Despite ways to manage many of these challenges, certain decisions in medicine are inherently going to remain extremely difficult.
Features of extremely difficult decisions in medicine:
An incorrect decision has a high risk of adverse consequences.
Limited information is available to make the decision.
Of these two features, we typically have no way to control the amount of risk involved in our decision. We might also feel that we have no control over having limited information, but this is incorrect.
We are actually able to manage information limitations in medicine.
The 40-70 Rule in Decision Making
Former U.S Secretary of State and General Colin Powell is known for the 40-70 rule in decision making, stating that a leader should make a decision when they have between 40% and 70% of the information available.
”If they make the decision with less than 40% of the information, they are shooting from the hip. But waiting for more than 70% of the information delays the decision unnecessarily.”
Applying this to medical decision making:
By the time you have gathered 40% of necessary information, a skilled clinician should have narrowed diagnostic and treatment possibilities enough to make an effective decision.
By waiting for more than 70% of information to become available, we may actually increase risk by delaying a decision.
The surprising part here is that by delaying our decision beyond a certain amount of information, we may end up with worse outcomes.
“A tribe is a group of people connected to one another, connected to a leader, and connected to an idea. For millions of years, human beings have been part of one tribe or another. A group needs only two things to be a tribe: a shared interest and a way to communicate.” ― Seth Godin
Despite the fact I was only able to attend the meeting for a relatively short time (Saturday evening until late Monday morning), I was able to be involved in a number of activities. I’ll have to come back for sightseeing in Boston another time.
The biggest thing I was involved in while in Boston was the ACR Social Media Bootcamp, with excellent sessions on Twitter and blogging for rheumatologists.
The next big thing was the #ACR14 Tweetup. This event is designed with the goal of helping myself and others meet more people face-to-face at a major medical conference, and was again a big success. As always, it was great to catch up with a number of friends from all over the globe.
During the conference, I had Tweeted out a link to one of my favorite articles:
I’m also including a link to “Episode 34 – Interview with Irish rheumatologist Ronan Kavanagh”, since it was such a fun episode to record and we had discussed a bit about the social media bootcamp (among many other things).
“When you first start off trying to solve a problem, the first solutions you come up with are very complex, and most people stop there. But if you keep going, and live with the problem and peel more layers of the onion off, you can often times arrive at some very elegant and simple solutions. Most people just don’t put in the time or energy to get there.” – Steve Jobs
The goal for this presentation is to try to remove the major barriers to entry into the world of blogging. Before moving onto the technical aspects of setting up a blog, I hope that the following observations also help break down a few other hurdles that might also be holding you back from starting.
There are a number of excellent blogging platforms currently available. As a general rule, the more control the platform gives you over the design of the blog, the more technical knowledge will be required. The 80/20 rule applies here again, such that only a small amount of technical understanding can have you running one of the most powerful blogging platfiorms: WordPress.
The simplicity of using WordPress is owed to the fact that it comes with both extremely well written documentation and has a large community of users, so you are usually able to find answers to most questions easily with Google.
Designing your site:
The best way to set up the design of your site is a relatively personal one. I think you should design a blog that you would enjoy reading. As you browse around the web, take note of which sites draw you in. Personally, my blog is inspired by the readability and simplicity of Medium.com and Instapaper.
In WordPress, the design or template of your blog is called a Theme. WordPress.org currently has over 2,700 free and premium themes in their directory, which can be installed with just a few clicks. Alternatively, a number of more advanced profession themes are available. This site is currently running Thesis 2 (of note, this specific theme does require you to be a bit more technically savvy, but the majority of them minimal additional technical knowledge).
These are the tools to add various functions to your blog. Often enough, whenever you think of something you want to add, a plugin already exists that you can install and have running with a few clicks. Details of the types and specific plugins I recommend are covered in my prior post: My WordPress Setup, Plugins and Writing Tools.
Driving traffic to your site:
Typically, the biggest driver of readers to your site is going to come from social media. On Twitter. adding a hashtag can be extremely helpful, and in the world of rheumatology, top suggestions would be to use a conference hashtag such as #ACR14 or the rheumatology education hashtag #RheumEdu.
The other way that people will find their way to your blog will be through search engines, which is referred to as organic search. Because of the algorithms that Google uses to index pages, it is worthwhile to think a little bit about Search Engine Optimization (SEO) so that readers can find you organically. On WordPress, there are a number of plugins that take care of most of this automatically. If you’re looking to really dig into some of the details you can read through Google’s Starter Guide.
The 80/20 of SEO for most bloggers simply requires that you:
Write good content.
Give your writing accurate titles.
Adding visual content to your site:
Humans are visual creatures, so adding images to your site and posts both draws people in, and will also improve social sharing.
If you’re not using one of your own photos, options for free images include public domain images (works that are free of known copyright around the world) or else images with certain Creative Commons licenses that usually allow works to be used with proper attribution. A nice resource for free images can be found here.
Last, I want to include a list of all of the current active rheumatology bloggers that I’m aware of at the time of #ACR14:
“There was a time when nails were high-tech. There was a time when people had to be told how to use a telephone. Technology is just a tool. People use tools to improve their lives.” — Tom Clancy
“One of the great challenges of our age, in which the tools of our productivity are also the tools of our leisure, is to figure out how to make more useful those moments of procrastination when we’re idling in front of our computer screens.” — Joshua Foer
I’m always drawn to everyday carry type posts and trying to figure out the optimal set of daily tools, which should have the following set of characteristics:
1. you use in your day to day life
2. a first tier level of preparedness for an unforeseen emergency
3. they need to be functional.
My current everyday carry gear (clockwise, from top left):
MacBook Air (13.3-inch, Mid 2013, 1.7GHz dual i7, 8GB memory, 512GB SSD). I bought the best MacBook Air available at the time refurbished from Apple, which was an amazing deal and would suggest to anyone. With the SSD, it is strikingly fast. The only thing keeping it from being the perfect machine is lack of Retina display, but everything else makes up for that.
iPad mini with Retina display. (64GB, Space Gray, WiFi only) with Blue Smart Case. I primarily use this for consuming longer form content using these four apps: Kindle App, Instapaper (saved articles from web), NewsBlur (RSS reader), or Documents by Readdle (for PDFs).
Kleen Kanteen (27 oz, stainless steel). These are great because they’re dishwasher safe. I have a few of them. Stay hydrated my friends.
3M Littmann Cardiology II S.E. Stethoscope. This is an older stethoscope that appears to have been replaced by the Cardiology III I have two stethoscopes: a Littmann Master Cardiology that I keep at the clinic I spend the majority of my time, and this one that I carry in my bag for when I’m seeing patients at the hospital or my weekly satellite clinic.
Small, cheap umbrella. I don’t believe in buying a big, expensive one.
Cocoon Grid-It. A great tool for organizing various cords and other things that end up wandering around your bag. I currently travel around with a 1 m Apple Lightning to USB cable, Apple EarPods, and a short micro-USB cable. There is also a pocket on the back that I keep a microfiber cloth.
IntoCircuit Power Castle 11,200 mAh USB Battery Pack. Carries enough power to recharge most of your devices multiple times. For comparison purposes, the iPhone 5S has a 1570 mAh battery, the iPhone 6 has 1810 mAh, the iPhone 6 Plus has 2915 mAh, and the iPad mini with Retina display has 6471 mAh.
“Tell me and I forget, teach me and I may remember, involve me and I learn.” ― Benjamin Franklin
The use of social media in medicine has experienced enormous growth in the past few years, and this short blog post can’t even start to scratch the surface.
A great overview of the importance of social media in the field of rheumatology was recently published earlier in 2014 by Dr. Francis Berenbaum (@Larhumato), rheumatologist from Paris, titled The social (media) side to rheumatology in Nature Reviews Rheumatology. This paper includes discussion of the use of social media in medical education (for providers and patients), how it has affected the doctor-patient relationship (in a great way), and its role in medical research.
Our hope is that we can lower the barriers of entry, decrease the learning curve, and enhance the experience of new users. But we’d also like to introduce experienced healthcare Twitter users to a fresh look, to new information, and to new people who share your passions.
With all of this in mind, I’m extremely excited to be part of the following social media events this year in Boston:
Social Media Bootcamp
The goal of the social media bootcamp is to introduce more individuals to the core tools in social media: Twitter and blogging. These sessions are the brainchild of Dr. Ronan Kavanagh (@RonanTKavanagh), and I’m happy to be involved moderating the Sunday session and speaking on the technical aspects of setting up a blog on Monday. Also speaking are Dr. Philip Gardiner (@PhilipGardiner) and Dr. Christopher Collins (@RheumPearls).
Sunday, Nov. 16, 9:00–10:00 a.m.: Twitter Basics—The thoughts, opinions and ideas of your rheumatology colleagues, in 140 characters or less, shared in real time for open discussion. Learn how to tweet and engage participants in live tweet forums during the conference!
Monday, Nov. 17, 9:00–10:00 a.m.: Blogging for Beginners—Learn the basics of setting up a blog and how to use it effectively to communicate with targeted audiences. Blogging can be a great resource for communicating timely and relevant content in easily digestible quantities. These will include two sessions.
When: Sunday November 16 from 4:30-6:00pm
Where: Room 150 of the Boston Convention Center
The yearly gathering of rheumatology Twitter friends from across the globe has gotten to be a bigger and better event each year. Take a look at my post on last years #ACR13 Tweetup and this post that includes links back to every prior rheumatology tweetup that I could find.
Just as last year, this event will again open to anyone who would like to attend. No need to RSVP (although I would appreciate it if you would leave a quick comment to this post if you plan on going, just to get a sense of how many people might attend).
If anyone has questions, feel free to ask me on Twitter (@psufka) or else in the comments below.
I look forward to catching up with everyone again this year.
“It’s best to have your tools with you. If you don’t, you’re apt to find something you didn’t expect and get discouraged.” ― Stephen King, On Writing: A Memoir of the Craft
The best way for physicians (or anyone) to control their online voice is to create their own content, and the best way for this content to be published is to have their own blog.
I am often surprised at how few physicians have what I would consider a bare minimum online presence: a simple webpage with their name and contact information. At the very least, this is necessary to take your place among the numerous physician rating websites that will show up in a search for your name.
While this may appear at first to be a more technical post, I hope that curating tips I have found helpful on running WordPress will encourage others who may be reluctant to starting their own blog.
While there are certainly more simple blogging platforms available, such as Blogger, Tumblr, or Squarespace, I specifically use WordPress given the power and flexibility of the platform, much of which comes from your choice in the additional plugins that are used.
Two ways to run WordPress
Free from WordPress.com. There are a number of limitations to this, such as being given a domain name (e.g. yourblog.wordpress.com) and having ads (although you can upgrade to your own domain name and to get rid of ads). The biggest downside in my opinion are the restrictions on plugins.
Hosting the free software available at WordPress.org on your own domain. This is the more powerful way to run WordPress, and the one I suggest. The easiest way to do this is to chose a host that supports automatic installation of WordPress (I use Dreamhost, which has been great).
This comparison chart between WordPress.com and a hosted WordPress.org site also helps explain many of the differences. If you’re worried that WordPress can get technical, keep in mind that it is the most used blogging platform, so if questions arise, finding answers is fairly easy, and the documentation is well organized.
Your WordPress theme is your template for the overall design of your page. There are a number of free options, or else you can pay for a premium theme, which is typically developed and updated by professional web designers, and will often have additional features. I use The Thesis Theme for WordPress, which has a number of simple tools for editing/managing content, and has built-in options for Google Analytics and SEO. This list of some of the most popular themes (both free and premium) can also provide some ideas.
As mentioned above, plugins are the tools to add various functions to your blog, and there are currently thousands available. The plugins that I currently use, broken into various categories are:
Akismet – automatically protects your blog comments from spammers.
Speeding up WordPress
WP Super Cache – Generates static html files that are sent to users, which speeds up loading by reducing load on your host server (otherwise, WordPress generates a new html file each time a user accesses your site, which can be slow). I previously used W3 Total Cache, but it never seemed fast enough and has some occasional problems.
WordPress SEO by Yoast – despite some Search engine optimization (SEO) being built into my Thesis Theme, I find that this plugin does a better job at optimizing searches for my name (which as a physician, is the result that I care most about). An alternative to consider (with overall easier setup) is All in One SEO Pack. While I haven’t compared my results with these two plugins directly, Yoast’s package seems to be more successful. [Update 11/4/2014: Since updating from Thesis version 1 to version 2, I have disabled WordPress SEO by Yoast owing to some compatibility issues, and am using the SEO built into Thesis. It appears these issues have been addressed, but I currently haven’t done any of the fixes].
Google XML sitemaps – XML sitemaps are files listing your sites URLs with important information about each to search engines. Yoast’s WordPress SEO has this built in, which is likely adequate, but this plugin gives you more control.
Jetpack – this is a must-have plugin that includes numerous features, but the one that I use most frequently are the site statistics.
Google Analytics – though not technically a plugin (Analytics is added by adding a tracking code to your site, which I do through my Thesis Theme, but could also be done through WordPress SEO), Google provides piles of free data about who is accessing your site.
Contact Form 7 – provides a simple but highly customizable contact form, which I like better than the one included in Jetpack.
It can also be useful to look at what plugins your favorite blogs are using with the WPThemeDetector website (although it cannot detect every plugin), or else browse the most popular plugins in the WordPress directory.
While you could write blog posts directly in WordPress, it can be a bit clumsy to do so. I use MarsEdit, which connects directly to your blog and allows you to write and upload posts with multiple editing options (it even supports Markdown). By connecting to your site, it actually downloads a copy of all of your posts which acts as an additional backup. Of note, if you use Google Authenticator, you’ll have to use an application specific password, since two-factor authentication is not currently supported.
For longer or more complex writing (such as my post on Decision Fatigue), I first write everything in Markdown using Scrivener, which is an incredibly powerful writing program that local author Patrick Rhone convinced me to purchase after this tweet:
It’s like an operating system for words. Everything one would need to turn words from concept to finished product is there.
This is the hard part. I like WordPress founder Matt Mullenweg’s post suggesting that you “write for only two people”: yourself and “a single person who you have in mind as the perfect person to read what you write”. As such, this post was inspired by Dr. Rebecca Grainger looking for tips on starting a blog via Twitter. [Update 12/07/2014: Dr. Grainger (along with Dr. Eimear Savage) recently started a blog: 2xrheum: A rheumatology blog is born.]
Twitter has had global impact in ways that never could have been imagined since the first tweets in March 2006. Now, with hundreds of millions of active Twitter users and tweets numbering over 500 million per day, we easily become tempted to follow so many accounts that it can become too noisy to be useful.
Looking for some guidance on a maximal number of accounts to follow on Twitter, I came across Dunbar’s number. This is a theory by British anthropologist Dr. Robin Dunbar that there is a “cognitive limit to the number of people we can maintain social relationships,” in which brain size “limits the number of relationships that an individual can monitor simultaneously” (PDF). He felt that this number was around 150 relationships in humans, although proposed numbers range anywhere between 100-230. The term Monkeysphere was coined in reference to an experiment confirming this correlation between brain size and social groups in monkeys.
Dunbar looked at whether his proposed cognitive limit also applies to Facebook, and wrote:
Facebook itself did a survey of its accounts about a year ago and found that the average number of friends was between 120 and 130.
The odd reality is that we are actually not capable of managing more friendships than you typically see on Facebook now—or more than people have traditionally maintained.
And concluded that:
If you have more than 150, it is because you are including people who have no meaningful relationship with you.
I don’t think there is a “correct” way to use Twitter, but given it has become my primary source of incoming information, I try to be thoughtful about both who I follow and how many I follow. Looking at an October 2012 study, the average Twitter user follows about 102 accounts, which is well within Dunbar’s observations. I certainly start to feel a bit of cognitive strain when the number I’m following is too high (which is most of the time).
My approach to Twitter is to generally focus on following thought leaders for topics I’m interested in, and have a low threshold to unfollow an account unless I’m finding they consistently add value to my network.
When you first start to filter your network and unfollow accounts on Twitter, you’ll be a bit nervous that you’ll miss something. Trust me, you won’t. If something is important, your well selected network is going to amplify that message and you’ll see it.
“Everything must be made as simple as possible. But not simpler.” — Albert Einstein
One of the most mentally fatiguing actions that physicians face on a daily basis is the number of decisions we must make. Although we likely only make one or two major decisions for every patient encounter, in total we make hundreds (or maybe thousands) of decisions every day. This includes deciding what labs, imaging, and other studies to order, followed by what those results mean, a diagnosis or list of possible diagnoses, treatments, monitoring, patient follow up, etc.
Unfortunately, it has been shown that the more decisions that we make over the course of a day, the worse we become at it.
The New York Times article Do You Suffer From Decision Fatigue? (highly suggested; approximately 22 minute read) begins by describing the rulings of parole board judges over the course of a year, finding that the pattern of their decisions fluctuated throughout the work day, favoring the prisoners who appeared early in the day.
The more choices you make throughout the day, the harder each one becomes for your brain, and eventually it looks for shortcuts, usually in either of two very different ways. One shortcut is to become reckless: to act impulsively instead of expending the energy to first think through the consequences.
The other shortcut is the ultimate energy saver: do nothing. Instead of agonizing over decisions, avoid any choice.
Predecisional Phase – assessing wishes and forming intended goal
Preactional Phase / Making a Decision – planning and choosing goal-directed actions
Actional Phase – implementing chosen actions
Postactional Phase – evaluating whether goal was achieved
It turns out that a number of studies have shown that the act of making the decision and committing to action is more mentally demanding than any other phase.
The idea of decision fatigue is explained by Dr. Baumeister through a theory called ego depletion, where decisions are higher level executive functions thought to occur in the prefrontal cortex, and every decision we make, no matter how important or unimportant, expends some of the energy of this system, until our ability to make decisions deteriorates.
Once you’re mentally depleted, you become reluctant to make trade-offs, which involve a particularly advanced and taxing form of decision making. In the rest of the animal kingdom, there aren’t a lot of protracted negotiations between predators and prey. To compromise is a complex human ability and therefore one of the first to decline when willpower is depleted.
This reluctancy to make trade-offs explains why the parole judges were reluctant to decide to give prisoners parole at the end of the day. As physicians, we need to be aware of the tendency for decision fatigue to occur during our long days. Unfortunately, there is no telltale symptom of when willpower to make decisions is low, and the best method to avoid decision fatigue is planning routines to avoid it:
“Good decision making is not a trait of the person, in the sense that it’s always there,” Baumeister says. “It’s a state that fluctuates.” His studies show that people with the best self-control are the ones who structure their lives so as to conserve willpower. They don’t schedule endless back-to-back meetings. They avoid temptations like all-you-can-eat buffets, and they establish habits that eliminate the mental effort of making choices. Instead of deciding every morning whether or not to force themselves to exercise, they set up regular appointments to work out with a friend. Instead of counting on willpower to remain robust all day, they conserve it so that it’s available for emergencies and important decisions.
Any opportunity to learn from extreme cases can offer incredible insight, and an extraordinary example of a decision maker to study is President Obama in Michael Lewis’ article, Obama’s Way, where he discusses routines with the President, who is well aware of the effects of decision fatigue:
You also need to remove from your life the day-to-day problems that absorb most people for meaningful parts of their day. “You’ll see I wear only gray or blue suits,” he said. “I’m trying to pare down decisions. I don’t want to make decisions about what I’m eating or wearing. Because I have too many other decisions to make.” He mentioned research that shows the simple act of making decisions degrades one’s ability to make further decisions. It’s why shopping is so exhausting. “You need to focus your decision-making energy. You need to routinize yourself. You can’t be going through the day distracted by trivia.” [Emphasis added]
An article from EMSWorld, When Thinking is Hard: Managing Decision Fatigue, discussed the implications of decision fatigue for EMTs and paramedics and agreed that trying to reduce overall decision load was the best way to manage this problem, and noted that individuals who were able to do this had routines and habits that included thoughtful planning, which reserved willpower for when it was needed most. As healthcare professionals, they noted the importance of having these planned routines:
We tell ourselves it’s how we perform under pressure that counts most, but the sum of who we are as professionals is just as much determined by the everyday habits which make up our work.
The idea that having specific routines to improve productivity is not new. The American philosopher and physician William James (1842-1910) wrote in detail about the importance of forming regular routines and the subsequent effect of allowing our brains to remain productive in his book Habit (open domain; review on Brain Pickings).
The great thing, then, in all education, is to make our nervous system our ally instead of our enemy. It is to fund and capitalize our acquisitions, and live at ease upon the interest of the fund. For this we must make automatic and habitual, as early as possible, as many useful actions as we can, and guard against the growing into ways that are likely to be disadvantageous to us, as we should guard against the plague. The more of the details of our daily life we can hand over to the effortless custody of automatism, the more our higher powers of mind will be set free for their own proper work. [Emphasis added]
As MDs, we will always be required to make numerous daily decisions, so we need to do what we can try reduce our own decision fatigue, which might actually improve our work as a physicians and lives in general:
Spend some time thinking about your routines at home and at work to avoid making additional decisions. Many of the routines described in Daily Rituals included repeating meals, dressing/grooming habits, and setups for getting work done.
Make important or difficult decisions first in the morning. Many of us have a habit of checking email first thing in the morning, which is often filled with a number of unimportant decisions that can wear us down. Instead, save this time of day for the tough ones.
When possible, put off difficult decisions that come up at the end of the day until the next morning. In the field of rheumatology, we are often faced with complex decisions, but luckily, the majority of them are not extremely time sensitive, allowing us time to research and discuss with collagues.
I find it difficult to say anything to the effect of “workup every case of x with tests a, b, and c”, but I do think that as physicians, we do need to have a good understanding of the workup and management for the common conditions in our fields, such that we are able to reserve decision making energy throughout the day.
Any suggestions on routines or other habits that you have found helpful? Mention them in the comments.
Live-tweeting as part of a community also allows participants to feel that they are taking part in the meeting – rather than just being passive recipients of information. It is during the informal information exchange between people that the real learning resonances and cementing of useful information takes place.
I completely agree that social media is probably the most accessible way to enhance learning at medical meetings, as users move from being a passive attendee of a lecture to an active participant. Being active in the conversation amplies the benefits of the meeting by bringing you to a higher cognitive level of learning.
The #ACR13 Tweetups went extremely well, and I’m very happy that so many people were able to make it. Since the goal of the Tweetups were to get people to connect, my request is for anyone that attended to make a point to follow up with someone you met in person. As I mentioned, each time this has led me to interesting things, and my hope is it will do the same for others.
The first gathering was Sunday evening at an Irish-style pub called Hennessey’s Tavern, with about 20 attendees.