Navigating Open Notes and the Information Blocking Rule: an AMA innovation panel discussion

AMA Physician Innovation Network Avatar
from the AMA-Assn.org website

https://innovationmatch.ama-assn.org/groups/ama-physician-innovation-network-public-area/discussions/navigating-open-notes-and-the-information-blocking-rule

There are a whole bunch of Open Notes experts (and also me!) on a panel this week (ends tomorrow!) discussing Open Notes experience in regards to the Information Blocking federal rule. Come join us! Ask challenging questions! See what others have done! Lots of discussion on the pros and cons, the pitfalls and the successes.

“The unattainable best is the enemy of all the available betters” @Bill Burnett

You have more than one life in you. Lets ideate THREE 5-year visions. Do this exercise to generate creative possibilities. — Bill Burnett

In my clinical practice this week, I met a patient with whom I discussed this idea: he was a senior administrator in an academic institution, highly accomplished, well respected, and yet quite miserable at work and at home, feeling trapped.

It made me think back to Design Thinking principles, and creative approaches to hard problems.

Having been to the Design Thinking for Social Systems short course at Stanford, I’ve been working to apply this thinking at work and at home. I posted last year on my enthusiasm for design thinking as a process and approach to creativity and innovation. I came across Bill Burnett’s online video which prompted me to dive back into the material again.

A couple of books to recommend.

Designing your life by Bill Burnett and Dave Evans. More about applying design thinking principles to your life.

Bill also gives an overview in his great Stanford TEDx talk.

Creative Confidence by David and Tom Kelly. A history and principles of design thinking by some of the originators

Designing for Growth by Jeanne Liedtka and Tim Ogilvie. A practical book for application of design thinking. See also the Field Guide.

It made me think of myself, my work, my home, and how “designing your life” might be an exercise we could all apply with immense benefit. Join me?

CMIO’s take: What are you waiting for?

Big data graphics: NYTimes – Every Building in America (and Ed Tufte)

In informatics, we often are faced with big data sets and how to make this data comprehensible. Here is an example from cartography. Beautiful graphics, highly usable. We can aspire this “data density” in our own graphics.

My favorite book crafting great information graphics from data, is of course Edward Tufte’s Visual Display of Quantitative Information. He talks about data density, sparklines, lots of cool stuff. AND he has an online course. I have been his disciple for years, and have ALL his books.

The only thing better than gathering and making sense of big data, is being able to explain it clearly to change minds and behavior.

My Failure Resumé (a talk)

What lessons can we learn from CT Lin’s failures?

Thanks to the Colorado Chapter of HIMSS (Health Information Management Systems Society) and to Bonnie Roberts and Rich Morris for co-hosting my presentation.

Based on my recent Failure Resumé 1 pager. Here are some personal stories, life lessons, and 3 exercises to help you build a failure-tolerant future.

With, of course, a bonus ukulele song at the end.

CMIO’s take: Have you written a failure resumé? Are you building a failure tolerant future? Let me know in the comments.

The Narrows at Zion Canyon: a visual travelogue

In November of 2020, my son and I toured the Southwest US. One of our stops was at Zion Canyon National Park, where we were excited to experience the Narrows. It seemed a great way to escape the pandemic and get away. Spend a few minutes on the journey with us!

Driving, we arrived late in the day at Zion lodge, in darkness. We saw this improbable sight outside our cabin in the morning: canyon walls rising thousands of feet overhead, just outside our door.

We had rented dry suits from Zion Adventures, and laid out our clothing that evening for the hike ahead. In case you’re wondering about the hyperlinks, no this is not a paid post. Just a joyful recollection of an aging parent…

Double boot liners, grippy-soled rubberized river boots, an impervious suit with rubber-gasketed pants and sleeves, and a huge diagonal waterproof zipper across the chest. Hard to wrangle but exciting! We felt like spacemen. We wore several clothing layers underneath.

Normally the Narrows is a super-popular hike through the spring, summer and fall. We had thought that with the pandemic and with wintry November weather, we would have no trouble booking a shuttle ride from the Lodge in the park up to the entrance of the Narrows, 3 miles away. Suffice it to say, plan ahead. Fortunately, we found a last-minute shuttle option with seats remaining. Whew, disaster averted. Otherwise, the lodge had offered us “bikes to rent and ride up there, suits and all.” That would have been more adventure than I needed.

We walked the paved path for the 1st mile. Giddy and nervous, we passed a number of casual hikers who stared at our gear, our dry suits, our 6-foot wooden walking poles, our backpacks. Here, with the residual heat deep in the canyon, the last remnant of fall colors contrasted with the snowscapes outside the park.

And then: the pavement ends. Into the stream! I can feel the cold water sloshing around inside the boot. Hey! my feet stay dry! I don’t care about splashing because I’m sealed in up to my neck, and my backpack has a dry sack inside with food and water. The cyanobacteria poisoning warnings do not deter us. Upstream we went.

Did I mention the incredible geology? We feel puny in its presence.

I was surprised at the grip of these rubber soled river boots. Crunching upstream over large and small rocks was easier than expected. Where was all the slipperiness, the unstable rocks, the twisted ankles? The equipment smoothed that away. I grinned at my son; this was a blast. The water depth was up to a foot and the going was not hard. The current ran a couple of miles an hour.

As we saw fewer hikers, the enormity of the cavern became apparent. At one point, it appeared that the walls were maybe 3 football fields tall, 1000-feet-high sheer walls of stone. These walls plunged right down into the river with no shore or beach to speak of.

From there the river got deeper and faster. In about an hour and a half we arrived at the fork to observation point on the right, with photographers set up to catch the changing light in the canyon. Then we took the left fork to “Wall Street,” presumably named for the impressive sheer walls narrowing in.

At times, the water rises to the hips. Some hikers with only waterproof pants turn back. One couple raised their jackets, exposing bare midriffs to keep their clothes dry, and gamely walked through the first deep crossing. That must have been cold, with the water at 40 degrees. It is sunny, but also snowing.

At a rock outcropping, we paused for lunch. We find a few larger boulders, unpack and have our bagels. Suddenly ravenous, we savor the calories, noticing snowflakes drifting down 1000 feet into the canyon. The light is peculiar: in shadow, with sunlight bathing the Canyon just around the curve, blue sky overhead. It looks like indoor light because of all the bounce and reflection.

This is our turn around point. We rest, recharge, hear the stream burble, feel the snowflakes, our hunger sated, snug in our dry suits, we smell the fall giving way to winter.

It feels – cold, but I’m sweating from effort. The canyon appears unforgiving, but we have supplies and equipment up to the task. Flash floods and cyanobacteria poisoning are a risk, but we have mitigated them. Unlike more extreme adventure-seeking adrenaline junkies, this is the degree of risk and adventure I’m ready for.

It is time to head back. Downstream, like downhill, would be quicker. My main concern was balancing Seeing with Photography.

There is the disappointing idea that the more photos one takes, the less the brain experiences. Or maybe not. Yes, there’s more to show off when you get home, but were you really present? Or did you just line up and frame the shot? But, if you don’t take photos, how interesting is your blog post later? #FirstWorldProbs.

I tried to do both. Who knows.

Downstream was a pleasant splash. Yes, it was 1.5 times easier and slightly faster. There was little resistance to swinging the shins through the water as it flowed with you.

There are great speedway-sized curves to this river, as the millennia of water microscopically carry away molecules of rock every day. The views are magnificent.

It is a hike that promotes mindfulness. Your focus is required for not-stumbling, for pushing upstream, for awakening your senses. The constant, echoed river babble precludes idle chatter.

It is: exploration, sightseeing, photography, companionship, escape, reflection, effort, appreciation for dry-suit and photographic technology, wonder, mindfulness, pure sensation, focus, curiosity, pride of offspring, joy. All at once. Each in turn.

We emerge from the river, dripping and yet perfectly dry. We make our shuttle home.

A perfect day.

The Eppendorf, CRISPR, Covid, and my medicine origin story

This post is THREE THINGS. A personal origin story, a (brief) book review, and a connection to recent stories on Pfizer and Moderna Covid vaccines. And, when we’re done, it might even tie together!

Image above: Dr. NoFronta Lobe, Mad Scientist. No this is not me in the research lab; this is me, a kindergarten parent at Halloween

My Origin Story (I was a budding molecular biologist in 1985)

I was alone in the brightly-lit sterile-white research lab; having spent 20 hours on a long, multi-day experiment. It was nearly midnight on Saturday in 1985. I was a college junior majoring in molecular biology, with aspirations of a scientific research career. I was studying P4 bacteriophage, a virus that attacks E coli bacteria.

The work sequence, I could now perform by heart: inoculate, incubate, centrifuge, enzyme reaction, pipette (fancy eyedropper tool) into an Eppendorf tube (a tiny plastic tapered tube. From a Q-tip-loaded with a single bacterial colony, I had carefully grown a quart of bacterial culture, then sequentially purified my sample down to 20 drops of a pearlescent white DNA solution.

So: 20 hours for 20 precious drops. 

Eppendorf tube, Fisher Scientific

Exhausted and looking forward to heading home, I was on my last steps before overnight refrigeration, so as I held the open Eppendorf in my left hand and my pipette in the right, I randomly thought: “What time is it? Am I going to miss the last Orange Line train going home?”

So, I moved to look at my watch…

And since my watch is on my left wrist, the Eppendorf tube in my left hand did a 180…

And I watched as all the liquid ran out … and onto the floor. 

I looked at the upside down Eppendorf, and then down at the floor and the drops of liquid there, uncomprehending. 

*How… what… nnnnnNNNNNOOOOOOOOOOO!!!*

My late-night-fogged brain finally registered SHOCK, DENIAL, ANGER, BARGAINING. The lab was deserted, I deemed it safe to express myself:

“F$*&@! S!#%! D&$%!” I said, eloquently.

Desperate, I dropped down and started using the pipette to suck up DIRTY droplets of DNA extract from the floor and replace it into the Eppendorf. After a few minutes I had about 1/3 of the liquid, now brown-tinged, back in the tube. Resigned, I put the tube in the fridge. 

NO time to fret, no time to start over. Nothing else to do. I got on my jacket and faced the Boston winter, and jogged for the Orange Line stop. 

Once on board that last train, I started to sob. There was no way that soiled sample would be any good. This COMPLETELY SUCKED. 

And, I realized, I really did not want to be here. I realized: I could do the scientific work, but, unlike some colleagues who revelled in long hours in pursuit of new knowledge, I was despondent, not very good at this, and missed being around people. 

That was the night I decided that bench research was not for me. I had thought my calling was in pure science, but this DNA catastrophe taught me where I didn’t want to be. I needed Humanism AND Science. So, medical school it was. I’ve never looked back. 

Molecular Biology after 1985 (CRISPR!)

Thirty-five years later after my profanity-laced change of career, Walter Isaacson chronicles the recent successes of genetic research, including the discovery of CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats) and CAS9 (CRISPR ASsociated protein #9).

Book review rating? 5/5 stars.

In a nutshell: Jennifer Doudna and Emmanuelle Charpentier, and many others raced to understand these strange “repeating sequences” in DNA and mRNA, realizing that they were bacterial defenses against “phage” viruses.

In this work, they discovered that CRISPR-Cas9, an mRNA plus protein complex could identify attacking virus mRNA and SLICE IT UP, deactivating it. They realized that this ancient protein complex could be taught to identify ANY RNA or DNA. Gene editing, invented by bacteria as a survival mechanism a millenia ago, co-opted by humans. Precise genetic scissors.

I enjoy Isaacson’s writing style. Not only does he clearly explain the adrenaline rush of scientific discovery (and the delicate dance between scientific sharing versus the race against other labs to publish and claim credit), but also the technical details of how CRISPR works.

Isaacson writes about Doudna and the response to Covid-19. What is even more astonishing about Dr. Doudna, the bench researcher and lab leader at Berkeley, is that she had the socio-political skills to bring together 40 leading geneticists across the Bay Area to successfully set up a brain trust to develop Covid-19 testing and vaccine development. This team lays much of the groundwork of the accomplishments of this past year.

Drs. Doudna and Charpentier were, deservedly, awarded the 2020 Nobel Prize in Biology “for the development of a method for genome editing.”

A personal note: my brief journey in molecular biology never quite crosses Dr. Doudna’s path, but I recognize the genetic tools mentioned, and studied the work of the luminaries in the field. I feel like a distant cousin to these scientists.

Highly recommended read, to understand the genetic foundation of our modern age.

Molecular Biology: the Covid fight

Here are 2 stories about Covid Vaccines, from the New York Times and WIRED.com, fascinating glimpses into the genomic-industrial complex. As of May 14th 2021, 36% of US adults are vaccinated against Covid-19. It is highly likely that these speedier and more effective mRNA-based detection tests and vaccines will forever be part of our lives. This could shorten development and improve accuracy of future vaccines.

WIRED.com story on Moderna’s Covid Vaccine trials

https://www.wired.com/story/moderna-covid-19-vaccine-trials/

CMIO’s take? Our modern world is built from advances in scientific method, computing and now genome editing. Despite my early failure in the lab, I feel fortunate, in the field of medical informatics, to be close to all 3.

Biochemistry of Condensates: hidden mechanisms of how life works

What are Condensates, and how do they enable the machinery of life inside cells?

https://www.wired.com/story/a-newfound-source-of-cellular-order-in-the-chemistry-of-life/

Click the link and read about Condensates. Since middle school, when I first learned about cells, and then later learned about nucleic acids and “self-assembly”, it has always puzzled me how everything gets to where it needs to go, at the speed that life happens.

In the context of SARS-CoV2 (the virus causing Covid-19), how does the mRNA that is injected into the cell by the virus find the ribosomes that encode the Spike protein and assemble daughter viruses? How does the ribosome find all the amino acids among the millions of molecules to assemble the right proteins? How do the assembled proteins move to the right spots on the cell membrane?

I can imagine a lonely ribosome with an attached mRNA just WAITING for the right amino acid to come along to assemble the next link in the protein chain. How does it happen so fast?

If movement in a cell is dependent on just Brownian motion (random vibrations), it seems like it ought to take a LONG time (minutes? hours? days?) but it takes seconds.

Now it seems like Condensates are how this works.

CMIO’s take? Every time we think we know something about microbiology and that we know how deep the rabbit hole goes, the rabbit hole always goes deeper, my friends. What are YOU reading to expand your horizons?