Vinod Kurup

Hospitalist/programmer in search of the meaning of life

Feb 21, 2011 - 6 minute read - Comments - running meditation braindump

Time is the most powerful force in the universe

Thanks to Mala’s inspiration, I’ve been running a lot more over the past month. Whenever I get into a good running rhythm, my mind starts to relax and I occasionally get bright ideas (believe it or not!). While I am running, these always seem Nobel Prize-worthy, but they seem to lose some of their glitter when the endorphins wear off. I still believe we could solve all the world’s problems if everyone was a runner.

On a recent run, I was thinking about how Einstein said that compound interest is the most powerful force in the universe. (Turns out he probably didn’t say that, but let’s pretend someone did.) It occurred to me that really, it’s time that is the most powerful force. Compound interest is a function of time and possibly may be the most efficient way to turn time into money, but time is what makes compound interest powerful. Compound interest over the course of 10 days isn’t very powerful. Any activity repeated over a long period of time can be a powerful force, even if each individual activity doesn’t accomplish much.

Spending a few minutes a day over the past few weeks has made a significant difference in my life. I’ve started a Habit spreadsheet to track some habits, specifically, brushing my teeth at night (wanted to start with something easy), writing, pushups, running and meditation. Each day’s activity is miniscule, sometimes to the point of seeming pointless, but over just a few weeks, I’ve seen tangible benefits. I’m writing more and therefore learning more about myself. Sure, I’ve also written some really bad stuff, but I know if I continue these sessions, my life will improve because I will know more about what I really want out of life. That small amount of time, compounded over days, weeks and years will make such a huge difference. The kind of difference where, in a year from now, I’ll be able to describe it better than “such a huge difference”.

I am probably in better shape than I’ve been in since college because I’m running, doing push-ups and playing more with the kids. I ran 40 miles last week, which I haven’t done since my marathon training days. It felt easy and most importantly it’s been giving my mind some time to relax (and generate blog posts like this!) Finally, I’m meditating daily and while that has felt like the least useful of the new habits I’m forming, it is the habit that I think has the most overall potential to improve my life. Having more control over my thoughts and my mind will have positive implications for all parts of my life. My mind has just been very hard to settle down during my sessions so far. (Any tips for a beginning meditator would be appreciated!)

I also started working on my website again and I found that I was able to pick up commands and bits of knowledge that I thought I had forgotten. Little pieces of web scripting and SQL just seemed to come back to me even though I haven’t actively used them in a couple years. Since I had put in so much time learning them before, I picked them up with much less effort now. Same with running. I find it impossible to run on days that I am working, so I have to wait for my “stretches off” to run. It used to be really hard to get to a decent level when I had taken time off, but now I can take a week off and still run 5 miles without feeling bad. Maybe that’s because I run so slow.

When I think about the huge benefit I’ve gotten in a few weeks with such a small amount of daily commitments, I just can’t wait to see what will happen in a few years! Thinking that far in the future used to seem ridiculous because I always wanted results now, but the older I get, the more I’m willing to wait. Paradoxically, stretching out my time-frame for results makes it more likely that I will see results sooner. When I was always trying to make things happen now, I would ignore the little self-improvement things in the name of efficiency. Now that I take the time to do those things, the benefits compound with time and I may end up seeing results even on the things that have nothing directly to do with the habits I’m performing daily.

I also thought about how I’ve been trying to simplify my life and I wonder whether it was worth it. As a general rule, simplifying is a great idea. Try to drive less, spend less, eat less. Those are all good things. But I also found that I limited the time that I spent developing my website. I moved it from OpenACS to a static template solution. There were steps in between, but each step since leaving OpenACS has been in the name of simplification. OpenACS (like all active free-software projects) was changing and I couldn’t keep up with it while also being a dad and a doctor, so I thought it would be better to outsource (Wordpress) or simplify (Jekyll/Blogofile). While that seems to make sense, it also means that I’ve spent less time on my website and one of the joys of my life became smaller. So, I am going to take a more active role in improving my website because I love doing it. I’m not going back to OpenACS, because I do think it was more complex than I needed. I’ve reimplemented google analytics and adsense because watching those numbers gave me some satisfaction.

Final thought for the day. I’ve gotten so much accomplished over the past few weeks because I’ve become more physically and mentally active. I used fatherhood as an excuse to avoid running and self improvement. I said I didn’t have time for it. That lack of activity just reflects poorly on everything else in life. I know that’s too dramatic, because life truly has been good for all of us. But, I guess my lesson to new parents would be to make time for exercise and self-improvement. It will make you a better parent.

Lessons from this run:

  1. Time is the most powerful force in the universe; using it to do meaningful things is never a waste.
  2. Don’t simplify things that you enjoy doing!
  3. Take care of yourself first.

Feb 19, 2011 - 3 minute read - Comments - minivan

Buying a Minivan

The time comes in every man’s life where he eventually has to break down and buy a minivan. That time has come. The Altima is on it’s last legs and we really need a vehicle which can seat our whole family plus a couple visitors plus luggage. Only a minivan fits those requirements.

I’ll probably wait until the spring to buy. That’s when the annual Consumer Reports auto issue comes out. In the meantime, I’m doing some preliminary research. The Honda Odyssey seems to get the best reviews, but it’s also the most expensive. The Toyota Sienna isn’t far behind on reviews (or on price) and is the only one that comes with AWD. If the controls on the Sienna are similar to our current RAV4, then that would simplify life. On the other hand, I’m not happy that our RAV4 alternator died just a month out of it’s warranty. The Kia Sedona gets decent reviews and is much cheaper, but at the expense of questionable reliability and poor resale value (which might make it worthwhile to buy gently used). Finally, the dark horse is the Mazda5. It was the top rated minivan by Consumer Reports last year though I hardly ever see one on the roads. It is significantly smaller than the others, but it’s cheaper and gets much better mileage. Reviews claim it can seat 7 adults without too much squeezing. We’ll have to test drive each of them, but I would love it if the Mazda5 fit our requirements.

Philip Greenspun recently posted an entertaining review of the 2011 Honda Odyssey. It’s a favorable review, but includes quite a few bits of Greenspun’s biting humor. My favorite was this comment about the lack of progress in automotive technology:

Suppose that you’re a sleep-deprived mother. Your infant is sleeping in the middle row of seats and you’ve forgotten all about him. You go into a store and leave him to bake in the Odyssey’s greenhouse of glass. The child starts to cry. The Odyssey has a sensitive microphone as part of its telephone Bluetooth interface. The Odyssey’s computer system is always on, waiting for a radio signal from the remote control. The Odyssey has multiple interior temperature sensors for the automatic climate control system. Does the Odyssey’s always-on computer have enough logic to say

    IF child crying in interior 
       AND car is parked and off 
       AND interior temperature is above 100 degrees
    THEN
       roll windows down
       send text message to owners

? No. In fact, the Odyssey’s computer will happily sit there, with all of its sensors telling it “a child is being roasted to death”, and do nothing.

Maybe someday our cars will be as smart as our phones. Anyone else have advice on a great minivan?

Feb 18, 2011 - 6 minute read - Comments - medicine education

Medical Student Oral Presentations

I enjoyed @FutureDocs' guide to medical student oral presentations, so I thought I’d share the cheat sheet that I give to the medical students and PA students when I start each teaching block. As she mentioned, presentations always have to be tailored to the listener, and each attending is different, so you’ll see minor differences in what I recommend.

To me, the most important aspects are organization and preparation. I don’t like to have the sense that the student is “winging it”. Prepare for each presentation like you are preparing to give a talk to a roomful of people. For me, that meant practicing the presentation at home and with the residents before I presented to an attending.

I also give each student a printed copy of the guidelines posted at the University of Washington’s medical education site. It goes into more detail about all of these issues. My favorite portion is the graph that they present, which I’ll reproduce here:

Listener Attention

Here’s a printable copy of my cheat sheet.

Initial Presentation:

CC/ID

Be Brief. Gets the listener primed for what type of case is going to be presented.

This is a 33 year old male with a history of asthma who presents with a chief complaint of dyspnea.

HPI

This is the meat of the presentation. Pretend that you’re telling the patient’s story to a friend. How much information would they need to really understand what the patient is going through? Think about it from the patient’s perspective. What was the tipping point that made them seek medical attention? What have they tried to make things better? Stay consistent in your timeline. I like to start at the last point that the patient was completely well. In patients with chronic illness, that is hard, so you may have to start at the last time that they were “relatively” well.

He was completely well (or “in his usual state of health” for chronically ill patients) until 5 days ago, when he noticed feeling short of breath after walking 300 feet to his mailbox. Over the course of the next 5 days, his dyspnea worsened to the point that he was short of breath at rest. He tried taking his albuterol inhaler, but felt no relief. Etc…

It’s also useful to split the HPI into 2 distinct sections. The first part is the patient’s story, as described above. In the second part, you take that story and decide what a reasonable differential diagnosis list would be after listening to the first part. Then provide the listener with appropriate ROS and PMH items to help them rule those other diagnoses out.

PMH

You may have mentioned a few of these in the CC, but repeat them here. For most conditions, just list the diagnosis, but if it has particular pertinence to the HPI, then provide more detail. Also, try to give some indication of the severity of the condition for certain conditions: CHF (EF), DM (A1C), COPD (FEV1).

Past medical history includes Asthma. He has been hospitalized twice in the past year, and required mechanical ventilation in April. He also has hypertension and allergic rhinitis.

Meds

List meds like a robot :-) Include doses if they are important. You’ll learn the importance of doses with experience. In general, if the med is related to the HPI, I want to know the dose. You can’t go wrong by just giving me the dose on each med. Just run through them quickly

FH/SH/ROS

You should obviously have done these portions of the interview, but if they were important, I would have wanted to hear about it in the HPI. (Pt lives in a nursing home… Pt smokes… etc.) It’s OK to go over it quickly, but probably better to say:

FH/SH/ROS is unremarkable aside from what was presented in HPI

Exam

List the VS: Temp/HR/BP/RR/O2 sat. Then provide an overall impression:

In general, the patient appears tired and seemed to be in mild respiratory distress.

Pertinent negatives and significant positives only:

Lung exam was remarkable for diffuse expiratory wheezes with accessory muscle use. Cardiac exam confirmed tachycardia. There was no lower extremity edema and the remainder of the complete physical exam was normal.

Be completely objective. Avoid downplaying your exam skills. It’s OK to get things wrong – it’s often the best way to learn. Avoid patient interpretations here.

Labs/Xray/EKG/Procedures

If it’s all normal, OK to say it’s all normal, but if any are abnormal, I like to hear each value in that group.

ER course

Brief sentence on what happened in the ER before you saw the patient.

Assessment/Plan

Second juicy part of the presentation. Identify each problem and go one by one. Put the most pressing issue first. If the diagnosis is in question, give me a differential diagnosis and let me know what we’re doing to rule out items on the differential. If the diagnosis is relatively certain, present me with various therapeutic options and the reason why you chose the one you did.

Think about “goals of care”, if appropriate

Always mention disposition. What are we looking for before the patient can be discharged? In some cases, this will be nebulous, but at least mention it. “Disposition is unclear at this point because of X”

Overnight course

What happened after you put your plan in place? Brief status report on how patient is doing today.

Subsequent Day Presentations:

1 line about patient:

Ms Jones is our 87 year old woman here with an aspiration pneumonia

Overnight course:

Since yesterday’s rounds, she has had a speech evaluation and they recommended a video swallow study. She had one temperature spike to 38.5 degrees and blood cultures were drawn. She appears to more comfortable this morning, though she is still confused.

Exam: Vitals, superquick exam describing pertinents only

Labs: Any new labs that came back since we met for rounds yesterday.

Plan for today: Go by problem again.

Problem 1: aspiration pneumonia, she’s on D3 of Zosyn and we will continue to followup cultures. Overall she seems improved, but we’ll have to continue to monitor her mental status and oxygenation for further improvement. Problem 2: Altered mental status: This is almost certainly due to her pneumonia, but if it does not improve by tomorrow, we may consider other etiologies. At that point, repeat labs, EKG, and head CT may be indicated. … Problem 53: Disposition …

Be prepared to answer questions if you have been appropiately brief!

Feb 17, 2011 - 1 minute read - Comments - medicine news

Dr. Watson

All I could think of while watching the news about the supercomputer Watson beating humans at Jeopardy was how this could be used in medicine. Looks like I’m not alone.

Time to start looking for a new job?

Feb 16, 2011 - 2 minute read - Comments - medicine

Aspirin for everyone

Aspirin is one of those wonder drugs - simple, cheap and effective versus so many deadly diseases. We know that aspirin prevents heart attacks and strokes, especially if you’ve had one before. There is also some data that it prevents colon cancers, but it was thought that this effect was only seen when using high doses of aspirin. The downside of aspirin is that it increases your risk of bleeding, especially gastrointestinal bleeding (usually from stomach ulcers). Using high doses of aspirin tends to increase the bleeding risk so much that it offsets any benefits.

When someone has had a stroke or heart attack, using aspirin is a no-brainer (secondary prevention). The question is when to start aspirin in patients who have never had a bad event (primary prevention). We used to be much more liberal about recommending aspirin for primary prevention, but there haven’t been many studies which have supported the practice. The current guidelines state to consider starting aspirin for primary prevention in men at age 45 and women at age 55, if their risk of vascular disease outweighs their risk of gastrointestinal bleeding. That’s a wishy-washy way of saying “Leave it up to your gut.” (No pun intended)

I decided to write about this because I saw a recent study showing decreased deaths from cancer in aspirin users, even at low doses. Overall cancer rates were 20% lower and gastrointestinal cancer rates were 35% lower than in people who didn’t use aspirin. These data come from 2 meta-analyses of retrospective studies, which tend to be a relatively weak type of study. Prospective studies are much better, but these numbers strike me as significant.

Given this new data, I would strongly favor using aspirin in most people once they hit those age cutoffs (45 & 55), which for me is pretty soon. Calculate your cardiovascular risk. If your risk is any more than 10% or so, I would recommend taking an aspirin daily, possibly even if it’s lower. The reasons that I would recommend not taking an aspirin are if you have frequent stomach ulcers, previous severe bleeding, or if you’re taking blood thinners or high doses of NSAIDs (ibuprofen, naproxen). Here’s a nice fact sheet that summarizes what I’ve just rambled about (Wish I had seen that before I wrote all this!)

Disclaimer: Don’t take medical advice from the internet. Show this to your doctor so they can tell you what a quack I am.

References:

Feb 4, 2011 - 3 minute read - Comments - car perspective life

I retract my previous tweet

I take it back. I was upset, OK? Never tweet when you’re upset. I’m writing this blog post to make up for it. See, a whole blog post. That definitely outweighs a tweet, right?

Last week, my 1996 Altima died. The starter seemed to be firing, but the engine never turned over. We tried jumping it, but that didn’t work. I called a tow truck and then tweeted about how upset I was with the universe.

Snarky, huh? Even stuck the childish #kthxbye in there. Blaming the universe is kinda like getting upset with God, in a scientist’s mind.

But, it’s been a week now, and I’ve had time to think about it and I now realize how lucky I am. Not just in general, because that’s certainly true and something that I remember every time I come home and see my beautiful wife and kids. But, how lucky I am that my car died. Let’s look at some details. The car was in our neighborhood’s parking lot when it died. I was coming home from work and saw Mala and the kids playing at the playground, so I pulled into the parking lot and played with them for a while. When we got in the car to go home, the car wouldn’t start. The car was dead in a parking lot, in a safe neighborhood, walking distance from our house. Just think of all the other places that it could’ve died. How lucky that it died in that location, where it was easy for a tow truck to access, where it was not in the way of traffic, where it was safe, and most importantly, where it was easy for everyone to get home. The kids enjoyed just about every moment of the experience (just like Kavi did when our RAV4 died in much more stressful circumstances in NYC last fall).

The tow truck came, did a little testing and then dutifully towed the car to my mechanic and dropped the key in their dropbox. They found a distributor filled with oil and some worn out spark plugs. The fixes weren’t cheap, but they weren’t too expensive (using rebuilt parts). I was driving again about 48 hours after the car died and life is back to normal now. Again, how lucky is that?

I was also thinking about the previous time that the Altima died. I remember writing this affirmation in my journal, while I was waiting for the tow truck back in September 2008:

Late entry. This was written on the day that the Nissan’s battery died. Everything will be fine. I will find out later how this will be a blessing in disguise. This car will give us another 2-3 years of great service.

It’s now been 2 and a half years since then and the car has been steady and reliable throughout that time. How lucky can a guy get? The Nissan is pushing 140,000 miles and it’s not the most convenient car with the 2 carseats taking up the whole back seat, so I think it’s time for a new car, but how lucky that I have the luxury of taking my time to find one?

So, Thank you Universe! I look forward to the next lesson that you’ve got in store for me.

Nov 7, 2010 - 3 minute read - Comments - business book-review

Growing a Business

I read this book in 2005, but never posted this review. So here it is…

Growing a Business by Paul Hawken

This is an honest and practical guide to running a business. I don’t remember where I first heard about this book. Maybe Lars?

It was written in 1987. Hawken talks about building a business. It’s often portrayed as a heroic or glamorous endeavor, but really it’s not. It’s a lot of hard work, but also a lot of common sense. He spends a chapter talking about a quality that you need to be successful in your own business. He calls it Tradeskill.

It’s like intuition, for business. He says its something you can’t acquire easily, except perhaps in childhood. People that were drawn into business activities at a young age have it. Those that weren’t, don’t. And no amount of book-smarts can make up for the lack of Tradeskill. If you’re not comfortable haggling in a flea market, you should think twice about going into business. Instead, he recommends dipping your feet in the water, without starting a business yourself. Take a part time job in a business that you’re interested in and try to take on as many roles as possible in that business.

Another theme in his book is the wisdom of growing slowly. Having too much money while starting a business is worse than no having enough. It’s something I read a lot now (Arsdigita, Paul Graham, 37Signals), but it’s interesting to see it written way back when as well.

Things I learned from this book

It’s probably not for me

Starting your own business is not for everyone. It takes a temperament that isn’t easily learned. I don’t think I have Tradeskill. I’m not going to let that stop me from learning about business, but I’m going to be a little more thorough in my planning and preparation if I ever do it.

The 5-15 report is a good idea

He mentions something called a 5-15 report. it’s a report that every employee in a company should have to write every week. It should take less than 15 minutes to write and less than 5 minutes to read. Part I is a progress report for the week, Part II is a report on the morale of the department and Part III is one idea to make the company better. I like the idea of a weekly low-commitment progress report.

Overstaffing is the root of all evil

A major problem of big business is over-staffing. Once an employee learns that their work is redundant, or requires little effort, they realize their job is expendable and that they must spend all their time preserving their job - through hijacking credit, office politics, etc. The basic result is that people hoard information. Information that, if freely disseminated, would allow the company to function better. If I have useful information that other employees don’t have, then I am valuable. Understaffed companies (start-ups) work in the opposite way. I have enough work as it is, so I’m happy to share information with you, because perhaps it will allow you to help me out with my workload. The company becomes more efficient. I see this effect of over-staffing where I work (although I didn’t recognize it as such until reading this book)

random quotes / concepts from the book

Flat management/employee structures are good. Trust the people you work with and give them wide latitude.

Problems are opportunities - dive into them.

“A good business has interesting problems. A bad business has boring ones.” (p. 39)

Have a partner. You shouldn’t ever think of going it alone.

“Being in business is not about making money. It is a way to become who you are.” (p. 19)

Nov 6, 2010 - 1 minute read - Comments - family parenting

First full phone conversation with Kavi

I had my first full phone conversation with Kavi today. I was about to leave work, so I called home to let Mala know that I was on my way home. (For the second time… I got called back to help in the ER on my first attempt, but that’s another story). When the phone rang, Kavi picked up the phone. “Hi Daddy, when are you coming home?” I told him that I was leaving now and that I’d be home in half an hour. “OK Daddy. Bye!” Click

Hopefully, he gave the message to Mala :-)

Nov 5, 2010 - 1 minute read - Comments - linux programming

Autopoint

If you get this error message:

Can't exec "autopoint": No such file or directory at /usr/share/autoconf/Autom4te/FileUtils.pm

Then, you need to install autopoint:

sudo aptitude install autopoint

I ran into this while building ledger today and had never needed to do that before. The error that acprep provides is even more cryptic:

Automatically preparing build ... Warning: autoreconf failed

Then, I ran autogen.sh and the autpoint error showed up.

Nov 5, 2010 - 1 minute read - Comments - elisp programming emacs

Making blog posting easier

Another piece of advice that I’ve heard over and over again is to make things easier. Automate! In that vein, I learned a little elisp in order to make it easier to create a new blog post. I create my posts in emacs, but I often cut and paste the YAML header from a previous post, which is tedious and time-consuming. Here is my new posting function:

(defun vk-blogpost (title)
  "Create a new blog post."
  (interactive "sPost Title: ")
  (let ((slug (replace-regexp-in-string " " "-" (downcase title))))
    (find-file (concat "~/web/kurup.org/_posts/"
                       (format-time-string "%Y-%m-%d")
                       "-" slug ".markdown"))
    (insert "---\n")
    (insert "date: " (format-time-string "%Y/%m/%d %H:%M:%S") "\n")
    (insert "layout: post\n")
    (insert "title: " title "\n")
    (insert "categories: \n")
    (insert "---\n\n")))

After asking me for a title, it creates a new file and massages the title to create a slug. It automatically enters the date of the post, both in the filename and in the YAML header. This took me about an hour to write, mostly in googling elisp commands. Hopefully, it will save time in the long run, but even if it doesn’t, it was fun to write :-)

Any feedback on my primitive elisp would be appreciated!