Scott Moses' FP Notebook is an astounding, and free, medical reference

Want to double check your doctor’s approach to your cholesterol problem?

Try this Family Practice Notebook (FPN) entry …

Hypercholesterolemia

… VII. Management: Less than two Cardiac Risk Factors

Cholesterol Management
Goal if LDL Cholesterol below 160 mg/dl (ideally <130)
Low Fat Diet if LDL Cholesterol over 160 mg/dl
Anti-hyperlipidemic if LDL Cholesterol over 190 mg/dl

Monitoring
Desirable lipids: Repeat Lipid panel in 5 years
Borderline lipids: Repeat lipid panel in 1 year
Elevated lipids: Repeat lipid panel in 3-6 months…

Or take a look at the cardiovascular medicine book. (In FPN-speak a “book” is a collection of topics, they are accessible from the top right menu.) Ok, I admit there’s a lot of implicit knowledge in those terse phrases. FP Notebook isn’t aimed at consumers, it’s written for family physicians, though it also works for internists and pediatricians. If you’re not a physician you may have to take my word for it — this is an efficient high quality information source for “up to date” (more on that below) evidence-based US medical practice. It’s also a one man show of epic scale (emphases mine)…

About FP Notebook

… This site is derived from a peripheral brain collection of medical notes and is divided over 5700 topics within over 600 chapters and 31 subspecialty books. Information is gleaned from reputable sources, referenced where possible, taken from lectures and workshops, peer reviewed articles and bulletins, and key texts.

… This site is personally funded by the site author, Scott Moses, MD. Additional funding is obtained via advertising support; all paid advertisements are clearly delineated as such. Our advertising related privacy policy may be reviewed at here

Please let us know if you find any advertising to be distasteful or inappropriate, or which you find dilutes the value or integrity of this web site. Absolutely no content on the site is influenced or authored by advertisers. Content is solely per the discretion of the site author….

… These medical notes began as a few scattered pearls of text stored with the Notetaker application of the HP Palmtop 200LX. Since 1995, notes from conferences, articles, textbooks and colleagues have accumulated to its current state.

As the collection of text grew, so did the complexity of its organization, and a program known as Brains was developed as a stand alone application for notetaking and for compilation of the website.

Brains is able to import raw text from the database, process the outlines, titles and synonyms, as well as images and links.

In its third iteration, Brains is written in C# with a SQL Server database and can output each of the site versions of html in 1-2 hours. This latest version also allows topics to be linked to the UMLS metathesaurus codes, and to be viewed on handheld devices.

… Most images on the site I have created myself. Many of the anatomy images were created using the 3d models from Zyogote. Others use a combination of Adobe Illustrator, Photoshop and Poser software.

When images are used from other sources, they are clearly cited. These include the NIH Virtual Human project and MedPix

… Gray’s Anatomy 20th edition from 1918 (Lewis) is in the public domain following expiration of its patent. Scanned images of the plates are available online at both bartleby.com and Yahoo.

In 2012, I started an anatomy series using the Zygote 3D models. I will provide 2 sizes of these images: 800x600 and 4096x3112 (poster size). I have maintained a margin on poster size images, such that they can be printed at 8x10,16x20, and 20x30 inches without losing content when cropping. Costco prints a 20x30 image for about $8.

You may use these images freely for printing (e.g. classroom poster) as well as presentations (e.g. Powerpoint) as long as they are not re-sold or modified…The author of the Family Practice Notebook, is Scott Moses, MD, a board-certified Family Physician practicing in Lino Lakes, Minnesota.

I think this is his hobby. Some people build cabinets, Dr Moses builds textbooks.

There’s really nothing like this any more - FPNotebook is a relic of a bygone world. Twenty years ago, when he started, there were quite a few free online medical references. I did a small one myself, many better ones were published by medical schools and hospitals. For a while some medical textbooks were available online for low costs, often bundled into services like MD Consult. That’s all gone now; Wolter-Kluwers Up To Date has replace many textbooks and online resources - at $500/year for an individual subscription. Once free references, like American Family Physician, are now buried behind paywalls (thereby raising a bit of revenue but sacrificing much good will).

Even if you have a subscription to Up To Date, perhaps through your institution, I suspect you’d find much to like in FPN. For example, take a look at the updates page including the May 2015 FAST exam update: “Test Sensitivity may be as low as 22% for abdominal free fluid in blunt Trauma”. Want to keep abreast of meaningful changes to American medical care? Forget those expensive newsletters, just subscribe to the (new) updates feed: http://fpnotebook.com/updates.xml. What a painless way to keep up.

Ok, you get the idea. This is an awesome resource — but how reliable can it possibly be? As Dr Moses notes, it’s entirely dependent on his vigilance and email feedback — nobody has volunteered to do peer review. I can give a partial response — because 10 weeks ago I started doing serious studying for my Family Medicine board exam. I last did family practice in 1994 and I don’t have an institutional subscription to Up To Date, so I used FP Notebook as a supplement to traditional texts, American Family Physician, and examination critiques. Over those weeks I covered a lot of family medicine in FPN; the only error I found was a minor misplaced section heading (an obvious copy/paste error that wouldn’t confuse any physician). I (and many others) found more mistakes in the closely edited ABFM exam critiques. There must be mistakes in 5.700 topics — but that’s an impressive record. I wouldn’t use FPN as my only guide to patient care, but I can testify to its excellence as a study and memory aid — and as a guide to what’s new and important.

FP Notebook is a dinosaur — straight out of Jurassic World, stomping over the puny mammals of the  modern web.

Try it, you’ll like it. (And say thanks — perhaps suggesting Dr Moses add a donation button. If nothing else, a charity donation button?)

Randall Munroe introduces world language and Google Translate training program using charming New Yorker article

XKCD’s Randall Munroe, the notorious interstellar sAI, has published a simplified vocabulary explanation of Special and General Relativity in the New Yorker.

This work is presumably taken from his almost released new book, Thing Explainer ($15 Amazon pre-order). The essay is entertaining and educational; it also promotes his new book and shows he is a smart pants man.

But that’s not the real reason he’s written this. Obviously his true agenda is to create an English dialect of a universal human language with a simplified vocabulary and grammar that is ideally suited to machine translation and, eventually, colloquial conversations with terrestrial AIs (contra the Wolfram Language for AI conversation, see also Marain. Siri-speak 2015 is a crude version of this.)

Let’s see how well his first version works, using the nsAI Google Translate to do round trip translations of a sample paragraph from the original muEnglish to another language and then back again. We’ll start with French, a language related to that of England’s 11th century conquerors, then we’ll do Chinese. I know from past experiments that round-trip translations from English to Chinese and back typically produce incomprehensible gibberish:

Munroe original (muEnglish)

The first idea is called the special idea, because it covers only a few special parts of space and time. The other one—the big idea—covers all the stuff that is left out by the special idea. The big idea is a lot harder to understand than the special one. People who are good at numbers can use the special idea to answer questions pretty easily, but you have to know a lot about numbers to do anything with the big idea. To understand the big idea—the hard one—it helps to understand the special idea first.

French version

La première idée est appelé l'idée particulière, car elle ne couvre que quelques pièces spéciales de l'espace et du temps. Celui-la grande idée-couvre l'autre tous les trucs qui est laissé par l'idée particulière. La grande idée est beaucoup plus difficile à comprendre que le spécial. Les gens qui sont bons à numéros peuvent utiliser l'idée spéciale pour répondre à des questions assez facilement, mais vous devez savoir beaucoup sur les numéros de faire quelque chose avec la grande idée. Pour comprendre la grande idée-le dur-elle aide à comprendre l'idée première spéciale.

French to English

The first idea is called the particular idea because it covers only a few special pieces of space and time. This great idea covers the other all the stuff that is left by the particular idea. The big idea is much harder to understand than the special. People who are good at numbers can use special idea to answer questions fairly easily, but you should know a lot about the numbers to do something with the big idea. To understand the great idea - hard - it helps to understand the first special idea.

Chinese

第一个想法就是所谓的特殊的想法，因为它涵盖的空间和时间只有几个特殊部位。另外一个大的想法，涵盖了所有剩下的由特殊的想法的东西。大的想法是很多更难理解比特殊的一个。人们谁是善于号码可以使用特殊的想法很容易回答的问题，但是你要知道很多关于数字做的大创意什么。为了解大的想法，硬一它有助于先了解特殊的想法

Chinese to English

The first idea is the idea of so-called special because the space and time it covers only a few special parts. Another big idea, covering all rest of the stuff from the special idea. Big idea is a lot more difficult to understand than the special one. People who are good at numbers you can use special idea is very easy question to answer, but you know a lot about what the figures do big ideas. To understand the big idea, hard and it helps to understand the idea of a special.

Munroe English (muEnglish) works rather well between French and English. If you’re interested in learning French, you might enjoy reading a future French version of Thing Explainer or simply run the English version through Google Translate (and use speech recognition for verbal work).

The Chinese round-trip experiment almost works, but falls apart grammatically. For example, “you can use special idea is very easy question to answer, but you know a lot about what the figures do big ideas” is missing things like “need” and “to” and a few pronouns. There’s also an unfortunate “numbers” to “figures” word substitution. Given that Munroe is a far more advanced AI than Google this essay will be used to enhance Google’s Chinese translation model (which desperately needs work).

I’m optimistic about this new language and happy that the Munroe is now taking a more active hand in guiding human development. Zorgon knows we need the help.

Update 11/19/2015: There’s a flaw in my logic.

Alas, I didn’t think this through. There’s a reason speech recognition and natural language processing work better with longer, more technical words. It’s because short English words are often homonyms; they have multiple meanings and so can only be understood in context [1]. Big, for example, can refer to size or importance. In order to get under 1000 words Munroe uses many context tricks, including colloquialisms like “good at numbers” (meaning “good at mathematics”). His 1000 word “simple” vocabulary just pushes the meaning problem from words into context and grammar — a much harder challenge for translation than mere vocabulary.

So this essay might be a Google Translate training tool — but it’s no surprise it doesn’t serve the round-trip to Chinese. It is a hard translation challenge, not an easy one.

[1] Scientology’s L Ron Hubbard had a deep loathing for words with multiple or unclear meanings, presumably including homonyms. He banned them from Scientology grade school education. Ironically this is hard to Google because so many people confuse “ad hominem attack” with homonym.

Mountain biking - crash and ride safety tips from Bicycling.

Bicycling Magazine has a surprisingly strong article aimed especially at mountain biker riding solo:

7 Things EMTs Wish You Knew about Bike Crashes (My instapaper link)

You always need to take an impact to the head seriously.” … call 911 if you or another rider has:
• ... a cracked helmet. That means you’ve hit your head hard.• ... a headache. Not just sore from the initial impact, but you have a headache that isn’t abating or is worsening.• ... lost consciousness. If you pass out, you need to get checked out.• ... confusion. If you don’t know who the president is or why you’re sitting on the side of the road, you need to get checked out.• ... vision changes. If the world doesn’t appear clear and normal, you need medical assistance.

Take a Deep Breath: Difficulty breathing is always an emergency situation. “Too often people crash and think they’ve cracked a rib, but figure ‘Why go to the hospital? They can’t do anything about it,’” says Martin. “But you need to go because those cracked ribs can have sharp edges and if it’s an unstable fracture and it shifts, you can puncture a lung.” If it hurts to take a deep breath, get to the ER.

Give Yourself a Gut Check: There’s a lot of vulnerable soft tissue and plenty of vital organs in your belly that can be damaged by impact with a handlebar. Take your hands and palpate your abdominal area. If you have an area that is more tender than others, you could have internal damage. If your belly becomes distended or firm, that’s a sign that you could have internal bleeding and need medical assistance stat.

Stop the Bleeding: Unless you’re a trained professional, forget what you’ve seen in the movies about fashioning a tourniquet around a limb to stop the bleeding. You risk doing more damage than good. The best way to deal with bleeding is basic first aid—direct pressure (preferably with something clean) on the wound. Keep it there till help arrives.

Be Smart About Your Spine: Neck and back injuries are scary. You can generally tell if you’re okay by checking your fingers and toes. Obviously, you want to be able to feel your fingers and toes, but if you have any numbness and/or tingling, that’s not good. You could have spinal injury. Also try slowly turning your head 45 degrees to the left and right. If you feel discomfort, stop. That’s also a sign of spinal injury. Get to the ER.

Make Your Personal Info Accessible: Whether you use Road ID, dog tags, or place ICE ('in case of emergency') information in your cell phone, having your personal information available for emergency workers can definitely save your life, says Martin. “We need to know your medications and your allergies," he says. "There are a lot of medications we can’t give you if you’re allergic to them… and we won’t give them if we don’t know.” New iPhones come with a Health app that provides a place for you to fill in all your medical information. Emergency personnel can access this information without unlocking your phone. “We know to look for it if you’re out there by yourself, unconscious, after a crash,” says Martin.

Leave a Note, or a Text: Riding alone? Take two seconds to leave a note or shoot a text to a loved one or buddy. “We’re all guilty of this,” says Martin. “We go out for a quick ride and nobody knows where we’re going. Even if you’re just 10 miles away, you might as well be 100 miles away if no one knows where you are.” The more remote of a place you ride, the more important this is.

It’s always safest to have a ride partner, but next best is to ride on well marked and trafficked trails. Riding on lesser traveled wilderness trails kicks the risk up several notches, just as with wilderness hiking or scrambling. Note the unstated implication of these recommendations is that you have a working cell phone and can call for help or advice after injury.

The iPhone Medical ID locked device access feature is obscure. You have to know to swipe to unlock then to tap the Emergency button then to look below the call keyboard and tap “Medical ID”. I hope EMTs are trained to do this. Apple forgot to enable Siri access, “whose phone is this” works on a locked phone, but “show me Medical ID” does not. I enabled Medical ID, but my phone’s lock screen has my contact info, more importantly, my wife’s cell number as Emergency contact. That was easy to do — I filled it out in iMessage, then took a screen shot, then made the screenshot my lock screen background. I need to check that I’ve set it up for my kids.

Sharing location on an iPhone using iMessage is easy, but also a bit obscure. You need to start with an existing message thread then tap the wee “i” icon top right. Just text that at start of a ride somewhere, update if you wish. I have Find Friend enabled, so if that works my family can track me (but they tend not to think of it).

Self-assessment with a head injury is tricky. I’ve had a concussion (inline skating actually), and it doesn’t help one’s judgment. If you whack your head out in the trail you should probably call in to a friend and have them check your thought processes. You may need to ride out before you can do anything more formal (assuming you can ride!).

Good stuff.

Trump explained: Non-college white Americans now have higher middle-aged death rates than black Americans

From today’s NYT Health section:

Death Rates Rising for Middle-Aged White Americans. Gina Kolata Nov 2, 2015

… middle-aged white Americans. Unlike every other age group, unlike every other racial and ethnic group, unlike their counterparts in other rich countries, death rates in this group have been rising, not falling…

… two Princeton economists, Angus Deaton… and Anne Case. Analyzing health and mortality data from the Centers for Disease Control and Prevention and from other sources, they concluded that rising annual death rates among this group are being driven … by an epidemic of suicides and afflictions stemming from substance abuse: alcoholic liver disease and overdoses of heroin and prescription opioids…

… the declining health and fortunes of poorly educated American whites. In middle age, they are dying at such a high rate that they are increasing the death rate for the entire group of middle-aged white Americans…

… The mortality rate for whites 45 to 54 years old with no more than a high school education increased by 134 deaths per 100,000 people from 1999 to 2014.

The article falls apart a bit here. What we want to know is how the absolute death rate for non-college middle-aged white Americans in 2013 and in 1999.  We want to know how the Long Stagnation has changed vulnerable Americans, but Kolata’s article mixes all white Americans with the no-college cohort.

Fortunately the PNAS article PDF is freely available, but unfortunately it explains Kolata’s problem — the data we want seems to be buried in an unlabeled parenthesis in Table 1. From that I think I can reconstruct the key information: [1]. 

Year	White no college	Black (all)	White some college	White BA+	White All
1999	601	797	291	235	381
2013	736	582	288	178	415

For the no-college White American 1999 was a pretty good year; probably the best ever. That was the era of NASCAR America and the candidacy of GWB, champion of the “regular” white guy. Employment demand was high and wages were rising. Yes, as a white guy without any college you had a shorter lifespan than the minority of white (Americans) with a college degree, but at least black Americans were even worse off. It’s always comforting to have someone to look down on.

After 16 years of the Great Stagnation though, things are different. Suicide and substance abuse have pushed no-college white mortality to the level of 1999 black Americans, yet during the same period black American middle-aged mortality has fallen substantially. White no-college Americans are now at the bottom of the heap [1].

This is why we have the inchoate white rage that thunders through the GOP. This is why we have Donald Trump.

A large and culturally powerful part of America is in crisis. A cohort with lots of guns and a history of violence. Maybe we should pay attention. Trump is a signal.

- fn - 

[1] There was no breakdown of black death rates by education; a 2012 census report said 29% of whites and 18% of blacks had a BA or higher. Since 80%+ of black Americans have no BA it’s likely no-college whites now have higher middle-aged mortality than no-college blacks.

See also

• Gordon's Notes: Donald Trump is a sign of a healthy democracy. Really. 8/2015

Update 11/4/2015

There’s been considerable coverage of this story, but it’s been disappointing. Both DeLong and Krugman missed the college vs. no-college white middle-age cohort, and I think that’s the important story. There’s also been some discussion of anger as a defining trait of the GOP base, but no connection to the extreme distress of their core voter.

I’ve seen speculation that this is all about narcotic overuse. I find that very hard to believe, but I admit the use of narcotics for pain relief in America has exceeded my expectations. I remember in the 90s when “pain is the new vital sign” and family docs were berated for inadequate use of narcotics. I guess my peers responded well to that feedback.

It has occurred to me that there’s a potential bias we’re missing. Over the past 40 years colleges have gone from predominantly male to predominantly female. The big story here is increasing mortality in the no-college white cohort. But if there’s been a gender shift in that cohort, say from 55% female in 1999 to 45% female in 2013, that will make the no-college numbers even more dramatic. Since mortality has increased even when college grads are included this isn’t the entire story, but it will make the no-college effect more dramatic.

Capitalism, fraud and maximizing wantability

WaPo has a delightfully meta-subversive headline for an article about the failings of 21st century capitalism: This Kardashian headline shows why two Nobel winners say the economy is broken. Beneath the headline is a photograph of 3 reasonably attractive women and the hit enhancing text “Kourtney, Kim and Khloe — arrive at the Maxim Hot 100 party”.

Jeff Guo’s article proceeds to an interview with Akerloff and Shiller, reasonably well regarded academic economists, about their book Phishing for Phools. Unfortunately Guo does get around to the Kardashians, which blunts the beauty of the introduction. Still, it is a lovely bit of meta; boosting page hits for an article about how easily humans are manipulated in the interests of feeding their wants.

Shockingly, it seems capitalism does not optimize our better selves.

I’ll let that sink in a bit.

Sure, you think it’s obvious that capitalism is a system for finding local minima traps in a 3 dimensional field where demand is gravity and information technology enables complexity enables deception. If pressed to respond further you might say something like “tobacco”.

It’s not obvious to Americans though. Our culture equates wealth with virtue, and the “invisible hand” of capitalism with the “invisible hand” of a Calvinistic God. It’s an authoritian-dominance attractor in culture-space, and we’re not the only people to get stuck in it.

So this is an article worth scanning, if only as a marker for the fading glamor of the 1990s capitalist (emphases mine) …

… Economics predicts that wherever there is a profit, someone will be there to make it. To that, Akerlof and Shiller propose a corollary: Wherever there is an opportunity to profit off people’s weaknesses, someone will exploit it…

… The basic idea of this book is that there is a “phishing” equilibrium, in which if there’s a profit to be made by taking advantage of your weakness, then that will be there.

… The standard view of markets (which is subject to problems of income distribution and externalities) is that markets will deliver the best possible outcome.

… that’s what the standard graduate student is taught. It’s what you’re told to believe, and what I think most economists do believe. As long as the markets are competitive, and there are no problems of income distribution and there are no externalities, it’s going to lead to the best possible world…

… that then has acquired a moral tone, which is that whatever happens in the market is okay. And that translates, in turn, into people arguing and thinking that it’s okay to be selfish. That if I earn this income, then I in some sense deserve it.

So this view that whatever markets do is good becomes this idea that whatever markets do is right…

… Kirman tracing the origins of this idea back to the Enlightenment. He says, “laissez faire made a lot of sense against the background of monarchy and controlling church.” So this idea of freeing the markets really came through at a time when businesses were being particularly oppressed….

… Irving Fisher was a Yale economist who in 1918 wrote a book saying the free market system is maximizing something but it’s not what Jeremy Bentham, the philosopher, called utility. So he named it wantability.

I did a Google N-grams search [how often a word appears in books] for wantability. The term enjoyed some popularity in the 1920s and 1930s, then exponentially decayed. After the Reagan-Thatcher revolution the term was gone….

… the children’s candy bars were put at children’s eye level …You have professionals who are designing everything. They are designing it for wantability.

Reading this a part of me thinks I should get a Nobel just for my blog rants. Economists don’t think market solutions have local minima traps? It’s novel to think markets produce things that are bad for us? Stockholm, it’s not that hard to find my real identity. I would’t mind the money. You can give me another prize for canopy economics and eco-econ.

So this isn’t a book I’m likely to buy. It’s an interesting marker, however, of our changing attitudes towards market capitalism and for the intellectual history of our judgments from Adam Smith to Donald Trump. Twenty years of lousy economic growth (great for elite, awful for non-college) will do that. I’ll be looking for more signs of thoughtfulness …

See also

• IT and productivity - two noteworthy posts from Equitable Growth 2/2015 - good set of links to my older stuff.
• Learning from an Amazon “Newer Galaxy” fraud: I too am prey. 10/2015. Just this morning! I got caught. 

Learning from an Amazon "Newer Galaxy" fraud: I too am prey.

I’ve been digging into thunderbolt 2 lately. It’s an orphan technology — sure looks like Apple has given up on it. In retrospect either Apple or Intel needed to make their own hubs — in a low-trust world leaving this to dying 3rd party manufacturers was a mistake.

For now I’ve settled on the OWC Thunderbolt 2 dock. It’s not perfect, I still have suspicions about how it performs under load. I wouldn’t be surprised if I need to power cycle it every few days. Yeah, like I said, Apple needed to make this. I tested it next to an Elgato hub with similar USB 3 performance, the deciding feature was support for legacy firewire 800.

During the testing period I used a (too) short thunderbolt cable bundled with the Elgato, but that’s going back with the return. Due to a misunderstanding about Apple cable prices I decided to get a OWC 2m cable, but in a moment of weakness I ordered it from Amazon (Prime shipping, speed, etc).

That is, I ordered from an Amazon page that said OWC cable on it, via “Newer Galaxy Distribution Company”. The page looked like this:

Yeah, look closely, It says made by OWC and the image has OWC on it, but the page title doesn’t actually say OWC. On the other hand, the text says:

Utilizes the latest Thunderbolt chipset for high-speed 10Gb/s Thunderbolt and 20Gb/s Thunderbolt 2 devices
Enhance video workflows with support for faster 4K video transfers + 4K display capabilities via DisplayPort 1.2
1 Year OWC Limited Warranty

So I was stupid, yes, but I wasn’t completely misguided. I even inspected “Newer Galaxy”’s sales count and ratings — though I know ratings systems of this sort are almost completely fake.

Damn. I know better than this. Yes, it was Amazon Prime, but that only means the returns are easier. It doesn’t mean it’s legitimate.

This is what’s being shipped:

A “2M” cable. It’s not actually a counterfeit cable at this point, it’s just not what I ordered.

There’s an upside to this experience. I can share it here for one, and every story like this is a small push for Amazon reform. Amazon returns are very easy, and for frauds like this there’s no return postage fee. (I’ll reference this blog post in the return comments.)

For another, I’ve also learned that I’m not as good at spotting fraud as I should be — I blame that on age. The data is clear that most of us become prey after age 55 or so. Prey have to learn fear, and I’m learning.

Best of all I learned that Apple has dropped its price on 2m thunderbolt cables from $60 to $40 (that price drop is probably why trustworthy alternatives have disappeared). So I’ll do that instead.

It would be good to have a trustworthy alternative to Amazon… 

Apple blogs: please stop confusing Apple shareholders with Apple customers

Apple made bazillions again. They won’t pay corporate tax on it. The share price has gone up.

That’s good for me in one way — I own index funds that hold Apple shares. On balance when those shares go up or Apple pays dividends I get more money. Yay for me, though I’d do just as well if the money went to, say, Microsoft or Google. My index funds own their shares too. So only a little Yay.

Whatever wealth I gain or lose from a change in Apple’s share price, however, is dwarfed by the money I spend on Apple products. Three laptops (one recently expired iMac), five iPhones, Airports, Apple TV, iTunes movies and TV shows and so on. That direct cost is exceeded by the life-time I spend managing Apple’s defects, quality issues, and nastily executed strategic killings. I think on balance I come out ahead — but some days I’m not so sure. The gap is smaller than it used to be.

As an Apple shareholder I’m mildly pleased with Apple. As an Apple customer though, I’m not so pleased. The Apple Watch leaves me cold. Using data lock customer retention while killing products (yeah, Aperture) without a replacement is just bad. The iPad should have been multi-user years ago. 3D Touch isn’t worth the cost, complexity and weight. The iBook mess. The nuttiness of putting a mechanical hard drive and a very expensive display in a non-serviceable iMac. Meanwhile Apple’s traditional 20% cost premium is turning into a 40% premium.

As an Apple customer I’d like to see Apple’s share price fall 20% - as long as one of my other funds gets the value instead. A falling share price might promote interest in existing customers.

So, Apple blogs, please stop paying so much attention to Apple’s share price. It’s just not that important to me.

Quicken spending spam - alert "feature"

In my mail this morning…

During a machine transition I reinstalled Quicken 2015, so I at first thought we’d unwittingly enabled Quicken Mobile and put our finances into Intuit’s Cloud. We hadn’t, but there’s an alerting “feature” I didn’t know about that can be changed in preferences. I’ve now disabled all alerts. 

I’d prefer Intuit (current owner, but Quicken has been abandoned) not know anything about me at all. I suspect knowing about me is, unfortunately, a significant part of their failing business model.

If you don’t want this, then stay away from Intuit and Quicken.

Preventive care: what's new in the past 7 years

While studying for my 2009 American Family Medicine board exams I wrote up a summary of the American Academy of Family Practice’s preventive care recommendations. For this November’s exam I updated my old notes, so I got to see what’s changed with preventive care over the past 7 years.

There are more listings now, but most of the additions are recommendations not to do anything. HPV and cervical cancer screening recommendations still don’t consider immunization status. Screening for diabetes in pregnancy was removed in 2008 (though everyone would still do it) but it’s back in 2015. Hep C screening is recommended for at risk or born 1945-65; that’s because we have decent treatments now. I was a bit surprised that HIV screening is now recommended for everyone age 18-65 — though the screening interval is murky. Screening used to be limited to higher risk populations.

Lung cancer went from “don’t screen” to equivocal, but PSA (prostate specific antigen) went from equivocal to “don’t screen” (remember when every senior guy needed that?).

And … that’s about it. Based on the news this week mammogram screening will be further reduced but that’s not part of the official recommendations yet.

Not a lot of change.

London

This year has been a different year. By circumstance not of my choosing, but not displeasing, I’ve more personal time than usual, but also, for a time, income. So each of our children got to pick a trip with Dad. My 13yo daughter, #3, chose London. 

I was thinking Chicago, or perhaps Manhattan, but she was being mischievous, so London it was. We spent six days touring the city. By the city I don’t mean only “Zone 1”, the city of Old London and West London, but all the way out to Zone 3 and 4 — we stayed in an Airbnb in Mitcham, an utterly unremarkable bit of the megacity sprawl about 25 minutes of overground south of Blackfriars station. For my own reason I’m going to make a few notes about our experience, but these must be hasty notes. Life spins on. So they will be roughly sectioned, and made of bullets rather than paragraphs. There are two parts - impressions of the city and practicalities of modern travel.

Impressions of the City (mostly my surprises)

Emily and I spent a day or two in London about 30 years ago. That’s almost halfway to post-war London, though we didn’t think of it that way. I didn’t know much about the city, we basically visited a museum or two.

This time I was better prepared. I purchased a Great Courses (Teaching Company) audiobook course on the the History of London. It was superb; the device of replaying walks through London of various times guided our travel. My favorite travel book was Fromer’s London Free and Dirt Cheap, and my favorite map was an old map once published by London Transport, the “London Map”. It's now a secret but still available from Visit Britain. I had difficulty finding a good map of London, the era of paper maps is passing quickly. I think it is also true that the scope of London is a challenge to map makers.

It took me some time to grasp the scope of London. Guide books and most descriptions fail here. London is a mega-sprawl like Atlanta, but unlike Atlanta it has a central Core. The Core, better known as Zone 1, is morphing from a place where people live and work and visit to a place where people work and visit — but do not live. Zone 1 is a kind of urban singularity — bending light and threatening to fall out of the scope of normal human interaction. The expenses of operating there are pushing food and recreating prices out of the scope of most humans, but it still defies gravity. Last year was another record breaking visitor year. Older museums remain free — but that accessibility seems to be at risk. Newer museums, and even some older ones like the Monument (to the Great Fire) charge high fees. On the other hand perhaps part of London’s modern attraction is the opportunity to watch the wealthy at play, a kind of zoo for bankers and billionaires.

London has some attractive and charming areas — we visited many of those. I think it has less than many European cities though, probably less than Leeds. It is a city of power and commerce, thrusting and urgent. The 19th century swept away much of old London, rebuilding in a confusing array of faux-oldness that recalls the changes of modern Beijing. WW II destroyed a lot, and rebuilding was rough. A bit, as is often noted, like the rapid reconstruction after the Great Fire. For a city with a lot of history London has some of the ahistoric callousness of Los Angeles.

Happily, London is also a city of vanity and show. We only walked through the theater district, but we did visit most of the “great” museums. No irony in those quotes, they are everything they claim to be. (Note to British Museum — please get some local banker to cough up 50 million quid so you can affix an artist’s picture of what the artifacts would have looked like with paint and context. Also, London’s Chinatown rarely gets a mention, but it has great food in the midst of the theaters.)

I’d read that London real estate was emptying out — that empty rooms are traded by billionaire speculators who want a bolt hole or a spot to stay when doing business. That felt true, but also lazy. This is true of Zone 1, which is not so large, and, I suppose, bits of Zone 2. There’s a lot of London where billionaires don’t go. We stayed in one of those parts, and traveled far East to visit the Dr Who Shop in another. (Our itinerary was largely set by my daughter, with a focus on Dr Who and Harry Potter and a bit of Sherlock. And shops — especially museum shops.)

This wasn’t our original plan, but I wanted to stay in a quieter place where we could visit grocery stores and save money and sanity by making our own breakfast and dinner. That meant Airbnb, and thanks to a bit of a mixup of mine we ended up in an utterly generic and relatively distant part of the London of Ordinary People. A place of vast sprawls of narrow homes and many languages — our particular area seemed to specialize in blue collar English, Poles and other Slavs, and 3rd generation south Asian. A similar region out East was more Islamic. Learning our residential neighborhood was one of the more remarkable parts of the visit. I think by British standards these are somewhat scary neighborhoods, but we are urban Americans. They are benign by our standards.

Londoners smoke. This really surprised me. Americans don’t smoke, particularly after teenage years. I felt like I’d taken a Tardis back to my childhood — adults of all ages smoking in the streets, but at least not indoors. My daughter was shocked. I wondered if part of this came from migration from cultures were smoking is widely accepted, but I feel it’s also a part of local culture — much as cocaine use was part of 1970s America. The urban air quality is also poor by our standards. 

Other surprises — how car-centric London is. Capacity pricing works, so the cars do flow, but they flow at full capacity all the time. Which is, really, a triumph of the market. A market triumph with an unintended consequence; a city full of wealthy drivers who pay heavily to drive is a city that will be utterly dominated by the car. I’d gotten a hint of this from reading a London Bicycling blog, but it was still a surprise given London’s reputation as a walking city. We walked 8-12 miles every day, and the streets are very crowded with walkers even in the off-season, but all of us pedestrians are second class. There are no crosswalk laws (de jure or de facto) — one crosses if a car allows or between gaps in cars. The city is not friendly to the weak — walkers need to move quickly and be alert.

The transit system does it’s part to screen out the unfit — “mind the gap” is a serious warning. Getting on and off the tube is similar to boarding a bus or train — only a few places can handle a wheelchair. Many tube stations work on escalators or stairs alone. There is nothing like the American accommodations for disability, even the much weaker Canadian accommodations.

Despite all of this, there are many cyclists. They are, however, serious commuter cyclists. With the exception of a few suicidal tourists on Santander cycles they are fast and fit cyclists wearing high visibility clothing and moving, when possible, in coordinated packs. There is no room to pass, bicycle commuting in London is a blood sport. Aside from a dull path through Hyde Park we saw no protected bicycle lanes — nothing like our home town of St Paul, much less Minneapolis, much much less Munich. They ride, I presume, because there are many transit advantages to London bike commuting, and because traffic often moves at the speed of a fast and fit cyclist.

London is much less safety conscious than an American city (perhaps our safety fetish is a response to our violent culture?). We are used to doors that open outwards for fire exit, in London doors open in and out. Some tube stations would be death traps in an emergency. The cars move slowly but implacably. The infrastructure is a mix of expensive deluxe (Heathrow Express from Paddington is a touch of wealth) and less-expensive-but-still-not-affordable rickety. Google Maps was brilliant at rerouting around broken underground links — the London transit network needs its switching redundancy.

Incidentally, some of the core attractions in London are effectively unavailable to normal people. My daughter wanted to do High Tea at the Ritz — but those tickets appear to be entirely purchased 6 months out, presumably by hotels. Same thing with theater tickets — I think if you want do theater you need to queue at Leicester square for the last minute openings. We did our High Tea at Fortnum and Mason instead — which worked well. 

Practical and Geeky Things I learned (in bullet points, because geeky)

• Google Maps for iOS and web are magical. I knew that, but in London, particular given our remote Airbnb residence, we depended very much on Google maps and ThamesLink.app. From ThamesLink we reviewed “overground” trains from Tooting station to Blackfriars, then used Google to evaluate transit options at various times or on the fly. When creating walking tours we could add point-to-point direction and have Google pick interesting routing and show us geographically related transit options. It’s not quite perfect — I’d like to be able to mix transit and foot connections when plotting routes — but it is a kind of magic only the old can appreciate.
   
• I thought we’d put in a SIM card and connect to London’s GSM network. Our hosts picked up a set of SIM cards for us to try, but I discovered that we couldn’t activate online them with an American credit card. We’d have had to visit something like a Carphone Warehouse and buy a GB there, or perhaps pick up a card at Heathrow. Instead we used AT&T’s Passport option. At roughly 0.25/mb it’s not cheap, but that’s nothing compared to London transit costs — and we didn’t feel like spending an hour getting kitted out. I locked down cellular use and turned on Data Roaming only when needed - usually for a Google Maps consult. The museums often have quite good WiFi, in the end our data costs were modest. London has some sort of citywide WiFi but it never worked for us, it’s just a source of interference. I found i was getting low speed 3G data until I allowed a Carrier Profile update; after that I had LTE. (There’s more complexity with GSM swaps than most of us imagine. I see why smart people don’t swap GSM cards but instead purchase a mobile hotspot device and swap cards in that.)
• Google Drive kind of sucks if you don’t have a constant data connection. It’s very awkward to force documents to be locally stored on an iPhone. I’m migrating to Dropbox for a variety of reasons, but for this trip I’d plot out our walking plans on my laptop using our Airbnb host’s excellent data connection, then print with maps to PDF in Google Drive, then on my iPhone I’d migrate the PDF to iBooks. Awkward, but it worked.
• I mentioned listening to the Great Course on London history (hint: much cheaper to buy via iTunes from Audible than from Teaching Company). I wish I’d created a short reference outline of English history in Simplenote that I could hang things off of. A list of key London events, related rulers, etc.
• We traveled with my 2015 MacBook Air (non-Retina and I love it), two iPhones and one iPad. Instead of hassling with lots of chargers I brought a 5 device charger (Anker makes good ones), a single UK plug adapter, and a simple 3 outlet extension cord. Worked perfectly. (Of course voltage adapters are no longer needed, with a few exceptions modern devices switch between 110/200 automatically.)
• I’ve had my issues in the past with Airbnb, but this time it seems to have worked out well. Airbnb encourages use of their system for communication between host and guest, but I wasn’t getting much in the way of responses that way. Once I started using direct SMS/iMessage instead the problem resolved. Young folk don’t do email.
• London is a city of Apps. Apps for transit, Apps for museums, etc. Pick up a few. I wish I’d tried History Pin.app or Localscope.app (or the equivalent) but I more or less forgot I had them.

Managing the TBs of videos and photos the kids produce

The kids generate a lot of images and video. Some of it I want to keep, other material is of temporary interest (instagram shares mostly), a lot of it is accumulated because, for them, storage is free. Meanwhile we’re overflowing our backup capacity — I just bought an 8TB Synology to replace a defective Time Capsule (4TB RAID 1)

The new policy is I put the media into dated folders on the server share. I quickly review my daughter’s images for things to add to our family archive (in Aperture, and, yes, I hate Apple). The kids have until the date on the folders to review the images for anything they want to keep. After that date I delete them.

I wonder what others do with this torrent of media. I suspect it just gets lost. There is a reason Apple gave up on Aperture — the entire market for amateur photo (much less video) management seems to be dying. Reminds me of the passing of personal finance software.

The "Paperless billing was requested" (minor) scam -- AT&T edition

I got this AT&T text message the other day...

Except, of course, I never requested paperless billing. I suppose I should have for purely ecological reasons, but Emily prefers the paper copy. It’s her workflow — and modern email is unreliable for many people (flow control is the big issue).

I suspect this was a side-effect of some minor service agreement, like accepting AT&T’s recent (unexpected) increase in our mobile share data allowance. AT&T is showing a bit of its old dirty tricks here (they are generally much reformed), especially the requirement to correct this by (ugh) making an (ugh) phone call.

I will probably accept this one — it feels like a battle not worth fighting. AT&T isn’t alone in this sort of thing, corporations have become quite clever at tricking customers into accepting paperless billing — without, say, offering to share the savings.

The eBook is dying. I'm the only person on earth who blames the DRM.

My main workaround for eBook misery has been to buy from Google Play, strip the Adobe DRM, and store the ePub (really should be written EPUB but nobody does that) files in folders in Google Drive.

I do this because Apple is incompetent and, among other things, can’t produce a workable iOS eBook reader (Wait, audiobooks are now worse). A set of folders and descriptive file names is the most scalable solution we can manage across iOS and OS X. Yeah, I could leave Apple — if I cut off my right arm. Apple and Google live and breathe customer lock-in, and i’m well locked.

Since iOS 9 and some Google Drive update this no longer works. It still works for dropbox, so this is probably Google’s fault.

Nonetheless, it makes eBooks suck even more. 

Which brings me to those recent articles pointing out that people now buy paper books, not eBooks. I’ve read explanations ranging from mystical beauties of paper to the high cost of digital books. Nobody mentions the DRM (FairPlay, Adobe, etc) and the data lock, including proprietary file formats, that block development of decent cross-platform eBook solutions.

I feel like a raving loon. Or like the sighted man in the country of the blind ranting about the approaching lava flow.

Damnit Jim, it’s the DRM. 

How data lock destroys the customer experience - Apple edition.

But for FairPlay, I would not use iOS 9 audiobooks. I wouldn’t swear every time it loses its place. I wouldn’t be pissed at Apple.

But for proprietary data formats I would not use Apple Aperture. I wouldn’t be pissed at Apple.

And so on.

Rheumatic syndromes remind me of pre-quark particle physics

This mornings board review included looking at the evolution of “inflammatory osteoarthritis” from 1970 to 2015. What was once described as an acute “inflammatory” (suddenly red and painful) form of osteoarthritis was later reformulated as “erosive osteoarthritis”, “psoriatic arthritis” and some vaguely described disorder that gradually morphs from osteoarthritis to rheumatoid arthritis — not to be confused with seronegative arthritis.

Bah. Humbug. It’s as bad as our mushy and obsolete classifications of neuropsychiatric disorders.

Unlike the neuropsychiatric disorders (autism, schizophrenia, etc) though, the rheumatic syndromes remind me of pre-quark partial physics. Lots and lots of fermions (neutrons, protons, etc etc) with mysterious distinctions; understanding the composing quarks brought a sort of sense to the world. Perhaps one day we’ll learn that seemingly distinct rheumatic syndromes are combinations of underlying simpler pathologies that in different contexts (microbiome, immune system etc) seem to make up different disorders...

Ok, not a great analogy. Just a thought. Classifications are powerful though, and that means they can be misleading — and harmful.

Update: On a quick literature scan it looks like psoriatic arthritis treatments (TNF inhibitors) haven’t worked that well for erosive osteoarthritis, which does suggest that inflammatory arthritis split is clinically meaningful...