Cruises, Then and Now

The old Nieuw Amsterdam. Source: Public Domain,

[Author’s Note:  This post got completely garbled when I tried to transmit it to the server using the terrible shipboard internet service in the middle of the Pacific Ocean.  If you tried to read it before and gave up, convinced I had downed a few too many Bloody Marys, you might want to give it another shot.]

As I write this I am in the middle of the Pacific Ocean, just east of Hawaii, heading home on the final leg of a cruise on the Star Princess, 5 days from landfall. I am not an expert on cruising, as I found out during dinner conversations with other passengers, who casually admitted that this was their 20th cruise. Nevertheless I have bookended my life with cruises, starting out when I was a child, and ending up in my retirement. In between was work, and no time for chunks of vacation taking up more than a week of my time. But I do have fond albeit remote memories of those old ships and cruises, and would like to compare and contrast that era with today.

Back in the 50s, 60s, and 70s, I traveled transatlantically or cruised in the Carribean on the Homeric, the Nieuw Amsterdam, the Rotterdam, and the Queen Elizabeth II. The Nieuw Amsterdam was the ship I went on the most, going on two Carribean cruises in the 1960s and a transatlantic crossing around 1970, just before it was retired from service. It was a vessel built in the 1930s and is typical of the design of the older ships. Staterooms were below, with portholes, not balconies. The public areas of the ship were on the superstructure: the Promenade Deck, Sun Deck, Lido Deck, and the like. The dining room was located in the middle of the ship, without windows, at the center of gravity to minimize rocking and presumably broken plates. Over the dining area a string quartet played on a little balcony. The ship had a gray and white hull, with two yellow, green and white striped stacks. It was a beautiful ship–seaworthy and sleek in design, unlike the topheavy behemoths of today.

In the public areas were shops, lounges, a movie theater, and a dance floor. There was no continuous buffet as is de rigeur on current ships. Nevertheless there were little buffets around the ship and no lack of food. There was no lack of activities, sports, and entertainment. In what would be considered an environmental horror today, I remember my father driving golf balls off the deck of the ship in a competition to see who had the best golf swing.

There was an open deck on which you could circumnavigate the ship and get fresh air, and a similar deck below, the Promenade Deck, on which you could do the same while protected from the wind and cold by windows. On this deck were pingpong tables and places to sit and play card or board games. I remember on my first cruise circa 1960 all the crew and sailors were Dutch (this was the Holland-America line), but even by 5 years later the economics of cheap labor had replaced them with crew from Thailand and Indonesia. Today the crew stem mostly from the Philippines and Eastern Europe, though the officers on this particular ship are Italian for some reason.

In contrast to the sleek ships of yesteryear, today’s ships are squat and topheavy with row after row of balconies. I like having a balcony (I am sitting on it now, watching the waves go by), but the result is an ugly ship. Life on the modern cruise ship is centered around the buffet, which operates non-stop and is always filled with people. Eating, drinking, and more eating and drinking seem to be the major activities on board. Because of the design of the ship, there is no deck that you can walk all the way around in the open air, without climbing up and down stairways. There is no Promenade Deck in the traditional sense. However, despite these changes over the years, the ocean is still the same, magnificent and mysterious. It has a vast calming influence and makes it all worth while.

Of the different modern cruise lines I have been on, Princess, Royal Carribean, Celebrity, and Cunard, only Cunard makes an attempt to uphold the sailing traditions of old. My experience is based on their ship the Queen Mary 2 (QM2), on which I have made several transatlantic crossings since retiring. The ship has clean lines and a better design. There are balcony decks, but there is also a deck around which you can walk in a continuous circle in the open. The ship has a large, beautiful library with comfortable chairs that face windows overlooking the sea. The ship I am on now, the Star Princess, has a puny library with just a handful of books. The QM2 has a tasteful decor, with less kitsch than usual. Overall it feels more like a real ship than a floating hotel, or floating buffet.

Make no mistake, I’m not complaining (too much)! Being gently rocked by the silvery Pacific Ocean and listening to the white noise of the waves is akin to Paradise. So enough of this! Back to the buffet!

Cutting Down on Coffee

Not coffee

This morning as I write this, there is on my desk a steaming hot cup of fake coffee. The ingredients are roasted barley, roasted malt barley, roasted chicory, and roasted rye. This is the sort of stuff people drank as a coffee substitute during wartime rationing. It smells odd. It is hot and black and looks like coffee. It tastes kind of meh–not bad, not good.  It has a depression era vibe.

As someone whose very life energy used to be fueled by coffee, the transition from coffee to not-coffee was difficult. I drank at least 5 or 6 cups per day. When I was working as a physician I depended on it to keep going. I usually took it black, never added sugar, and completely eschewed Starbucks overwrought concoctions. I loved simple espresso based drinks, particularly Americanos, but, like a true addict, any bottom of the pot leftover coffee would do the trick. But then I was forced to go cold-turkey.

I was having some epigastric pains. The doctor told me to cut out coffee and spicy foods (that’s another saga). So I did.

The day after I quit coffee was filled with headaches and fatigue. The next day was a little better. By the third day I felt fine.

After quitting coffee and a course of omeprazole, my stomach felt better. I also felt pretty good energy-wise sans caffeine. So I cautiously reintroduced some coffee into my life.

I don’t drink it every day. When I do drink it I limit myself to one or two cups. Afterwards I feel a distinct “high” that I hadn’t really appreciated when I was a chronic imbiber. In the past I drank coffee just to feel normal. Doubtless I had built up a tolerance to it. If I didn’t drink it I felt bad.

Now when I don’t drink it I feel normal. When I do drink it I feel a burst of energy. But I don’t need to feel that way all the time. So most of the time I am drinking a coffee substitute or an herbal tea rather than coffee. It works for me.

Your mileage may vary.

The Death of Dr. Shock

Dr. Shock
By Source (WP:NFCC#4), Fair use,

The call came from one of my attendings at night during my cardiology fellowship. It had a touch of the black humor that medical persons don’t like to admit bubbles up to the surface from time to time.

“You know Dr. Shock, the guy on TV? He’s being transferred. He’s having a big infarct and is in cardiogenic shock.”

I was at home. I quickly pulled myself together and got into my car to drive to the hospital. During the drive I reflected on the call.

Of course I knew who Dr. Shock was. He was a staple on local Philadelphia UHF television. Back in the 1960s and 70s, before cable TV with its hundreds of channels, there was just broadcast TV. In Philadelphia I still remember the channels: 3 (NBC), 6 (ABC), 10 (CBS), and 12 (PBS). However, beyond this VHF set of channels there was also UHF TV. Instead of the usual rabbit-ears antenna, these channels used a circular antenna. They also tended to be fuzzy and staticky. The shows were low budget and local, but well worth watching after school as a kid growing up in the Philadelphia suburbs. Local TV personality Wee Willie Webber introduced me to Ultraman and 8th Man on his show. Sally Starr presented Popeye cartoons and Three Stooges shorts.  Dr. Shock hosted Horror Theater while prancing around in a Dracula get-up and presented old black and white monster movies. He was a funny, silly host, defusing the scariness of the movies in a tongue-in-cheek manner that later hosts, like Elivra, Mistress of the Dark, and Joel and Mike in Mystery Science Theater 3000 would come to perfect. So, yeah, I certainly knew who Dr. Shock was.

When I saw him in the hospital, I myself was shocked. This was a young looking man. Without his makeup, he didn’t at all resemble TV’s Dr. Shock. I found out his real name was Joseph Zawislak. He was just 42 years old. He was in the CCU with a big MI and low blood pressure. He shook my hand and was polite, dignified, and deferential. “Do what you can, Doc.” I had been directed by my attending to place a Swan-Ganz catheter.

This was 1979. I was a first year cardiology fellow. There wasn’t a whole lot we could do for someone in cardiogenic shock from a big myocardial infaction back then. It was the dawn of the thrombolytic and angioplasty age and those treatments were not readily available. Infact size limitation was all the rage, using nitrates, balloon pumps, and various magic potions. Practically speaking though, a large infarct with cardiogenic shock was usually a death sentence.

So it was that poor Dr. Shock arrested that night and couldn’t be resuscitated. Now, almost 40 years later, after so many forgotten patient interactions, I still remember him and that night clearly.

The End of Cardiostim

A few days ago I received an announcement by email that the Cardiostim meeting for 2018 has been cancelled. The Cardiostim website confirms this, and it looks like the meeting is gone for good.

Back in June, 2000, while still an academic electrophysiologist at the University of Colorado, I attended my first Cardiostim meeting in Nice, France. I loved it. The beautiful weather, the azure Mediterranean, the restaurants and cafés, and the charm of “Old Nice” were a relaxing break from work. The abstract presentations, poster sessions, and workshops were not too different from those of the Heart Rhythm Society back home, though obviously the European influence was greater. For good or ill, the lack of an FDA meant the Europeans got to play with new technology sooner than we did. Sure, industry was there in a large hall with all their exhibits, just like at HRS. But when they realized I was an American they didn’t really bother me. Their targets were the Europeans.

An electrophysiologist in Nice

The coffee, bread, and pastries were excellent.

Two years later, I brought a couple of my fellows with me back to Cardiostim. They presented a poster and a couple of abstracts. I went swimming out to the buoys off-shore. I ran a 5K sponsored by Biosense-Webster along the Promenade des Anglais. It was a great experience for the fellows and another enjoyable visit for me.

In 2003 I went into private practice with a large cardiology group in Kentucky. Nevertheless in 2004, and every two years after that (the meeting was biannual), I attended Cardiostim. Along the way I dumped HRS, tired of the conflict of interest between its mission to represent electrophysiologists and its industry support, whose goal was to expand device implantation by recruiting non-electrophysiologists to implant. And so Cardiostim became a biannual bright spot to look forward to during the drudgery of private practice.

The last Cardiostim I attended was in 2012. In 2014 I returned to Nice during Cardiostim, but I didn’t attend the meetings. I had retired from medicine. Nevertheless it was fun to see the city invaded one more time by the nerdy guys in their blue blazers (and women in equivalent uniforms) carrying their Cardiostim bags. It was clear the electrophysiologists were in town.

Cardiostim swag

In 2016 I didn’t visit during Cardiostim.   Later that year, in November,  I was in Villefranche-sur-mer, the town next door, at the Institut Français, pursuing my post-retirement goal of learning French. The Institut had fewer than their usual number of students that year. Enrollment had dropped after the terrorist truck attack in Nice on Bastille Day. That had occurred after Cardiostim. We visited Nice. Hundreds of hand-made memorials had been placed in a park adjacent to the Promenade des Anglais. The Promenade itself was in disarray. Areas of fencing and pavement were being repaired. New pylons were being put up, as an after-the-fact defence against a sickness that can’t be cured by putting up pylons. Nevertheless people were stretched out on the rocky beach as usual, joggers and cyclists plied the pavement, and business carried on as usual.  Although this attack had nothing to do with the end of Cardiostim (which was apparently due to Europace splitting off from them and lack of industry support), it seems like a sad coincidence that the meeting died after that vile attack.

So, goodbye Cardiostim.  Thanks for the memories.

Informal memorial to the Bastille Day victims
Nice on the Côte d’Azur

Tips for using your cellphone

A cellphone

Congratulations on your purchase of a new cellphone! While this tiny rectangle of metal and glass may not look like much, you will soon find yourself drawn into its world  —  inexorably. So as not to become one of those zombie cellphone users you see around you, crashing their cars, walking off cliffs, and ruining friendships, we have some tips for you. What’s that? This is your 10th cellphone purchase? Well pay attention, sonny boy, you might learn something too.

Like all technologies, cellphones are neither good nor evil. It is how they are used that matters. True, there are certain technologies, like nuclear weapons and cellphones, for which finding good uses is a bit of a stretch. Nevertheless we will try.

  • Waste time more efficiently
    You’re stuck in the waiting room at the doctor’s office. Go ahead and use your cellphone. It’s got to be better than that tattered June 2010 edition of People Magazine.
  • Read good stuff
    Millions of books, articles, online courses, and other good stuff are available to read via your cellphone. Use it to learn. Avoid mindless social media and amateur videos. If you’re going to walk off a cliff, do it while reading Tolstoy instead of while perusing cat videos.
  • Push vs Pull
    Alexander Graham Bell’s telephone was the first disrupting — no, interrupting — technology created (thank you very much!), and the cellphone is a much more malignant interrupter. Not only is it already a telephone, liable to go off at any moment — and unlike an old-fashioned telephone you can’t go outside to escape it — but it will also cheerfully beep or ping or vibrate incessantly with so-called “push notifications.” You need to set limits. Who’s the boss here: you or the cellphone? Do you really need to be alerted to the astounding fact that so-and-so, someone you’ve forgotten about, has finally tweeted something after not tweeting for a long time? Push notifications are usually on by default, and need to be turned off for each app, which is a pain. Nevertheless it is worth the effort to do so. Short of North Korea declaring war on the US, these notifications can wait until you decide you want to check them.
  • Don’t be rude, there are other people out there
    Long ago, at the dawn of the cellphone age, I saw a woman at the train station seemingly talking to herself in the middle of a crowd of people. I thought she was schizophrenic, talking to an imaginery person. Now such a sight is common, and people share their end of a private conversation with abandon in the midst of a crowd of perfect strangers via their cellphone plus or minus some bluetooth accessory. Don’t do this.
  • Put it away
    Two people at a restaurant. Man and woman. A lovely couple. Ignoring each other while fully mesmerized by their cellphones. This scene is repeated everywhere thousands of times a day. Why? Even if the other person is more boring than a cat video, can’t you at least pretend to be a human being who still is interested in others of your species?

It is hoped that by following the guidelines above, you will remain a sane and productive cellphone user.

George Mines and the Impermanence of Knowledge

George Mines

It was a chilly Fall morning in Montreal. A Saturday, the campus of McGill University was quiet. Students, not much different in 1914 from those of today, were sleeping off their Friday night activities. A cleaning woman entered the Physiology Laboratory to dust the glassware and wash the floors. As she turned a corner she was startled to see a young dark-haired man, sitting in a chair. She recognized Professor Mines, the handsome English scientist whom she had often seen working in the laboratory at odd hours. He appeared to be sleeping. His shirt was open and a strange apparatus was strapped to his chest. Rubber tubing stretched from this apparatus to a table filled with equipment next to him. A smoked paper drum rotated slowly. The needle of the drum was motionless, then suddenly jumped. Startled, she let out a little gasp. “Professor, Professor,” she called out. “Are you alright?” She noted he looked very pale, deathly so. She touched his hand. It was cold.

She ran to get help. The police took Professor George Mines to the hospital. There he briefly regained consciousness, but not long enough for him to explain what had happened. He died later that day. He was 29 years old. During his brief life, he used animal models to describe the physiology of reentry in the heart. He described the mechanism of supraventricular tachycardia in Wolff-Parkinson-White Syndrome long before that syndrome was described. He used a telegraph key to deliver timed electrical shocks to rabbit hearts, inducing ventricular fibrillation which he described without the benefit of an electrocardiogram. He thus was the first to report the existence of the ventricular vulnerable period. Despite all this amazing work, much of what he discovered was little noted at the time, until “rediscovered” by later researchers.

It seems likely that he was the first to induce arrhythmias in a human, long before the field of clinical cardiac electrophysiology. Unfortunately that human was himself, and the result was his own death.

The published papers of George Mines are fascinating to read. His very primitive equipment by today’s standards was more than compensated for by his remarkable ingenuity and keen powers of observation and reasoning.  He described the relationships between conduction velocity and refractoriness in reentry, the existence of an excitable gap, and deduced the reentrant nature of ventricular fibrillation. In one memorable experiment he cut fibrillating tissue into larger and larger loops until he was left with just one circulating wavefront. Amazing stuff! What more would he have accomplished had his life not been cut short?

Back in the days before the Internet, I used to keep photocopies of medical articles in a file cabinet (actually several large file cabinets). In those days of academia I enjoyed going to the stacks of the medical library and randomly reading articles from old bound journals, some dating back to the 19th century.  I learned a lot.  One thing I learned was that science has a problem with collective amnesia.  Discoveries are often forgotten or ignored, only to be rediscovered years later.

Nowadays everything is online. Or is it? Recently I wanted to look up Bazett’s original article on correcting the QT interval for heart rate. It was published in Heart in 1920 (Bazett HC. (1920). “An analysis of the time-relations of electrocardiograms”. Heart (7): 353–370.) These old volumes of Heart have not been digitized and are not online. Such a famous article though is surely reprinted? Indeed it is, on the Wiley Online Library site. I can get a copy of the PDF for $38. Absurd! An article from 1920 costs $38!

Here we see the bitrot of science, the impermanence of knowledge. On the one hand, modern scientific research is largely hidden behind a paywall, so that the poor (in the financial sense) reader must rely on abstracts, news reports, online sites such as Medscape, and presentations at medical meetings to keep up-to-date, instead of a careful reading of research methods and results. On the other hand, our precious scientific heritage, the published papers of previous generations, remains largely undigitized, residing in the dusty stacks of libraries, increasingly ignored by newer generations to whom nothing matters if it is not online. There are some exceptions. The Journal of Physiology has digitized all of its content back to Volume 1 from 1878. But most publishers haven’t bothered doing this.

At least half of early films have been lost. Early TV archives, like those of Dr. Who were routinely destroyed or copied over, resulting in loss of these shows forever. The situation is not so dire with old scientific research. The libraries will remain for a long time, and paper has a good half-life. But the beautiful work of George Mines and those like him, the true pioneers of medicine, will remain largely obscure to future generations unless that work is available online.

Perhaps some portion of the $38 for a PDF copy of a 1920 article could go to that cause.

The Smartphone is an Essential Medical Instrument

The storage capacity of the human mind is amazing. One estimate of the size of the brain’s “RAM” is as high as  2.5 petabytes (a million gigabytes). The number is based on the total number of neurons in the brain and the total number of possible connections per neuron. I suspect it is an overestimate, given the vagaries and innate inefficiency of biological systems. Nevertheless the true figure is undoubtedly impressive. But not infinite.

There are well-documented feats of human memory and calculating prowess. Ancient Greeks could memorize and recite the epic poems of Homer. Indeed this was how the Iliad and the Odyssey were passed down for generations before the Greeks acquired writing. Savants can quickly perform cube roots of long integers or have memorized pi to over 20,000 decimal places. Musical prodigies like Mozart or geniuses like Einstein impress us with the capabilities of their brains. Yet for the average person who has trouble memorizing a shopping list, these stellar examples of mental fortitude provide little solace. The old myth that we are only using 10% of our brain capacity has been debunked . So unless you’re willing to believe the combination kelp-Ginkgo-biloba-blueberry supplement you heard about on the radio is really going to work, you are pretty well stuck with the brain and memory capacity you have right now. At least until things get worse as you get older.

While the brain’s capacity may increase due to evolutionary forces over the next few thousands years (or not, see the movie Idiocracy), the amount of information that it is required to hold is not constrained by such a slow process. According to one source , there are now over 50 million scientific publications, with about 2.5 million new articles published each year. There is a 4-5% increase in the number of publishing scientists per year. No one can absorb all this. The days of the “Renaissance Man” who could quote Bulwer-Lytton while relating the latest experimental data from Maxwell and then play a Bach fugue while giving a dissertation on Baroque counterpoint are long gone. So what’s a 21st century scientist (or physician) to do?

One thing we should not do is to attempt to memorize everything. It is important to off-load as much information from our brains as possible. Our brains need to be more like an index than a database. We need to know what information we are looking for and where to find it. Information that we use all the time is automatically memorized and we don’t have to look it up. But a lot of information that we don’t use frequently is better off external to our brains. As long as it is easily retrievable, it will be available. Better to look something up that we are unsure about, such as a drug dose, than hazard a guess and be wrong.

Fortunately we live in an era when we can implement this strategy very easily. We carry smartphones that are constantly connected to the Internet. All the data we need is at our fingertips and incredibly easy to look up. Similarly we can store data on these devices for later retrieval. This constant availability of information makes life easier for doctors and undoubtedly makes for better patient care because of decreased mistakes due to memory errors.

There are those who would argue that relying on these devices is a crutch, and any good doctor wouldn’t need them. What would happen if a doctor’s plane crash landed on some remote island, where there were no charging ports? How could that doctor function?

I think it’s time to put aside such nay-saying and embrace our digital assistants. These devices are our tools, as essential to modern medicine as ultrasounds, blood tests, and MRI scanners. Take away any of these tools, and doctors will be limited in what they can do. We should be proud of the impressive technology that allows us to carry powerful computers in our pockets, and we shouldn’t be ashamed to use them.

Notwithstanding the above, medical board certification is still old-school, rooted in that outmoded 19th century Renaissance Man philosophy that doctors should hold everything in their heads. Certainly some medical board questions are practical and test things all doctors should know. But thrown into the mix are a lot of obscure questions about obscure facts that may be difficult to regurgitate during a testing session, but would be easy to look up online in a few seconds in a real-world setting. So, do these tests actually test one’s abilities as a real-world practicing doctor armed with modern information technology or are they just a particularly arcane version of Trivial Pursuit?

I’ll leave the answer to this question as an exercise for the reader.

Trying Out Vim Using Emacs Evil Mode

After using the text editor Emacs for over 20 years, and after listening to debates on the merits of Emacs vs Vi/Vim  (henceforth in this post referred to as simply “Vim”) for at least as many years, I decided that I wanted to give Vim a try. To be fair, I had used Vim before, but, also to be fair, I had never tried to master it or given it a real chance. I knew enough Vim keybindings (the “hjkl” keys and “ZZ” to save and quit) to get by when editing a file via a remote terminal. But I had never taken the time to really learn Vim to the point that it would be an efficient text editor for me. And I certainly didn’t want to abandon Emacs, mostly because of Org mode  the best organizational tool there is, and Magit , the best Git interface there is. Nevertheless the constant key-chording of Emacs, which uses control key combinations for most editing tasks, continued to be awkward despite many years of practice. The question kept coming up: was using Vim a better way to edit text?

My initial resistance to Vim was not just because I liked Emacs. Vim is a modal text editor, so-called because entering text and editing text require changing modes. Moreover, the “Normal” mode in Vim is the text editing mode. To actually enter text, you use a keyboard command to switch to “Insert” mode. To return to Normal mode, you use the Escape key. So you use the Escape key a lot. On my Mac keyboard, the Escape key is located at the top corner of the keyboard, a tiny sliver of a key that is several inches away from my left pinky. New MacBooks don’t even have a dedicated Escape key anymore.

The modal concept caused problems in my prior limited use of Vim. I would constantly forget what mode I was in and start typing in the wrong mode, causing havoc to my text. But still, lots of people used Vim and liked it a lot.

So I started reading more about it. I bought Drew Neil’s book,  Practical Vim, and skimmed through it. Something he said in chapter 2 of the book I found attractive. To paraphrase him, text is to the writer as a painting is to a painter. A painter spends time studying his subject, mixing paints, selecting brushes, and so forth. Only a fraction of time is used to actually apply paint. Likewise a writer, or programmer, spends a lot of time thinking and editing rather than just putting text down on the screen.

While I suspect the analogy appeals more to my vanity, comparing writing to art, than is true (because I think both writers and painters probably spend most of their time applying words or paint to canvas), I think the theory is at least worth trying to put into practice. Editing is what turns mediocre writing into good writing, and what bit of writing wouldn’t benefit from more editing?

Beyond the theoretical, Drew’s book is chock full of examples in which Vim shines as a way to edit text rapidly with a minimum of keystrokes. I had used Emacs’ macros on occasion to do repetitive tasks, but it looked like Vim had the potential to really rev up my editing speed.

Enter Evil mode  for Emacs. Evil mode is an Emacs major mode that transforms Emacs into a Vim clone. You can edit text using Vim keybindings, and still have all other Emacs functionality available. In other words, the best of both worlds. I have been using it for about a week now, and I think it’s great.

It works fine out of the box, but some tweaking always helps. First off, I remapped my Caps Lock key to be the Escape key in my System Preferences. It’s right next door to the “A” key and makes changing modes (referred to as “States” in the Evil manual, since the word “mode” has its own meaning in Emacs) a snap.

Then I added some fixes so that cursor movement with the “hjkl” keys would respect visual lines instead of physical lines, since a lot of my writing uses Emacs word wrap mode. Here is what I inserted into my .emacs file:

;; play with evil mode
(use-package evil
:ensure t
;; make it default, gulp!
(evil-mode 1)
;; Make movement keys work respect visual lines
(define-key evil-normal-state-map (kbd "<remap> <evil-next-line>") 'evil-next-visual-line)
(define-key evil-normal-state-map (kbd "<remap> <evil-previous-line>") 'evil-previous-visual-line)
(define-key evil-motion-state-map (kbd "<remap> <evil-next-line>") 'evil-next-visual-line)
(define-key evil-motion-state-map (kbd "<remap> <evil-previous-line>") 'evil-previous-visual-line)
;; Make horizontal movement cross lines
(setq-default evil-cross-lines t))

Finally, there are some unexpected niceties of Evil mode that makes it perfect for someone wanting to transition to Vim. First of all, it is pretty easy to tell what mode/state you are in because the cursor changes shape and the mode line has a little indicator like so: <N> that indicates the state.

Second, you can easily go back to Emacs keybindings at any time by pressing C-z. The state indicator indicates for Emacs mode. Press C-z again to return to Vim keybindings.

Third, while in Vim Insert mode, a lot of Emacs keybindings work! You can move around with C-f, C-b, M-f, M-b, etc.! So no need to constantly change modes if you don’t want to. I expect I will use this less as I get more used to “The Vim Way,” but it sure is helpful for learning.

Finally, many other Emacs keybindings work too. C-l centers the cursor in the page. I can use C-x C-s to save the file, as opposed to :w in Vim. Of course M-x commands all still work too. And C-g, the Emacs get of jail key, works as well.

So if you want to have the best of both worlds, and bring the editor wars to a peaceful settlement, Evil mode is the answer.

Here is a good talk on YouTube that also contributed to my decision to try Evil mode.

EHR Copy and Paste Considered Harmful

DRY principle – Don’t Repeat Yourself

How bad are Electronic Health Record (EHR) programs? Let me count the ways. Rather, let me not, as I and many other folks have already done so. Even non-tech savvy doctors (of which there are fewer and fewer) realize something is wrong when they compare their experience using an EHR with virtually every other computer program they come across, such as the apps on their phones. As the click counts required to do simple tasks mount up and repetitive stress injury of the hand sets in, even the most sanguine of medical personnel will eventually realize that something is not quite right. And as EHR companies forbid sharing of screenshots of their user interfaces, you’ll just have to take my word for it these UIs are, let us say, quaint. Hey EHRs, the 90s called and want their user interfaces back.

In this post I’ll point out just one of the many problems with EHRs: EHRs violate the DRY principle.  The acronym DRY is familiar to computer programmers, but not to most medical people. DRY stands for “Don’t Repeat Yourself.” In computer programming it means don’t write the same code in two or more different places. Code duplication is what some programmers refer to as a code “smell.” There is no reason to duplicate code in a computer program. A single block of code can be called from multiple procedures.  There is no reason for each procedure to have its own copy of this code block.   Code duplication leads to code bloat and code rot, where two procedures supposed to do the same thing get out of sync with each other because of changes in one copy of the duplicated code and not in the other.

Applying the DRY principle to a database requires that every item of data has a single location in the database. Multiple copies of the same data increase the size of the database and invariably cause confusion. Which copy is the original? Which copy is the true copy when copies disagree?

An EHR program is at root a gigantic database. Ideally Patient Smith’s X-ray report from 1/1/2017 is filed away properly in the database and easily retrieved. Same with his blood work, MRI results, etc., etc.

Enter Copy and Paste.

Copy and Paste is evil. Unlike Cut and Paste, Copy and Paste’s close cousin that moves data around without duplication, Copy and Paste is bad, lazy, and sloppy.  Copy and Paste needlessly duplicates data. Copy and Paste violates DRY.

EHR notes are rife with Copy and Paste. X-ray reports are copied and pasted. Blood work too. Even whole notes can by copied and pasted. It is easy to copy and paste a prior progress note and then make a few changes to make it look like it wasn’t copied and pasted. Everyone does it.

Many EHR progress notes fall just side short of novel length. Whole cath reports, MRI results, other doctor’s notes, kitchen sinks, and other potpourri are thrown in for good measure. Usually with a bit of skillful detective work one can determine the minor fraction of the note that is original. Usually it is last line. Something like: “Continue current plans.” These could be the only words actually typed on the keyboard. Everything else is just copied and pasted.

So you get all the downsides of DRY: bloated notes, duplication of data, possible inaccuracies and synchronization problems. The X-ray report may be revised by the radiologist after it is copied and pasted into the note. Nevertheless the unrevised report persists forever sitting as a big blob of text in the middle of a now inaccurate note. Of course there is some consolation that no one will ever read the whole note anyway, with the possible exception of a malpractice lawyer.

Why is Copy and Paste so prevalent in EHR notes? It isn’t just laziness. Like the pulp fiction writers of the 30s, doctors are effectively paid by the word, so that the longer the note the better. Longer notes reflect higher levels of care, more intricate thought processes, more — wait a minute! No they don’t. Longer notes reflect mastery of Copy and Paste, something that’s not too difficult to master. Even non-tech docs seem to have no trouble with it. Long notes are a way to justify billing for a higher level of care, i.e. more dollars. Since the Powers That Be Who Control All of Medicine (i.e. not doctors) decided that billing would not be based on what doctors do, but on what doctors write in the chart, it doesn’t take a crystal ball to predict that note bloat, electronically enhanced, would be the inevitable outcome of such a stupid policy.

What are the alternatives to Copy and Paste? The best is the use of hyperlinks, something that you might be familiar with if you ever use something called the World Wide Web. If I want to put a YouTube video on my blog, I don’t copy the video and paste it here, I just provide a link. Similarly, if you want to refer to an X-ray report in a progress note it should be possible to just provide a link to it. Something short and sweet.

Of course the example note I referred to above would be reduced in length to just a number of links and the sentence “Continue current plans.” This will hardly satisfy the coders and billing agents and whoever else is snooping around the EHR trying to find ways not to pay anyone (i.e. insurance companies). Nevertheless these shorter notes would be much easier to digest and might even encourage a doctor to elaborate a bit more in his or her own words on the history, physical, diagnosis, and plans. Unlinking billing and documentation would go a long way towards making EHR notes more manageable and informative. No one seems to keen on doing this however. Documentation as a proxy for care  is just one of many broken pillars of the Byzantine edifice known as the American Health Care System.

[note: the title refers to a famous (in computer circles) 1968 letter by Edsger Dijkstra entitled “Goto Statement Considered Harmful.” It has inspired tons of computer articles with similar titles, including this one.]

The Art of the Compromise

The Book

I haven’t read “The Art of the Deal,” but I suspect that part of it has to do with the give and take that is necessary in order to achieve a deal. My understanding of the word “deal” implies that I get some things I want, and you get some things you want. I don’t get everything I want, and you don’t get everything you want. But presumably each gets enough to be satisified. In other words, a compromise.

Compromise is a lost art nowadays in our political discourse. There is no middle ground, only absolutes. There are no deals. Either I get everything and you get nothing, or vice-versa. Take the issue of gun control for example (brought to mind by the shooting yesterday at the Republican congressional baseball practice). Certainly there are some on the left who would want to ban all weapons more powerful than a cap gun and there are some on the right who see nothing wrong with tactical nuclear weapons in the hands of the mentally ill. But I suspect most people are somewhere in the middle. They don’t want to ban guns outright, but wouldn’t mind at least a smidge of regulation in their sales. However there is never any compromise on this issue in Congress. The NRA raises the “slippery slope” argument, namely that any regulation at all only leads to more and more regulation, until guns are outlawed completely, and only outlaws have guns. The slippery slope argument can be applied to any position one takes and immediately shuts down any attempts to compromise.

Why is compromise a dirty word today?  The word “compromise” as a verb as oppose the the noun has always had negative conotations. A person who has been compromised is open to criticism or even blackmail. Compromise, like the word “sanction”, is a bit of a contronym, that is, a word with meanings that are at odds with each other. How much of the conflation of the good and bad meanings of compromise is the result of politics and how much the result of imprecision of language is difficult to gauge. Whatever the reason, compromise is a bad word in Washington, and possibly in the minds of many people. The constant demonization of the other side, fueled by talk radio and biased news sources, makes any attempt at compromise a “deal with the devil.” Moreover, many people approach debatable topics from an immutable position and with religious fervor, which is understandable because their position is based on religion. Religion and compromise are not words that belong in the same sentence. Religious positions, such as views on abortion and contraception, are simply not open to debate. Thus attempts to limit abortion indirectly by increasing availability of contraceptives and sex education, though logical, fall on deaf ears to the religiously indoctrinated. The increased influence of the religious right in the Republican party has certainly contributed to squelching the spirit of compromise that once existed in Congress.

The left is guilty as well. They demonize any who criticize the tenants of Islam (tenants that are anti-gay, anti-woman’s rights, that include death for apostasy and blasphemy, and so on) as “Islamophobes” and racists. While there is, no doubt, some vicious anti-Muslim sentiment on the right, the attitude that any criticism whatsoever of a religion is forbidden only serves to shut down debate and increasingly polarizes people. It is impossible to advance the debate under these circumstances, and thus we are all paralyzed into inaction while terror attack after terror attack occurs. The mandatory “thoughts and prayers” don’t seem to be cutting it in preventing these attacks.  We need a rational debate on the ideologies that lead to terror attacks, but this isn’t happening.

Returning to the baseball shooting, it was depressing to read the social media posts on Twitter afterwards. References to Kathy Griffin’s decapitated Trump stunt and the Julius Caesar play with Trump as Caesar as instigating factors were common. I do think it is likely that such anti-Trump, anti-Republican imagery and similar violent talk on the left played into the attacker’s rationale for taking matters into his own hand. After all, the attacker was an angry man who supported Bernie Sanders. On other hand there has been no dearth of similar violent talk from the right, and if anything, attacks inspired by the right, such as the knife attack in Oregon on three men defending two Muslim teens, seem to be more common. The point that both sides must now realize is that extreme, violent rhetoric can inspire a nut from either end of the political spectrum, with tragic results.

Let’s face it. In a more and more polarized country, no one is going to get his way, at least for long. Sure one party can come into power and effect its agenda. But then the pendulum will swing, as the other other side gets angry and comes out to vote. Then the other side will come into power and undo everything. This is an incredible waste of resources and a failure of leadership. The only sane course is that of compromise, taking a middle course, and realizing that neither side has all the answers. Of course that only works if the people themselves can move towards the center, away from their protective bubbles on the right and left. I’m not sure this can happen, due to the constant propaganda from non-objective media outlets and the coarsening of discourse via social media.

In an alternative universe there may be a Donald J. Trump who authored “The Art of the Deal” and came to Washington to actually make deals across party lines. Someone who forced Republicans and Democrats to find common ground and to work out legislation that would appeal to both sides. Each side would get some things they liked and some things they didn’t like. Each side could think that perhaps next election the balance of power would shift and they could get a few more things they liked into law. No side would ever be completely happy, but neither they would be completely unhappy either. But each would be respectful of the other side, would use courteous language, and would not accuse each other of being unpatriotic or un-American.

What am I thinking? I sound like a typical libtard snowflake.