Goodbye Blackberry: What I miss about you!

Recently our workplace stopped supporting the Blackberry and moved to iPhone 5.  This is now the only supported smartphone for getting corporate email.

While I am always excited to get a new device, I am already missing my Blackberry Bold.  What do I miss the most?

1. Speed dial.  I had several buttons programmed to dial with one long press.  Speed dialing did not need me to touch the screen, swipe, or use voice control.  Thus I could press the H key for home, the D key for dad etc.  The iPhone since it lacks a physical keyboard can not have this functionality.  Yes one can use Siri or create favorites or even do some workarounds using "xxx-xxxxxxx.tel.qlnk.com" but nothing even gets close to the simplicity of having a single key press for speed dial.
2. The trackpad:  This is probably one of the most brilliant features of the BB.  While it had a touchscreen, the trackpad made it almost unnecessary to touch the screen.  One could navigate the cursor precisely to the necessary spot and click the exact spot you wanted.  One could swipe, scroll etc without touching the screen.  This made it a very simple one-handed operation.  The iPhone 5 being a particularly taller screen makes it harder to reach all navigation areas with the thumb while hold the phone in the palm and fingers.  
3. Zooming a video:  While the iPhone has a somewhat non-intuitive pinch to zoom function for the camera it does not appear to have this for the video which seems quite an important omission for a 500+ dollar device that claims to have the best camera on any smartphone.  Yes there are apps that enable video zooming but IMHO this should be a built in functionality.
4. The form factor:  The fact that a lot of navigation controls are near the top e.g. the email navigation buttons; and the home button is near the bottom means the phone has to be moved around in the palm  to reach these.  The phone is just too tall for one handed operation and too narrow to feel secure holding it in the palm/fingers.  Due to the insecure grip, a case is a must which means there is no point to the gorgeous look?  Never even thought about getting a case for the BB as it was secure in the palm and just the right width.
5. The BB magnetic holster:  It is possible on the BB to set up certain profiles/behaviors based on whether the device is in the holster or outside.  This would also save battery life by automatically putting the screen to sleep/locking the device when placed in the holster.  

A Dynamic and Productive Soccer Sideline?

Converting Potential Energy into Electrical Energy!

I have spent many hours driving to and watching our daughter's soccer games.  These are something I look forward to as it gets me out of the house even on cold and rainy days.

But these trips come with a bit of a guilt trip.  I fret about the many miles we drive and the gas we burn as hundreds of families descend on these soccer fields.  Also folks bring a folding chair and promptly plop it down on the sidelines, and then sit and shout for the whole game while encouraging kids to run faster and play harder.

Potential Energy ready for harvesting!

Would it not be great if there was a row of stationary bikes on the sidelines that were plugged into a device that could generate electricity and possibly even push it into the grid?  Yes, yes I know the amount of energy generated by a stationary bike is minuscule but there are hundreds of people sitting on the sidelines.  Plus imagine the side benefits.  The folks would get some exercise, and possibly be too out of breath to curse at the referee.  The kids would be thrilled not to have their parents shouting at them.

Think this is impractical?  Seems there are several devices like this in the market that can be plugged into regular bikes with the rear wheel raised on a stand to make them into stationary bikes.

"Nah none would use it!" you say.  Well how about giving them some motivation.
We could pit parents of the two sides against each other and even have a power meter indicating which side is generating more power.  Thus while the kids play peacefully in the middle, parents can duke it out constructively on the sidelines.

What if the soccer facility provided the bikes and parents would swipe an ID to register themselves and their energy production could be tracked and they would get back some credit?  This system already has been imagined for bike rental systems here.

Any takers?

Infographics: Can they make reading journals easier?

As we struggle with information overload and clinical overload, it is harder to keep up with updates in medical literature.  Several journals are trying to make it easier to scan articles and get the salient points quickly e.g. Annals of Internal Medicine provides a commentary summarizing the practical implications of a study.
My assumption is that most readers scan the abstracts of articles before deciding which ones to read in full.  Appropriate use of graphics can improve comprehension and possibly make this scanning process more efficient.  As the old saying goes "A picture is worth a thousand words".  Clearly graphics are very popular as can be seen by the popularity of Infographics and Pinterest.
So I decided to try out a free infographic creation tool Piktochart to create a visual representation of the salient points of a study.

I chose this study from JAMA - because it was the first study that caught my eye in my Google Reader stream after I thought of this idea.  So this is what the abstract looks like:

As you can imagine it took me a few minutes to get the main message of the study.  What if I had seen this infographic instead?  I took all the information from the study abstract.  The only thing I added was the Number Needed to Treat (NNT) that I calculated myself.  

Infographic Created by Neil Mehta

So what do you think?  Does an Infographic make it easier to scan journal articles?  If so, should journals have data visualization experts on their editorial team to help create these?  Should there be standards for creating these e.g. Blue circles for control groups and yellow for intervention groups, etc?

The Search Hub - search the Web, Email, Cloud storage and Bookmarks from one place!

We know how Google transformed how we find information.  It is the default search engine for majority of users.  But many users may not be aware of 2 features that help me tremendously.

1. Google is now doing a field trial that lets you search your Gmail and Google Drive for the search terms
2. When you search using Google it can simultaneously search your Diigo Bookmarks.  

So now you can from one hub search the web, your email, your cloud storage and your bookmarks!  

Google Search Field Trial - search Gmail and Google Drive from Google Search!

Search your Diigo Bookmarks from Google Search.

Bring your own device (BYOD) and the Ecosystem

Recently I was talking with a very bright colleague who is about to cave in and buy a tablet.  He does not even own a smartphone. He has managed to stay out of this technology maelstrom for so long that he was asking folks for advice about which was the ideal one to buy.  I was impressed that he did not just jump in to buy the iPad since that is what everyone had heard of.

I told him there were many factors to consider like the carrier, the size of the device, whether it has a microSD card etc but one of the factors was the ecosystem.  Seeing the look on his face, I knew I had some explaining to do.  So what is an ecosystem?

In biology, an ecosystem describes the complex interactions between the living organisms and their environment.  In technology, it describes the hardware and software on the device and the content and the applications that they interact with that often reside in the cloud.  [This is my made up definition and would be glad to know of a more formal generally accepted one].

He still looked puzzled so I drew a few circles representing Google, Apple, Microsoft and Amazon on the back of a paper napkin.  Then I drew some boxes on the circumference representing the following:

An Example of an Ecosystem

• App Store
• Music
• Games
• Movies
• eBooks
• Apps
• Devices
• SmartPhones
• Tablets
• Desktops/laptops with OS
• Cloud storage
• Documents/Office apps e.g. documents, presentations and spreadsheets
• Social Networking
• Email
• Calendaring
• Contacts
• VOIP and Video conferencing
• Content Management Systems
• Groups
• Maps
• Browsers with syncing across devices
• RSS feedreaders
• Search

At this point his eyes were getting a bit glazed over.  He appeared to be asking, "What has all this got to do with buying a tablet or smartphone?"  So I gave him an example of how these are all integrated and having a device that is part of the ecosystem makes a lot of tasks easier.  Thus if you like using Google Voice, you may want to lean towards getting an Android device as it is seamlessly integrated into the phone.  

While it is often possible to access parts of an ecosystem from another type of device, it may not always be smooth.  Thus one can access Google Drive from both an Android and an iOS tablet (iPad) but generally the Android tablet gets features before the iPad.  The recent Google Maps issue on iPhone 5 is another example.  

He got it.  He was actually pretty amazed at how much these devices could do.  I felt bad about leaving him without any direction.  I was trying not to bias him but then he asked me what I would do if I was him.  I told him I would probably get the Nexus 7 tablet.  It was recently named the top gadget and top tablet of 2012.  He asked me, "Does that preclude me from getting an iPhone later?  Isn't the iPhone the best phone out there? And what about a computer OS? Google does not have one does it?"

"Great questions!" I said, "You may want to take a look at the this video before you consider buying an iPhone 5"

"And as far as the OS goes, Google does have computers with the Chrome OS but you can get the entire Google Ecosystem from a Chrome browser which you can install on a computer with any OS."  At this point, he was almost convinced.  But then I had to break the bad news to him.  "Of course, you need to know that our workplace does not support Android; only the Blackberry is supported.  Also only devices bought through work will be able to access the enterprise e-mail.  This is for security reasons."

I really don't like to see grown men cry!  Wish the BYOD philosophy was easier to embrace for organizations.  

Google+: "Connecting and Sharing among People with Common Interests

The last few months a lot has been written about Google+, comparing it to Facebook.  I have personally found myself using Google+ much more than Facebook and I was not sure exactly why.  It was only recently when I tried to explain Google+ to some people that I gained an insight about this.

I started using Google+ because I like to try out new things.  I enjoyed exploring its various features and how to apply them to my work.  As I used it, I realized I was not going back to FB as much as I used to.  Initially I wanted to try and get my "friends" from FB over to Google+ and it bothered me a bit that they did not.  Then one day I realized it did not bother me at all.  I realized something that I think I knew all along, that at a very fundamental level Google+ and FB are completely different. How so?

FB's tagline says "Connect and share with people in your life".

My interpretation of "people in your life" is people you know or have known.  Once you connect with them i.e. "friend" them on FB, by default everything you post is visible to ALL your "friends".  The Pew Research Center in its report in May 2012 found:

• On average, users make 7 new Facebook friends per month; they initiate 3 requests and accept 4.
• Women average 21 updates to their Facebook status per month while men average 6.
• In a month, about half of our sample made a comment on a friend's content, and about half received a comment.
• Fewer than 5% of users hid content from another user on their Facebook feed.

Another key difference is the reciprocal relationship with other FB users.  Thus only after both users have mutually agreed to be friends can one see the other person's posts.

What this means is that till you agree to be friends you see NOTHING of what the other person posts and after becoming friends you usually see EVERYTHING that the other person posts.

Google+ at its very foundation was built on the concept of Circles and also allows Public posting which is very similar to a blog.

Public posts can be seen by anyone who follows you and are searchable on Google. People can comment on them, share them or +1 them.  You can see who these people are and view their public posts and decide if there are enough common interests that you can follow them back.  This leads to finding people of similar interest across the whole world - most often people you DO NOT KNOW.
People posting publicly are aware that these are open to the world and thus will not post private information like photos of their kids or what they had for breakfast.

Circles allow you to target your posts to specific people, and these are not visible to anyone outside the group (Circle) you specify.  This may seem to be similar to FB but it is not.  The list of people in your circles is unique to you.  Thus you could have a circle called Close Friends and have 5 people in that circle.  One of those 5 people may also have a circle called Close Friends and it may have 15 people in it.  You may not be in that circle.  These asymmetric circles can be confusing but allow for great autonomy in targeting your posts and filtering your stream.  The ability to mention specific people in posts allows you to include them in the conversation in a granular manner.

Create Circles based on you interest or projects

Now you can target your posts to those circles or keep them Public

You can filter your information stream using your circles and notification settings

Google+ allows you to share a circle.  Thus if you have collected a group of people with interest in HDR photography from across the world you can share it with other users.

The consequence of these differences are:

1. You are more likely to connect with people you DO NOT KNOW on Google+ compared to FB.  In this way it is a bit like Twitter.  
2. You are more likely to connect with people with similar interests.  The shared circles feature is a bit like Twitter lists.  
3. You are less likely to see uninteresting or irrelevant content on Google+ especially things that you feel people should have shared with a fewer folks. 
4. Due to the ability to filter your feeds and adjust your notifications (in a very easy manner) you feel in control of your information stream.

Ladies and Gentlemen, Please Silence your Cameras!

We should have expected this, it was just bound to happen.  But when it came, it still took many aback.

I am talking about the use of smartphone cameras to capture speaker slides during presentations.  I recently attended the AMEE 2012 meeting and noticed a large segment of the audience taking endless photos during presentations.  They took multiple photos of one slide either because the shot was not focused or the speaker was building the sliding via animation and they missed some bullet points.

Personally I have no problem with this practice.  I have been doing this myself in a limited manner using my Motorola Xoom tablet and Evernote.  The problem is that people are forgetting to mute their cameras and can be irritating and distracting to the people around them.  When many people start taking multiple photos, the issue can be quite serious.

At one session one of the audience members got so upset that she got up and asked everyone to silence their cameras.  I expect that presenters will soon be adding something on their first slide to ask the audience to silence their cameras.

Hidden Curriculum in Medical Schools - Are we teaching what we want students to learn?

We all know that

• The amount of information is increasing rapidly
• The 1/2 life of knowledge is shrinking - what we knew few years back does not hold true anymore.

As Alvin Toffler said, 

“The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn. ” 

Once our students leave the formal education settings of medical school, they will have to learn how to keep up with literature and new advances on their own.  Thus medical educators want to teach students how to become self-motivated self-directed lifelong learners.  

The hidden curriculum is the unintended lesson/s, usually about norms, values, beliefs or behaviors, learned during a learning experience.  Thus in medical schools students are taught a particular way to communicate with patients.  When students see health care practitioners interact with their patients differently, they get a different message.

One of the biggest hidden curricula is the way students are expected to learn in medical schools.  Traditionally, they are expected to attend lectures and seminar, show up in clinical rotations and have information delivered to them, drilled into their heads.  [A number of medical schools are trying to break out of this mold]. These students get the unintended message that someone else is taking the responsibility for their learning.   This hidden message is more powerful than the intended message for their need to be self-directed learners.  

To truly help students become the independent, self-directed learners we want them to be, schools need to reform the way they educate.  Instead of large lecture halls, early in the training the students need to learn how to look up and find information to solve problems.  Students can learn individually or in small groups (e.g. Problem based learning and Team based learning).Passive learning should be avoided.  This  will create a hidden curriculum that will help our students learn the only useful lesson we can teach! 

What medical educators can learn from the car industry

Formative and Summative Feedback

Formative feedback - that is the ongoing, near real time, specific, non judgmental feedbak - is critical to learning and helping change behavior [Ref].  Unfortunately medical educators have for too long used only summative feedback for assessing medical students - you know the end of rotation grades, the USMLE scores etc.

Part of the problem is that faculty and preceptors are the ones who need to provide this feedback as they work with students on a daily basis.  But they are unaware of the need for such feedback or are not trained to provide it or unable to provide it for logistic reasons.  Clerkship directors meet with the students only infrequently and do not have such feedback to review and share with the students.  They often have comments like "Excellent" or "Great presentation" or "needs to work on presentation skills" which is not specific or helpful.

How can we train our faculty in giving useful formative feedback? Since most faculty members went through traditional medical school programs and did not receive much formative feedback, they may not be aware of what it is and the importance of giving this.  A metaphor we can use is something we see almost daily and comes from the car industry.  [For some interesting reading on this see the National Renewable Energy Laboratory Report (pdf) by Gonder et al]

Learning Objective: Learn to drive in a way that improves fuel efficiency.

Cars now give immediate and constant feedback to the driver regarding the rate of fuel consumption as miles per gallon.  This is visible on a visual scale next to the odometer.  It also shows a color indication in a ring around the speedometer (e.g. green if driving at optimal speed and acceleration).   This is an excellent example of formative feedback and can lead to correction in behavior.


Cars also provide an average fuel consumption for a particular duration, and can be reset by the user.  In most cases it is reset on refilling the fuel tank.  Looking at this at the time of refueling gives the driver summative feedback on their performance for that duration.  If the number is low, it should not come as a surprise to the driver who has been getting constant feedback and has failed to change behavior.  The driver has control over how she/he chooses to drive.

While drivers can choose to ignore the feedback, in case of students, they come to a medical school to become good physicians.  They want to get such feedback and to constantly improve.  Using this metaphor hopefully we can train our faculty to provide more useful, timely, non judgmental feedback.  One hopes this will lead to them spending more time in helping all our students become better physicians and less time comparing and ranking them.

If the car industry can understand this, why not medical educators?

My Gold Medal Goes to....

Achievements in Olympics reflect huge sacrifices, long years of training and planning and performing under high pressure in front of a global audience.  The feats of these athletes serve as inspiration for us common mortals and help to hopefully unite the world.

While the London Olympics are underway, something even more difficult than any individual or team performance and more awe inspiring just took place - the landing of a huge rover on Mars using a maneuver never used before after 7 minutes of terror.  Here is a video explaining the difficult procedure.

Very early this morning (EST) Curiosity landed successfully on the surface of Mars and sent back its first images.  The world cheered but the video of the NASA team watching with bated breath and then their emotions when they got the good news brought tears to my eyes.

Without belittling the performance of the athletes, if I had to give a gold medal it would easily go to the NASA team for their amazing work in the face of budget cuts and political uncertainties.  Congratulations NASA!  

This post was prompted by an online conversation on Google+ with @Brad Gill one of the many brilliant students to come out of our medical school. 

The Olympics: Hunger Games or Human Games?

Following the Olympics has been a emotional roller-coaster of a journey and has led to a lot of soul searching.
There have been some amazing moments - with Michel Phelps getting probably the most press - coming fourth in one event, missing gold by .05 seconds in another, winning the most ever Olympic medals along the way..
Watching the US athletes on the podium listening to the "Star Spangled Banner" invariably brought tears to the eyes.  Serena unleashing a powerful performance in the finals to win 6-0, 6-1 was jaw dropping.  The US flag was not there - blown away by a gust of wind at Wimbledon - bringing much needed humor at a solemn moment.

Image linked from  http://theybf.com/category/sports

Along the journey something kept bothering me.  Seeing young teens competing in individual events carrying the hopes and expectations of their family, friends, schoolmates, their country on their young shoulders.  Watching a 15 year old Katie Ledecky blowing away a super strong field in the 800 meter freestyle and 17 year old Missy winning multiple events in swimming was a celebration of youth.  The tears of 17 year old Victoria Komova on losing the gold in the individual all around (she won the silver) showed the incredible pressure on these young shoulders.  The 16 year old Chinese sensation Ye Shiwen forced to defend herself against allegations of using performance-enhancing drugs because she has improved dramatically over the last year.  Then the image of a Canadian trampoliner going from shock to breaking out in smile when her Chinese competitor fell at the end of her routine realizing she had won the gold with that spill.  The latter reportedly declined to wear her bronze medal.  These young athletes are damned if they win and damned if they nearly win and damned if they don't win.  All this under the microscope of social media and 360 degree 24-7 fast news coverage.  These scenes reminded me eerily of the Hunger Games.  As we celebrate the champions, do we hear the stories of all the people who did not make it, who were proud to just compete, to try, to give it their all, their sacrifices, their heart breaks?  Are they learning the right lessons, is the Olympic movement working, is the Olympics spirit alive and well?

And then I reflect on the following images and my faith is restored:

• Jordyn Weiber crying her heart out on missing out competing in the individual all-around event and then coming back to cheer her team mates on in the event she missed.
• Margot Shumway in the women's double sculls learning a new sport so she could get to the Olympics and coming from behind to make it to the A Finals with her mother in the audience - fighting lung cancer - making it to London to watch her daughter between 2 rounds of chemo
• Oscar Pistorius a double amputee who had an epic struggle to get accepted to the Olympics because folks thought the "blades" gave him an "unfair" advantage.  He was just happy to be able to compete.  His mother wrote in a letter for him to read as an adult, ""The real loser is never the person who crosses the finishing line last,'' she wrote. "The real loser is the person who sits on the side, the person who does not even try to compete.''
  [From http://sportsillustrated.cnn.com/2012/olympics/wires/08/04/2090.ap.oly.john.leicester.040812/index.html#ixzz22bTuSQQM].  

They don't need medals, they don't need their photos on cereal boxes.  But we need their stories to be told just as loudly and frequently and proudly as those of the medal winners.  Once we do that, the Olympics will truly be the Human Games instead of being the Hunger Games!

Au Revoir Dear Friend

I never had a pet before, I thought dogs were not worth the trouble
I did not want to wake up early to take you for a walk
I did not want to pick up after you when you went on a lawn
I wondered if having you meant we could not travel any more
I thought you would bring in fleas and shed on my carpet
I assumed you would bark when I was trying to sleep
I worried you would nip my child and gnaw on the furniture
Still I loved my daughter and wife too much so I reluctantly said yes

I was never so wrong in my life

The innocence of those bright eyes, the boundless joy of that wagging tail
A reward for a long day at work
You were my daughter's pillow, her best friend as you grew up together
The selfless love, the trusting companionship made it all worthwhile.

As the lymphoma ravaged your body,
Your eyes told us you wanted to go
With dignity and peace at home on the front porch
On a beautiful sunlight eve, among all the scents that you loved
One last car ride to the funeral home

Au Revoir dear friend, You changed my heart!
A lasting lesson not to prejudge anyone again.

I will miss not having to worry about stepping on you when I get up in the dark
I will miss having to comfort you during the next thunderstorm
I will miss those Border Collie eyes tracking my every move
I will miss your whine and whimper when my pager goes off
I will miss racing you up the stairs - I never did get to beat you till you got ill
I will miss how you chased the deer and geese knowing you could never catch them anyway
I will miss the long walks around the soccer fields

It was all worth while
I was never so wrong in my life, except
You did shed,  but now that you are gone, 
I don't want to vacuum those last memories from the carpet....

A day later....

But hark, what is this?
A lightening of the heart, a lifting of the gloom
This presence besides me
Of course, you will always be with us,
How did I assume you would ever leave us for long
How did I misjudge you again?
I was never so wrong in my life!

A Sobering Saturday

I woke up this morning reading a post by Jonathan Smith on Google+.  There I found a link to a video of a lecture by Albert Bartlett on YouTube.


It was the most sobering 80 minutes I have spent watching and listening anything online.  So what was so sobering?

I recently blogged about the need for civil and informed discourse for a successful democracy.  That post was about the Affordable Healthcare Act.  But there is an even more important issue facing the country and the planet that is similarly reduced to a squabble of statistics and jargon and conflicting emotionally charged opinions.

Humans have created a system where short term performance outcomes counted in terms of money are used to measure success e.g. corporate performance measured in quarterly cycles, Presidential performance measured in 4 year election cycles.  Another fundamental problem with the system is the assumption that if people look out for and vote for their own interests, and if the majority of the people vote for something, the country will be better off.  In essence we now have a system that will prevent a minority who have the knowledge and altruism and want to work towards long term global benefit from ever accomplishing something.

Imagine that everyone knew that at some point in the future we will run out of fossil fuel.  What would that mean?

• Most of the food we eat uses fossil fuels to produce and transport.  
• Our personal comfort - heating, cooling, communication, travel, entertainment requires energy - a lot of it produced from fossil fuel.

Suppose we knew that regardless of when we reach/reached peak oil state, we are depleting a finite resource and as our population grows and our economics require each economy to grow, this depletion will occur faster and faster.  Finding more fossil fuel sources will only postpone this inevitability.

Suppose we knew whether impacted by mankind or not, the planet is getting warmer and will lead to dramatic extremes of weather including floods, droughts, storms, blizzards all requiring more energy and causing more scarcity.

Suppose we knew this incredible change in our lives was going to occur sometime this century.  What would we do?

• We would scramble to find solutions that make non-fossil fuels possible
• We would force our governments and corporations to invest in these technologies
• We would build small self-sustained communities
• We would move towards using agriculture to produce food for humans rather that for cattle
• We would conserve all the fossil fuel for critical activities that focus on solving this huge problem
• Dissemination of information for education of people
• Communication and collaboration among scientist and engineers working on this problem
• Manufacturing renewable energy producing units like wind turbines, solar panels etc.
• Ensure that we don't run out of fossil fuels before we had implemented solutions
• We would start planning like we would for a local disaster
• Install solar panels on our roof and a wind turbine in our backyard and a geothermal heat system in the basement.
• Find a way to get to work without a car or work from home
• Install a greenhouse and divert all the effort from maintaining a lawn to growing vegetables
• Drill a well with a solar powered pump and an overhead water tank.
• You get the idea...
• But we don't because we are in denial and because we worry about the cost of all these modifications and whether they are worth it or whether they will be needed in our lifetimes.  "With fracking, gas will be cheap and we will have unlimited supplies to heat our homes" right?

Our current socioeconomicpolitical system will not be able to turn this ship around without a serious wake up call. Unfortunately the best chance of having something like this expired in the 1970s when the national and global awareness was at a peak.  If we wait for the next peak in awareness, it will be too late.  It is probably already too late.  The question is whether it will be a crash or a slide.  

The best consolation for the current generation is that when they pass away they will not be missing out on seeing a great future.  The best years of humankind are probably already behind us.  Everything that they learned to love and depend upon is going to be at a premium in the near future.  Also we probably don't want to be alive to hear the curses from our grandchildren!

Does economics violate the laws of physics? http://www.scientificamerican.com/article.cfm?id=does-economics-violate-th
Playlist of Dr. Bartlett's lecture
http://www.youtube.com/view_play_list?p=6A1FD147A45EF50D
ABC interview with Michael Mann http://abcnews.go.com/blogs/technology/2012/07/new-mccarthyism-described-by-climate-scientist-michael-mann/

Score 1 for Internal Medicine.

Those who follow this blog already know that we recently returned from a meaningful/purposeful vacation in Peru.  I am an Internist and my wife is an ophthalmologist and we were precepting students on a medical mission in the Sacred Valley in the Andes.  Our middle school daughter was our Medical Spanish translator.

She would split her time helping in both areas, Ophthalmology and Internal Medicine.  She got a kick out of helping patients get prescription glasses and the thrill of helping some kids see clearly for the first time.  After a couple of days, she got very comfortable with this and was able to independently get 20 patients a day to 20/20.

When helping in the Internal Medicine area, she learned the importance of history taking and the conversation in diagnosis and patient care.  She got a good exposure to this as she was the one translating the questions to the patient and translating the answers back to me.  After a couple days she told me, "This is so cool!  Its like solving a mystery by talking to people.  I love it! You guys are Low Tech, but High Talk!

There is hope for Internal Medicine yet!  

PPACA and informed opinions in democracy - a pipe dream?

The Patient Protection and Affordable Care Act (PPACA) was just upheld by the SCOTUS.  This verdict has split the entire country down the middle as shown by a recent Gallup Poll.

Image linked to Gallup Poll website

The law is complex and difficult to interpret.  The law will be implemented in stages over several years which makes it even more confusing.  The fact that even independents are split so evenly makes it more than just a political bias.  There are some places to find summaries of the law.

• Reddit summary of law with citations
• Reddit - some doctors' concerns
• Official site

Looking at the discussion at some of these sites also gives one an idea of the very strong and diverging opinions.  People struggle to separate the issue of whether this is the "right thing to do" vs. whether it is constitutional vs. the right way to do it.  Thus most would agree that folks should not have to worry about getting health care when they need it and they should not have barriers to getting preventive care to keep them healthy.  How to achieve this and how to finance this seem to be questions causing the arguments.  The complexity of the law makes having intelligent informed discussions difficult.  The emotions around the issue make it difficult to keep personal bias out of the discussion.

It is a fascinating time to see democracy "working".

I personally have not read the text of the original law or the entire text of the SCOTUS opinion.  Why not?  One reason is the difficulty in making sense of the legalese and staying awake while doing so.  I have spent quite some time trying to understand it - probably more than the average citizen.  I have read the Cliff notes versions, the statements issued by various organizations for their members and public and participated in discussion in social media to get a better understanding from various perspectives.  During these discussions I have noticed many incorrectly informed opinions expressed from both sides.

To try and get a better handle at the level of complexity of this law, I tried to read up about a "simple" law that I describe below.

Recently I went to an event that raised a number of questions in my mind requiring me to go to the original law.

First let me describe the setting.
This was a concert at a huge facility - with a covered pavilion near the stage and a larger lawn seating area around it.  There is no wall or other physical barrier between the lawn and the pavilion. On summer evenings, it makes for a beautiful setting to listen to live music.  My previous experience of this facility was listening to Beethoven and Bach or the Boston Pops playing John Williams tunes, sitting under the stars on a blanket with a picnic basket.  This was clearly going to be different experience and I thought I was prepared for it, and I was except for one thing.

Smoking was allowed in the lawn portion of the facility!  And almost half the people were smoking - to the extent that a pall of smoke hung over the entire area.  The facility is in a bowl shaped valley which probably contributes to this situation.

In Ohio smoking is not allowed in a "Public place" even in bars and restaurants, even at the Cleveland Browns Stadium which is not a covered roof stadium.  A facility this big could not be willfully breaking the law so I had to look this up when I got home.  The law can be found here.  The key provisions/definitions it seems were:

“Public place” means an enclosed area to which the public is invited or in which the public is permitted and that is not a private residence 

“Enclosed Area” means an area with a roof or other overhead covering of any kind and walls or side coverings of any kind, regardless of the presence of openings for ingress and egress, on all sides or on all sides but one.

“Outdoor patio” means an area that is either: enclosed by a roof or other overhead covering and walls or side coverings on not more than two sides; or has no roof or other overhead covering regardless of the number of walls or other side coverings. 

Apparently the law provides an exception to outdoor patios to allow smoking.  Based on my non-legal interpretation the setting of this facility does not fall under the smoking ban law because it is completely uncovered and is thus an outdoor patio.  The pavilion has an overhead roof and is somewhat circular so difficult to "count" how many sides it has.  My guess is that it is not an enclosed area as the majority of the perimeter does not have walls.

So the questions that came to mind were

• The point of the law is to protect people from the dangers of second hand smoke.  Why would the law fail to provide protection to people who go to this facility.  A few minutes there and I felt my lungs filling up with fumes.  So clearly there was second hand smoke exposure
• How do we balance the freedom of a person to smoke with the right of a person not to be injured by another person?  Adults should have the right to smoke if they want to and understand the risks (will not debate who pays for their smoking related health conditions).  People come to this facility to enjoy and smoking is possibly a part of that experience for them. What about the enjoyment of the other paying audience?  Even if one could debate the long term risks of 2 hours of second hand smoke exposure, what if they had migraine or asthma triggered by this?  
• What would it take for a facility like this to set up some non-smoking zones with a big no-mans-land around it to at least diminish the exposure?  The Cleveland Browns set up a Family zone where even alcohol is not permitted even though that is not a legal requirement (I think).
• I saw several young kids brought in by their parents.  Do the kids have a choice and the ability to make an informed choice?  I overheard a very angry comment made by the parent of one of these kids about the situation.
• The facility does mention on their web site that "light smoking" is permitted in the lawn area.  Whatever does that mean? 
• Would the facility reimburse people who find the smoking more than "Light"?
• What are the options for those folks who want to attend a live event like this but cannot bear the second hand smoke or want to take kids?  

You can see how what seems like a simple issue can be so complicated and difficult to interpret.  The health care law is complex and polarizing.  Democracy depends on people making informed decisions and voting accordingly.  When people depend only on others to tell them what a law means, there is serious risk of bias. When people involved in healthcare don't have time to read and digest all the details of the law, what can we expect from the whole population?  Informed consent in medicine is supposed to mean that patients understand the various risk benefits and alternatives of a procedure before agreeing to it.  In order to do this we need to use language that can be understood by our patients.  There are of course laws describing how to provide informed consent (e.g. link to informed consent for human subject research).

This fall, people will be voting partly influenced by the PPACA.  Can we hope that these will truly be informed opinions?  On an issue of such importance how can we ensure that the answer is yes?  Do we need a law requiring voters to pass a quiz before voting? 

A doctor goes to middle school - A physician relearns physics!

Learning lessons relearned! Or

Should weight be measured in Newtons?

A small group (n=3) of middle school kids recently asked me to work with them on some physics topics.  Why they asked me a physician who has not read physics since high school is a mystery.  I think it had something to do with them knowing my interest in education.

I am a sucker for this type of stuff and thus I agreed.  I did not even ask what topic they were struggling with; after all how difficult could middle school physics be?  The fact that they asked me while we were at a charity fund raiser probably meant I was under the influence (of good thoughts!).

Turns out they wanted to know more about simple machines, solving problems regarding mechanical advantages of levers and inclined planes and pulleys.  I had to do a crash course on the topic quickly finding some resources on the web that helped me get up to speed.  The detailed description of the session follows but if you want to cut to the chase, here are the take home points.  These were brought home to me very strikingly during the 2 X 90 minute sessions I spent with them over the next 2 days.  Looking back these are the essence of constructivism and it was great to see these validated at a personal level.

Take home points:

• Spend more time on the fundamentals even if the learner appears to have gotten them.  Don't assume they know these even if it should have been learned a while back.  If nothing else, it helps to revise.  
• The learners needs to know why they are learning something before they learn it
• Connect to practical real life examples
• You have to know what they already know and don't know
• Words are constructs and carry a much deeper meaning for each person.  Having a learner rephrase something in their own words will tell you how much they understand
• Since peers are more likely to be at the same level they innately understand the perspectives and understanding of their co-learners.  
• If you sense that one of them had an AHA moment, let them explain it to the others in their words. The thrill of a learner's AHA moment will give you goosebumps.  Savor it and leverage it.
• When only one person in a group does not appear to get it, it is not because they are less intelligent but often they are thinking about it differently or even at a deeper level.  This conflict between their prior knowledge and what is being discussed is a great opportunity to leverage further discussion to clarify the fundamentals.
• Learning occurs best when the learner is motivated to learn.

As I started my crash course on simple machines, I found myself struggling to remember the definitions and units of force and work and power and the relationship between them.  So I quickly brushed up on some basics:

• Force (Newtons) = Mass (kg) X acceleration (m/sec/sec)
• Work (Joules) = Force (Newtons) X distance (metres)
• Power (Watts) = Work (Joules)/Time (sec)

As I reviewed this material, all the memories of the joy of learning physics came rushing back.  I was ready to work with the students.  I hoped I could get them to love physics as much as I used to.  I decided to make sure they were well founded in their concepts before we got into any calculations.  Our conversations went something like this (there might be some inaccuracies here but read this in the spirit in which this conversation took place):

Me: What does a machine do?
S1: It makes work easy
Me: What does that mean?
S2: It lets you do more work than you put in
S3: But that's not possible, you cannot generate more work than you input!
S1: You mean you cannot create energy right? That the principle of conservation of energy
Me: What is the relationship between work and energy? Are they the same thing?
S2: Well their units are the same
S3: You put in energy to do work right?

We went of on a tangent here:   

 Work = force X distance = mass X acceleration X distance = Kg X m/sec/sec X m = kg m^2/sec^2

 Kinetic energy = 1/2 mv^2 = 1/2kg (m/sec)^2 = 1/2 kgm^2/sec^2

 Potential energy = mgh = kg X m/sec^2 X m = kg m^2/sec^2

 So they got the idea that the units of work and energy are the same. 

Me: So what does a machine do?  Seems you decided it cannot do more work than you put it.  What is work?
S1:  It is force X distance
Me:  So how does that apply to a lever?
S2:  In an ideal case with no friction, the work put in = work put out.  So force put in X length of effort arm = force put out X length of resistance arm
S3:  So depending on the length of the 2 arms, the lever changes the amount of force.
S1: So the amount of work stays the same, the lever can make things easier by making you put in less force to do work!


Me:  Great job!  Now lets take another question.  What does it mean when you get on your bathroom scale and it reads 98 kg?
S1: That your weight is 98 kg?
S2: punches S1 lightly
S3: I am not sure what you mean.
Me: What would happen if you used the same scale on Moon?
S1:  Oh I see what you mean.  98 kg is your weight on Earth.  It would be less on Moon
S2:  Yeah, its got less gravity of course.
Me:  What about in space?
S3: Well the scale would read zero I think? Since you are beyond Earth's gravitational force.
S1:  That's 9.8
Me:  9.8 what?
S2:  9.8 Newtons.... No...  g is 9.8 m/sec^2
Me:  So what would that be...
S3:  that 98/9.8 = 10
Me: 10 what?
S1:  98 kg / 9.8 m/sec^2 = 10 kg/m/sec^2
Me: so what is the difference between mass and weight?
S2:  Oh I get it, what you weigh on Earth is your weight and the amount of matter you contain as measured in space is your mass.
Me:  OK, so what is the unit of mass?
S3:  Kg of course.
Me:  So you just told me in space a 98 kg person would "weigh" 10 kg/m/sec^2
S1:  This is confusing.  Seems like the units are all messed up.
Me:  Seems like it doesn't it?  What happens when you stand on a scale on Earth?
S2:  Your weight pushes it down.
S3:  The gravity acts on your mass and pulls it down.
S1:  You are exerting a downwards force on the scale
Me:  How much force?
S2:  Is that your weight?  So weight is a force?  Then why is measured in kg?
S3:  Yeah the unit of force is Newton!
Me:  What is force according to Newton?
S1:  Mass X acceleration
S2:  Newton is kg X m^2
Me: So how does that convert to your weight?
S3:  I get it, its the gravity acting on your mass
S1:  Yeah it is 10 kg X 9.8 m/sec^2 = 98 kg m/sec^2
S2:  Which is 98 Newtons
S3:  So weight is a force?  Why do we measure it in kg?
Me:  Yup so weight should be measured in Newtons not kg, I think we use kg because its become ingrained in our system.
S1:  Got it "The heavier you are, the more you weigh!"
On that very profound note we took a break while S2 and S3 gave S1 very strange looks!

We covered many other questions.
Why are screws and wedges like an inclined plane?
How does the concept of distance apply to inclined planes and to pulleys?
How does a movable pulley generate mechanical advantage when a fixed one does not?

The conversations went on for a long time.  Their eyes were shining, there were numerous "AHA" moments.  They were excited.  They were teaching each other.  I had the most fun I had in a long time.

The only problem...
They want me to do physics sessions with them throughout the summer vacation!

I wonder where all the retired folks go... this would be an amazing win -win situation.  They could work with school kids to help ignite their passion for the sciences or other subjects while keeping their own brains and hearts young.

Google Drive and Kindle - connect them automatically!

I have written a lot about reading articles on the tablet - referring mostly to an Android tablet.
For those who have a Kindle or a Kindle Fire, with the advent of Google Drive and Wappwolf, there is now an automated way for getting your articles sent to the Kindle.

Google Drive is the new incarnation of Google Docs.  This works a bit like Dropbox but has 5GB storage.
Kindle is Amazon's eBook reader
Wappwolf is a great app that works with Google Drive (and also Dropbox).  When you save a file in a specific folder in Google Drive, it will complete a set of predefined tasks for you.  Thus whenever you see an article that  you may want to read on your Kindle, just save it to a specific folder (e.g. "Send to Kindle") in the Google Drive.  This will automatically show up on your carousel or book shelf on your Kindle.

Wappwolf has a number of other automations that it can perform e.g. photographs saved in a specific folder could be uploaded to Facebook or Google+.

The Wappwolf website indicates that SkyDrive and Box functionality will be coming soon.

This is a great advantage of cloud storage and cloud apps.  They can automate your repetitive tasks and improve efficiency.  I am waiting for the app that when I save an article to "Send to my cortex" folder will upload it to my brain while I sleep!

Is Academic Medicine Reaching a Twitter Tipping Point?

The last 3 days have been exciting and invigorating - meeting old friends and making new ones at the SGIM Annual Meeting in Orlando.  There have been some amazing presentations and workshops.

Looking back over the last few days, it seems that SGIM members are beginning to adopt social media.

• The SGIM education technology group decided to use Twitter instead of a listserv to stay in touch between the annual meetings.  The plan is to use a #SGIMedTech hashtag for the group
• There was a great tweetup of SGIM tweeps 

• A Social Media Interest Group was created with #SGIMSoMe hashtag
• There is now a growing list of SGIM members using Twitter
• The group decided to do a project to study the effect of SoMe to help other interest groups improve communication between meetings.  

Does this mean academic medicine is reaching a tipping point?  There is still a lot of reluctance to adopt Social Media but the walls might be coming down.  I expect in 1 or 2 years, I will look back at this post and remember how this all started with a tweetup on one Thursday evening in Orlando!

Challenges in doing Social Media Workshops for Medical Educators

In the last 2 weeks, I have had the privilege to be invited to do presentations on use of Social Media in Medical Education at 3 different places.  It is exciting to see the growing interest levels in social media in medical academia.  There is a buzz in the air at these events which is quite refreshing.

Each of these was a large group presentation to an unfamiliar audience.

Sitting at the airport waiting for a flight back home from the last one of these, here are some reflections:

• Presenting when you don't know your audience's level of expertise with the topic is always challenging.
• Use Google Moderator if possible to get some idea of what the audience would like to see.  This is a great tool do a needs assessment and also weave a social activity into the hidden curriculum.
• Find out as early as possible about Internet access at the site.  Will the audience have Internet access?  Is it a public WiFi or is a password or some other security measure required?
• If you require your audience to go online project a slide with appropriate instructions before your presentation.  
• If you need the audience to download an app or create an account, ideally you want to send these instructions out by e-mail well ahead of time.  Thus if you want to do a demo of a Twitter chat you may want them to create a Twitter account ahead of time and remind them to remember the password.  
• Expect a significant portion of the audience not to have followed up on those instructions. There could be many good reasons for this, e.g. did not want to create a Twitter account due to privacy concerns. Or they are in a different stage in Kolb's learning cycle (more on this below).  Say something to prevent chaos (e.g. "how do I get connected?" or "I never got the instructions!" or "I am worried about creating a public profile").  Say something like, "How many have created a Twitter account? That's great, we have enough participants for a good demo.  Those who have not, will be able to watch the exercise as we will project it on the screen.  Those who did, please follow the instructions in your handout (or on the screen) to get started. 
• One of the best ways to think about the audience participation is to review Kolb's learning cycle.  According to Kolb, when people learn new things, they either want to watch and think OR feel and do.  This is a bit of a simplification and you can read more about this here.  Kolb has a learning style inventory that people can fill out and share with you so you can know ahead of time what their learning style is.  But that is a long questionnaire and is not free.
  I wonder if one could pair up an Assimilator (watch-think) person with an Accomodator (feel-do) person and have them work together through the exercises?  
• Somehow we also have to account for the participants' digital competence.  Ideally you could create small groups which include at least one computer expert and one Accomodator.  
• The auditorium/room where you are presenting might preclude working in small groups.  
• All you can do is cross your fingers and toes and hope for the best!  Just try and light the fire and leave them with resources to go back to.  I tell the audience to find a social media mentor at their local institutions who can get them started.

Will Medical Educators Adopt Social Media?

This morning I had the privilege to do a presentation on the use of Social Media in Medical Education to a group of seasoned medical educators.  David Pilasky, Jason Korenkiewicz and Nicholas Arcieri made up the rest of the presentation team.  This was a group well versed in pedagogy and the changing landscape of healthcare in the country.  But they were mostly unfamiliar with possible pedagogic uses of tools like Tweetchats and Google Hangouts.
We did a pre and post session poll to gauge the knowledge of and attitudes towards use of Social Media in Medical Education.

Here is a storify summary of the session.  It is impressive to see the gradual change in the audience as the session went on.

by Neil Mehta

23 minutes ago · 1 views

• 52

The MedEd Plenary on Social Media

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An introductory session on the use of Social Media in Medical Education - participants included people involved in various aspects of medical student education and were mostly new to Twitter.

1. Asked the audience about their reaction to Twitter. Tweet's captured the response from the audience! (Not the poster's opinion)
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   First reaction on the use of Twitter. "Ugh" #someded

   David_Pilasky

   
   

   12 hours ago

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   #someded Why people don't use twitter? Get off my lawn, too busy.

   
   

   David Wiener

   
   

   12 hours ago

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4. The audience slowly began to thaw 
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   Educators beginning to see the use of social media. @Neil_Mehta is on fire! #someded

   
   

   Jason Korenkiewicz

   
   

   12 hours ago

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   Knowledge is about to be disseminated, loving it! #someded

   
   

   NicholasArcieri URMC

   
   

   12 hours ago

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   Love it! @dsmwiener: #someded About to learn more about social media from Neil Mehta

   
   

   UChicago Pritzker

   
   

   12 hours ago

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8. Gave a very very brief demo of how to use Twitter with #Someded hashtag.  There were a few tentative first tweets!
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   #someded Hello everyone. This is my first tweet ever!

   
   

   
   

   
   

   12 hours ago

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    #someded

    
    

    
    

    
    

    12 hours ago

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    #someded hello

    
    

    
    

    
    

    12 hours ago

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    #someded hello everyone

    
    

    
    

    12 hours ago
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    #someded I finally got through!

    
    

    
    

    12 hours ago
14. Nicholas Arcieri did a great job encouraging the users.
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    Don't be afraid of Twitter, it can't bite, I promise! #someded

    
    

    NicholasArcieri URMC

    
    

    12 hours ago

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    everyone is doing a great job for their first time tweeting! #someded

    
    

    NicholasArcieri URMC

    
    

    12 hours ago

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17. We started off with a demonstration of a case discussion on Twitter
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    We have a 50-year old male with low back pain #someded

    
    

    Neil Mehta

    
    

    12 hours ago

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    From CWRU: Does he have bladder or bowel incontinence? #someded

    
    

    David_Pilasky

    
    

    12 hours ago

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    History of cancer? #someded

    
    

    Jason Korenkiewicz

    
    

    12 hours ago

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    @KorenkiewiczJ great question... no cancer, no incontienece #someded

    
    

    Neil Mehta

    
    

    12 hours ago

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22. We got some questions about the typical red flags.  Prompted the audience for more questions and got some great ones.
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    Any other questions? before we proceed to exam #someded

    
    

    Neil Mehta

    
    

    12 hours ago

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    Does he have fever or chills? #someded

    
    

    David_Pilasky

    
    

    12 hours ago

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    #someded does he have insurance?

    
    

    David Wiener

    
    

    12 hours ago

    
    

1. Any other symptoms? #someded

   
   

   NicholasArcieri URMC

   
   

   12 hours ago

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   #someded what is height and weight

   
   

   David Wiener

   
   

   12 hours ago

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3. There was a great response from the group, they start seeing the potential and start thinking of potential applications.
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   How do medical educators use social media? @Neil_Mehta uses tweet chat w/ students. #SoMedEd

   
   

   
   

   ReplyRetweet12 hours ago
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   <- chat room on steriods #someded

   
   

   
   

   12 hours ago
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   #someded Very cool!

   
   

   
   

   12 hours ago
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   Hi! This may have promise! #someded

   
   

   
   

   
   

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   #someded multiple uses in med ed

   
   

   
   

   
   

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   #someded we are getting there

   
   

   
   

   
   

   12 hours ago

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    #someded could use this to chat with incoming students.

    
    

    
    

    11 hours ago

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    #someded A great advantage is connecting with people you don't normally get to collaborate with!

    
    

    
    

    11 hours ago
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    #someded grouptweet.com for private conversations

    
    

    David Wiener

    
    

    12 hours ago

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    #someded @Colleenocg Twitter and Twitter fountain could be useful for use in Group Application Exercises within TBL

    
    

    
    

    
    

    11 hours ago

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    Storify sounds like it has a lot of potential... #someded

    
    

    
    

    
    

    11 hours ago

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15. The conversation was picked up by folks outside the meeting
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    RT @UCPritzker: How do medical educators use social media? @Neil_Mehta uses tweet chat w/ students. #SoMedEd

    
    

    Allison

    
    

    12 hours ago

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    RT @UCPritzker: How do medical educators use social media? @Neil_Mehta uses tweet chat w/ students. #SoMedEd

    
    

    Kaplan MCAT

    
    

    12 hours ago

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    RT @UCPritzker: How do medical educators use social media? @Neil_Mehta uses tweet chat w/ students. #SoMedEd

    
    

    Alex Djuricich MD

    
    

    8 hours ago

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    RT @UCPritzker: How do medical educators use social media? @Neil_Mehta uses tweet chat w/ students. #SoMedEd

    
    

    MD at IAU

    
    

    11 hours ago

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20. Some concerns, some anxiety, barriers and some great humor!
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    #someded I'm going to start just printing the Internet

    
    

    
    

    
    

    11 hours ago

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    #someded Very informative article. Glossary makes me realize how little I know.

    
    

    
    

    11 hours ago
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    #someded This seems complicated for widespread faculty use

    
    

    
    

    
    

    11 hours ago

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    I am a novice in learning a new skill #someded

    
    

    
    

    11 hours ago
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    #someded we need tutors/mentors

    
    

    
    

    
    

    11 hours ago

1. Many concerns about identity authenticity & management #someded

   
   

   Jason Korenkiewicz

   
   

   12 hours ago

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   #someded iPad interface is not great

   
   

   
   

   
   

   11 hours ago

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   #someded that's it! I'm going back to stamps!

   
   

   
   

   
   

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4. Some feedback; Some Tips and resources
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   #someded Well worth the time. 

   
   

   
   

   11 hours ago
6. 
   Share
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   IT session was user friendly and fun--CWRU was outstanding! #someded

   
   

   
   

   
   

   11 hours ago

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   Great time talking to student services, very good questions. #Someded

   
   

   NicholasArcieri URMC

   
   

   11 hours ago

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   The article is very informative as I knew nothing about this new thing #someded

   
   

   
   

   
   

   11 hours ago

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   RT @PeterMMarzuk: #someded thanks to all our friends from case for a great meeting

   
   

   
   

   
   

   11 hours ago

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    You can follow people in this feed by putting the mouse over their name and the follow button should pop up, then just click follow #someded

    
    

    NicholasArcieri URMC

    
    

    12 hours ago

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    RT @nicholas_urmc: Here is a great guide on #GettingStartedWithTwitter paulpduxbury.com/HowToTwit...#someded

    
    

    Jason Korenkiewicz

    
    

    12 hours ago

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    RT @nicholas_urmc: You should take your IT guy to lunch and make him tell you all of the twitter secrets.... #someded

    
    

    David Wiener

    
    

    12 hours ago

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13. We did a pre and post session ARS poll which showed an impressive change in knowledge and intention to change behavior (use SoMe in teaching).  This was a terrific audience - who says medical educators can't be open minded about change!

What about the pre and post data?  Well we did not do an IRB for this study so would not be able to reveal that results ;-(