Greek to me

It's that time of year again! (Well, actually, it's never quite the same time of year, but that's part of the fun.) Orthodox Easter is upon us, this time over a month after the rest of Christendom celebrated it. Here's my post from last spring, explaining why the Gregorian and Julian calendars aren't in sync.


Dr. Tony is hosting the thirty-first edition of Grand Rounds. He's presenting the week's best posts from the medical blogosphere, in convenient department format. Not a bad idea, since he's a multi-disciplinary kind of guy, himself. When do we get to hear more about the SWAT team, Doc?

Next week's host is a fellow MD/PhD student, who goes by mudfud.

Wise beyond his years

Now that the hard part of Step II is over, I'm catching up on some magazine reading. This month's Atlantic had a wonderfully sharp piece on the consequences of longevity, by Charles C. Mann. I'd already heard the data on social security taxes, on divorce rates being correlated to lifespan, and even the chilling effect of longevity on career advancement (last year the Boston Globe profiled a 70-something year old lawyer, who was still waiting to take over the family firm from his centenarian father.)

But this Atlantic piece goes farther, predicting more of the strains that arise from a civilization full of elders: They'll be rich and powerful, thanks to lobbyists and compound interest. They'll be disconnected from other generations, having spent only a small fraction of their lives raising children. And their kids! With no hope of rapid career advancement, and no prospect for timely inheritance, more young adults will spend their twenties and thirties bumming around and getting educated (in the future, I guess, everyone will be a mudphud):
From our short-life-expectancy point of view, quasi-adulthood may seem like a period of socially mandated fecklessness—what Leon Kass, the chair of the President's Council on Bioethics, has decried as the coming culture of "protracted youthfulness, hedonism, and sexual license." In Japan, ever in the demographic forefront, as many as one out of three young adults is either unemployed or working part-time, and many are living rent-free with their parents. Masahiro Yamada, a sociologist at Tokyo Gakugei University, has sarcastically dubbed them parasaito shinguru, or "parasite singles." ...

...To Kass, the main cause of this stasis is "the successful pursuit of longer life and better health." Kass's fulminations easily lend themselves to ridicule. Nonetheless, he is in many ways correct. According to Yuji Genda, an economist at Tokyo University, the drifty lives of parasite singles are indeed a by-product of increased longevity, mainly because longer-lived seniors are holding on to their jobs. Japan, with the world's oldest population, has the highest percentage of working senior citizens of any developed nation: one out of three men over sixty-five is still on the job. Everyone in the nation, Genda says, is "tacitly aware" that the old are "blocking the door."

In a world of 200-year-olds "the rate of rise in income and status perhaps for the first hundred years of life will be almost negligible," the crusty maverick economist Kenneth Boulding argued in a prescient article from 1965. "It is the propensity of the old, rich, and powerful to die that gives the young, poor, and powerless hope." (Boulding died in 1993, opening up a position for another crusty maverick economist.)

Kass believes that "human beings, once they have attained the burdensome knowledge of good and bad, should not have access to the tree of life." Accordingly, he has proposed a straightforward way to prevent the problems of youth in a society dominated by the old: "resist the siren song of the conquest of aging and death." Senior citizens, in other words, should let nature take its course once humankind's biblical seventy-year lifespan is up. Unfortunately, this solution is self-canceling, since everyone who agrees with it is eventually eliminated. Opponents, meanwhile, live on and on. Kass, who is sixty-six, has another four years to make his case.

I remember discussing Lucretius' "On Death" in a college philosophy class. We couldn't quite get our heads around the author's conclusion: it's ok to fear the pain of dying, but fearing death itself was irrational, since death was nothingness. One of the eighteen- or nineteen year-olds in the class implored the professor that fearing death made sense, we were young, we had goals, etc. We all wanted to live forever.

Our prof (who couldn't have been more than thirty-five) said we'd get over that, when we were his age. Time may yet prove him right.

Inflammatory Accusations

Sunday's Boston Globe had a nice article on pain management, particularly the historical assumptions and laws behind pain medication. It was particularly timely, given recent arrests and criticisms of pain clinics.
Medically speaking, then, pain has come to be understood not as the character-building crucible of old but as a dangerous medical problem. As a result, doctors have started to look to stronger measures to treat it - including so-called opioid analgesics like morphine and oxycodone (the active ingredient in Oxycontin). According to Portenoy, such drugs are "by far the most reliable and the most powerful analgesics available to humankind."

While morphine was the wonder drug of the 1800s, for most of the 20th century doctors prescribed such drugs sparingly, partly out of addiction concerns and partly from fear of prosecution. In the three decades after the 1914 passage of the Harrison Act, the nation's first drug law, 25,000 doctors were arrested for prescribing opiates.

In the 1970s, however, doctors treating terminal cancer found that their patients were much less likely than had previously been feared to develop an addiction - or even to experience the trademark opiate high. As a result, physicians began to see opioids as a possible treatment for more ordinary types of chronic pain, such as back pain or rheumatoid arthritis. In a highly influential 1986 paper, Portenoy and Foley argued that opioid therapy could be "a safe, salutary, and more humane alternative" to existing treatments for chronic pain. Two other pain specialists, J. David Haddox of Emory University (now an official at Purdue Pharma, maker of Oxycontin) and David E. Weissman of the University of Wisconsin, coined the term "pseudo-addiction" to describe how some patients who displayed what might be seen as addictive behavior were simply trying to treat their pain.

I think most doctors -- particularly emergency physicians -- develop a good sense of who's seeking and who's hurting. I'm not there yet, and tend to err on the side of comfort. It'd be nice to know, though, that I won't be prosecuted for guessing wrong.

Some of the doctors and pain centers that have recently come under fire were prescribing astronomical doses of pain meds. But then again, I've seen a few patients who routinely require four or five fentanyl patches a day -- a dose that'd take my breath away (literally). I'm curious how these trials will turn out.

History of O

There was pleasure & pain in the Boston Globe Ideas section today. In addition to the pain article (above), they ran this stimulating article was about female orgasm:
Even in humans, male-female coitus is an iffy route to female orgasm, Lloyd notes in her book. (She declined to be interviewed for this article.) According to research she cites, only 55 percent of women have orgasms more than half the time during intercourse, while 5 to 10 percent never have them under any circumstances.

The "tremendous variation in the manifestation of the female orgasm," says Richard Wrangham, a professor of anthropology at Harvard, "doesn't seem compatible with an evolutionary history in which it is enormously important..."

...Lloyd likewise dismisses the explicitly feminist theories of Sarah Blaffer Hrdy, professor emeritus of anthropology at the University of California at Davis. Hrdy, who been tinkering with her theories since the late 1970s, believes that the female orgasm evolved to encourage females to mate with numerous men in pursuit of those elusive fireworks. The evolutionary benefits of multiple partners? Not only would women be more likely to conceive, but men would be less likely to kill the resulting infants, since no one would be sure whose child was whose.

I can't afford to comment on this piece. But I will say that author Christopher Shea has touched upon a hot-button subject. If you've ever wondered about the "upsuck theory" or primate proclivities, this is quite an article.

The Gateway to the Madhouse

Madman's got an enlightened post about the pros and cons of Emergency Medicine, from an internist's perspective. Plus, historical context! And then, his own impression:
Overall, I am kind of jealous of these emergency room physicians. I think that we as internists lost a lot when this specialty came into existence. The entire chapter of “presentation” is missing from our clinical experience. “Stabilization”, an art in itself, is too. For me, this is the exciting part of medicine, when the life of the patient is in your hands and the knowledge you’ve labored to learn can really make a difference.

He's given me some grief in the past, so it's nice to see his true feelings finally revealed.

Electric Bugaloo

Step 2 wasn't so bad... I think. Actually, there was a point about seven hours into it where my computer froze -- just for a moment -- and I thought: I really hoped they saved my answers. There's no way I'm taking this again.

What happens during power failures? Are the students asked to come back, and go through the nine-hour exam again? I've heard the 360-odd questions on USMLE tests are drawn from a bank of thousands, so it's unlikely students can take advantage of a repeat administration. But can they really expect students to sit through it, twice?

I wouldn't be surprised. One of the test-takers at my center was a German doctor, who had flown in to take Step 3. That two-day exam is apparently not offered outside the US. It's incredible what they make foreign medical grads go through to practice here.

Controversy lives on

Sadly, KHOU in Texas is reporting that Todd Krampitz has died. Krampitz was a successful young man stricken with cancer, who took unprecedented steps in organ procurement. He started a website and bought billboard space, begging for a liver donor. He received one in short order, from a family moved by his story.

Say what you will about his methods, but he didn't cut ahead in line -- the cadaveric liver was donated from outside the existing organ pool. He recruited at least that one donor, and potentially encouraged many more.

His old website,, is running an obituary and update. Upon his death, Krampitz became an organ donor himself:

All are grateful that Todd left a legacy to wake up America of the need for organ and tissue donation, which saves the lives of others.

His hopes and dreams were to increase organ donation awareness and help others to make the decision to donate. The increased awareness is evident through the overwhelming number of people who have shared their wishes to donate the gift of life. Today, Todd too was able to donate and improve the lives of others through donation.

Julie would like to express sincere thanks and gratitude to the wonderful team at LifeGift, the numerous doctors and nurses, the donor family and all of his friends and family.

In lieu of flowers, the family request that donations be made to LifeGift. LifeGift can be contacted at 1-800-633-6562 or

Interestingly, the director of LifeGift was opposed to Krampitz going outside the system. His prognosis was poor, with or without a new liver -- and soliciting organs seems distasteful and unfair to many. GruntDoc, Rangel and I blogged about Krampitz in August, and the issue came up again in December when a family asked for a kidney on Craigslist.

Choosing organ recipients amidst such shortages has been called "a grim calculus." I can't fault any family in that situation for going public. And though his liver didn't buy him a lot of time, I think Krampitz' efforts will ultimately be seen as beneficial to the cause of donation.

Published errata

Like a tetracycline user who blisters in the sun, the scientific publishing world reveals its putrescence with exposure to the light of day. First there was Slate's damning article on peer review (discussed here). And today, DB relays the story of how pharm companies try to ghost-write manuscripts:
The whistle-blowing article by Dr. Adriane Fugh-Berman recounts how the author was approached to serve as the front author on a manuscript already written by a “medical education company” on behalf of a pharmaceutical company. The manuscript purported to be a review of interactions between warfarin and herbal remedies. The manuscript was provided to Dr. Fugh-Berman in essentially complete form, with her name on the first page as first author... the apparent goal of the manuscript was to disparage warfarin, the drug with which the pharmaceutical company’s new product would compete.

For every whistleblower, who knows how many pharm efforts succeeded? Also, Capsules has thoughts on the rise of pay-for-print -- when journals require authors to pay the printing costs. Often, if the authors can't afford it, their paper doesn't get printed. She wonders about conflicts of interest:
[I]s this really more of a conflict than traditional advertisers pose? I tend to think yes, since we're conditioned to be skeptical about ads, but tend to trust what looks like a well-researched article.

And finally, in what may or may not be a well-researched article, the Onion reports on viscious peer-review process among 10 year-olds:
Panel members said Nogroski's work contained an alarming number of invalidated claims and irrelevant findings. They were particularly disconcerted by the figures in Nogroski's third paragraph, which begins "How do otters survive? Here are some facts about that."

"He didn't even say how they survive," Glass said. "He was just like, 'Otters are about one to 1.2 meters long. Otters' whiskers are about three inches long.'"

"I know!" Swain said. "It's like, 'Hey Mike, how do sea otters survive?' 'Dur. I'm Mike. Sea otters survive by being one meter long.'"

"Hey Mike," LaMott added. "What do sea otters eat? 'Dur, I'm Mike. Sea otters have whiskers that are three inches long. Also, I don't bathe and my jacket is acid-washed.'"

Alas, manuscripts full of illogical ramblings aren't confined to the realm of acid-washed third graders. And if only reviewers were this mature!

I Can See For Miles

I first got into satellite mapping a few years ago, when I got my Handspring Visor GPS receiver and tried geocaching. There was a free program called USAPhotoMaps that took advantage of Microsoft's TerraServer -- with some tinkering I was able to plot my travel routes directly onto the maps.

It was pretty cool, but cumbersome. Now Google's brought satellite imagery to the masses, and by overlaying high arial photos with road maps, they've got a feature that's insanely addictive.

There are at least two metafilter threads (1,2) that talk about the process and point out some sites. And hackers are making inroads: Curbed cites the an innovative tool that combines GoogleMaps and Craigslist rentals, and the sociological implications. And Flickr has a new section for "memory-maps" -- satellite photos with personal annotations. And there's some funny ground-level views (1,2) of what google searches must look like.

But the best of all is a new blog called Google Sightseeing, where readers submit interesting and comment on them. Recent highlights include the 98-acre Boeing factory, the planes caught in-flight, and the "Leucke" signature, easily the world's largest font. My submission is the spewing volcano Kilauea.

No one can tell me yet why my home state looks so dreary. Keyhole has meticulously photographed the state in a different season, or with a different camera, than the surrounding states. It makes Massachusetts look drab and gray, and reminds me a little of this TNG episode, but in reverse.

Though when you look at the Big Dig circa 2003, it does kind of resemble a wasteland.

State of the Union

It's time for the 30th edition of Grand Rounds, hosted at Living the Scientific Life! See the latest and greatest of the medical blogosphere, in a tidy convenient package, conceived this week under particularly difficult conditions.

Go check it out. Next week's host is Dr. Tony.


Kevin MD alerts us to this deal, involving the National Republican Congressional Committee's Physicians' Advisory Board and at least a dozen doctors.

It works like this: You give about $1250 to a certain political party. In turn, they bestow upon you the award, "NRCC Physician of the Year." Then, you make a big deal about your award -- misleading employers and patients into thinking you've earned a unique distinction.

Kos is keeping a list of docs that have cited their "award" in ads and curricula vitae. Some of the commenters say that they, too, were contacted by the NRCC, and were told very explicitly that if they donated, they could use the title.

This is apparently a variation of RNC "Businessman of the Year" awards from years prior. But when patients are misled, it somehow seems more egregious. And, the thing is, I think I'd be completely ok with this, if they simply called it "Physician of the Inner Circle" ... or what about just "World's Greatest Grampa" ? People claim that all the time, and no one seems to mind.

Multiple Gripe Test

These past few weeks I've been studying for USMLE Step II -- the middle installment in the series of board exams needed for licensure. I took Step 1 five years ago and forgot how mind-numbing and trivial it could be. Also, back then, I had a study partner, instead of a blog. This time around, I'm sharing my gripes with you.

The questions on the test are clinical vignettes, where a patient's history, physical, vitals or lab results are presented, and we're asked to guess the diagnosis or appropriate therapy.

It sounds reasonable, except every now and then the vignette has nothing to do with the question, or is utterly superfluous. On these practice tests, you wade through three paragraphs of a case presentation, confusing lab reports, maybe a histology slide, and at the you read: "Which sequelae of strep pharyngitis arises despite antibiotics? Is it rheumatic fever? Glomerulonephritis?"

That's fair, ok, but did I really need to read about the little kid with the sore throat and dark urine? Seriously -- it's bad enough when doctors dehumanize patients, treating them like problems instead of people. But now we're being trained to ignore the clinical vignette, too?

Anyway, this is a big change for me, because it's my first multiple-choice test in which I can draw on real-world experience, along with my book-learnin'. This makes some questions a lot easier, but some actually become harder.

For instance, take a septic knee in a twentysomething with a negative gram stain (please). I think most doctors would empirically give antibiotics for both staph and gonococcus, but apparently for this exam, that would be wrong. You're supposed to go by the demographics and guess it's a gonococcal infection if the patient is under age 40 -- if they're older, you treat it as a staph infection. This shift isn't due to differences in biology, it's just the test-makers' assumptions about philandering. Nice.

I also enjoy these "distracters" that they throw into the practice tests. I guess the theory behind distracters is that they're seductive but wrong, and keep you from recognizing the right answer. For me, though, I actually just get distracted -- some of the fake answers make me wonder, "why haven't I heard of that disease before? What the heck is that?"

My favorite is "Amok", which has appeared as an answer in a few psychiatry questions. Apparently it's an example of a culture-bound syndrome, specifically, Indonesians who abruptly exhibit violent rage, followed by amnesia. I was familiar with the term but never knew it as a clinical entity. Amok may be more common than previously thought, and indeed, with another week cooped up studying, I suppose anything's possible.

After this, it'll be time for the Step II clinical skills exam, which is easy but no less gripeworthy. Izzy is on his way now to take the exam, I'm curious if his opinion will differ from that of any other med student who's taken it...

Thought Process

This got buried in draft-mode for a month, so I'm posting it now before it's completely obsolete. It's a response to Mudfud's question, What's the Deal with Neuromarketing?

Neuromarketing, a marketing research technique that uses brain imaging to assess marketing messages was born at Harvard in the late 1990's when Gerry Zaltman (a marketing professor) began scanning people's brains for corporations. From the corporation's standpoint, neuromarketing allows for more concrete data to be collected that is free from problems that plague other types of marketing research, such as self-reporting biases.

She points to self-appointed public servants who's asking a lot of "what-if" questions: what if neuromarketing changes our habits, worsening our diabetes and oil dependency?

The use of neuromarketing by companies that produce tobacco, alcohol, junk food or fast food could be damaging to public health... Neuromarketing could make [political] propaganda more effective, potentially leading to new totalitarian regimes, civil strife, wars, genocide and countless deaths.

Oh, my. This is not an argument so much as excessive hand-wringing, coupled with a plea for regulation from an authority that doesn't exist.

Are we defenseless against neuromarketing? Of course not -- just as we are not defenseless against rhetoric, flattery, viral marketing, or any other new or old forms of advertising. Awareness of the advertiser's game is the first and most important safeguard in avoiding manipulation.

Mudfud also refers to an article that seemed familiar, when I realized I noted it about 18 months ago.

Montague tried to gauge the appeal of Coke's image, its "brand influence," by repeating the experiment with a small variation: this time, he announced which of the sample tastes were Coke. The outcome was remarkable: almost all the subjects said they preferred Coke. What's more, the brain activity of the subjects was now different. There was also activity in the medial prefrontal cortex, an area of the brain that scientists say governs high-level cognitive powers. Apparently, the subjects were meditating in a more sophisticated way on the taste of Coke, allowing memories and other impressions of the drink -- in a word, its brand -- to shape their preference.
Pepsi, crucially, couldn't achieve the same effect. When Montague reversed the situation, announcing which tastes were of Pepsi, far fewer of the subjects said they preferred Pepsi. Montague was impressed: he had demonstrated, with a fair degree of neuroscientific precision, the special power of Coke's brand to override our taste buds...

The Times article also hints at progress in pinning down "self-identification" -- the coveted "that's me" response that advertisers are looking for when they show a silhoutted iPodder or a speeding Camaro.

But because this research also promises tantalizing clues to understanding consciousness, banning it is the last thing we should be considering. The same features that make fMRI attractive to marketers will make it a valuable tool for cognitive scientists, psychiatrists, and neurologists.

Besides, consumers have always been in an equilibrium with advertisers and hucksters -- some gullible people will fall for anything, while others are impervious to all manipulation. The rest of us just have to hone our critical faculties to weigh the advertiser's pitch with our own needs and desires.

The questions I asked back then still seem to be the pertinent ones: can this research lead to improvements in identifying learning styles? Personality typing? Dealing with phobias? fMRI lie detectors? The potential of this reseach is great. Someday, we might even undertand what goes on in the minds of those who reflexively tried to stop it.


This week's Grand Rounds is hosted by GruntDoc. Go see why he's won all kinds of accolades and awards, and check out the week's best medical posts. Lots of new contributors this week!

Be sure to tune in next week when GrrlScientist hosts.

We're Number One

After twenty-three years of education, I'm getting ready to start a job with some responsibility. One of the pleasant rituals of the employed is apparently a drug screen. My classmates and I have been joking about this for weeks, and I've been diligently avoiding poppy-seed bagels (not a myth!).

Anyway, I decided to make my donation for the cause today. After studying in the morning and watching the Red Sox ring ceremony this afternoon, I called the local testing facility to get hours and directions. I was surprised to learn they closed at four -- I'd have to rush! So I packed up my books, brushed my teeth, relieved myself, and headed out the do--



Damn. Force of habit, I guess.

I checked the clock -- it was 3:15 PM.

I checked the fridge -- two cans of diet Pepsi. Two bottled waters.

I knew what I had to do. The funny thing is, I'd just been reading about psychogenic polydipsia.

Thirty minutes later, I dragged my bloated self into the car and started the drive across town. While circling around, looking for parking, I had that first twinge of fear that I might not make it. It wasn't the only twinge I was feeling -- perhaps I had overcompensated with my earlier imbibing.

Under mounting stress, I found a spot at 3:58 Verizon Time. I gingerly climbed the steps to the testing facilty but, once inside, was surprised to see their clock read 4:05.

"Hi, I'm here for a drug test... It's kind of urgent," I announced to the receptionist.

"You're too late. It's after four. The last samples have already been collected!"

I was staring into the void. "Excuse me," I protested, "but I think your clock is running fast..."

Making herself crystal-clear, she said, "We're done for the day."

After all I'd been through, my plans were down the drain. Gee whiz. I was starting to feel a little pissed off.

I'd be leaving empty-handed, but I decided I'd be leaving empty, as well:

"Can I ... use your restroom?"

Family / Emergency

There's more match-blogging from two surgeons, Aggravated DocSurg and
Cut-to-Cure, who've each pored over the results and make observations on the decline of family practice and rise of the specialties.

Kevin is also hosting a provocative discussion on the future of family practice, which grew out of an earlier post that I commented on, regarding efforts to foster continuity-of-care in medical education.

They're right to speculate about students choosing internal medicine or pediatrics over family medicine. Cut-to-Cure's Dr. Bard-Parker in particular wonders if the lack of fellowship opportunities make Family less attractive -- could students instead choose IM, and delay the decision between primary care or specialization? Very possible.

It also seems to me that Emergency medicine may be picking up some of the med students who, in the past, might've gone into Family practice. EM has the same broad diversity of presentations, but with training for resuscitation and a good number of procedures. (Family has procedures, too, but as Dr. Tony notes, these privileges vary from place to place.)

More from on the EM NRMP match from Louis Binder, in this month's ACEP News:

Emergency medicine was cited by the NRMP as one of the more competitive first-year residency positions, along with dermatology, general surgery, orthopedic surgery, and plastic surgery.

At least 95% of the available positions in these specialties were filled, with 80% or more filled by U.S. seniors, according to the NRMP's 2005 data.

"Emergency medicine is clearly in the growth stage, although at some point, you'll see a saturation of the numbers in medical schools," Louis Binder, M.D., associate residency director at MetroHealth Medical Center in Cleveland and professor of emergency medicine at Case Western Reserve University, told ACEP NEWS. "It's one of the top three competitive residencies."

"Competitive" is a loaded term -- it's hard to measure the aggregate selectivity of these programs, or the qualifications of the students, FMGs, and PGY-1's comprising this July's EM residents. But I think it's clear that EM residency is very desirable now.

"Spring forward" thinking

Via CNN, a familiar twist to an peculiar institution:

Lawmakers crafting energy legislation approved an amendment Wednesday to extend daylight-saving time by two months, having it start on the first Sunday in March and end on the last Sunday in November.

"Extending daylight-saving time makes sense, especially with skyrocketing energy costs," said Rep. Fred Upton, R-Michigan, who along with Rep. Ed Markey, D-Massachusetts, co-sponsored the measure.

It seems appropriate to bring this up again, what with all the new daylight and all. Last year I shed some light on the subject, linking to this site:

...Following the 1973 Arab Oil Embargo, Congress put most of the nation on extended Daylight Saving Time for two years in hopes of saving additional energy. This experiment worked, but Congress did not continue the experiment in 1975 because of opposition -- mostly from the farming states.

In 1974, Daylight Saving Time lasted ten months and lasted for eight months in 1975, rather than the normal six months (then, May to October). The U.S. Department of Transportation -- which has jurisdiction over Daylight Saving Time in the U.S. -- studied the results of the experiment. It concluded:

Daylight Saving Time saves energy. Based on consumption figures for 1974 and 1975, The Department of Transportation says observing Daylight Saving Time in March and April saved the equivalent in energy of 10,000 barrels of oil each day -- a total of 600,000 barrels in each of those two years.

Daylight Saving Time saves lives and prevents traffic injuries. The earlier Daylight Saving Time allowed more people to travel home from work and school in daylight, which is much safer than darkness. And except for the months of November through February, Daylight Saving Time does not increase the morning hazard for those going to school and work.

So, don't just think of it as Daylight Saving. Think of it as life-saving. It'll make those dark winter mornings more bearable.

The energy issue is actually a little discouraging: Since the US uses 20 million barrels a day, extending DST will knock off an underwhelming 0.05% of our oil consumption. Still, attempts at reducing consumption are few and far between these days. It's a step forward.

Just let me know when it starts.

Sentimental Journey

I'm not a big believer in fate, but I do find satisfaction in a narrative that comes full circle. That's how I'm choosing to view the following occurrences:

  • My final medical school elective, on musculoskeletal diseases, involved a weeklong sojourn to the anatomy lab. I haven't smelled those smells, or touched those prosections, since 1998. The same instructor was there, pointing to structures and drilling the students. We've learned so much since then, but, apparently, have forgotten a good deal, as well.

  • Because Match Day was on St. Patrick's Day, the post-Match party and debauchery had to relocate from its traditional Irish pub site. So instead, we got together at a restaurant that seemed familiar... It turns out I had a meal there once with my father, after he'd help me move into my place before med school.

  • helpfully offered to ship my board study books to an apartment I lived in briefly six years ago, and I apparently agreed to the arrangement. Fortunately, the current residents held the package for me, and I got a chance to see what's become of a place that holds a few fond memories. It looks like the eastern wall hasn't caved in yet, which is nice.

    I'm looking forward to more of these little moments, now that I'm on the lookout for them.
  • Trifecta

    Orac is the first, in the annals of blogdom, to complete this hat trick: He's hosted the Skeptics' Circle, Grand Rounds, and now, Tangled Bank.

    Offer him your congrats. And hey, somebody start up a new weekly science roundup for him to host! (my suggestion: Carnival of the Colonoscopists).

    Orac's theme (as usual) is original -- he's fashioned the Tangled Bank roundup of science posts as a letter to a journal editor from a disgruntled manuscript author. Check it out.

    UPDATE Ann's Fuse Box has spearheaded the challenge and is going to maintain a frequently-updated Carnival of the Carnivals. At last! The power of Grand Rounds -- with its collected writings of doctors, nurses, and health professionals -- is now presented alongside pictures of cats.

    Peer review, reviewed

    Daniel Engber of Slate has some opinions on the future of peer-review for journal articles. Given the shoddy work that sometimes passes through peer review, he recommends a sea-change in the way we look at new scientific results:

    Paul Ginsparg, who runs a digital archive for unpublished physics papers, has suggested that putting "preprints" of scientific papers on the Web could let the community as a whole decide which papers are most useful. Unpublished work could be tracked by an objective measure—like how often it's cited or downloaded—and then passed along for formal publication. Government funders like the NIH could hire professional reviewers to evaluate grants, or they could replace grants with cash prizes for successful research.

    What I find most striking is that people have been studying whether peer-review of submitted manuscripts actually improves the quality of science. It turns out, it's not so easy to prove:

    The study of peer review turns out to be tremendously difficult. To test whether it works, you'd need to compare the quality of papers that had gone through peer review with the quality of those that hadn't. But how would you get papers for the control group, given all the professional benefits that come with peer review? And assuming you could convince scientists to forgo the process, how could you objectively judge the quality of the papers? At Rennie's fifth congress this year in Chicago, several hundred studies will be presented, but no one will claim to have answered the big question: Does peer review work?

    (It reminds me of the difficulty in producing evidence for evidence-based medicine.)

    The article doesn't dwell on it too much, but peer review faces at least one structural problem: expertise is getting narrower and narrower. If you submit a your latest methods paper to a small, field-specific journal, chances are good the editors will farm out the review to someone you know. They may even run a lab in competition with yours.

    I've heard stories about five-page manuscripts that come back covered with red ink, and ten pages of typed comments on why the authors' methods are flawed, their results dubious, and their conclusions irresponsible. I've also seen manuscripts returned with nary a stray red mark.

    This point was driven home to me during a graduate school class, in which a professor showed the beginning of a recent "anonymous review" on an overhead transparency. It went something like this:

    "The authors of this groundbreaking manuscript have a long history of innovation in this field."

    The professor blushed, and wrote:

    TRANSLATION: "Hey, buddy! The journal sent us one of your papers to review again! How's it going?"

    I'm still not sure how bad the problem is. Maybe these anecdotes aren't representative. And journals do take steps to prevent pettiness or chuminess from influencing the review process. Also, all the reviewers I've known take their role very seriously (except, of course, when we were poking fun at the egregious mistakes of some submitters. Ah, memories).

    Who knows -- maybe Ginsparg and Engber are on to something, and in the future, all submissions will go straight to the web, where an army of scientist-bloggers stand ready to critique and praise (and copy?). This is a format that has some precedent -- like open-source coding, or those websites where musicians encourage remixes of their songs.

    Science as it's practiced now would look pretty different. The emphasis would shift from blockbuster papers nurtured in secrecy, to discrete chunks of cross-referenced data, dribbled out piecemeal. Writers and reviewers alike would save time, leaving them to do what they love most. But it's still an open question how grants would be awarded under this scheme, and indeed, if it even drives knowledge forward, faster.

    Emergent Phenomenon

    Dr. Louis Binder has compiled his annual emergency medicine match statistics. It's currently available on

    1. Emergency Medicine experienced an increase of 37 entry level positions in the 2005 Match over 2004 Match numbers (a 2.9% increase), occurring from a combination of quota increases occurring in EM 1-3 and 1-4 programs, and three new programs in the EM match. Emergency Medicine now comprises 5.5 percent of the total NRMP positions and 8.4% of matched US seniors (both all time highs).

    2. The overall demand for EM entry level positions increased substantially, from 52 additional US graduates ranking only EM programs to 113 more US graduates and 182 more total applicants ranking at least 1 EM program in 2005, after similar levels of growth of the applicant pool in 2004. The majority of this increase came from US seniors who ranked EM programs. This growth in demand for EM positions far exceeded the increase in supply of positions. The excess applicant demand over and above the size of the training base is 48 to 356 applicants (4% to 27% surplus), depending on how the parameters of the applicant pool are determined.

    More programs (now 132), with more spots at existing programs, but still the demand for emergency is outstripping the supply. Of all incoming spots at all residency programs, 5.5% are now EM, and 8.4% of US senior med students matched into emergency medicine. That's 991 of us this year.

    It's hard to pin down why these shifts occur, why some specialties prosper as others fade. Some would argue economics dictate everything -- students go where they'll be well-compensated, where the hours are benign, etc.

    I'm not denying it plays a role. But I think most students are insightful enough about themselves and their path to place too much importance on these considerations.

    Because the latter half of med school is essentially just auditions in various specialties, we can see how we fit in these different settings -- get to know potential colleagues, get a feel for the challenges and demands of each field.

    It was suggested to me, early on, that the decision to specialize isn't made by cool calculations of pros and cons, or financial benefits. Instead, through sampling the third year clerkships, we simply choose the field where we met the most inspiring doctors, saw the most incredible patients, and had the most fun.

    And now, medical schools are offering better clerkship experiences in emergency medicine, with more mentorship opportunities. Academic EM is coming into its own. And, given the proper exposure, more of us are concluding it's the best field to be in.

    Astonishing Tales

    Scott at is hosting this week's Grand Rounds. Go check out the latest and greatest medical posts from bloggers 'round the world. And be sure to take the super hero (and villain) quiz.

    Polite Dissent has pretty much cornered the market in medical interpretation of comic book storylines. If you've ever been curious about what a transfusion from Superman would be like, this is the site to browse.

    Tune in next week, when Grand Rounds returns to Grunt Doc. Other upcoming editions are listed here, amongst the archives.

    Informed Commentary

    Hey! National Blog Comment Week has come and gone -- though the news may not have filtered down to my readers.

    One blog that is getting a bajillion comments is the ever-provocative CodeBlueBlog. His last Schiavo post has over 300 responses. The level of discouse is actually started quite high, too -- there was discussion about the criteria for diagnosing persistent vegetative state, the duties of radiologists vs. neurologists, etc, before it degenerated into a free-for-all about the husband's motivations, the judge's missteps, and the blogger's undisclosed past.

    Alas... having comments enabled is a two-way street. I mean, it's usually a thrill to hear what readers think, and to see that I've made some connection across the ether. And it's a little disappointing when a post doesn't click with anyone (though I take comfort in speculating that, were I to blog about my social life, I could quickly accumulate an avalanche of feedback).

    But to have your posts misinterpreted, or have your site used as a soapbox for those with an agenda, must be the worst outcome. Still, I think it's a worth it for medical blogs to allow public feedback. It's one way to avoid the perceived isolation and underaccountability of the mainstream media. It keeps us on our toes. And it lets us survey the audience in a way sitemeter cannot.

    One of CBB's early comments in this thread explains his motivation for the CT scan challenge, and his CSI series:

    One reason [CBB blogs] is because of the total horror I experience every time I read medical "news" in the MSM [mainstream media]. They always get it wrong. They never ask the right questions. YOU ARE ALWAYS IN THE DARK.

    Why is that? Because those reporting the news (and managing your health care) have little regard for your intelligence. It is believed that the average American is so dumb that he or she cannot possibly manage this information -- so WE have to do it for you. And WE are leading YOU and the AMERICAN HEALTH CARE SYSTEM to the slaughterhouse on the way.

    I am trying to WAKE YOU UP before you get there.

    I bring this up every now and then, mostly because I'm not satisfied with the options. I'm sure the problem isn't simply, "the reporters have a disregard for the public's intelligence." There is a little dumbing down. But there's also a big discrepancy between the background education of the reporters covering medical stories, and some of us reading and critiquing them. Even the Columbia School of Journalism has acknowledged this gap and is taking steps to address it.

    It's clearly important to give expert-journalists complete access in misreported issues like riot control deaths, and arguably important for cases like Terri Schiavo's. Yet even if every reporter had an MD, what's disclosed by various sources is still up to the patient's (and doctor's) discretion. And there are perfectly good reasons to keep some tests and procedures private: it may make the patient or doctors look bad, or maybe the public just won't understand.

    Don't get me wrong, I'll never underestimate how quickly a "lay" audience can get up to speed on complex issues. Recently, for instance, a nonmedical friend of mine was in the hospital for choledocholithiasis, and within short order he was asking me questions about ERCP that I need to look up to properly answer.

    Perhaps we should distinguish between lay readers, and the casual readers who just browse headlines and RSS blurbs before forming an opinion and spouting off. I think it's these casual readers that patients and privacy advocates worry about. And maybe they're right to do so.

    When I last brought this up, I quoted a CBB post, and tackled some of the issues he raised about privacy, access, and news micromanagement. Then, a commenter skimmed the quotes, saw some famous names used as examples, and ignorantly accused me of despicable gossiping about celebrities.

    Maybe I need to write (and blockquote) more clearly. Or maybe casual readers aren't ready for unfettered medical blogging.


    Over the weekend, reported a story about a blind student, Tim Cordes, who's about to earn his M.D.:

    Without sight, Cordes had to learn how to identify clusters of spaghetti-thin nerves and vessels in cadavers, study X-rays, read EKGs and patient charts, examine slides showing slices of the brain, diagnose rashes -- and more.

    He used a variety of special tools, including raised line drawings, a computer that simultaneously reads into his earpiece whatever he types, a visual describer, a portable printer that allowed him to write notes for patient charts, and a device called an Optacon that has a small camera with vibrating pins that help his fingers feel images.

    The article says he's got "Leber's Disease" -- I thought at first that meant Leber's Hereditary Optic Neuropathy, the mitochondrial DNA disorder. But his symptoms and onset would be atypical (diagnosed at 5 months, completely blind by 16 -- LHON tends to hit in the twenties, and usually spares some peripheral vision.) Browsing pubmed, I learned about Leber's Congenital Amaurosis, which is even rarer, with potentially systemic problems.

    This is a remarkable accomplishment, yet Cordes seems really modest and down-to-earth about it all. There are other reports about blind doctors practicing, but Cordes is different because his disease struck before medical school. Even with the tools mentioned above, and other details from the article, I can't really imagine how he experienced third and fourth year. Even with sight, I often felt like I went through clerkships flying blind.

    The article leaves me to surmise that he's going into research -- there's no talk of residency, and he's finishing up his PhD work after he gets the MD. If he doesn't practice, it would be a loss -- he could have inspired a lot of patients.

    Update: in Kevin's comments on this story, a litany of living blind practioners is presented. Written by a former classmate of a blind med student. I love blogs.

    Collective efforts

    Last year at this time, Google debuted GMail, and many thought it was a prank, too good to be true. This year they're rolling out Google Gulp (with AutoDrink), and removing all doubt.

    I'd like to participate in this kind of chicanery, but for the second April First in a row, I'm away from home and unable to put in the effort to craft a good prank. Maybe next year, as an intern! For the record, this year's hastily sketched-out plan was to liberalize the definition of online medical writing, with the goal of making this explosive blog the permanent host of Grand Rounds.

    Speaking of fun, far-reaching medi-blogger collaboratives, check out the traveling story over at Dr. Charles: Seven creative bloggers, two intertwined medical lives, and one harrowing and hilarious night in the emergency department.