Can We Trust Information on YouTube?

Once upon a time, in my academic career, I worried that inaccurate mass media depictions of, say, diabetics would cause people to make bad care choices. If you’re thinking of Julia Roberts in Steel Magnolias right now, trust me: Julia Roberts in Dolly Parton’s hair salon is the tippy-tip of the iceberg. Now I worry more about YouTube, the modern-day Library of Alexandria of instructional videos.

In the past year or so I have watched YouTube videos, off the top of my head, to learn to: change a blinker bulb in my car, fix my thermostat, learn to run specific reports within Quickbooks, refresh my memory on how to do certain math problems for helping with my daughter’s homework, and shut off the “move to wake” feature in my iPhone. And dozens more.

But I’ve also used YouTube in the past to remind myself how to reduce my son’s dislocated elbow (my son’s orthopedic history gets more complex by the year). There’s an old saying in medicine: “see one, do one, teach one.” I needed to “see one” again before I subjected my son to it. The procedure was successful, for what it’s worth. (Being a doctor’s kid is weird. I digress.) Are you scheduled to have your thyroid gland removed? YouTube can show you the procedure. Are you a new type 1 diabetic who wants to practice carbohydrate counting for insulin dosing? Boom. Starting chemotherapy and interested in using cooling therapy to reduce hair loss? Look no further. Recently we talked about the reliability of physician rating sites (spoiler: potentially useful, but with major caveats). How do YouTube videos stack up for general medical information? For the purposes of this post, I’m mostly ignoring obvious conspiracy-mongering about COVID vaccinations, cholesterol medications, and whatnot. Like pornography, I trust that you’ll know those when you see them.

To get an answer on the accuracy and utility of YouTube videos for medical inquiry, I looked not to YouTube, but to PubMed, the search engine of the National Library of Medicine. Here’s what I found:

YouTube contains so much information that investigators tend to categorize it by learner, generally either medical trainees or the general public. Videos for medical trainees seem to be relatively generously reviewed by researchers. Using our example of thyroid surgery from above, one study found that most YouTube thyroid surgery videos were posted by surgeons operating in academic institutions, which they took to mean the intentions of the videos were purely educational and not promotional. But the researchers also noted that surgeons who had no history of traditional academic publications–i.e., not necessarily the most respected people in the field–posted the majority of surgeon-sourced videos. This led the authors to conclude that “Trainees and educators alike should critically analyze the quality of video content,” which is the academic equivalent of throwing shade. A systematic review of studies of YouTube videos aimed at medical learners backed this up, concluding that “While videos authored by academic physicians were of higher quality on average, their quality still varied significantly,” and “Video characteristics and engagement metrics were found to be unreliable surrogate measures of video quality.” That is, a video’s slick production and millions of views did not mean it was accurate.

Videos aimed at the general public tend to be more harshly judged. One study by two emergency room doctors investigating the quality of videos pertaining to the management of low blood sugars went so far as to say that “health videos should only be uploaded by physicians,” a statement hilarious in both its confidence and its wrongness. Surely someone without a medical degree somewhere, at some point, has been filmed saying something accurate and helpful. But, in general, the quality of public-facing YouTube videos does appear to suffer in comparison to professional learner-directed videos. A systematic review from 2015, admittedly ancient history in internet years, concluded that “YouTube contains misleading information, primarily anecdotal, that contradicts the reference standards and the probability of a lay user finding such content is relatively high.” But, on the bright side, they also found that “videos from government organizations and professional associations contained trustworthy and high-quality information.” We at KBGH, who have produced and posted videos of our own, hope that we fall into that category.

Let’s bottom-line what we can take from this research. First, beware of any video that makes claims that seem extraordinary. Someone who says that removing a food from your diet is as powerful as taking cholesterol medications for preventing heart attacks, for example, better have good evidence to back that statement up. Second, pay attention to the source. Videos from academic centers, government agencies, and professional associations appear to be the most reliable. But they’re also, I suspect, the most conservative. Few such organizations are willing to put themselves out on a limb compared to their peers. Finally, beware of using the number of views or shares as a marker of the reliability of a video’s contents. As we’ve discussed before in this very blog, the internet is set up to make sure the most radical statements get the most eyeballs.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Do we need to coach patients how to read their notes?

Do you know what is in your medical record? I don’t mean dry lab values or x-ray reports. I mean your doctors’ interpretations of those things, along with intimate, personal details like the results of your physical examinations and their impressions of your adherence to medications and home environment. The information is about you, but it also belongs to you. But it wasn’t always available to you. The 1996 Health Insurance Portability and Accountability Act (HIPAA) gave patients the legal right to review their medical records. But few lay people other than medical malpractice attorneys knew what to do with the information. 

And electronic health record (EHR) vendors have historically treated your data as proprietary, in spite of whatever HIPAA had to say about it. The data was treated as the EHR vendor’s property and was difficult to transfer from one health record to another. Stopgap measures like the Kansas Health Information Network popped up to try to make the data transferable from one hospital or clinic to another. But even this was suboptimal. Compare your experience with your health data to your experience with your financial data, which is probably almost as sensitive. You have undoubtedly used your ATM card from, say, Intrust Bank, to check your balance at, for example, a Fidelity ATM. We take it for granted, just like I take for granted that my USB drive from my home Mac computer will plug into my work PC. I don’t have to rely on the substantial expertise of a middle man to know that the data will transfer.

Since the 1990s several experiments have led to a movement for patients to have ready access to their doctors’ notes, be they on paper or in an electronic format. The best known organization goes by the name “Open Notes.” Now, new federal rules stemming from the 21st Century Cures Act aim to promote further patient access to their electronic health records via secure online “portals.” With a few exceptions, starting April 5, 2021, clinical notes and much other electronic information must be made available free of charge to patients. And the new rule forbids health systems or electronic health record vendors from “information blocking,” the practice of treating electronic health data as a proprietary asset and restricting access. The Annals of Internal Medicine (paywall) has a nice infographic:

Annals of Internal Medicine

Annals of Internal Medicine

To help folks transition to this new world, I think employers, insurers, and health care providers need to be proactive. To start, we should encourage our patients or employees to find their health record and to discuss it with their treating practitioner. Medical records are teeming with mistakes, due to cut-and-paste, poor user interoperability, and old-fashioned errors. Patients who find these mistakes shouldn’t run straight to the nearest malpractice attorney. Instead, both the patient and the doctor might be enlightened by a discussion of what should have been in the note.

Second, we should teach our employees and patients that what is in the record is meant to be objective. It is not a subjective judgement of anyone’s value as a human being. When I was in full-time academic practice, I remember a colleague being berated by a patient for noting that the patient smelled like urine (because she did, objectively, smell like urine). But once the patient’s embarrassment over reading the note faded, she was able to have a very meaningful conversation with her doctor about her urinary incontinence, and she was prescribed a medication that helped tremendously. Without access to her record this may never have happened. 

Finally, we need to remind patients that their record is truly private. In the era of predatory social media companies we’ve largely given up on the idea that any of our personal information should be private. But Facebook is probably not the best forum in which to litigate disagreements with doctors or nurses or to share screenshots of one’s medical record.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Is “Social Media Hygiene” The Next Frontier In Workplace Wellness?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Social media takes up an inordinate amount of our time. A recent report by Activate Consulting found that, when multitasking with consumer internet and media activities are accounted for, the new “normal” day is 31.5 hours:

avg-day-by-activity-graphic-social-media-blog-post.png

The amount of time we spend on these platforms is not likely to go down. According to that same Activate Consulting report, the number of social media networks an average person participates in is projected to almost double in the next four years, from 5.8 to 10.2 per user.

And in spite of snarky comments—many of them, yes, on social media—about the habits of millennials or Generation Z, it is Gen X workers in their forties and fifties who are the heaviest social media users, at almost seven hours per week, rising about 17 minutes per year.

All this virtual communication may be bad for us. Studies that are now several years old show that the more Facebook you use, the worse you are likely to feel. As anyone who has ever been accidentally pulled into an email argument that could have been solved with a single two-minute face-to-face conversation can tell you, in email and on social media in particular, we may abandon social norms in response to feedback from other users, since the algorithms that drive the platforms reward content that is highly emotionally charged. Tweets that use the greatest amount of moral-emotional language are the most likely to be retweeted or liked. Facebook posts that display not only disagreement, but indignant disagreement, are more likely to be liked or shared.

Why is this?

Researchers believe that virtual conversations lack the “advanced analogue cues” that in-person, video, or phone conversations have. Without clues like body language, tone of voice, and facial expressions, we have a hard time discerning the true intent or meaning behind innocuous statements.

What can be done?

A randomized trial by Stanford investigators showed that people who were paid to deactivate their Facebook accounts—as compared to people paid to continue their usual activity—were happier and reported increased well-being, decreased political polarization, and increased time spent with friends and family. And, presumably because of the drug-like effect of social media platforms, people who were paid to discontinue Facebook experienced apprehension at re-starting, just as a former smoker may be nervous about going outside around other smokers at break time.

But because of the strong network effect of social media, asking employees to cancel their accounts is probably unrealistic. Instead, we should look for healthier ways to use the platforms. After sifting through the mainstream medical literature, here are some of our tips:

  1. Encourage your employees to use social media as a bridge to in-person connection and real experiences, preferably outdoors and definitely away from screens. Using social media this way to connect to other people you’ve lost touch with may even have profound professional benefits.

  2. Create this bridge to in-person connection by changing the way you approach social media. Do not seek “likes.” Do not like other people’s posts, even though that may seem rude at first. Instead of passively scrolling through your Twitter, Instagram, or Facebook feed and hitting the “like” button, intentionally reach out to people. One study found that even one week of increased composed, directed social media posts to friends and family increased happiness. Another study compared this strategy to simply “liking” or sharing posts on Facebook. People who received targeted, composed messages from friends or family felt better; those who simply got “likes,” status updates, or shared posts experienced no change.

  3. Encourage employees to enforce “sacred spaces” where no devices are used, in order to reclaim conversation and non-verbal advanced analog cues. At home this may mean the kitchen, the dining room, and the bedroom, since even the presence of a device on the table may alter conversations, and looking at bright screens before bed can disrupt sleep (to say nothing of sex). As technology researcher Sherri Turkle famously said, “The greatest favor you can do to your sister, mother, lover, professor, student, is put away your phone.”

  4. While you’re at it, encourage employees to delete all social media apps from their phones and use social media only on a device they have to seek out, like a desktop computer. If that seems too severe a step, encourage them to go to their phone’s settings and kill notifications from all social media.

Are there strategies you’ve tried, either at home or in the workplace?  We’d love to hear them!

How to break up with your phone, Double Arrow Metabolism edition, day twelve

Today's assignment seemed a lot like the assignment from Day One, when I downloaded Moment to keep track of my phone time. Because today is Day 12: Download an App-Blocker. The idea, Catherine says, is to download an app to block specific sites and apps that I get sucked into. The irony of this is not lost on her. She recommends FREEDOM.

mel-gibson-freedom-gif-4.gif

You knew that was coming. 

The idea is to set up "block lists" of problematic sites or apps. I came up with "News" and "Blogs."

News

  • The Atlantic
  • CNN
  • ESPN
  • FiveThirtyEight
  • Slate
  • The Ringer
  • Vox

Blogs

  • Kottke
  • Longform
  • Geekologie
  • The Morning News

I don't really have any time-sucking apps; they were all deleted earlier in the project. I guess I could put email in that category, but occasionally I'm in a pickle and have to use my phone for email. So I didn't want to block it, especially since I have all the alerts turned off, anyway. I'm lucky that I don't have to use social media for work. 

Next, I'm supposed to set times. My most productive time of the day is generally about 9-12 AM, so I thought it might be good to block myself during that time. Off I went. But even though I consider myself to be at least fluent in technology, I could. not. figure. out. FREEDOM. FREEDOM (the app, not the idea) sucks.

Is this a joke? Should I follow Freedom right before I block it? 

Is this a joke? Should I follow Freedom right before I block it? 

FREEDOM was more like this:

I feel your pain, Mel. Just don't go blaming this on the Jews. 

I feel your pain, Mel. Just don't go blaming this on the Jews. 

So I deleted FREEDOM. Instead, I decided to get rid of all non-essential bookmarks. All the websites you see above got deleted. If I get a hankering to see what they're saying, I'll have to type in the URL manually. I'm pretty happy with my compromise. 

How to break up with your phone, Double Arrow Metabolism edition: Day Five

Today's instruction from Catherine is to delete all my social media apps. Since I don't have any social media apps on my phone to delete (I'm not counting Strava), I moved immediately to the second instruction for today, Day Five of Technology Triage, which is to download and use a password manager. I've been using Keeper for years, so I'm good there. Ironically, I've worried that Keeper is one of the apps that keeps me attached to my phone. So be it, I guess. I have hundreds of passwords, and I can't see myself going back to pencil and paper for them. Finally, she recommends that I spend some of my newfound phone-free time with friends and family. So I'm going out to dinner tonight with my wife and some friends. On my way out, I thought I'd share a couple breakthroughs from today:

First, I was a few minutes early to the student capstone presentations for the University of Kansas School of Medicine-Wichita's Population Health in Practice course. Today I leaned into my boredom. I sat without checking my email or looking at Vox. I was super-creepy with all the eye contact. I didn't even start this blog post, in spite of the presence of the app on my phone. Don't get me wrong; I made notes. But I wrote them on paper, which is somehow less off-putting (I think) than tapping away on a device. 

Then this afternoon, I was in a meeting with a clinic administrator and my phone buzzed in my pocket. I knew it was either a new e-consult, a calendar appointment, or a message from Moment, since those are the only apps that have notifications enabled. In the past, ninety-nine times out of a hundred, I would have taken my phone out of my pocket. I would have tried to be discreet, but I think in reality my discreetness has historically come off more as "drunk high school kid tries to play it cool with his parents." Not today. I left the buzzing device in my pocket, finished the meeting, and walked all the way back to my cubicle before checked the messenger and completed the e-consult.

 

How to break up with your phone, Double Arrow Metabolism edition, Day Two

Today (Tuesday) is my chance to "Assess my Current Relationship" with my device. I've been instructed to answer the following questions:

1. What do you love about your phone?

I like podcasts. A lot. I don't subscribe to many of them, but the ones I like, I really like. An hour of Zwift time with a podcast in my earbuds is a very, very good way to start the day. Not as good as riding outside, earbud-free, but still.

I also like my calendar. I remember my pre-smartphone days, barely, when I lugged around a thick planner full of crossed out appointments and smudged eraser marks. I graduated to a Palm Pilot in my third year of medical school, and it transformed me. I put surgical schedules and hospital rounds in the calendar and missed or was late to a tiny fraction of them. I am much more reliable as a result of Google Calendar. It may have come at the expense of some part of my brain that would normally be keeping track of my schedule, since my first instinct at the thought of any new obligation or appointment is to put it on my calendar. But on net, the effect seems very positive.

I love doing RubiconMD consults, and my phone helps me get them done. Mostly, it makes me get to a computer to do them, since I don't love the RubiconMD app, but it alerts me reliably. RubiconMD makes me feel like a real doctor, even on the days when I'm doing things that aren't particularly doctorly, at least in the classic sense. I'm not sure I'd have that opportunity sans smartphone.

Finally, I love the idea of having the world's knowledge in a rectangular piece of glass in my pocket. When I watch period movies set pre-smartphone, I want to take an iPhone back in time to the poor detectives and academics.

2. What don't you love about your phone?

I despise notifications. They are the most intrusive thing I've ever encountered, save for 2 am blood glucose calls from the hospital. But back in my days of 2 am glucose calls, I was at least getting paid for the work. Notifications don't pay squat. They're the absolute worst. I've disabled almost all of them. 

I hate that people don't have silly arguments anymore. In college, we settled more than one argument in the dorm by using a neighbor's almanac(!). Phones have destroyed the free-wheeling, ridiculous tavern-style arguments people used to have. Everything is too available now. People don't think about their answer to the problem as much as they think about what somebody else's answer to a problem might be. I think half the amateur economists on the web just go to Tyler Cowen's website and see what he has to say about a problem, then pretend they made up the answer.

I wish people still made plans. Once upon a time, if someone didn't show up for a movie or a dinner date, we went looking for him or her, since we suspected something bad had happened. Now, with texting, people are so squirrelly that I only half-expect anyone to show up for an appointment we've made. Plans mean less than they used to. I can't imagine trying to date in the smartphone era, even without Tindr and its cousins.  

3. What changes do you notice in yourself--positive or negative--when you spend a lot of time on your phone? (Depending on how old you are, you can also ask yourself if you've noticed any changes since you got a smartphone to begin with)

I don't notice any of the physical manifestations that some people talk about. My phone doesn't make my neck hurt. I suspect I read enough already that my phone doesn't change my position much. I'm doomed to have a stooped neck someday. I don't text enough to get the thumb pain I've heard described. I have noticed my eyesight getting worse the last couple of years. Some of it is surely due to nighttime insomnia reading of my phone. (some other fraction is probably due to my advancing [but still young! still young!] age)

But if I let myself get too attached to my phone, I feel like I'm over-caffeinated. I can't focus. I can't feel. I try to drown every little negative thought with another click through my favorite websites or my email. It doesn't work. I stop observing my surroundings. I feel like I miss things that I should be noticing. 

But to be honest, I'm more annoyed with other people's phone use. When I see a family at a restaurant and three-fourths of them are on their phones, I want to slap the phones out of their hands, Dikembe Mutombo-style. Maybe it's because I know I sometimes look as bad as they do. FWIW, I've never actually committed assault on a phone user. But I've definitely fantasized:

ThinHomelyAnemoneshrimp-max-1mb.gif

In the process of finding that gif of Dikembe, I stumbled across this one. I don't know what he's disgusted with, but I hope it's his phone:

4. Imagine yourself a month from now, at the end of your breakup. What would you like your new relationship with your phone to look like?

I'd like to leave my phone in the car during most of my trips into a place where I expect to either watch or listen to something I've paid for, or into places where I expect to interact with others. I want to no longer feel phantom buzzes. I want to be freed from pre-movie warnings to silence my phone. I want to have the same relationship with my phone that I have with the pliers in my toolbox: I know they're there, but I use them only when I have a task that I need them for.

5. What would you like to have done or accomplished with your extra time?

I like to write. I like public speaking. I'd like to do more of both. I'd like to set an example for my kids that screens aren't the only pastime worthy of our attention. I'd like to ride my bike more. 

6. What would you like someone to say if you asked them to describe how you'd changed?

"The last time we talked, you made me feel like the most important person in the room."

7. Write your future self a brief note or email describing what success would look like, and/or congratulating yourself for achieving it.

Dear Dr. Moore (I didn't do nine years of medical training to call myself "Mr."),

Congratulations on becoming human again. While our cyborg future may be inevitable, with cardiac implants and insulin pumps and brain dust and the like, we shouldn't have to sacrifice our attention or our humanity in order to achieve great gains in health from technology. I hope you're enjoying your extra hour a day. I hope you're using it to do something that makes you a better person and maybe makes the world a 0.00000000001% better place. I hope you can have a conversation without peeking at your phone. I hope you don't feel phantom buzzes in your pocket anymore. I hope your kids don't think that "acting like a grownup" means being glued to a phone non-stop. 

Sincerely,

Justin

How to break up with your phone, Double Arrow Metabolism Edition: Day One

Anyone who has come within ten feet of this blog knows that my relationship with technology, social media, and my smartphone is, shall we say, tumultuous. So I came to read Catherine Price's book How to Break up With your Phone the way I suspect a lot of people do. I've been stewing about my attachment to my phone for a couple years now, and I've made steps to decrease my use:  

I have essentially no social media presence. I've worked to make my phone less desirable. I tried putting it in grayscale, but it made my calendar too hard to read. I developed an unnecessarily complicated strategy for deleting apps. The ones I use monthly or more, I keep on the home screen. The ones I don't use monthly get demoted to the "Misc" folder, where they are in danger of being deleted if they don't get used in a certain amount of time. Any app in the Misc folder that gets used two months in a row gets moved to the home screen. Like I said: complicated. But the system has resulted in a pretty austere home screen:

Just me, Atul, and Tracy. No big deal. 

Just me, Atul, and Tracy. No big deal. 

I've turned off all notifications, audio and visual, with a couple exceptions: I can still see text messages when they come through, but they make no noise. I still have notifications enabled for RubiconMD, an app I use for peer-to-peer consultations with other docs. I want to make sure I know when those come through. My phone still rings when I'm called, but any texts or calls I get that are robocalls or from a telemarketing source get immediately blocked. 

So the big things that I end up using my device for are texting, the calendar, my task list, and old-fashioned telephonery. I also use Strava for recording cycling mileage, but much of my data in it comes via my Garmin or via Zwift. I don't use the phone as my primary GPS very much. I'm not much of a photographer, so I don't really need my phone around for pictures. I also listen to an hour or more of podcasts per day, but I'm not sure that counts. 

But I still find myself excruciatingly drawn to my phone. I use it for my alarm clock. I tap the screen to check what time it is during nocturia rounds. I tap my pants pocket to make sure it's there before I leave the house.

So I bought the book. Catherine is a very accomplished, competent science writer, and it shows. The first half of the book is mostly a recap of the greatest hits of the evils of constant connectivity, referencing expertly many of the books and articles I've posted or talked about here in the last year. She leaves out Cal Newport's Deep Work, one of my favorites, but hits other work by Nicholas Carr and Jean Twenge that are equally good. After the review she gets down to the nitty-gritty of detoxing, outlined in a 30-day plan.

Week One is "Digital Triage."

She says to take notes. Done. And digitally, even! Extra computer karma for me. She also says to invite friends to join in (no thanks; I'm too shy and too much of a loner for that kind of thing). She says to answer a question ahead of time:

What do you want to pay attention to?

Answer: I want to pay attention to long-form literature and journalism. I get more joy out of a well-written book than almost anything. It can be fiction or non-fiction. I like both. I also love, love, love magazine articles. I can take or leave newspaper articles or cable news.

I also want to pay more attention to my kids. I'm not a distant parent, and we have pretty firm rules around the house for when devices can be on. We never have devices at the dinner table, for instance, and electronics of any kind, even the radio, are verboten during meals. But even with those rules I'm frustrated at how often I'm distracted from my kids by my phone. I like my work, but I long to solve problems that can't be solved from a computer keyboard, and my kids are a deep vein of this kind of problem. 

Catherine says to use the lock screen on his or her phone as a reminder. Done:

So long, Dr. Gawande. 

So long, Dr. Gawande. 

She says to schedule my phone breakup, ideally starting on a Monday, and to put it on my calendar. I'm typing this on a Thursday, but I'll be on a brief vacation over the weekend, which may affect my phone use under even normal circumstances, so I want to have a larger dataset to work with. Which brings me to:

Day One: Download a Tracking App

Before I actually download the app, though, she tells me to answer a couple questions:

1. How many times a day do you think you pick up your phone?

I'm going with forty. Four-zero. 

2. How much time do you estimate that you spend on your phone per day?

I know from reading the first half of her book that the national average is about four hours a day(!). I'm nothing if not slightly above average, so I'm going with two hours. Still a shocking amount of time, but at least it's not long enough to complete a medium Tour de France stage. 

Catherine recommends Moment. In the spirit of not spending a bunch of time on my phone trying to find an app to keep me from spending so much time on my phone, I downloaded it. Then, to show how committed I am to this process, I allowed it 1) to know my location, and 2) to send me notifications. Those are privileges that almost no other app gets. And, just to get my rationalization off to a good start, I spent an inordinate amount of time setting up the app and screenshotting for this post. So this afternoon might be an outlier. We'll see. Catherine says not to change my behavior. Just be myself and gather data. Since I'm on quasi-vacation the next couple days, I'm going to wait til Monday to publish this just to make sure my initial data doesn't represent any kind of statistical anomaly. See you then. 

Why are there fewer posts on here than there used to be?

In the New Year, I've been trying to severely curtail my internet use. A side effect of this has been far fewer posts on this blog linking to articles or papers or videos that I've found interesting.

This is the next brick in a path I've been headed down for a while now. When I was a first-year med student, a classmate of mine was famously addicted to her flip phone. It would buzz and ring through lecture, and people would give her the stink eye, and as soon as the last Powerpoint slide clicked off the last reaction in the Krebs Cycle, she would bolt from the room and start making calls like a Wall Street veteran. Like Dan Akroyd in Trading Places. What would she have been like if she'd had a smartphone? Well, we know what she would've been like, because most of us are exactly where her trajectory was headed, and we're doing it with almost no social stigma. She would've answered all those calls with texts, right there in the lecture hall, and she would've checked multiple social media accounts to boot.

Needless to say, I was not an early adopter of social media. Once I had a couple accounts, I quickly found that social media made me act differently than I do in other situations or media. The act of trying to market myself for "likes" or "pins" on a platform of someone else's design was an act perfectly designed to produce insincere, awkward content. And thought I'm generally sincere, or at least I try to be, I'm somewhat socially awkward. That is, I'm awkward enough without someone else's help. I found that the effort I put into social interaction on platforms like Facebook and Twitter didn't enrich me. If anything, it impoverished me. It made me feel bad.

I was mystified by people's willingness to give up all the same information that we try so hard in the medical world to keep private. Facebook in particular seemed to be engineered specifically to tweak my smoldering social anxiety. It tried to choose my "friends" for me. But as I accumulated hundreds of "friends," the value of real friendship seemed to be degraded. And the privacy. Lordy. The day I put it to sleep came on my birthday a couple years ago. In spite of my almost religious tending to social media to keep details like the date of my birth off of them, people knew. Just like Wolfram Alpha knew. And I didn't want them to know. So I deleted it.

A year or so ago, I read Cal Newport's book Deep Work as part of a book club. I was still wading around the fever swamps of Twitter at the time, because I thought it was good to stay engaged for work. It wasn't completely by choice. I had suspended my Twitter account at one point, but then I'd applied for work with a company that used Twitter for much of its internal non-secure messaging. So during my grace period with Twitter (they give you a chance to come back for a month after you delete your account. Surprise!), I re-activated the account.

The discomfort with it remained. I started to talk about social media in less-than-flattering terms in posts a few months ago. Then I paused. I thought maybe I was being stereotypical: the middle-aged guy yelling at younger people to get off my digital lawn. But I kept some thoughts in draft form while I thought it over. I even considered getting a Facebook page for Double Arrow Metabolism, just to drive a little more traffic.

When the 2016 presidential election happened and I got glued to the daily outrage of social media as it responded to a shifting political landscape. I was left with two options: 1) master the software, or use it in such a narrow sense that it didn't control me, which seemed unlikely. I'm a reasonably smart guy, but my reptile brain can't outsmart thousands of computer engineers. Or 2) kill the software and get to know myself better. I don't mean blow up Twitter; I mean kill my interaction with it. I chose #2, eventually. I feared it would hurt business, or make me less knowledgeable about the world.

Then I read Newport's "any benefit" argument: we stay on social media because we can't bear the thought that there's some unknown, as of yet unseen benefit to it. In other words, what will we miss out on? It reminded me of what my parents lovingly called this the "unsmelled fart rule" when I was a kid. I'd be told to go outside, away from the party, and when I objected, I'd be asked, "What's the matter? You afraid somebody's gonna fart and you won't get to smell it?" That's exactly what I was afraid of with Twitter. But after I read Newport's book, I just quit. And it hasn't made a bit of difference in regards to my knowledge about the world. If something bad happens, I'm going to hear about it, social media or not. 

So I've been off social media for a little over a year, I think. Scratch that-it's not completely true. I still have a Strava account, albeit with no notifications enabled. And I still have a LinkedIn page. LinkedIn is like social media status post fun-ectomy, though, so I don't really count it. I even experimented briefly with Figure 1, but I didn't think it was useful. If I'm going to look at cases, I want to either get money or CME credit in return. Figure 1 provided neither.

But it wasn't just awkwardness or privacy concerns that bothered me. It was a gnawing sense of unease. And I couldn't quite put my finger on what bothered me until I read Andrew Sullivan's piece about the phenomenon a year or so ago, "I used to be a human being."

"Every minute I was engrossed in a virtual interaction I was not involved in a human encounter. Every second absorbed in some trivia was a second less for any form of reflection, or calm, or spirituality. 'Multitasking' was a mirage. This was a zero-sum question. I either lived as a voice online or I lived as a human being in the world that humans had lived in since the beginning of time.

And so I decided, after 15 years, to live in reality."

Time on social media, and now to some extent time on the internet, was taking away from time in the real world. You might be pointing out right now the apparent hypocrisy of the position I'm in the process of staking, since you're currently reading these words from a screen. Why, you're asking the screen (and by extension me), do you spew forth on this blog if you're so against public sharing? Fair point. But my content has decreased. And whether you like what I have to say or not, I don't make money off of it, even though I do make money off the consulting work that sometimes makes a guest appearance on the site. And I don't spend a lot of time looking at the analytics on my site to see how many of you are reading. So this particular shout into the void is my way of getting what I consider my fairly radical beliefs about health out into the world. But I figure the people reading this blog have at least a passing interest in me or in what I have to say. If you're here, I've in some way earned your eyes on this page. Artificial intelligence did not move Double Arrow Metabolism higher in your feed. So sure, I'll share with you, like the authors of some of my favorite blogs share with me:

Velominati, Kottke, Study Hacks, Wait But Why, Slate Star Codex, Mr. Money Mustache, Red Kite Prayer, Marginal Revolution

But I won't share with a thousand people who caught wind of my birthday through a complicated algorithm and are only posting about it because said algorithm makes it easy to do and makes them feel bad if they forget. I want to generate content that--good or bad--takes me longer to write than it takes you to view. Call it anti-Twitter.

So the fact that I'm not posting as many links is dual purpose: it keeps me off the internet, and it keeps me from turning this site into something I didn't set out for it to be. If what you want is a bunch of interesting links, many, many websites serve that purpose better than this one. One of them is Twitter. But Twitter has a fatal flaw in that it has no end.

Comedian Aziz Ansari, a guy who it turns out was a creep on a date, but who literally wrote a book on how technology has changed romance, has this to say:

"I’ll say, the times where I haven’t read that stuff, the stuff that I normally read on the Internet, just nonsense blogs or whatever, the next day I’ve felt like I’ve missed nothing...Cause you’re not reading it for the information. What you’re reading it for, and this is just my personal theories about this stuff, what you’re reading it for is a hit of this drug called the Internet...Like, here’s a test, OK. Take, like, your nightly or morning browse of the Internet, right? Your Facebook feed, Instagram feed, Twitter, whatever. OK if someone every morning was like, I’m gonna print this and give you a bound copy of all this stuff you read so you don’t have to use the Internet. You can just get a bound copy of it. Would you read that book? No! You’d be like, this book sucks."

Again, Ansari, a comedian whose job seems to have been created in a laboratory to achieve maximum benefit from social media, had this to say to Stephen Dubner of Freakonomics before adopting his new social media, internet-lite life philosophy:

"I never read anything. I’ve never read all these novels that are like these beautiful stories that have continued to have a resonance with people for so many generations, like beautiful works of art that I could read at any point. But instead, I choose not to read them. And I just read the Internet. Constantly. And hear about who said a racial slur or look at a photo of what Ludacris did last weekend. You know, just useless stuff. It’s like, I read the Internet so much I feel like I’m on page a million of the worst book ever. And I just won’t stop reading it. For some reason it’s so addictive."

Aziz quit the Book of Internet. The Book of Internet is a shitty book. Double Arrow Metabolism will not be a chapter. 

Since my departure from social media and my sharp reduction in internet consumption in general, I haven't come across much to change my mind. I read Jean Twenge's Have Smartphones Destroyed a Generation? I read John Lanchester's A Criticism of Facebook. They reminded me of a teaching course I attended at Beth Israel in Boston in roughly 2009, when "teaching the 'millenial learner'" was already a hot topic. They were different than Gen Xers and Gen Yers, we were told, in that they hadn't been quite so "latchkeyed" (a term d'art for what some might consider excessive babysitting as a symptom of absent parents). They also were perceived to want more of a personal touch in their instruction; more feedback. But Twenge notes that in her data, something shifted a few years after my teaching course on millenials. It was in 2012, the year that smartphone ownership in America surpassed fifty percent. So she calls the group at the tail-end of millenials the "iGen." Smartphones and social media have been ever-present in their lives. They've never known a world without tablet devices. Three out of four of them own an iPhone. 

Rusty's Last Chance, a landmark bar in the Aggieville district of Manhattan, Kansas, was a beacon to Kansas State University students and nearby Fort Riley soldiers for decades, but it closed in February of 2017. Bars and restaurants close all the time, but I cannot help but think, based on my experiences in going back to Manhattan in recent years, that students' taste for virtual contact over the real thing didn't have something to do with it. I'm still volunteer faculty at the local med school, and one of the criteria we're expected to evaluate students--med students! Adults!--is their willingness/ability to stay off their phones during sessions.

At this point, if you're still reading, maybe you're ok with all this. Maybe you don't think your time is worth that much, and maybe you've heard if you aren't that bothered by an algorithm guiding you away from your true self, and maybe then that information you've paid to give up is used to reduce you to a set of numbers or yes/no questions that define you, just as medicine so imperfectly tries to define you by race, body mass index, blood pressure, and soon your genetic "fingerprint." After all, teen pregnancy is at an all-time low, and teens' addiction to their phones surely has something to do with that. It's hard to impregnate someone if you're spending your weekends in your bedroom scrolling through Snapchat. And kids are physically safer than ever; it's hard to die in a drunk-driving accident from the comfort of your bedroom, and I've never seen a drinking game whose rules involved immersion in tindr (but, come to think of it, I'm sure it exists). Psychologically, though, kids may in trouble. Twenge notes that since 2011, depression and suicide have "skyrocketed." I'm not sure this is true. I'm too exhausted by the internet right now to go and find the primary data. But it doesn't take a social scientist to watch toddlers engrossed in YouTube Kids at the grocery store and deduce that we're in the middle of a profound change. We're running an uncontrolled experiment on ourselves and our kids.

So how should we handle smartphones with our kids? Based on no empirical evidence whatsoever, my wife and I have decided that 1) our kids will not have their images posted on social media other than in extremely rare circumstances (nobody wants to be the guy that torpedos an entire birthday party, after all). And our kids, upon entry into middle school, will have access to a good, old-fashioned cell phone. But if they want a smartphone, they'll have to earn the money for it themselves.

At home, we try to enforce what I'll call the "White House" rules. I don't know how the White House handles the issue precisely, but I'm fairly certain that unsecured cell phones are a no-no in the White House. So, like a Jack White or Chris Rock or Dave Chappelle show, people are asked to put their phones away upon entering. So I follow the same rules: when family members come into my house, they put their phones in a central location, and we go about our business. 

In case this all just sounds like so much "get off my lawn"-style old man grouchiness, I engage with technology. I help docs run their electronic medical records more effectively and efficiently. I listen to podcasts in my free time. But I can listen to podcasts while I accomplish other things. And EMRs, at least in theory, have value beyond the immediate. 

Sigh. So that's the story. Expect fewer posts on this site than there used to be, because I'll simply have less to post, because I'll have spent less time on the internet than I once did. But I'll probably keep my smartphone. I like the calendar.

"The greatest favor you can do is...put away your phone."

Sherry Turkle from the MIT Media Lab talks about the frequency she hears people say they'd "rather text than talk." People say they feel less vulnerable when they text than they feel in a face-to-face conversation. I agree. I feel less vulnerable texting, too. 

So don't be a phone worm. When I was in medical school in the late '90s, I remember classmates making fun of a woman in our class who was pathologically attached to her cell phone. We'd all just learned the word "pathologic," and our family members were already asking us for medical advice, so we all felt comfortable making the diagnosis. Anyway, hers was the phone that would ring its Nokia ringtone multiple times a day to interrupt class back when this was still a novel occurrence:

In the year 2017, I'm not sure she'd even hit the average cell phone use. Recently, at my kids' gymnastics lesson, I was flanked by two women on cell phones. The first one sat to my right, bouncing off my shoulder as she sat. I forgave her for this, because she couldn't see me past the smartphone glued to her left ear. Then she proceeded to scream intermittently at two kids who were not in the gymnastics class, all while never removing the phone from her ear. I didn't blame the kids for being wound up; it was after school, and they were stuck in a building watching a sister when they would've undoubtedly preferred to be outside on the playground. But she couldn't be bothered to interrupt what seemed like a very non-urgent conversation.

I moved to a quieter place, sacrificing my chair for the floor. Then, three feet away, a second person started talking at full voice on her cell phone, telling the unfortunate listener on the other end repeatedly how pissed she'd been earlier in the day. Keep in mind, it was sunny and 66 degrees outside. Either person stepping outside to take her call would have been healthful and humane. But both women, insofar as my amateur observational skills could tell, sat in the middle of a crowded room and talked on their phones for the duration of the one-hour practice, save for the intermittent screaming at their kids. One child actually begged lady number two not to talk on the phone anymore, and was told to "zip it." A third man, who I assume was also a parent, broke his phone conversation only to tell a toddler to "stop fucking around." The toddler did not heed his instruction, and the man was soon sufficiently lost in his talking and texting to allow, shall we say, ample f'ing around, toddler-style. 

Sherry Turkle doesn't get into this directly in the brief video above, but this is all consistent with her observations that technology is killing social skills. We collectively show decreased empathy and a decreased ability for self-reflection. A big part of my job is handling sometimes delicate negotiations within clinics or within medical systems or between payers and doctors. In those situations, vulnerability is key. If the interested parties can't look one another in the eye and feel insecure and feel like their decisions impact the other people around the table, we get nowhere. 

Don't get me wrong. I've taken my share of calls and texts in crowds. But I've felt like an asshole almost every time. So to keep from being a hypocrite, I've set my phone to no alerts for messages or emails, and I frequently put it on sleep mode, meaning it won't ring unless an immediate family member or neighbor calls (I figure the neighbors have the best view of my house burning down). And though I've occasionally feared that this would kill my productivity, I'm fairly certain now that it does the opposite. I'm more productive the more time I spend apart from my device. People think email is urgent, for example. According to psychologist Dan Ariely, it's not. Yuval Noah Harari, author of some incredible work including Sapiens, meditates for two hours a day. And the astonishingly productive computer scientist and self-help writer Cal Newport is "indifferent" to his smartphone, still subscribes to paper newspapers, and only upgraded from a flip phone because his wife guilted him into it when they had their first baby. 

So here's a challenge for this week: Go outside your phone (comfort) zone. The next time you're standing in line waiting for something to happen, or watching your kids jump on the trampoline, or between innings at a softball game, or waiting for a movie to start, leave your phone in your pocket. Better yet, take it to whatever vehicle brought you to the game (except your skateboard; skateboards are a bad place to store a phone). It'll be hard to do, but you have the strength. Concentrate on your breathing. Once you've safely stowed the phone away, look at the others around you. You might have to work for some eye contact, because they probably aren't following the same rules you are. While you're gyrating around trying to get them to look at you, think about their stories. It'll give you something to ask them about. If they won't talk to you, make like Yuval Harari and make this time your meditation. If you're not the meditative sort, think about what you want to accomplish with the rest of the day. Make a mental plan. For a few minutes, don't be a phone drone.

See also: CRANK UP THE BASS, HOW ELSE CAN YOU CRANK UP THE BASS?, SOCIAL MEDIA IS A SET OF COMMON PLATFORMS TO DRAW OUT OUR WORST TENDENCIES, HAVE SMARTPHONES DESTROYED A GENERATION? 

2. Social media is a set of common platforms to draw out our worst tendencies

(note: this is a continuation of a rant from a couple weeks ago)

I know it's absurd for me to be talking about "social media" as though it's some homogenous monolith. I'm sure aficionados could tell me the subtle differences between platforms the way a sommelier could tell me the difference between a Malbec and a Cabernet. But at the end of the day, those are just two varieties of red wines, and like them, Instagram and Twitter are more similar than they are different. And one of their similarities is they tend to bring out the worst in us.

Before my departure from social media, I saw people on Facebook joining or "liking" pages devoted to searing hatred of immigrants. These same people in some cases had testified at deportation hearings for undocumented family friends. What was it about the choice architecture of that "like" button that made the sort-of-evil decision the easy one? 

This isn't that different from the other happiness-draining things our consumerist society throws at us with the promise that we'll be happier if we use them. Tobacco, junk food, and social media all want the same thing from you: they want to take away your control over your life, health, and happiness. But while we've made strides to combat tobacco and junk food, like smoke-free laws and taxes on bug juice, we seem stuck in a self-sustaining vortex that tells us that more connection, more technology, will solve our problems instead of creating new ones. If a drug hit the market and prompted some of the behaviors that we see with social media, would we applaud it?

And the children. The children. We're training our kids to avoid boredom at all costs. How many kids have you seen dialed into a phone at a restaurant? How many staring into a screen at a playground? How many being beseeched to turn down their phones while at a restaurant or basketball game?

These are not behaviors that any of us are proud of. Were you to point them out to the very people exhibiting them, they would be ashamed, right after they got done telling you off and posting on Facebook about what a jerk they just ran into at the restaurant. But pride aside, there is probably real harm being done here. I'm frankly suspicious of any claim that the fake news on social media swayed the last US Presidential election, but it certainly didn't lead to a more erudite, informed electorate, either. But a kid who sits at a restaurant with earbuds in, staring at a screen, is being trained that boredom is unacceptable. What will happen to this person the first time he's confronted with a situation that requires delayed gratification or an attention span? 

So even though I'm a bit of an anti-incrementalist, I'm hoping to see just a series of small ticks in mobile/social media use. Comedian Chris Rock is having fans lock up their phones at his shows. Jack White has been doing it for a while now. I don't think these guys are doing it out of general fuddy-duddyness; they're trying to bring out the best in their audiences and to make sure everyone has a shared experience. Schools, historically afraid of parent backlash to less-than-100-percent-available kids, are even in on the act, establishing "phone free zones" with the same technology Chris Rock is using. 

2. Social media is designed to be a time-suck*

*This is the third in what's turning into a series of posts. If you want the rant from the beginning, click here. 

Other than the intense junior-high-dance-level social anxiety, the things I most remember about my time on social media is that 1) my phone never seemed to shut up, no matter how fastidious I was about un-checking "notify" buttons in the settings, and 2) even if my phone wasn't buzzing, beeping, or flashing banner alerts at me, my mind was always subconsciously occupied in making sure that I was getting good wallpaper for my social media.  I was so busy worrying about tweeting of 'booking or 'gramming my life that I wasn't present. The social scientists call this and the related angst of seeing other people's fabulous posts "FOMO," for "fear of missing out." My mother more accurately called it, in the parlance of the 1970s, "Fear that somebody'll fart and you won't get the chance to smell it." How times change.

Here's the deal. As the Onion is wont to do, it perfectly captured the zeitgeist of 20-teens America. We accept constant intrusion into our lives because we've been told so many times that Silicon Valley is changing the world for the better that we've started to believe it:

And 3. (related) social media's goal is to take control of my life from me.

I didn't descend into the dark, lonely chasm of social media forever. At some point I realized that it's real purpose wasn't to help me or even to entertain me, unless you consider my juvenile efforts to use Facebook updates to relieve my own separation anxiety at the expense of my social anxiety. Social media, to paraphrase Jaron Lanier, was a way to avoid the closed door at bedtime, the empty room, the screaming vacuum of my isolated mind. But to draw attention on social media, I had to manufacture a version of myself that I thought people would like. By drawing me further from my true self and closer to the manufactured version of me I was putting out there for the sake of likes and re-tweets, social media's goal was to evolve a program that knew me better than I knew myself. The perfect social media platform would know what you really wanted, even if you were playing the game of trying to make yourself seem cooler than you really are. The sole purpose of this is to entice us with strategically placed alerts and rewards so that it can place ads in front of us. And yeah, I know that social media has been central to some very positive events in the past, like Tahrir Square. But I suspect that real action like that represents a tiny fraction of what comes from Twitter. The daily outrage is the more impotent, more common form of Twitter activity. 

The coders behind social media applications believe--with good evidence on their side--that you can't control your own behavior. They think you're manipulatable only by the clever use of algorithms and well-placed alerts on your smartphone. You know this isn't true. But to prove it, you have to break away.  Even still, after deleting essentially every social media app I've ever had (Strava is the exception) my hand is drawn to my iPhone like a professional baseball player's hand is drawn to his crotch.

Hi, little fella! Any re-tweets today?

Hi, little fella! Any re-tweets today?

I'm not alone. The average smartphone user checks his device 1,500 times a week. Add in the master social psychology of Silicon Valley and it becomes almost irresistable.

So I've developed a set of behaviors that I think have helped me take my life back:

1. I've deleted all social media accounts with the exception of Strava and LinkedIn.

2. I've turned off all notifications from Strava, and I have no app on my devices for LinkedIn. I've done my best to turn off all email notifications on LinkedIn, but they seem to trickle through every week or two, anyway.

3. Whenever possible, I leave my phone in the car or at home.

4. Whenever possible, I leave my phone in a face-down position.

5. I've turned off notifications for text messages. This may sound worrisome to anyone in the mood to text me, but the reality is that I still see my phone several times an hour for other reasons, so I have plenty of chances to see the little red dot on my message icon.

6. I keep my phone on sleep mode (that's the little moon in iOS; I'm sure other operating systems have a similar function) as much as I can. An advantage of non-traditional practice, I guess. No more pages in the wee hours of the night. 

 

What the hell is water?

There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says, "Morning, boys. How's the water?" And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes, "What the hell is water?"

-David Foster Wallace

 

I don't know exactly what the late, great DFW meant by this. Tragically, he's not around to tell us. But what I think he meant is that the most important realities are often the ones that are the hardest to detect. And to continue to borrow DFW's analogy, most of us paddle forward as best we can without ever feeling the flow of water against us, pushing us back, keeping us from reaching our potential. That rush of water consists of a lot of things, but most of them are visible if you look closely.

I’m a physician, as you might have deduced by the initials after my name. And physicians by training are supposed to notice the things that others don't. But most of us don't, and I've been more guilty of this than anyone in the past. See, I'm an endocrinologist. That’s a specialist in metabolic and hormonal disorders (think disorders of the pituitary, thyroid, and adrenal glands; and osteoporosis and diabetes and whatnot). You’d think that an endocrinologist is a person particularly well-trained to help patients escape the vortex of fancy motorized wheelchairs, faux-food, time-sucking devices, and all the other things pulling us under.

But that’s not at all what I was trained to do. In fact, I found during my career as an academic endocrinologist that instead of getting people safely to shore, I was often quickening or deepening the vortex that my patients were swimming in. In 15-minute office visits, I’d prescribe drugs that cost thousands of dollars and have trite, brief (in case the 15-minute visit didn’t give it away) conversations about what they could do with their weight, or their fatigue, or their sadness. The visits cost me 15 minutes, that is. They cost my patients a lot more. A lot more.

I was doing my best, obsessing over the things I could measure or manipulate, like blood sugars, cholesterol, blood pressure, and weight. All those are important. Don’t let anything you read here convince you otherwise. But I was swimming in the vortex myself. I simply paddled forward in the water I was trained to swim in, comfortably moving myself from today into tomorrow, spending the loads of money I made on things that didn’t make me happy and working extra hours to pay them off. I drove like a maniac between two clinics and four hospitals, often putting almost 100 miles a day on my car. The vortex deepened. The extra hours ate into time that I should have spent doing things I loved, like chasing my kids or riding my bike, so I weighed thirty pounds more than I wanted to. The water sped up. And then my blood sugars--one of those things I prided myself on controlling--started going up. And then I started getting really unhappy and resentful at work. I was swimming as hard as I could, but spiraling. What I couldn’t detect was that I and my patients needed to become people again.

What’s that? My patients weren’t people? What am I, a veterinarian?

P. henrylawsoni can out-wrestle A. woodhousii any day of the week.

P. henrylawsoni can out-wrestle A. woodhousii any day of the week.

What I mean is, that once a person crosses that gauzy threshold from the waiting room to the exam room, he experiences a transition from personhood to patienthood. And patients are bad swimmers. Let me illustrate. Most of us, whether we’ve thought about it or not, exist somewhere on this spectrum:

  1. I feel great. I’m as healthy as I can be, and I’m intentionally doing things daily to improve my health.
  2. I’m healthy, but mostly by accident.
  3. I’m not sick, but I don’t feel good. I’m always stressed out.
  4. I have one or two health problems that I manage pretty well, but I’m broke.
  5. I have a few health problems that I struggle to manage, I’m broke, and I’m working a second job to pay medical expenses.
  6. I have been hospitalized one or more times in the last year for chronic health problems, and I can’t work.
  7. I’m in a nursing home or assisted living because I can’t take care of myself anymore.
  8. I am dying.

The thing about this spectrum is that the strategy for moving up on it depends on where you start, and it’s never a straight line. If you’re one of the unfortunates at #7 or #8 that our system most definitely calls patients, my thoughts are with you. If you are at #5 or #6, your strategy for moving up may involve a lot of pharmaceutical help. I have opinions, at least metabolically speaking, on what that help might look like. But if you’re at #4 or above, and you’re working on getting to #1, the path to get there may meander through the local pharmacy for a bit, but most of the path is outside in the sunshine and fresh air. The path most definitely does not intersect with your couch.

So by reading this blog, if you’ll bear with me, you’re going to learn to feel the water around you, and you're going to get the skills to map out your own path out of the evil vortex. I intend to be completely honest and transparent about what I know and what I’m not so sure about. There’ll be philosophical stuff, like what a good partner in health ought to offer. There may even be diversions into seemingly unrelated topics, like pop culture, the weather, or my favorite, cycling. If I haven’t scared you off yet, come back for the next post.