Alto’s Odyssey

The sequel to my favorite iOS game came out last week. Alto’s Adventure, which came out in 2015, was a snow-boarding-themed endless runner that has remained the iPhone’s best meditation app for several years.

I’ve been playing the new sequel Alto’s Odyssey since it came out last week, and it builds on the original to deliver an outstanding sequel. It’s sandboarding instead of snowboarding, so the ambiance is freshened, and there are several new gameplay elements including bouncing hot air balloons and canyon wall-grinding. But most of all, there is still an incredible attention to detail with countless little design touches that are, frankly, delightful coupled with another fantastic relaxing soundtrack. It’s awesome.

Focused Nonchalance

Focused nonchalance is, I believe, the ideal attitude to cultivate when preparing for and taking a high-stakes exam.

While much much easier said than done, the goal of attitudinal preparation is to strive for a state of flow when answering multiple-choice questions: focused and potentially even joyful as you take an exam, marshaling all of your cognitive resources without falling prey to anxiety and self-doubt.

Flow, the now widely-phenomenon phenomena akin to being in “the zone,” was first described in the 90s by the prominent psychologist Mihaly Csikszentmihalyi in Flow: The Psychology of Optimal Experience:

In normal life, we keep interrupting what we do with doubts and questions. ‘Why am I doing this? Should I perhaps be doing something else?’ Repeatedly we question the necessity of our actions, and evaluate critically the reasons for carrying them out. But in flow there is no need to reflect, because the action carries us forward as if by magic.

While the optimal experience and apparent effortlessness of flow as it is most popularly described is probably out of the reach most students taking a multiple-choice test, my point in this discussion is to state firmly that achieving focused nonchalance or even a flow state is not dependent on your actual test-taking skills and prowess or the fraction of questions you get right easily, but is instead a reflection of your attitude and preparation. (Don’t get me wrong, if you always do well on exams and are a natural narcissist, this will likely all come easier). Csikszentmihalyi never argued that flow necessarily meant you were doing awesome; even in the title, he suggests that flow leads to an optimal experience. Nonetheless, that optimal experience goes a long way on a long and stressful examination.


Hitting the Wall

Many people who put in a considerable study effort eventually hit a score wall or plateau where more and more effort seems to yield minimal or even worsening score results.

Your specific goal, whatever it is, is awesome and I hope you get it, but you also need to realize that goals are only helpful as a means of motivation, not something to tie your entire self-worth into. Otherwise, the wall is crippling. A friend’s performance, peoples’ forum posts—absolutely none of that matters.

Putting aside the reality that people presumably do have a natural maximum performance range and the fact that the tendency to focus on learning fringe esoterica is unlikely to pay dividends test by test, I think a significant fraction of the mutable wall comes from two places: overthinking and fatigue.



Overthinking a question is a symptom of underconfidence. When you overthink and question yourself it’s because on some level you believe that you are insufficiently prepared to determine which facts are critical within the information provided to derive a correct answer. Therefore you start searching for hidden clues to avoid making a “silly” mistake.

The solution is to believe that at any point you are as prepared as you can reasonably be and that you should use the skills you have at that moment to answer to the best of your actual ability. Going hunting or dowsing for tricks isn’t going to help you if you don’t really know what it is you’re looking for.

The components of a question that matter to you only matter because you actually know what to do with them and what they signify. If you change your answer from what you would otherwise pick due to a hunch, you’re guessing. If you want or need to guess that’s fine, everyone does with some frequency, but then guess happily and move on. However, changing what you believe is the best answer just because you wonder if some detail might make a difference but aren’t sure is unlikely to consistently lead to better results.

Overthinking and dumb mistakes are actually two sides of the same coin: one tends to happen when you try to prevent the other. So you oscillate back and forth, even from question to question within a single block. When you check your answers, either in a tutor mode scenario or at the end of a block, the questions you get wrong are a head-slapping frustration-fest instead of learning opportunities.

This frustration is (naturally) compounded by being emotionally invested in your performance. This is why you need to believe that you’re going to do as well as you can. Agony helps no one.

When you’re stumped by a question, the answer isn’t to be sad or angry at yourself. The response should be, “Ah, here’s one of those irritating questions that I’m designed to get wrong. Time to narrow down as possible, guess, and move on.” Even if you know that you used to know the answer, you’re still human.

Your job isn’t to get the all the questions right; that’s an outcome you can’t control. Your actual job is to take each question individually, apply your knowledge and reasoning to it, and pick what you feel is the most likely answer.


Guess. Guess again. Guess better.

When you’re down to two choices, try to see if one answer might feel more right. Often, you will like one answer better but won’t be able to “rule out” a second choice. This second choice sometimes seems like it could be correct. Most high stakes exams including the USMLE use a “single best answer” format. This means that other answers don’t all have to be wrong, just that one of them stands out as better (i.e. “the best”). You don’t technically have to know the right answer, you just have to pick it.

Medical school sadly may not contribute very much to your 10,000 hours toward becoming a great doctor as Malcolm Gladwell popularized in Outliers. But it does give you a lot of mileage on the goal of being a great MCQ test taker.

So, the ability to instinctively and comfortably guess the correct choice is another reason to do tons and tons of practice questions from a reputable source. You can develop your innate question sense by practicing and practicing. Using low-budget or alternative questions can be a bit dangerous, as some of these resources over-test minutia or try to trick you in ways that are not typical of the real USMLE.


There’s wrong, and then there’s wrong

I remember that when I’d get questions wrong on UWorld, a lot of the time I would say, “oh wait, that doesn’t count, I knew that one.” But the fact is that there is more than one way to get a question wrong. Most people think of really being “wrong” when they’re totally clueless, but that typically makes up a minority of cases. Many times you will actually know (or tell yourself you “know”) the fact being tested even when you get it wrong in question format. Doing questions means continuing to pair up facts with answers, and it takes time.

One of the difficulties many of my former students had with studying through questions is that getting questions wrong is demoralizing. Again, the bottom line is that when you’re studying over the long term with UW or any qbank, your goal isn’t to get questions right; your goal is to learn. There’s almost as much to learn from the questions you answer correctly as the ones you get wrong.


Building the Routine

As you get closer to game day, however, the need for simulation outshines the learning benefit of savoring each question in a pressure-free study session between looking at Instagram stories. Taking several blocks in succession and not being able to check answers or take large breaks is mentally different than normal studying. The difficult questions wear on you, shake your confidence, and, psychologically, it’s hard to maintain peak performance and concentration. What you want is to achieve Flow but what you are is nervous and miserable (even on a practice NBME).

Athletes train in similar circumstances as their competitions so that they don’t get nervous on game day. Wholehearted simulation is key. I am generally a huge proponent of tutor mode, but this does mean that as you get closer to test day you want to fix your habits and strain your test muscles so that the big day is just another day:

2 weeks out at the minimum is when you want to get your sleep and other habits in line. But being mindful of your daily practices should start now. You’ll need to start doing test mode and doing two or three block chunks in a row so that you get used to working long stretches.

Never forget that the real thing can really feel terrible. It’s long and you never get any positive reinforcement. The questions you had to guess on will weigh heavily in your mind. This is all test psychology. How it feels doesn’t actually need to matter; chances are you are doing exactly as well as you normally do, and that’s what you need to tell yourself as you go through the day to make that true.

Remember, the goal is focused nonchalance. Don’t forget: “this test is a poorly constructed hurdle” is a better mindset than “this test determines my future.”

Concussion Protocol

Shaun King reacting to Josh Begley’s short reverse-highlight reel “Concussion Protocol” in The Intercept:

It’s not a headache. It’s not “getting your bell rung.” You don’t have a bell. It’s a traumatic brain injury.

iPhone X: First Impressions


I generally try to spend money deliberately, particularly when it comes to what might be considered “nonessential” purposes. This year that included the iPhone X.

Our son is two and a half, so the main reason I’ve been upgrading my phone annually the past few years is to have the very best smartphone camera possible. My wife has the iPhone 7 and (until last week) I had the 7 Plus. The increased quality of the plus (particularly portrait mode, but also low-light performance and even macro) was so substantial that when we’re out and about we would almost exclusively use my phone for photos. The best camera—the saying goes—is the one you have with you, so the premium to capture my son’s moments has been the primary motivator.

(It’s snowing!)

Also, I like shiny things. And it was also my birthday.

I also do what I imagine is a surprising amount of my writing on my iPhone. I dictated the majority of my second book as well as large portions of my blog posts (including parts of this one) using Siri. I even do a fair amount my typing on the phone directly with my handy Bluetooth keyboard and Ulysses. All in all, I consider having a great phone to be a worthy business expense (obviously, I’m still trying to justify myself).

Design & Screen:

I’m ambivalent about the notch. The speaker, selfie camera, and sensors have to go somewhere. Perhaps one day they can be embedded in the screen, but overall I don’t find it as galling as some reviewers have. My main pet peeve is that so far a lot of apps haven’t been updated to make use of the unusual “ears” or rounded corners on the display. Updated apps will often show the clock on the left and wifi/cell signal/battery indicators on the top. Older apps just pretend all that space isn’t really there leaving a black bar at the top and bottom as if it were the size of a regular iPhone 7/8. Over time this will improve, but I’m not sure how well cross-platform apps or the many apps that are essentially webpage viewers will be able to accommodate the new design.

The new OLED screen is really nice. It’s beautiful, bright, and for some reason, almost a little more paper-like and less fatiguing when reading text on a white background.

Face ID:

Touch ID is better, but Face ID works as advertised (mostly). It works in light and dark, with or with my glasses or even sunglasses. It’s marginally slower than Touch ID but not enough to make a difference in most situations, and the change in notifications mostly makes up for it. Now notifications are private on the unlock screen, only showing the app but not the content/message itself until unlocked by Face ID. Then you can tap the notification to go straight into the app, which is a clever little improvement. Elegant.

My main fail point is when lying down or holding the phone at an exaggerated angle it often won’t engage. I haven’t figured exactly how much face the phone needs to see but my experience has been variable (generally poor) in these situations. Bedtime is not a great time for Face ID. I also had a cold recently and if I coughed or made an odd face while trying to unlock it would also fail (it was a bad cold; this was happening more than you’d expect). Chewing also causes it to fail.

My other irritating corner case pet peeve is that Face ID is terrible for using your phone on a table or desk. With Touch ID, you could keep your phone on the table and unlock it with your index finger, never having to pick it up to look at alerts etc. With the X, you either have to hit the side button and loom over the phone to unlocked it or pick it up.


In my limited usage thus far, the main difference for me between the 7 Plus and X has the speed of portrait mode (in addition to the new portrait lighting effects). The problem with fast moving toddlers is that sometimes the lag of portrait mode means losing the best moment by the time the photo is actually taken. It’s almost as fast as a regular photo now, though I have noticed some serious auto-focus glitches with close up portrait mode, which I hope will be resolved soon.

I rarely use the front-facing camera, so I haven’t taken any decent front-facing portrait mode photos yet, though it does work as advertised.


I like it. Like every new iPhone I’ve purchased over the past six or so years, the iPhone X is the “best” phone I’ve ever had. But it’s still (just) a magical glass brick. Face ID is still mildly irritating and forces a number of unwelcome behavioral changes, and the bugs are annoying. The X’s design is nice but I think most Apple customers would be better off just sticking with the iPhone 8 Plus for this iteration.

More Open Access Journal Shaming

There seems to be a never-ending shaming parade of “peer reviewed” open access journals that exist to extract one-time lump sum payments from desperate authors in exchange for a publishing credit and poorly formatted PDF.

“The conceptual penis as a social construct” in Skeptic Magazine takes it the next level, by also lampooning an entire discipline of academic thought. The article’s approach, summarized by the authors:

We didn’t try to make the paper coherent; instead, we stuffed it full of jargon (like “discursive” and “isomorphism”), nonsense (like arguing that hypermasculine men are both inside and outside of certain discourses at the same time), red-flag phrases (like “pre-post-patriarchal society”), lewd references to slang terms for the penis, insulting phrasing regarding men (including referring to some men who choose not to have children as being “unable to coerce a mate”), and allusions to rape (we stated that “manspreading,” a complaint levied against men for sitting with their legs spread wide, is “akin to raping the empty space around him”). After completing the paper, we read it carefully to ensure it didn’t say anything meaningful, and as neither one of us could determine what it is actually about, we deemed it a success.

This one is a fun ride.

I actually have a case report in an Open Access journal back from my I’m-going-to-be-an-interventional-radiolgoist days (it wasn’t all that good, and my colleague did most of the work, bless him). We submitted but didn’t pay—I think they may have been desperate for articles to publish and just put it up. Case Reports are almost unpublishable now outside of these types of pay-to-publish journals, which creates a bizarre counter-incentive to trying to share interesting one-offs with other physicians and scientists.

I wish—in addition to a robust mechanism for consistently sharing negative results—that there was a better mechanism for sharing research outside of peer review, which is expensive, inefficient, and, in many cases, broken.

Academic publishing is stuck in the pre-digital era. All we’ve done is move physically printed journals online behind paywalls. Comments, updates, additions? Sorry, no. Journals are static, even though science is not. It’s ripe for a big investment by a billionaire to change the status quo. Gates, Zuckerberg—you guys listening?