Virtual bubble


While the internet has connected us in many ways, it has also made it much easier for us to find and congregate with people who agree with our ideas and our opinions.  We carefully curate our social media feeds and populate them with people who are often very similar to ourselves. The social media companies suggest material, advertisements, and friends that they think best match us. And they certainly do not present us with people or ideas with which they think we will dislike and disagree. Often we don’t even see this when it is happening. Take the last election cycle. Many people were amazed that Trump won. Within many liberal, urban centers there was a sense of shock at the results of the election. In academia, which now is broadly notorious for the liberal skew, many people couldn’t name many friends or peers who would vote for Trump. Everyone’s feed from Twitter or Facebook is an extremely poor representation of the larger population on nearly every topic. Instead of promoting diversity of thought and diversity of opinion, some areas of the internet have enabled a paucity of thought and a clustering of yes men (or women) who congregate in the same virtual areas. Perhaps even worse, when we do encounter the ideas and opinions of people with whom we disagree online, this is a caricature of the whole person and the method of communication is starkly one dimensional without many rules, non-verbal cues, or incentives to be courteous and give the person the benefit of the doubt. I still have yet to meet someone who got in a battle over Twitter or Facebook and who was won over through the sound reasoning and convincing rhetoric of the other side.

So find friends, online or offline who disagree with you. In the words of Thomas Jefferson, “I never considered a difference of opinion in politics, in religion, in philosophy, as a cause for withdrawing from a friend.” As much of our lives now involve some aspect of internet based technology, so the bubble we are has enclosed this space as well. In a digital age that pushes us away from people unlike ourselves, this becomes a task in which we must be constantly intentional. Both offline and online engaging with real people with ideas and beliefs different from ourselves is not an accident. It must become a habit critical to our growth and our identity as citizens of the global community.

Drifting a river or overcoming enemies


We all have people we agree with, books that we love, and schools of thought that we endorse. When you read a book or hear a speaker and agree, it is empowering and encouraging- you want to do it again. I recently read a book by Jocko Willink titled Disciple Equals Freedom.  I was all about the ideas, the drive, the motivation. There was a book, perhaps the polar opposite of Jocko’s book called Blue Like Jazz written by Donald Miller a number of years ago. Blue Like Jazz is a book that meanders its way through the story of the author through the different adventures and experiences he had over several decades. Donald’s approach to life could be summarized as going with the flow and slowly drifting down the river of life enjoying the feeling of the light breeze. Jocko’s approach is better summarized as mental toughness and meticulous planning are key (As a former SEAL, I think he mostly means in enabling you to kill all your enemies…but there are parallels to less intense things as well). People are wired differently. People who are all about intensity and discipline love Jocko’s book. People who enjoy the experience and the journey are all about Donald’s book. However this is probably opposite from what these people need to hear. Those who are drifting down the river, beer in hand, would benefit the most from the discipline and planning of Jocko. Whereas those who love the grind in their home gym and overcoming challenges would benefit from being dumped in a slow flowing river with no cell service next to Donald. The sad part is that we often skip the books that would benefit us the most and even when we do read them, we forget to take to heart the parts that would be most valuable to us because they don’t agree with our current way of thinking. So read an author you don’t see eye to eye with. Or read a book that’s not right up your alley. Ask yourself what you can take away to become a better person. After all, you can always go back to working out and plotting ways to overcome your enemies another day. And the river will still be flowing and the beer will still be there for you to come back to.


The long haul


Things in the zeitgeist are not the things with which you should be primarily concerned. There will always be another hot topic, another cause of public outrage, another new theory to consider. This is certainly not to say that the things in the popular discourse aren’t important. They certainly are. But, the zeitgeist is fickle and pet topics fleeting. If you have found the cause or topic you are passionate about, stick with it, while it is popular, and perhaps more importantly, even when no one else is talking about it. Be an independent thinker. Do not be bullied by the moods of the masses. The numbers take years to change whereas the twitter feed is constantly shifting. The problems and causes that were popular years ago, are often just as much a problem today as they were then. The problems today will continue to be a problem even when they are not trending on social media anymore. Pick a cause where you don’t care about the tide of popular opinion. If that is immigration, awesome. If it is healthcare reform, great. If it is a rare disease, fantastic. If it is accessible education, good. If it is addiction assistance, sweet. But if your list of causes mirrors that of the news feed or the top tweets reevaluate. Public campaigns come and go, but the real problems last much longer and the solutions require years and decades. We need reformers and advocates in each area who are dedicated to the long haul, to doing whatever it takes, with no regard to whether it is popular. This is how you win a war, change the culture, and make a difference.

Are we happy?




We have become a culture concerned with happiness. If you are not happy with your job you are encouraged to look for a new one. If you are not happy with your relationships you are encouraged to move on. If you are not happy with your home, your car, or any number of things you are encouraged to change them in order to become more happy. Advertisements are based on the idea that some new product will make you happier, assuming of course that everyone’s goal is to be just a little bit happier.

And happiness is certainly a good thing. If you are consistently making decisions that make you less and less happy you should probably change some things. Yet the problem is that constantly checking the barometer of internal happiness is a self-defeating exercise. The more we are concerned with our happiness, the less happy we often become. “Am I unhappy?” followed by “how could I become a little more happy” becomes our obsession. And with no clear end goal, this becomes an ultramarathon we cannot win. Imagine running a marathon. Every 10 seconds or so contemplating “Are my legs tired or hurting?” Of course the answer is going to be yes at some point. And constantly thinking about that pain is going to amplify the perception of the discomfort.

One area of our lives in which this problem has become prominent is in romantic relationships. The search for a future partner has become, in many ways, like looking for a new television or car. The argument in favor being that, because we can often get a superior television or car by comparative shopping, the same should be true for a partner or spouse. On the surface this seems like a great plan. However, consider what you do with your new television or car. You’re happy with it for a bit but as you use it consistently you ask yourself if it is better and you are happier. You notice that the blue-green ratio of the screen is off, and that it doesn’t quite fill out the space that you were hoping it would. You realize the seat heaters only warm your butt and not the lower back like you were hoping they would. Worst of all you start to hear a squeak in the dashboard. Asking these questions you forget about all of the things that are great and begin making a list of things you will make sure the next television or car has. With a television or car this system is less than ideal but clearly not disastrous.

However, t is disastrous in our relationships to constantly be thinking “Is this making me happy? What do I dislike about this person?” Now occasionally sitting down and discussing your relationship is good, but constant contemplation of happiness and unhappiness is toxic. Unlike the car or the television, building something great together is the goal, not momentary happiness. Unlike a car or television you are not looking for someone to replace after a few years with a newer model. You are looking for a partner, a friend, and someone to build something great with. And incidentally, true happiness is often found in this, and not in the frenetic search for someone to please you in the moment.

On Selecting a Mentor


Irving Weissman, a Professor at Stanford, member of the National Academy of Sciences, and a prolific scientist specializing in stem cell biology, had lunch with a handful of students following one of his seminars. As we were talking, he asked what we thought the most important criteria for selecting a mentor should be. Trajectory of past trainees was the answer. This is the simple litmus test everyone should consider when looking for a mentor and is applicable across fields.

Having completed my PhD I realize how fortunate I was to have a good mentor. Yet I recognize I stumbled into that more by luck than by methodical planning. Had you asked me what the most important criteria for selecting a mentor was five years ago I probably would have replied with a non-specific combination of adjectives from Mad Libs such as “smart, well-funded, collaborative” or perhaps the worst “nice”. Not that these things are not important. You certainly do not want a mentor who is the opposite of these “dumb, unfunded, solitary, and mean”. However, these criteria do not generally differentiate between mentor. The trajectory of previous trainees tells you how invested the mentor is into propelling you into a career, how well they know how to train (teaching is as important as being a content expert in this regard), and if they have the resources to help trainees complete their training.

Let’s revisit the “nice” criteria for a moment. You are picking a mentor who will function as a coach. You want someone who invests in you, speaks truth, motivates, sees your weaknesses, and pushes you harder than you think you can be pushed. Training is precisely that. Training. If you were in boot camp you don’t want a cheerleader, you want an experienced instructor. If you hope to be an world class athlete you don’t want someone who hands out water breaks and foot rubs. You want to be made excellent. In the boxing ring or the octagon you don’t want a yes man (or woman) but someone ruthlessly pushing you to become better. Now nice people are important as well. Find faculty to meet with occasionally who are nice and who don’t always push you. Find fellow trainees who are your friends regardless of how you are performing. These are the people in the stands, those rooting you on. They are nice! Always encouraging even when you are playing the game poorly or losing. But down on the field, pick a coach who knows the stakes and makes you perform at your best. One final note, sometimes “nice” is simply a mask for indifference. If you make it through training without frustrating your mentor and without your mentor frustrating you, this is less than ideal although it may feel better. My PhD mentor and I ruined each other’s weekend or evening every few months which is part of the cost of working hard together on something you both care about. If your mentor is “nice” when you are inefficient and ineffectual and is complacent about you working towards something great, this is indifference and is one of the most toxic things in a mentor-mentee relationship.

When picking a mentor, pick one who has a proven record as an invested coach and effective instructor.

One at a time




One at a time.

One day at a time. One run at a time. One mile at a time. One step at a time. Any task can overwhelm even the most talented, competent, and prepared individual if they try to do everything, all at once.

In a long distance race, thinking about every mile while standing at the start line is terrifying. Even more, standing at the edge of the water before a triathlon thinking about the swim, then the hours on the bike, then the many miles of running. Mentally, it is the stress of doing all three disciplines at the same time.

Occupations can be the same way. To become a physician or scientist many stages of training are required. If you want to do medicine and research, the problem is further compounded. Undergraduate education takes 4 years, a PhD or MD take around 4 years (or combined 7-9 years). Then comes at least 3 years of residency, often followed by 1-3 years of fellowship, and for the research minded, a 3-4 year post doctoral fellowship. It’s like graduating from your undergraduate work and realizing you have to repeat kindergarten through 12th grade all over again. Just writing all that down in one place is enough to elevate the stress levels. No one could finish that training by waking up every morning and counting down the days (The count at the end of undergraduate work would be something like 6,200 days left). Planning ahead but also taking each challenge as they come, not mentally all at once, is essential.

The same can be said for other life events. Launching into a responsible adulthood does not mean buying a car, getting a mortgage on a house, finding your life companion, starting a retirement account, and getting a salaried job all at once. It means gradually progressing towards the long term goal of independence.

So whether in a race, an occupation, or life in general, it is important to take the next step without fighting every battle and taking on every future challenge all at once.

“Do not worry about tomorrow, for tomorrow will worry about itself. Each day has enough trouble of its own.” (Matthew 6:34)

This however, is often easier said than done.

Making decisions easy



Simplistically, making good decisions is rejecting the bad while acting upon the good. In many cases, rejecting the bad is almost a more difficult and continuous task than acting upon the good. For example, the decision to maintain a healthy diet certainly entails eating healthy foods. However most people struggle more with not eating junk food than with eating a salad here and there. The same can be said for spending. While it is easy to put away a set dollar amount every month for savings, it is much more difficult to constantly avoid spending throughout the whole month.

One attempt to help alcoholics avoid drinking is Antabuse, a drug that causes flushing, vomiting, and a host of other unpleasant side effects, if alcohol is consumed.  Those struggling with alcoholism often find it difficult to constantly say “no” to alcohol. Since it only takes a momentary lapse in resolve and the opportunities to drink occur incessantly all day, every day, the journey of sobriety is often fraught with relapses. The thinking behind Antabuse is that it takes the job of constantly saying “no” throughout the day and replaces it with a single “yes” decision to take the medication.

In the modern world, nearly every pleasure and temptation are available conveniently and constantly. Want a burger and side of fries? You’ll probably pass at least 3 or 4 places on your way home from work or school promising you just that. Want a sweet treat? There are aisles filled with just that at any number of grocery stores, corner stores, and gas stations within a few blocks of you home or office. Feel like something else? Amazon, Uber, or another delivery service will drop it off to you wherever you are. And that’s just food. Alcohol, entertainment, sex, and nearly anything else are available to everyone at any time, with minimal effort.


Creating a more simple and productive life must seek to make the good choices the easy and convenient choice. This means selecting a workout plan that is nearby or even at home. This means keeping foods close by that are healthy and making the less healthy foods a treat rather than a regular part of the diet. It is much easier to say no to several pints of ice cream once a week at the store than to avoid eating several of the delicious pints that are conveniently already sitting in your freezer. It may mean planning out meals, using tools to increase our productivity on our devices while limiting distractions, and pre specifying our budget each month.  It means establishing convenient times and methods of communication for keeping up with important relationships. It is a different type of intentionality. One that seeks to make good decisions easy and makes it convenient for us to ignore our vices.

Making cases to ourselves


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


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


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