The Negativity Tendency

The late Hans Rosling gave an amazingly popular TED talk back in 2006 (and many other popular talks since). You may have seen it. It’s the one showing recent human progress by following counties over time as a series of bubbles. It’s not all rosy, but it shows us how counterintuitive reality can be compared with our usually grimmer assumptions. One could summarize: things can be bad but still be improving. Trajectories matter.

In his follow-up book, Factfulness, Rosling discusses the fact that almost all “news” by definition is bad news. His helpful grounding suggestion: When you hear bad news, ask yourself if similar good news would be able to reach you.

* * *

In healthcare, M&M is full of bad outcomes. Do you hear about the patients who recover uneventfully in the hospital? Not really. Do people gossip about the patients who go home after surgery with well-healed incisions? No, they do not. As a radiologist, I only hear about my misses. About once a year, someone congratulates me on a good catch, and usually, that’s coming from another radiologist who read the follow-up.

As an attending evaluating my residents’ overnight work, I have to grade every change. We have grades for verbiage changes, incidental additions, small relevant misses, and big emergent misses. There’s nothing forcing me to tell my residents that I recognize the great job they’re doing tackling a large volume of complex cases. Most of what they see is negative feedback, even though that parade of bad news doesn’t really tell them an accurate story about the work they’re doing.

When I was a resident, my program had a separate grade for doing an amazing job. You could receive a coveted “1” on the 1-4 scale for crushing a subtle case, performing at a subspecialty level, etc. 1’s were rare.

One evening as I logged in for another shift, I was reviewing my grades from the night before and I saw I’d received a 1. Exhaustion aside, I was always excited when I earned a 1. The comment said, “Everyone deserves a 1 every now and again, so here’s yours.” I didn’t know how to parse that cryptic statement, so I clicked on the link to see the case.

It was a completely normal head CT in a young patient.

I hadn’t changed a word of the template.

* * *

We learn medicine through the slow accumulation of emotional microtrauma. As an educator, it takes special effort to try to really teach through praise and positive reinforcement; usually the vague “great jobs” show up on end-of-rotation evaluations. I’ll be the first to admit I can be too far on the pedantic curmudgeon spectrum.

Yes, feedback–even negative feedback–is a critical component of the learning process. But, when you’re beating yourself up about your mistakes and questioning your skills/growth, you also need to ask yourself:

What are the odds that I’m receiving the true positive side of the same coin?

The answer is you’re probably not.

Things can be bad and still be improving. Trajectories matter.

You can have a lot to learn and a long way to go and still be doing a great job.

On Building

Highlights from Build: An Unorthodox Guide to Making Things Worth Making by Tony Fadell (who led the teams for the iPod, iPhone, and Nest Learning Thermostat):

On the need to divide decisions into two main camps, data-driven or opinion-driven:

Data-driven: You can acquire, study, and debate facts and numbers that will allow you to be fairly confident in your choice. These decisions are relatively easy to make and defend and most people on the team can agree on the answer.

Opinion-driven: You have to follow your gut and your vision for what you want to do, without the benefit of sufficient data to guide you or back you up. These decisions are always hard and always questioned-after all, everyone has an opinion.

Every decision has elements of data and opinion, but they are ultimately driven by one or the other. Sometimes you have to double down on the data; other times you have to look at all the data and then trust your gut. And trusting your gut is incredibly scary. Many people don’t have either a good gut instinct to follow or the faith in themselves to follow it. It takes time to develop that trust. So they try to turn an opinion-driven business decision into a data-driven one. But data can’t solve an opinion-based problem. So no matter how much data you get, it will always be inconclusive. This leads to analysis paralysis-death by overthinking.

“Data can’t solve an opinion-based problem” is a core problem of the universe.

And the problems are worse when you can find a way to shirk responsibility for making those decisions:

But we fell into the same trap as everyone else. We were wowed by the consultants, excited by the numbers. And we quickly became far too reliant on them: everyone wanted data so they wouldn’t have to make decisions themselves. Instead of moving forward with a design, you’d hear, “Well, let’s just test it.? Nobody wanted to take responsibility for what they were making.

So you’d run the test. And then run it again. On Monday the customer panel would pick option X. On Friday, the same group would go with option Y. Meanwhile, we were paying millions of dollars to consultants who took a month and a half to put their own slant on everything.

The data wasn’t a guide. At best, it was a crutch. At worst, cement shoes. It was analysis paralysis.

“Design by committee” is an adjunct to the crutch of data, where there is no vision for the product and no responsibility for the outcome. I see this in medical schools, residency programs, and medical centers of all varieties. So many meetings to discuss so many dashboards. The analytic tools have become robust, so we are awash in numbers and react by massaging our processes to push various metrics in the right direction, often with no regard to second-order effects.

We so often seem locked into a rearranging deck chair approach to problem-solving instead of designing from first principles to make better products and achieve better outcomes.

On being a doofus:

I remember we had a huge all-hands meeting at Apple once these meetings would only happen two, maybe three times a year. And a guy stands up during the Q&A and starts asking Steve Jobs why he didn’t get a raise or a good review. Steve looks at him in stunned disbelief and says, “I can tell you why. Because you’re asking this question in front of ten thousand people.”

On quitting:

Anyone who’s ever stuck with a job they hated knows the feeling.

Every meeting, every pointless project, every hour stretches on and on. You don’t respect your manager, you roll your eyes at the mission, you stagger out the door at the end of the day exhausted, dragging yourself home to complain to family and friends until they’re as miserable as you are. It is time and energy and health and joy that disappear from your life forever. But hey, that title, that stature, that money it’s worth it all, right?

(He’s asking a rhetorical question.)

The threat of leaving may be enough to push your company to get serious and make whatever change you’re asking for. But it might not. Quitting should never be a negotiating tactic it should be the very last card you play.
So before you quit, you’d better have a story. A good, credible, and factual one. You’ll need to have a rationale for why you left.

And you’ll need one for why you want to join whatever company you’re heading to next. These should be two very different narratives. You’ll need them for the interview, but also for yourself to make sure you’ve really thought things through. And to make sure you’re making the right choice for the next job.

The last part I think is sometimes underappreciated. You don’t just quit from something. Until you retire, you’re also quitting to something.

I wrote a brief article last year on evaluating jobs, where I referenced a 2020 study that showed 41% of radiologists had changed jobs in the past 4 years. I bet it’s even higher now given the current market. Lots of folks are quitting. The question is, are they learning from their experiences?

On the benefits of integrating old and young people:

The best teams are multigenerational Nest employed twenty-year-olds and seventy-year-olds. Experienced people have a wealth of wisdom that they can pass on to the next generation and young people can push back against long-held assumptions. They can often see the opportunity that lies in accomplishing difficult things, while experienced people see only the difficulty.

The generational conflict is real, and it’s often amazing to see in person how easily both groups generously weigh only their own strengths.

Rules to Live By

Summarized from the epilogue of Humankind: A Hopeful History by Rutger Bregman, itself a pretty compelling read that summarizes the real world flaws and scholarship foibles of most negative philosophical and psychological research about man’s beastly nature (e.g. Machiavelli, Lord of the Flies, the Stanford Prison Experiment, etc) and instead argues that we are, on the whole, decent.

No. 1: When in doubt, assume the best
No. 2: Think in win-win scenarios
No. 3: Ask more questions
No. 4: Temper your empathy, train your compassion
No. 5: Try to understand the other, even if you don’t get where they are coming from.
No. 6: Love your own as others love their own.
No. 7: Avoid the news
No. 8: Don’t punch Nazis
No. 9: Come out of the closet: Don’t be ashamed to do good
No. 10: Be realistic

“Don’t punch Nazis” absolutely requires some context/explanation, but I don’t want the ruin the great story it derives from.

What I Read in 2022

2022 was the ninth(!) year that I’ve kept track of my book consumption. I’m still trying to get better at capturing even just some brief thoughts/impressions about what I read (especially the fiction, which sometimes fades from memory almost as fast as I can read it). I still read most of my nonfiction on my Kindle (or on the kindle app on my phone) because of the very handy highlight feature. A fraction of those highlights typically then find their way into my digital brain archive and some eventually become posts on this very site.

Prior years here: 2021, 2020201920182017201620152014.

  1. Atomic Habits (I’ve gone through this best-selling-in-whole-world book as a centering routine for the New Year a few times now)
  2. The Almanack of Naval Ravikant (some decent lines/ideas, my favorites are in this post)
  3. Appleseed by Matt Bell (environmental speculative fiction, a sprawling epic with well-crafted prose; Mr. Bell very nicely rejected a short story I wrote for his literary journal back in 2010)
  4. The Lies of Locke Lamora by Scott Lynch (Ocean’s Eleven meets epic fantasy; these books are awesome, and one of the unusual parts of these stories is that while this world has magic, the main characters are just blokes equally out of their element in dealing with it).
  5. Red Seas Under Red Skies by Scott Lynch (Gentleman Bastards #2)
  6. Republic of Thieves by Scott Lynch (Gentleman Bastards #3)
  7. The Poppy War by RF Kuang (way younger than me so we didn’t overlap, but Kuang apparently went to my high school)
  8. Termination Shock by Neal Stephenson (Stephenson, who first coined the term metaverse, writes super engaging sprawing near future speculative fiction. This is climate-related and just great)
  9. The Fifth Season (Broken Earth Trilogy #1) by NK Jemisin (2016 Hugo Award winner, gosh this is so good. May also be the only book where a partial second-person perspective totally works)
  10. Pangea Online: Death and Axes by SL Rowland
  11. Pangea Online: Magic and Mayhem by SL Rowland
  12. Pangea Online: Vials and Tribulations by SL Rowland
  13. Girl Logic by Iliza Shlesinger (my wife bought this but Iliza is probably now the most famous person I sorta knew growing up. She was a few years ahead of me in high school and probably even briefly knew my name at the time).
  14. Forward Collection edited by Blake Crouch
  15. The Obelisk Gate (Broken Earth Trilogy #2) by NK Jemisin
  16. The Stone Sky (Broken Earth Trilogy #3) by NK Jemisin (Again, very original. Not always the most fun read but a great story and incredible world-building).
  17. Stories of Your Life and Others by Ted Chiang (the title story is the mind-bender that gave rise to the movie Arrival)
  18. Exhalation by Ted Chiang (the newer collection of this award-winning writer of speculative short fiction, also unusually thoughtful)
  19. The Dragon Republic (Poppy War Trilogy #2) by RF Kuang
  20. Robot Dreams by Sara Varon
  21. Just Keep Buying by Nick Maggiuli (data-driven personal finance, some takeaways here)
  22. The Burning God (Poppy War Trilogy #3) by RF Kuang
  23. Lock In by John Scalzi (a master of the short, snappy, snarky, sci-fi thriller)
  24. Head On by John Scalzi (a sequel, but both are totally stand-alone)
  25. He Who Fights with Monsters by Travis Deverell (yes, it’s silly LitRPG, but the protagonist this time is Australian.)
  26. He Who Fights with Monsters 2 by Travis Deverell
  27. He Who Fights with Monsters 3 by Travis Deverell
  28. He Who Fights with Monsters 4 by Travis Deverell
  29. He Who Fights with Monsters 5 by Travis Deverell
  30. He Who Fights with Monsters 6 by Travis Deverell
  31. The Kaiju Preservation Society by John Scalzi (light, funny, enjoyable; though not as funny as Red Shirts)
  32. Wabi Sabi by Beth Kempton
  33. Warrior of Light by Paulo Coelho (I really liked The Alchemist. This was a bland platitude companion, 100% not worth it).
  34. The Cat Who Saved Books by Sosuke Natsukawa
  35. Man’s Search for Meaning by Viktor Frankl
  36. The Simple Path to Wealth by JL Collins
  37. Sufficiently Advanced Magic (Arcane Ascension #1) by Andrew Rowe (Meh. Magic system and plot, not so bad. Characters and writing, pretty painful even for YA.)
  38. On the Shoulders of Titans (Arcane Ascension #2) by Andrew Rowe
  39. The Torch that Ignites the Stars (Arcane Ascension #3) by Andrew Rowe
  40. Consider This by Chuck Palahniuk (Writing advice from the author of Fight Club among others; this was really good writing about writing).
  41. Good Omens by Neil Gaiman and Terry Pratchett (two of fantasy’s greats, working together in a way distinct from either alone)
  42. Jade City (Green Bone Saga #1) by Fonda Lee (Winner of the World Fantasy Award. The world-building is a bit a slow burn but this series ended up being exceptionally good.)
  43. Four Thousand Weeks by Oliver Burkeman (Refreshing “time management” that reads like happy nihilism)
  44. The Lion Tracker’s Guide to Life by Boyd Varty (briefly quoted here)
  45. Jade War (Green Bone Saga #2) by Fonda Lee
  46. Pacchi Festival (Bushido Online #4) by Nikita Thorn
  47. The Order by Jeremy Robinson (I didn’t get how Robinson was trying to pull together all of his stand-alone novels into a giant universe with a whole bunch of crossovers at first, but it’s working surprisingly well).
  48. Reckoning (The Beginning After the End #9) by TurtleMe
  49. Building a Second Brain by Tiago Forte (nothing convinced me to change my current workflow)
  50. Jade Legacy (Green Bone Saga #3) by Fonda Lee
  51. He Who Fights with Monsters 7 by Travis Deverell
  52. Rules for a Knight by Ethan Hawke
  53. Babel by RF Kuang (This was a singular book, nothing else quite like it)
  54. Dawnshard by Brandon Sanderson (Stormlight novella)
  55. The Android’s Dream by John Scalzi (I can see how the author who wrote this amusing book would go on to write the excellent Interdependency Trilogy)
  56. Unsouled by Will Wight (Cradle #1) (More progression fantasy)
  57. Soulsmith by Will Wight (Cradle #2)
  58. Blackflame by Will Wight (Cradle #3)
  59. Skysworn by Will Wight (Cradle #4)
  60. Ghostwater by Will Wight (Cradle #5)
  61. Underlord by Will Wight (Cradle #6)
  62. Uncrowned by Will Wight (Cradle #7)
  63. Wintersteel by Will Wight (Cradle #8)
  64. Bloodline by Will Wight (Cradle #9)
  65. Reaper by Will Wight (Cradle #10)
  66. Dreadgod by Will Wight (Cradle #11)
  67. Gilded Ghost (Ripple System #3) by Kyle Kirrin
  68. Agent to the Stars by John Scalzi
  69. Old Man’s War by John Scalzi
  70. The Doors of Eden by Adrian Tchaikovsky
  71. Throne of the Crescent Moon by Saladin Ahmed (Arabian Nights-esque fantasy. I’ve been meaning to read my copy of this ever since I published one of Ahmed’s stories in Nanoism, which was subsequently a finalist for the annual Best Small Fictions Anthology.
  72. Gallant by VE Schwab (Schwab is a great and very-bestselling writer. This ghost story reminds me a bit more of Neil Gaiman’s work.)
  73. The Black Prism (Lightbringer #1) by Brent Weeks (at first I wasn’t sold on the magic system/world-building but I was wrong. This series is great).
  74. The Blinding Knife (Lightbringer #2) by Brent Weeks
  75. The Broken Eye (Lightbringer #3) by Brent Weeks
  76. The Blood Mirror (Lightbringer #4) by Brent Weeks
  77. The Burning White (Lightbringer #5) by Brent Weeks (a rare satisfying series conclusion!)
  78. Farmer in the Sky by Robert Heinlein (some of these classic sci-fi books really haven’t aged well)
  79. Methuselah’s Children by Robert Heinlein
  80. He Who Fights with Monsters 8 by Travis Deverell
  81. The Lost Metal (Mistborn era two, #4, the conclusion) by Brandon Sanderson (Honestly fell kinda flat? The whole second arc just isn’t as good as the first, and I’ll admit I find the overall Cosmere integration slow burn to be mostly frustrating at this point)
  82. Noise by Daniel Kahneman (I’ll be quoting this book in more posts, but here’s a taste)
  83. Khaos by Jeremy Robinson (the penultimate volume in the Infinite timeline)


My son is getting older, so in addition to me reading to him, he also now reads a ton to himself, and sometimes I read a book or two in the series he’s currently enjoying or to introduce him to a new one:

  1. The rest of this Pokémon box set
  2. No One Returns from the Enchanted Forest by Robin Robinson
  3. Caveboy Dave by Aaron Reynolds and Phil McAndrew
  4. Sunken Tower by Tait Howard
  5. Some of the Wings of Fire graphic novel renditions by Tui T. Sutherland (talking dragons!)
  6. Boulder Brothers Mo and Jo by Sarah Lynn
  7. Cat Kid Comic Club Perspectives by Dav Pilkey
  8. Lightfall: The Girl & the Galdurian (Lightfall #1) by Tim Probert (such a beautiful art style; this was great)
  9. Lightfall: Shadow of the Bird (Lightfall #2) by Tim Probert
  10. Portions of the Minecraft Woodsword Chronicles by Nick Eliopulos
  11. Star Knights by Kay Davault (also a really cute standalone graphic novel)
  12. All five of the 5 Worlds graphic novels by Mark Siegel (which were awesome, he loved these)
  13. The first two books in the classic Chronicles of Narnia series by CS Lewis, which I kept in great condition from childhood for just this purpose!
  14. Several entries in the Amulet series by Kazu Kibuishi, which he thought were super epic. Fantastic art.

Losing the Track is Part of Tracking

From The Lion Tracker’s Guide To Life by Boyd Varty:

You must train yourself to see what you are looking for.

Perhaps the most concise description of radiology training.

“I don’t know where we are going but I know exactly how to get there,” he says.

Process > outcome.

I think of all the people I have spoken to who have said, “When I know exactly what the next thing is, I will make a move.” I think of all the people whom I have taught to track who froze when they lost the track, wanting to be certain of the right path forward before they would move. Trackers try things. The tracker on a lost track enters a process of rediscovery that is fluid. He relies on a process of elimination, inquiry, confirmation; a process of discovery and feedback. He enters a ritual of focused attention. As paradoxical as it sounds, going down a path and not finding a track is part of finding the track.

Uncertainty is part of life, but a search pattern helps.

Data-driven Personal Finance Takeaways

Some interesting passages and food for thought from Just Keep Buying: Proven Ways to Save Money and Build Your Wealth by Nick Maggiulli (a personal finance book with much more data behind its analysis than average for the genre).

On saving:

And one of the most common financial stressors is whether someone is saving enough. As Northwestern Mutual noted in their 2018 Planning & Progress Study, 48% of U.S. adults experienced “high” or “moderate” levels of anxiety around their level of savings. The data is clear that people are worried about how much they save. Unfortunately, the stress around not saving enough seems to be more harmful than the act itself. As researchers at the Brookings Institute confirmed after analyzing Gallup data, “The negative effects of stress outweigh the positive effects of income or health in general.” This implies that saving more is only beneficial if you can do it in a stress-free way. Otherwise, you will likely do yourself more harm than good.

That’s a counterintuitive claim: stressing about not saving enough does more harm than not saving enough.

On spending:

Researchers at the University of Cambridge found that individuals who made purchases that better fit their psychological profile reported higher levels of life satisfaction than those who didn’t. Additionally, this effect was stronger than the effect of an individual’s total income on their reported happiness.

For example, it has been well documented that people get more happiness buying experiences over material goods. However, what if this is only true for a subset of the population (e.g., extroverts)? If so, then we may be generating spending advice based on the 60%–75% of people who are extroverts to the dismay of introverts around the world.

I suspect Maggiulli is right to point this out. Just like scientists get annoyed when news media take a small experiment or a mild trend in the data and throw up a big bold headline, the idea that all humans benefit from the same things in the same sorts of ways doesn’t pass intuitive muster. For many people, I suspect there are probably plenty of high-impact ways to spend on some things and dumb ways to buy experiences.

On valuing an educational/career investment:

The proper way to find the current value of these future earnings is to discount this payment stream by 4% per year. However, there is a simpler way to approximate this—divide the increase in lifetime earnings by two. This will be roughly equivalent to a 40-year payment stream discount by 4% per year. I prefer this shortcut because you can now do the math in your head. Therefore, a $800,000 increase in lifetime earnings over 40 years is worth about $400,000 today.

Value of Degree Today = (Increased Lifetime Earnings/2) – Lost Earnings While things like taxes and other variables can affect this calculation, it’s still a simple way to check whether a degree is worth the cost.

Food for calculus when considering not just expensive degrees but also lengthy medical training or an additional fellowship.

On the health impact of debt:

For example, research published in the Journal of Economic Psychology found that British households with higher levels of outstanding credit card debt were “significantly less likely to report complete psychological well-being.” However, no such association was found when examining households with mortgage debt. Researchers at Ohio State echoed these findings when they reported that payday loans, credit cards, and loans from family and friends caused the most stress, while mortgage debt caused the least. On the physical health front, a study in Social Science & Medicine found that high financial debt relative to assets among American households was associated with “higher perceived stress and depression, worse self-reported general health, and higher diastolic blood pressure.” This was true even after controlling for socioeconomic status, common health indicators, and other demographic factors.

What makes buying a home even easier is if you can afford it. This means being able to provide 20% as a down payment and keeping your debt-to-income ratio below 43%. I chose 43% because that is the maximum debt-to-income ratio you can have for your mortgage to be considered qualified (i.e., lower risk). As a reminder, the debt-to-income ratio is defined as: Debt-to-Income Ratio = Monthly Debt / Monthly Income

Part of what makes mortgage debt less impactful to mental health is presumably the fact that mortgages feel universal and almost no one you are likely to know (at least early in your professional career) has the money to buy a house with cash.

Nonetheless, I suspect I will have a measurable well-being boost when mine is gone.

On why to invest:

In essence, by investing your money you are rebuilding yourself as a financial asset equivalent that can provide you with income once you are no longer employed. So, after you stop working your 9 to 5, your money can keep working for you. Of all the reasons why someone should invest, this might be the most compelling and also the most ignored. This concept helps explain why some professional athletes can make millions of dollars a year and still end up bankrupt. They didn’t convert their human capital to financial capital quickly enough to sustain their lifestyle once they left professional sports. When you make the bulk of your lifetime earnings in four to six years, saving and investing is even more important than it is for the typical worker.

Fund the life you need before you risk it for the life you want.

The conversion of human capital to financial capital is an excellent way of looking at/arguing for investing.

On being realistic about wealth:

For example, research in The Review of Economics and Statistics illustrates that most households in the upper half of the income spectrum don’t realize how good they have it…households above the 50th percentile in income tend to underestimate how well they are doing relative to others…even households at the 90th percentile and above in actual income believe that they are in the 60th–80th percentile range.

For example, you would need a net worth of $11.1 million to be in the top 1% of U.S. households in 2019. However, after controlling for age and educational attainment, the top 1% varies from as little as $341,000 to as much as $30.5 million. For example, to be in the top 1% of households under 35 that are also high school dropouts you would only need $341,000. However, to be in the top 1% of college educated households aged 65–74 years, you would need $30.5 million.

It’s incredibly easy to find some Joneses to keep up with.

On green grass:

But why does happiness start to decline in the late 20s? Because, as people age, their lives usually fail to meet their high expectations. As Rauch states in The Happiness Curve: “Young people consistently overestimate their future life satisfaction. They make a whopping forecasting error, as nonrandom as it could be—as if you lived in Seattle and expected sunshine every day…Young adults in their twenties overestimate their future life satisfaction by about 10 percent on average. Over time, however, excessive optimism diminishes…People are not becoming depressed. They are becoming, well, realistic.”

Part of the curse of medical training is to coincide with this natural stage of disillusionment.

Earning the Bare Minimum

From the (the free or inexpensive) The Almanack of Naval Ravikant: A Guide to Wealth and Happiness:

If you look at even doctors who get rich (like really rich), it’s because they open a business. They open a private practice. The private practice builds a brand, and the brand attracts people. Or they build some kind of a medical device, a procedure, or a process with an intellectual property. Essentially, you’re working for somebody else, and that person is taking on the risk and has the accountability, the intellectual property, and the brand. They’re not going to pay you enough. They’re going to pay you the bare minimum they have to, to get you to do their job. That can be a high bare minimum, but it’s still not going to be true wealth where you’re retired but still earning.

The problem with employment: “They’re going to pay you the bare minimum they have to, to get you to do their job.”

It’s always in the interest of the suits to pay you as little as they can get away with. It’s always in the interest of the hospital, the university, or the company to either pay you less, push you to produce more, or both. It certainly seems to be a very hard temptation to resist at the moment.

Speaking of retirement:

What is your definition of retirement? Retirement is when you stop sacrificing today for an imaginary tomorrow. When today is complete, in and of itself, you’re retired.

…one way is to have so much money saved that your passive income (without you lifting a finger) covers your burn rate. A second is you just drive your burn rate down to zero—you become a monk. A third is you’re doing something you love. You enjoy it so much, it’s not about the money. So there are multiple ways to retirement.


Lusting for money is bad for us because it is a bottomless pit. It will always occupy your mind. If you love money, and you make it, there’s never enough. There is never enough because the desire is turned on and doesn’t turn off at some number. It’s a fallacy to think it turns off at some number.

When it comes to helping people turn their jobs from just the income-generation game or the I-need-a-passive-income-side-hustle game, we need to move more industries (and here I’m thinking about healthcare) into more of a cooperative venture and less of a competition.

My co-founder Nivi said, “In a long-term game, it seems that everybody is making each other rich. And in a short-term game, it seems like everybody is making themselves rich.”

I think that is a brilliant formulation. In a long-term game, it’s positive sum. We’re all baking the pie together. We’re trying to make it as big as possible. And in a short-term game, we’re cutting up the pie.

The scarcity mindset sours the calling.

Atomic Habits

Atomic Habits was apparently the very best-selling book of 2021.

I don’t re-read books often, but James Clear’s entry is short and tactical, and it makes for a nice “get your head in the game” reset prior to a new effort (such as new year’s resolutions if that’s something you typically enjoy planning and then not doing).

Clear isn’t a scientist, but he did a nice job summarizing the work of others, particularly Charles Duhigg’s The Power of Habit and BJ Fogg’s Tiny Habits (though the latter’s popular book came later). It’s an example, like Yuval Harari’s wildly popular Sapiens, that synthesis, packaging, and storytelling are all considered valuable and certainly rewarded by the market (much more so than rigor).

Clear had a pretty solid newsletter for many years prior to the book, so he put in the time to generate some great quotes.

My two favorites:

You do not rise to the level of your goals. You fall to the level of your systems.

Every action you take is a vote for the type of person you wish to become.

I love the idea of identity-based habits. People love goals and are obsessed with outcomes. But not hitting your goals isn’t always a failure, and outcomes are often not within your locus of control. The inversion here we are affirming is of course the classic, “it’s the journey, not the destination.”

Habits are an effort to be the kind of person we want to be–internal validation–and not focused on outcomes that might happen as a result–external validation. That identity is more who we are and less exactly what we do.

From a post about residency interviews last year:

So much of your identity feels tied to your success in school, the match, and your developing career as a physician. But internal validation is always superior to external validation. You don’t and can’t control outcomes. You–at best–control yourself and your approach.

Perhaps we would do better to think of ourselves foremost as listeners or healers and less as a specific role like trauma surgeon or dermatologist.

What I Read in 2021

It turns out that this was the eighth year that I’ve kept track of at least the book-reading fraction of my entertainment consumption. It’s a practice I encourage, especially if you can jot down a few notes to yourself about your thoughts afterward (I read most of my nonfiction on my Kindle because of the very handy highlight feature, which helps). A fraction of those highlights typically then find their way into my digital brain archive and some eventually become posts on this very site. That and a new daily note habit are part of my ongoing fight against the forgetting curve.

Prior years here: 2020, 2019, 2018, 2017, 2016, 2015, 2014.

  1. Atomic Habits by James Clear (re-read this for pandemic new year inspiration)
  2. The Math of Life and Death by Kit Yates (I’ve long wished people were generally numerate, especially after reading the book Innumeracy in college. This pandemic has only made that desire stronger.)
  3. Derelict by Dean Henegar (This is a sub-subgenre of LitRPG called DungeonCore, where the main character is a sentient dungeon. This wasn’t very good, but the genre itself is sorta weirdly engaging, as if a tower defense game were a novel with lots of internal monologue.)
  4. Derelict #2 by Dean Henegar
  5. A Promised Land by Barack Obama (Obama is a good writer.)
  6. Quit like a Woman by Holly Whitaker (Alcohol culture is pretty toxic.)
  7. How I Built This by Guy Raz (origin stories of some modern unicorn companies. Honestly less interesting than I thought it would be.)
  8. Weird by Olga Khazan (also much less interesting than I thought it would be.)
  9. Exo Hunter by Jeremy Robinson (Everything this guy writes is a fast-paced romp. He has the page-turner plotting down to a science. This is one of the worst but still perfectly enjoyable.)
  10. Vagabonds by Hao Jingfang translated by Kevin Liu  (The Dispossessed [a Le Guin class] as if written by twenty-something year Chinese man writing in Mandarin in 20xx.)
  11. Happier by Tal Ben-Shahar
  12. God’s Eye Awakening by Aleron Kong (new series based on The Land; we’ll see…)
  13. On Writers and Writing by Margaret Atwood (meh, as far as writing about writing goes, I much prefer Ursula K Le Guin’s and Stephen King’s entries)
  14. Life Reset (#1) by Shemer Kuznits (another LitRPG, yes, but in this one, the main character is a monster, so there)
  15. Life Reset: EvP (#2) by Shemer Kuznits
  16. Life Reset: Hobnobbing (#3) by Shemer Kuznits
  17. Life Reset: Human Resource (#4) by Shemer Kuznits
  18. Life Reset: Conquest (#5) by Shemer Kuznits
  19. Infinite 2 by Jeremy Robinson (solid, but honestly Infinite [1] was probably better off on its own. That was a seriously fun book.)
  20. Range by David Epstein (If you ever feel frustrated that we’re all hamsters spending more and more time learning about less and less, this is the book for you)
  21. The Hobbit by JRR Tolkein (thought I’d return to the classic)
  22. Project Hail Mary by Andy Weir (super duper enjoyable book. This [not Artemis] is the real spiritual sequel to The Martian.)
  23. How to Take Smart Notes by Sonke Ahrens (the most academic of the recent takes on the Zetellkasten system of creating a repository of personal knowledge like those facilitated by recent apps including RoamResearch and Obsidian. It is also very repetitive and dry).
  24. World Tree Online (#1) by EA Hooper (enjoyable LitRPG; also nice that it’s a trilogy with an actual ending!)
  25. Demon Lord (#2) by EA Hooper
  26. World Tree’s End (#3) by EA Hooper
  27. Backable by Suneel Gupta (written by the brother of the much more famous Sanjay Gupta; meh; made it into some posts about medicine here and residency interviews here.)
  28. Adventures in Opting Out by Cait Flanders (thought this might be fun as a quick sequel to her first book, but it mostly wasn’t)
  29. The Emergency Mind by Dan Dworkis MD PhD (A book of mental models for decision making in high-stress situations [e.g. an emergency department]. Dan was actually the older brother of a close friend growing up. Super smart dude. Brief post here.)
  30. Israel by Noa Tishby (a very accessible whirlwind tour)
  31. Talking to Strangers by Malcolm Gladwell (It’s refreshing how willing Gladwell is to take the flip side of the coin he popularized in Blink. Brief post here.)
  32. Andrea Vernon and the Superhero Industrial Complex (#2) by Alexander C. Kane (not as good as the original)
  33. Vanishing Fleece by Clara Parkes (a story about modern American textiles; I find these types of memoir-ish deep dives to be oddly interesting. I knew nothing about yarn–until now.)
  34. The Practice by Seth Godin (truly half-baked)
  35. Ascension (The Beginning After the End #8) by TurtleMe
  36. Metropolitan by Walter Jon Williams (The world-building and characters in this book are extremely vivid.)
  37. City on Fire (#2 of 2) by Walter Jon Williams
  38. The Midnight Library by Matt Haig (This is one of those books that became extremely popular. I get why given the world we live in, but ultimately perhaps too tidy, dry, and predictable.)
  39. The Mayor of Noobtown by Ryan Rimmel
  40. The Village of Noobtown (Noobtown #2) by Ryan Rimmel
  41. Castle of the Noobs (Noobtown #3) by Ryan Rimmel
  42. Dungeons and Noobs (Noobtown #4) by Ryan Rimmel
  43. Noon Game Plus (Noobtown #5) by Ryan Rimmel
  44. The Blade Itself (First Law #1) by Joe Abercrombie (often held up as the best example of Grimdark Fantasy. This was really, really good in addition to being brutal.)
  45. Before They Are Hanged (First Law #2) by Joe Abercrombie
  46. The Last Argument of Kings (First Law #3) by Joe Abercrombie
  47. The Hundred Thousand Kingdoms (The Inheritance Trilogy #1) by NK Jemisin (I’m still not sure how I feel about this series.)
  48. The Broken Kingdoms (The Inheritance Trilogy #2) by NK Jemisin
  49. The Kingdom of Gods (The Inheritance Trilogy #3) by NK Jemisin
  50. The Awakened Kingdom (The Inheritance “Trilogy” #4) by NK Jemisin
  51. Mirrorworld by Jeremy Robinson
  52. Red Shirts by John Scalzi (Hugo Award winner; such a great sci-fi subversion; breaks the fourth wall and then beyond)
  53. The Amazing Adventures of Kavalier and Clay by Michael Chabon (a novel set primarily in the golden age of comics. Won the Pulitzer Prize and has been on my shelf to read for a decade. Truly excellent. Chabon is a master.)
  54. Shadeslinger (Ripple System #1) by Kyle Kirrin (I think this is really the last new LitRPG series I expose myself to for a while. All of these LitRPG series are essentially examples of a subgenre called Progression Fantasy, essentially stories focused on character growth like the shonen-style of anime that’s been popular for the past 30 or so years, and–in that way–they’re addictive and soothing at the same time, a balm for the mind in these troubled times.)
  55. Life Reset: Salvation (#6) by Shemer Kuznits (another series concluded!)
  56. The Hospital by Brian Alexander (a depressing tale of modern healthcare and small-town decline through the lens of a midwestern community hospital. Brief post here.)
  57. Everyday Vitality by Samantha Boardman
  58. What Happened to You? By Oprah Winfrey and Bruce D Perry MD Phd
  59. Greenlights by Matthew McConaughey (some interesting stories but almost painfully self-indulgent)
  60. Taste by Stanley Tucci (warning: will make you desperately want really good Italian food)
  61. Keep Sharp by Sanjay Gupta (synopsis: exercise, eat right, and don’t retire)
  62. Cytonic by Brandon Sanderson (Skyward #3)
  63. Will by Will Smith (even more interesting stories but even more self-indulgent)
  64. Black Sand Baron by Kyle Kirrin (Ripple System #2)
  65. The End of Craving by Mark Schatzker (I really found The Dorito Effect interesting as a look at modern food science, the flavorings industry, etc. I honestly don’t have the background to evaluate the claims this book makes about food additives. Could all be raving pseudoscience for all I know. I can at least recommend his first book. But clearly, in the words of Michael Pollan, “eat [real] food, not too much, mostly plants” would be better for all of us.)
  66. The Invisible Life of Addie LaRue by VE Schwab (This was enjoyable, with echoes of The Time Traveler’s Wife. I preferred the Shades of Magic, but VE Schwab is a solid writer.)
  67. Crying in H Mart by Michelle Zauner (though this is supposed to be a moving memoir about acculturation, assimilation, family, food, and loss, it mostly made me want to head to our local H Mart to re-stock my freezer and pantry because it’s been a while.)

I didn’t do a very good job keeping track of what I read to my son, but here are some of the chapter books and graphic novels:

  1. We eventually finished the 27-volume Magic Treehouse series and read the first five or so of the sequel Merlin Missions.
  2. Yeti Files by Kevin Sherry
  3. Cat Kid Comic Club by Dav Pilkey
  4. Rowley Jefferson’s Awesome Friendly Spooky Stories by Jeff Kinney
  5. The Magician’s Nephew by C.S. Lewis (I would really like to continue reading Narnia with him, but he’s more interested in Pokemon and Lego at the moment…)
  6. The Forbidden Power (Lego Nexo Knights: Knights Academy #1) by Max Brallier (honestly far better than it deserved to be)
  7. Glitch by Sarah Graley
  8. The first two volumes in this Pokemon novelization box set, which we are enjoying, um, asymmetrically.

Shallow versus Deep. Prolific versus Profound.

From Rest: Why You Get More Done When You Work Less:

We see work and rest as binaries. Even more problematic, we think of rest as simply the absence of work, not as something that stands on its own or has its own qualities. Rest is merely a negative space in a life defined by toil and ambition and accomplishment. When we define ourselves by our work, by our dedication and effectiveness and willingness to go the extra mile, then it’s easy to see rest as the negation of all those things. If your work is your self, when you cease to work, you cease to exist.

What fraction of doctors (and miscellaneous business workaholics) do you think still believe rest is for the weak and that the ability to slog and hustle is not just good but truly enviable?

Second, most scientists assumed that long hours were necessary to produce great work and that “an avalanche of lectures, articles, and books” would loosen some profound insight. This was one reason they willingly accepted a world of faster science: they believed it would make their own science better. But this was a style of work, Ramón y Cajal argued, that led to asking only shallow, easily answered questions rather than hard, fundamental ones. It created the appearance of profundity and feelings of productivity but did not lead to substantial discoveries. Choosing to be prolific, he contended, meant closing off the possibility of doing great work.

Just like many jobs are bullshit jobs, much of our research is bullshit research. If we reward volume, we disincentive depth.

As Vinay Prasad was quoted in the Atlantic, “Many papers serve no purpose, advance no agenda, may not be correct, make no sense, and are poorly read. But they are required for promotion.”

When we treat workaholics as heroes, we express a belief that labor rather than contemplation is the wellspring of great ideas and that the success of individuals and companies is a measure of their long hours.

And this is one of the tough parts about almost everything written about deep work, rest, the power of no, when to say yes, and everything else in the modern business/productivity/self-improvement genre. The approaches just don’t apply very well out-of-the-box to service workers.

Doctors are primarily service workers. If we work more hours, we see more patients. While there is almost certainly a diminishing return in terms of quality care, there is no diminishing return for billing. A doctor generates more RVUs when they have more clinical hours, and that means more profits for their handlers (until someone burns out and quits).

William Osler advised students that “four or five hours daily it is not much to ask” to devote to their studies, “but one day must tell another, one week certify another, one month bear witness to another of the same story.” A few hours haphazardly spent and giant bursts of effort were both equally fruitless; it was necessary to combine focus and routine. (He lived what he preached: one fellow student recalled that in his habits Osler was “more regular and systematic than words can say.”)

Cramming is bad. Overwork is bad. A reasonable concerted effort over a long period of time is good.

Studying 4-5 hours a day was apparently a reasonable amount to Osler’s sensibility. Olser, if you recall, founded the first residency training program at Johns Hopkins.

Do you remember when the heads of the NBME and FSMB suggested in 2019 that a pass/fail USMLE Step 1 would be bad because students might take the decreased pressure as an opportunity to watch Netflix? Because I do.