There’s been at least a 200-300% increase in care complexity between when I started medical practice and today. Many new classes of medications for fairly common disorders, many more specialty interventions that may be considered.
At the same time computer based clinical decision support systems have been a surprising failure. (Emily uses Epic, I use VistA/CPRS). In the 90s we expected far more than we actually got.
We are asking a lot of the modern primary care physician.
I ordered the Greenlight cards for our children. Only one is a minor (and she uses a regular debit card) but two are special needs adults who are more vulnerable to financial scams or misjudgments. I also got one for a sibling with some similar issues though that is certainly not the Greenlight market.
So far it’s been a mixed experience. The Greenlight site has suprisingly poor documentation — basically some simplistic FAQs. They don’t document where the cards don’t work but from customer support I got:
Since our cards are meant for children, there are certain places that our cards will not work. Liquor stores, gambling websites or establishments, money orders, MoneySend and wire transfers are some examples of things that our cards will not work for. Since we are a prepaid debit card, we have also had families experience some trouble when attempting to use our cards to pay bills. We recommend not transferring funds to the Greenlight card that need to be used for utilities or other bills.
That seems reasonably, but it’s not the complete list. They don’t work for Patreon for example — my son wanted to donate there. Greenlight won’t provide a full list.
There’s also a problem with Greenlight.app behavior on one child’s phone. Again, this is undocumented, but I think there are two paths it should follow on launch. One path should enable access to card balance, the other is for requesting a card. On his phone it goes down the wrong path. Hard to sort out since, again, there’s no documentation.
The vibe I get from Greenlight is that is a venture funded effort that didn’t scale quickly enough …
My son bought me a slim book on rock climbing techniques. Rock climbing was my brother Brian’s gig, but I could see doing it when my knees knock me out of CrossFit. It’s something I did in college back when we belayed using ropes wrapped around our body (no belay hardware).
The book talks about single finger pinch holds. Specifically, it says not to try them until at least two years of building up tendons and ligaments.
Two years is a fair amount of time. I’ve not seen that mentioned in any clinical references I read. I suspect it’s right though; it’s obvious muscles can develop much faster than tendons.
I think we should be more aware of this in CrossFit training. Young muscles develop fast, but ligaments and tendons take time. To lift heavy things safely we need connective tissue to be at least as strong as muscles (ideally stronger).
In my 60th year I lift significantly heavier things than I did when I was younger-Old. Probably heavier than I could have done in my mid 30s. My muscles are somewhat stronger, but I think a lot of that is connective tissue development, and that took years. More than two years for Olds I think.
Robert F Kennedy Jr showed up in a scrum of pro-measles whackos recently. It me wonder how he got so nuts.
There’s an extensive wikipedia page for him, starting with a time I remember:
He was 9 years old when his uncle, President John F. Kennedy, was assassinated during a political trip to Dallas, and 14 years old when his father was assassinated…
Despite childhood tragedy he was a successful academic and he’s done some decent work legally and for the environment. He seems to have started off the rails in the 80s:
In 1983, at age 29, Kennedy was arrested in a Rapid City, South Dakota airport for heroin possession after a search of his carry-on bag uncovered the drug, following a near overdose in flight.
By 1989 he’d started on vaccines — but not with autism …
His son Conor suffers from anaphylaxis peanut allergies. Kennedy wrote the foreword to The Peanut Allergy Epidemic, in which he and the authors link increasing food allergies in children to certain vaccines that were approved beginning in 1989
By 2000s he’d jumped from immunizations causing his son’s anaphylactic disorder to immunization causing autism. He became "chairman of “World Mercury Project” (WMP), an advocacy group that focuses on the perceived issue of mercury, in industry and medicine, especially the ethylmercury compound thimerosal in vaccines”. It was a downward spiral from there.
Despite his vaccine delusions and troubled marriages he seems to have maintained a fairly active wealthy person life. He’s said to be a good whitewater kayaker.
Psychiatrically it’s curious. He combines fixed irrational beliefs (the definition of delusions) with relatively high functioning in other domains. He reminds me of L Ron Hubbard, founder of Scientology.
We need to keep him far from the political world.
I am a strong-AI pessimist. I think by 2100 we’ll be in range of sentient AIs that vastly exceed human cognitive abilities (“skynet”). Superhuman-AI has long been my favorite answer to the Fermi Paradox (see also); an inevitable product of all technological civilizations that ends interest in touring the galaxy.
I periodically read essays claiming superhuman-AI is silly, but the justifications are typically nonsensical or theological (soul-equivalents needed).
So I tried to come up with some valid reasons to be reassured. Here’s my list:
My list doesn’t make superhuman-AI impossible of course, it just means we might be a bit further away, closer to 300 years than 80 years. Long enough that my children might escape.
I haven’t written recently about why Crisis 2016, sometimes called Crisis-T, happened. For that matter, why Brexit. My last takes were in 2016 …
How has my thinking changed two years later? Now I’d add a couple of tweaks, especially the way quirks of America’s constitution amplified the crisis. Today’s breakdown:
That 1% for Facebook et all is pretty small — but the election of 2016 was on the knife’s edge. That 1% was historically important.
Rupert Murdoch will finally die, though his malignant empire will grind on for a time. Patriarchy can’t fall forever, eventually that process is done. We now understand the risks of Facebook and its like and those will be managed. So there’s hope.
But the crisis of the white non-college will continue and our constitution will continue to amplify that bloc’s political power in rural areas. Even if civilization wins in 2020 the crisis of 2016 will continue. It will test human societies for decades to come.
In 2018 I met one of my two CrossFit Life Goals (tm) - 10 consecutive dubs (hit 42 in a wild fluke the other day). Only took me five times as long as anyone else I know.
The other goal is the Kipping Bar Muscle-Up. So that’s on the list for 2019. I’m also planning an IMBA “Epic” mountain bike trek — the Maah Daah Hey, but that’s mostly about showing up and moving my feet. The Bar Muscle-Up may be impossible, so it’s more interesting. (Watching Paoli video I should be able to do it now [1], but that’s now what I’m feeling!)
I’m putting my training notes and references on this page.
Examples
Movement notes
Some of the best tips came from a post in the CrossFit Physicians Facebook group.
For the pull up & over the bar. Pick a spot on the floor in front of you. Your goal is to stare at that spot all through the first part of the kip and the initiation of the transition into the hollow position & first part of the pull. At some point, as you pull your hips up to the bar, you're going to lose that spot from your vision (it's unavoidable - the head tilts backwards), but your goal is to see that spot again as soon as possible. The instant you don't see the spot anymore, your sole focus is to find it again. This will help you with the speed necessary to execute the transition. Actionable cue: "find the spot".
Training programs
Some of these are for the (ring) muscle-up, the bar muscle-up is considered to be harder
Training exercises
[1] Well, not now exactly. My left biceps is strained, so I have to rehab that first.
Update 2/3/2020
I posted the first version of this on Dec 27, 2018 and I succeeded on Feb 3, 2020.
It took me over 13 months. At one point, probably June 2018, I bet my 17yo daughter I’d get it done by my 60th birthday on Aug 1 2018. If I’d succeeded she owed my $10. If I failed, I would pay her college.
Emily and I are paying her college.
In August 2018 I was feeling kind of bleh and this looked impossible. To my surprise I started to recover in October and have been getting stronger over the past 5-6 months. Maybe the protein and creatine shakes helped. I also started doing more CrossFit for weird (but good) family reasons — 4-6 a week instead of 3-4 a week.
I didn’t end up following any of the programs above. I just worked on pull-ups whenever I could and I practiced with bands. I could do BMUs with a “green and blue” (green is BIG), then the sequence went like this (typically 3 at a time, the first is usually hardest):
- 1/9/2020: single black band 3 consecutive
- 1/20/20: red and blue then thin red, orange, blue
- 1/22: blue+thin red+orange
- 1/29: blue and 1 orange
- 2/3/20: During a “max MU in 4 minutes” WOD I started with blue, red, and orange bands and in about 4 sets of 3 I dropped bands until I did 3 with two thin orange bands and then one with no bands. When I actually succeeded it didn’t seem that hard. Timing is key.
The most useful advice I was given was "wrap your hands as far over the bar as possible. It's basically a 'false grip' maneuver that you've probably seen on the rings, just on the bar.” I didn’t really understand it at first, but it means having wrists above the bar when you start. I had note understood how hard I had to grip the bar and lever myself up.
I hope I do more, but in terms of my goal I only had to do one.
I didn’t know Sir William personally, but I think he’d be appalled by the descriptions of patient-disorders in our medical textbooks.
We typically present a collection of findings, sometimes organized by ‘history’ or ‘physical’ or ‘lab’, but the sequencing and relationships are all lost.
We should have textbooks that describe a disease or disorder with 3-8 case histories that span a reasonable spectrum of presentations. So not x% have red eyes and y% have chest ache, but a case called “common” that might be “8 yo both with cough, then red eyes for day and a swollen lymph node, then a day later some red palms …” and another case called “often”, and 2-3 called “unusual1”, “unusual2”, and so on.
Ok, it’s not just my Oldness. I’ve been grumpy about this for roughly 25 years, even when I was only old in spirit. It annoys me a great deal.
Now I’ve said it.
We’ve been using Quicken for Mac for the past year. I’m satisfied with the software, but I no longer trust their pricing and renewal.
We paid $60 for Quicken for Mac 2015 on 7/31/2015. On 1/8/2017 we paid $48.41, presumably for 1 year of subscription service. On 12/31/2017 we paid $32.35; we probably switched from a “deluxe” plan to a basic plan.
Today I received an email requesting renewal:
Your Quicken membership will expire on 12/31/2018. In order to continue enjoying all of the benefits of Quicken, including connected services such as bank downloads, stock price updates, account sync, and free phone support, please click here to renew your plan.
The link goes, however, to Quicken for Windows where we are shown as “deluxe” plan for $50.
Ok, so that’s presumably a mistake — albeit a bad mistake. When I go to https://www.quicken.com/mac/compare I can see the Mac plans - Starter at $35 (so probably a 15% price hike from last year) and “most popular” Deluxe for $50. I can’t compare to last year but it looks like most of the features added in the past year or so require the “deluxe” option now.
Which leads me to reconsider my previously relatively positive attitude towards software subscriptions.
I’ve been generally in favor of subscription pricing for software. I think Microsoft has done a great job with Office 365. It does, however, come with temptations for vendors. Subscription pricing makes it too easy to hide price increases and game features. It promotes “information asymmetry”.
I think Quicken has fallen for that trap.
I don’t trust them now.
We are evaluating options.
Amazon reviews have long been helpful to me, and were once a big part of Amazon’s value proposition.
That is no longer true. Amazon is filtering out negative reviews.
I learned this after attempting to review Anker bluetooth earbuds I bought for Emily’s birthday. The power switch was defective. That wasn’t a complete surprise, I have a similar pair and I often have to push 2 or 3 times. Anker should have spent another 10 cents on that part.
Amazon made the return easy, but when I tried to write a review I got this notice:
“Sorry we are unable to accept reviews for this product …”
I then switched to Emily’s account. There I was at able to start a review, and even able to give in a two star overall rating. When I clicked 1 star for material quality however the “unable to accept reviews” notification appeared:
This is, of course, worse than if Amazon removed all product reviews. They are promoting systemic bias in their closed world. The Fox model is catching on elsewhere, Apple is doing something similar with the Mac App store.
A week ago, in a Facebook group for CrossFit physicians, I read a post blaming poor parenting (i.e., poor mothering) for childhood obesity.
There and elsewhere I read confident statements on nutrition. I read confident statements about market movements (usually retrospective) and white men.
I always imagine these confident people are young, but I believe that is not always true.
There are likely things. There is entropy and death (but also the inexplicably low entropy of the early universe, and it is possible for an Old person to be stronger than they were in middle age).
Most things though, they are … complicated. They are some of this and some of that. If you cannot imagine a worse outcome than an obese child you have not opened your eyes enough, or lived long enough for the world to pin your eyelids back and burn reality into your retina.
Look for the Old of any age. Some have something that might be wisdom. Ask them about certainty.
There’s a nasty flaw in Minnesota’s vote by mail process.
When you apply for a mail ballot you are asked to provider either a SSN last 4 or License number or State ID number.
When you complete the ballot you are asked to provider either a SSN last 4 or License number or State ID number.
The two numbers have to match or the ballot will be rejected.
Hope you remember if you used your MN License number or your SSN Last 4 on the ballot application.
I tried testing for the identifier I used by querying my absentee ballot status, but it found the same status regardless of which identifier I used.
First came CHIP - Clonal hematopoiesis of indeterminate potential (Jan 2018)
… a bizarre accumulation of mutated stem cells in bone marrow increases a person’s risk of dying within a decade, usually from a heart attack or stroke, by 40 or 50 percent. They named the condition with medical jargon: clonal hematopoiesis of indeterminate potential…
… Up to 20 percent of people in their 60s have it, and perhaps 50 percent of those in their 80s …… large numbers of study participants had blood cells with mutations linked to leukemia — but they did not have the cancer. Instead, they had just one or two of the cluster of mutations…
… [mutations], especially those linked to leukemia, seem to give stem cells a new ability to accumulate in the marrow. The result is a sort of survival of the fittest, or fastest growing, stem cells in the marrow…
… researchers described a 115-year-old woman. Nearly her entire supply of white blood cells was generated by mutated stem cells in her bone marrow.
At the first she had developed just two mutated stem cells. But over time their progeny came to dominate her bone marrow. She lived about as long as a human can, nonetheless, and died of a tumor.
… Mutated blood cells began proliferating in the mice, and they developed rapidly growing plaques that were burning with inflammation.
“For decades people have worked on inflammation as a cause of atherosclerosis,” Dr. Ebert said. “But it was not clear what initiated the inflammation.”
Now there is a possible explanation — and, Dr. Ebert said, it raises the possibility that CHIP may be involved in other inflammatory diseases, like arthritis.
That was mindboggling. An entirely new mechanism of disease! It’s easy to speculate on relationships to unexplained disorders like osteoarthritis.
This week the clones are everywhere …
Researchers Explore a Cancer Paradox Oct 2018
… a large portion of the cells in healthy people carry far more mutations than expected, including some mutations thought to be the prime drivers of cancer…
… rogue cells spread out across the esophagus, forming colonies of mutant cells, known as clones. Although these clones aren’t cancer, they do exhibit one of cancer’s hallmarks: rapid growth.
“These mutant clones colonize more than half of your esophagus by middle age” …
… By examining the mutations, the researchers were able to rule out external causes for them, like tobacco smoke or alcohol. Instead, the mutations seem to have arisen through ordinary aging. As the cells divided over and over again, their DNA sometimes was damaged. In other words, the rise of these mutations may just be an intrinsic part of getting older…
It’s been a long time since we’ve had an entirely new class of pathophysiology. We may be entering a new and exciting era of medical research with near term clinical implications. Nobel prizes have been awarded for less.
Six years ago I wrote about browsing the blog blacklist and the need to resurface content from old blog postings. Today, even in the supposed twilight of blogs [1], I was again reminded how much we need a tool for excavation of old posts. I can think of at least one way do it (standard metadata for blog history, random selection of past posts based on internal and external inbound links) but there are probably several.
Maybe something for a future blog renaissance to tackle. Or if Feedbin is looking for a new feature set …
- fn -
[1] On the one hand I accept that RSS and blogs are vanishing, on the other my Feedbin stream is a rich and engrossing as ever, covering hundreds of sources.
The hamstrings (biceps fermoris, semitendonosis, semimembranosus, some include adductor magnus) flex the knee and extend the hip. The erector spinae and latissimus dorsi flex, extend and rotate the spine [1].
These muscles don’t directly connect with one another. They are innervated by different nerve roots. As far as we know [2] they only connect in the brain.
So it’s curious to observe the connection between the minor back strains I get [3] and my hamstrings. I normally have a good hamstring stretch for my age, but even a minor erector spinae strain will immediately tighten the ipsilateral (same side) hamstring. Improving the back strain is likewise intimately related to stretching the hamstring.
I presume it’s some kind of injury reflex, but I can’t figure out why it’s adaptive.
—
[1] Kudos to my all-time favorite medical app, Visible Body’s Human Anatomy Atlas.app, for helping me visualize these areas. It takes a while to learn this powerful app, but it’s worth the time.
[2] Decades after we thought we understood anatomy we keep learning new things. So who knows :-)?
[3] There’s a personal history here. I have been mildly surprised how little this history interests other people — including people with disabling back pain. The back strains I get now are more annoying than painful; they are usually related to heavy weights and intense exercise.
