Making cases to ourselves

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Making a case is a valuable skill and an important part of developing as a person as well as working as part of a team. Making a case is a great way to get a new perspective and decide what idea is best within the marketplace of ideas. Although certainly not perfect, a debate between two genuine, curious people is an important way that we make progress. Making a case for yourself is also a key skill in pursuing new opportunities. When applying to medical school you make a case for yourself, presenting why you are going to be an excellent physician and a contributing member of the community. You are decidedly not presenting truth and hoping that the admissions committee sorts it out for you. Your personal statement is not a list of good and bad things you’ve done (best to leave that time you pushed Suzi into a puddle for your diary). Rather, it is a well crafted argument about your attributes. In general, making cases should be reserved for presenting to others where opposing cases and impartial observers can challenge these cases.

One problem I have had, and seen others have as well, is that we often confuse which one of these tasks we are doing. Instead of presenting our cases to others, we begin making cases to ourselves. As we like ourselves, and fancy that we are right the vast majority of the time, we tend to accept our cases without developing opposing arguments. For example, weighing whether to get a new bike can rapidly become making a case for buying a new bike. Deciding whether to workout or relax can become an argument for why you deserve the couch. Without anyone else in your head to oppose your case, you’ll certainly win every time. For minor things, like a new bike or a workout here and there this is barely even problematic. However in more important decisions this can be a huge blindspot. For example,  in deciding what stock to invest in you don’t want to make a case for one stock as much as to get to the truth of which stock might be most profitable in your given time frame. This means weighing both the good AND the bad. In deciding what house to buy, who to date, who to marry, what career to choose, how many kids to have, we must avoid making internal cases (this more closely resembles a delusion than a search for truth), and begin to weigh both sides. At least two sides to the case must be argued in good faith.

To quote Richard Feynman,

“The first principle is that you must not fool yourself, and you are the easiest person to fool.”

Information: Collecting and synthesizing

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Computers have changed everything. We all know it. Most of the things that computers have changed have been changed for the better. Many of the fears that we had with the advent of computers have not come about (…yet). In the preface of one of the versions of the Divine Comedy by Dante Alighieri, the comment is made that in Dante’s age one could know everything that was known in the world. Whether this was empirically true of Dante’s age is hard to say, however the point is well taken. That is to say that collecting information about the world was the rate limiting step and a very useful attribute for an individual to have.

Fast forward to the modern age, there is far too much information for one person to know. Even within a single field, say biology or medicine, there is far too much for one person to take in. It is estimated that 1.5 million academic papers were published last year alone. To merely keep up with new knowledge is an insurmountable task, not even counting the enormous amount of information that already exists. Teachers or professors cannot principally teach facts. This is not a tradition of passing on an oral history from one generation to another. The vast number of facts on the internet make it so that professors who pass on facts will soon be obsolete. The job of the professor and indeed the job for all of us, is to learn how to synthesize information. This is taking in large amounts of data and reaching a conclusion from which actionable steps can be taken. Computers are currently stunningly bad at doing this type of thing. Creativity, that is developing an objective that is not predetermined, operating in a system where the rules are fungible, and recognizing opportunities between disciplines and between tasks, are all things with which increased computational power has not endowed computers. These are, for the near future at least, tasks for which humans are uniquely suited.

Although there is much discussion (ahem…debate) about where artificial intelligence will take us, there is consensus that artificial intelligence will be used, and is being used, to augment human abilities. Our role, both now and in the future, is not to accumulate information but synthesise information and to creatively solve problems and come up with new goals. It is, and will continue to be, a new way to do things, but one in which the benefits are enormous. You may remember from a previous post the fact that there are over 7,000 known diseases and many scientists estimate there could be double that number that actually exist. No human can keep that straight. That is a recipe for failure as a physician and a lot of missed diagnoses and opportunities in patients. Artificial intelligence augmenting physician knowledge and skills is the solution to this problem. The computational power and memory capabilities of artificial intelligence would keep the diseases, indications, complications, medications, and everything else straight. So why even need the physician at all? Precisely because of the weaknesses of computer based intelligence mentioned earlier. In medicine there are no set rules and no clearly defined goal. Each patient is different, has different baselines, and unique attributes. Further, there is no guarantee that there is only one solution or diagnosis to the puzzle. There may be (and often are) many different disease conditions and diagnoses all occurring at once. Obtaining information from the patient, tailoring their diagnosis and treatment to the individual, and ensuring that the patient as a whole is cared for will be the domain of the physician. Recalling large amounts of information, integrating the newest clinical trials, and identifying rare diseases will be the critical contribution of the machine.

But whether in medicine or any other field, the times have changed and so too has our role. Instead of collecting information we must synthesize information and use our creativity to solve practical problems.

On outcomes

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You cannot always guarantee a positive result but you can certainly guarantee a negative outcome.


As the saying goes, “nothing is certain but death and taxes”

You can make certain outcomes- good health, responsible children, financial security, successful marriage- likely, but no one can guarantee any of these, even with vast amounts of effort. As important as a healthy diet and exercise are to health, taking care of your body does not ensure a healthy and long life. Cancer, underlying genetic predispositions, accidents, or other diseases can strike even the people with the healthiest of lifestyles. However, by drinking large amounts of alcohol, smoking, and neglecting essential nutrients, you can certainly guarantee a negative outcome and an early death. Even the most successful person cannot guarantee financial security. MC Hammer for instance… wait, nevermind that’s a bad example, but you get the point. Money now does not guarantee money later even when stewarded well. Fluctuations in an economy and a financial system that even the smartest of us do not understand, health problems, bad business partners, or criminal acts can all result in loss of financial security. However, by stewarding money poorly, spending lavishly, running up debts, and living outside your means, you can certainly guarantee that a future that is financially destitute. Even the best parents with the best techniques cannot guarantee that their children will grow up to be responsible. The wrong friend crowd or an innumerable number of other tangible and intangible things can wreak havoc on even the best upbringing. However, through neglect, abuse, unfair criticism, and a poor example, you can certainly set up children for failure. It is extremely difficult to rebound from a poor upbringing during the early years (see A Path Appears by Nicholas Kristof and Sheryl WuDunn). A successful marriage, like any partnership, is never fully under your control. You can work towards a great marriage through picking the right partner, developing solid methods of communication, being attentive to one another, and learning to accept and compensate for the strengths and weaknesses of the other person. However, people change, and like any partnership, nothing is ever fully in your control. On the other hand, you can certainly guarantee an unsuccessful marriage by not attending to the other person or being abusive and neglectful.

All this is very cheery and I’m sure I’ve brightened your day through sharing all the ways you can tank important aspects of your life. Importantly, this highlights the fact that the negative outcomes are the default, not the positive. Healthy living is an choice and a constant one at that. The couch is the default, the treadmill is the choice. Fast food is the baseline, a balanced diet must be selected and prepared. Squandering money is the default with plenty of credit cards, lending services, and advertisers to help. Financial planning and building wealth requires meticulous planning. Lazy, irresponsible children are the default, respect and character must be actively taught over many years. A crumbling marriage with poor communication is the default. A successful marriage must be fought for and intentionally built.

So that’s the encouragement. Although nothing in life is guaranteed, with meticulous planning and intentional actions we can make some of the most valuable things in life highly probable instead of impossible.

Live with intention  

The good and the bad

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We have a wealth (also known as a glut) of information around us and in the news. There will always be something terrible happening that we can read about. Horrible people do horrible things. Nature does horrible things. Horrible things randomly happen. In generally things are improving despite what the news cycle tells us. People’s behavior is improving (see Angels of Our Better Nature by Steven Pinker) and fewer people are dying around the world from preventable or treatable diseases (see Bill Gates and the Gates Foundation). In general, things are improving yet we can still overwhelm ourselves with all the stories of evil.

Balance in this area seems to be difficult. One one hand we do not want to be in an isolationist bubble. We want to be aware of what is going on around us. However we also should keep ourselves focused on the good, those things that might not be news but are encouraging. As Philippians says “whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable, if anything is excellent or praiseworthy, think about such things.”

Any idiot can be a downcast “realist” by thinking about all the bad things that are going on and all the bad things that could happen to them. It takes far more work and discipline to engage in the important struggles of the day while maintaining an attitude of gratefulness and an optimistic outlook. In general, if it is something you can directly change, engage with it. Otherwise move on to the causes that you can directly change. The idea that feeling sad or indignant or angry or dwelling on bad things in the world is, by itself, a virtue is poorly formed. Dwelling on these things without action means nothing. Be intentional about being grateful for the good and actively work to improve the bad.

Towards being intentional

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Let’s talk for a moment about social media, in particular Twitter. Social media is not inherently bad, but it is probably not as innocuous as it appears on first pass. And, as we’ve seen in the past several years, a simple 140 characters is enough to end careers and uproot lives. The larger problem of social media witch hunts aside, the fact that a quick tweet can drastically change things, is an important consideration. One of the reasons that guns or cars can be so dangerous and must be handled carefully is for that exact reason. A small squeeze of the trigger can have irreparable consequences. Losing focus on the road can have dire consequences. In the same way, small tweets have been used to destroy careers, announce major policy decisions from the government, and spark debates that waste everyone’s time and energy. It would be nice if there was a safety on Twitter, something like grammerly but for insensitive and alienating comments. Not something that censors (We are big fans of the first amendment after all), but something that says “this is racist/sexist/mean, are you SURE you want to post this for everyone to see?”. Perhaps a voluntary breathalyzer or drug test before you could post would also be beneficial. The things that take years to build can often be destroyed in seconds.

The big push in using social media must be being intentional about it to relate to one another in positive ways. Thoughtless scrolling and mindless posting is dangerous, and the drastic downside far outweighs any potential upside. Live intentionally.

 

Jack of all trades, Master of none

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It is surprising to me how often I hear this used as a compliment still. Although it is intended as a compliment, it is most assuredly a criticism not an aspiration. At most we should hone a handful of crafts, a handful of things, because the opportunity cost of trying to learn a little bit about everything is knowing everything (or at least, a lot) about a single thing. An inch deep and a mile wide.

Consider how we got to where we are today. Specialization plays a huge role in that. Look at the things around you. Few, if any of them could you have made by yourself without the help of many experts or professionals. Most of us could not build a computer from the ground up, and even if we could we certainly could not manufacture the necessary parts alone. Most of us could not build a car even if we had all the rights parts and a detailed instruction manual. Most of us are probably not doing ourselves (or our doctors) a favor by surfing Web MD or watching Dr. Oz to try to self diagnose what seems to be ailing us. Most of us cannot act well, sing well, or write well. Most people cannot grow enough food or gather enough provisions to keep themselves fed. If we each tried to make our own clothes the result would almost assuredly be extremely time consuming and uncomfortable.

I was listening to the Director of the National Center for Advancing Translational Sciences at the NIH. He commented on the fact that there are over 7,000 diseases. SEVEN THOUSAND, with more being discovered every year. As a medical student with books and books just summarizing the most common of these diseases this can be discouraging. The reason there are so many advocacy groups for less common diseases is that physicians cannot keep the signs and guidelines for every disease in their head all at once. The key is knowing when and who to ask for help.

The reason we have specialists is because they can have in depth knowledge about a specific area without concern for everything else. In the Emergency Department or with the primary care physician, the task is to know the most common diseases, recognize when someone is acutely ill, and then know who to call (or page) in each instance. A primary care physician memorizing large lists of genetic loci and rare neurologic conditions is not benefiting his or her patients through this impressive, but futile efforts. Stabilize, recognize, and treat or refer. The emergency physicians and primary care physicians are experts in that task! Even the more “general” medical disciplines are still specialists as it pertains to their job.

The physician however should NOT be working to be the best accountant, or computer programmer, or car mechanic. Physicians fixing their own cars could probably cause enough accidents to generate a whole new medical speciality.

Find what you want to be an expert in. Develop your craft. Hone your skills. And, be content with being ignorant in many areas of life. That is the cost of specialization and contributing to society as a whole. That is the cost of progress.

A student and a patient

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Often when I was first talking to and working with patients I felt bad for them. As a student there is always someone there who could do a better job than you whether that be the resident, fellow, or attending, and instead the patient is stuck with you. Sometimes your stethoscope (or hand) is cold or your questions annoy them (how dare you, of course, they have never smoked, drank or done drugs). Naturally, most patients are sick, and many sick people want to be left alone. All of these made me feel slightly bad for the patients I saw.

Several things changed how I view my interactions with patients. First, they are not receiving lower quality care by any means. If anything, they have another set of eyes and someone who is attentive to their problems. The expertise of the attendings and the appropriate care will all be provided regardless of whether the student is present. The one thing that the patient is giving the student is time. In very few cases have patients ever seemed to mind that my questions and exam take longer than someone more experienced, or that I might have to pop back in at a later time to obtain a piece of information I missed initially. In fact many patients appreciate the extra time and the extra efforts you go to. Second, the thing that most sick patients want more than to be left alone is for someone to care. Listening to someone’s story, to how long the disease has caused them pain, or to how many doctors they have seen can be its own form of therapy. As the saying goes the job of a physician is to cure rarely, to treat often, and to comfort always. Students and patients often have time in the hospital during which they are not busy and listening to the story can be a key aspect of comforting. Third, you are doing this for the patients you will see in the future. When it takes a little longer to hear a murmur in a patient’s heart or the patient has to take a couple of extra deep breaths so you can hear the wheeze, it is for the patients who will be seen and treated by you in 10 years.

So instead of feeling bad for patients, I appreciate the extra time I have with them and the experience they provide me for treating patients in the future. And I am thankful for their patience with me and their gift to the patients I will treat in the future. 

External validators

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The percentage of the population that will complete a marathon during their lifetime has dramatically increased. At the same time the average marathon time has also dramatically increased. On the one hand this is great. More people are getting out of the house and participating in a group activity to increase fitness. In a day and age when poor eating habits and a sedentary lifestyle are rampant, getting people involved in an activity to counteract that is often difficult. Physical exercise, is a critical component of both physical health as well as mental health. Marathons provide goals for people to strive towards and a sense of accomplishment once they reach them. In many ways the increased number of people finishing marathons, even at a slower rate, is fantastic.

On the other hand this is also troubling. One likely reason for the increase in average marathon times is that people are entering races with less preparation than in previous decades. This is unfortunate as there seems to be a move towards treating the marathon as a bucket list item rather than a culmination of adequate and meticulous training. I had a professor who used to call examinations “celebrations of learning”. In many ways I think that in school, in running, and in life, this is a much healthier attitude to have. Today, in schools as well as in marathons there are large numbers of people who desire the external validation of a diploma, an award, or medal, rather than the internal validation of knowing they learned something or became stronger through the process of diligent planning and execution. While the external validations can be helpful measures of our progress or how our efforts compare to those around us, the internal validation, the internal compass, is far more important to long term success and development as a human being. Any idiot can fill a shelf with awards, degrees, medals, and ribbons. However the real rewards are in watching all the hours in practice, all the hours of work, all the hours of study come together into a thing of excellence. Diligently pursuing meaningful skills day after day is the way to excellence. The external validators are merely artificial finish lines and illusory goal lines.  Do things that matter.

Finding your hill

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Often lack of purpose and direction is mistaken for lack of will and drive.  The two of these could not be more different. Will and drive are the means to get to a prespecified end. It is the blood, sweat, and tears that it takes to achieve a goal. Purpose and direction, on the other hand, are what defines that end and marks the goal. It is the line marking the finish or the syllabus at the beginning of a term. To have purpose and direction does not mean that one will also have the will and drive to reach the end. And to have will and drive does not mean that progress in a productive direction is being made. One must have both in order to succeed. The ability to look ahead and set a course must also be coupled with an unyielding will and a ruthless grit. Without one, progress halts. Purpose without the drive presents itself as one listlessly bobbing in the current, looking at the nearby island and wishing they were already wading ashore. Drive without purpose results in a similar lack of progress but presents itself as a wild thrashing in the waves without a pause to chart the course to shore.  

I would guess that most people struggle, not with drive as some would suppose, but with finding a purpose. While older generations look at the younger generations and criticize their drive, I wonder if instead, the issue lies within finding a purpose. As humans, endless striving is in our nature. We are constantly pursuing more. We are constantly looking for the next thing. However, we are also constantly searching for purpose and a meaning to our existence. Anyone will work tirelessly when a great vision is cast, a compelling mission is presented, or a worthy opponent presents itself. The threat of fascism in World War II united nations and compelled individuals to work without selfishness for a greater purpose. The problem is never people are not willing to sacrifice, but that they need to see the greater vision they are working towards. Great leaders (NOT great humans), are able to cast this vision and provide a unifying purpose and direction. Hitler rose to power with such abilities. As did Mao. To counter these great leaders (and great human beings) united their people under an even more compelling purpose. Churchill lead his nation from the edge of destruction to the freedom of Europe. Roosevelt rallied the industrial and military might of the United States and used the fight in Europe to also fight the economic war at home.

They say the first thing you should do when you know you are lost is to stop walking. Stop. Think. Orient yourself and establish a course. The same is true in life. There are too many hills to take them all. Pick the strategic ones. The ones that will improve the world and improve yourself. Don’t run up every hill, don’t spread yourself too thin. Find your purpose, and the drive will find itself.

A focus on food

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I am unclear why two things we love, eating and entertainment, have become so linked. Sit down to eat a snack or a meal by yourself and most people find themselves checking their phone, reading a newspaper, or watching TV. I am certainly no exception. But, as research and personal experience both demonstrate, our brains are wired so that actual multitasking, in this case, fully enjoying both food and the entertainment, is impossible. Yet we do this All. The. Time. It is easy for us to demolish large quantities of food without appreciating or even acknowledging it when we are focused on something else. We do this at the movie theatres where huge bins of popcorn and giant cups of soda are consumed on autopilot while we focus on the plot unfolding on the screen in front of us. We used to visit a man who hated to eat and listen to the radio at the same time because he found that he would get enraptured with the radio and the next thing he would know, the food would be gone without any enjoyment by him. Multitasking food and entertainment steals enjoyment both from our food and the entertainment and for no significant gain.

Try this sometime. Sit down in a quiet room and eat. Enjoy the meal. Consider how it tastes and how it takes away the feelings of hunger. Even in a quiet room focusing on the food and not on the to do list in your head is an issue. Don’t talk with other people or surf the internet. Don’t think about your favorite book, movie, or TV show. Don’t think about other people who would like the food. Don’t make plans for the rest of the day. Focus on the food and the act of eating. Then focus on the entertainment.

Your attention is one of the most valuable assets you have, spend it wisely.