It’s not like we are grandchild-deprived. We have two wonderful grandkids in Minneapolis – Harry and Meri – courtesy of Jonathan and Mandra, plastic surgeon and nurse anesthetist, respectively. Distance dictates a more distant relationship than we or they wish. Meredith Clare is closing in on 5 years old; her articulate curiosity is delightful, and her social (and manipulative) skills are jaw-dropping. Watching her work a crowd would make anyone, except maybe Bill Clinton, jealous. Harrison Dean is a butch nearly 2 year-old who looks great in his bomber jacket and his open-faced joy at riding the Roomba is infectious.

Cynthia’s anticipation of the arrival of her first grandchild by way of John and Jessica has been a bit much by Paternicus’s (me) rather curmudgeonly standards, but her joy at having a grandchild nearby to fuss over and for whom she can buy cute (you are supposed to squeal a bit when you say cute) clothes cannot be denied.

Tomorrow is D-day for Samuel Vandeford Trippe, and there is a very good chance he will be on time for his date with his destiny. John Trippe’s family is a historic clan with places and things in Eastern Maryland named for it. Sort of like landed gentry without land or wealth, but certainly with cool names.

I would kill for a name like that. I was stuck with Jackie Dean Swanson until confronted by the admissions office at Harvard with the incredulous question “Is that what you want printed on your diploma?” At least I can proudly claim a family of oil field roughnecks on my biologic father’s side, including Dowd Swanson who continued to work in the oil fields into his 80’s.

For those stumbling on my neglected blog on the day before D-day, check out Jessica’s picture from last week on the family album.

And welcome to the McCue family, Sam.

It started innocently with a free ticket to a “friendship concert” of chestnuts by the Tokyo Symphony and George Barati, the conductor of the Honolulu Symphony Orchestra. The big draw was the 1812 Overture, in which the symphony was augmented by the entire Fifth Army Band brass section and four 155 mm howitzer canons. When he heard of the plans, which he testily (albeit accurately) described as bombastic, Barati refused to conduct the overture, leaving that part of the concert to the director of the Fifth Army Band. But a great time was had by all, thank you George. The next day I went to the Post Exchange in Tokyo and bought a transparent red vinyl LP of the 1812 by Felix Slatkin and the Hollywood Bowl Symphony, with Japanese liner notes. That led to Tchaikovsky’s fifth symphony, then the sixth symphony, and it never ended. I still have the 1812 LP, but have not had the courage to play it for decades – I think the memory is better than reality.

FYI – 6283 CDs is about 260 linear feet of heavy plastic. In the mid-2000s Stereophile Magazine reviewers began to claim, consistently, that a CD copied to a hard drive and played back with a decent DAC sounded better than the original disc. Remember that these are the folks who said that CDs sound better if you paint the edges of the CDs with a green marker, or elevate your interconnects on little wooden trestles. But sometimes they are right. A DAC is a digital to analog converter – probably most people give it little thought, but any gadget that can take a digital file and make sound (which is “analog”) has to have a DAC. Most DACs, like the ones in your smart phone or most computers, are pretty cheap and not equipped to handle high-resolution digital recordings. But the better ones, which now can cost as little as $250 or as much as $25,000, have revolutionized audio music. If you listen through 1” speakers, or worse, you won’t notice the difference. But if you have a decent stereo, you certainly will notice the benefit of a good DAC and high resolution recordings (such as SACD, DSD, or high-definition – sort of like the difference between ordinary TV and high-definition TV). But just ordinary CDs sound better too when you convert them directly to sound from the digital files that are stored on the CD, and skip the CD player.

Back to having too many CDs. Loading CDs into my computer at the rate of 5 per hour, a rate that I cannot sustain for more than an hour or two, my collection would have taken 1256 hours, or about 6 years of 40-hour work weeks. That does not include the “grooming” (the most critical and time-consuming step). iTunes does it for you automatically, but you get what you pay for, which is not very much. Fortunately I met Ari Margolis http://www.goldeneardigital.com 4 years ago. He has a robot that automatically copies CDs at a reasonable price that includes grooming. Fortunately for my sanity, Ari is an excellent musician with a deep knowledge of classical and jazz, and an audiophile (hence “Golden Ear Digital”) – also with a touch of OCD, a necessary job skill for his business. A robot is a cool gadget that picks up each CD from a stack and feeds it into a computer that copies (“rips”) it, and then picks up the CD and puts it back in a stack. I would love to have one, just to watch it work.

Once you are finished with the copying, you have to groom the CDs – the meta-tagging that records the information about the music on the CD is somewhere between unreliable and annoying. Ari is a master at JRiver, an amazing music database program that just keeps getting better. With its flexibility, however, comes complexity, and it takes a while to get to know it – and even then it is the playground of geeks. But if you need it to do something – like print out a pdf of your collection – it can do it. It just takes a bit of trial-and-error and deciphering of inscrutable computer-ese. So what is new?

And then all your music is neatly stored on external hard drives. My collection ended up being a little more than 7 TB, which was an unthinkable amount of storage space until recently. But now it costs less than $500 to buy 8 TB. I prudently backed-up my collection, which had now cost thousands of dollars to transfer to hard drives. I even sent one hard drive to the most trustworthy person Cynthia and I know – her sister Chris. If I told Chris that if her house caught fire the first thing she had to rescue was the hard drive, she would do it. Even better, she lives in Florida, which, unlike California, refuses to have earthquakes.

The hard drive Chris shepherded through TSA inspection (I think they thought Chris might throw it at the pilot and tell him to fly to Malaysia) is now on its way back to California. Three of my four hard drives crashed – two could not be resuscitated. They are officially dead. The third was resuscitated and is contentedly humming next to my computer. With that drive and the one winging its way from Florida, I will be able to put things back together. If I had not been able to do so, I would have lost 2 years of work.

The morals: Backing up is not fun, but you never know when melt-downs occur. And if you do what I did with your CDs, go to The Container Store and buy some big $10 storage units and put the archival CDs under your bed. Never trust a hard drive…

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.