Something happened to the text! I hate to re-write something, but I guess I have to now that the Westminster Dog Show is over.

The idea for the UCSF Wikipedia project, which has some very talented and energetic people behind it (emails typically get answered after midnight), is to harness the knowledge and creativity of very smart 4th year medical students. If they choose to take the elective, which is of course an optional part of the curriculum, they adopt an article from the list of articles on medical topics that have been rated "important" and also not ranked as one of the higher-quality articles. And then with some education and faculty help, they hopefully drag it up to a higher quality rating.  Here is some more information about the elective and the people behind it: 
https://en.wikipedia.org/wiki/Wikipedia:WikiProject_Medicine/UCSF_Elective_2013

What the students get out of the experience is a work in progress, in more ways than one. They universally like it, they have the opportunity to master the topic that the article was based on, they feel as though they were making a contribution (very important in the Wikipedia world, which is well represented with zealots), and they learn editing skills. Wikipedia editing skills are actually sort of low level programming skills, but they are geeky and clumsy enough to make most people shy away from editing. 

Key to the Wikipedia editing process is the understanding of how it views itself. It was intended to be a tertiary source -- an openly-edited encyclopedia that is neutral and does not have a point of view to offer in its articles. There is no room for opinion -- if you state something as an opinion, it will get yanked by another editor or promptly deleted if it gets through the first level of review. Everything must be referenced, and hopefully with an agreed-upon high-quality reference. The students act as primary sources (writers or, if you will, editors) who research secondary sources (references or citations), and then create a tertiary source -- an encyclopedia. 

This is not something that fits well into the medical world, which is quite top-down -- anathema to the Wikipedia crowd. If you read a medical review article or a book chapter, it is written by an expert whose job is not only to know the research on which his field is based, but, importantly, to offer opinion that ties the research together and fills in the holes with experience. But Wikipedia medical articles are anonymous, at least until you start drilling down into the talk page, which only the committed will do. Theoretically, everyone can be the (anonymous) expert.

The details about WikiProject Medicine, of which this elective is a little piece, are here: https://en.wikipedia.org/wiki/Wikipedia:MED I will try to summarize. The best articles are rated FA (Featured Articles -- gold star!). When about 25,000 medical articles were rated for importance, only 114 were FA; of the 1025 that were considered as top or high in importance (the remaining 2 of the 4 categories are mid or low importance), only 27 were in the FA category and an additional 52 were Good. All the remainder fell into B (not too bad, really), C, "Start", or "Stub" -- the latter two meaning that there was not really much information in the article. To put another way, about 22,500 of the 25,000 articles were C or worse, and about 650 of the 1025 top/high importance articles were C or worse.

To make it sound as bad as it actually is, a majority of the articles that were considered top/high importance articles were C or worse, and only about 10% were in the best (FA) category. Now if you are looking up an article on Charles W. Eliot, it is probably not all that important -- you may get some incorrect facts, but nobody will be harmed. On the other hand, if your aunt is diagnosed with acute lymphoblastic leukemia, and you do what a majority of people in the world currently do and run to the Internet, i.e., Wikipedia, you will encounter an article that is both high in importance, but only B in quality. Hopefully you have a hematologist/oncologist on the case and no harm will result, but you could get some incorrect, unbalanced, or incomplete information. And for many medical articles, you will get some incorrect information. If you are like me (until recently) you have never clicked on that folder tab in the top left-hand corner labelled "talk" which will give you some juicy chatting and a rating that senior editors in Wikipedia have given the article. But what is the alternative? The other medical sites are skimpy, spotty, often amusingly shallow and dippy, and often downright dangerously opinionated with an ax to grind.

More to come...sorry.

About 10 years ago a friend who was tech-savvy (defined as my not having any idea what he was talking about, but it seemed that I should be paying attention) told me about 2 new Internet projects that he was excited about. True to form, I had not a clue what he was talking about, but I nodded appreciatively at his sharing the inside knowledge of what was happening in the cutting-edge SF Bay area tech world. Strangely, I remember what he told me about the two new projects that were already up on the Internet on a small scale, and if popularity can be the judge, he was correct.

The first was Twitter. My reaction then, which I cowardly kept to myself, was that if something can be said in less than 140 characters, it isn't worth reading. What I was not appreciating is omnipresence of the small screen, and the fascination of being able to communicate largely useless information at any time, like when driving on freeways. But I still hold to my curmudgeonly conclusion at the time. Tweeting is a colossal waste of time, but so are many of the things we do, like writing a blog.

The second was Wikipedia. I do recall what he was saying about open programming of a free encyclopedia -- and it did sound cool, although it has taken a decade of watching it develop and finally participating in parts of it myself to get a deeper understanding. My understanding is really not very sophisticated compared to some people I now work with, but it turns out to be a lot more so than anyone with whom I have discussed WikiProject Medicine.

Wikipedia's strength is its greatest weakness -- its openness means that anyone throughout the world can contribute knowledge -- and literally millions of people do all the time. And its openness means that anyone throughout the world can contribute what he thinks is knowledge, and unless a more knowledgeable "editor" does something about it quickly, that contribution will stick. And until someone else takes the more courageous step of removing that silly bit of supposed information, it will stay there. It takes more courage to remove stuff  -- much more courage -- that is already in a published article than it does to add some inane text that has some sort of inane reference citation to support it.

A few months ago I volunteered to help with an effort at UCSF to improve the content of medical articles on Wikipedia. But more on that tomorrow when you and have more patience. Moreover, the Westminster Dog Show starts today.

In the early 1990s prisons began banning tobacco smoking by prisoners, and some banned it for prison employees as well. Estimates were that 80% of prisoners and 50% of guards were smokers, but these figures are likely conservative and a California prisoner’s assessment in 2005 that “everyone smokes” is more likely the accurate number (http://www.cbsnews.com/news/cold-turkey-in-california/). I hate cigarette smoke to the point that my wife has to calm me down when we go to Europe, where attitudes are more permissive (although not as much now as they used to be). But if I were in prison, I would smoke. It is something to do. Among the many punishments endured by prisoners, boredom is one of the greatest. As one of my prisoner-patients said to me, “every day is the same.” And when you consider multi-decade or life sentences, that is a lot of sameness and boredom. Being a prisoner is one of the more stressful lifestyles, and I am told by smokers that a cigarette or perhaps, in the case of e-cigarettes, nicotine relieves some stress. Whether it primarily relieves the stress of nicotine withdrawal is, in my opinion, more likely – smokers have never struck me as less stressed than non-smokers. Furthermore the multitude of health and well-being risks from smoking are a tough sell when a prisoner is looking at life behind barbed-wire-and-bars.

California did not get around to banning smoking until 2005, a few days (literally) before a federal judge placed the health care system in CDCR (California Department of Corrections and Rehabilitation, although it could be shortened to CDC since very little R goes on) under receivership – basically dictatorial control by a court-appointed “receiver” who reports to the judge, not the CDCR. Needless to say, CDCR health care did not get placed under receivership for its exemplary medical care.

Of course there are many good reasons to ban smoking in prisons, and it is nearly impossible to argue against it. It is getting there – from universal smoking to no smoking – that is the problem. My patients have told me that heroin is easier to kick than smoking. Part of the reason is probably the social environment that promotes smoking – advertisements, smoking actors, the irresistible urge for immature adolescents to be cool, cigarette breaks at work, associations with alcohol or sex, as a start. Heroin just doesn’t have good marketers behind it, so its use is pretty well confined to a scruffier pathetic stratum of our society.

In the 1980s a medical school university hospital where I was a member of the faculty had cigarette machines in the hospital on every floor (including the ICU) and the dean himself chain-smoked. Granted, the medical school was named after a member of the Reynolds tobacco family and it was North Carolina…but still! Really!

I have been on two hospital campuses when they went non-smoking. It was not easy to do, and both tried half-measures, such as smoking areas, or allowing smoking in the psychiatry ward. Ultimately, half-measures cannot be sustained, and a tough total ban is necessary. I found the argument for the psych unit persuasive: patients admitted for acute psychiatric conditions should not have tobacco withdrawal added to their list of problems. Tobacco withdrawal is, moreover, much easier to treat than mania or acute schizophrenia. Nicotine patches were used, of course, but there is more to smoking than nicotine addiction. Ultimately the psych unit directors had to back down and implement a tobacco ban. We (the medical administration and medical staff) nervously awaited the consequences, but nothing happened. Nada. I guess if you are stoned on high doses of psych meds, complaining about not being able to smoke drops lower on your list of bitches.

When the CDCR decided to ban nicotine patches from its drug formulary in 2011, I was the only medical executive to object. Not that it did any good. The behavioral manifestations of nicotine withdrawal when prisoners are processed at the “reception centers” could be prevented with a standard withdrawal regimen of nicotine patches for a few weeks. The behaviors one would like to prevent, when possible, are aggression toward guards, fellow inmates, and themselves. I will toss aggression toward doctors into the mix, for good measure. The medical system in prisons has a deeply entrenched, and in my opinion (which is of course correct) deeply unethical, propensity to consider itself an agent of punishment rather than an advocate for patient care. It is a very complicated issue, but prison health care providers have not acquitted themselves well as subtle thinkers of the complexities involved in giving medical care to inmates.

You are probably wondering where I am going with this…or more likely just what my problem is. An article in Thursday’s NY Times added a new twist. The benefits of selling nicotine to inmates! http://www.nytimes.com/2014/01/24/us/in-rural-jails-a-calming-vapor.html

Banning cigarettes immediately created a prison black market for smuggled cigarettes, which could be sold for a very tidy markup to bored inmates. How the inmates get away with smoking was a mystery to me, and matches or lighters are of course banned. But I consigned it to the category of things that I just really did not want to know about. The source of contraband cigarettes was probably guards in most cases – it is much easier for them to smuggle smokes (which don’t set off metal detectors, and which I suspect the other guards do not really care a whole lot about anyway) than the prisoners who, one would hope, are more closely watched than the guards. A lot of prisoners are pretty nice guys underneath all the antisocial behavior, and it would be a mitzvah to slip a few cigarettes to a nice guy prisoner who could, for that matter, make your life a little easier.

Some Tennessee county jails came up with a good old American entrepreneurial approach of selling e-cigs to prisoners through the commissary, which usually deals with staples of prison life like ramen and chips. In addition to the profit to the system, they noted a calming effect on prisoners and fewer behavioral problems in those who used e-cigs. The markup is 400%, which is considerably worse than the markup on wine at nice restaurants. And as the Macon County chief deputy sheriff pointed, it is cheaper than fixing broken noses. I will bet that it never happens in California.

My neighbor lent me Gertrude Bell: Queen of the Desert, Shaper of Nations by Georgina Howell, a bit like tossing an extra cup of charcoal starter on a hot grill for a T. E. Lawrence aficionado. It was a ripping good story about a remarkable woman -- brilliant, courageous and fearless, principled, athlete extraordinaire, socially assertive, and feminine with a love for fine clothes, family and a gracious home. And a heartbreaking story of a woman who lost her married lover, the love of her life really, who was an officer at arguably the biggest folly of the British Empire (but there is a long waiting list for that distinction) - Gallipoli. 

Lawrence In Arabia (Scott Anderson) is an epic that is more readable than Seven Pillars of Wisdom; Gertrude Bell is more personal and gives a unique perspective of the experience of a powerful woman in the bizarre, dangerous, misogynous world of devout Arabs in the early twentieth century - not to mention the bizarre, dangerous, misogynous world of Edwardian England. But the question that is immediately posed is "Where has Gertrude been all these years?" Was she really a central figure in the key decisions of this decade in the Middle East -- decisions that we live and die with today. Anderson does not mention her even once in his wide-ranging, comprehensive book. Lawrence himself mentions her twice -- once in passing, and once only as "storied traveler". 

I suspect that as much as we and Howell might wish her to be a transcendentally heroic figure, she was merely an incredibly (truly incredible) heroic figure in a time that needed her more than it could have her, or would have her. I cannot imagine, having read both books, not reading both, side by side. I don't believe the importance of Gertrude's story as much as I would like, but that is just fine, thank you.

My little (7500 souls who are willing to be counted) town of Fairfax seems to have a special relationship with Tibet, at least at the trinket level. There are possibly more Tibetan tchotchkes available for sale per capita than any other place in the US -- but I do not know that for a fact and am not going to spend time to confirm it. It will just have to stand on its own as a reasonable supposition. Tibetan statuettes (I think they are Tibetan anyway) sit in yards and driveways, and Tibetan prayer flags hung on fences and gardens gracefully fade and disintegrate - intentionally, I am told - along the morning route my Tibetan and I take. I know I risk the wrath of those who believe that she is a companion and not "mine", but I earn literary license daily but accommodating to her quirks. 

I became more aware of the peculiarities of a relationship with my companion animal, as the more sensitive among us would have it, after retirement. The rhythm of one's day becomes slack -- it loses the snap that a work schedule and commuting to the office brings to the weekday. A dog then brings its own rhythm to your day. 

Trixie the Tibetan quickly sensed the rhythm vacuum, and supplied her own, one that is tailored to her more focused needs and wishes: morning and afternoon walks, accompanied by cheese treats freely given for not running away or lagging too far behind on garbage day, replete with delicious smells that we human companions do not perceive; prompt notification if the opportunity for participation in an afternoon nap arises; belly rubs after dinner (or any other time an occasion for a rub presents itself); placement of dinner plates on the floor for licking before they are put in the dishwasher; notification when there is availability of peanut sharing (one for me, one for you...) when it is time for a glass of wine, a good book, and music (and thee, she would add, meaning her); predictable making of the bed so she can lie right in the middle, making it nearly impossible to move the bedspread. It goes on, of course, as any Tibetan companion can tell you, but what is notable is the regularity of the rhythm. The schedule is precise, and when deviated from, the deviation is brought to the human companion's attention after a suitable interval of waiting. The insistent nudge in the knee or thigh is a signal that time for walk, treat, play with a toy, or belly rub is overdue. 

I first noticed that she had an impeccable sense of clock (human) time when the firm nudge first came at 3 PM, then at 15 minute intervals thereafter, until I stopped whatever less-important task I was occupied with and took her for the afternoon walk. I know none of this is news, but it is by way of recommending my birthday book to anyone in search of an utterly delightful and sophisticated compendium of dog stories, poetry, and cartoons. The Big New Yorker Book of Dogs is best consumed in 20-30 minute doses, after peanuts and red wine...on schedule.at 6:15 PM...after a 4 PM walk...and before a 9 PM belly rub.

Pictoral proof is supplied in the family album.

Not many families have the advantage of a pro to do their Christmas video. Here is John Trippe's account of our Christmas:  http://youtu.be/M9FYx94h7ls

I am not a fan of cruises -- seems lately that there are too many guys who look like me who take cruises. It is a bit like opera on Sunday afternoon -- you are relieved to see someone younger than you are. The cruise ships have exploded in number and size, bringing prosperity to provincial coastal towns, and of course dramatically changing what made those places so attractive in the first place. But it is hypocritical to complain about the effects of tourism when you are a tourist yourself -- a point well made by Rick Steves many years ago. It is much better to do your best to enjoy the people you meet and let them know how you appreciate their land and customs. There is the undeniable advantage of seeing places that there really is little practical way to visit otherwise, but it is hard to get away from the feeling that you are in a prosperous capsule (US dollars and 110 volts) floating from one tourist location to another. One good thing about the capsule is its international staff, who are unfailingly cheerful (good training, I am sure) and make you happy to be around them. And the triumph of gaining only 2.5 lbs despite having 4 meals a day. Louis de Berniere's Birds Without Wings made a wonderful trip companion to our stops in Turkey and Greece, and somewhat to Italy as well. Lawrence In Arabia (Scott Anderson), absolutely obligatory for T. E. Lawrence nuts, fleshed out Birds nicely but was too heavy to pack.

A friend introduced me to the classic travel trilogy by (Sir) Patrick Leigh Fermor: A Time of Gifts; Between the Woods and the Water; The Broken Road. It is not an easy read, despite its gracious writing. For one thing, his vocabulary is so immense that I surrendered to his erudition, and stopped looking up words that I did not know. I keep an unabridged dictionary next to my reading chair, and I rarely use it because nearly all books I read fall well within the scope of my own vocabulary. But it just took too long to look up two or three words on some pages, so I began to let them wash over me. 
As the scion of British nobility, the 1200 mile walk that the rebellious 18 year old planned from Rotterdam to Istanbul in 1933 became more often castle-hopping than an arduous camping trip. He and his family just had too many connections with the great families of pre-WW2 European families to be left to trudging along dusty roads and sleeping under the stars -- although he did do that too. It turns into an essay on what happens to your view of the world when you get a (real) liberal education, and can't turn it off. In addition to literature, his commentary on history, linguistics, art, architecture, religion... it goes on, although music is largely left out. 
These three books, and insistent coaxing from my wife, reengaged in my planned project to read, or in the case of many books, re-read the content of The Harvard Classics. The initial plan, when I bought my beautiful leather-bound set nearly 20 years ago, was to read them when I retired. They were abused by brutish Baltimore movers in the ensuing years - ones that included their transcontinental trips from Massachusetts to California to Maryland and back to California (with many stops in between). 
I got distracted by the story of the books themselves, their editors, and their sometimes sleazy publishers, and abandoned what turned out to be a very arduous journey, indeed. It has some interesting parallels to that of Sir Patrick's, at lease in an allegorical way. So I am going to try again. Cynthia's version is that after 50 years from graduation from Harvard, I shall revisit the concept of the liberal education by reading The Harvard Classics as President Charles W. Eliot, arguably the greatest Harvard President, intended. I may reach my destination, but like Sir Patrick I may not live to tell about it. It is much harder than you can possibly imagine, and I am certainly not the target audience for President Eliot's journey across the civilized world.
Sir Patrick's was a decorated war hero, and the Wikipedia summary of his life is succinct and engaging http://en.wikipedia.org/wiki/Patrick_Leigh_Fermor.

Memory is an attribute that age treats unkindly, but I do remember Fred Hallaran MD from our brief time together nearly 4 decades ago ...or at least I think so. He was the preceptor for my group of 4 first-year medical students, and was accorded the improbable task of helping us become comfortable interviewing and examining patients, not an easy undertaking considering that we knew less about medicine than the ward clerk. This was a revolutionary concept at Case Western Reserve -- to introduce students to patient care from the very first day of medical school (the Dean of the school was a psychiatrist with a keen interest in somatotyping!). I have no idea if the early introduction really matters, but lots of medical schools, including UCSF, do it now with the hope that it keeps students focused on why they are in medical school (although most are actually there because our mothers insisted).
Dr. Hallaran was a solo practice primary care internist in Cleveland; he was  a CWRU graduate who almost certainly was doing his payback. He was thin, had a pronounced limp from a paretic right leg resulting from childhood polio, and wore a loose brown suit with, I think, a brown fedora. He carried a black bag holding the tools of the trade, which at that time included a small stock of drugs used in house calls.
My payback day was last Thursday when I was introduced to my wonderful group of whip-smart medical students at UCSF -- as diverse a group as can be imagined, and mostly Californian -- only a few had been imported from one of the 49 other alien states. We talked a lot -- actually I talked most of the time because I was probably more nervous than they were. And then we learned and practiced how to take pulses and do blood pressures. I talked a lot about keeping your eyes open, paying attention, and observing; I used a little parlor trick of making them do observations on my dusty and worn black bag, an Eli Lilly heirloom from the days when drug company gifts were innocent and well-meant. It was an exciting two hours for me, and I hope for them as well. We forgot to learn percussion, a time-honored and occasionally useful physical exam skill. That will have to wait until next Thursday when we tackle the entire head.
In the end, I hope they are inspired to do their payback some day, perhaps four decades hence.