Monthly Introduction to Tech Medicine

Happy New Year!

What's this blog all about?

My goal in Tech Medicine will be to explore the intersection of medicine, new technologies, and the Internet. This is a purposefully broad topic. Several times weekly I will post focused reviews of issues interesting to health professionals and nonprofessionals alike. Posts may include examinations of medical devices, pharmaceuticals, scientific advances, internet services, and other technologies involving health care and the practice of medicine. Mirroring as it does the nature of the Internet and the sometimes surprising nature of new technologies, the content may also include topics that are wonderful, unusual, hilarious, or strange.

What are some recent posts on Tech Medicine?

Topics of recent posts have included medicine and the ambient orb, free patient-physicians email, mind doping, feed reading, medical audiobooks. home hemodialysis, a review of an online personal assistant (Sandy), thoughts on handwashing, and digital pedometers.

Who are you?

I'm trained as a nephrologist (a kidney and blood pressure specialist). For the last two years I've written Kidney Notes, a blog designed to filter and process medical news. Most recently, Kidney Notes has become a collection of links, commentary, and scraps of information -- a reference database of interesting things with the help of a popular social bookmarking service called del.icio.us. While I will continue posting to Kidney Notes, several friends have asked me to write longer posts of original content -- and this is what I will be writing on Tech Medicine. (Recently, I have also written a blog on personal productivity called The Efficient MD.)

There are many topics I plan to cover, but I'm also open to suggestions and tips. Please email them to techmedicine@gmail.com.

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Praise for Audiobooks and Audible.com

Five years ago, I thought Audible.com was surely doomed. With the proliferation of free podcasts -- including many medical podcasts -- how could a company selling downloadable audiobooks survive?

I was wrong. A few months ago, I rediscovered Audible. This week alone, on my daily commute, I listened to two audiobooks. (And that's not unusual. I finally purchased a yearly subscription.)

Why am I such a fan of Audible and audiobooks?

• Quality. Until you regularly listen to audiobooks, it's hard to appreciate the many good books out there that you'd never have time to read otherwise. Podcasts are good, but books are usually better.
• It's simple to listen to audiobooks anywhere. I use an iPhone, which means I always have an audiobook immediately available in my pocket. (I also usually listen to books on "faster" speed.) No fishing around in your bag for a book. Helpful if you're standing on the bus or subway.
• If you have a yearly subscription to Audible, you're free to experiment with books you never would have taken a chance with otherwise. (Many of the books I list below fall into this category.)

Here's a selection of books I've listened to in the last 5 months. I recommend them all. I've listed the books on medicine first.

Books on Medicine
How Doctors Think by Dr. Jerome Groopman. Here's the publisher's summary:

A New Yorker staff writer, best-selling author, and professor at Harvard Medical School unravels the mystery of how doctors figure out the best treatments - or fail to do so. This book describes the warning signs of flawed medical thinking and offers intelligent questions patients can ask.

On average, a physician will interrupt a patient describing her symptoms within 12 seconds. In that short time, many doctors decide on the likely diagnosis and best treatment. Often, decisions made this way are correct, but at crucial moments they can also be wrong - with catastrophic consequences.

In this myth-shattering book, Jerome Groopman pinpoints the forces and thought processes behind the decisions doctors make. He explores why doctors err and shows when and how they can, with our help, avoid snap judgments, embrace uncertainty, communicate effectively, and deploy other skills that can have a profound impact on our health.

Groopman draws on a wealth of research, extensive interviews with some of the country's best physicians, and his own experiences as a doctor and patient. He has learned many of the lessons in this book the hard way, from his own mistakes and from errors his doctors made in treating his own debilitating medical problems.

How Doctors Think reveals a profound new view of 21st-century medical practice, giving doctors and patients the vital information they need to make better judgments together.

Complications: A Surgeon's Note on an Imperfect Science by Atul Gawande. Publisher's summary:

Sometimes in medicine the only way to know what is truly going on in a patient is to operate, to look inside with one's own eyes. This book is exploratory surgery on medicine itself, laying bare a science not in its idealized form but as it actually is - complicated, perplexing, and profoundly human.

Atul Gawande offers an unflinching view from the scalpel's edge, where science is ambiguous, information is limited, the stakes are high, yet decisions must be made. In dramatic and revealing stories of patients and doctors, he explores how deadly mistakes occur, why good surgeons go bad. He shows what happens when medicine comes up against the inexplicable: an architect with incapacitating back pain for which there is no physical cause; a young woman with nausea that won't go away; a television newscaster whose blushing is so severe that she cannot do her job. Gawande also ponders the human factor that makes saving lives possible.

At once tough-minded and humane, Complications is a new kind of medical writing, nuanced and lucid, unafraid to confront the conflicts and uncertainties that lie at the heart of modern medicine, yet always alive to the possibilities of wisdom in this extraordinary endeavor.

Better: A Surgeon's Notes on Performance by Atul Gawande. Publisher's summary:

The struggle to perform well is universal: each one of us faces fatigue, limited resources, and imperfect abilities in whatever we do. But nowhere is this drive to do better more important than in medicine, where lives are on the line with every decision. In his new audiobook, Atul Gawande explores how doctors strive to close the gap between best intentions and best performance in the face of obstacles that sometimes seem insurmountable.

Gawande's gripping stories of diligence, ingenuity, and what it means to do right by people take us to battlefield surgical tents in Iraq, to labor and delivery rooms in Boston, to a polio outbreak in India, and to malpractice courtrooms around the country. He discusses the ethical dilemmas of doctors' participation in lethal injections, examines the influence of money on modern medicine, and recounts the astoundingly contentious history of hand washing.

And as in all his writing, Gawande gives us an inside look at his own life as a practicing surgeon, offering a searingly honest firsthand account of work in a field where mistakes are both unavoidable and unthinkable. At once unflinching and compassionate, Better is an exhilarating journey narrated by arguably the best nonfiction doctor-writer around. Gawande's investigation into medical professionals and how they progress from merely good to great provides rare insight into the elements of success, illuminating every area of human endeavor.

Other Books
The Now Habit by Dr. Neil Fiore
Spook Country by William Gibson
The Dip by Seth Godin
Falling Man by Don DeLillo
Against the Day by Thomas Pynchon
It's All Too Much: An Easy Plan for Living a Richer Life with Less Stuff by Peter Walsh
Getting to Yes: Negotiating Agreement Without Giving In by Roger Fisher and Others
On Writing Well by William Zinsser
The Secrets of Body Language in 30 Minutes by Tony Wrighton
Negotiation Genius: How to Achieve Brilliant Results at the Bargaining Table by Deepak Malhotra and Max H. Bazerman
Consider the Lobster and other Essays by David Foster Wallace
Fiasco: The American Military Adventure in Iraq by Thomas E. Ricks
The Bad Beginning, A Multi-Voice Recording: A Series of Unfortunate Events by Lemony Snicket
The Four Hour Workweek by Timothy Ferriss
The Power of Full Engagement by Jim Loehr and Tony Schwartz
The E-Myth Revisited: Why Most Small Business Don't Work and What to Do About It by Michael Gerber
The Art of Mindful Living by Thich Nhat Hanh
On Writing: A Memoir of the Craft by Stephen King
Stein on Writing: A Master Editor Shares His Craft, Techniques, and Strategies by Sol Stein

Labels: audible, audiobooks

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Feed Reading, Three Ways

Here's a simple version of the story of feeds.

First, the Internet had too much information. Then, RSS feeds came along, which were designed to reduce the torrent of information from the Internet into something more manageable. RSS feeds (or just "feeds") are simplified streams of information from websites: just the headlines, or if you want, the full text. No longer would you have to individually visit each site to read new content. By subscribing to the site's feed with an "feed reader," the content would now come to you. Quoting Wikipedia:

RSS is a family of Web feed formats used to publish frequently updated content such as blog entries, news headlines or podcasts. An RSS document, which is called a "feed," "web feed," or "channel," contains either a summary of content from an associated web site or the full text. RSS makes it possible for people to keep up with their favorite web sites in an automated manner that's easier than checking them manually.

RSS content can be read using software called an "RSS reader," "feed reader" or an "aggregator." The user subscribes to a feed by entering the feed's link into the reader or by clicking an RSS icon in a browser that initiates the subscription process. The reader checks the user's subscribed feeds regularly for new content, downloading any updates that it finds.

All good. But then, websites with useful information proliferated -- news, medical information, blogs -- and they all published feeds. And the feeds proliferated. And different feed readers also proliferated, each with their own advantages and disadvantages, some online (like Google Reader), some integrated with web browsers (like Firefox), and some standalone applications (like NewsGator).

And then there were too many feeds. Even with feed readers, it seems impossible to keep up with all the potentially important information that's out there. Feeds, that were initially designed to solve the problem of information overload, have actually contributed to the problem because they're too easy to subscribe to and read.

Here's one solution. In the following sections, I'll propose three methods of reading feeds using three different systems: Google Reader, Email, and Netvibes. Each of these methods is appropriate in different situations. And together, they can make the torrent of information from feeds manageable again.

--

To start, here are some initial questions to ask about any feed to which you're thinking of subscribing: "How important is this? Is this something I want to read every day? Is this website of sufficiently high importance and/or quality that I don't want to miss a single post?"

If you answer "Yes" to these questions, then the best way to read the feed is probably by email. (This is the first way of reading feeds that I'll discuss.) This might be counterintuitive (or even controversial). After all, isn't the purpose of feeds to provide a stream of information apart from the website itself and apart from your regular correspondence?

All true, but email remains the best way of ensuring that everything gets to you and nothing is lost. (And if you use gmail, forwarding feeds to email also ensures that all your feed content is forever archived and searchable).

However, reading feeds by email is a mixed blessing. If you aren't careful, feeds will clog up your inbox and you could easily become frustrated and not read them at all. Choose the feeds you read by email carefully.

My personal favorite service for converting RSS feeds to email is Feedburner -- it's fast, reliable, and the formatting is usually perfect. Certain websites, like BoingBoing, offer the option to subscribe by email through Feedburner on the main page. Other websites, like Tech Medicine, Kidney Notes, and The Efficient MD, also offer links to subscriptions by email. Most services like Feedburner offer the option to subscribe to the feed as a digest (one large, daily email of all posts) or as individualized emails. (I usually prefer the digest format.)

But what if the website doesn't offer the option to subscribe by email? Feedburner, as far as I know, doesn't allow you to subscribe by email unless the website allows it, but other services are available. Two popular services as Rssfwd and Feedblitz. After copying and pasting the feed's address, each website will then deliver the feeds to you by email. Rssfwd even offers a bookmark that you can place in your browser that allows you to automatically subscribe to the websites you visit. (I personally prefer Rssfwd to Feedblitz because the formatting on the iPhone is better.)

For medical news, two feeds that I subscribe to by email are Kevin, MD and The Wall Street Journal Health Blog. Non-medical sites that I subscribe to include Boing Boing and The Secret Diary of Steve Jobs.

--

In the last section, I suggested that the best way to read your most important feeds is by email.

But what if you don't want to read every word of the feed? What if the feed is important, but not that important?

Consider using a customized home page. Put simply, these pages allow you to display the headlines from multiple feeds on one page, like a newspaper. You can then quickly scan the feed's headlines for items of interest and click to reveal the full view.

Two popular free home page services are iGoogle and Netvibes. Each service allows you to create multiple tabs for different subjects. One tab, for example, could contain general news, while another could contain news about medicine, and a third could contain the tables of contents of popular journals. Here's a page from Netvibes, as an example. On this page, the feeds are all about science and technology:


The advantages of using customized home pages are many. The feed's recent items are all there, so it's unlikely that you'll miss any. You don't need to see the full text of the items, and you can click on any items that interest you. And can flexibly create tabs which contain different topics -- medicine, science, or whatever else you choose.

In the next section, we'll look at the third and final way of reading feeds: feed aggregators like Google Reader.

--

Let's recap. It's difficult (if not impossible) to keep up with all the new information posted to countless websites without using RSS feeds. In the first section, I suggested that the proliferation of feeds and the ease of reading them may have actually contributed to the problem of information overload. There's simply too much good stuff to read.

One strategy to deal with this problem is to use different methods to read different feeds, depending on their importance. In the second section, I argued that the best way to read your most important feeds is by email. For example, if you rely on Kevin, MD as a major source of medical news and you don't want to miss a single post, then visit Rssfwd.com and enter Kevin 's feed ("http://feeds.feedburner.com/KevinMd-MedicalWeblog"). That's it. Kevin will email you all new posts -- in daily digest form, if you prefer -- from now on.

In the last section, I suggested that some feeds are best read by using a customized home page, like iGoogle or Netvibes. If Rssfwd turns feeds into letters that are emailed to you, then iGoogle and Netvibes turn feeds into newspapers, complete with topic sections and headlines.

The third way of feed reading is to use a feed aggregator like Google Reader. This type of aggregator turns feed reading into the equivalent of surfing channels -- in the case of Google Reader, the new feed content (usually just the headlines) scrolls endlessly up the screen. Clicking on any headline reveals the full text.


This type of feed reader is most appropriate for content that you'd like to keep up with, but you don't mind missing. (Of course, it's possible to have all your feeds in Google Reader and make generous use of folders to ensure you don't miss the most important feeds.) Google Reader is the most sophisticated way of reading feeds, and has recently added many new features, like discovering new feeds and sharing feeds with your friends.

If you're feeling overwhelmed by the number of feeds you read, and you haven't yet tried Rssfwd.com, iGoogle/Netvibes, and Google Reader -- try them. They might simplify your life and make reading feeds manageable again.

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Mind Doping

Performance enhancement by athletes using illegal drugs and hormones is old news. So in a recent article, the Los Angeles Times turned their attention to a different type of enhancement: "mind doping."

Mind doping (also known as "brain doping" or "cosmetic neurology") is the enhancement of cognitive performance by drugs, many of which are legal or available by prescription. Steroids and other hormones are used by athletes; in comparison, cognitive enhancing drugs are used by students, musicians, executives, and other professionals.

The most widely used cognitive enhancing drug is caffeine. (Who hasn't stayed awake for long hours drinking multiple cups of coffee?) Alternatives to caffeine discussed in the article include Ritalin and Adderall, both types of amphetamines ("speed"), which are always illegal and dangerous when used for unapproved purposes -- like staying awake to study for that final exam.

A relatively new drug designed for "wakefulness promotion" is Provigil (Modafinil). Provigil is not an amphetamine and the mechanism of action isn't clear, but it apparently acts directly on the area of the brain that promotes wakefulness. Provigil is formally approved for narcolepsy and "sleep work shift disorder" (SWSD), defined here:

SWSD is a sleep disorder that affects people who frequently rotate shifts or work at night. Schedules of these people go against the body’s natural circadian rhythm, and individuals have difficulty adjusting to this different schedule. SWSD consists of a constant or recurrent pattern of sleep interruption that results in insomnia or excessive sleepiness. This disorder is common in people who work non-traditional hours, usually between 10:00 p.m. and 6:00 a.m.

The legal use of Provigil by professionals with erratic sleep/work schedules is becoming more common. In this article in the New England Journal of Medicine, the use of Provigil in patients with SWSD led to a decrease in sleepiness, attention lapses, and accidents or near accidents on the way home.

The article in the Los Angeles Times on mind doping is here.

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Someone Please Create Free, HIPAA-Compliant Patient-Physician Email

This is a rant. Or a plea. Or a pitch for a product idea that I wish someone would just run with. It would be invaluable to everyone involved.

Free, encrypted, HIPAA-complaint patient-physician email. Simple. Easy-to-use. Ad-supported. Perhaps by Google ads, like Gmail.

But I'm getting ahead of myself. Think about it. Most physicians actually want to email their doctors. And many doctors would email their patients if there was a free, encrypted, private, easy-to-use system available. But most physician-patient email systems are expensive or are cumbersome to use. (For more background, see this three part series on patient-physician email on Tech Medicine.)

So here's my proposal:

Dear Google (or another company with resources and ambition),

Please create an email system where all communication between physicians and patients is encrypted to comply with the HIPAA privacy law.

Make it free. Advertise it to doctors. Emphasize the HIPAA-compliant part. Emphasize the free part.

Monetize it with Google adwords or some other system. In fact -- if this is Google I'm speaking to -- just build it on Gmail. Countless Gmail users are already fine with seeing contextualized ads right next to their email. I don't think doctors and patients would mind. And if they do, well, those people won't use it. Plenty of other people will.

I understand there are technical limitations. But people have designed HIPAA-compliant patient-physician email systems before. I'm just asking you to do it better. And for free.

It would be huge. Not only in terms of potential advertising revenue, but it would provide a real service to patients who would love to email their doctors. And it might strengthen the physician-patient relationship like few things could.

Thanks for listening.

Photo Credit: Flickr

Labels: email, hipaa

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Feed Reading, Three Ways (Part 4)

This is the final part of a series on reading feeds more efficiently.

Let's recap. It's difficult (if not impossible) to keep up with all the new information posted to countless websites without using RSS feeds. In part 1, I suggested that the proliferation of feeds and the ease of reading them may have actually contributed to the problem of information overload. There's simply too much good stuff to read.

One strategy to deal with this problem is to use different methods to read different feeds, depending on their importance. In part 2, I argued that the best way to read your most important feeds is by email. For example, if you rely on Kevin, MD as a major source of medical news and you don't want to miss a single post, then visit Rssfwd.com and enter Kevin 's feed ("http://feeds.feedburner.com/KevinMd-MedicalWeblog"). That's it. Kevin will email you all new posts -- in daily digest form, if you prefer -- from now on.

In part 3, I suggested that some feeds are best read by using a customized home page, like iGoogle or Netvibes. If Rssfwd turns feeds into letters that are emailed to you, then iGoogle and Netvibes turn feeds into newspapers, complete with topic sections and headlines.

The third way of feed reading is to use a feed aggregator like Google Reader. This type of aggregator turns feed reading into the equivalent of surfing channels -- in the case of Google Reader, the new feed content (usually just the headlines) scrolls endlessly up the screen. Clicking on any headline reveals the full text.


This type of feed reader is most appropriate for content that you'd like to keep up with, but you don't mind missing. (Of course, it's possible to have all your feeds in Google Reader and make generous use of folders to ensure you don't miss the most important feeds.) Google Reader is the most sophisticated way of reading feeds, and has recently added many new features, like discovering new feeds and sharing feeds with your friends.

If you're feeling overwhelmed by the number of feeds you read, and you haven't yet tried Rssfwd.com, iGoogle/Netvibes, and Google Reader -- try them. They might simplify your life and make reading feeds manageable again.

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Feed Reading, Three Ways (Part 3)

This is a series on how to read feeds more efficiently. (This is part 3. Part 1 is here and part 2 is here.)

In part 2, I suggested that the best way to read your most important feeds is by email.

But what if you don't want to read every word of the feed? What if the feed is important, but not that important?

Consider using a customized home page. Put simply, these pages allow you to display the headlines from multiple feeds on one page, like a newspaper. You can then quickly scan the feed's headlines for items of interest and click to reveal the full view.

Two popular free home page services are iGoogle and Netvibes. Each service allows you to create multiple tabs for different subjects. One tab, for example, could contain general news, while another could contain news about medicine, and a third could contain the tables of contents of popular journals. Here's a page from Netvibes, as an example. On this page, the feeds are all about science and technology:



The advantages of using customized home pages are many. The feed's recent items are all there, so it's unlikely that you'll miss any. You don't need to see the full text of the items, and you can click on any items that interest you. And can flexibly create tabs which contain different topics -- medicine, science, or whatever else you choose.

In part 4, we'll look at the third and final way of reading feeds: feed aggregators like Google Reader.

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Medicine and the Ambient Orb

For years, I've had a small glass orb in my kitchen with multicolored LEDs inside, capable of displaying dozens of colors. One early morning this week, it was pulsing dark blue.

This meant it was going to be 20 degrees outside, according to the orb, and snowing. And it was.

The Ambient Orb is a "glanceable internet appliance." It's based on a simple idea: complex information should be translated into simple forms that can be understood at a glance.

The orb can be configured to display more than colors representing the weather report. It can display the movement of the stock market (green for up and red for down), the Homeland Security color code, or even information on the number of people waiting in an Emergency Department.

Paul Levy, the CEO of Beth Israel Deaconess Medical Center, has done just that. He writes in his blog ("Running a Hospital") that he's installed an Ambient Orb on his desk to monitor the ED.

Being an MIT grad (and apparently sharing one of John's geekiness genes), I couldn't resist, and he was kind enough to get one for me and install it. You see it on my desk [below]. It gives me a signal of how many people are actually in the waiting room in our Emergency Department. The Orb supports 35 different colors and glows blue if no patients are waiting, greens for 1 to 5, yellows for 6 to 10, reds for 11 to 20 and flashing red for over 20....

Ambient's website discusses the philosophy behind the orb:

Ambient devices elegantly embed digital information into the objects and environments that surround us. These displays are in the form of sound, air pressure, motion, light, smell, and other media that complement the full range of our human sensory modalities. They exist in the periphery of our senses, where they provide continuous information without being distracting.

Maintaining "situational awareness" in complex healthcare environments is a struggle, and technologies like the Ambient Orb -- and the philosophies behind it -- might make this easier. (A simple manifestation of this concept is in laboratory reports which display values outside the normal range in red.)

More on the Ambient Orb in this article in Businessweek.

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