Center for Personalized Education for Physicians

Physician Evaluation Services - Educational Intervention

In response to today’s society where a person’s financial and family responsibilities can change quickly and unexpectedly, career mobility and preparedness is paramount. CPEP’s new program enables physicians to return to clinical practice with the training and support they need to resume their medical career after an extended absence. Physicians are eligible for this program if they were in good standing in the medical community prior to leaving practice.

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Traditionally one could leave practice for some years, then return and resume practice without formal retraining. Colorado no longer allows this, so a reentry market has developed. Good to keep note of this for non-practicing docs like myself.

Orwell uber alles

Ugly Truths About Guantanamo (washingtonpost.com)

Orwell, however, was off by only 20 years. With immense satisfaction, he would have noted the constant abuse of language by the Bush administration -- calling suicidal terrorists "cowards," naming a constriction of civil liberties the Patriot Act and, of course, wringing all meaning from the word "torture." Until just recently when the interpretation of torture was amended, it applied only to the pain like that of "organ failure, impairment of body function, or even death." Anything less, such as, say, shackling detainees to a low chair for hours and hours so that one prisoner pulled out tufts of hair, is something else. We have no word for it, but it is -- or was until recently -- considered perfectly legal.

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The current Orwell Awards focus on "freedom of the press". A noble cause, but not the root of Orwell's concerns. He would perhaps be more concerned about the "corruption of the press", a phenomena now well established in America.

We need a different group than journalists to present a new set of Orwell awards for 2005. I suggest High School english teachers, and I nominate George Bush as the premiere winner.

Tsunami Victims: VISA/MC waive transaction fees?

Tsunami Victims: How to Help (washingtonpost.com)

From a WaPo transcript about aiding Tsunami victims:

Los Angeles, Calif. With so many people making spur-of-the-moment donations, I bet that Visa and Mastercard are making a fortune from the fees they charge. Are they going to waive these fees? They should!

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Hmmm. This is an interesting question, one that didn't occur to me. The administrative costs to VISA/MC and AMEX on these types of donations is presumably quite small. It would be good corporate policy for them to donate their fees.

In fact it probably wouldn't be that hard for them to do so. If Americans donate $200 million via credit cards to this cause, fees are less than $5 million. I suspect AMEX/VISA/MC can manage that donation.

Krugman returns: the privatization of social security

The New York Times > Opinion > Krugman: Stopping the Bum's Rush

... we can't have a Social Security crisis without a general fiscal crisis - unless Congress declares that debts to foreign bondholders must be honored, but that promises to older Americans, who have spent most of their working lives paying extra payroll taxes to build up the trust fund, don't count.

Politically, that seems far-fetched. A general fiscal crisis, on the other hand, is a real possibility - but not because of Social Security. In fact, the Bush administration's scaremongering over Social Security is in large part an effort to distract the public from the real fiscal danger.

There are two serious threats to the federal government's solvency over the next couple of decades. One is the fact that the general fund has already plunged deeply into deficit, largely because of President Bush's unprecedented insistence on cutting taxes in the face of a war. The other is the rising cost of Medicare and Medicaid.

As a budget concern, Social Security isn't remotely in the same league. The long-term cost of the Bush tax cuts is five times the budget office's estimate of Social Security's deficit over the next 75 years. The botched prescription drug bill passed in 2003 does more, all by itself, to increase the long-run budget deficit than the projected rise in Social Security expenses.

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The Bush plan only makes sense if one assumes he will also privatize medicare.

American Chechnya -- the Economist's perspective

Economist.com | Iraq

The Economist this week features a grim summary from one or more embedded journalists (the Economist does not provide bylines). It reminds me a bit of the letter home from the WSJ's Iraq journalist, only this one was printed.

It has been well cited in the blogs I read. The news is relentlessly grim throughout Sunni Iraq. Fallujah is described as "demolished", which reminds me a bit of Grozny.

The US is hanging on until the Shias take over and the Kurds split away. After that, presumably, the true civil war begins.

One paragraph stood out for me:

Barely six months ago, Mosul was one of the most tranquil spots in Iraq. Now it is one of the most violent, and least policed. It may be no coincidence that, until last January, around 20,000 American troops were billeted in and around the city and led by a most dynamic commander. With troops urgently required elsewhere, they were replaced by 8,500 soldiers, around 700 of whom were diverted to Fallujah and Bagh.

So with sufficient forces, and extraordinary leadership, it might have been possible to occupy Iraq and hold real elections. Of course the US doesn't have a large enough army to do that, it would take years for us to build an army of occupation, rather than one of invasion, and it would probably require something like a draft.

I've always supposed the real issue with Shinseki's @2001 300,000+ prediction was that it meant, effectively, that we couldn't invade Iraq in the first place. If that's true, it's rather interesting that the print media didn't point this out a few years ago.

Y2K: give thanks to the Geeks who saved your butt

American RadioWorks - The Surprising Legacy of Y2K

... Koskinen points to evidence that the fix was needed. Some computers that didn't get fixed stopped working on New Year's Day. He says some of those glitches would normally have been big news, but since people were expecting the end of the world, they didn't seem like that big a deal. Koskinen was in the Y2K nerve center in Washington, D.C. that night, monitoring systems all over the world. He says the public doesn't realize how many things went wrong.

Koskinen describes the scene as he saw it unfurl. "The low level wind shear detectors at every major airport go out at 7:00 on Friday night, the defense intelligence satellite system goes down, the French intelligence satellite goes down, the Japanese lose the ability to monitor a couple of their nuclear power plants, and come Monday morning, there are thousands of businesses that when you buy something with your credit card charge you every day of the week.

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Yes, the Y2K crisis was real. It's the curse of prevention, whether in medicine or in business, that one never gets credit for a disaster deterred.

So why is it credit card companies tolerate so much fraud?

Faughnan's Notes: CC Fraud Take II

While I work through the 7K of fraudulent charges on my AMEX card, I have the opportunity to think again about how the basic infrastructure of credit card security seems little changed from my experience 7 years ago.

An NPR Morning Edition story fills in the blanks. VISA/MC and AMEX are very, very profitable endeavors. They probably pull in 75 billion every year on interest payments alone; then add atop that 1-2% of most retail transactions. In other words, they have money to burn.

Let's say they put a system in place that made fraud much more difficult. All the solutions I know of would make online purchases somewhat more difficult -- OR they would open the door to non-credit card alternatives. Either way, I bet it would cost the card industry billions. If an alternative to credit cards emerged, it could cost the card industry tens of billions of dollars every year.

Even today, that's a lot of money.

Far better to lose a few billion to fraudulent transactions every year. Since they probably only lose less than a hundred million dollars a year, credit card fraud will be a growth industry for years to come. If the only factor were economic, I'd guess fraud could be more than 10 times as common as it is now, meaning each year most of us would see some fraudulent activity on our statements.

A series of amateur photos of the incoming tsunami

Tsunami

In this series of photos, the victims are casually watching the incoming waves. Until it sweeps them away many seem unaware of the danger. Looking at the pictures I can imagine why. The Tsunami does not seem so high or great a wave; what cannot be seen is the immense "width" (volume) of water and the exceptional velocity of it. It is the volume (mass) of water times the square of the velocity that does the terrible damage.

Most misleading news coverage: a nominee

Reuters AlertNet - Study shows no one knows which diets work best

Wow, a new standard for most misleading news coverage and title. The study was of the commercial dietary companies, it wasn't a study of medical/dietician diets. They found, shockingly (not), that the commercial diet companies had no real evidence to back their claims of exceptional efficacy. Weight Watchers did better than the commercial competition.

Reuters isn't the only ridiculous headline, Google News had many examples.

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Update 1/12/05: I finally read the original JAMA article. Wow, the media coverage was even worse than I thought.

This was really an ambitious study. They looked at the Atkins (low carb) vs. Zone vs. Ornish (low fat) vs. standard (Weight Watchers) diets. They actively intervened for two months then followed up a year later. Subjects didn't get to pick their diet of choice -- they were randomly assigned.

The result was they all the dieters did dismally. In fact, they did worse than the dismal results one usually gets from diet studies. We don't know why -- was it something about how they were recruited? Was it related to all those lost to follow-up? Was it because people do better when they get to pick their own diets?

The main conclusion was the low card (Atkins) diets don't work any better than any other diet. Low carb seems to work a bit better at the 2 month mark (perhaps, as my friend Jim Horn noted, because it's so much work to prepare the food people eat less) but then people stop complying.

There's an increasing suspicion that obesity, once established, is not a treatable condition. Yeah, in theory it's reversible, and sure some lose weight for years (almost always due to serious exercise increases with some moderate food limitation), but we actually have better treatments for most of the leukemic disorders than we have for obesity.

We know obesity can be prevented. Among wealthy societies there are some settings with more obesity, some with less. Activity is the key variable. We also know than in an infotech centric, sit down, fly around society in which most persons can easily afford vast amounts of food, that we are heading for a plague of obesity that may break our healthcare budget.

We need serious new drugs, and the drug companies are investing billions (trillions) looking for this grail. (Billions for antiobesity drugs, a trifle for new antibiotics -- it's a bad story.) At least half of humanity will take these drugs for their entire lives -- or until we genetically modify humans so we eat less.

PS. Is the situation really so hopeless? Yes. In theory we could do many things to encourage and facilitate physical activity in all domains of our society. Sure. In practice this is the social equivalent of an individual actually sticking with a diet. Theoretically possible, but practically implausible -- especially in the current political climate where riding a bicycle is a sign of communist/terrorist sympathies.

The stagnant information architecture of the web: ten years of stasis

Reviving Advanced Hypertext (Jakob Nielsen's Alertbox)

...In 1995, I listed fifteen hypertext features that were missing from Web browsers. None of these ideas have been implemented in the ten years since, except for Firefox's search box and Internet Explorer's search sidebar.

Is there any hope that the next decade will bring more progress? I think so. For one, most of the ideas mentioned here are rich sources of user interface patents, which offer a sustainable competitive advantage. (I invented at least five potential patents while writing this article, but didn't bother filing because I'm not in the business of suing infringers; a big company could rack up the patents if so inclined.)

The last ten years were a black hole: much attention was focused on doomed attempts at making the Web more like television. Hopefully, the next decade will focus instead on empowering users and giving us the features we need to master a worldwide information space.

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I don't think these are Nielsen's ideas -- Berners-Lee wanted bidirectional links & collaboration from day one. On the other hand, I have Nielsen's book and he did a good job of summarizing the state of the art back in 1995. There's been zero progress since then. (I remember Hyper-G, a Gopher derivative .. for example. Jon Udell has also written about this.)

He's absolutely right that the information infrastructure of the web has stagnated, but that was inevitable once Microsoft took monopolistic control of the browser. Perhaps Firefox, Google and Amazon will lead us out of the darkness.

Disasters: World Vision's list of myths

World Vision: "Top 10 Myths of Disaster Relief -- Aid Groups Address Public Stereotypes About Overseas Disasters"

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I don't often link to conservative religious sites, but this is a commonsense list. Bottom line -- just send money. I like CARE.ORG.

Audio-Digest Foundation: Moving the media world from CD to iPod

Audio-Digest Foundation: Past Issues

I use this company for my medical CME. I've previously described how I leverage my iPod to facilitate completing my CME requirements. My method works, but it would be more convenient for me to get my lectures via Audible.com rather than via CD. This is a revised version of an email I submitted to their site:

I am a subscriber -- FP Audio Digest. Love it. I (legally) import the CDs into iTunes, upload the track names to the iTunes DB service, and store the lectures on my iPod. I listen when traveling, working, driving, etc. The iPod now has about 80 lectures. A 30 minute lecture is 13MB; I think with a better codec the size would be about 6MB.

This works well, but it's inefficient. I wish you'd consider Audible.com, an Apple iTunes store distribution partner, as your distributor. This could be quite efficient for you, though I don't know if there's enough cash flow to motivate Audible (you know the numbers).

There are many possible approaches, but please consider the radical option:

1. Separate access to the audio from CME services. Users pay one price for access, another for CME (either per lecture or per series).
2. Subscribers get access to all lectures in their domain -- ex. FP Audio domain. (Remember, once the infrastructure is in place it costs very little to supply a lecture to a subscriber). Also sell lectures separately. This means you can make money not only from physicians, but also from interested laypersons.
2. Subscribers get CME credit only when they pay you, either on a subscription or per-lecture basis.

With this option you wouldn't have to mail me a CD. This ought to save you some money. This distribution model will also allow you to earn money from the large pool of non-physician interested laypersons.

The increased convenience is worth money to me as well, so you could charge me slightly more for the service (esp. if you provide access to 2-3 years of the FP Audio library).

Some lectures are, of course, much better than others. Audible supports user comments. I would actually prefer to pay for lectures and CME based on user comments rather than one price for all.

I have no commercial interest in Audible.com. It would just help me out. If you're a subscriber and like this idea, you can go to the Audio-Digest site and submit your comments.

I suppose if Audio-Digest doesn't take this up, I could always take a whack at this business myself :-). (Depends how bored I get, rather unlikely I'd say.)

The demise of Wikipedia

Why Wikipedia Must Jettison Its Anti-Elitism || kuro5hin.org

Alas, it was not to be. An article by a former Wikipedia founder outlines a root problem:

The root problem: anti-elitism, or lack of respect for expertise. There is a deeper problem--or I, at least, regard it as a problem--which explains both of the above-elaborated problems. Namely, as a community, Wikipedia lacks the habit or tradition of respect for expertise. As a community, far from being elitist (which would, in this context, mean excluding the unwashed masses), it is anti-elitist (which, in this context, means that expertise is not accorded any special respect, and snubs and disrespect of expertise is tolerated). This is one of my failures: a policy that I attempted to institute in Wikipedia's first year, but for which I did not muster adequate support, was the policy of respecting and deferring politely to experts. (Those who were there will, I hope, remember that I tried very hard.)

And an article by a former Encyclopedia Britannica editor goes further:

... Then comes the crucial and entirely faith-based step:
Some unspecified quasi-Darwinian process will assure that those writings and editings by contributors of greatest expertise will survive; articles will eventually reach a steady state that corresponds to the highest degree of accuracy.

And there's the rub. Where is the "natural selection" process that selects for truth? Humans do not have an innate instinct for truth; if we did, we would not have had to develop the scientific method (devise model, specify testable predictions, tests, measurements, publication, review, revise model, iterate). Humans do have a predilection for creating narratives, hence the rich beauty of religious and spiritual writing (which may be true, but are not testable).

On the other hand, when I was working recently on a talk on knowledge representation, Wikipedia had one of the most helpful discussions of directed graphs that I've found. It was much more accessible than most of the literature on this domain; once I understood the Wikipedia description it I could validate the work against published reference materials. After reading the digested, populist version, I could read the work of recognized experts and interpret that work. So in this case Wikipedia filled an interesting niche -- a "popular" rendering of an esoteric topic that would, in the normal course of things, never be presented at anything other than the language of a post-graduate specialist.

So the Wikipedia will probably fail in its stated mission. It may, however, still have use -- as a way to popularize esoteric topics that other encyclopedias don't cover. The reader, however, must take the next step of comparing the writing of Wikipedia to an authoritative, less accessible source.

Outsourcing and quality control: the Apple experience

MacInTouch Home Page

A particularly appalling story of Apple's repair program. For various reasons, I believe this story is true:

I have a customer who had a 12.1' iBook G3/600 which exhibited the classic logic board exchange out of warranty issue, which Apple has a special extension for. This means the unit displayed flake video and sometimes would black out entirely.

This customer is meticulous and his equipment shows it. The unit was immaculate when it got to me even though it had been purchased second-hand and was in use by a kid.

I spoke to Apple and they agreed that it was within the scope of the extended warranty repair program, even though the serial number wasn't within the range published.

We did the DHL ship to the repair depot, and a week later the machine was returned to me. It had a very noticeable scratch on the bezel surrounding the LCD, and the Airport didn't work. I called Apple again and we did ANOTHER round trip to the depot. They made a note about the scratch, but it wasn't so bad, so I figured we could live with it.

Upon the second return (13 days, but Christmas intervened, so understandable), the unit worked OK, but had a very noticeable misalignment of the case work and ANOTHER scratch in the front lower case (right where you would press the tabs to release the bottom case).

I contacted Apple again, and they offered to replace the plastics and repair the unit if I shipped it to them a third time. I told them it had taken too long already, and could they compensate me some other way and I would pay to have the case put together properly in town... The guy's name was Dean and was super nice and agreed to send me out a new battery, which this unit needs anyhow.

So, when I go to straighten out the case work, as soon as the bottom is removed, it becomes clear there are multiple screws and parts MISSING. The LED which signals sleep wasn't even reinstalled, and at lease one important screw is AWOL.

Whoever is doing the repairs for Apple on this program is doing a terrible, sloppy job and there is clearly NO quality control in place for this.

As an Apple stock holder this is really appalling, as it clearly is costing way more then a new iBook to get this squared away. Three round trips via DHL and two logic board exchanges, plus ...

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I don't think this is purely an Apple issue. It's really an outsourcing story. Apple outsources their services. That means they lose control over quality. Episodes like this one, especially when broadcast on the very influential Macintouch site, cost them a fortune.

Outsourcing is very tricky.

Bush rule: The Revenge of Andrew Jackson

The New York Times > Opinion > Op-Ed Contributor: The Cabinet of Incuriosities

... Whatever the roots of Mr. Bush's overriding devotion to loyalty, it partly stems from his disdain for the concerns of old-style meritocrats, the kind of people who wince when the president places his confidence in someone like Mr. Kerik. Mr. Bush has never been comfortable in America's so-called meritocracy. Undistinguished in college, business school and in the private sector, he spent nearly 30 years sitting in seminar rooms and corporate suites while experts and high achievers held forth.

Now it appears that he's having his revenge - speaking loudly in his wave of second-term cabinet nominations for a kind of anti-meritocracy: the idea that anyone, properly encouraged and supported, can do a thoroughly adequate job, even better than adequate, in almost any endeavor.

It's an empowering, populist idea - especially for those who, for whatever reason, have felt wrongly excluded or disrespected - that is embodied in the story of Mr. Bush himself: a man with virtually no experience in foreign affairs or national domestic policy who has been a uniquely forceful innovator in both realms...

... Now that Mr. Bush has won his final campaign and holds high a gleaming national mandate, he can be ever more himself. And for Mr. Bush, personality is destiny. What you do is not as important as whether you are deemed morally sound and trustworthy. In other words, a "good" man - or woman - beats a leading expert every time. Welcome to the new meritocracy.