The Map of Reality is Not Reality: Guidelines and Melanoma

How often do you use GPS to get somewhere? I use it all the time. Whether it be going to the hospital, dropping off my son at daycare, and even going back home, I have GPS on. Using GPS is useful. If there is traffic on the route, GPS will reroute me to a better route. If I am lost, I can easily get home with a few touches on my phone.

Relying on a map can lead to a variety of problems. The map can be wrong, missing information, or can be interpreted incorrectly. Maps should be treated as a guide, not the rule.

Map is not the territory

In 1931, mathematician Alfred Korzybski popularized the idea that the map is not the territory. Basically, the description of something is not something itself. Abstraction is not reality.

Alfred Korzybski poses three downfalls to using maps.

  1. Maps can be incorrect without our realization.
  2. Maps are a reduction of reality by necessity, and this reduction can lose viable information.
  3. Maps require interpretation, which in turn can generate errors through misinterpretation.

A map is a representation of a territory. We use maps all the time. Whether it be physical maps or Google maps, maps are useful in getting from point A to point B. However, maps are not perfect representations of reality. Maps should be served as a guide, but if something in reality does not appear on the map, we should trust reality. With this mental model in mind, I successfully treated and continue to treat one of my longest living patients with active cancer.

Beyond the guidelines: Treating melanoma in a Jehovah’s Witness

An elderly male with past medical history of advanced melanoma presented as a follow-up in my clinic. He is a known patient of mine who was initially found to have melanoma of his right axilla (armpit) several years ago. At the time he had no sites of metastatic disease. The standard treatment for him would have been surgery followed by immunotherapy. However, his melanoma was almost 10cm in size which would have been a big surgery. Further, he was a Jehovah’s Witness. Jehovah’s Witnesses believe that Christians should not receive blood transfusions, even from themselves.

Since the surgery would have been extensive requiring blood transfusions, I presented the case to our multidisciplinary tumor board. We reviewed the guidelines and decided to treat with radiation first followed by immunotherapy. With radiation, he would not require blood transfusions. Immunotherapy was successfully given to patients with melanoma after surgery, but there is a paucity of data on radiation only. There are no guidelines to support this approach, however based on clinical experience and reasoning, this approach was the best option.

At the follow-up, he is doing well. He has been on immunotherapy ever since his radiation treatment with no sites of recurrence. In fact, the melanoma has been stable and decreasing in size. His quality of life returned back to baseline and is enjoying life.

Guidelines are like maps. Every patient is different so there is no one size fits all type of treatments. Religion is not a factor mentioned in the guidelines for treating melanoma, however it is a huge factor for patients in real life. If the guidelines contained nuances for every religion and personal belief out there, the guidelines would be too large for any clinical benefit.

Better decision making requires a firm grasp on reality

By remembering that the map is not the territory, we can make better decisions. Maps don’t strictly apply to geographic areas but to guidelines for life as well. By staying footed in reality, we will make better decisions. If reality and the map contain a discordance, follow reality. Remember who created the map as their perspective may not necessarily coincide with ours. And there is plenty in reality not seen in the map.

If I strictly followed guidelines for my patient, I would have likely recommended no treatment. He would have passed a long time ago. Instead, by following reality, he is alive today.

I read 60+ books in a year, you can too!

Warren Buffet, the greatest investor of modern times, was once asked how to read more. He held up a stack of papers and said, “Read 500 pages like this every week. That’s how knowledge builds up, like compound interest.”

Everyone knows that we should read more. The question is how?

In 2020, I read over 60 books. I did this while working as a medical doctor during the ongoing COVID-19 pandemic and raising two little boys. So when people tell me they don’t have time read, I interpret it as they don’t choose to read. Super productive people like Elon Musk have only 24 hours a day, and so do you. Need some help? Here are some tips that helped me read more.

Develop a love for reading

In order to read more, you need to actually like reading. So to develop a love for reading or for anything else, just do it. Start with the small stuff. It can be even the “junk” that people tell you to avoid reading. Angel investor Naval Ravikant says “There’s no such thing as junk. Just read it all. Eventually, you’ll guide yourself to the things that you should and want to be reading.” For me, when I don’t feel like reading heavy nonfiction, I turn to fantasy. Currently, I’m working through Brandon Sanderson’s epic fantasy series Stormlight Archive. Call me a nerd, but like the Immortal Words that the Knights Radiant lived by, I live by too: “Life before death. Strength before weakness. Journey before destination.”

Quit more books

In elementary school, we were taught to finish what we read. There were deadlines to finish books. In the real world, no one is keeping tab. As long as you get one new idea from a book you’re reading, I think that’s enough. Even if the idea is that the book isn’t any good, then it should be even more reason to put the book down and move to something else. James Joyce, author of Ulysses, put it best, ““Life is too short to read a bad book.”

Read several books at the same time

To read more, you need to read more books. Don’t be afraid of reading multiple books at once. Read one book at a time, but feel free to switch to different books when you get bored. Bill Gates, Microsoft founder and avid reader, carries with him a bag of several books he’s currently reading at any given time. Reading more books at the same time brings multiple benefits: you’ll finish more books and never get bored.

Allocate time for reading

Time is the most valuable and precious resource we own. In order to read more, you need to allocate more time to it. Don’t have time? Make a routine. One method is to schedule time for reading. Try scheduling at least one hour of your time to read. Write it down in your calendar. If one hour is too long, try at least 15 minutes.

“When you don’t have much time, a routine helps you make the little time you have count. When you have all the time in the world, a routine helps you make sure you don’t waste it.”

Austin Kleon, author of Steal like an Artist

Make reading a habit

James Clear, author for Atomic Habits, describes creating a habit into four steps:

“How to Create a Good Habit

The 1st law (Cue): Make it obvious.

The 2nd law (Craving): Make it attractive.

The 3rd law (Response): Make it easy.

The 4th law (Reward): Make it satisfying.”

To make reading obvious, reduce the friction to reading books. I know having a tidy place is the priority for some people. It is for me. I was brought up and taught to always put things back to where they belong. My fiancé on the other hand leaves things out everywhere. At first it drove me nuts, but then I realized by leaving my books out everywhere, I was more likely to pick it up and read it if I saw it. So some mess is ok, as long as it’s conscious mess. Besides, life is supposed to be a little messy, so I’ve learned to live with the mess.

To make reading attractive, Clear recommends temptation bundling. Take a daily habit and pair a habit (reading) you want to do with it. For example, when I wake up I reach for my phone to turn off the alarm. With my phone on, I open the Kindle app and just start reading whatever I was reading last night for a few minutes.

To make reading easier, Clear describes the “2 minute rule.” Start with a smaller, mini task that takes less than two minutes to complete. This can be picking up the book and opening it and reading at least one page. Even if it’s one page, that will be better than none. If it’s a book you like, it will be more than one page.

For your reward, you can keep a book list and cross things out as you read them. For me, I kept a numbered list of books I finished on my Notes app on my iPhone. Seeing the numbers increase gave me enough dopamine rush to keep going.

Bonus: Speed reading

There’s a lot of debate on whether speed reading works. Personally, I think some techniques make more sense than others. Here are two techniques that I use and seem to work for me.

Tracing

How many times have you reached the end of the paragraph and wondered what you just read? Hopefully, it’s not this post! That is called regression, and one method to prevent that from happening is called tracing.

Tracing is simply taking a pointer like your finger or pen to run across the text. The point of tracing is not to go as fast as you can. Tracing prevents regression. For me, tracing keeps me focused on the page at hand instead of drifting to the next page or elsewhere. For paper books, I use a pen and glide the pen over the words as I go along. For the kindle, I hover my finger above the text. Tim Ferris, author of Four Hour Workweek, does a great job of explaining this method here.

Minimize subvocalization

Remember when you were little and had to read in front of the class out loud? I do and still hate it. Unfortunately that’s how we all learned how to read. Subvocalization is your inner voice speaking the words you read in your head. Many studies have shown that eliminating subvocalization won’t increase your reading speed, but minimizing it may.

The average reading speed is about 150-250 words per minute (wpm). And the average talking speed is exactly the same. Minimizing subvocalization can increase your reading speed to 450-700 wpm!

So how do we minimize subvocalization? Try being a visual reader. When we read, we extract ideas from the words written down. Sounds abstract, but a concrete example would be to think of a “STOP” sign. When you are driving and see the “STOP” sign, do you you say the word “stop” in your head? If you’re like most people, you understand the combination of those letters means stop. So, you stop your car (hopefully) when you see the “STOP” sign. This is similar to being a visual reader. When you look at the words, try to take in the meaning of what’s written instead of saying it to yourself in your head. This skill will take practice, but I guarantee it will be a useful tool for you and your reading endeavors.

Now read more

To read more you need to develop a love for reading, quit books quicker, read several books at once, schedule time for reading, and make reading a habit. Speed reading is up for debate, but tracing and minimizing subvocalization will help you read faster and more efficiently. Remember, reading is for fun and learning. So, now go have fun and learn something!

Have any other tips on reading? Let me know what you think!

Fastest Way to Get Out of a Funk: Negative Visualization

What’s the worst thing that can happen?

Some days are harder than others. For me, it would be rainy days. The rain made me feel trapped inside the house. I didn’t like feeling wet so I’d avoid going outside. Being stuck inside made me think of all the things I was missing in life: the super successful job, the huge house, the Tesla. It became a vicious cycle of victim mentality and self-criticism. Being so negative reminded me of something I read on Stoicism and the practice of negative visualization.

What is negative visualization?

Negative visualization is a practice where you think about what your life would be like without your loved ones or possessions. Sounds simple at first, but the exercise is quite profound.

By practicing negative visualization, we enjoy every moment as if it were our last. The Stoics recommended that we imagine losing our most valuable people and possessions. We must imagine our loved ones dying, our house burning down, or losing our job. By doing this, we learn to appreciate our loved ones, house, and job more than we normally would.

The final step that many Stoics believed would be imaging our own death. By contemplating our own death, we discover what really matters.

Don’t believe me? Amazon CEO Jeff Bezos had a similar practice called “regret minimization framework.” Bezos imagined himself at 80 and whether or not he regretted trying this decision. Also, former Apple founder Steve Jobs once said, “Remembering that I’ll be dead soon is the most important tool I’ve ever encountered to help me make the big choices in life.”

Practicing negative visualization is essentially thinking with the end in mind. By thinking of the end, we are able steer our lives towards the end result we want.

How to do negative visualization?

Practicing negative visualization is really quite easy. The main method is to ask what if. “What if my loved ones died suddenly? What if my car was stolen? What if I lost my job?”

Negative visualization does not have to be just the big things. We can find value in the small things as well. Tired of your iPhone because it’s not the newest one out there. Try imagining what if you didn’t have a phone at all. Now you can value your current phone and all the wonders that it can do like call, text, surf the web, and watch anime.

3 lessons I learned from practicing negative visualization

If every time is the last time, then make every time the best time.

Practice every goodbye as the last goodbye. When I say goodbye to Kari (my fiancé) before work, I imagine that might be the last time I see her. By thinking that in my head, I am refocused on the moment. Thinking that this may be the last goodbye, I hold on to her a little bit longer and stare into her eyes with more precision. What normally would be a pat on the back and peck, becomes an intense embrace and kiss.

When I am alone with my sons, instead of waiting for time to pass by, I imagine that this might be the last time I played with them. All of a sudden, dancing with them becomes more fun than annoying. Letting them ride me like a horse doesn’t cause as much back pain. I get to enjoy their presence instead of being annoyed by it.

Keep in mind, the Stoics focused more on actions rather than words. I do not tell Kari or my sons that I’m thinking of their death, I only think and act with it in my mind. Otherwise, I don’t think they would take me thinking of their death the right way.

By contemplating that everything is only temporary, we are forced to realize that this might be the last time. So if it is the last time, might as well make it the best time.

To be happy is to desire what we already have.

By imagining the loss of everything we own, everything we own becomes much more valuable in our eyes. The other day, I dreaded waking up early to walk our rescue dog, Coral. It was freezing and the sun was not out yet. I just wanted to spend a few more minutes in bed. While in bed, I imagined what if Coral died later today and this might be the last time I walk her. Like with Kari and my sons, walking Coral became a blessing rather than a chore.

I thought the same thing to when I was stuck in California traffic the other day. All around me I saw Teslas, BMW’s, Lambo’s zoom past me as I was driving my mom’s Toyota Camry. I sure longed for the nicer car, but then I reminded myself, what if I couldn’t drive anymore? What if I had to take the public transportation to get where I was going? Not to hate on public transportation, but it’s essentially nonexistent where I live. Driving became fun and I was glad I could.

Negative visualization is not resignation.

Although we are pretending that we might be living our last day, this isn’t meant to change what we do. The point, the Stoics believed, was to change how we thought about what we do. Instead of giving up on everything or making dumb decisions a la “YOLO” (You Only Live Once), we should still continue our daily lives and remember to appreciate today. So don’t go spend your life savings because you might die tomorrow. Instead, continue to save for your goals and appreciate that you are able to do such things because you might die tomorrow.

Conclusion

Life can feel hard. Life can feel mundane. Life can feel unfulfilling. By practicing negative visualization, we can learn to appreciate the now and make the best of today. So practice saying your goodbyes as if it were your last goodbye, make every time the best time, and feel blessed with what you have. For me, what if it was that last time it rained? Wouldn’t I miss it? I sure would, so I put on my rain coat and took the boys outside.

Want to learn more about negative visualization? Check out this awesome book, A Guide to the Good Life, by William B. Irvine.

What if this was the last time you read this blog? What would you comment?

DAD Guidelines

“To me, fatherhood meant a man had made it in life.”

Matthew McConaughey, Greenlights
Being a dad is hard, but I still recommend it!

As a father, I made it! I’ve got two young happy boys (Zac (2.5 year old) and Archer (1 year old)). Ok what do I do next? The thing is that most people don’t tell you what to do after you made it.

What I can tell you is that being a dad is by far the hardest thing I’ve ever done. They cry, pee, poop, eat, sleep, need to be held, and need your attention. Sometimes in that order, sometimes randomized, and sometimes all at the same time! Plus, they don’t even help pay for rent.

Being a dad tops medical school, residency, and fellowship. You are literally on call 24/7. You are expected to give 100% effort, all the time.

In medicine, I’m used to having guidelines on how to treat different diseases. Care for the most common diseases usually have national guidelines that everyone goes by. You have pneumonia, I know exactly what to do. Heart attack, American College of Cardiology has got me covered. Even cancer, (my specialty) had guidelines on what chemotherapy to give. That’s why they call it the standard of care.

There are no guidelines on how to raise kids

I needed help. I did not have many friends who were parents. Online google searches would just confuse me. I’d often get sucked into the clickbait without any substance. I wanted substance, so I needed a book. Since no one goes to the library anymore, I did the next best thing – Amazon!

I typed into the Amazon search bar, “parent books.”

I came across this gem, The Montessori Toddler by Simone Davies.

To say that this was one of the most influential books I’ve read is an understatement.

What is the Montessori method?

Dr. Maria Montessori, an Italian physician from the 1900s, developed a philosophy of education on teaching children called The Montessori Method.

Dr. Montessori’s method challenged the traditional method of teaching

Traditional education involves teachers directly teaching children. This included primary instruction and external discipline. Children are passive learners through primary instruction. External discipline included reprimands from the teacher and the dreaded timeout.

Montessori method placed more emphasis on the child. Children are cultivated with the desire to learn. They are encouraged to ask questions. Environment plays a big role in developing internal discipline. Changing the environment promotes self discipline. Creating things such as yes spaces and worlds for kids to explore are roles for the adult teacher.

The thinking of the Montessori Method excited me

Instead of doing all the work, I can make my kids do the work. I can sit back and enjoy my kids grow to be the wonderful people they are.

So, if you’re like me and need some help on raising your kids, here are my favorite tips from The Montessori Toddler

Teach the basics, first

Show by example. Show first, talk later. It’s better to show new actions like drawing slowly without saying anything. Toddlers are still trying to process thoughts, so overwhelming actions and words may be too much. An acronym I read in The Montessori Toddler was “SHOW.” “SHOW” stands for Slow Hands, Omit Words. So keep it slow and quiet.

Have age-appropriate expectations and be prepared

I would take blank sheets of paper and draw with Zac. He’s a toddler and is still learning to draw. So I would draw only lines and squiggles. The thought is if we show them something too difficult like drawing a car or house, they might not even try at all. Of note, I can’t even draw a car or house.

Cultivate the desire to learn instead of dumping facts

When Zac started talking more, I’d always ask him to tell me about what he sees. I’d keep asking him why he liked certain things. The point is to encourage curiosity. With enough questions, he learns to question everything – even his dad.

Toddlers are always testing you, so keep limits consistent

Use positive language instead of negative language. Give information. Say “Yes, you can do this” instead telling your kids “No, you can’t.” Kids learn from you. So if your kids are saying no a lot, you need to adjust your language. So instead of saying “Zac, stop pushing your baby brother!” say “Zac, we are gentle with babies.”

Change the environment, not the child

If your kids love climbing on furniture (or you), create obstacle courses for the kids to climb. Sometimes, I would be sitting in the living room and Archer and Zac would just climb me for no reason. By creating a pillow fort, I was able to rest in peace as they played in the fort. I forgot how much I loved making pillow forts as a kid until I made a fort for my kids.

Use one word commands

Using one word commands allow kids time to process ideas . My favorite command is “Shoes!” Every time before we go out Zac has a habit of sprinting out the house. By yelling “Shoes!” he stops and puts his shoes on. Sometimes the most simple idea is the best idea.

Always ask the kids to help out

Kids love to be part of the family. So why deny them? At the supermarket, Zac, Archer and I chase their mother around as she picks out groceries. Once we catch her, she hands them a grocery item. Then the kids would throw the groceries in our cart. Every time they make it in, I’d comment with “goal!” or “slam dunk!” It makes grocery shopping fun, although we are quite loud!

Be present

Toddlers are focused on the moment. They are present all the time. By spending time with them, we learn how to be present. So the best gift we can give them is to be present with them as well. I practice this by focusing on my breath while Zac and Archer are climbing on me. Breath in. Breath out. Repeat.

Summary

These were my favorite tips from The Montessori Toddler. Remember, they are still kids so we need to show them how to do things at the easiest level. Teach less. Cultivate their desire to learn. Keep limits consistent. Creatively change the environment for fun. Kids love being part of the family, so let them be. Always be present with them. And most importantly, kids need time with you.

“A French journalist who was writing a piece about my book Trust Me, I’m Lying once told me that love is best spelled T-I-M-E. I don’t think I’ve heard anything truer or more important in my role as a husband or father.”

Ryan Holiday, 33 Things I Stole From People Smarter Than Me

Spending time, any time, is better than no time. Leave work at work and be home with your kids. Take them to the grocery. Go out for a walk. Or even just let them follow you around the house. Kids grow up faster than you think, so make the most of it now before it’s too late.

What do you think? Do you have any other Montessori tips to share?

A Swollen Arm, Radical Mastectomy, And Becoming A Doctor: How To Overcome Failure

Holly, a 68-year-old woman, came in with a red, hot, and swollen left arm. On presentation, her left arm was at least twice the size of her right arm. She’s a thin lady, so the contrast was remarkable. She told me that the arm blew up 2 days ago. Her left arm felt extremely hot. She chronically gets arm swelling because she had a mastectomy of her left breast about 5 years ago. This type of swelling is a common side effect of the surgery. Lymphatic ducts in the arm cannot drain the fluid correctly, thus congesting and blowing up the arm like a water balloon. Ever since the surgery, Holly tells me that her arm keeps on swelling up, but never this big. Normally she goes through her physical therapy very religiously; she never misses a session. She’s frustrated that her arm is infected, but she states she’s not going to let this stop her.

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Crohn’s Disease, Poop In The Urine, And The Reclining Buddha: How To Sell Yourself To Yourself

The nurse comes into my office with a grim look on her face.  She tells me that my next patient threw up in the exam room. The nurse adds that the patient has severe abdominal pain. I save my note, get up from my desk, and briskly walk to see the patient. In the room, I see a light-skinned African-American 29-year-old female embracing her stomach and crouched over. Her name is Rae.

Rae’s afro was bobbing up and down due to the pain. She’s crying and wincing while clutching her stomach. I ask her what’s wrong. Rae tells me for the past month she’s noticed increasing amount of feces in the urine. I ask her how does she know it’s feces. She tells me that it’s brown and it smells.

I rush the history and physical. I tell the nurse to give her some pain medication and to straight catheterize her. When the nurse catheterized the patient, 100 millilitres of brown, fecal matter mixed with urine came out. I call the hospital and admit the patient. She had surgery the same day. The patient had an acute flare up of Crohn’s disease.

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A Flood and Fiesta For The Common Good: How Family Might Save U.S. Healthcare And You

Over the past three weeks I have been traveling throughout Asia including Vietnam and Philippines. I don’t speak any of the languages, but it didn’t take much to see the culture of community and family.

On one particular day in Biên Hòa, a suburban area one hour away from Saigon, a storm flooded the street. As I stood at the doorstep of the place I was staying at, I watched cars and motorcycles trudging across the high water. I looked at the stores around my area and saw people helping each other put their belongings away, move their scooters inside, and even push cars through the torrent. There was hardly any hesitation in any of their actions – a firsthand example of working for the common good.

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Flood one hour away from Saigon, Vietnam. 5/12/16

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Paralyzed Breathing and 2 Simple Steps To Be Happy Now

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Kari’s feet on a kayak in Halong Bay, Vietnam. Photo taken 5/16/16.

Several months ago, Gary came to my hospital complaining of weakness. Gary was 72 years old, so weakness was a pretty common complaint in his age population. While lying in bed, Gary told me that this morning he could not move his feet. Since then, the weakness has gotten progressively worse and traveled up both his legs. At presentation, Gary said that he could not even lift either of his arms or legs. I lifted up one of his legs, and let it go. The leg dropped like a dead weight. In addition, Gary said he recently got over a cold. Gary also told me he had a similar illness over ten years ago. He said at the time he was hospitalized for 3 weeks with over 10 days connected to a breathing machine. Essentially, what he had ten years ago was the same as what he had at presentation.

Gary had Guillain-Barré Syndrome.

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The Body Destroying Itself And Creating Your Own Luck

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In the emergency department, I saw a 52-year-old female that was here for a flare up of her systemic lupus erythematosis (SLE). Let’s call her “Lupe.” So Lupe has been in and out of the hospital for the past several years for different reasons. One time it was for severe back pain. Another time was low energy from anemia. The most recent time was for acute lupus nephritis (kidney failure) which required for her to start hemodialysis every other day (hemodialysis is a method of purifying the blood when the kidneys aren’t working properly).

Lupe was here this time for a lot of critical lab values found on her blood work – a poor sign for those with kidney failure.  SLE is a devastating disease, and it can affect almost everything in the body. If kidney failure is one of them, it’s usually a poor prognosis. I felt sorry for Lupe because she was so crippled from this menacing illness.

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Ventricular Tachycardia, Bomber Planes, And Checklists: How To Decrease Cognitive Load To Be More Productive

On my last day on the ICU rotation block, one of the patients went into an irregular heart rhythm called ventricular tachycardia. He was a 60-something year old guy with multiple medical problems and connected to a breathing machine. All of a sudden, he became unresponsive and hypotensive and had a heart rate of 150+ beats per minute. As we all rushed into the room, we systematically ran through the ACLS algorithm. We initially evaluated him, checked for pulses, started CPR, established the  airway, monitored blood pressure, identified the rhythm, and gave a dose of treatment. We repeated the process until the patient was stable. It was efficient, it was effective, and most importantly it was routine. It was a checklist that was used around the world and saved many lives.

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