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?

Grand Canyon: optimism, knees and fatherhood

In November of 2020, my son and I set out on a cross-country adventure to check on my parents in Los Angeles. Here are some life lessons (for me).

The CANYON

In November of 2020, my son and I set out on a cross-country adventure. We stopped and hiked the Grand Canyon, on our 2000-mile round trip.

The Buick

By Arthur Hu (Wiarthurhu at en.wikipedia) – Transferred from en.wikipedia to Commons by Kobac using CommonsHelper on Labs., Public Domain, https://commons.wikimedia.org/w/index.php?curid=18438206

About 30 years ago, my parents drove me out in our Buick Station Wagon with faux wood paneling to attend medical school in California. On the way, we stopped by the Grand Canyon, goggled at the enormity of seeing a canyon 17 miles wide. On that day, with the smog, the North Rim looked more like a dingy painting rather than an impressive canyon. We read about adventurous souls who would hike down into the canyon either by mule or on foot, but it would never be us.

I have always dreamed about coming back and doing that hike, down to the river, and back. 

The Road Trip

Fast forward to 2020. My 18-year old son agrees on a 2-week road trip with Dad during his pandemic-infested gap year, so off we go. Finding my parents healthy, we spent a few days together in Los Angeles, and then headed back homeward.

On our return leg, we stay at the Grand Canyon Lodge. We take out our maps of trails to plan the next day. I reveal to him my long-forgotten, yet deep-seated hope of the massive Rim to River to Rim hike in one day. “Hey, it’ll be fun! What an adventure!”

The Lecture

To my amazement, my son starts lecturing me about knowing my limits.

Son: “Dad, you know this is 10,000 feet of elevation and 17 miles IN ONE DAY.”

Dad: “Yeah, I know. I can do it.”

“No, Dad, you haven’t trained for this. This is like climbing a 14-er. Remember how hard that was for you? Also like the ski-up to the 10th Mountain Hut trip. Remember how you said you would NEVER do that again? This is like that.”

“Oh. Right.”

“Wow, I sound a lot like Mom.”

“Yup, your mom always says that Dad has too much unwarranted optimism for his own good.”

“Um-hmm.”

“Well, it has been a dream of mine to hike down to the Colorado River at the bottom of the Canyon someday, and I think tomorrow is my chance to do it.”

“Sigh. Ok, sounds like your heart is set on it. We will have to make sure we give ourselves enough time. The ascent will be the hardest. Lets see…”

And so, my son the planner, set it all up. 

The Plan

  1. We get up at 4 am
  2. We arrive at the shuttle bus stop by 5 am (first bus), since no one is permitted to park AT the South Kaibab trailhead.
  3. We set off with flashlights on the trail at 5:15am. We allocate 4 hours for the descent, 7.7 miles, 5000 feet from 7500 to 2500. 
  4. We plan on 30 minutes for a meal at the river
  5. And then upwards, estimating 1 mile per hour for old Dad. Nearly 8 miles, nearly 8 hours. 
  6. We hope to reach the Rim again before dusk at 5pm. 

Whoa

Our first surprise: switchbacks. My son is in the lead, and he suddenly shouts “WHOA.”

Turns out our flashlights only see about 6 feet in front, and the switchback came up quickly, and his next step would have been…(shines flashlight), into the abyss. On our return trip, we look down, about 300 feet to the first rock outcroppings.

Whew.

IMG_9195.jpg

A bit chagrined, we continue. About 20 minutes later, we pause. Look up at the stars. The Milky Way about as bright as we’ve ever seen it. No sound. No birds. No wind. No hum. When it is THAT quiet, your ears sometimes make up a faint ringing just to fill the silence…

A minute later another traveler, jogging along. 

Son: “Hi there! How far you going?”

Traveler: “Rim to Rim to Rim. Have a good one!”

Wow. There is always someone crazier. 

The Glow

About an hour later, an orange glow on the horizon. Second hour, the crests of the North Rim start to glow bright orange. 

We take a water break, a potty break, small snack, then back on the trail. Fortunately, very cool still, 50 degrees, no wind, sunrise is spectacular in phases. I forgot my hiking poles! D’oh! but my knees were still doing remarkably well. 

The Mule Train

Third hour, sun is definitely up, and we get passed by the mule train.

Remarkable how fast those guys go. Clip-clop, doesn’t seem fast, but they keep really constant speed over everything. They pack in water and supplies for Phantom Ranch, and pack trash back out. Very cool. We must stay there someday. 

The River

8:30 am: We see the bottom of the canyon! and arrive at the Colorado River, bright green. 

The 3 Layers

There have been three layers of canyon: the very big painterly one, the middle sub-canyon that appears 2 hours into the hike, and then the final mysterious crevasses where the actual river runs now. The way it unfolded was brilliant and super-cool. In other words, I have no adequate words for it. 

Arriving at 8:30 is heartening. We are ahead of schedule. I did scrape my knee after the second switchback up top, and turns out, I have 4 sizable gouges in my knee, but the adrenaline blocked all the pain. Some blood seeped through my thick pants. My red badge of courage. Lunch of 2 bagel sandwiches, water. I always soak my feet in rivers or oceans when available (habits of a Florida boy), so 5 minutes in 35 degree water is about all I can take, but wow it is awesome after 7.7 miles. Brush off the sand, socks, boots back on. We are back on the upward trail at 9 am. 

The Upward Path?

Son: “OK Dad, I’m expecting us to go 1 mile an hour including stops, so we should be up by 5 pm, just before sunset. Let’s get going.

Dad: “I can do it. I feel pretty good.”

“Yeah, but it’s UPHILL now.” 

A couple more mule trains pass us going up. Some horseback riders from Phantom Ranch. Not many people on the trail really. We were up before most, so we only see 3-4 hikers in the first 3 miles, then only 10 going the other way in the rest of the hike (Ranch lodgers or Angel campgrounders). We flip the masks on for every one who passes. The ascent is hard on the old knees, but manageable. We allocate 30-minute scheduled breaks for water and trail mix, seems like a good schedule. Met some mules: they have names! (Betsy, Parker, Ralph). 

Finally, the sun hits part of the South Rim trail (otherwise in shadow all this time). And from pretty-cool, it becomes BAKING HOT. How does that happen so fast? I’m suddenly grateful for November, and a non-busy trail. Now we are looking for shady spots to rest and hydrate.

The False Summit

It is amazing to emerge from lower canyon to mid, and mid to upper. The false-summit problem comes up repeatedly. The top looks so close! but SERIOUSLY? THIS is not the summit, and there is another couple thousand feet! Too bad I did not note the starting altitude on my watch. 😦

My son notices that my pace is flagging as we ascend, and asks me in the later miles: 

“Want to rest here?”

“No. If I stop, I will lie down and cry, and I won’t ever get up again.”

“Ok”

The Non-verbal communication

The last 2 miles, we see kids and families hiking tentatively down, we see the dropoffs and switchbacks we did not see before. We see the massive vistas that we did not see before. The son starts getting annoyed with Dad taking SOOOOOO MANY PHOTOS.

Reviewing photos, now we can see him being fed up. Funny I didn’t see it when taking his photo. So much for my ability to spot nonverbal communication (one of my supposed specialties). 

IMG_9242.jpeg

We arrive at the top, giddy as schoolkids. Dad Survives. We shuttle back to the car. It is only 2:30 pm at the top. Take that, pessimistic son! 

Son: “Proud of you Dad. Good job. That was amazing. Whoo!”

Dad: “I need a BIG PIZZA and then shower and bed. These rubber legs are DONE.”

IMG_9341.jpg

CMIO’s take? Don’t forget the hiking poles. And, sometimes sons (and canyons) have hidden depths.

INFORMATICS: Put the road signs on the road, not in the garage

Why make folks go to training or read a tip sheet if you could guide them just-in-time as they do their work?

Here’s a lovely example of our Physician Informatics Group (Large PIG) evolving as we improve the “intelligence” that our Electronic Health Record (EHR) supplies to our hardworking providers (physicians and advanced practice providers).

In the past

clinicians might have pulled up an app on their smartphone dedicated to the ASCVD: atherosclerotic cardiovascular disease RISK CALCULATOR, punch in some numbers and get a result to type back into the EHR.

Later on, some well known national websites would do the calculation for you. Still requires finding the website and typing in numbers.

Even later, we would put hyperlinks within the EHR to link you automatically, but the typing was still required to get an answer.

NOW

we have built a smartphrase (while using the EHR, in any text field, type “.ASCVDRISK”, hit the RETURN key, and Voila, the answer above:

Risk calculated based on what the EHR knows about your patient: age, sex, diabetes, smoking, blood pressure, cholesterol. AND THE ANSWER: 9.1%. FURTHERMORE, disappearing help text guides you to use this information appropriately, and only saves the relevant info to keep in your progress note.

My colleague’s wonderful metaphor for Clinical Decision Support like this?

Put the road signs on the road, not in the garage.

It is already hard enough to use an EHR with patients. Don’t make me go looking for that training document from weeks or months ago, don’t make me think. Make it easy to do the right thing. It is a small celebration every time we can do this right.

CMIO’s take? Thanks to Rich Altman MD for a beautiful new tool in our system. What road signs can YOU take out of the garage and put on the road?

Predictive Analytics or Predictive Shrub?

What can informatics learn from a plant?

https://www.wired.com/story/the-humble-shrub-thats-predicting-a-terrible-fire-season/

The chamise plant in California is a harbinger of a high risk fire season this summer. Fascinating analysis of ecology-based prediction.

CMIO’s take: What can informatics learn from a plant? Sometimes simple methods can be effective.