Doctoring under the influence: EMRs, mobile phones, and cognitive load

My wife, a physician, commented today how annoying it was to have her personal physician staring at a laptop during the entire patient visit. It made me think of the vast literature on mobile phone use and driving. The negative multitasking impact probably varies by age and ability, but it's generally compared to a few glasses of wine.

Is there any reason to expect that interacting with a computer is less demanding than talking on a cell phone? Does anyone have any doubt that the cognitive load of dealing with a software package (electronic health record, EMR, EHR, etc) impairs the ability to think about patient care?

There's been surprisingly little research done on this, though I do recall a quite good opinion piece on the topic a few years ago. Fertile ground for future scholars, no doubt.

Problems in Google-land: Gmail, Blogger and do you really trust Web 2.0?

Last week a bad update broke Google's BlogThis! tool. It took them a week to fix it, and there was never any official notification of the problem, though Google's support people did post in response to numerous help group complaints.

This week Gmail's spam filter is malfunctioning. The "whitelist" functionality is broken and it's miscategorizing email. I tried to post about this on the Gmail Group but the "problem" group is down (really, I'm not joking, they're out of order). Users who get large volumes of spam will inevitably lose email in the mess.

Google has not provided any notification on any blog, or on their help page, of the Gmail malfunction. (They did provide notification us that the Gmail Help Group is down, but that's rather obvious.)

It's the failure to notify, more than the bugs, that really concerns me. Google is not treating their customers respectfully.

The foundation of "Web 2.0" apps (what we once called "application service provider") is trust in the service provider. The "web 2.0" model doesn't need to be perfect -- all software has bugs and local hard drives fail, so traditional "owned" software models have their own problems. The "web 2.0" model does, however, require trust, and trust requires respect.

If Google can't respect their customers, who can? What does this say about all the other web 2.0 services that we increasingly rely upon?

2011: The year American life changes

When will energy costs in general, and gasoline costs in particular, fundamentally change the way middle-class Americans live and work? We know gasoline prices will rise until something changes, even if the US never implements a carbon tax.

Of course change like this is not generally abrupt, it's a process and it's probably underway now. So, really, what I'm asking is when will the change be obvious and undeniable?

I think a reasonable marker is the year that the baseline gasoline price hits $5 a gallon. I used to think it was $7 a gallon, but that was before I paid attention to what my commute was costing me. If the average American burns 3 gallons of gas during each daily roundtrip commute, and gas costs $5 a gallon, then each daily commute costs $15 in gasoline alone, or about $3,000 over 200 commuting days. For a family with two commuters that's $6,000 a year.

That's a meaningful percentage, perhaps 10-13% of the average American family's after-tax income. It doesn't include the effects of cost increases for heating and cooling, lights and computers, and all the rest of our lives.

That's a number that a middle-class American will start to notice, and it can't come out of savings. Middle-class American's don't save -- their assets are in their homes. Americans will have to change their behavior. It means smaller cars, hybrids, bicycles for some, closer employers, working at home, etc. Employers will have to change their behavior, setting up peripheral offices at transit hubs, investing in remote work support and collaboration solutions ...

The 'working at home' bit is particularly interesting. I've been in distributed work groups on and off for years, and they're terribly ineffective for complex or innovative product work. We get far more done with less money when everyone sits in walking distance; but it's getting harder, not easier, to get people to relocate and stay relocated. Of course part of the problem is that employers have not seriously thought about how to make remote work groups effective (hint: technology is an enabler, it's not a solution). Commuting costs of $15 a day and more mean that employers will have to get very good, fairly quickly, at supporting remote work groups.

So when does it happen? I'll pull a number out of the air, extrapolating from my amateur chart and the Copernican Principle, and guess, even without a carbon tax or the complete collapse of Iraq, that it's 2011.

Iraq 101: Why some people may hold a grudge

It's useful to remember that some people may hold a grudge against former Baathists ...

The Iraq war is lost | Salon.com

... Abdul Aziz al-Hakim leads the Supreme Islamic Iraqi Council (SIIC, previously known as SCIRI), which is Iraq's leading Shiite party and a critical component of Prime Minister al-Maliki's coalition. He is the sole survivor of eight brothers. During Saddam's rule, Baathists executed six of them. On Aug. 29, 2003, a suicide bomber, possibly linked to the Baathists, blew up his last surviving brother, and predecessor as SCIRI leader, at the shrine of Ali in Najaf. Muqtada al-Sadr, Hakim's main rival, comes from Iraq's other prominent Shiite religious family. Saddam's Baath regime murdered his father and two brothers in 1999. Earlier, in April 1980, the regime had arrested Muqtada's father-in-law and the father-in-law's sister -- the Grand Ayatollah Baqir al-Sadr and Bint al-Huda. While the ayatollah watched, the Baath security men raped and killed his sister. They then set fire to the ayatollah's beard before driving nails into his head. De-Baathification is an intensely personal issue for Iraq's two most powerful Shiite political leaders, as it is to hundreds of thousands of their followers who suffered similar atrocities...

It's a good overview article. The main point is that while it is true that the Iraqi government has not acted on any of the core requirements of the Bush administration, the requirements are probably unwise anyway.

Fallows: Petraeus cannot change water into wine

 Fallows has written an excellent review of the "Petraeus will save us" strategy of Bush and the entire GOP ...

James Fallows: David Petraeus and the "New Jesus" problem

... The recent astounding column by Wiliam Kristol had a similar "Petraeus will save us" tone: "What it comes down to is this: If Petraeus succeeds in Iraq, and a Republican wins in 2008, Bush will be viewed as a successful president."

It's tempting to spend more time on that one sentence of Kristol's ("What it comes down to is this: If I can beat Roger Federer, I'll be successful at Wimbledon.") The real point involves Petraeus.

He is a smart man. He is a brave man, not just in the obvious sense but also for reminding his troops soon after taking command in Iraq that there are still proper rules of conduct, even though we are "a nation at war."

But -- and in the current context, this may come as a shock -- he is not Jesus, nor is he supernatural in any way. His manual of counter insurgency strategy is a big step forward from the stupid brutalize- and-alienate approach of the early stage of the Iraqi occupation. (The manual is here -- a 12 meg PDF download.) But that manual and its underlying strategy -- which I heard discussed and thrashed out by Petraeus and his colleagues at Ft. Leavenworth last spring; I think Tom Ricks was there for that conference, and I know that Kristol and Graham weren't -- is neither magical nor holy. It is not going to undo what has gone wrong in the last four-plus years. It is not going to make the Maliki government seem legitimate, and it is not even going to shape up the Iraqi security forces...

The sources I respect think very well of General Petraeus and his idiosyncratic team of advisors, but even if he were not hobbled by Cheney/Bush he'd have an impossible mission. Throw in those towering incompetents and ...

Incidentally, Cheney has been remarkably silent about General Petraeus. Maybe he didn't like the Petraeus anti-torture stand.

Seeking a twin cities blog or wiki dedicated to skate and bicycle trail news

I live in Saint Paul, the quieter of Minnesota's "Twin Cities". Minneapolis, in contrast, is a notorious den of hedonistic excess and sinful pleasure. Alas for the injured ego of we Paulites, Minneapolis also has one of the finest bicycle and skating trail networks in North America -- we're only in the top 10.

So, really, we ought to have a local resource focusing on trail news. The trails are expanding everywhere, but also occasionally out of order -- we need something very topical. There are huge multi-lane bike trails and obscure suburban trails, packed stone trails and lovely smooth asphalt trails (inline skaters pay a lot of attention to surfaces), scenic trails and utilitarian arteries, hilly zippers and rail trails -- lots of everything. We need a Google markup map and, above all, a multi-author blog. It has to serve the needs of our major bike clubs and our inline skate club.

I haven't found anything like this so far, but I'd welcome email on the topic to jfaughnan@spamcop.net -- including mention of a similar project in another city. In my search I found a local blog with active comments on the 2007 Twin Cities Bike Map, I posted this as a comment:

Little Transport Press » Blog Archive » Twin Cities Bike Map

... I found this posting because I was looking for a blog dedicated to news and updates on twin cities inline skating and bicycle trails.

If anyone is aware of such a blog please email me ... I’d like to see a multi-author blog and I’d be willing to contribute or help administer.

Possible sponsors include our local bike clubs, the Minnesota Inline Skate Club and Little Transport Press (of course). It could, for example, be used to promote and develop Little Transport Press products. I’d also like to see it integrate with a shared Google Maps/Google Earth toolset for sketching out the trails and I could help with that too...

The key is to leverage many contributors in a structured format, an open source model that leverages our emerging toolkits of blogs, maps and wikis ...

TPM: the polls in WW II

TPM, for the second time, deflates the theory that a lack of popular support for Bush somehow resembles a mythical lack of support for Roosevelt ...

Talking Points Memo | Polls

...The key point is that many polls were taken during the war. And approval of the president's conduct of the war, understanding and belief in the goals of the war and other similar measurements all remained constant at very high levels or in some cases actually went up. One key data point you can see on the chart is the number of Americans will to make peace with Hitler -- that is, an negotiated end to the war rather than the unconditional surrender which was a key allied war demand. The number was under 10% for most of 1942 and 1943. Then it briefly surged up to just over 20% in early 1944 (roughly the time of the invasion of Italy) before falling back down to about 15% for duration of the war in Europe...

I like the historical aspects of this most of all. BTW, TPM has moved to a proper blog format, and it's a great improvement.

Immunotherapy for sarcoma - in the 19th century

Damn Interesting is one of my favorite blogs, and this week's post is of particular interest to physicians (note the UK spelling of "tumor") ... 

Damn Interesting » Coley’s Cancer-Killing Concoction

... The story so convinced Coley that he– perhaps cavalierly– contrived to contaminate his next ten suitable sarcoma cases with Streptococcus. His initial approach was to inject a solution of live bacteria deep into the tumour mass on a repeated basis over several months. The first patient to undergo this treatment was a bedridden man with inoperable sarcoma in the abdominal wall, bladder, and pelvis. Using this experimental method, the patient was cured spectacularly. He staged a full recovery, and survived another twenty-six years before dying from a heart attack. But subsequent results were mixed; sometimes it was difficult to get the infection to take hold, and in two cases the cancer responded well to treatment but the patients died from the Streptococcus infection.

Coley’s discovery, as it turns out, was actually a re-discovery. The idea of a link between acute infection and the resolution of tumours was not new, and the phenomenon of infection-related "spontaneous regression" of cancer has been documented throughout history. A 13th century Italian saint was reputed to have his tumour-afflicted leg miraculously healed shortly after the malignant growth burst through the skin and became infected. Crude cancer immunotherapies working along similar lines to Coley’s early experiments were known in the 18th and 19th centuries, and may extend back to the time of the pharaohs. Ancient writings suggest that the renowned Egyptian physician Imhotep may have used a similar infect-and-incise method to treat tumours....

I've been fond of medical history ever since I enjoyed a thinly attended history of medicine course at McGill in the 80s. I don't recall ever hearing about Dr. Coley or his early use of immunotherapy for sarcoma -- a cancer that's often incurable even now. The article implies that the treatment has been long forgotten, which is not quite true, the work of Coley is periodically revisited.

Dr. Coley deserves a Wikipedia page, but as of 7/17/07 none exists.  Perhaps a scholar somewhere will insert one based on this article (A review of DI could be the source of several new topic pages really.)

Why the GOP dislikes McCain - it's not his support of the conquest of Mesopotamia

I've read several articles about McCain's campaign collapse; all of them cited his support for Cheney/Bush's war as the main reason for his poor prospects. I never questioned this oft-repeated theory, so I was impressed when Glenn Greenwald blew it away.

Of course Greenwald is right -- now that I've read his arguments I'm surprised I was ever so naive as to buy the party line. This is not Bush's war alone, it's the war of Bush's supporters, the hard-core dead-ender 30-percenter ... [update: decreased my"name calling" quotient] ... who are the heart of the modern GOP.

If I were a nobler soul I'd find some sympathy for dolts like Giuliani and Romney who have to kowtow to these people, but I'm not so noble.

Why I blog - Gordon's Notes and Gordon's Tech

I posted this as a Cosmic Variance comment, I've revised it a bit here ...

.. There's a meme about “commodity bloggers” and “echo chambers” that’s been simmering for a while but was fired up by a recent Jakob Nielsen post. CH has a good overview.

I think this is a sub-meme of the “blogging” is “destroying all that is good and pure and noble in human civilization” usually alternating with the “wikipedia is destroying education” meme. (More on the latter soon, maybe...)

Beyond these memes is an unspoken wariness about the increasingly subtle distinctions between an “echo chamber” blog and a splog — the more sophisticated splogs are eerily similar to low end commodity blogs.

I’ve nothing else to add to the good comments on the CV thread, save perhaps that my own very low readership blogs are written for these audiences in this order:

1. Myself. It’s how I learn and think.
2. The GoogleMind: building inferential links for search and reflection.
3. Tech blog: Future readers who find my posts useful to solve a problem they have that I've solved for myself.
4. Gordon's Notes: My grandchildren, so I can say I didn't remain silent -- and my tiny audience of regular readers, not least my wife (hey, we don't get that much time to talk!).

I, of course, agree with the obvious consensus that blogs are intended to be read by subscription tools (like bloglines) and that descriptive titles and label/categories should allow readers lots of tools to decide what to read. I do think the readers can, and will, make better use of metadata (themes, categories, labels, etc) in years to come.

Update: I revised my "why I write" list as I thought it over a bit more.

Update 7/17/07: Excellent comments by Rosenberg. For love, not money.

Reading to kids: don't do it for the test scores

I'd always assumed that the claim that reading to young children improved their academic performance was mostly wishful thinking, but I hadn't realized where the belief came from ...

Freakonomics Blog � The Benefits of Reading to Children, Tested With a Data Pool of One

... Children from low-income households average just 25 hours of shared reading time with their parents before starting school, compared with 1,000 to 1,700 hours for their counterparts from middle-income homes.

These oft-repeated numbers originate in a 1990 book by Marilyn Jager Adams titled, “Beginning to Read: Thinking And Learning About Print.” Ms. Adams got the 25-hours estimate from a study of 24 children in 22 low-income families. For the middle-income figures, she extrapolated from the experience of a single child: her then-4-year-old son, John …

This is a bit like the old saw about "using only 15% of your brain" and other urban myths. This one was a useful myth, it meant that poor test scores could be blamed on parents who, obviously, didn't read to their children enough (perhaps because they were struggling to keep the roof in place) [1].

It's fun reading to kids, though of our 3 we've had 2 that sat still for it and one who'd have needed four point restraints. Do it because it's fun, but don't get bent out of shape about it. There's no evidence, yet, that reading to children will make a significant contribution to their academic performance.

[1] Of course even if there was a causal relationship between reading to children and test scores that would be fallacious reasoning, but we're talking about hairless apes here!

Patrick Leahy is my hero. You must listen to this.

The video is quite short. It's your duty as a citizen to listen to it.



It is an undeserved miracle that America, in a dark time of failed citizenry, was given Patrick Leahy as head of the senate judiciary committee. He is an old man. This is his hour. Thank you Patrick, we don't deserve your service.

The WSJ's Laffler curve fitting: thank you Mr Murdoch

Rupert Murdoch cannot possible diminish the Wall Street Journal. It's already hit rock bottom.

Exhibit A: A physicist reviews the diagram the Wall Street Journal published. Yes, they really published the curve, just as CV describes. Editorial page, of course.

The WSJ is the laughing stock of anyone with any sense.

Do your worst Rupert.

The OS X iPods

Daring Fireball (48,800 bloglines subscribers*!) tells us Jobs confirmed that Apple is working on OS X based iPods. So the next generation of iPods ought to be feature competitive with the iPhone's music capabilities. That's great, but he asks the next, much more interesting, question:

Daring Fireball: Regarding OS X-Based iPods

...The biggest question, as I see it, is whether Apple plans to introduce iPods that are more or less just the iPod app from the iPhone (i.e. just music and video players), or iPods that are everything but phones, with Wi-Fi networking for email, web, and more...

By "more" I assume he means the thought that none dare speak - VOIP.

On the one hand, one might imagine that the AT&T contract forbids a "VOiPod". On the other hand, that is a delicious thought. OS X on the iPhone occupies 680MB and requires a serious CPU and battery, so it's hard to imaging putting it on an iPod just to plays music and movies ...

Of course there's more than one way to play video. Cringely thinks Apple will bundle a hardware H.264 decompressor chip into the next iPod. Jobs is on record as saying the current "Apple TV" is a "hobby".

Hmm.

H.264 HD decompressor chip. VOIP. Apple TV. Rumors that Apple has again bought up all Flash supplies over the next few months...

* That's just Bloglines. He probably has 2-3 times as many regular readers. That's a big enough lever to move even Apple ...

Broder and O'Reilly: comic relief from the right wing

Tom Tomorrow can't resist a Broder rant:

This Modern World » Blog Archive » Mr. McBobo strikes again!

... David Brooks takes wrongness to levels undreamt of by lesser mortals. David Brooks is the Olympic Gold Medal Champion of Being Wrong About Things. David Brooks could write a column about drinking a glass of water, and the end of it, you would sit at your kitchen table puzzled, thinking to yourself, “Has he ever actually had a glass of water?”

(… readers interested in a refresher course in the Unbearable Wrongness of David Brooks are directed to this classic article by Sasha Issenberg.)

Really, who can resist? Broder reminds me of John Dvorak, a computer industry writer who invents stories carefully calibrated to drive page views by easily outraged geeks. Over time we've mostly learned to ignore Dvorak, but Broder is so pompously vacuous we can't leave him entirely alone. (I never actually read his column though -- that would increase his page counts. I get the best stuff in excerpts.)

In the meantime, O'Reilly tells us to fear lesbian street gangs carrying guns, beating up heteros, and pushing Sappho. Of course he's making it all up.

In an era where malevolent incompetents lead the executive branch, Dvorak and O'Reilly are our best sources for accidental humor. Long may they writhe.