes.

EP Coding is intended not for coders, who definitely need the AMA documentation, but for physicians who need to document with codes (in addition to documentation in their procedure notes) the procedures that they do. With the advent of EHR (Electronic Health Records) there is frequently a need to enter codes by the physician directly into the system. This is true of the EPIC EHR that I’ve had experience using. Entering codes is not an easy task. As the CPT® descriptions are obtuse, at least as presented in EPIC, looking up codes by description is difficult if not impossible. For example, a search for “PPM” which is a common abbreviation for pacemaker yields 0 hits in EPIC. Searching for “PACEMAKER” or “PACER” yields a very long list of hits, but they are all hardware codes for individual pacemaker types and not procedure codes. Searching by code, such as the code for dual chamber pacemaker implant, code 33208, yields this:


Hardly intuitive! Similarly searching for “ABLATION” yields over 50 choices, many not related to cardiology, and search for “AFB” yields “AFB stain” used to diagnose tuberculosis. The actual code for AFB ablation, 93656 yields this:


So there is a need for a “cheat sheet,” a list of codes relevant to his or her specialty that the physician carries around to help remember the codes and enter them in the computer. This list of codes may not be enough however. One must remember that one can’t code transseptal puncture or LA pacing and recording with AFB ablation, or that 3D mapping is already included in VT ablation. This sort of information is ideal for encoding into a mobile app.

As the app improves physician coding skills and thus enhances the ability of the physician to code accurately and quickly so he or she can then turn his or her attention to more pressing matters, the app meets the criterion that its purpose is educational and benefits science and the public. There is no benefit from keeping the physician in the dark regarding these codes. The physician is not going to buy or carry the whole AMA CPT® code book around, nor should he or she, given the very limited number of codes that need to be used in his or her line of practice. Certainly an actual written “cheat sheet” that is commonly used is considered fair use. The EP Coding app merely is a more intellegent version of that cheat sheet.

Regarding the commercial nature of the work, the app is priced at a very low cost (99 US cents) both to help defray the costs of development and to discourage downloading by those who don’t need access to these codes. EP Studios does generate some income, but has not generated a profit. Its main purpose is to help my colleagues by developing apps relevant to practicing medicine.

Thus with these points I believe the app qualifies for “fair use” by the first criterion.

The nature of the copyrighted work.

Despite their absolute necessity for the practice of medicine in the United States, the AMA has a copyright on the CPT® codes. This is despite the fact that the CPT® codes are also the level I codes required by Medicare for all providers to use. The AMA code books are expensive and license fees are required to use the codes as well. The amount may be debatable, but there is no doubt the AMA makes a lot of money from their codes. The codes are essentially a database, matching code numbers with descriptions, as well as information of what codes cover and what codes can and cannot be used together. Professional coders definitely need to know all the ins and outs of these codes, however physicians only need to know a subset of the codes. The EP Coding app uses some of the numbers and paraphrases the descriptions of the codes. As such it is not a direct copy, other than of the numbers. Numbers as such may not be subject to copyright. It should also be noted the the CPT® manual is largely a functional and not artistic work, and as such may be more subject to fair use than other less functional works.

The amount and substantiality of the portion used in relation to the copyrighted work as a whole.

A Google search for number of CPT codes gives various sites stating a number from 7800 to 8800. These figures are unsourced, but there is no doubt the number of CPT® codes in in the thousands. As of February 16, 2014 there are 73 codes in EP Coding. Assuming 7800 total codes, that is 73/7800, i.e. 0.9% of the total number of CPT® codes. This is a small percentage of codes. Note that the codes used in EP Coding are only codes for electrophysiology and are limited further to only non-surgical codes (i.e. excludes codes utilizing thoracotomy). In addition codes for office visits, hospital visits, and device checks are not included. The text of the descriptions is not copied from the AMA manuals, but is a paraphrase. Thus the amount of text copied is limited to a small subset of the code numbers. The ideas associated with these numbers are used, but not copied directly. Note that copyright protects literal text, but not the ideas underlying the text. Per the US Copyright Office:

“Copyright does not protect facts, ideas, systems, or methods of operation, although it may protect the way these things are expressed.”

In addition, most if not all of the information in this app is readily available online. For example this article outlines how to code EP procedures.

The effect of the use upon the potential market for or value of the copyrighted work.

EP Coding is intended for physicians, who are not the intended audience of the AMA documentation. That audience is made up of professional coders. EP Coding is more akin to a cheat sheet than a work competing with the AMA code book. Physicians are not likely to purchase the AMA book whether or not they use EP Coding. Coders cannot substitute EP Coding for the AMA book. Thus there is no real competition between the app and the AMA copyrighted works.

In summary, I believe that use of CPT® codes in a limited way in the context of the mobile app EP Coding meets all 4 criteria for fair use under US Copyright law.

Le Truman Show

The Truman Show

The Truman Show

Le “Truman Show” est un film qui est sorti en 1998.  C’était réalisé par Peter Weir et c’était écrit par Andrew Niccol.  Le personnage principal est Truman Burbank qui est joué par Jim Carrey.  Truman Burbank est un homme normal qui vit dans une ville normale. Son enfance était heureuse. Il es     t réceptionniste pour une compagnie d’assurance, il vit une vie ordinaire, il a une femme ordinaire, un voisin ordinaire et un ami ordinaire qui apparaît de temps en temps avec un six-pack de bière.  Mais Truman n’est pas heureux avec sa vie. Il veut voir le monde

Clip 1

Il veut sortir de son plaisante mais étouffante vie – toujours rangée – pour s’échapper de sa petite ville qui est sur un île au bord de la mer – une ville qui est toujours propre, toujours ensoleillée et en fait, trop parfaite. En réalité, Truman était le produit d’une grossesse non désirée. Son «père» (pas son vrai père), Christof, un producteur de télévision qui Truman n’a jamais rencontré, a réalisé le Truman Show – le plus grand spectacle sur terre – un spectacle dans lequel la vie est en direct – la télé-réalité. En fait, Truman ne sait pas qu’il vit dans un petit monde de de télévision qui a été inventé par Christof parce qu’il a grandi dans ce monde et il était là depuis son enfance. Donc, tout le monde autour de Truman est acteur avec un peu de casque à l’oreille. Même sa femme est actrice qui fait beaucoup de publicités pour le camera à la stupéfaction de Truman.

Clip 2

Un jour, Truman trouve accidentellement une zone de restauration dans un faux ascenseur de son bâtiment de bureaux et devient assez suspecte. Peu à peu, il vient à la conclusion qu’il ne vit pas dans le monde réel.

Truman découvre que tout son monde est un ensemble de film et que tout était contrôlé par Christof, son «père» son “créateur” qui travaille dans un studio dans une ersatz lune du monde de Truman.

Clip 3

Enfin, Truman réussit à s’échapper de son monde irréel. Il repousse son créateur, son père Christof. Truman ouvre une porte dans une peinture de paysage et il va à un monde qui n’est jamais vraiment montré dans le film. Ce monde reste inconnue, c’est notre monde.

Clip 4

Je crois que le film est très prémonitoire.   Au temps de son sortie, le Facebook n’existait pas et la télé-réalité était à son début.  Cependant, le film démontre que la démarcation entre la vie privée et la vie publique est devenu floue.  C’est aussi une critique des effets que la publicité ont sur notre comportement et même nos pensées.  C’est une critique de la vie occidentale (surtout la vie américaine), de la religion, du capitalisme, des médias et de nos perceptions de la réalité.  À la fin du film, en regardant Truman part son monde iréel, on espère que son nouveau monde sera réel. Toutefois, cette question reste sans réponse.

“Le Truman Show” est un film de science-fiction qui est à peine different de la vérité aujourd’hui. C’est aussi un drame philosophique qui provoque beaucoup de pensées et qui peut vous encourager de regarder votre vie un peu plus près.  C’est un film à ne pas rater ou manquer et un film qui a tout pour le revoir.

Device Reps and Patient Care — An Inconvenient Truth

Device Programmer

Device Programmer

Most people who don’t deal with the Health Care System on the inside are likely unaware of the exact role that industry representatives play in the care of patients. As a cardiologist who implants pacemakers and defibrillators, I have worked with the representatives of the companies that manufacture these devices for many years. I will use the term “device reps” for these people, mostly because that is usually how they are referred to on a day-to-day basis, but in using this term I am referring both to device sales representatives and to device field clinical specialists. In theory the sales reps are more involved with sales, and the field clinical specialists with technical support, but in practice there is a blurring of these roles, with considerable overlap even in the job descriptions and training required, as can be seen here. Generally both jobs require at least a bachelor’s degree and training by the device complany. Although there is no specific requirement for a health care degree, some of these people are former nurses, cath lab technicians, or physicans assistants. On the other hand some, in particular the sales reps, have a background in business and not health care. Despite this, the job description of the sales rep includes providing pacemaker and defibrillator follow-up, technical assistance, programming, troubleshooting, and training.

So what does this translate into in practice? For one thing, these device reps are present in the cath lab or operating room when pacemakers and defibrillators are implanted. They are there to provide the actual devices and run the programmer (essentially a specialized computer for testing and programming devices). In my experience they never scrub in or otherwise assist in the procedure. Using these same programmer machines (note that each company has its own programmer and they are not compatible with other company’s programmers) the reps test and reprogram devices throughout the hospital, at least technically under supervision of a physician, though the physician may not be physically present. They often do the same thing in doctor’s offices, especially for physicians who do not have dedicated staff to follow pacemakers or defibrillators. They provide these services at no cost to the hospital or physician, though presumably the cost is bundled into the rather hefty price tag of pacemakers and defibrillators.

These services are not performed rarely. The reps take call at night and are expected to be available 24 hours 7 days a week. Each device company provides its own group of reps.  Because the implantable device business is very competitive, any company providing less than this level of service would soon lose its business. Hospitals and physicians receive a “free” service that, if it did not exist, would have to be provided by hiring their own technical personnel at considerable cost. The industry argues that only they know their proprietary products well enough to provide adequate technical support, and there is certainly some truth to this argument.  In general, I think most hospitals and physicians see the present system as perhaps a little awkward but beneficial and don’t want to kill the goose that laid the golden eggs.

Nevertheless, the current system is rife for abuse. Let me first say that most of the industry reps I know and have worked with are exceedingly technically knowledgable and good, ethical people whom I would rather have program my pacemaker than some of the doctors whom they work for. But I also should say that there are exceptions, and a small minority are really just interested in sales and are not so technically knowledgable. So this brings us to the most obvious problem with this system:

Why is a sales person assisting in implanting my pacemaker or changing settings on my implantable defibrillator?

This is the first question that would occur to most people. The person adjusting the IV is a trained nurse. The person adjusting the ventilator settings is a trained respiratory technician. Neither one is trying to sell IV equipment or ventilators. Why does a sales person program a pacemaker?

I remember back when I was in training in the early 1980s the TV program 60 Minutes  came to Baylor in Houston purportedly to do a documentary on new pacemaker technology. Our pacemaker specialist, Dr. Jerry Griffin, was interviewed in his office about this subject. The CBS crew then requested to film a pacemaker implantation procedure in the cath lab. Consents were signed and the procedure was filmed. No one realized that the whole thing was a bait and switch. Everything else was edited out and the only thing shown on TV was the bit where Jerry asked for the pacemaker from the sales rep in the room. The show was actually an expose on relations between the pacemaker industry and physicians and the fact that industry sales people were in the cath lab assisting in pacemaker implantation. About the same time, there was a US Senate investigation of the pacemaker industry, and amongst the many criticisms and abuses identified, the role of the sales reps in pacemaker procedures was noted. All this has led to a crackdown on industry reps providing physicians trinkets such as pens, but the role of the reps in device implantation and follow-up seems not to have changed a whit.

The present system is flawed and suffers from a lack of oversight. Despite an attempt by the Heart Rhythm Society to codify the relationship between industry and physicians, there really aren’t any hard and fast rules. This leads to abuse of the reps themselves, and some questionable practices. The reps have been trained never to say “no” to any request by a physician. Courts have ruled that it is not the responsibility of the rep to correct the physician if the physician is doing something wrong. So what is a rep to do if an undertrained physician asks him or her to program a device in a fashion detrimental to a patient? The rep is in a bad spot, risking losing business from that physician if he or she doesn’t just “follow orders.” Although it is well established that other healthcare personnel should speak up and question orders they seem to be in error, there is no expectation that a sales rep should do so. In large part this is a fault of the device industry that has often tried to train physicians in pacemaker implantation who have not undergone formal pacemaker implantation training, in order to increase sales.  This can result in the awkward situation of the rep being more knowledgable than the supervising physician.

Device reps are also often asked to program devices on and off for surgery, when it really is not necessary to do this. Much of the time no programming needs to be done in this situation, or only a pacemaker magnet needs to be applied during the course of the surgery to put the device into a “safe” mode that won’t cause problems when the surgeon uses electrocautery. These unncessary programming interactions are abusive to the device reps, could conceivably result in incorrect programming, are costly to the patient (device programming is billed by the supervising physician), and lead to delays in starting surgery while waiting for the device rep, notified invariably at the last minute, to drive from one hospital to another. Since the whole device rep system is outside the normal hospital chain of command, it is difficult for the devices reps to find a champion who would talk to the anesthesiologists or surgeons and change this policy. I mention this example because I saw it again and again in one hospital in particular in Louisville, Kentucy, where I worked.

Device reps can get in over their heads. In the emergency room in the middle of the night they may be asked to use the device to electrically cardiovert or pace terminate an episode of ventricular tachycardia. They may be the only one in the room who knows what they are doing. The cardiologist is happy he or she doesn’t have to get out of bed to do this. Yet here again this is a person often without a medical degree performing a medical procedure with potentially serious consequences. The device rep may also be asked to turn off a defibrillator or pacemaker in a terminally ill patient. While turning off a defibrillator generally has no immediate effect, turning off a pacemaker in a patient who is dependent on the pacemaker results in death that occurs about as fast as a gunshot to the head. To push that button on the programmer that shuts off the pacemaker is as morally vexing an act as one can conceive of, yet this is something that we ask the device rep to do (“under physician supervision”).

Device follow-up in the office doesn’t have to be done by device reps, yet it often is. In the Heart Rhythm Center at my former work-place all the device follow-up was done by trained nurses and technicians. Many cardiologists though have a rep come to their office periodically to do device follow-up. There is push-back against changing this system, because device follow-up generates income. Yet often the “supervising physician” has no training in pacemaker follow-up and leaves the programming decisions to the rep. This is wrong.

So, what to do about all this? The system is quite well-entrenched and I’m not sure if it can be changed. I think having the rep in the cath lab during device implants, that was so shocking to the 60 Minutes viewers, is probably the most justifiable of these practices. They are equipped with all sorts of leads, adaptors, and devices that really are necessary to have to do the procedure. Their role of assessing pacing thesholds and device function is not particularly troublesome, especially as this is the one situation where the supervising physician is actually guaranteed to be present.

Regarding device follow-up and reprogramming in the hospital and doctor’s offices, I do think it would be better if it were done by specialized personnel who work for the hospital or doctor, and not for the various device companies. This is already done is some doctor’s offices, such as our own. This would require an outlay of cost by the hospitals, as someone would have to be on call all the time for these services. I suspect that most hospitals would prefer to keep the current system, but in the long run having a minimal sales presence in the hospital might lead to lower costs of devices.

I’m curious what other physicians or health care workers think about this. What do the reps think about it? What do people on the receiving end, i.e. patients with implantable devices think about it? It doesn’t seem to be discussed very much. Please feel free to leave any comments you might have.

Paris Update #2

We are starting our third week in Paris.  Here’s a quick update.

The little alley we live on.

The little alley we live on.


Continued cold and rainy.  No snow.  Apparently not as cold as back in the US.  Maybe the Gulf Stream protects us from Polar Vortices.


We went to two museums this weekend.  The Museé des Arts et Métiers (Museum of Arts and Crafts) is housed in an old abbey.  It is full of old scientific instruments, old cars and trains, steam engines, and so on.  The main reason I wanted to see it was because it is an important location in the book Foucault’s Pendulum by Umberto Eco (you may be more familiar with his book The Name of the Rose, which was made into a movie with Sean Connery).  The pendulum in question hangs from the dome of the abbey, and is pretty cool, especially if you have read the book.  The other museum we went to today was the Centre Pompidou, which is a modern art museum.   It is an extremely out-of-place looking building that looks like a conglomeration of hamster tubes.  Inside there is all the weirdness of modern art.  I have been there before and it is a fun place to walk around.  There is a small church down our street where there are regular concerts and we are going to one one Monday.  Paris is not a huge city, and a lot of our entertainment just consists of walking around and exploring.

Centre Pompidou

Centre Pompidou


We try not to eat out too much except on the weekends.   Since I am a vegetarian we have to be a little selective in our restaurants.  This weekend we went to dinner at a Tibetan restaurant and Pakistani restaurant.  Basically any kind of food you want is here.  There is even an American restaurant called Breakfast in America that serves things like pancakes and hamburgers (including a veggie burger).  I am also getting addicted to Mars bars, unfortunately.


If you read the prior post, one of the things I need over here to stay more than 3 months is a Carte de Séjour which is a residence card.  When we went the first week to the Préfecture de Police there was a very nice lady there who told us what we needed for the card.  When we went back we did not get to see the same lady.  Instead, we ran into a woman who can only be compared to the Hound of Cerberus, the three-headed guard at the gates of Hades.  This woman was not going let me get my card — not on her watch.  She even tore up the instructions the other nice lady had given me.  Now we have to get our marriage certificate translated into French by an official French translator here in Paris (we had already gotten it translated and the translation notarized in America, but that was not good enough for this harpy), and we had to get original bank statements showing we were not destitute, not just the printouts from the Internet that we brought with us.  And, we had to cut down the biggest tree in the forest — with a herring.  Actually that last is from Monty Python, but you catch my drift.  Anyway, to escape this bureaucratic nightmare, we have hired a lawyer who specializes in this stuff, and hopefully we will get this done soon.

Look at those shoes.  They scream American!!

Look at those shoes. They scream American!!


I doubt anyone cares, but our Internet service here is fine, except for a persistent problem with our Android phones losing connectivity with the Wifi router.  I thought I had the problem fixed by making some changes in the router, but each time the phones work for a while and then the access point becomes “Saved, and secured” but not “Connected.”  Basically any changes I make to the router reset it, so it looks like the problem is fixed, but then eventually the problem develops again.  It never happens with the Apple stuff I have, or, curiously, with my Nexus 7, which obviously is also Android.  I am convinced this is just a problem with the router, and I’m debating getting another wireless access point.  After all, I am going to be here 6 months so it would be nice if everything worked.  By the way, Netflix and Hulu are both blocked in France.  YouTube works fine, and I can download movies with Google Play and with iTunes.  But it seems odd that Netflix and Hulu are missing out on the market here.

What Am I Doing Here?

Good question.  I am feeling a little less isolated because I am understanding the language a little better, and understanding how thing works here better too.  Gretchen is taking her advanced French courses every weekday morning, and I am starting a French course too (I think the name of the course translates into something like “French for complete morons”).  I am also working on my coding app for EP.  More on this soon in a future post.

For now, Au Revoir!

Paris Update

Eiffel Tower, January 19, 2014

Eiffel Tower, January 19, 2014

We’ve been in Paris (France, not Kentucky) a week now.  We have moved into the apartment that will be our living space for the next six months.   Gretchen and I have spent the week settling in, figuring out where to shop for food, how to get around the city, how to work the washing machine, and other essential tasks.   She has started her classes at Alliance Français, and I have been walking around trying to look inconspicuous, hoping no one will ask me a question in French that I can’t answer (which would be pretty much any question).  Here are some of my initial observations.


Not too different from Louisville, Kentucky in the winter.  Some cloudy days, some clear, some rainy.  No snow so far.  Temperatures in the 40s and 50s mostly.  Nothing too extreme.


Scarfs are de rigueur.  So we each bought one.  I already knew the French wear dark clothing from prior trips, so that’s what I wear too, though my white-gray sneakers are a pretty good give-away that I am not French.  Women wear dark tights and short skirts (yes, I do notice these things), or pants tight enough that they might as well be tights.  No one appears to be overweight and if they are they are probably Americans.  People walk around and avoid eye contact, quite unlike the casual friendliness of Kentucky and the US South.  When we were in New York City people there also did not greet each other, so this is hardly a unique European characteristic.

Living Space

We moved into our apartment, which went well.  It is small, though everything is smaller here than in America.  The kitchen and bathroom are slightly bigger than a phone booth (if anyone remembers phone booths these days).  There is a living room and a bedroom.  Anything bigger would have been too expensive.  Living in Paris isn’t cheap and we need to keep costs down.


We attempted to complete two major tasks our first week.  One was to start up a local bank account.  This would allow us to wire money from the US to the local bank and avoid a lot of charges involved in using a credit or debit card abroad.  We went to a bank and found we had to make an appointment to start an account.  We came back for the appointment and spent about and hour and a half filling out paperwork to start the account.  Thank goodness Gretchen is fluent with French, as the people in the bank spoke almost no English.  Gretchen has dual citizenship (American and Italian).  Having a European Union passport allows her to do a lot that would be difficult for a US citizen.  Anyway, after much filling out of forms the bank account was settled.  The second task was to get me a Carte de Séjour.  This is basically a residency card that allows me to stay in France over 3 months.  Gretchen with her EU citizenship can stay as long as she wants in any European country.  The husband of a non-French EU citizen (it is actually harder if your wife is French, but that’s another story) can also stay in France without a visa as long as he produces proof of marriage to the Préfecture de Police.  Well no one, including the French, seemed to know exactly where to go to get this done.  After being misdirected to 3 different wrong places (and putting about 20K steps on my FitBit) we finally reached the right place.  We then took a number and, after waiting, went in only to find we didn’t have all the documents with us we needed.  So we will try again tomorrow.


We brought a lot of electronics with us, including our two Android cell phones, two Apple iPods, an iPad, my Nexus 7 tablet, and two Apple laptops.  Our apartment has phone, TV and Internet service all through a DSL modem (not a cable modem).  The router is a “DartyBox” with IP address  Of course the web interface is all in French, but using Chrome to translate works fairly well.  The reason I tried to fool with the router was that not all our devices can connect to the WiFi interface.  Specifically there are no problems with the MacBook Air, MacBook Pro, the 5th generation iPod Touch, and the Nexus 7.  Unfortunately both Android phones (including a Droid Maxx with Android 4.4 “Kit-Kat”), and the older generation iPod won’t keep the connection (We haven’t even tried the iPad, which is first generation).  Resetting the router allows these devices to connect, but eventually they disconnect.  The Android phone label the SSID as “Saved and Secured.”  But not “Connected” unfortunately.  Some fruitless googling and examining the router setup failed to achieve an answer.  I have never had this problem before and I think it is probably the French router doesn’t play well with some of our American devices.  I could buy a different router, but there is no guarantee it would work.  I guess I should be satisfied that at least some of our devices work.  The Internet speed clocks to about 15 Mbps, not bad.


As Dorothy said, we’re not in Kansas anymore.  I hope with future posts to share more of what I discover in the “City of Lights.”  Stay tuned.