Web 2.0 and Social Media for Cardiologists - one-click solutions

I was preparing for my presentation at a major medical conference in India.  The presentation is on use of Social Media for Physicians.  The conference is focused on mostly cardiology topics for general internists.  The organizers asked me to make sure the talk was practical and could leave the attendees with some easy to follow take home points.

As always the challenge with a presentation is knowing your audience.  I did not have a good feel for this, not having attended this conference before.  I struggled to select the appropriate content for the presentation.  I needed to show them what was possible, and then what they could do to get started.

I decided to give them some highlights on using Google Reader to stay current with medical (cardiology) literature and use of Twitter to network with cardiologists and to get updates and insights.  To make it easy for them to get started I created

• An OPML bundle of cardiology journal feeds and
• A Twitter list of cardiologists to follow - this post by Larry Husten was very helpful to get started.

Having gone through that effort, it is probably worthwhile to share these for others to use and share.

Getting your cardiology journals delivered to your "doorstep"

• Get started with Google Reader
• Then subscribe to 11 top cardiology journals and 3 blogs with one click.  (Click on subscribe)
• Go to Google Reader and all 11 journal feeds should be available at one place.  These can be tagged and shared on Twitter, FB or Google+, Tumblr etc and also be searched!

RSS Feed Bundle or 11 top Cardiology Journals

Getting your cardiology fix on Twitter

• Create a Twitter account (optional for read-only mode)
• Go to the Twitter cardiology list
• View Tweets and follow the conversations and links
• Join Twitter to participate

Twitter List for Cardiology Updates

So there you are - 2 quick one-click solutions to introduce cardiologists into Web 2.0/Social Media.

Addendum:
A conversation with @Allan Palmer on Google+ made me realize that this might have come across as a final solution for the attendees.  I need to stress that this is just the first step. There are several frameworks for understanding why some people are late to adopt IT innovations.  The Technology Adoption Model is based on:

• Perceived Usefulness and 
• Perceived Ease of Use

The Diffusion on Innovation theory by Rogers adds that an innovation must be easy to try, and its use should be visible to others (peers).  

Based on these frameworks, one would seek to provide late adopters an easy to use approach to try these tools, and allow them to see other colleagues using it.  Ideally one would add some hypothetical cases to illustrate the utility.

Thus for this conference, I could create an example of a patient on a statin who has questions about adding niacin to the regimen or a patient with history of coronary artery disease who is on a betablocker and getting severe fatigue from it.  These would lead to recent articles on these topics and conversations on Twitter and blog posts about these studies.

Confessions of an Early Google+ Adopter

Google+ has had the best features of FB and Twitter with granular control to fine tune of the stream, ability to get to know folks from all over the world with similar interests, no ads, ability to have longer coherent discussions, very few of the "I ate a bagel for breakfast" posts, combined with the integration with Hangouts and Google Drive for collaborative document authoring and video conferencing.

With the launch of Communities, there are even more possibilities for collaboration and sharing but there is a serious possibility that we will see the influx of businesses and marketers.  Lets keep our collective fingers crossed!

Don't ban mobile devices from meetings; leverage them!

Just read a post on Techcrunch "Tech Is Making Meetings Worse, It’s Time For Digital Hat Racks" which recommends that we should make people check in their mobile devices before starting a meeting.  The author Nir Eyal feels that there are only rare occasions when attendees actually use their devices in a productive manner and thus these act as distractors.  

From Techcrunch linked to http://techcrunch.com/2012/12/09/digital-hat-racks/

This is issue is very similar to faculty members complaining about their students not paying attention during class, spending time on Facebook or texting instead.

My response to this post is that one can have very productive meetings when we use devices appropriately.  I find that meetings can be excellent working meetings when we have laptops and other mobile devices and use them purposefully.  I am involved in several standing meetings through out the week which follow the following model:

1. The team has a shared folder on Google Drive
2. Before each meeting, a document is created in the shared folder - the title is the date of the meeting
3. Participants populate the document with agenda items prior to the meeting
4. During the meeting one laptop is used to project the Agenda document on the screen
5. At least one other person uses another device, usually a laptop to load the same document and edit it collaboratively.  This device is often passed around among the attendees depending on who needs to edit it.
6. During the meeting we use the devices to
1. Look up information - rather than assigning the task to someone to look up after the meeting and thus postponing the decision making to the next meeting
2. Communicating - often via email or alpha pagers (yes we still use those) - send message to get answers or more information.  
3. Project data or web sites 
4. This information is entered into the agenda document which essentially becomes the meeting minutes.
7. Since everyone has access to the document, no minutes need to be emailed, or approved.  
8. While a lot of work does get done during the meeting, we of course make decisions about projects and this is captured on Trello.  We use Trello as a project management tool.  This serves to bridge the meetings by creating a list of to dos for each project and assigns these to a team member.  Team members review Trello between meetings and use this to organize their work and then update the agenda document for the next meeting.

This model has worked very well for us and we have expanded it to create a Google+ circle of team members.  This allows us to do hangouts for meetings where someone is unable to attend in person and also continue the conversation between meetings.  

The same model can be adopted for learning sessions, but the faculty need to be aware of and comfortable with technology tools that can help improve the learning experience and make the process more active, fun and efficient.

Getting my Google ecosytem on an iPhone 5

If you have been following this blog, you saw that our workplace recently switched from a BB to an iPhone. While the iPhone 5 is a wonderful device, the BB clearly was excellent for what it did - email, phone and BB messaging, connecting to resources behind our corporate firewall etc.

Playing around with the iPhone, I have been trying to customize it to suit my daily workflow.  Here is a snapshot of where I am right now.  Clearly this will evolve as I use it more and as new apps become available or existing apps get updated.

Chrome works better for me than Safari as it keeps track of my favorites and recently closed tabs and tabs on my other devices.  It allows me to share to Google+ easily (no workarounds like this).

Gmail app works much better than gmail on the iPhone mail app as it lets me do labels and organize in Gmail more easily.

I have been using Google Voice since it was "Grand Central" or something similar sounding.  It has terrific features and I still trying to figure out the best way to integrate it with iPhone 5 and iMessaging.  Unlike an Android device, the iPhone does not allow automatic calling via Google Voice.  So right now I have both on my the Phone and GV on my home screen.

Of course, I have a link to the Google Maps mobile web page but also have the iOS Maps app but that will go away as soon as the Google Maps gets released for iOS 6.

I also have a shortcut to the mobile Google reader web page on another screen.

I am probably being a bit passive aggressive about this but I think there is at least some logic behind this?  And yes I should be catching up with my e-mail rather than blogging!

Why don't we see patients in our pajamas?

Professional identity and social media are being hotly debated ever since the rise of Facebook.  The topic raises questions about how physicians should  behave on social media.

The fact is that social media is bringing to the forefront something that has been around for ever.  Lets look at some of the background literature on this.

Goffman in 1967 wrote in the "Interaction Ritual - Essays on Face-to-Face Behaviour;

"Every person lives in a world of social encounters, involving him either in face-to-face or mediated contact with other participants.  In each of these, he tends to act out .... a pattern of verbal and nonverbal acts by which he expresses his view of the situation and through this his evaluation of the participants, especially himself. Regardless of intent, he will find that he has done so in effect.  The other participants will assume that he has more or less willfully taken a stand, so that if he is to deal with their response to him, he must take into consideration the impression they have possibly formed of him."

"When an individual appears in the presence of others, there will usually be some reason for him to mobilize his activity so that it will convey an impression to others which it is in his interests to convey"

Schlenker wrote about Impression Management and self-presentation:

 "Impression management is the goal-directed activity of controlling or regulating information in order to influence the impressions formed by an audience.  When people are trying to control impressions of themselves, as opposed to other people or entities, the activity is called self-presentation."

Schlenker goes on to discuss that self-presentation does not have to be Machiavellian or purely there for self-advancement or self-prormotion.

"Self-presentation is a fundamental feature or characteristic of interpersonal experience.  It is inconceivable to discuss human social behavior without employing the concept.... we package information to help audiences draw the right conclusion.  This packaging is a pervasive feature of interpersonal behavior."

One must be aware of how people are perceiving and responding to our self-presentation so that we can deliver the package to meet the appropriate goal - something that does not have to be deceptive or immoral.  It may take as much social skill to create an accurate self-presentation as a misleading one.

This fact has been highlighted by the popular press with books like, "How to win friends and influence people" and "Getting to yes".  Social media has truly brought this home into every minute of our awake state.

Sherry Turkle in her NY Times op-ed talks wistfully about the loss of conversation for mere connection.

"Texting and e-mail and posting let us present the self we want to be.  This means we can edit.  And if we wish to, we can delete.  Or retouch: the voice, the flesh, the face, the body.  Not too much, not too little - just right.

She laments how we are getting comfortable with the intrusion of technology into "real" life

"We expect more from technology and less from one another...We use technology to define ourselves by sharing our thoughts and feelings as we're having them.  

Nathan Jurgenson has coined the term "Digital Dualism" for this separation between online and offline and calls it a fallacy.

"Instead, I want to argue that the digital and physical are increasingly meshed, and want to call this opposite perspective that implodes atoms and bits rather than holding them conceptually separate augmented reality."

And in the Atlantic he writes,

"Emile Zola stated back in 1901, 'You cannot claim to have really seen something until you have photographed it.'  Today, we joke, 'It did not happen unless it is posted on Facebook.  Photography caused a global sensation around the new possibility: to document ourselves and our world in new ways, in greater detail and in lasting permanence."  

Just as photographers who may not be able to look at a scene without imagining how it would look through a camera's viewfinder, today's digital native may perceive "reality" by how it could be posted on Facebook.  Our parents took photographs on vacation trips and did looooong presentations at dinner parties with Kodachrome slides!  We now take photos with our smartphones and post these instantly on social networking sites.

But every time we do this, we are doing impression management and more specifically self-presentation.  We are constantly creating, modifying and managing our identity in the social networking space.  We are consciously or subconsciously aware of our environment and our perceived audience and have have an impression of how they perceive us and how each share in the social space affects that perception.

This again is just an extension of our life as usual.  Physicians wear a white coat and/or a tie or other appropriate clothing when they see patients.  Why don't they wear their pajamas?  There is a perception of what patients think a physician should be wearing.  This has been drilled into us often subliminally as we go through medical schools and residency training.  It may be difficult to break out of that mold.
But we dress differently when we go to watch a football game or to the grocery store.  Thus physicians clearly have a sense of self-presentation for different environments and perceived audiences.

So why do we have all these cases of unprofessional conduct in social media?

Firstly the problem in case of new entrants to the profession might be due to them not recognizing that the rules of engagement are now different.  Some of the folks who saw them as a college kid now might expect to see them as a future doctor.  But more importantly they now may have a new audience that perceives them only as a future doctor.  This is a problem if they have not locked down their social media profile and thus may be visible to the public.

Secondly, any person can make a slip and in a momentary lapse forget to don his social media white coat when interacting on a public forum.

I would suppose that when there is a wide gap between the baseline persona and the self-presentation situation, a person would find that environment more stressful and if not careful, is more likely to commit a bigger lapse of professionalism.

This leads to a question of why can a person not be "himself" (if there is such a thing), instead of having to don all these different personas?  I guess one should study mindfulness or Engaged Buddhism where Thich (Thay) Nhat Hahn preaches how to be truly happy,

"To be beautiful means to be yourself. You don’t need to be accepted by others. You need to accept yourself. When you are born a lotus flower, be a beautiful lotus flower, don’t try to be a magnolia flower. If you crave acceptance and recognition and try to change yourself to fit what other people want you to be, you will suffer all your life. True happiness and true power lie in understanding yourself, accepting yourself, having confidence in yourself."

Listening to the Sage from Omaha

I am not an investment buff but when you get a chance to listen to a sage at your doorstep, you take it.  Today the Cleveland Clinic ideas for tomorrow series hosted Warren Buffett.  It was quite an amazing experience, and I came away with the impression that he is

• Simple
• Genuine
• Funny
• Smart

I live tweeted the session omitting the second t from his last name.  It is quite amazing how often one can read something and not know how to spell it till you actually write it.  Anyway, quite unedited, here is my Twitter stream from the session.  There are some absolute gems in this, something that will stay with me a long time.

Coming full Circle in Google+!

Had an amazing journey today and made me realize how sometimes one can learn so much if you have the right people in your circles on Googe+ (or follow the right people on Twitter).

It started early morning when I saw this post by Dirk Stanley who is a physician and a Chief Medical Information Officer.

I followed the link to his excellent blog where he describes his thoughts on EHRs and alerts.  I 1+'ed is post and went on with my day.  Later I came across this post by Marcius Herbert who is a Computer Science Educator in the UK. The post was about using SMS to persuade learners - linking to an article in the British Journal of Education Technology.  This sounded fascinating as I was aware of the use of SMS in helping patients comply with physician instructions.  

At work I was able to get the full text of the article which used an instrument called MSLQ (motivated strategies for learning questionnaires) and referenced the work of B J Fogg who has done amazing work in the field of motivation or "Behavior Design" at Stanford. The article referenced his book "Persuasive Technology; Using Computers to Change What  We Think and Do"  I perused this and learned about the term he coined, "Captology" and his principles organized under

• Computers as Persuasive Tools
• Computers as Persuasive Media and 
• Computers as Persuasive Social Actors

This was fascinating stuff and I realized how this was so closely related to how we try to design Clinical Decision Support Systems and alerts in Electronic Health Records to try and change physician behavior if they are doing something inappropriate.  

My day had come a full circle!

iPhone 5 - Should it have a back button?

As I posted earlier, our workplace moved from BB to iPhone 5.  The iPhone will be the only supported device for corporate e-mail.

As I use the iPhone, I realize that it seems to be missing something very simple that I have gotten used to using on both the BB and the Android.

The home button at the bottom has to serve the purpose of 3 buttons on Android 

Consider these cases:

• You get an e-mail with a hyperlink.  You click on the hyperlink and it displays the web page in the browser.  Now you want to return to the e-mail.  How do you do it?
• You are reading Google news.  You click on an item of interest and it opens a new tab.  Now you want to go back to the news stream.  How do you do it?

I cannot find a way to do it in iOS with one click.  Maybe I am missing something but seems like a simple oversight. 

The first versions of iOS did not allow multiple apps to run concurrently I believe.  Maybe there was no need for a back button then.  Seems it is high time for iOS to get this IMHO.

Another issue is the height and width of the iPhone 5 combined with a "back" navigation button at the top of the screen makes it very difficult to have a one-handed operation.  

Android has a back button along with the home button and a button to show the running apps at the bottom of the screen.  In the Google News example above, the back button closes the newly opened tab and takes you back to where you were in the news stream with a single click!  

The back button is integrated into all Android devices at the bottom left.

Goodbye Blackberry: What I miss about you!

Recently our workplace stopped supporting the Blackberry and moved to iPhone 5.  This is now the only supported smartphone for getting corporate email.

While I am always excited to get a new device, I am already missing my Blackberry Bold.  What do I miss the most?

1. Speed dial.  I had several buttons programmed to dial with one long press.  Speed dialing did not need me to touch the screen, swipe, or use voice control.  Thus I could press the H key for home, the D key for dad etc.  The iPhone since it lacks a physical keyboard can not have this functionality.  Yes one can use Siri or create favorites or even do some workarounds using "xxx-xxxxxxx.tel.qlnk.com" but nothing even gets close to the simplicity of having a single key press for speed dial.
2. The trackpad:  This is probably one of the most brilliant features of the BB.  While it had a touchscreen, the trackpad made it almost unnecessary to touch the screen.  One could navigate the cursor precisely to the necessary spot and click the exact spot you wanted.  One could swipe, scroll etc without touching the screen.  This made it a very simple one-handed operation.  The iPhone 5 being a particularly taller screen makes it harder to reach all navigation areas with the thumb while hold the phone in the palm and fingers.  
3. Zooming a video:  While the iPhone has a somewhat non-intuitive pinch to zoom function for the camera it does not appear to have this for the video which seems quite an important omission for a 500+ dollar device that claims to have the best camera on any smartphone.  Yes there are apps that enable video zooming but IMHO this should be a built in functionality.
4. The form factor:  The fact that a lot of navigation controls are near the top e.g. the email navigation buttons; and the home button is near the bottom means the phone has to be moved around in the palm  to reach these.  The phone is just too tall for one handed operation and too narrow to feel secure holding it in the palm/fingers.  Due to the insecure grip, a case is a must which means there is no point to the gorgeous look?  Never even thought about getting a case for the BB as it was secure in the palm and just the right width.
5. The BB magnetic holster:  It is possible on the BB to set up certain profiles/behaviors based on whether the device is in the holster or outside.  This would also save battery life by automatically putting the screen to sleep/locking the device when placed in the holster.  

A Dynamic and Productive Soccer Sideline?

Converting Potential Energy into Electrical Energy!

I have spent many hours driving to and watching our daughter's soccer games.  These are something I look forward to as it gets me out of the house even on cold and rainy days.

But these trips come with a bit of a guilt trip.  I fret about the many miles we drive and the gas we burn as hundreds of families descend on these soccer fields.  Also folks bring a folding chair and promptly plop it down on the sidelines, and then sit and shout for the whole game while encouraging kids to run faster and play harder.

Potential Energy ready for harvesting!

Would it not be great if there was a row of stationary bikes on the sidelines that were plugged into a device that could generate electricity and possibly even push it into the grid?  Yes, yes I know the amount of energy generated by a stationary bike is minuscule but there are hundreds of people sitting on the sidelines.  Plus imagine the side benefits.  The folks would get some exercise, and possibly be too out of breath to curse at the referee.  The kids would be thrilled not to have their parents shouting at them.

Think this is impractical?  Seems there are several devices like this in the market that can be plugged into regular bikes with the rear wheel raised on a stand to make them into stationary bikes.

"Nah none would use it!" you say.  Well how about giving them some motivation.
We could pit parents of the two sides against each other and even have a power meter indicating which side is generating more power.  Thus while the kids play peacefully in the middle, parents can duke it out constructively on the sidelines.

What if the soccer facility provided the bikes and parents would swipe an ID to register themselves and their energy production could be tracked and they would get back some credit?  This system already has been imagined for bike rental systems here.

Any takers?

Infographics: Can they make reading journals easier?

As we struggle with information overload and clinical overload, it is harder to keep up with updates in medical literature.  Several journals are trying to make it easier to scan articles and get the salient points quickly e.g. Annals of Internal Medicine provides a commentary summarizing the practical implications of a study.
My assumption is that most readers scan the abstracts of articles before deciding which ones to read in full.  Appropriate use of graphics can improve comprehension and possibly make this scanning process more efficient.  As the old saying goes "A picture is worth a thousand words".  Clearly graphics are very popular as can be seen by the popularity of Infographics and Pinterest.
So I decided to try out a free infographic creation tool Piktochart to create a visual representation of the salient points of a study.

I chose this study from JAMA - because it was the first study that caught my eye in my Google Reader stream after I thought of this idea.  So this is what the abstract looks like:

As you can imagine it took me a few minutes to get the main message of the study.  What if I had seen this infographic instead?  I took all the information from the study abstract.  The only thing I added was the Number Needed to Treat (NNT) that I calculated myself.  

Infographic Created by Neil Mehta

So what do you think?  Does an Infographic make it easier to scan journal articles?  If so, should journals have data visualization experts on their editorial team to help create these?  Should there be standards for creating these e.g. Blue circles for control groups and yellow for intervention groups, etc?

The Search Hub - search the Web, Email, Cloud storage and Bookmarks from one place!

We know how Google transformed how we find information.  It is the default search engine for majority of users.  But many users may not be aware of 2 features that help me tremendously.

1. Google is now doing a field trial that lets you search your Gmail and Google Drive for the search terms
2. When you search using Google it can simultaneously search your Diigo Bookmarks.  

So now you can from one hub search the web, your email, your cloud storage and your bookmarks!  

Google Search Field Trial - search Gmail and Google Drive from Google Search!

Search your Diigo Bookmarks from Google Search.

Bring your own device (BYOD) and the Ecosystem

Recently I was talking with a very bright colleague who is about to cave in and buy a tablet.  He does not even own a smartphone. He has managed to stay out of this technology maelstrom for so long that he was asking folks for advice about which was the ideal one to buy.  I was impressed that he did not just jump in to buy the iPad since that is what everyone had heard of.

I told him there were many factors to consider like the carrier, the size of the device, whether it has a microSD card etc but one of the factors was the ecosystem.  Seeing the look on his face, I knew I had some explaining to do.  So what is an ecosystem?

In biology, an ecosystem describes the complex interactions between the living organisms and their environment.  In technology, it describes the hardware and software on the device and the content and the applications that they interact with that often reside in the cloud.  [This is my made up definition and would be glad to know of a more formal generally accepted one].

He still looked puzzled so I drew a few circles representing Google, Apple, Microsoft and Amazon on the back of a paper napkin.  Then I drew some boxes on the circumference representing the following:

An Example of an Ecosystem

• App Store
• Music
• Games
• Movies
• eBooks
• Apps
• Devices
• SmartPhones
• Tablets
• Desktops/laptops with OS
• Cloud storage
• Documents/Office apps e.g. documents, presentations and spreadsheets
• Social Networking
• Email
• Calendaring
• Contacts
• VOIP and Video conferencing
• Content Management Systems
• Groups
• Maps
• Browsers with syncing across devices
• RSS feedreaders
• Search

At this point his eyes were getting a bit glazed over.  He appeared to be asking, "What has all this got to do with buying a tablet or smartphone?"  So I gave him an example of how these are all integrated and having a device that is part of the ecosystem makes a lot of tasks easier.  Thus if you like using Google Voice, you may want to lean towards getting an Android device as it is seamlessly integrated into the phone.  

While it is often possible to access parts of an ecosystem from another type of device, it may not always be smooth.  Thus one can access Google Drive from both an Android and an iOS tablet (iPad) but generally the Android tablet gets features before the iPad.  The recent Google Maps issue on iPhone 5 is another example.  

He got it.  He was actually pretty amazed at how much these devices could do.  I felt bad about leaving him without any direction.  I was trying not to bias him but then he asked me what I would do if I was him.  I told him I would probably get the Nexus 7 tablet.  It was recently named the top gadget and top tablet of 2012.  He asked me, "Does that preclude me from getting an iPhone later?  Isn't the iPhone the best phone out there? And what about a computer OS? Google does not have one does it?"

"Great questions!" I said, "You may want to take a look at the this video before you consider buying an iPhone 5"

"And as far as the OS goes, Google does have computers with the Chrome OS but you can get the entire Google Ecosystem from a Chrome browser which you can install on a computer with any OS."  At this point, he was almost convinced.  But then I had to break the bad news to him.  "Of course, you need to know that our workplace does not support Android; only the Blackberry is supported.  Also only devices bought through work will be able to access the enterprise e-mail.  This is for security reasons."

I really don't like to see grown men cry!  Wish the BYOD philosophy was easier to embrace for organizations.  

Google+: "Connecting and Sharing among People with Common Interests

The last few months a lot has been written about Google+, comparing it to Facebook.  I have personally found myself using Google+ much more than Facebook and I was not sure exactly why.  It was only recently when I tried to explain Google+ to some people that I gained an insight about this.

I started using Google+ because I like to try out new things.  I enjoyed exploring its various features and how to apply them to my work.  As I used it, I realized I was not going back to FB as much as I used to.  Initially I wanted to try and get my "friends" from FB over to Google+ and it bothered me a bit that they did not.  Then one day I realized it did not bother me at all.  I realized something that I think I knew all along, that at a very fundamental level Google+ and FB are completely different. How so?

FB's tagline says "Connect and share with people in your life".

My interpretation of "people in your life" is people you know or have known.  Once you connect with them i.e. "friend" them on FB, by default everything you post is visible to ALL your "friends".  The Pew Research Center in its report in May 2012 found:

• On average, users make 7 new Facebook friends per month; they initiate 3 requests and accept 4.
• Women average 21 updates to their Facebook status per month while men average 6.
• In a month, about half of our sample made a comment on a friend's content, and about half received a comment.
• Fewer than 5% of users hid content from another user on their Facebook feed.

Another key difference is the reciprocal relationship with other FB users.  Thus only after both users have mutually agreed to be friends can one see the other person's posts.

What this means is that till you agree to be friends you see NOTHING of what the other person posts and after becoming friends you usually see EVERYTHING that the other person posts.

Google+ at its very foundation was built on the concept of Circles and also allows Public posting which is very similar to a blog.

Public posts can be seen by anyone who follows you and are searchable on Google. People can comment on them, share them or +1 them.  You can see who these people are and view their public posts and decide if there are enough common interests that you can follow them back.  This leads to finding people of similar interest across the whole world - most often people you DO NOT KNOW.
People posting publicly are aware that these are open to the world and thus will not post private information like photos of their kids or what they had for breakfast.

Circles allow you to target your posts to specific people, and these are not visible to anyone outside the group (Circle) you specify.  This may seem to be similar to FB but it is not.  The list of people in your circles is unique to you.  Thus you could have a circle called Close Friends and have 5 people in that circle.  One of those 5 people may also have a circle called Close Friends and it may have 15 people in it.  You may not be in that circle.  These asymmetric circles can be confusing but allow for great autonomy in targeting your posts and filtering your stream.  The ability to mention specific people in posts allows you to include them in the conversation in a granular manner.

Create Circles based on you interest or projects

Now you can target your posts to those circles or keep them Public

You can filter your information stream using your circles and notification settings

Google+ allows you to share a circle.  Thus if you have collected a group of people with interest in HDR photography from across the world you can share it with other users.

The consequence of these differences are:

1. You are more likely to connect with people you DO NOT KNOW on Google+ compared to FB.  In this way it is a bit like Twitter.  
2. You are more likely to connect with people with similar interests.  The shared circles feature is a bit like Twitter lists.  
3. You are less likely to see uninteresting or irrelevant content on Google+ especially things that you feel people should have shared with a fewer folks. 
4. Due to the ability to filter your feeds and adjust your notifications (in a very easy manner) you feel in control of your information stream.

Ladies and Gentlemen, Please Silence your Cameras!

We should have expected this, it was just bound to happen.  But when it came, it still took many aback.

I am talking about the use of smartphone cameras to capture speaker slides during presentations.  I recently attended the AMEE 2012 meeting and noticed a large segment of the audience taking endless photos during presentations.  They took multiple photos of one slide either because the shot was not focused or the speaker was building the sliding via animation and they missed some bullet points.

Personally I have no problem with this practice.  I have been doing this myself in a limited manner using my Motorola Xoom tablet and Evernote.  The problem is that people are forgetting to mute their cameras and can be irritating and distracting to the people around them.  When many people start taking multiple photos, the issue can be quite serious.

At one session one of the audience members got so upset that she got up and asked everyone to silence their cameras.  I expect that presenters will soon be adding something on their first slide to ask the audience to silence their cameras.

Hidden Curriculum in Medical Schools - Are we teaching what we want students to learn?

We all know that

• The amount of information is increasing rapidly
• The 1/2 life of knowledge is shrinking - what we knew few years back does not hold true anymore.

As Alvin Toffler said, 

“The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn. ” 

Once our students leave the formal education settings of medical school, they will have to learn how to keep up with literature and new advances on their own.  Thus medical educators want to teach students how to become self-motivated self-directed lifelong learners.  

The hidden curriculum is the unintended lesson/s, usually about norms, values, beliefs or behaviors, learned during a learning experience.  Thus in medical schools students are taught a particular way to communicate with patients.  When students see health care practitioners interact with their patients differently, they get a different message.

One of the biggest hidden curricula is the way students are expected to learn in medical schools.  Traditionally, they are expected to attend lectures and seminar, show up in clinical rotations and have information delivered to them, drilled into their heads.  [A number of medical schools are trying to break out of this mold]. These students get the unintended message that someone else is taking the responsibility for their learning.   This hidden message is more powerful than the intended message for their need to be self-directed learners.  

To truly help students become the independent, self-directed learners we want them to be, schools need to reform the way they educate.  Instead of large lecture halls, early in the training the students need to learn how to look up and find information to solve problems.  Students can learn individually or in small groups (e.g. Problem based learning and Team based learning).Passive learning should be avoided.  This  will create a hidden curriculum that will help our students learn the only useful lesson we can teach! 

What medical educators can learn from the car industry

Formative and Summative Feedback

Formative feedback - that is the ongoing, near real time, specific, non judgmental feedbak - is critical to learning and helping change behavior [Ref].  Unfortunately medical educators have for too long used only summative feedback for assessing medical students - you know the end of rotation grades, the USMLE scores etc.

Part of the problem is that faculty and preceptors are the ones who need to provide this feedback as they work with students on a daily basis.  But they are unaware of the need for such feedback or are not trained to provide it or unable to provide it for logistic reasons.  Clerkship directors meet with the students only infrequently and do not have such feedback to review and share with the students.  They often have comments like "Excellent" or "Great presentation" or "needs to work on presentation skills" which is not specific or helpful.

How can we train our faculty in giving useful formative feedback? Since most faculty members went through traditional medical school programs and did not receive much formative feedback, they may not be aware of what it is and the importance of giving this.  A metaphor we can use is something we see almost daily and comes from the car industry.  [For some interesting reading on this see the National Renewable Energy Laboratory Report (pdf) by Gonder et al]

Learning Objective: Learn to drive in a way that improves fuel efficiency.

Cars now give immediate and constant feedback to the driver regarding the rate of fuel consumption as miles per gallon.  This is visible on a visual scale next to the odometer.  It also shows a color indication in a ring around the speedometer (e.g. green if driving at optimal speed and acceleration).   This is an excellent example of formative feedback and can lead to correction in behavior.


Cars also provide an average fuel consumption for a particular duration, and can be reset by the user.  In most cases it is reset on refilling the fuel tank.  Looking at this at the time of refueling gives the driver summative feedback on their performance for that duration.  If the number is low, it should not come as a surprise to the driver who has been getting constant feedback and has failed to change behavior.  The driver has control over how she/he chooses to drive.

While drivers can choose to ignore the feedback, in case of students, they come to a medical school to become good physicians.  They want to get such feedback and to constantly improve.  Using this metaphor hopefully we can train our faculty to provide more useful, timely, non judgmental feedback.  One hopes this will lead to them spending more time in helping all our students become better physicians and less time comparing and ranking them.

If the car industry can understand this, why not medical educators?

My Gold Medal Goes to....

Achievements in Olympics reflect huge sacrifices, long years of training and planning and performing under high pressure in front of a global audience.  The feats of these athletes serve as inspiration for us common mortals and help to hopefully unite the world.

While the London Olympics are underway, something even more difficult than any individual or team performance and more awe inspiring just took place - the landing of a huge rover on Mars using a maneuver never used before after 7 minutes of terror.  Here is a video explaining the difficult procedure.

Very early this morning (EST) Curiosity landed successfully on the surface of Mars and sent back its first images.  The world cheered but the video of the NASA team watching with bated breath and then their emotions when they got the good news brought tears to my eyes.

Without belittling the performance of the athletes, if I had to give a gold medal it would easily go to the NASA team for their amazing work in the face of budget cuts and political uncertainties.  Congratulations NASA!  

This post was prompted by an online conversation on Google+ with @Brad Gill one of the many brilliant students to come out of our medical school. 

The Olympics: Hunger Games or Human Games?

Following the Olympics has been a emotional roller-coaster of a journey and has led to a lot of soul searching.
There have been some amazing moments - with Michel Phelps getting probably the most press - coming fourth in one event, missing gold by .05 seconds in another, winning the most ever Olympic medals along the way..
Watching the US athletes on the podium listening to the "Star Spangled Banner" invariably brought tears to the eyes.  Serena unleashing a powerful performance in the finals to win 6-0, 6-1 was jaw dropping.  The US flag was not there - blown away by a gust of wind at Wimbledon - bringing much needed humor at a solemn moment.

Image linked from  http://theybf.com/category/sports

Along the journey something kept bothering me.  Seeing young teens competing in individual events carrying the hopes and expectations of their family, friends, schoolmates, their country on their young shoulders.  Watching a 15 year old Katie Ledecky blowing away a super strong field in the 800 meter freestyle and 17 year old Missy winning multiple events in swimming was a celebration of youth.  The tears of 17 year old Victoria Komova on losing the gold in the individual all around (she won the silver) showed the incredible pressure on these young shoulders.  The 16 year old Chinese sensation Ye Shiwen forced to defend herself against allegations of using performance-enhancing drugs because she has improved dramatically over the last year.  Then the image of a Canadian trampoliner going from shock to breaking out in smile when her Chinese competitor fell at the end of her routine realizing she had won the gold with that spill.  The latter reportedly declined to wear her bronze medal.  These young athletes are damned if they win and damned if they nearly win and damned if they don't win.  All this under the microscope of social media and 360 degree 24-7 fast news coverage.  These scenes reminded me eerily of the Hunger Games.  As we celebrate the champions, do we hear the stories of all the people who did not make it, who were proud to just compete, to try, to give it their all, their sacrifices, their heart breaks?  Are they learning the right lessons, is the Olympic movement working, is the Olympics spirit alive and well?

And then I reflect on the following images and my faith is restored:

• Jordyn Weiber crying her heart out on missing out competing in the individual all-around event and then coming back to cheer her team mates on in the event she missed.
• Margot Shumway in the women's double sculls learning a new sport so she could get to the Olympics and coming from behind to make it to the A Finals with her mother in the audience - fighting lung cancer - making it to London to watch her daughter between 2 rounds of chemo
• Oscar Pistorius a double amputee who had an epic struggle to get accepted to the Olympics because folks thought the "blades" gave him an "unfair" advantage.  He was just happy to be able to compete.  His mother wrote in a letter for him to read as an adult, ""The real loser is never the person who crosses the finishing line last,'' she wrote. "The real loser is the person who sits on the side, the person who does not even try to compete.''
  [From http://sportsillustrated.cnn.com/2012/olympics/wires/08/04/2090.ap.oly.john.leicester.040812/index.html#ixzz22bTuSQQM].  

They don't need medals, they don't need their photos on cereal boxes.  But we need their stories to be told just as loudly and frequently and proudly as those of the medal winners.  Once we do that, the Olympics will truly be the Human Games instead of being the Hunger Games!

Au Revoir Dear Friend

I never had a pet before, I thought dogs were not worth the trouble
I did not want to wake up early to take you for a walk
I did not want to pick up after you when you went on a lawn
I wondered if having you meant we could not travel any more
I thought you would bring in fleas and shed on my carpet
I assumed you would bark when I was trying to sleep
I worried you would nip my child and gnaw on the furniture
Still I loved my daughter and wife too much so I reluctantly said yes

I was never so wrong in my life

The innocence of those bright eyes, the boundless joy of that wagging tail
A reward for a long day at work
You were my daughter's pillow, her best friend as you grew up together
The selfless love, the trusting companionship made it all worthwhile.

As the lymphoma ravaged your body,
Your eyes told us you wanted to go
With dignity and peace at home on the front porch
On a beautiful sunlight eve, among all the scents that you loved
One last car ride to the funeral home

Au Revoir dear friend, You changed my heart!
A lasting lesson not to prejudge anyone again.

I will miss not having to worry about stepping on you when I get up in the dark
I will miss having to comfort you during the next thunderstorm
I will miss those Border Collie eyes tracking my every move
I will miss your whine and whimper when my pager goes off
I will miss racing you up the stairs - I never did get to beat you till you got ill
I will miss how you chased the deer and geese knowing you could never catch them anyway
I will miss the long walks around the soccer fields

It was all worth while
I was never so wrong in my life, except
You did shed,  but now that you are gone, 
I don't want to vacuum those last memories from the carpet....

A day later....

But hark, what is this?
A lightening of the heart, a lifting of the gloom
This presence besides me
Of course, you will always be with us,
How did I assume you would ever leave us for long
How did I misjudge you again?
I was never so wrong in my life!

A Sobering Saturday

I woke up this morning reading a post by Jonathan Smith on Google+.  There I found a link to a video of a lecture by Albert Bartlett on YouTube.


It was the most sobering 80 minutes I have spent watching and listening anything online.  So what was so sobering?

I recently blogged about the need for civil and informed discourse for a successful democracy.  That post was about the Affordable Healthcare Act.  But there is an even more important issue facing the country and the planet that is similarly reduced to a squabble of statistics and jargon and conflicting emotionally charged opinions.

Humans have created a system where short term performance outcomes counted in terms of money are used to measure success e.g. corporate performance measured in quarterly cycles, Presidential performance measured in 4 year election cycles.  Another fundamental problem with the system is the assumption that if people look out for and vote for their own interests, and if the majority of the people vote for something, the country will be better off.  In essence we now have a system that will prevent a minority who have the knowledge and altruism and want to work towards long term global benefit from ever accomplishing something.

Imagine that everyone knew that at some point in the future we will run out of fossil fuel.  What would that mean?

• Most of the food we eat uses fossil fuels to produce and transport.  
• Our personal comfort - heating, cooling, communication, travel, entertainment requires energy - a lot of it produced from fossil fuel.

Suppose we knew that regardless of when we reach/reached peak oil state, we are depleting a finite resource and as our population grows and our economics require each economy to grow, this depletion will occur faster and faster.  Finding more fossil fuel sources will only postpone this inevitability.

Suppose we knew whether impacted by mankind or not, the planet is getting warmer and will lead to dramatic extremes of weather including floods, droughts, storms, blizzards all requiring more energy and causing more scarcity.

Suppose we knew this incredible change in our lives was going to occur sometime this century.  What would we do?

• We would scramble to find solutions that make non-fossil fuels possible
• We would force our governments and corporations to invest in these technologies
• We would build small self-sustained communities
• We would move towards using agriculture to produce food for humans rather that for cattle
• We would conserve all the fossil fuel for critical activities that focus on solving this huge problem
• Dissemination of information for education of people
• Communication and collaboration among scientist and engineers working on this problem
• Manufacturing renewable energy producing units like wind turbines, solar panels etc.
• Ensure that we don't run out of fossil fuels before we had implemented solutions
• We would start planning like we would for a local disaster
• Install solar panels on our roof and a wind turbine in our backyard and a geothermal heat system in the basement.
• Find a way to get to work without a car or work from home
• Install a greenhouse and divert all the effort from maintaining a lawn to growing vegetables
• Drill a well with a solar powered pump and an overhead water tank.
• You get the idea...
• But we don't because we are in denial and because we worry about the cost of all these modifications and whether they are worth it or whether they will be needed in our lifetimes.  "With fracking, gas will be cheap and we will have unlimited supplies to heat our homes" right?

Our current socioeconomicpolitical system will not be able to turn this ship around without a serious wake up call. Unfortunately the best chance of having something like this expired in the 1970s when the national and global awareness was at a peak.  If we wait for the next peak in awareness, it will be too late.  It is probably already too late.  The question is whether it will be a crash or a slide.  

The best consolation for the current generation is that when they pass away they will not be missing out on seeing a great future.  The best years of humankind are probably already behind us.  Everything that they learned to love and depend upon is going to be at a premium in the near future.  Also we probably don't want to be alive to hear the curses from our grandchildren!

Does economics violate the laws of physics? http://www.scientificamerican.com/article.cfm?id=does-economics-violate-th
Playlist of Dr. Bartlett's lecture
http://www.youtube.com/view_play_list?p=6A1FD147A45EF50D
ABC interview with Michael Mann http://abcnews.go.com/blogs/technology/2012/07/new-mccarthyism-described-by-climate-scientist-michael-mann/

Score 1 for Internal Medicine.

Those who follow this blog already know that we recently returned from a meaningful/purposeful vacation in Peru.  I am an Internist and my wife is an ophthalmologist and we were precepting students on a medical mission in the Sacred Valley in the Andes.  Our middle school daughter was our Medical Spanish translator.

She would split her time helping in both areas, Ophthalmology and Internal Medicine.  She got a kick out of helping patients get prescription glasses and the thrill of helping some kids see clearly for the first time.  After a couple of days, she got very comfortable with this and was able to independently get 20 patients a day to 20/20.

When helping in the Internal Medicine area, she learned the importance of history taking and the conversation in diagnosis and patient care.  She got a good exposure to this as she was the one translating the questions to the patient and translating the answers back to me.  After a couple days she told me, "This is so cool!  Its like solving a mystery by talking to people.  I love it! You guys are Low Tech, but High Talk!

There is hope for Internal Medicine yet!  

PPACA and informed opinions in democracy - a pipe dream?

The Patient Protection and Affordable Care Act (PPACA) was just upheld by the SCOTUS.  This verdict has split the entire country down the middle as shown by a recent Gallup Poll.

Image linked to Gallup Poll website

The law is complex and difficult to interpret.  The law will be implemented in stages over several years which makes it even more confusing.  The fact that even independents are split so evenly makes it more than just a political bias.  There are some places to find summaries of the law.

• Reddit summary of law with citations
• Reddit - some doctors' concerns
• Official site

Looking at the discussion at some of these sites also gives one an idea of the very strong and diverging opinions.  People struggle to separate the issue of whether this is the "right thing to do" vs. whether it is constitutional vs. the right way to do it.  Thus most would agree that folks should not have to worry about getting health care when they need it and they should not have barriers to getting preventive care to keep them healthy.  How to achieve this and how to finance this seem to be questions causing the arguments.  The complexity of the law makes having intelligent informed discussions difficult.  The emotions around the issue make it difficult to keep personal bias out of the discussion.

It is a fascinating time to see democracy "working".

I personally have not read the text of the original law or the entire text of the SCOTUS opinion.  Why not?  One reason is the difficulty in making sense of the legalese and staying awake while doing so.  I have spent quite some time trying to understand it - probably more than the average citizen.  I have read the Cliff notes versions, the statements issued by various organizations for their members and public and participated in discussion in social media to get a better understanding from various perspectives.  During these discussions I have noticed many incorrectly informed opinions expressed from both sides.

To try and get a better handle at the level of complexity of this law, I tried to read up about a "simple" law that I describe below.

Recently I went to an event that raised a number of questions in my mind requiring me to go to the original law.

First let me describe the setting.
This was a concert at a huge facility - with a covered pavilion near the stage and a larger lawn seating area around it.  There is no wall or other physical barrier between the lawn and the pavilion. On summer evenings, it makes for a beautiful setting to listen to live music.  My previous experience of this facility was listening to Beethoven and Bach or the Boston Pops playing John Williams tunes, sitting under the stars on a blanket with a picnic basket.  This was clearly going to be different experience and I thought I was prepared for it, and I was except for one thing.

Smoking was allowed in the lawn portion of the facility!  And almost half the people were smoking - to the extent that a pall of smoke hung over the entire area.  The facility is in a bowl shaped valley which probably contributes to this situation.

In Ohio smoking is not allowed in a "Public place" even in bars and restaurants, even at the Cleveland Browns Stadium which is not a covered roof stadium.  A facility this big could not be willfully breaking the law so I had to look this up when I got home.  The law can be found here.  The key provisions/definitions it seems were:

“Public place” means an enclosed area to which the public is invited or in which the public is permitted and that is not a private residence 

“Enclosed Area” means an area with a roof or other overhead covering of any kind and walls or side coverings of any kind, regardless of the presence of openings for ingress and egress, on all sides or on all sides but one.

“Outdoor patio” means an area that is either: enclosed by a roof or other overhead covering and walls or side coverings on not more than two sides; or has no roof or other overhead covering regardless of the number of walls or other side coverings. 

Apparently the law provides an exception to outdoor patios to allow smoking.  Based on my non-legal interpretation the setting of this facility does not fall under the smoking ban law because it is completely uncovered and is thus an outdoor patio.  The pavilion has an overhead roof and is somewhat circular so difficult to "count" how many sides it has.  My guess is that it is not an enclosed area as the majority of the perimeter does not have walls.

So the questions that came to mind were

• The point of the law is to protect people from the dangers of second hand smoke.  Why would the law fail to provide protection to people who go to this facility.  A few minutes there and I felt my lungs filling up with fumes.  So clearly there was second hand smoke exposure
• How do we balance the freedom of a person to smoke with the right of a person not to be injured by another person?  Adults should have the right to smoke if they want to and understand the risks (will not debate who pays for their smoking related health conditions).  People come to this facility to enjoy and smoking is possibly a part of that experience for them. What about the enjoyment of the other paying audience?  Even if one could debate the long term risks of 2 hours of second hand smoke exposure, what if they had migraine or asthma triggered by this?  
• What would it take for a facility like this to set up some non-smoking zones with a big no-mans-land around it to at least diminish the exposure?  The Cleveland Browns set up a Family zone where even alcohol is not permitted even though that is not a legal requirement (I think).
• I saw several young kids brought in by their parents.  Do the kids have a choice and the ability to make an informed choice?  I overheard a very angry comment made by the parent of one of these kids about the situation.
• The facility does mention on their web site that "light smoking" is permitted in the lawn area.  Whatever does that mean? 
• Would the facility reimburse people who find the smoking more than "Light"?
• What are the options for those folks who want to attend a live event like this but cannot bear the second hand smoke or want to take kids?  

You can see how what seems like a simple issue can be so complicated and difficult to interpret.  The health care law is complex and polarizing.  Democracy depends on people making informed decisions and voting accordingly.  When people depend only on others to tell them what a law means, there is serious risk of bias. When people involved in healthcare don't have time to read and digest all the details of the law, what can we expect from the whole population?  Informed consent in medicine is supposed to mean that patients understand the various risk benefits and alternatives of a procedure before agreeing to it.  In order to do this we need to use language that can be understood by our patients.  There are of course laws describing how to provide informed consent (e.g. link to informed consent for human subject research).

This fall, people will be voting partly influenced by the PPACA.  Can we hope that these will truly be informed opinions?  On an issue of such importance how can we ensure that the answer is yes?  Do we need a law requiring voters to pass a quiz before voting?