ramen and pickles

science, technology, and medicine served up with some tasty noodles

Do No Harm & The Dressing Station

I’ve just finished reading two surgical memoirs which I read back to back, switching between the two, both by surgeons trained in the British system, Jonathan Kaplan and Henry Marsh.

 

Jonathan Kaplan is a medical and media vagabond and his book is The Dressing Station: A Surgeon’s Chronicle of War and Medicine.  Henry Marsh is senior consultant neurosurgeon (equivalent to department chair I suppose) at a major London hospital (soon to retire), and his new book is Do No Harm: Stories of Life, Death and Neurosurgery is not widely available in the US, and I had to order it from the UK.

Structurally, the books are fairly similar.  They are both organized as a set of episodic chapters which largely stand on their own.  The Kaplan book is mostly organized around his different jobs and travels, for example a chapter or a few chapters might be dedicated to his experiences in Mozambique or his time working as a ship’s doctor on a cruise ship based in the Manilla, and they are typically titled by the country/place (e.g. Namibia or Kurdistan).  Marsh writes his chapters usually organized around a specific case or a few related cases (sometimes his own experiences as a patient) and titles his chapters around themes of disease, symptoms or situation (Glioblastoma, Medulloblastoma, Melanoma, Trauma).  Many of these chapters would stand relatively well on their own, perhaps as the sort of case reports with personal commentary that show up in places like the NY Times or the New Yorker.

As interesting side note, relatively late in the book Marsh notes two of the great advantages to being in medicine are 1) an inexhaustible supply of interesting anecdotes, sometimes amusing but often terrible and 2) a good knowledge of where to get very good healthcare for yourself and your loved ones.  Both authors certainly take advantage of their supply of anecdotes, but terrible and amusing in these books.

There are some similarities between the authors.  Kaplan grew up white and privileged in apartheid South Africa to a long line of physicians and surgeons.  Marsh grew up privileged in England (white as well), although his family were more of the humanities side of things, such as the law.  Kaplan fled South Africa after medical school to avoid mandatory military service for the oppressive apartheid regime and goes to the UK for his clinical training (the part that corresponds to residency in the US), so they both had training (house office, registrar, etc.) in the old British system.  They are both surgeons with literary interests.  Both are interested in improving medical care in the developing world.   Both are critical of the modern NHS (the British socialized health system).  Both are somewhat irreverent and anti-authoritarian.

They both have done international work, much of Kaplan’s career has been in the remote regions of the world, many areas of ongoing conflict.  Not for him is the safe life of organizations like Medecins san Frontieres, instead he joined up with much, smaller more wild outfits running into regions with active conflict, much of the time not even working primarily as a physician, but often being a journalist or documentarian.  He covered such topics at the slaughter of elephants during the many African wars he witnessed, their ivory pillaged to buy weapons, although often even on these non-medical jobs, he has been involved in providing medical care to refugees, accidental trauma victims, or those intentionally injured by warfare and conflict.  Much of this work in the developing world is without renumeration, so in between dangerous adventures, he seems to try to recover from PTSD of the horrors of wartime surgery and artillery shells exploding nearby by taking up various temporary medical posts such as cruise ship doctor, medical supervision/escort of patients being airlifted around the world, and even the occupational health of highly stressed bankers in London.

The international work of Marsh has been in several countries, but most of it has been focussed in the Ukraine.  In many ways it is much less dramatic, certainly less dangerous, as he has worked to improve neurosurgical care in post Soviet Ukraine by training their physicians, bringing them supplies, and treating some of their most difficult cases.  I originally became familiar with him through the documentary The English Surgeon which mostly focusses on his work in Ukraine.  It’s a good movie, which I enjoyed a lot:

When reading the Kaplan book I was struck by the lack of a coherent sense of something accomplished or some greater truth learned.  He has certainly saved many lives, helped many people, but he himself admits a few times to feeling like it was not a great contribution and contrasts his work to an engineer providing clean water in Iraq who saves thousands of lives in a very short period of time.  He readily admits that many of his best skills are really suited for things like operating a surgical trauma center in a hotspot in the developing world and don’t often transfer over to medical life in places like the US or England.  I am somewhat struck with getting a feeling of an unfulfilled life.  Despite all his amazing adventures, I didn’t get a sense reading it like he really enjoyed things or felt much achievement.  I’m not sure if that sense of restlessness is what drives him on his adventures, but in his writing it seemed to be there.  There is a sense of being a bit burnt out on human suffering and the burnt out on the lack of empathy and response; he thinks of the Western World as being disinterested and callous about human interests stories on things like just more “War in Africa”, and I guess he is right.  I was also surprised that the book had no pictures.  I know from some video interviews I have seen that he takes very interesting and compelling photography (below).  Part of his travels he was producing documentaries or new stories for the British or Dutch media, so he should have a lot of photographic evidence.  Maybe some of it is someone else’s copyright, but he must have some material to include.

The Kaplan book also has a lot of of the socio-political history of various conflicts in the 70′s-90′s.  I sent me off into several forays into Wikipedia to learn about things like FRELIMO.  On reflection, the book might have benefited from some maps.  I did not go into this book being very familiar with things like geography of Eritrea or Burma, so even just a simple map of his rambling adventures might have helped put things into better context.

Overall, one gets the sense reading the book that he has seen a tremendous amount of human suffering (starting from his early days being aware of the conditions in South Africa), and has done a lot of work to help ameliorate it, but perhaps feel like someone who has taken a few little scoops of water out of the ocean.  There are interesting, exciting stories, but it is somewhat discouraging to think about doing this sort of work.  He tries to end some of his most serious stories with with a happy story encountering a patient he had saved in a makeshift trauma hospital, recovering well later in a bar.  However, he robs this a bit of the uplifting message by somewhat cynically noting that the journalists he is with enjoy it as being a happy ending to a story of their time in Eritrea.  Some of these experiences have pictures, shown in this video interview:

Kaplan is a bit critical of the modern NHS, but Marsh takes it much further and is incredibly critical of the current NHS, which comes off as being absurdly bureaucratic, authoritarian, and barely functional.  He cites numerous examples of the top down driven system making all sorts of policies and the medical equivalent of papal bulls on all manner of aspects of medical care, some of them seemingly absurdly picayune (rules forbidding doctors from wearing wristwatches when seeing patients) to bizarre results of their rules such as sending a CD of medical images in one taxi and a piece of paper with the password in the other to comply with privacy concerns.

Marsh is very open about his surgical errors, writing very openly about judgment errors and mistakes (with a great shout out to Kahneman-Tversky  style biases), including going through a major liability settlement against him.  He talks about one of the serious, major realities of neurosurgical practice being that often patients are left alive, but severely compromised (paralyzed, brain damaged, in a persistent vegetative state).  However, he does rejoice on some difficult cases with good outcomes, patients saved from a death sentence from brain tumor or the chronic pain of trigeminal neuralgia.   He has worked to improve the infrastructure and training program at his hospital, but one also gets something of a feeling of defeatism, as he is happy to be resigning from his post as he is pessimistic of the path the NHS is taking and where it is going.

Both authors write pretty openly about their personal lives.  Kaplan includes some of his sexual escapades, although he seems to remain unmarried without serious interpersonal relationships, other than some comrade-in-arms type close friendships from his adventures (in the video he mentions a girlfriend).  Indeed, it might be hard for someone who has seen so much trauma to relate with many other people.  Marsh’s workaholism led to a divorce from his first wife, but he does seem happy in his current relationship.  He also talks about some of his experiences being the parent of a child with a brain tumor, as his son needed neurological surgery early on in Marsh’s training.   The books both have a lot of introspection about the meaning of what they do and the meaning of their craft and their own personality quirks.

Overall both authors provide very interesting stories about lives spent in the service of others.   I imagine them most tremendously and hope that I can emulate some of their tireless efforts of service.  I would recommend them to anyone interested in global health, medical ethics, and/or the profession of surgery.

 


 

 

 

 

 

To be skilled or to feel skilled – which is more important?

Is it better (more important?) to be really good at something or to feel like you are really good at something?  To be very good at something or is it important to be the best around?  A decent sized fish in a big ocean or the biggest fish in a small pond?

Malcolm Gladwell gave an interesting talk at the Google Zeitgeist conference (video link below) last year on this topic.   He was presenting some of the ideas from his latest book, David and Goliath, which has drawn relatively sharp criticism from Esquire and the New Republic, the latter of which called him “American’s best paid fairy tale writer”, so caveat emptor.

Caveats aside, he talks about a few different things, but one element is issues in what causes college students to switch out of STEM majors, which seems to be relative performance to local peers.  For example, even if you are one of the top 10 performing students (say as measured by an exam) in the world, but you are at a school with the 9 people in the world who rank above you, then there is a good chance you will give up, despite being better at your chosen discipline than everyone else in the world except the other people in your local group.   An example of why this is important (if you think money is important) is that being in a STEM major seems to be one of the major determinants of future income, as highlighted by the latest PayScale report, and although there is some dependence on where you went to school, the choice of major seems to be a much more important factor.   So one thought is that if you are studying something really difficult, and you seem to be the worst at it around, it may be in your long term best interest to stick it out, even if immediately you feel horrible.  As an aside, I have heard this joke: “What’s the graduate of Harvard Medical School with the worst grades called?  Doctor.”

However, Gladwell goes into some research on publication success of economists, and how that the same effect seems to be at work here as well. I guess I have seen very talented people at elite universities sort of “intimidated” out of academia because of their peers, despite being incredibly talented on their own, so maybe there is something to it. However, there is also the important aspect that you need to be challenged by talented people and cooperate with talented people to drive success. In some of his (Gladwell’s) other work he has talked about pockets of high achievers appearing in different areas, supporting the idea of the advantage of a critical mass of people all challenging and driving each other toward excellence, so there is a flipside and an advantage to finding a very good group to work with and not looking for a small pond to be the big fish. I have certainly found that I am most productive when I’m working with the smartest people I can find.

I have heard boxing coaches (maybe this was just in a movie about boxing though, I can’t remember, so take this anecdote with that in mind) talking about how to support the career of a new boxer. You have to have the new boxer move up through bouts progressively. If they go up against the champ right away, they get intimidated and basically ruined. However, they also need to be challenged by progressively more difficulty opponents so they improve their abilities as they go along. Incidentally, that’s how video games work to be wildly addictive.  Relatedly, certainly people have written about why winning a bronze medal can be psychologically more satisfying than winning a silver medal.

I think it is important to recognize the importance or being an expert or leader at something in your life for your happiness. Robert Sapolsky (one of my heroes) has talked about this before with regards to stress reduction. There seems to be an emotional need to feel like you have prestige and competence in one area, and I think that’s a good thing (as long as that thing is a pro-social area). If everyone can have different aspects of life in which they have a lot of prestige, then everyone can be happy at having their own little bay where they can retreat to and be the big fish, but also swim in the larger ocean most of the time to flex their fins. To paraphrase the Lego Movie, “Everyone is the Special”.

Anyway, I certainly feel (or at least think I feel) like it’s more important to be really good at something for the sake of working hard and trying to be good at something, independent of what anyone else is doing.  There is a certain reward to progressive improvement at a task all on its own.

Good luck out there!

 


 

 

 

How long is an average PhD thesis?

There is a great blog post over on http://beckmw.wordpress.com/2013/04/15/how-long-is-the-average-dissertation/ looking at dissertation length.  It is definitely a standard based upon discipline, as we can see from this figure.

 

 

There is some great R code over there to show how to analyze the data from the U of Minnesota’s digital storage of dissertations and create the figures.

Mine was a total of 112 pages, and probably the closest academic discipline on the chart is biostatistics, so I guess it was very close to “industry standard”.   However, a lot of mathematics theses are notoriously brief.

John Nash‘s thesis is about 26 pages of content, has two references (one to Von Neumann, and one self-cite), and led to a Nobel Prize in Economics (1994).  That is efficiency.

John Nash is an interesting dude.

Did you do a dissertation?  How long was it?


 

 

 

 

A Mathematician’s Lament

I found this 10+ year old essay by mathematician (and teacher) Paul Lockhart on all the things wrong with education in mathematics education in K-12 and on mathematics as a form of art, entitled “A Mathematician’s Lament”:

http://mysite.science.uottawa.ca/mnewman/LockhartsLament.pdf

He’s got some great stuff in there, highly quotable, such as “PRE-CALCULUS: A senseless bouillabaisse of disconnected topics. Mostly a half-baked attempt to introduce late nineteenth-century analytic methods into settings where they are neither necessary nor helpful.”

Although it makes for great reading and has a lot of good points, I’m not sure I agree 100%.  I do remember the transition of going into more advanced mathematics in college and the professor essentially laughing at the formal way we had been taught to do proofs in high school geometry.  My first year in university, when we were proving something, he had us write it out in a much more conversational style, with the mathematical notation flowing with the text, as sentences.  It totally blew my mind.  In the same way, when I was writing my first really scientific paper, I was laughed at by the PI for using passive voice, as we had been taught all the way through in our lab reports:  “50 mL of water was pipetted” instead of “we then added 50 mL of water”.   The first sounds ridiculous in retrospect, and the latter has exactly the same information but sounds like it was written by a human being.

However, I would stress some of the practical applications of mathematics as being really important and useful, and I am a little skeptical of the ability of most math teachers to really teach the beauty of mathematics in such a free form way, and I am also skeptical that a push in this direction won’t move us away from actual learning of skills.  For example, if you just teach poetry and encourage the beauty of literature, you end up with people who don’t know where to put commas in a business email.  I know many highly educated people with this problem, presumably because they were taught English by teachers who probably had dreams of being like Robin Williams in Dead Poets Society and awakening their student’s minds instead of teaching them grammar.  Paul Lockhart obviously isn’t saying that you don’t teach any technique or any formality, but I think it is worth mentioning this as a potential problem.  I think the same is true of teaching some of the fundamentals.  The New Math which was a real step backward in mathematics education is the fault of the fictitious Nicolas Bourbaki, a pseudonym for a bunch of French mathematics researchers who were trying to make sure math was more rigorous and beautiful.  I’m not always sure that when you plan out what should be part of mathematics curriculum you shouldn’t include just as many physicists and engineers as mathematicians in the discussion.

Instead of learning how calculate, students are encouraged to learn all sorts of abstract concepts instead of learning how to do useful things with mathematics.  At the same time, kids are often taught weird algorithmic, formal solutions for problems that aren’t even that relevant. For example, I did some substitute teaching of high school mathematics, and one of the things students were being taught was the Sieve of Eratosthenes.   In principle, I can see that it might be considered useful as a way to think about prime numbers, but these kids were having trouble with fractions and arithmetic.   It’s not that people won’t have access to calculators, but you should know roughly what the calculations should be like.  Learning how to do rough, back of the envelope estimates is an incredibly useful skill and I’d note like to see it be replaced by the art of mathematics for art’s sake.

For example, this response to a mathematics problem from the Common Core was making the rounds with a lot of parents:

Overall, I don’t have any particular solution, but I do like the essay by Dr. Lockhart, and I encourage those interested in mathematics education to read it.

Part of what is beautiful and satisfying about mathematics is that there is a correct answer.  There aren’t as many of the same semantic arguments that cause so much discussion in much of human discourse.   That’s also what makes mathematics hard but also worthwhile.

Part of my personal lament I suppose is that I don’t think a lot of my mathematics education prior to University was very good.  Although I did have some great teachers in my early education, my later years in K-12 were terrible.  For example, in 8th grade (middle school), I was given a textbook from the high school and told to sit in the back of the class and teach myself the material, as I was more advanced than the other students (partly because I enjoyed mathematics, partly because I had come from a better school system).  I just had to pass the midterm and final exams that came down from the high school.   That wasn’t a great method of education, particularly as the textbook sucked.  Maybe if I Dr. Lockhart had been my teacher, I would have more happy memories of my early education.

 

 

Comments appreciated in the section below.


 

 

 

Women in STEM & Impostor Syndrome

 

This is a short piece by the president of Harvey Mudd talking about Impostor Syndrome. I am daily surrounded by some of the brilliant women on the planet, and I have definitely noticed that these women seem so suffer a greater proportion of self-doubt and to a greater extent. It is entirely subjective, but that is my impression, and it seems to be supported by studies.

For those unfamiliar with Harvey Mudd, it is a small college in Southern California, and one of the best engineering schools in the country. So good, that its graduates are the highest paid college graduates: http://www.theatlantic.com/business/archive/2014/03/which-college-and-which-major-will-make-you-richest/359628/

As a side note, apparently “impostor” and “imposter” are equally valid spellings: http://grammarist.com/spelling/imposter-impostor/

The same is true for “adviser” and “advisor”: http://grammarist.com/spelling/adviser-advisor/

For some reason, “imposter” and “advisor” are the natural spellings to my eyes, but statistics on usage seem to favor their rival spellings.

 


 

 

 

The Mona Lisa is not Tim’s Vermeer

I recently watched Tim’s Vermeer, and I enjoyed it quite a bit, but I’ll get back to that in a bit.  I was also recently interested in why the Mona Lisa is so popular and iconic, so I thought I write about each of these things a bit.

Why is the Mona Lisa so famous?  You can read about it being famous and well regarded as soon as it was painted, but it certainly had nothing like it’s iconic status until the beginning of this century.  You’ve  heard of the Mona Lisa and see her iconic half-smile everywhere.  How about the Portland Vase? If you believe Google Books N-Gram viewer is a something of a model of popularity, or at least discussion and public awareness, the Mona Lisa, was not nearly as popular at the Portland Vase just a few generations back.  Just to be careful, I also tried other aliases for the painting such as La Gioconda, but to no avail.

Mona Lisa Fame

Da Vinci’s painting got a little fame when, in 1869, Walter Pater wrote a popular essay on Da Vinci and praised the painting. At that time, reproductions began to get some popularity in England. However, it really got famous in 1911 when the Mona Lisa was stolen from the Louvre by an Italian nationalist and went missing for two years, during which there was a lot of publicity. So why is the Mona Lisa famous? As far as I can tell, it is disproportionately famous because it’s theft from the Louver received a lot of publicity at the time. Because it got popular and renowned as valuable, it has then served to represent fine art in popular media ever since, only magnifying its fame.  If you are interested in you can read a longer piece on it’s fame HERE.  Suffice it say that although I enjoy it as a painting, it certainly seems overrated, even after I went to go see it in the Louvre.

I encourage you to discover the works of Katsushika Hokusai if you are unfamiliar with anything other than Under the Wave Off Kanagawa.  It was interesting to see an interest growing in the late 19th century with the Orientalists, and then a bit peak in the 60′s counter-culture.

As much as I like Da Vinci, I am probably more a fan of the painting of Vermeer.  That made the idea of a computer nerd trying to figure out what technological innovations Vermeer might have used to help him paint quite interesting to me.  Tim’s Vermeer is definitely a movie by and about geeks for geeks, but I enjoyed it tremendously:

There seem to be some art critic type people who seem to think that this misses the point of Vermeer, but that is the sort of attitude of someone who thinks that understanding the refraction of light ruins the beauty of a rainbow.  When you understand more about a process you can understand and appreciate its beauty all the more.   When you understand a little bit more about the handwork and insight that goes into the process, I think you gain a greater appreciation for his genius.

If you’re interested, The Girl in the Pearl Earring barely makes a blip in the N-Grams compared to the others.

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Naomi Sushi, Menlo Park

It’s been there for a while, but I hadn’t been before.  Naomi Sushi on El Camino is quite a good place.  It is sort of a typical sushi bar in the US, a little fancier than many. The staff were very friendly, and there seem to be a lot of regulars who go there who are familiar with the staff.

That had some good specials, including some bluefin chutoro and some very good aji (horse mackerel).  The simple rolls on the menu (tuna, cucumber, yellowtail, etc.) were quite reasonably priced.

Overall, I would recommend this place.  It’s also near another tasty Japanese restaurant, Gombei, just a block north on El Camino.  Gombei is good for bento boxes, and a variety of mixed dinner meals, not quite izakaya, but maybe more homestyle.  Two good places to get a good Japanese meal for not too much money.

 

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Sam’s Chowder House, Palo Alto, CA

I finally got around to trying  a somewhat new restaurant in Palo Alto, Sam’s Chowder House.  I tried it because Oren’s Hummus restaurant had at least an hour wait.  That place is good, but it is way to crowded and busy.

I am from New England, and my uncle (retired police detective) had a lobster boat for a while, and even now at 75 years old has a commercial clam digging license in Maine, so I grew up on this style of seafood, and I am probably very picky.  However, I was really pleasantly surprised by this place.

Starting with their clam chowder, since something like chowder is very subjective, I will base my comparison with the chowder from Legal Seafood, which is fairly representative of a standard, decent quality New England style chowder.  Other NE style chowder that I have gotten around here in Northern California has been similar, often a little bit more gelatinous, presumably with thickeners such as corn starch or carrageenan or something.  Anyway, the soup at Sam’s was quite different.  In some ways it was a lot thinner, so less creamy and thick, but I actually found it very pleasant.  It had a lot of herbs and celery in it, which gave it a nice, refreshing flavor.  It has a nice subtle smoky richness, presumably from the bacon which is on the ingredient list.  There were nice big chunks of clam, with had a fresh taste to them, and some small chunks of potato.  So compared to Legal Seafood, it was much less hearty, but I think more flavorful and delicious.  If you are expecting the really thick and hearty style, you might be disappointed that it doesn’t meet expectations, but I thought it was good and would very much recommend it.

Sam's Chowder House

The lobster roll was really outstanding.  It was full of large chunks of lobster, maybe meat from 6 claws on top, with more meat under the claws.  There wasn’t any mayo that I could detect, which for me was a huge positive, as I don’t like it, especially places which fill it with mayo back in NE.  There were just some little celery nuggets and lots of butter.  The perfectly toasted roll was quite butter and delicious.  The lack of mayo was definitely made up for in butter.

Overall, I think this place is great.  It wasn’t cheap, but if you’re looking for cheap, University Ave in Palo Alto is probably not the place to go looking.  The service was good, it had a nice atmosphere, with friendly people.  Overall, it’s a definite recommend.

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Ryowa Vegetarian Ramen

There aren’t many options for vegetarian ramen, however Ryowa in downtown Mt View, CA has one, and I hadn’t remembered if I had tried their vegetarian ramen.

Ryowa has some tasty ramen in general, and I like some of their options.  They have an oxtail ramen which is not common, and a delicious butter corn ramen.  They also have a really good pork fried rice plate to go with the ramen.  However, as I was doing a vegetarian dinner, I didn’t get any of this delicious rice this visit.

Ryowa Vegetarian Ramen

The noodles were tasty, and the broth was okay, but certainly laking the really good umami flavor which I guess usually comes from the meat.  I got the egg as an extra, and unfortunately it was hard-boiled, so soft runny yolk at all.  The mushrooms had a chewy consistency, like chantrelles which I didn’t like (not the richness of the black ear mushrooms which are my favorite in ramen).  There was tofu, both raw and fried in the soup, and it didn’t go well.  I like tofu in things like miso soup or just alone with some green onions, but it didn’t go well to me compared with the chewy texture of the ramen noodles.  The veggies were decent, but maybe not enough.  I would rather have crunchy veggies than the softness of the mushrooms and tofu.

Although I like Ryowa and I would recommend it to someone looking for ramen in Mt. View, I can’t really recommend their vegetarian ramen.

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A great collection of free R books

If you are into statistical computing (or want to be), this is a great collection of freely available PDF texts on a range of topics.

http://blog.revolutionanalytics.com/2014/03/an-r-meta-book.html

 

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