I have always been fascinated by playing card manipulation, partly because there is an analytical component to card games. For the masses,  Hollywood has  been responsible for publicizing card gaming, through Rounders and 21.

However, the appeal of gambling as a profession is attributed to Jon Chang, who spearheaded the MIT card club into a lucrative business. “Lucrative” is certainly not exactly an accurate description of the profession anymore, but much can be gleaned from gaming history nonetheless.

The game of choice at the time was Blackjack, which was simple enough at the time produce a probabilistic advantage to the player. The fundamental premise behind winning in Blackjack is to keep count of which cards have been cycled out, and increase your bet when there is a higher chance of obtaining face cards (table is hot).  Casinos have since implemented strategies to discourage card counting. One frequent finding in casinos is simply shoe recycling. Dealers and pit bosses have much lower thresholds to reshuffling the shoe even after about 50 cards in a 6-deck shoe. In Vegas, the tables with more lenient shuffling policies tend to have a higher minimum bet. Overall, winning in Blackjack consistently is more of a chore. Read more…

misc work

I used to toss sensitive documents in the hospital shredder bin. The bin is usually a locked cabinet that is emptied occasionally by a professional shredding company.

Several weeks ago, I noticed that a few of the hospital maintenance workers were digging around the “locked” bin. Since then, I’ve acquired a cheap-o-shredder for shredding purposes.

What I’ve discovered is that the standard 6-8 page vertical shredders are junk. You can’t aggressively shred anything thicker than 5 pages without jamming the grinder. In addition, the papers shreds could actually be reconstructed without too much difficulty if all the pieces were available.

I guess I have two alternatives:

1. Buy a nicer, cross cutting shredder with larger blade.
2. Burn my documents.

Or shred AND burn them. That would be entertaining and most effective.

misc humor, work

Every year, the Academy of Ophthalmology holds an annual meeting that most ophthalmologists attend. Those that are usually left behind are junior surgeons who end up covering the on-call pager.

I was unfortunate to be covering the primary pager for the hospital this weekend, which is Academy weekend. Generally speaking, this is the worst weekend to have an eye problem, because your primary ophthalmologist is probably out of town in a meeting (or getting drunk). My pager rang early yesterday morning with a long distance callback number. Bad news. When the emergency room or floor resident pages me, I usually receive the hospital extension. A long distance number always means that you’re getting shit that you don’t want to (and should not have to) deal with.

The call turned out to be from one of my attending’s wife. She woke up with an itchy eye and foreign body sensation. Her husband was at the AAO meeting in San Francisco, and she did not wish to bother him with a call. Her son-in-law, daughter, nephews, and nieces were all ophthalmologists at the meeting as well. Her primary ophthalmologist was in town, but she did not wish to bother him either because it was Saturday (Jewish sabbath).

WTF?

I suppose that leaves me, the on-call resident. I offered advice to the best of my abilities over the phone and offered to see her in the emergency room (the one where patients wait 4 hours to be triaged). She politely declined.

Lesson to be learned: if everyone in your family is an ophthalmologist except you, you should go with them to the Academy meeting.

medicine ophthalmology, rant, work

I remember when Instant Messaging flooded the workplace computers back in the tech-boom days. My colleagues working at IBM would get company-wide emails stating that IM decreased productivity and was prohibited. When company threats weren’t heeded, port 5190 was blocked on the company firewall.

Now that instant messaging has been superseded by text messaging and MMS, I see my colleagues “texting” away during conferences and lectures. It’s become a nuisance. If you’re simply notifying your spouse that you’ll be late for dinner, that’s one reason to be texting during fluorescein conference. However, checking the stock ticker? Chatting with your medical school classmate? What are you thinking? That is simply abusing technology. Perhaps I say this only because I don’t have a data plan on my phone, but there is a point in which your attention should be directed toward the lecturer and not your iPhone.

Our eye clinic is in the basement, where our cellphones unreachable by the outside world. You’d think that there wouldn’t be any contact with the outside. Wrong. Last week one of the technicians (who are supposed to be obtaining visual acuity for our patients) was logged onto her MySpace page. Another computer was logged onto Facebook.

I wonder how much social networking affects workplace productivity. A quick search online shows that this actually increases productivity. USAToday also states that we work better with social networking… The caveat? None of these companies are involved with healthcare.

computing, medicine rant, tech, work

In medicine, patients who have been admitted to the hospital have an option to leave despite being deemed too ill to be discharged. We refer to these patients as leaving “against medical advice”, or AMA.  Many times patients sign out AMA whenever they feel a desire to leave the hospital when work-up is still pending. I once had a patient who presented with symptoms suspicious for myocardial infarction, but had a flight to India several days later. He felt symptomatically better a day after presentation, and decided to leave to pack his bags even though we had not completed all of this cardiac tests.  I had another patient who was admitted for a gastrointestinal bleed from ruptured esophageal varices. No sooner had I finished transfusing him 6 units of red cells did he demand to leave. This guy was a cocaine addict who needed another fix. These are the cases which disobeying medical advice could result in death.

Other cases are not as obvious. I had a young diabetic teenage patient who was admitted for drainage and antibiotic treatment of an infection neck abscess. He left AMA before bacterial cultures could be speciated. While he was unlikely to die from premature cessation of his antibiotics, he did not complete his treatment and risked developing a superinfection or worse, a superbug.

Interestingly enough, the one universal bond that I have noticed about AMA patients is that they were all cared for by a medical team. Not a surgical team. Not a gynecological team. You can argue that fewer surgical patients leave AMA simply because there are fewer surgical patients in the hospital, but I believe the explanation is simpler: surgery has more tangible results.

The argument that surgeons “do more” for their patients is not only stated by surgeons, but also perceived by patients. When I was a medical student, the surgical attendings considered themselves the “Physician +” because they are expected to manage their patients medically and surgically. Those students choosing to specialize in surgery crave the satisfaction of intervening in order to make the patient better. Patients admitted to the surgical service expect a tangible intervention, like removal of an organ or excision of a tumor. They are not likely to leave against the advice of the doctor. Even those surgical patients who are managed medically, such as the small bowel obstructions, almost never leave the hospital without a doctor’s blessing. They are in pain, they cannot eat, and they also know that there is still a possibility that they may be cut open.

Sadly, the same cannot be said about patients managed by internists. The diabetic in ketoacidosis will start feeling better when their anion gap is near closure, but we cannot send them home if their white count is sky high from an unidentified infection. The patient doesn’t see this. He feels better, and wants to go home. The HIV patient with cryptococcal meningitis feels great after I hit him with some narcotics and a dose of amphotericin. He thinks that all he needs are some painkillers. Think again. If he goes home after this, he will be as good as dead–the amphotericin will have just enough time to frag up some fungi in his system to trigger whatever is left of his immune system to go berserk and maybe put him into sepsis.

It is unfortunate that medicine is perceived in this manner, by doctors, patients, and even insurance companies. It is at times frustrating to practice medicine in the context of this disconnect; it feels as if doctors are broadcasting on a different frequency as everyone else. Policy needs to be revised. Policy is being revised. But in the meantime, we will have to wait it out.

medicine medicine, work