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Atomic Habits

01.04.22 // Reading

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

01.02.22 // Reading

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.

06.03.21 // Medicine, Reading

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.

Focus on the drive, not the distraction

05.27.21 // Reading

NYT Columnist David Brooks writing about “The Art of Focus” back in 2014:

If you want to win the war for attention, don’t try to say ‘no’ to the trivial distractions you find on the information smorgasbord; try to say ‘yes’ to the subject that arouses a terrifying longing, and let the terrifying longing crowd out everything else.

There are whole books written about The Power of No, but I wouldn’t discount how our environments shape our behavior. Whether or not willpower is muscle or decision fatigue is real, there are plenty of data to show that making suboptimal activities harder improves outcomes in a variety of contexts.

I can tell you, for example, that the proximity of a Panera to one of the imaging centers I work at is not helping me make good lunch choices (bread bowls are my kryptonite).

But Brooks does reframe the classic “If you do what you love, you’ll never work a day in your life” adage to make it more approachable.

I think “find your passion” is generally terrible meaningless advice in most circumstances. If you have one, great. But if you don’t, it’s not exactly straightforward to meditate for a few minutes, analyze your innermost desires, and manifest your calling.

However, there’s also no denying that having a “pull” to do something (say, teaching others or writing) is the antidote to other less impactful activities. If you are drawn to something that matches your desired identity and goals, then it automatically makes it easier to avoid the “trivial distractions.”

As in, it’s easier to focus when you don’t want to escape the thing you’re trying to do.

Residency and the Craftsman Mentality

05.12.21 // Medicine, Reading

From Cal Newport’s excellent Deep Work: Rules for Focused Success in a Distracted World:

Whether you’re a writer, marketer, consultant, or lawyer: Your work is craft, and if you hone your ability and apply it with respect and care, then like the skilled wheelwright you can generate meaning in the daily efforts of your professional life.

You don’t need a rarified job; you need instead a rarified approach to your work.

Let’s add “physician” to Newport’s list.

One of the more disheartening aspects of medical school is the siloing of medical specialties such that different breeds of doctors appear to compete in the hospital and medical students come away with the idea that one specialty should spark passion in their hearts (and that they will be professionally unhappy if they then don’t match into that one specialty).

It doesn’t have to be this way.

The satisfaction of professional growth and a job well done can transcend specialty choice. If the results of the match weren’t what you wanted, apply yourself to developing a craftsmen’s mentality. Get good at what you do, take pride in it, and passion can follow.

 

 

The One Thing

04.30.21 // Reading

From The ONE Thing: The Surprisingly Simple Truth Behind Extraordinary Results:

When everything feels urgent and important, everything seems equal. We become active and busy, but this doesn’t actually move us any closer to success. Activity is often unrelated to productivity, and busyness rarely takes care of business.

You can become successful with less discipline than you think, for one simple reason: success is about doing the right thing, not about doing everything right.

Maybe a collection of bland truisms, but…it’s amazing how enticing the pull of doing urgent but unimportant things can be.

 

Scheduling Slack

04.15.21 // Medicine, Reading

From Alan’s Weiss’ classic Getting Started in Consulting:

Medical consultants advise doctors never to schedule wall-to-wall appointments during the day, because inevitably there are emergencies, late patients, complications on routine exams, and so forth. These create a domino effect by day’s end, and some very unhappy scheduled patients. Instead, they advise some built-in slack time that can absorb the contingencies. If not needed, slack time provides valuable respite.

Ha.

I read this book years ago when I was a resident and came across this passage when reviewing my Kindle highlights the other day.

Perhaps there are consultants in real-life operating as Dr. Weiss suggests, but this common-sense approach to sustainable medical practice is not what many large health systems employ.

In my wife’s old outpatient academic practice, lunchtime wasn’t respite. It was an overbook slot, and her schedule was so jam-packed that there were always patients clamoring to squeeze in.

In order to make that all work, the average doctor spends 1-2 hours charting at home per day.

Contrast that with her current solo practice where she has complete autonomy: her patients aren’t scheduled wall to wall, and she has time for the inevitable emergencies, hospitalizations, collateral phone calls, prior auths, and the other vagaries of modern medical practice.

I’m proud of the practice she’s built—during a pandemic no less!—but it’s crazy that even academic medicine has become so corporatized in its paradigm that it was easier to craft her own business in order to practice on anything approaching the terms that would best serve her patients and herself.

 

Attending

04.08.21 // Medicine, Reading

A few separate passages I’ve combined from Dr. Ronald Epstein’s Attending: Medicine, Mindfulness, and Humanity:

Altogether, I saw too much harshness, mindlessness, and inhumanity. Medical school was dominated by facts, pathways, and mechanisms; residency was about learning to diagnose, treat, and do procedures, framed by a pit-of-the-stomach dread that you might kill someone by missing something or not knowing enough.

Good doctors need to be self-aware to practice at their best; self-awareness needs to be in the moment, not just Monday-morning quarterbacking; and no one had a road map.

The great physician-teacher William Osler once said, “We miss more by not seeing than by not knowing.”

The fast pace of clinical practice—accelerated by electronic records—requires juggling multiple tasks seemingly simultaneously. Although commonly thought of as multitasking, multitasking is a misnomer—we actually alternate among tasks. Each time we switch tasks we need time to recover and, during the recovery period, we are less effective. Psychologists call this interruption recovery failure, which sounds a bit like those computer error messages we all dread. We increasingly feel as if we are victims of distractions rather than in control of them.

Outside of the OR (and not always even then), it’s rare to find an environment that promotes the space for deep focus and self-awareness. Mindfulness, insofar as a daily approach to medical practice, is something that goes against the grain of one’s surroundings.

Good doctors need to be self-aware to practice at their best; self-awareness needs to be in the moment, not just Monday-morning quarterbacking.

I like that. Medicine is generally ripe for Monday-morning quarterbacking (and radiology in particular due to the permanent, accessible, and objective nature of the imaging record).

But doctors don’t work in vacuums. We are humans.

Consider for a moment the discipline of human factors engineering:

Human factors engineering is the discipline that attempts to identify and address these issues. It is the discipline that takes into account human strengths and limitations in the design of interactive systems that involve people, tools and technology, and work environments to ensure safety, effectiveness, and ease of use. A human factors engineer examines a particular activity in terms of its component tasks, and then assesses the physical demands, skill demands, mental workload, team dynamics, aspects of the work environment (e.g., adequate lighting, limited noise, or other distractions), and device design required to complete the task optimally. In essence, human factors engineering focuses on how systems work in actual practice, with real—and fallible—human beings at the controls, and attempts to design systems that optimize safety and minimize the risk of error in complex environments.

(I first found that passage plagiarized on page 8 of the American Board of Radiology’s Non-interpretive Skills Guide.)

Despite the rise of checklists and evidence-based medicine, humans have been almost designed out of healthcare entirely. Rarely is anything in the system—from the overburdened schedules, administrative tasks, constant messaging, system-wide emails, the cluttered EMR, or the byzantine billing/coding game—designed to help humans take the time and mental space to sit in front of a patient (or an imaging study, for that matter) and fully be, in that moment, a doctor.

Organization Habit Loops

04.05.21 // Reading

From Charles Duhigg’s The Power of Habit: Why We Do What We Do in Life and Business:

That’s when [Alcoa CEO Paul] O’Neill’s education in organizational habits really started. One of his first assignments was to create an analytical framework for studying how the government was spending money on health care. He quickly figured out that the government’s efforts, which should have been guided by logical rules and deliberate priorities, were instead driven by bizarre institutional processes that, in many ways, operated like habits.

Healthcare in a nutshell, from the tippy top of Medicare and the FDA down to the hospitals and institutions. It’s all path dependence. We are where we are because of where we’ve been, but we’d never choose to be here doing it like this in the first place.

Bureaucrats and politicians, rather than making decisions, were responding to cues with automatic routines in order to get rewards such as promotions or reelection. It was the habit loop—spread across thousands of people and billions of dollars.

This has always been true, but the optimist in me always hopes that a big event—like a generation-defining pandemic—might shock people into cohesive collective action focused on outcomes instead of the typical saber-rattling over competing values.

Old Guard Medical Wisdom? Rest

03.26.21 // Medicine, Reading

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

Neurosurgeon Wilder Penfield, for example, warned medical students that unless they cultivated other interests, “your specializing will expose you to an insidious disease that can shut you away from all but your occupational associates” and “imprison you in lonely solitude.” Penfield’s mentor, William Osler, warned that without care, “good men are ruined by success in practice,” and that “ever-increasing demands” can leave even the most curious person “worn out, yet not able to rest.” It was essential to develop “some intellectual pastime which may serve to keep you in touch with the world of art, of science, or of letters.”

These statements came from an era when residents literally lived in the hospital and Osler’s famous surgical colleague William Halstead’s work ethic was fueled by cocaine.

And even they thought it was important for doctors to be well-rounded, have hobbies, and get a life.

Honestly, I’m more interested in what you do for you than what boxes you’re just checking to impress me.

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