Pulse check

Now that Medium's gotten more bloggy I expect to use it more - for topics too long for a tweet, but too short for an EPMonthly article.

So head over to Medium to read a few brief takes - like my thoughts on Snellen eye chart apps. Or view my Prezi on medical apps for the #AllNYCEM8 conference.

At EPMonthly, my recent article on healthcare workplace violence is available.

And check back here around May, for links to #SAEM15 resources.

Medium high

So it's been three years since I sang the praises of Tumblr, and about two years since I last logged in. Much like the iPad was a "in between" device whose appeal plateaued as smartphones get bigger and laptops get more nimble, for me Tumblr was always stuck between short Tweets and real sit-down-and-think writing. And both Twitter and real writing are taking up more of my mindshare.

I've been writing and blogging a bunch (not here, of course) over at EPMonthly. Specifically I'm enjoying the weekly Crash Cart, commenting on new EM stories with Bill Sullivan and Mark Plaster. The fodder is chosen by the EPMonthly staff (lately Matt McGahen has been on fire), we try to keep the writing incisive but informative, and the whole thing is fun and rewarding.

Elsewhere on the web, my circle of Twitter contacts and sources has been great lately. And whenever I feel Twitter is grating, I just tweak my lists, add some fresh voices, and it all gets better again.

So for me Tumblr never took off, despite its strengths. The aggregator was spiffy, and I really liked how Tumblr allowed me to elegantly collect posts on certain topics, But I never was able to engage with the various Tumblr communities - posting and sharing things to Tumblr was like decorating a snazzy room that no one visited.

Still, I'm still drawn to the idea of reinvigorating my web presence. Which brings me to Medium, the popular writing platform that's trying hard to not be a blogging platform. Each article is beautiful; a pleasant experience to read and write. But they've deliberately made it hard to aggregate content or set up a 'presence' for yourself (in the mobile app, for instance, you can't view your own writing, or even search for it).

For a while I waited to make the leap to Medium; I just figured more features were on the way. Only now do I kind of understand what Ev & co have been up to: Medium can't be gamed - it will only show you quality writing. Yeah, it's recommendations are based on your interests and the kind of people you follow. But you can't leverage your page design or tags or posting frequency or social connections to increase the visibility of your writing. You just have to write well. It's as if they decided everything else - the blogrolls and hashtags and carnivals and follower counts - has all been a distraction.

So I'm going to give Medium a shot, sharing some pieces from EPMonthly and here that could use a little fresh air.

To be continued...

Order Sets & the Art of Medicine


When I was part of Jeff Neilson's illustrious Informatics Research panel at SAEM in Dallas this past spring (we were recently invited back for San Diego next year) I spoke on the topic of simple clinical decision support projects, particularly evidence-based order sets. I also talked about incorporating clinical calculators into orders, so trainees could enter discrete patient data into the EHR and see if the test they were considering was appropriate.

These are feasible research projects that can have measurable impacts in utilization or even care, don't require big budgets, and can be done in a resident-friendly timeframe. 

There was a question from the audience. Someone wanted to know if order sets and clinical calculators were antithetical to the idea of resident education - that organizing tests and meds by complaint, and building calculators into the EHR, made it too easy to be a doctor. Might we consider abandoning order sets and focusing on memorizing doses and appropriate indications for tests? By focusing on these things, were we failing to train doctors in the Art of Medicine? 

I was surprised by the question. Perhaps it's because I'm in a bubble - surrounded by colleagues who know as much (or more) than me about patient safety, bedside teaching, EHR usability, and evidence-based guidelines for care. 

I don't remember exactly how I responded. I said something about how order sets and clinical calculators are here to stay, unquestionably reduce errors, improve efficiency and encourage appropriate resource utilization (when implemented well) and the only challenge remaining is making them as current and easy-to-use as possible. 

That was a start, but I should have also pointed the audience member to the Checklist Manifesto, which covers the evidence, obstacles and psychology behind getting doctors to put their ego aside, be humble and make sure everything worth doing is getting done. After all, there was probably a time where pilots complained about losing the artistry of flying, but the public cared about their planes not crashing. Similarly, in an era where we are trying to get 100% compliance on core measures, when we're asked to do more, and see more, with less time and less support, it's imperative we make the EHR work for us as best it can. 

The Art of Medicine may have once involved regaling patients and staff with feats of memory; now it seems more appropriately about forming a fast rapport with patients, and explaining Bayesian algorithms for risk stratification. Let computers do what they're good at - lists and calculators - and let doctors have meaningful conversations with patients. This seems like the new state of the Art. 

Analyzing Twitter for Public Health Research – #med2 tutorial

Michael Chary and I presented our tutorial, Analyzing Twitter for Public Health Research, at the Medicine 2.0 World Congress in Maui just recently.

Our audience was a diverse group of clinicians and researchers. There was substantial pre-meeting prep, where we guided prospective attendees through registering on dev.twitter.com and GitHub, then logging into a new account on Codio and forking our repository full of setup scripts and sample code.

At the meeting we presented slides and references, passed around handouts and gave hands-on help and advice to the room.

We think we've given our audience a good foundation to apply new techniques for public health research, collect good data and draw reasonable conclusions from their results.

In the course of preparing this material, we also learned a lot, about how to effectively disseminate these techniques. Now we're looking for new venues to share what we've learned - perhaps there's a role for more traditional media...

More to come.

Modern convenience

I'm glad some people choose to share their health data - be it RunKeeper routes and times, or WiThings weights or blood pressures, or the latest Quantified Self device. There's certainly evidence that social pressure can promote real change in people's lives.

It's just not for me. At least, not at this time.

But I'm finding the problem with these modern fitness apps is, they're each in a deadly competition for VC funding, for market share, for app store rankings. So they're under huge pressure to grow their user base - and that means, increasingly, pestering users to access one's contacts and one's social feeds.

So now, if I want to use RunKeeper, I've got to tap through all these social popups, to decline to share my info, after each run.

Is there a way I can just spend a few dollars to not be annoyed by my own software? I loved the Moves app, which was elegant and minimalist, and with its one-time up-front fee, didn't pester me with sharing popups. But then it was bought by Facebook - so it's likely my data's available for sharing, despite my efforts.

Folks used to argue that Apple could charge a premium for Macs because you were paying to eliminate cruft - so that you didn't have a desktop full of AOL, MSN, or other unwanted services. 

Now, with Google and Facebook matching Apple in terms of sleek design, the premium is simply going to be privacy, and lack of social prompts. 

Coming down on The Night Shift


I've been reviewing episodes of NBC's The Night Shift for EPMonthly. Specifically, I took the pilot, then episodes 5-8, while Dr. Aaron Bright handled episodes 2, 3 and 4.

It's not a good show. The plot twists are predictable. The characters are mostly caricatures. Worst of all, to me, is that the medicine is awful - it's absolutely impossible for an emergency physician to say, "We manage patients like that," or "That's what my job is like."

But I understand there are fans of the show. A lot of them. And they may want a collection of our medical impressions. So, here you go:

Episode 1 - Pilot
Episode 2 - "Second Chances"
Episode 3 - "Hog Wild"
Episode 4 - "Grace Under Fire"
Episode 5 - "Storm Watch"
Episode 6 - "Coming Home"
Episode 7 - "Blood Brothers"
Episode 8 - "Save Me"

Greg Henry also chimed in, with his opinion.



If you're looking for one episode to hate-watch, make it Episode 5, where a storm causes a power outage, a main character delivers his twins in the rain (one is breech!), another main character confronts her father in ED after he gets stabbed, and another ED doc does everything for a patient, taking her from he wrecked home, via ambulance, all the way to the OR - without ever actually working in the ED. This is a typical episode, but is notable because it was directed by "ER" alum Eriq La Salle, and because it features the most 'progress' in the show's marquee romance (an ill-advised, childish affair).

If you're looking for their best episode, make it #6, the only time a major character had a real arc, making difficult decisions, facing consequences. All the other "drama" on this show is how characters respond to the unbelievable stuff that rolls into the ED (spoiler alert: they respond with grit and determination and occasionally, flashbacks to the war).

From my ep 1 review:
Sadly, however, it's been twenty years since "ER" debuted on NBC, and this show seems like a giant step backwards for medicine on television. It probably won't do much for public perception of emergency medicine either. Sure, "ER" had some unbelievable scenarios, particularly in the later years, but there was always a healthy volume of bread-and-butter cases, and it was clear the writers took pains to portray the medicine, procedures and specialities accurately. On "ER" you'd take it for granted that the doc would call out the right meds, do the right procedure, and hand-off to the right specialist if needed. On "The Night Shift," everyone seems trained to do everything (because, Afghanistan?) and very little feels right about the resuscitations. And the characters on "ER" had more depth and nuanced relationships than the broad brushstrokes we saw last night. 
From the season finale:

It’s genuinely discouraging to know millions of people are watching this show, and seeing the most outrageous caricatures of emergency care. A bunch of EPs joined me in live-tweeting the show and our impressions - mostly eye-rolling, snark and cringing - were in stark contrast to the praise coming in from most tweeters using the #NightShift hashtag. 
We used to fret that patients would develop unrealistic expectations, when in-hospital cardiac arrest survival rate on 90’s TV shows was higher than real life. Now we must contend with the expectation that any EP can perform any surgery in any setting, or the most serious and spectacular injuries are routinely encountered, and usually survivable with minimal complications after a few hours. And I’m still waiting for evidence that the job “Overnight Onsite Administrator” and “Chief of the Night Shift” are jobs that exist, anywhere. 
All this medical fiction may be worth it, if was in the service of telling good stories. But all the characters - despite their unbelievable medical abilities - are rarely driving the action. Stuff comes into the ED, and the cast responds. I can only think of one episode where a main character chose a course that was personally difficult, and grew as a result. Instead, the writers usually substitute medical feats for character development - somehow thinking that, if the doctor sweats a bit before performing a miracle, the audience will relate. 
So here’s hoping for season 2 to be more grounded in medical reality, which will give some breathing room for the characters to grow and develop - and not just react.

It occurs to me our profession, and viewers, would be better off if NBC just aired EPMonthly's own Mark Plaster reading his "Night Shift" columns.  That's as accurate a portrayal of our job as any, and the protagonist actually thinks and grows over time. But apparently that's too much to ask from a big budget network show.