Transitioning to a New EMR | American Resident Project →

A couple of recent posts [1] have posited that dramatic change will happen as millenial doctors (currently in med school, residency, or junior positions) move up the ranks. This post from Danielle Jones MD is representative of what we are likely to see—astonishment first at the state of current EMRs and incredulity at health care workers resistance to change for improvement. At the very least, millenials may finally resolve medicine and technology’s tenuous relationship.

  1. ‘Can technology be a change agent for health care?’ by Jay Parkinson MD MPH; ‘Change will happen when millennial doctors step into leadership roles’ by Davis Liu MD  ↩

✚ Tech Rounds - Pinboard

[This is the first post in a new series I am launching about the digital tools I use and how I use them. I am always fascinated to read others’ posts about the tools they are using, especially ‘tech people’ who always seem to have the coolest toys. Through this series, I hope to introduce people to tools they may have never seen or novel workflows…at least that’s the idea. Please contact me with any feedback or suggestions for new things to include in Tech Rounds.]

I chose Pinboard as the first subject for Tech Rounds because in less than a couple weeks, it became an indispensable tool for me. Give it a shot and I think you will find it indispensable too.

What is Pinboard—Pinboard is a web-based bookmarking service. Instead of bookmarking a site in your browser, you send it to Pinboard. At the most basic level, it saves a website URL, a title for that URL, a short description, and tags. Though that is the bulk of what Pinboard does, its simplicity belies its power.

Web-based means universal access—The biggest appeal of any web-based service is that so long as you have an internet-connected device with a web browser (a low bar these days), you can access the service. Creating bookmarks in your browser is convenient, but it confines those bookmarks to not just that computer but the specific browser on that computer where the bookmark was created [1]. Also, there isn’t much you can do with browser bookmarks; you can’t save bookmarks from other devices or apps and those bookmarks can’t be sent elsewhere. With Pinboard, you can access your bookmarks from anywhere and do lots of things with your bookmarks.

A universal inbox—I spend many spare moments browsing through content on the internet, usually on my iPhone. Often, I don’t have time at that particular moment to read a 5,000 word New Yorker article, or even a 300 word blog post. Or I come across an interesting service or uniquely designed website that I’d like to take a look at later. I need a single place to stash those things. Previously, I’ve tried using regular bookmarks, Evernote, Instapaper, even a plain text file; each has their own drawbacks [2]. Pinboard’s universal accessibility, simple design, great search, and integration with other apps make it a perfect place to not only stash things temporarily but permanently.

Saving to Pinboard—The simplest way to save a link to Pinboard is to go to the website and add it manually. This also happens to be the most inefficient method. Pinboard supplies a bookmarklet which you can install in any browser’s bookmark bar. Clicking this bookmarklet on any webpage brings up a pop-up that allows you to save the page to Pinboard. This is probably the most common way to save links. I use it often, though I use a slightly different bookmarklet [3]. Many apps have integration with Pinboard, which represents the other way I add bookmarks. My Twitter clients have mechanisms for me to send tweets and links directly to Pinboard. You can also do things like connect your Instapaper account so that when you favorite an article in Instapaper, it automatically send it to Pinboard. IFTTT also supports Pinboard, which increases the uses of Pinboard exponentially.

Using bookmarks—While I use various methods to get bookmarks into Pinboard, I really only use the basic website to access those bookmarks later on. The minimalist design of the website make easy to use and the search functionality with tag cloud make finding anything a breeze. The only other places I access Pinboard is through ReadKit (a Mac app I will cover in a future post) and my iPhone [4]. Pinboard is also my default ‘read later’ service.

Never delete—With regular bookmarks, Instapaper, and Evernote, I feel compelled to keep things neat and organized. I give Pinboard no such regard. I have a low threshold for saving something to Pinboard and almost never delete anything. Pinboard’s search makes such a cavalier attitude acceptable. Search is quick and comprehensive; I have yet to have a problem finding something [5].

Hopefully this has given some insight into how I’m using Pinboard to make my life a little easier. This is only a primer; there are many, many more features and uses for Pinboard (I didn’t even mention the social features…probably because I don’t use them). For a little bit more on Pinboard and some other tips on how to use it, check out ‘A Beginner’s Guide to Pinboard’ on Shawn Blanc’s blog. Please let me know if you have any questions or comments.

[I have no relationship with Pinboard, financial or otherwise. I would not promote something on mediio if I had such a relationship.]

  1. Yes, it is very much true that synchronization in Chrome and Safari has changed this to a degree but those services have not made the bookmarks universally accessible.  ↩

  2. Regular bookmarks aren’t easily or universally accessible and aren’t searchable. Evernote will work as a universal inbox, it just seems ill-suited to the task. Instapaper was my go-to universal inbox before I switched to Pinboard. But, like Evernote, it really isn’t designed for bookmarking stuff temporarily. Plain text files for bookmarking…I don’t think I even need to discuss why that is a horrible idea.  ↩

  3. Per Shawn Blanc’s suggestion, I’m using Joel Carranza’s “Particular Pinboard” bookmarklet. Installing this bookmarklet is a little tricky because it’s only hosted on github. Here is the easiest way to do it for most people: Install the default Pinboard bookmarklet following their instructions. Once you have done this, go to this website and copy all the jumbled text on it (don’t worry, this is just the raw javascript from Joel’s bookmarklet). Now go to the original Pinboard bookmarklet in your bookmarks bar and right-click to edit. Paste the copied code into the ‘address’ or ‘URL’ field (which should already contain some jumble that starts with ‘javascript’). Then save this.  ↩

  4. Several Pinboard apps exist for smartphones and tablets. I’m currently using Pinner on my iPhone, but am still open to suggestions.  ↩

  5. Recently, I wanted to reference all the 23andMe stuff that went down a few weeks ago for a post. Instead of searching Google or my own blog, all I had to do was search ‘23andMe’ in Pinboard to find virtually everything I had read myself on the subject.  ↩

Medical trainees have access to far too many resources | Sharon Rikin MD →

But often we are too far removed from the actual money exchanging hands to see the necessity in practicing cost-effective medicine.

In addition to being removed from the impact of care costs, we are far too removed from the other 'costs' of tests—time, pain, and sequelae (i.e.—additional testing, scarring, stress, etc). For most of us, it is a simple checkbox on a screen. I think we need to be periodically reminded of all costs, not just financial ones. And I agree with Dr Rikin, we constantly need to ask ourselves, 'What is the one best test?'

Twitter buzz about papers does not mean citations later | Nature →

The title of this article should be updated to include ‘…for now’. Despite the number of active participants we see in our own online circles, the use of Twitter among academics is still relatively novel. Among my professional colleagues [1], I would estimate less than %10 actively participate online and even less than that use it as a professional tool [2]. Among my medical school classmates, use is muuuucch higher, but again, students are largely not using it as a professional tool and certainly not using it to keep up-to-date on the latest research. In the near future, this will change—more and more academics will become active on social networks and a greater percentage of their use will be for professional purposes.

  1. That is, more senior colleagues that I research with and those working as attendings.  ↩

  2. As opposed to using social media to keep up with friends and family or interacting with other for purely recreational purposes.  ↩

Doctors and Secondhand Stress | 33 charts →

An excellent post from Doctor V. I truly think this begins with scheduling. I have worked with physicians who regularly overbook their schedule; their care suffers. They don't think it does; they tell themselves that they are doing a service to their patients by squeezing an urgent appointment in, but neither is true. Good medicine takes time. Avoiding passing on secondhand stress is partially about mindfulness and focus when you walk in the exam room door, but this is certainly better accomplished when you aren't thinking about the 5 other patients already waiting.

Finally, Digital Health Startups Get The Same Toys As Everyone Else | Omada Health →

This is an older link, but I missed this news originally and think it is vitally important to anyone interested in medicine and technology. In the past, many tech companies that provide useful tools for startups (like Amazon Web Services) were not taking the necessary steps to become HIPAA-compliant (in terms of signing contracts; their services have been plenty secure for some time). Changes to HIPAA within the HITECH Act—which took effect in Sept 2013—meant these companies would have to start complying. Thus, many new tech tools are now available to digital health startups.

Medicine's Problem of 'Incidental Findings' | The Atlantic →

The notion of 'incidentalomas' and their consequences is well-known among doctors. The lay public is less informed. In writing about one of her own experiences with a patient, Danielle Ofri MD says:

Nevertheless, I felt boxed into a clinical corner, forced to order expensive and complicated tests to rule out the minute chance of malignancy.

This is the ultimate outcome—more tests and more stress for patients. Both doctors and patients are risk averse and will almost always want to pursue further workup of an incidental finding. As noted in this article, we need to anticipate the likelihood of incidental findings and have a plan to deal with them. Be proactive, not reactive.

Are Today’s New Surgeons Unprepared? | NY Times →

Pauline Chen MD presents, in her usual excellent fashion, an examination of resident work hour restrictions' impact. Restricting hours is proving to be far too a simplistic solution for a complex problem.

Doctors crowdsourcing primary care | Short White Coat →

Project ECHO was developed 'as a means of sharing specialist knowledge with primary care doctors practicing in rural New Mexico' using telemedicine technologies. Seems like such technologies may be better suited to providing specialist education for providers, rather than attempting to conduct specialist visits with patients.

cTAKES: Turning clinical notes into knowledge | Vector →

I’m happy to see this open source project from Boston Children’s. I was very impressed to read that cTAKES can ‘help build clinical timelines.’ Paper records compartmentalized data (e.g.—different sections for notes versus laboratory data) and did not lend themselves to re-orginization (e.g—stuff was written in ink). Moving around bits is obviously much easier and we need tools to put patient data into the most comprehensible order—chronologically.

Doctors need to take the reins of the mHealth movement | mHealth News →

Eric Wicklund reporting for mHealth News:

[Data overload] is what’s plaguing the mHealth movement right now—too much data coming in from too many locations that don’t have any effect on the patient-provider relationship, and which may even be having a harmful effect.

Something sorely missing from current medical education is data science. Med students and residents receive cursory classes in epidemiology and biostatistics, but so rudimentary it is basically useless. Physicians will be challenged more and more with massive amounts of data. We can sit back and let others—epidemiologists, data scientists, computer engineers, startups, etc—define what role such data will play in the practice of medicine or take on leadership in this arena. It starts with much needed medical education in data science.