Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction – Mayo Clinic Proceedings

Rock, Table, Morning

“More and more I believe that art—via imagination—is the necessary counter to our information-glut crisis. I explain this by referring back to the root concepts of imagination and information. Imagination is a formative inward power, independent and generative. Information, by contrast, and by original definition, imparts inner form from the outside. To be informed is to receive the print of ideas or—and again I heed the etymology—impressions.
Imagination creates shape; information imposes shape.”
Sven Birkerts

Changing the Subject: Art and Attention in the Internet Age

We are all great photographers now. Anyone with an iPhone can create a perfectly exposed, perfectly focused image. With just a bit of thought and awareness, composition of the image is without imagination with a direct view of the image, followed by instant feedback once the picture is taken. Post-processing is assisted by algorithms that create interesting looks with no effort. Event traditional darkroom techniques of adjusting contrast and exposure or local adjustment of light and dark (dodging and burning) can be done right on the phone. No money, skill or training is required to publish the image to the entire world on a social media platform like Twitter, Flickr or Instagram.

Awash in images, the value of a good image is devalued. The image on this page was captured this morning and post-processed with 6 different algorithmic engines in about 10 minutes. I’ll admit it has less value to me than if I had begun the morning in the darkroom developing a roll of film and then printing later this afternoon after it had dried. Yet taking the image and adjusting it to reflect how I feel at the moment was no less genuine, just faster and less important today. And here it is to share with hundreds on Flickr and the few who will read these thoughts.

Like many photographers of a certain age, I remember vividly seeing my first print emerge on paper in the darkroom under the red safelight. It wasn’t instrumental, it was purely experiential, seeing how film and paper transformed a particular view at a certain moment into a flat image with the impression of light and odd effects that were no longer at all what had been there. The smell of stop bath.

It’s hard to make a living as a photographer now. It’s no longer a life of collecting images on slides and providing them to a stock photography vendor. Magazines no longer support the artisans that supplied them images. Our best photographers today are performers, engaging us via social media and selling us vision in return for clicks.

But that’s the value proposition of the image and its maker, not the value of making an image. Making it faster and easier is an aid to imagination, not an impediment. Let’s use the speed and lightness of the virtual to soar.

Turning doctors into clerks with Electronic Medical Records is a major contributor to burnout

Disembodied World

The Isolated Field

We are victims of the post-Enlightenment view that the world functions like a sophisticated machine, to be understood like a textbook engineering problem and run by wonks. In other words, like a home appliance, not like the human body.
Nassim Nicholas Taleb
Via Nicolas Bate

Let’s say the mind is separate from the body; maybe it can be optimized like an industrial process. If the mind is software running on the hardware of the brain, maybe it can be debugged and, gradually, perfected.

On the other hand, if mind is just what the brain does, then as the world affects our brains, the changes become what we think. As we scatter our attention through the always available immaterial world of digital devices, we must become physically attenuated as well. A book or a photograph represent a reality one step away, but one that we can mentally step into and inhabit. Email, messaging and social media are all many steps away–bigger, wider, less personal and less immediate.

Perhaps we become diffuse, abstract and extended in a disintermediated online world. Faster and less solid, having lost its “specific gravity”. It’s all too easy to be part of the crowd in world where nothing is real or permanent.

Then we leave the infrastructure- the computer systems, smart phones, social media platforms, mapping programs, music selection, all for those very clever technologists to run and further optimize, providing us more content, ever faster, all free. Leaving the world to be run by those who know how to minister to the machines that provide our virtual experience, never understanding that we ourselves have become the product, no longer the agent, no longer ourselves. Left with an urge to be real.

Half the people buying vinyl don’t actually bother listening to it: “

Our Diminishing Value

Hero

“That we have a different, much diminished sense of human presence now; that what might be called the specific gravity of things––objects, events––is lessened in proportion to the expansion of our field of awareness.”
Sven Birkerts
Changing the Subject: Art and Attention in the Internet Age

There was long an expectation that as worker productivity increased, wages would increase. After all, if I can do the work of two, then I should earn twice as much. Or at least make more for my increased output.

Sadly, it doesn’t work that way, does it? As we do more we receive no more. In fact, as work gets easier it’s value is diminished. Where a skilled short order cook once stood now stands a burger production machine, taking frozen, preformed patties at one end of the conveyer belt and depositing tasty finished food at the other. It’s operator is diminished.

As Birkerts points out in Changing the Subject: Art and Attention in the Internet Age, we’re increasingly removed from the world, just as we no longer touch our vinyl LPs, our relationship to streamed music is diminished. We rely on Google Maps and never experience the space, not even as represented on a paper map.

As it now all just happens, its of very little value. As we experience more and more in this attenuated manner, we value the experience less. Should we be surprised that we ourselves are now also valued less? Producing nothing real, we are really just the controllers of nothing of substance. We feel.

Increasing the “specific gravity” of experience, feeling its true weight, is a start in returning to reason. The feeling of loss is not mere nostalgia, it is a yearning for real purpose.

“Twenty men crossing a bridge,
Into a village,
Are twenty men crossing twenty bridges,
Into twenty villages.”
Wallace Stevens
Metaphors of a Magnifico

The View Back

Dried Pomegranate

“In its most complete meaning, intellectual humility is accurate self-awareness from a distance.”

David Brooks The Road to Character

Temperament is innate. Just as we are determined to be short or tall, we are calm or reactive by nature. The qualities we bring into the world shapes personality and character because they affect how we react to the world, how the world treats us and thus determine how the world occurs to us: our model of who we are and what to expect.

Brooks, in The Road to Character, wants to provide us with infinite flexibility to whoever we aspire to be, stating “character is not innate or automatic”. On the contrary, it seems to me that character is just as automatic as everything mental quality. If you want to change it, it will take the same kind of deliberate practice that it takes to become a good chess player or musician. One can indeed become one of the character elites.

Brooks, I think is just further participating in the elevation of the self by promoting “character” as another elite pursuit. Of course we want to be rich, but we also want to have a beautiful, heartfelt elegy at our funeral.

From his purely secular viewpoint, Brooks wants to appropriate religious ideals like gratitude and humility, but apparently doesn’t see that the abandonment of these religious and spiritual tradition themselves serves to promote a worship of self above all. If there is something bigger, we are dwarfed and humbled automatically. If not, we are alone as ourselves.

For example, his chapter on vocation is in contradiction to my view that a job is a job. We need to work to live. Some few do work that they are called to or do work more important than just making a living. But most of us sell things or make things, that’s all and its how it has to be. It’s not a moral failure to need to make a buck.

No, it’s how we do the work before us and how we spend our allotted time that we must strive to make better. Maybe it is not ourselves we must improve but rather improve what we do and say. It’s the integration of self and the mental models we possess that allow deciding better in the moment.

“I suspect it is for one’s self-interest that one looks at one’s surroundings and one’s self. This search is personally born and is indeed my reason and motive for making photographs. The camera is not merely a reflecting pool and the photographs are not exactly the mirror, mirror on the wall that speaks with a twisted tongue. Witness is borne and puzzles come together at the photographic moment which is very simple and complete. The mind-finger presses the release on the silly machine and it stops time and holds what its jaws can encompass and what the light will stain.”

Lee Friedlander

The Small World of AI

What really makes us smart is not our ability to pull facts from documents or decipher statistical patterns in arrays of data. It’s our ability to make sense of things, to weave the knowledge we draw from observation and experience, from living, into a rich and fluid understanding of the world that we can then apply to any task or challenge.

The Glass Cage: Automation and Us

Nicholas Carr

What is human intelligence? It seems to be a miraculous facility that enables man to make complex decisions based on intuition and feelings. We don’t usually consider all the options options, calculate probability of success or really think about whether we really want what we’re going to get? How is it that we are such incredibly sophisticated, rule-based decision making machines?

##Deciding Better
Is it even possible to get better at decision making or has evolution done all of the work already?

Years ago, I began with the premise that formal decision tools could help make more rational, more successful decisions. I learned the concepts of decision making under conditions of uncertainty from consultants and practitioners in the field of Decision Theory. The basic tools like decision trees and simulation were presented as simple consequences of statistical principles. I worked through a basic textbook, Robert Clemens’ Making Hard Decisions: An Introduction to Decision Analysis and began writing about making decisions here at ODB.

After a few years, I realized that no one outside of the world of management consulting and corporate strategy offices really used these tools. Eventually I came to a fundamental reimagining of decision making based on belief models and my training in Neuroscience. The tools of decision analysis, mathematical models, and simulation seemed to best characterized as tools to augment human imagination and understanding. They were useful fictions to guide thinking, merely simple representations of the complex world. I think it’s definitely possible to improve decision making, but the task is as much improving the mental decision making machinery as it is understanding the mathematical tools.

##The Subjective Nature of Probability
I’m not alone in reaching this conclusion. There have always been similar lines of argument, going back to some of the original works in the field of Decision Theory and modern statistics. In Statistical Rethinking, the book I’ worked through to learn Bayesian statistical methods, Richard McElreath provides a wonderful introduction to the Bayesian interpretation of probability. Decision theory is predicated on a specific interpretation of probability. Probability is seen as the subjective likelihood of a particular future event, whether it’s the outcome of a coin flip or the choice of nominee by a political party. These things happen only once, so probability is prediction.

There has been a decades long discussion about whether the probability of heads in a coin flip and the probability of a complex event in the real world can really be the same kind of probability. McElreath presents the formulation of Jimmy Savage, one of the foundational thinkers in the field. Savage proposed that there is a difference between the “small world” of the coin flip which can be accurately reduced to a simple mathematical model and the “large world”, where simple models don’t necessarily hold.

##The Brain Is Not a Small World, Artificial Intelligence Is
The brain is complex and unpredictable and so is by Savage’s term, a large world. Because of our ability for symbolic reasoning, it can contain within it small worlds, models of part of the world that are sometimes explicit but most often implicit. We use these internal models for decision making.

The brain can easily imagine the mechanics of the Bernoulli distribution. But the brain can also contain the mental model of neurological disease and the potential effect of a new medicine. Perhaps machine and other algorithmic, mathematical “small world” systems can never match the “large world” human decision making brain. Why?The brain itself is part of the even larger real world, constantly exchanging information with it, something that we have yet to achieve with our machine intelligence.

Privacy and the Extended Mind

Our thoughts inhabit the most private of spaces. The brain activity an individual perceives as mind is completely inaccessible to any one else. Others know our thoughts only through what we say. There is an absolute ownership of mind based on the metaphysics of the activity, one no police or court can access.

I paused when I read this suggestion that smartphones could share the privileged privacy of mind:

I wonder if every future iPhone product announcement comes wrapped in a message about the importance of smartphones as “an extension of ourselves,” as Cook said today. If you read between the lines, that sure sounds like an argument that smartphones should be a warrant-proof space like the one between our ears.
Tea and scones in Cupertino: The “Loop You In” Apple event – Six Colors

Is it possible that the theory of extended cognition of Andy Clark and others is reaching a wider audience and affected how we think about our personal devices? Clark and others suggest that the physical basis of mind should include parts of the world outside the brain used for thinking or to aid memory. It may follow that if mind is embodied both in the brain and in the physical artifacts that we use to aid thinking, then of course the smartphone could held to be as private as the brain itself.

Speech and writing are not privileged in the same way as thought because once words are put out into the world, others can perceive and interpret the symbols for themselves. But a private language or a coded communication is completely privileged. Of course, a government could ask for those artifacts to be decoded or interpreted, but that’s no different from them asking the brain what it’s thinking. One can simply refuse to answer, refuse to decode, refuse to provide the password. Can the government break into the mind without permission?

Just as thought is encrypted in the brain through its physical medium of neurons and synapses, so are symbols deeply hidden in an encrypted phone. As I contemplate the mind, arising from the interaction of brain with the world, I see the logic in extending the private nature of mind to the personal devices used for extended cognition.

P-Values Are For Small Worlds

This week, the American Statistical Association released a statement on “Statistical Significance and P-Values”. The statistical community is trying to help us with  the problem we’ve gotten ourselves into in science by confusing “statisticial significance” with “truth”.

The validity of scientific conclusions, including their reproducibility, depends on more than the statistical methods themselves. Appropriately chosen techniques, properly conducted analyses and correct interpretation of statistical results also play a key role in ensuring that conclusions are sound and that uncertainty surrounding them is represented properly.

The statement by the ASA alludes to the broader issue I’ve begun discussing in the context of Savage’s Small vs Big World dichotomy. Statistical significance is a simple mathematical calculation that holds true within the “small world” of the sample and the questioned asked of the data. The problems arise from overgeneralizing the principles of probability into realms of uncertainty where they no longer apply.

An Example

All me to provide a simple example. If I measure the height of a few Dutchmen, there’s clearly utility in summarizing the central tendency (mean) and the spread of the distribution (standard deviation). These distributional statements are true in the small world exercise of collecting data, making measurements, using some partictular scale, etc. But the relationship of my calcuations to the “real” height of Dutchmen is a more complicated.

For example, If I now move on to measure the height of a sample of New Yorkers, I’ll have a second sample to compare to the Dutchmen. And with the small world of these two measures, I can summarize and even make a statistical inference about the difference between my sample of Dutchmen and my sample of New Yorkers.

As soon as I decide that I need to  actually  determine whether Dutchmen are really taller than New Yorkers for some real world decision, I’ve moved onto a question to determine “Truth”. In the real world, concluding the Dutch are taller than New Yorkers matters once I decide to act on the result. As William James wrote in Pragmatism:

Pragmatism, on the other hand, asks its usual question. “Grant an idea or belief to be true,” it says, “what concrete difference will its being true make in anyone’s actual life? How will the truth be realized? What experiences will be different from those which would obtain if the belief were false? What, in short, is the truth’s cash-value in experiential terms?”

The moment pragmatism asks this question, it sees the answer: True ideas are those that we can assimilate, validate, corroborate and verify. False ideas are those that we cannot.

So if my real problem is to decide how long the beds for my New York hotel need to be in order to accomodate my usual New York customers and the occasional Dutchman, the question may need to be recast, probably involving the extremes of height, tourist samples and the available length of hotel beds. Perhaps there is a value proposition as well. How many Dutchmen am I willing to distress with a too short bed? What’s the price of extra long beds and bedding? The truth will be known by the satisfaction of my customers and the profitability of my hotel.

Do We Verify in Drug Development?

The truth in medicine and drug development is similarly real world, but our proof comes from the smaller world of a clinical trial or two. I can compare the cardiac output of patients with MI in the presence or absence of a new drug, a small world, mathematical comparison. But once my question moves on to the real world value of the medicine, the question is recast into a large world question and the small world statistical model is one part of the larger question of whether I will accept the efficacy of the drug as true or not.

The truth in medicine will be known by the patients, by the cost to those who pay for the medication. Yet we tend to rely solely on the small world result of the clinical trial, a result that we generally fail to “validate,  corroborate and verify”

Norbert Weiner on Yielding Decisions to Machines

The sense of tragedy is that the world is not a pleasant little nest made for our protection, but a vast and largely hostile environment, in which we can achieve great things only by defying the gods; and that this defiance inevitably brings its own punishment. It is a dangerous world, in which there is no security, save the somewhat negative one of humility and restrained ambitions. It is a world in which there is a condign punishment, not only for him who sins in conscious arrogance, but for him whose sole crime is ignorance of the world around him.

The Human Use of Human Beings: Cybernetics and Society
Norbert Wiener

The last 400 years have seen social changes unlike any earlier period. As our technological reach has grown, our machines threaten to become more than our tools. Our creations seem to slip out of our control and become our masters.

In the early 1950’s Norbert Wiener wrote a slim book, The Human Use of Human Beings: Cybernetics and Society, that was a set of meditations on the relationship of man to his machines. Weiner, who died in 1964, was a American mathematician and philosopher who coined the term “Cybernetics” to describe the complex, unpredictable behavior of simple control systems. In the 50’s, the concern was with automata, robots capable of independent action like those controlling factories or missile systems. It’s striking how different the attitude was toward calculating machines, what we would broadly call “computers”. At the time, these were still large, simple tools without any autonomy. One fed them punch cards and they provided printouts. Weiner clearly saw the changes that telecommunication would bring to automation, worrying that these intelligent machines would move further out of the control of man, talking to each other.

But Wiener was more afraid of man in organizations than organizations of machines:

I have spoken of machines, but not only of machines having brains of brass and thews of iron. When human atoms are knit into an organization in which they are used, not in their full right as responsible human beings, but as cogs and levers and rods, it matters little that their raw material is flesh and blood. What is used as an element in a machine, is in fact an element in the machine. Whether we entrust our decisions to machines of metal, or to those machines of flesh and blood which are bureaus and vast laboratories and armies and corporations, we shall never receive the right answers to our questions unless we ask the right questions.

The Monkeys Paw of skin and bone is quite as deadly as anything cast out of steel and iron. The djinnee which is a unifying figure of speech for a whole corporation is just as fearsome as if it were a glorified conjuring trick.
The hour is very late, and the choice of good and evil knocks at our door, I find it coming back seated on the whirlwind.

Weiner was one of the early systems thinkers, a group that realized that when individual components were put into an interacting system, the behavior of the whole could not be predicted from the behavior of the individual parts. As The Human Use of Human Beings: Cybernetics and Society makes clear, this is true when the parts are logical systems in a computer, mechanical feedback loops in a robot, neurons in a brain, or people organized into a corporation or political party. Weiner and those who followed destroyed hopes and fears of easy prediction of a clockwork, Newtonian universe. The Large World is a place where simple models don’t hold.

Eventually, these fears abated as we avoided nuclear catastrophe and totalitarianism seemed to recede into history. As Wiener predicted, this was an illusion as we are once again threatened by human machines of death and new “bureaus and vast laboratories” armed Big Data and machine learning algorithms. I believe we are entering another stage in our need to reassert our human ability to make our own decisions and do our own work, resisting the urge to surrender to our own creations.

Worlds, Large and Small

What really makes us smart is not our ability to pull facts from documents or decipher statistical patterns in arrays of data. It’s our ability to make sense of things, to weave the knowledge we draw from observation and experience, from living, into a rich and fluid understanding of the world that we can then apply to any task or challenge.
The Glass Cage: Automation and Us    Nicholas Carr

What is this human intelligence that enables man to make complex decisions based on intuition and feelings without any formal consideration of options, probabilities or relative desirability of outcomes? Are we incredibly sophisticated, rule-based decision making machines? Is it even possible to get better at decision making or has evolution done all of the work already?

These fundamental questions continue to drive my interest in decision making. It’s a practical matter for me, since drug development requires making plans, spending money, and making innumerable decisions on the path of turning a chemical into a new medicine for clinical use all with near total ignorance of the chances of success.

To further On Deciding, Better, I’m delving into the origins of Decision Theory for the first time. I learned the concepts of making decisions under conditions of uncertainty from consultants and practitioners in the field. The tools of decision trees and simulation were presented as simple consequences of statistical principles. I worked through a basic textbook, Robert Clemens’ Making Hard Decisions: An Introduction to Decision Analysis and began writing about making decisions here at ODB.

After become expert, I realized that no one outside of the world of management consultanting and corporate strategy offices really used these tools. Eventually I came to a fundamental reimagining of decision making based on belief models and my training in Neuroscience. The tools of decision analysis, mathematical models, and simulation seemed to best characterized as tools to augment human imagination and understanding. They were useful fictions to guide thinking, merely simple representations of the complex world.

Working through the subject more deeply now, I realize there were similar lines of argument throughout the original works in the field. In Statistical Rethinking, the book I’m working through to learn Bayesian statistical methods, Richard McElreath provides a wonderful introduction to the Bayesian interpretation of probability. Decision theory is predicated on a specific interpretation of probability. Probability is seen as the subjective likelihood of a particular future event, whether it’s the outcome of a coin flip or the choice of nominee by a political party. These things happen only once, so probability is prediction.

There has been a decades long discussion about whether the probability of heads in a coin flip and the probability of a complex event in the real world can really be the same kind of probability. McElreath presents the formulation of Jimmy Savage, one of the foundational thinkers in the field. Savage proposed that there is a difference between the “small world” of the coin flip which can be accurately reduced to a simple mathematical model and the “large world”, where simple models don’t necessarily hold.

Where does the subjective judgement of probability made by the human brain fit into this scheme? The brain itself clearly is an unpredictable large world, but can contain within it small world models, both explicit and implicit, used for decision making. The brain can easily imagine the mechanics of the Bernoulli distribution. But the brain can also contain the mental model of neurological disease and the potential effect of a new medicine. Perhaps machine and other algorithmic, mathematical “small world” systems can never match the “large world” human decision making brain. If I had to guess why, I’d say it’s because the brain itself is part of the even larger real world.

I can’t take notes while reading

I have a hard time combining reading with taking notes. Reading is a focused activity in itself while taking notes requires a different state of mind. How can you notes and maintain focus while reading?

Cal Newport points in Deep Work, not only is doing the work the path to sucess in the 21st century, it is meaningful, satisfying, and fulfilling. Reading to learn with purpose is one of those joyous activities that increases appetite for a full life. Cal identifies this pleasurable state as flow, described famously by Csikszentmihalyi, arguing that Deep Work is not only valuable and rare, it is also meaningful. Flow is that state of “optimal experience” where time dissolves in the face of completely focused, single minded immersion in doing.

Reading often is a state of flow, making switching to writing notes a problem. Flow is not simply about enjoyment and challenge, it involves continuity. It’s interesting that one of the highest rated experiences is actually driving a car. Sadly, pathological gambling is also a state of deep immersion leading to gamblers fainting at the slot machines, failing to eat or drink. Perhaps Csikszentmihalyi was being a bit too much of a positivist when he wrote so glowingly about entering the mental state of flow. But reading is an easily accessable route to a positive, valuable flow state.

Becoming good at entering a state of flow makes it easier to do Deep Work at the highest level for signicant periods of time. Practicing entering that state of mental performance makes it easier and easier to sit down at a desk and do the work. That work will be of higher quality when the barrier between inside and outside models dissolves- mental energy is not needed to support all kinds of extraneous hypotheticals when the mind is in the world, not in the head. This is an extended or expanded consciousness. When driving a car or, better, a motocycle, down an interesting rural two-lane, the internal mental state becomes the perfect mirror of the process of moving down the road.

I struggle with maintaining the state of flow in taking notes when reading, so have reached something of an accomodation over the years. I was helped a few years ago by the wonderous and appropriatedly titled How to Read a Book by Mortimer Adler and Charles Van Doren who actually break down the process.

“Reading a book analytically is chewing and digesting it”

Once you realize that reading is an activity- or really a group of related activities, then reading can fit into the overall plan of doing the work. On the one hand, there’s the great advice to always be reading by having books at hand and deep pipeline of reading ready to go. But on the other hand, one needs to capture knowledge deliberately.

I’ve found it works best for me to read deeply over a chapter or section of text and avoid taking notes unless the thought that’s occurred to me is so signficant and pressing that I’m compelled to get a notebook and paper to avoid the possible loss of the idea. Making notes while reading is distracting. I’ll read to get the book’s content first, then later review and create notes in conversation with the author. That’s a different, more active frame of mind, the chewing and digesting. Of course some books are spit out and not worth the work.

This kind of note taking is very different from taking notes during a lecture or meeting where the talk pulls you back and wont wait for long interruption of writing. Lectures and meetings proceed more slowly than thought most of the time and there’s plenty of time for notes in the pauses and other mental spaces.

Reading has to become work at some point; thoughts need to processed into notes and the notes have to be further processed into summaries and analyses. Something I happen to have been doing here, writing this post. Thanks for your help.