Local by Flywheel logo

Local by Flywheel (Pressmatic) and Symlinks

I’ve changed development environments a couple of times. I started out using DesktopServer, a wonderful app. Gradually I grew disappointed with their update schedule and v4.0 ever on the horizon. One of the things I didn’t like was my inability to choose the PHP version I was developing in. I know there must be a way but it wasn’t obvious.

Feeling like I needed a challenge, I set out to learn how to use Vagrant and VVV cause all the cool kids were using it. Once I got it up and running it worked well. There were a number of quirky things that I needed to figure out for my workflow.

From my initial time with DesktopServer I was using GitHub and local git on my MacBook Air, using Tower, for version control. Currently I’m using GitKraken, but that’s another post. I kept all my local repos synced on GitHub. When using DesktopServer I would create a symlink to the /wp-content/plugins or /wp-content/themes folder of the local environment from my local repo.

This didn’t quite work in VVV as symlinks don’t work in Vagrant. Vagrant requires creating a synced folder which is similar, but not the same. I was able to create a Customfile, custom config file, for my VVV installation that would create synced folders at each vagrant up. This synced folder appeared on the desktop as an empty folder but in the site it ran perfectly. The problem was that in my IDE, PhpStorm, there was nothing in the folder to edit. I found that removing this synced folder and replacing it with an actual symlink made everything work in both my IDE and on the site. Perfect, I was back to my usual workflow.

The issue I had was that every time I did a vagrant up or a vagrant reprovision, Vagrant would destroy my synced folder and I would have to run the Customfile again to recreate it. As many know, Vagrant isn’t a speed demon during a vagrant up and the additional code of creating multiple synced folders was considerable. Add to that the extra step of creating the symlinks each time, then I was set.

When Pressmatic came on the scene I was already considering dipping my hand into Docker, but was slightly intimidated. Pressmatic made all of that so much simpler. Pressmatic was purchase by Flywheel, rebranded and released as a free tool, Local by Flywheel. OK so the name is kinda blah and the really cool Pressmatic logo is no more, but it works great! Local soon developed an add-on that created shared/synced volumes which pretty much was the same result as my Customfile in VVV. The only problem was I couldn’t find any simple way to re-create my experience of switching to a symlink. Part of the problem was that I was very dissatisfied with amount of time required at provisioning in Vagrant and the thought of having to do this multiple times a day was daunting.

I changed my workflow to use an small app that synced folders in the background. It worked, but was clearly a kludge. Out of curiousity I created a synced folder using the Local by Flywheel Volumes Addon and then changed this folder to a symlink. Instantly I was back in business when using my IDE. The best part was that the symlink persisted through the Local Machine restarts and re-provisioning the individual sites.

Since then I’ve created a bash script to automatically create the symlinks after the Volumes have been added. I can now effectly re-create my normal workflow and even better as in Docker, synced folders seem to be persistent.

I’m sure my understanding of synced folders was probably incorrect and they were persistent all along. I just didn’t see it at the time.

As of this writing both Local by Flywheel and the Volumes addon have been updated several times. The current versions are completely compatible and functional.

This setup may not be for everyone, but I’ve found it allows me to develop locally and continue to use git for version control.

Filed under: code, computer

Medical Staff – Hospital Alignment

I’ve been on staff and practicing at Desert Regional Medical Center for almost 20 years. During that time I have taken ED call for General Surgery and for half of that time for both Trauma and General Surgery. I have noticed many significant changes during that time.
Over the course of the past few decades the practice of hospital medicine has shifted significantly. Initially, ER call was the primary method of increasing your practice and with the payor mix there was never really an issue of either paid call or not having enough physicians taking call. Beginning around 15 years ago the reimbursement for physician services changed dramatically. It soon became obvious that office expenses were ever increasing and reimbursement was ever decreasing. The economics of the private practice physician was quickly becoming economically unfeasible.
Fundamentally the problem arises as many medical staffs, ours included, do not seem to understand the symbiotic relationship between themselves and the hospital. Many have openly expressed that the hospital wouldn’t exist without us. They don’t seem to understand that our livelihood also depends on a strong, viable hospital providing services and infrastructure that we depend upon. Most have no clear understanding of HCAPS scores, quality dashboards, PSI-90, or any other metrics by which hospitals are measured.

Giving Millenials a Bad Rap

As background, DRMC has never had large or even moderate sized physician groups. It has always been an aggregate of individual practitioners with a smattering of small groups. As the economics of medicine has shifted away from the viability of the solo practice towards a group practice, our physicians were set in their ways and seem unable to join together under any sort of meaningful cooperative venture. I believe that much of the current state, both in general and in specific, stems from the medical staff having a sense of entitlement. There are two distinct groups with different reasons for the sense of entitlement. Firstly, millennials, as a group, have a well documented sense of entitlement. This comprises our newer staff members. Secondly, our older, established physicians, seeing their reimbursement decline and their expenses increase believe they too are entitled because for years they supported the hospital and now they feel that the hospital owes them. With decreasing reimbursement there is more competition for patients.

Mercenaries?

Many specialists are holding the hospital hostage in exchange for ED call coverage. We have seen the rapid growth of hospital based physicians filling some of this demand. To these physicians the threat of no longer taking call is thrown at every opportunity to get something they need/want from the hospital.

Can’t Tell the Players Without a Scorecard

I believe the solution, or a solution, lies in the understanding that the economics of medicine has shifted from physicians with outpatient practices who often practiced at the hospital, to

  • outpatient practices who rarely practice at the hospital
  • outpatient practices who need the infrastructure and services of the hospital for their primary practice, and
  • hospitalist based physicians whose primary practice is the care of the emergency department patient and the inpatient.

The first group, those with outpatient practices who rarely practice at the hospital, aren’t the problem. Unfortunately they aren’t the solution either.
The last group, hospitalist based physicians, I believe, comprise the majority of the solution. However, the current economics of solely having a hospital based practice requires non-RVU based compensation in many circumstances. It really doesn’t seem to matter whether this practice is ER, Anesthesia, Radiology, Surgery, Trauma, Hospitalists, Intensivists, or OB Hospitalists. I think the opportunity to create buy-in with these groups is much greater as they clearly have more incentive to assist with hospital administrators and their goals.
The second group, solo or small group specialists, seem to have an unmistakable sense of self importance as they are the ones making all the money for the hospital. Because of this attitude they have little incentive or desire to assist in the overall goals of the hospital. They see the hospital as unable to exist without them.

I’ll Take Door Number…

I believe a hybrid solution is the answer. The administration should commit to a core group of employed physicians who would provide the bulk of the patient care for the ED and the inpatients. Whether these are directly employed physicians or physicians employed under a foundation model will depend entirely on State law and the hospital’s overall model. The traditional RVU based model will not work as the sole method of reimbursement as there are many intangibles, call coverage, physician alignment, etc. that are infinitely easier to accomplish and benefit the hospital more than simply counting RVUs. I refer to HCAHPS and other dashboard and quality metrics that may be difficult, if not impossible, to fully achieve without a motivated, responsive medical staff.
The challenge is with the second group. I believe here the solution may lie in creating service line co-management agreements with these specialists. It is important that membership in these agreements is controlled by the hospital and that there is a clear benefit to being a member and working towards the service line’s goals and objectives. Members could be given benefits, such as preferred scheduling of procedures as one example. Of course those not cooperating for the mutual benefit would loose out.
I understand that this is asking the hospital administration to offset declining physician reimbursement for the opportunity to have a much more engaged and aligned medical staff. I’m not quite sure an easier solution exists. But clearly having an engaged and aligned medical staff is essential to maximize both the quality and profitability of any hospital.
When I first became Chief of Staff, I told our CEO that if I had a problem, I would try to bring a solution as well. I never promised a perfect solution, but hopefully a starting point.
I believe there is a new paradigm in the delivery and practice of medicine and that new paradigm requires a tighter integration between hospitals and their medical staffs.
Any thoughts?

Filed under: medicine

WordCamp Orange County 2016

Below are my slides for WordCamp OC 2016. They are rather generic. When the talk comes out on WordPress TV I will update here to include a link.
BTW, these slides are embedded using my Plugin-A-Palooza third place plugin, Embed PDF Viewer. I think I want a recount. 😉

Contributing To Open Source

or from SpeakerDeck.

Filed under: WordPress