Blogborygmi

Eponymous

2012-01-10T11:30:00.000-05:00

I love being at an academic institution for many reasons. One of which is that the residents keep me on my toes -- they've read the latest stuff, they want justification for proposed workups and treatment plans, and...

....they've got the sharpest grammar?

Yep. I can only imagine the patients watching us in the ED -- when we're not hunched over our keyboards, charting, reviewing and ordering, we can be seen gesticulating wildly about things like the placement of apostrophes in eponymous diseases.

For instance, can you pick what's proper, below?

Down Syndrome or Down's syndrome

Legionnaire disease or Legionnaires' disease

The rule I've always heard is: if the disease is named for a patient, it deserves an apostrophe. If the disease is named for its discoverer, the apostrophe is inappropriate. Lou Gehrig's disease was his, and the Legionnaires had theirs, but Down didn't own his syndrome. More here.

The most consistently misattributed apostrophe, I think, belongs to Crohn -- though that's slowly changing, too. We'll leave for another time the discussion of proper possessive apostrophe usage when a name ends in s (Legionnaires' or Legionnaires's), perhaps until agreement can be reached the Chicago Manual of Style and AP Style.

I just want to highlight the body of work of Tsung O. Cheng, who has been writing about eponymous diseases and the inappropriateness of apostrophes for fifteen years -- including how to handle the situation when the discoverer of the condition is also a patient.

While Dr. Cheng is Professor of Medicine and has been a prolific author, churning out 10 medline-indexed publications on this trivial topic means either medical grammar is an exciting and contentious field for potential scholarship -- or that our system of academic promotion and peer review is kind of messed up.

So, I humbly suggest: Deciding on whether to devote one's energies to adding lines on one's CV, or actually trying to contribute to the body of knowledge in medicine, shall henceforth be known as Genes' dilemma.

An inflammatory condition

2012-01-06T11:24:00.000-05:00

I've noticed more patients complain of gout recently -- maybe it's a sign the economy is improving (gout has long been considered a disease of excess).

As I discovered while revising Rosen's new chapter on arthritis emergencies, the price of colchicine, an ancient gout treatment, has gone way up lately -- while suggested regimens for treating gout have recently changed. These are not unrelated, and the connection is actually quite interesting. You see, colchicine was grandfathered-in as an approved therapy by the FDA at its inception in 1938. Its safety and efficacy were never formally reviewed by the FDA...

...until 2009, when URL Pharma submitted the results of their new trial to the FDA, showing comparable efficacy and somewhat improved safety to high-dose colchicine regimens, using a simple 1.2 mg dose followed by a 0.6 mg chaser an hour later.

The FDA, bound by Hatch-Waxman exclusivity, considered this a new indication for colchicine, and responded by granting 3 years of market exclusivity to URL Pharma. The price of colchicine (now called Colcrys) subsequently shot up from 9 cents a pill to $4.85 -- though if you read the drug company's site, they make it sound like they're doing patients a favor, protecting them from unapproved forms of the drug that worked well enough, for decades.

I appreciate the way the authors of this NEJM opinion piece considered this state of affairs:

It seems reasonable to expect that costly new drugs or increases in drug prices would be accompanied by a substantial benefit in disease management to be enjoyed by these patients. This standard is not met by Colcrys; in this instance, the public may bear considerable costs for a poorly executed administrative goal.

Yep. A few US Senators sent URL Pharma a strongly-worded letter this past spring, but I don't think anything came of it (you can't say the company's done anything illegal, and our society is well past the point where we can expect corporations to act in any interest but their own).

I'll just be interested to see what happens in August 2012, when the 3-year exclusivity period should end and colchicine prices return to, hopefully, to a less painful place.

A few more iOS 5 considerations, for EM

2012-01-03T08:00:00.000-05:00

I've been using my iPad in the ED, with my white coat's sewn-in iPad-sized pocket, for some time now -- mostly for patient and resident education, and to look up dosages or rashes. Hitting up my Evernote database or Dropbox documents is also useful. Occasionally I'll use my iPhone, for its LED light (when the otoscope can't reach to where I need to see) or rarely, its camera (in compliance with my hospital and department photo policy, naturally).

Our ED's EHR isn't quite accessible enough via iPad for me to quickly check results or place orders at the bedside -- right now it's just too cumbersome. But there's been progress -- enough so that I start to wonder about the flip side: instead of reviewing iOS medical apps and pining for an optimized EHR experience on the iPad, what if there are features of the iPad that could limit the utility of medical apps?

Well, there are some product design issues, like impact resistance and bacterial colonization, that have been discussed. But the operating system, iOS 5, has some quirks, too. Some have received a lot of attention. Some are maddening in their capriciousness.

But if you're an administrator, or an app developer, working on healthcare apps for folks with iPads, there's got to at least a few special considerations on your plate that you've never had to worry about, before (beyond the whole portrait/landscape issue). I've listed a few that seem novel to me, below:

1. Photostream, and iCloud. The other day, a colleague asked me to take a picture of an area behind her ear, to see how a lesion was healing. The next day, when I was home, polishing charts and playing tunes, my Apple TV's screensaver activated, and I found myself staring at my friend's ear, blown up to alarming proportions. My iPhone had sent the pic to the cloud, where iTunes found it and shared it with my set top box.

This is a separate issue from security, which I think Apple's iOS handles well enough. iPads can be locked and remotely wiped of data, if stolen. Facetime is HIPAA-compliant. But photostreaming is something that happens quietly, behind the scenes, and without much fanfare, until that pic your patient consented to is suddenly shared on all your devices and the cloud. Oh well -- hopefully your consent form has this possibility baked-in. And fortunately, Apple's finally made it possible to delete individual images from one's photostream.

2. My iPad knows when I'm sleeping. When I first pick it up after it's been laying dormant for a while, all the alerts and notifications that have been building up come tumbling out. In other words, iOS 5 is smart enough to know not to fire alerts when it's been off for hours and hasn't moved, and to let them build up and fire when I'm good and ready for them.

This is especially noteworthy, given my erratic sleep schedule.

I'm sometimes tempted to just pick up my iPad abruptly and unpredictably, hoping to catch it in the act of updating a Newsstand subscription or wireless sync. But if I've ever interrupted it, the iPad's never complained with any sluggishness or warnings.

It's a smart feature, but in healthcare there are some warnings that need to break through. And as iOS gradually replaces pagers and other communications systems, there are a few sleeping doctors that will need to be woken up -- instead of letting all alerts wait until the iPad's on.

3. Where's Save? When you've written a note in most iOS apps, it's just done. Automatically, quietly saved. In fact, it wasn't until I used the new Gmail app for iPad that I realized how incongruous the classic "Save" disk button looks in iOS.

But when you've finished a long draft in, say, Papers, and want to move on, it's a little unsettling to assume everything "just works" and your efforts are saved and retrievable. I've been burned too many times, in the past few decades. And frankly I think most of my colleagues would be paralyzed with fear if they'd written a patient note and there's no clunky, inelegant way to mark it as saved.

Hopefully this is only a problem we dinosaurs from the 80s will have to deal with. Perhaps we could get used to Apple's elegant solution, and maybe younger users will never feel weird about relying on the OS to act responsibly. But so long as developers like Google keep offering Save buttons, the iOS paradigm won't fully catch on (and a part of me will be relieved to click Save).

I've highlighted a few (relatively minor) quirks that may drive administrators, or users, crazy. There are undoubtedly others. Apple's innovations with tablets and iOS have led to great consumer products. But compromising for business uses has never been their strong suit. Getting these devices into hospitals, where they can make a big difference, will unfortunately require either administrators to be flexible and creative, or Apple to compromise. Immovable object, meet immovable force.

The most productive time of the year

2011-12-30T17:27:00.000-05:00

For years I noticed a burst of productivity around the holidays. stuff that had been hanging over my head for months would suddenly get done. New ideas would suddenly pop into my head.

I attributed it to things like the psychology of the calendar, or just having fewer emails to answer, or more unstructured time... But the recipe is simple:

Eat well. Sleep well. Stay connected to loved ones. Get some exercise.

That's it. That's all it really takes to complete projects, tackle nebulous fears, and poke the box.

Deck the halls (with questionable statistics)

2011-12-15T19:28:00.000-05:00

Today's ACEP Member Communication email (entitled Emergency Medicine Today, in affiliation with BulletinHealthcare) had this as its top story: Injuries Linked to Holiday Decorating on the Rise, from a website called HealthDay News. The reported cites a US Consumer Product Safety Commission press release, crafted with help from Underwriter Laboratories (the wire engineers). They claim:

In November and December 2010, more than 13,000 people were treated in U.S. emergency departments for injuries involving holiday decorations, up from 10,000 in 2007, and 12,000 in 2008 and 2009, according to the U.S. Consumer Product Safety Commission (CPSC).

"A well-watered tree, carefully placed candles, and carefully checked holiday light sets will help prevent the joy of the holidays from turning into a trip to the emergency room or the loss of your home," said CPSC chairman Inez Tenenbaum in an agency news release.

Good advice. Though it's been said many times, many ways. So when it came time for CPSC and UL to raise the topic, did we need the very questionable statistics to justify it?

If you're having trouble wrapping your head around the number of decoration-related emergency department visits, consider this similarly bizarre statistic: 8000-10,000 kids are injured each year from falling televisions. So, for perspective: in the November to December period, Americans now endure more holiday-decoration-related trauma than an entire year's worth of falling TVs (though, now that I think about it, there may be some overlap, like if while putting up some Christmas lights, Dad knocks over the TV and it lands on Junior's foot -- that could be one ED visit logged in both categories.)

Another way to think about it -- 13,000 visits over two months spread over the approximately 1800 EDs in the US translates to about seven (7) holiday-decoration-related visits per ED. Not much, when the average department sees 5000+ patients a month (and Americans visit the ED 130 million times a year). I'm not even sure it's significantly more than it was a few years ago, when EDs could expect -- get ready for it -- six (6) visits related to holiday decorating.

Still, I've yet to see my first misletoe-hanging trauma. I have seen more than my share of frankincense and/or angel dust intoxication lately, but I don't think that counts as a decoration-related ED visit.

In fact, I handle a lot of statistics and analysis for our ED, and I could not tell you how many holiday decoration injuries we've seen this year, or last. To really do it right (ie, publication-quality data that could stand up to peer review or joint commission scrutiny) we'd have to build a query to retrospectively through the text of all patient notes, looking for mentions of menorah fires or tree-felling injuries, then do a chart review. Or we could code a checkbox and ask our triage nurses to prospectively screen for this, along with suicidality, domestic violence, and HIV.

Probably what CPSC is doing, instead, is drawing from a few statewide databases or surveys like NHAMCS and generalizing broadly (certainly, there are no scholarly papers on holiday decoration emergencies -- the literature on falling TVs is much more robust).

Survey data is fine for identifying new threats to the population, or changes in abuse patterns, but it's hardly precise and when I see dozens of headlines about the rise in ED visits from holiday injuries (Google news counts 291 stories at the time of this writing) it makes me cringe. If next year's holiday decoration visits fall back down to 10,000, does that mean we've turned a corner on educating the public about the menace of holiday decorations? And so we won't need to be so vigilant anymore? Or is it just a statistical blip, well within the margin of error, not at all worthy of a headline?

And on that note, I must break off to do some holiday-related shopping, confident (but somewhat disturbed) in the knowledge I've now spent more time mulling this over than anyone involved in writing or selecting that press release for inclusion in ACEP's daily email.

Without a trace

2011-12-05T14:09:00.000-05:00

Heard about an old friend, sharing the stage with Billy Squier at our high school's send-off event (as another alum of some distinction noted, the building is being demolished).

Their performances got me thinking of a lot of the songs we practiced, growing up. And while I did say recently that music is "done" from the perspective that we can hear pretty much any song we'd ever want to hear, on demand, anywhere, the truth is there are some songs that seem lost to time.

If Google can't find a tune, does it really exist? There was some truly strange songs, burned into my head from repetition in middle school orchestra. From time to time, the tune or lyrics pop into my head -- but when I try to pin down that song -- Google's got nothing.

For instance, there was a whole awkward teen coming-of-age musical we put on. I think it was actually called Coming of Age. Songs included, "If I Had A Friend," "On the Outside, Looking In" and "Broken Home on the Range."

I want to know, were other middle schools forced to perform this, as well? Who wrote these songs? I'm not saying I'd be a fan, but I'm driven by a little nostalgia, plus the same kind of curiosity, I think, that drives people to hear Wesley Willis works.

Another example is a musical about singing troubadours -- this is the only reference I can find online. We praticed these songs on professional-looking sheet music, learning them by heart, just a few decades ago. Yet no trace of these songs seems to have made it into the digital era.

I suppose as every bit of trivia and ephemera from our lives makes its way onto the web, and we come to accept that no new experience will go undocumented, these last few holdouts will rankle, out of proportion to their significance.

Powered on

2011-12-02T06:58:00.001-05:00

Sometimes, the blogosphere just decides they're going to discuss something in great detail. And now, with holiday travel upon us, we're talking about the inane rules that airlines inflict upon passengers -- especially the "turn off all electronic items that have off switches" rule at the beginning and end of flights.

This past summer, when the IATA issued a largely anecdotal report on a few dozen incidents with no real bad outcome (spanning a period covering millions of flights), I thought the time for discussion was ripe, and compared some of the rituals of aviation to similar maddening rituals in healthcare.

But now James Fallows is covering the topic, and has terrific input from a diverse and smart audience (it helps that he's a pilot, himself, and a terrific writer). Read it all -- just not during takeoff or landing.

Built for speed

2011-12-01T13:07:00.000-05:00

I had a couple of slow shifts in the emergency department recently, around Thanksgiving. And it made me think of Nomar Garciaparra, the old Red Sox shortstop.

Nomar always had to throw off-balance, while running and jumping. You can see his style on display when throwing the ceremonial first pitch at Fenway last year.

In an interview (can't find the reference, sorry) he said he always had to throw this frenzied manner, even for an easy grounder where he'd normally have time to collect himself. If he paused too long to think about it, the throw would come off badly, he said.

I always thought this was a psychological issue -- dubbed "Steve Sax Syndrome" by some.

But on those slow holiday ED shifts, I think it's just a good habit. When you're used to functioning well at a fast pace, slowing it down doesn't necessarily make you any better. Our ED's workflows, our data collection, and our decision-making, all all calibrated to work at a certain speed. Slowing it down sometimes lets us unearth a valuable piece of information -- but more often, it just pushes the signal-to-noise ratio toward more noise.

And hey, it's not like Nomar's quirk kept him from having a stellar career.

FDA: Food & Drug (& App?) Administration

2011-11-30T12:16:00.000-05:00

We've been considering FDA oversight of medical apps for a while, over at Medgadget.com. Now, the public comment period has concluded on the FDA's draft of how this oversight might look. The story:

The FDA will scrutinize medical apps that act as an accessory to a medical device and those that transform the mobile device into a medical device. A draft guidance issued by the FDA includes an extensive list of applications that will have to undergo review. Examples of apps that fall under the regulatory oversight are:

* Applications that allow the user to view medical images, such as digital mammography or digital images of potentially cancerous lesions on a mobile platform, and those that perform a health analysis or provide a diagnosis by trained health care professionals.

* Applications that allow the user to view patient-specific lab results.

* Applications that connect to a home use diagnostic medical device to collect historical data, or to receive, transmit, store, analyze, and display measurements from connected devices.

Great, right? The apps that do heavy lifting of patient information and connect to real medical devices get regulated, but the fun and educational apps I am working on remain free and open. Still, Harvey Castro, my favorite EM-doc-and-app-developer, was worried:

“Overall, I believe safety is the most important item when it comes to providing patient care,” said Harvey Castro, MD, an app developer (www.deeppocketseries.com) and emergency physician. “Unfortunately, I believe this will hurt small businesses and entrepreneurs by making it cost-prohibitive to enter the market.”

“Applications will be dominated by a few companies capable of paying the high fees to get FDA approval. I will be saddened to see these changes in the future.”

For their part, the FDA said it's nothing to worry about:

...the FDA said the regulatory requirements will not impede the advancement of medical apps. “We are eager to support the continued development of mobile medical apps without the burdensome regulations that would stifle innovation,” the spokesperson said.

I've perused the FDA's draft and still have a lot of questions. What if I install an app from a non-American app store -- could I still use it on American patients? What are the penalties for apps that should have been submitted for FDA review, but weren't? Will there be a grandfathering status, like with pre-1930's drugs? Will educational app makers have to submit a form asking for FDA exemptions?

The biggest question: will the FDA heed the recent IOM recommendation that another (non-FDA) government agency take up the regulation of EHR vendors? What if Congress fails to create such a body (I have a hard time imagining, in this political environment, how funding for creating a new regulatory agency would transpire). What if the FDA is the only agency that can expand its mandate? Wouldn't it act? Why should FDA expand to medical apps but not EHR?

The FDA has a proud and progressive tradition; the laws underlying its authority were passed in response to public outcry regarding food and vaccine preparation, and misleading labeling. There were big problems, improved by the FDA. Even now, critics argue the FDA doesn't go far enough -- approving medical devices later found to be flawed, and recalled.

So I don't understand this push into an area where they have no clear mandate, and where there's no public pressure (yet?) to intervene. Don't get me wrong -- I'm not opposed to the idea of med app oversight, someday. There's no doubt that would be good for Americans. I do worry, though, that by moving in to the medical apps realm before most people have ever used them, and before a bad outcome has even been encountered -- or learned from -- is premature. Though the FDA says they don't want to stifle innovation, I can't imagine that, with their current budget, their fees and regulations can be anything other than a significant hurdle for developers.

Grand rounds 8.11 call for submissions

2011-11-29T09:48:00.000-05:00

Many thanks to AfternoonNapper for hosting this week's edition of Grand Rounds.

Next week, I host Grand Rounds... but not here! It'll be over at my new Tumblr blog.

Want to be a part of it? Please mail me at nick -at- blogborygmi.com with the subject Grand Rounds, along with a URL link of your submission and a brief excerpt. Photos are also welcome!

Submissions are due by 11:59PM, Sunday December 4 (Eastern US time). Then, head over to blogborygmi.tumblr.com on the morning of December 6 for the first Tumbl’d Grand Rounds.

Thoughts on tumblr

2011-11-28T11:00:00.000-05:00

Remember how people said there was no real need for a device category between smartphones and laptops? And then Apple sold 40 million iPads?

That's kind of how I felt about Tumblr.

Blogs are obviously great for musings, essays, and a web presence, and Twitter's fine for thoughts and links and pics. Why have something else, in between?

I don't really have a good answer, just like I can't fully articulate why the iPad experience is so much better than a laptop or smartphone. But I'm starting to see the appeal of Tumblr.

Beyond the usual accolades from early adopters / influencers, something that stayed with me was a quote from Tumblr's founder: "No one is proud of their identity on Facebook."

Very true. And true of a Twitter page, as well. But Tumblr sites... can be something to be proud of. And they're effortlessly fast to set up. While I have strong sentimental attachment to this site, Blogger's recent attempts to make themselves slick feel like so much else Google does these days -- uninspired, clunkier copies.

I've been looking for a way to breathe new life into the 8+ years of writing here. Tumblr's "random" button and their vibrant archive views are a great start. When you consider how easy is is on Tumblr to tag old posts, and how elegantly you can display redirect pages for tagged posts (or photos, or music) and offsite material in the sidebar, well, I was sold.

Then, of course, I had some buyer's remorse. Tumblr is unapologetically different from other social networks. It took me a while to even realize that their "dashboard" is nothing like Blogger's, and in fact more like Facebook's news feed. And it's taking me some time to get comfortable with "reblogging" which almost seems like effortless plagiarism, if you're not conscientious about citations.

Tumblr's search function is completely broken. I have to believe they're working on a fix, but probably making a point of taking their time -- as if to say we're living in a post-Google age.

While I lamented Tumblr's decision to stop importing RSS feeds a few months back, I see the wisdom. I would have gone to town with importing thousands of tweets and countless photos, on top of all these blog posts. As it is, it's still possible to reintroduce old content -- it just takes a little more effort. Just enough to tip content generation in Tumblr's favor, rather than using it as a lifestream repository like Evernote or Friendfeed.

Still, it was fun to watch people throw some hearts at some old photos I uploaded, and I didn't mind the occasional reblog. And really, Tumblr's too good-looking to fill it with a bunch of text links to tweets (maybe someday we'll have something like Postano's yolink feature, to fetch images and content from those links, along with the tweet).

Twitter will always remain to go-to choice for conversations and conferences, and I think Blogger will still be my first option for sit-down-and-think kind of writing. But for now when I'm browsing and come across something interesting, I'm just going to try Tumbling first. And I'll be watching to see what new tools come online, as Tumblr grows to become the next great social network.

Medscape EM year in review

2011-11-25T09:31:00.000-05:00

Medscape's EM editor asked Amal Mattu, Robert Glatter and me to discuss 2011's important papers in emergency medicine. I felt compelled to include an all-around terrible (but still important) paper, and a tidy nice decision-support paper for discharge prescriptions, among others. See what you think about my picks, as well as the great selections from Drs. Mattu and Glatter.

Thoughts on a reading, sharing & archiving solution

2011-11-21T09:33:00.000-05:00

Music's pretty much done, right? It's fairly easy to hear any song you've ever liked, anywhere you happen to be. As a bonus, those songs can be stored, shared, tagged, rated, and linked to lyrics and album art.

Movies and TV... their delivery is not quite perfected, but the general outline seems apparent. Already I can watch the WKRP Turkey Drop episode in the kitchen on my iPad's Hulu app, and mirror it to my TV (via Apple's set top box) when I'm ready to sit on the couch. Other shows or films require more effort, though the combination of Netflix, iTunes, and for the remainder, torrents plus the Air Video server app, make it easy enough.

But reading? The written word, for whatever reason, still lags behind. While strides have been made, a simple and universal, Apple-like solution to the problem of reading, sharing and archiving remains elusive.

It seemed for a while that RSS was going to solve reading, but despite this, for a while, I resisted the call of RSS aggregators. I wanted to experience sites as the bloggers wanted them laid out -- if it was just uniformly presented text, I feared I'd lose some of the author's personality and voice. I had a hierarchy of bookmarks that I perused.

But I found, even with Grand Rounds, that I was missing out on new voices. Using bookmarks to visit older blogs that were sputtering out was frustrating. Messing with my bookmarks was not as simple as adding or rearranging RSS feeds. And so, at some point in 2006, I made the leap to Google Reader.

And for a while, things were great... I could efficiently consume the blogosphere, as never before. Until I came to regard catching up with RSS feeds as a chore.

So I muddled along, using a combination of bookmarks, Google Reader, and increasingly, Twitter feeds, to keep up with old friends and new sources. Good stuff I came across was starred, or retweeted, or bookmarked, or cut and pasted into ~~Google Notebook~~ Evernote for future reference. Or Instapaper'd. Or posted to Facebook. At one point set up FriendFeed to aggregate all my commenting activity, but it was no way to absorb new information.

Then the iPad came along, and with it, Flipboard, Pulse, and the Kindle app. Flipboard hooked into my Google Reader feed but never made catching up on blogs seem like work -- instead, it felt like I was browsing through a magazine that featured all my old blog friends and twitter buds. Flipboard also let me retweet, or post links to my Facebook page. Pulse is a little less slick than Flipboard, but they make it easier to plow through more content, add new feeds, and share or save material. Kindle's app is pretty great, and lets me take notes that can be shared publicly. It's a little work, though, to turn that public notes page into an RSS feed or Evernote folder. Currently, the Newsstand periodicals don't offer any sharing or notes archives, which has really limited my use of them (though they're still fun to read).

That the iPad should be a superior device for browsing and sharing RSS, books, Twitter and Facebook feeds is not surprising -- there's been surprisingly little demand to bring Flipboard and its like to the Desktop; Kindle has a desktop version that I've only used for novelty's sake.

I just wonder if Google knows what it's lost, by neglecting the Reader experience (which has only gotten worse lately)? I think so. Sources say they've got something in the works to compete, for tablet browsing. And many expect Google+ to come out with the APIs to make this kind of sharing and logging possible. Just not yet (and maybe too late).

In the meantime, I'm starting to make use of ifttt (if this then that), a simpler version of Yahoo Pipes that monitors feeds, tweets, and calendars and carries out pre-programmed actions for you -- so my starred Tweets are automatically sent to Evernote, for instance, or Facebook photos tagged with me are sent to Dropbox.

Ifttt makes Twitter and FB more useful, but it only makes clear how limited these social networks are for archiving, by themselves. It seems there ought to be a universal browsing / sharing / archiving app, for Tweets, Facebook wall posts, RSS, eBooks, and magazines, that looks as slick as Flipboard but has more capacity and flexibility. The fact that I can imagine this means it's too obvious for Apple to be working on (and probably not profitable enough, either). I worry that Google's solution may not adequately incorporate Twitter and FB (because if it did, why use Google+?) Maybe Amazon will surprise us again, or maybe Flipboard, Pulse, Evernote, Instapaper, or another startup will make it happen.

Until then? It's surprising but the simple, ancient act of reading has failed to adapt, technologically, to the extent that music and video have.

Airborne toxic event

2011-11-14T22:17:00.001-05:00

Longtime readers know my fondness of comparing the healthcare industry to the airline industry (based on similar goals of training, rituals of safety, and differing approaches to error, for starters).

Recently I've learned of a new intersection between medicine and aviation, when Delta chose to air ads to their captive cabin audience purchased by NVIC, the National Vaccine Information Center. The ads talk about staying healthy, maintaining good hygiene, and asking your doctor questions about the different flu shots available -- to stay informed and keep all the options open.

Sounds ... innocuous ... right?

Sure, the CDC recommends the influenza vaccine as the single best defense against influenza deaths, though additional hygiene measures can help. But what's the harm in asking questions of your doctor? Being informed?

Well, during the three-minute informercial, the NVIC website URL is shown. Their site is the opposite of information -- a mixture of pseudoscience and innuendo, laced with bromides about patriotism and personal freedom.

I recently flew Delta and didn't see (or recall seeing) this ad, though I do remember a loud car commercial right after takeoff, that I couldn't stop, or quiet. Inflight advertising is said to be unusually effective at prompting recall among passengers, well after landing. Since a fair number of people report some upper respiratory issues after flying, I've got to admit the NVIC initiative is well-planned.

But dangerous. In the words of AAP president, Dr. Robert Block:

The AAP and many other child health organizations have worked hard to protect children and their families from unfounded and unscientific misinformation regarding vaccine safety. The influenza vaccine is safe and effective.

By providing advertising space to an organization like the NVIC, which opposes the nation’s recommended childhood immunization schedule and promotes the unscientific practice of delaying or skipping vaccines altogether, you are putting the lives of children at risk, leaving them unprotected from vaccine-preventable diseases. Diseases like influenza can have serious consequences. From September 2010 to August 2011, 115 children died from influenza disease, most of whom were unvaccinated.

A petition is circulating to ask Delta to stop putting their passengers at risk. For their part, Delta has said that they'll change their ad purchasing policy, and the NVIC ads will only run until the end of the month. Wolfram Alpha suggests that, at about 200,000 passengers a day, that's another three million viewings of the informercial.

I rounded the daily passenger rates up slightly, for the Thanksgiving rush. Maybe, though, we could round it down -- #dontflydelta is trending on Twitter.

At the recent BWELA conference social health track, a bunch of us were talking about ways healthcare providers could affect positive change, in a media sphere where stories, novelty and fear usually trump statistics and uncontroversial, boring truth. This sounds like just the opportunity we were looking for -- pushing for a measurable outcome (Delta stopping the ads early), fighting pseudoscience with evidence-based recommendations, and using social networks for a decidedly anti-viral purpose.

The IOM Weighs In on Health IT Safety

2011-11-08T21:29:00.000-05:00

Thanks to a tip from Brian Ahier, I've caught wind of excerpts from the IOM report on Health IT Safety a few days before its scheduled release.

iWatch has the scoop:

But the push [to adopt electronic health records] is occurring so far without any agency really ‘watch dogging’ the safety of health IT — the software, hardware and systems that record and manage patients’ health information. These expensive devices by and large have not gone through any regulatory checks for safety in the way that food, drugs and other medical technology must; most of that oversight is handled by the FDA. But at the moment, no one is required to report instances of harm caused by health information devices and no government agency currently monitors their safety.

“With all of that money, marketing and public outreach, most simply affirm the value of health IT as an article of faith, rather than investigate it via careful evaluation,” said Ross Koppel, adjunct professor of sociology at the University of Pennsylvania and its School of Medicine, and investigator for RAND Corporation. He is listed as one of the reviewers of the report.

I've read Ross Koppel's work, and seen him speak, and firmly believe he's a brilliant guy. But I disagree that we're accepting health IT's value on faith, because of marketing. We've seen IT transform the way we do business in every other sphere of American life, and many of us have experienced the benefits of easily retrieved patient records and clear, electronic communication between providers. As I've said before -- aside from a few train-wreck implementations, who would go back to paper records, if given the chance? Who would build a new hospital based on anything but an electronic system?

The IOM isn't saying paper's better, but they do recommend caution with, and further study of, health IT:

...In its report, the IOM committee says the FDA would likely restrict market innovation in health IT, which could also jeopardize patient safety. Stringent regulations “can negatively impact the development of new technology by limiting implementation choices and restricting manufacturers’ flexibility to address complex issues,” the report says. The FDA currently receives voluntary reports of health IT-related incidents, but has no resources or protocols through which to take action; the agency has long fought a losing battle with health IT vendors over trying to monitor the technology.
The report also notes the agency does not have the investigative capabilities, funding or manpower to regulate devices such as electronic health records, personal health records or health information exchanges.
...To adequately oversee health IT safety, the committee recommends that the secretary of health and human services create and fund a new independent watchdog agency, along the lines of the National Transportation Safety Board. Like NTSB, the new agency would conduct investigations and make recommendations for all stakeholders, including the secretary of the health and human services, vendors and health care organizations. Vendors of the technology would be required to report adverse events, while reporting would be voluntary for clinicians. Like NTSB, though, the new agency would also have no enforcement power.
I'm all for reporting safety issues, near-misses and other risks of health IT. I think the vendors have really done themselves a disservice here by insisting on gag rules among their hospital clients -- doctors would be in violation of their contracts if they posted a screenshot of their EHR software online, let alone spoke publicly about some clunky or possibly dangerous glitches.

And I kind of like the idea of an NTSB-like agency, swooping in after a prescription error or lost bed assignment. Certainly, that model seems preferable to an FDA oversight, which might require extensive pre-implementation testing (beyond the current certification process) and I think would tend to slow down the pace of innovation and lock-in the clunky, slow interfaces doctors have come to expect from EHR.

But I have to ask: what country, what era, has the IOM been living in? Because expecting the creation of a new regulatory agency in the US in 2011, with an obstructionist Congress that's breaking filibuster records just to spite the administration, is a pipe dream.

And if no new regulatory agency is forthcoming, where does that leave the federal incentives for adoption and meaningful use of electronic health records? Already, the effort is stalled and seems likely be dragged out over an additional period. Now critics of MU will point to this phantom Health IT safety board, which ought to exist but probably won't, as a further excuse to delay, delay, delay. The status quo is cheaper. It's familiar. And so we'll keep handwriting notes and shooting paper orders through pneumatic tubes, in the name of patient safety.

The iWatch kicker:
In its report, the IOM panel also recommended that more studies be conducted to quantify health IT-related deaths, serious injuries or unsafe conditions so that the safety concerns can be properly addressed. “You can only improve what you measure,” says the report.
So true! And what we have in place now, across the majority of US hospitals, is patient care managed with clipboards and three-ring binders, full of handwritten notes and orders. Can those be measured in a systematic way (you know, for the sake of improvement)? Of course not.

It seems like health IT is a victim of its own capabilities. Because technology lets us measure and record how we practice, it is scrutinized to a far greater extent than the antiquated system it aims to replace. Because we can't begin to calculate how dangerous the status quo paper-and-clipboard system is, we'll end up keeping it, longer than any other US industry.

EHR Cutting & Pasting, in Perspective

2011-11-01T11:54:00.000-04:00

I've started to think the medical record is akin to DNA. Maybe 10% (or less) is useful information; the rest is junk. When folks want to find a sequence of significance, risk or reassurance, they've got to search for the good stuff and filter out all the garbage.

But junk DNA is believed to have a purpose. Some regions of junk DNA are highly conserved -- found in organism after organism -- suggesting an important function. In medical charts, conserved regions are also repeated. And they also serve an important function.

It's this repetition that Dr. Bryan Vartabedian called "Cut and Paste medicine" in his excellent recent post. He's concerned that all these computer-generated phrases of historical elements, exam findings and decision-making makes all patients look alike, and hurts continuity of care, as it becomes harder to discern what's actually going with the patient.

It's a reasonable concern. This problem, created by documentation regulations, compounded by declining reimbursements, and exacerbated by quick-fix features of some electronic records, can be solved through technology, too. Just as researchers and geneticists built tools to sift through DNA, to find the small section they're looking for, we need to easily search through records to show the details of patient care relevant to us.

Maybe this solution will simply highlight free-text sentences and paragraphs, and gray-out all the checkbox-generated prose. Maybe these searches will involve natural-language processing, or complex filters based on provider or position. I'm hopeful this problem will be solved, because medical records aren't getting shorter.

And here's where my analogy with DNA breaks down: junk DNA is also called "noncoding regions" because those sequences don't code for proteins. But in the medical chart, those junk sections are actually designed for coders -- they have key phrases that medical billing companies look for, to show to the insurance companies, to pay us. You could be providing the most competent, compassionate, time-consuming care in the world, but if those phrases aren't in the chart, nobody gets reimbursed. Other instances of these oft-repeated, computer-generated phrases in medical charts are designed to protect against legal liability, which also serves the financial interest of providers and healthcare institutions.

The good stuff, the free-text prose that describes what the doctor is thinking, may only be a short paragraph in a sea of vital signs and lab results and macros and checkbox-generated text. While this section is the most important part of the chart to future caregivers, from a medical billing perspective, it's essentially a noncoding region.

There was a time when medical charts were short and designed soley to communicate patient care to future providers. Medpundit once wrote of a mentor who could boil down an encounter to two terms, like "ROM - Amox" (right otitis media, given amoxicillin). Years later, a similarly simple encounter would have to run for 10 or 20 lines of prose.

By 2008, Peter Viccellio wrote:

When an ED visit for a cough, with diagnosis of pneumonia, consumes 17 pages of print, something has gone awry. (Or perhaps things went awry when pulmonary edema was no longer considered an emergency unless there was a documented family history, social history, and 10 reviews of systems.)

True. Things have gone awry. But I can't see any way back. So tell me: why should the medical chart ever printed, in a hospital? (Besides the increasingly rare scenario where a patient moves from an electronic part of the hospital to a paper-chart area). And if the chart's not printed, well, why should anyone on the care team have to scroll through 17 screens' worth of prose? Caregivers should see the parts of the chart really relevant to patient care.

Let's recognize the vast majority of the chart for what it is: coding regions that keep the hospital or the practice afloat, and comparatively safe from prosecution. These sections are not really important for patient care, and they're the last thing I want to see when I pull up a chart about a prior visit. Recognizing that, and building EHR search and display functions around that, and you'll solve a good deal of the frustration around electronic records and their cut-and-paste confusion.

The biggest reason we haven't done this already, I think, is pride. It's too painful to admit that most of what we're doing on the computer is not directly relevant to patient care. Let's get past that, recognize the checkboxes and macros serve a primarily financial function, and give those sections the low status they deserve when we run our searches and pull up our charts.

Anywhere but here

2011-10-31T05:51:00.000-04:00

While the output here has fallen from blogborygmi's heyday, this site's original purpose was to foster writing opportunities with, you know, real publishing platforms. By that standard, this past year has been a good one. If you're interested in reading more of my stuff, from health informatics to social networks, see below:

RIP Google Health. A look at the nearly-late, nearly-great Google Health, and the prospects for personal health records.

Twitter, and emergency response. What if social media was available on 9/11?

Redefining EMR Usability. When I got into electronic medical record usability, I thought it'd be about physician satisfaction, consistency, and counting clicks for key tasks. Recent developments suggest, however, it's going to be about estimating and reducing errors.

Getting Social. How social media can change the public face of emergency medicine.

When Charts Cry Wolf. The evidence surrounding the annoying, often irrelevant drug interaction warnings served up by electronic medical records.

EPMonthly EMR Roundtable. A freewheeling discussion on electronic medical records, conducted by Mark Plaster and featuring Rick Bukata, Bruce Janiak, and yours truly.

Meaningful Use: A Really Good Kick in the Pants. My interview with Maimonides CMIO (and emergency physician) Steven Davidson

MU and You. A primer on meaningful use of electronic health records, and what it will mean for emergency medicine.

The ACEP Sessions

2011-10-24T15:01:00.001-04:00

At ACEP last week, @drsamko tweeted a stat from the great Amal Mattu: the audience forgets 40% of new content from a presentation within 20 minutes, and 90% after a week.

I replied, "The Twitter audience never forgets!"

If I had more room, I might have been a little more precise. Twitter makes forgetting less likely, as pearls from different lectures can be broadcasted, shared and debated.

But Twitter is not Google or Pubmed. Once shared, Tweets, like good talking points from a lecture, have a way of disappearing into the ether.

So I applaud GruntDoc for his reprinting 95 ~~theses~~ tweets from ACEP, on a more permanent form on his blog (look at what we've come to, when blog posts are considered durable).

Here are a few of my own from ACEP #SA11 lectures and wanderings (largely stripped of hashtags, grouped by lecture, oldest first). If you make it all the way down, I have some (brief) thoughts on process of tweeting from conferences.

At infectious disease trivia session at #SA11. Learned: mortgage foreclosures led to neglected swimming pools, big rise in west Nile virus

Listeria! 2 month incubation period means maybe we haven't heard the last of cantaloupe scare. Pregnant pts particularly vulnerable

West coast heroin is not as pure as what we have in NYC. More incidence of botulism. They keep the antitoxin at airports!

Fidaxomicin for c. diff is $300 a day -But good compliance and better at preventing recurrence than flagyl. Beats a fecal transplant

@gruntdoc I think most of my patients would rather pay big $ for antibiotics than get poop transplant. Maybe I'm not explaining it well

Cook keynote #SA11: diff between 2006,2010 landslides in house? Small movements in independents who aren't watching fox, msnbc

Cook's #SA11 talk is a primer on politics,polls,electoral math, nothing (yet) on healthcare or even policy. Maybe that's why he was chosen?

Finally Cook #sa11 talks medicine, saying economy so bad, Obama will likely lose - if republicans can nominate a "placebo."

Cook #sa11: "I know less about health care than anyone in this room..." But he knows the politics of healthcare repeal pretty cold.

Cook done speaking? his conclusion is "dunno future of healthcare repeal; lots of uncertainty." wish keynote wasn't just handicapping

Watching @MDaware field questions by his poster (110) on residents' perceptions on teaching time vs value pic

Schoenberger on new ED gadgets: early gadget lit often written by investors, fans. But devices that take off don't depend on EBM

Schoenberger: McGrath video laryngoscope is too portable; easy to misplace this $10,000 instrument. Newer stuff cheaper, mountable

Schoenberger: King LT supraglottic device is replacing combitube in EMS purchasing. Single-use fiberoptic also show promise

@MDaware hmm maybe this speaker needs a better vendor rep; the high price of McGrath was a major talking point

Schoenberger: ultraportable sono smartphone based devices are cool but wait for an iPad device: that may be sweet spot for EM docs

Schoenberger is showing videos of S-cut trauma shears in staged competitions. So much destroyed leather!

Bmeye Nexfin noninvasive monitoring can tell (to some degree) cardiac output, stroke volume and SVR from a pulse-ox like device

There's a device coming out that will transmit EKG data through a shirt to an iOS device. Looking forward to getting rid of wires

Schoenberger just gave a plug to @Medgadget, then @epmonthly to keep up with device news

Interesting times at the @epmonthly board meeting this morning. Now off to ACEP's informatics section meeting

@RogersMatthew AR goggles!? We're still adapting to informatics as an approved subspecialty & writing an EMR pt safety white paper

Now at anesthetic lecture #SA11 learning evidence for bupivicaine, which seems to decrease opioid consumption days after drug is cleared

Kip Benko on supraperiosteal injection: topical first, insert bevel to bone, inject to get at the root (2/3 of tooth is hidden)

Benko on infraorbital nerve block: "needle doesn't have to get into the foramen to work - this isn't golf."

Benko showed beautiful diagram: mental foramen, corner of mouth, infraorbital foramem, and pupil all line up. That pic worth 140 char

Benko tips: inject palms up (see your palms) for best control. Distracting lessens inject pain, so pull lip or press qtip near site

Benko: easy to miss inf alveolar nerve, hit buccal or lingual instead, numbing wrong part. Angle in from over contralateral canine

Next is one ive been looking foreward to: Badanowski & Rice, on medical liability in the age of electronic health records #EMR

known legal cases on #EMR: bad time stamp sync, delayed documentation, info entered on wrong charts, ignoring available info

So far this #EMR talk is short on specifics, no concrete actions to recommend. Are they still introducing the topic?

First real recommendation: have good backup plan when #EMR goes down; one makpractice case was lost by inadequate downtime system

@gruntdoc the poor readability of these slides is evocative of many poorly designed #EMR interfaces, may be intentional

Medical providers can be liable for use of faulty equipment; #EMR is no exception. You can't let known problems fester

Vendors make hospitals, EDs sign "hold harmless" clauses re: #EMR use or misuse #SA11 (they also gag users who try to speak out on dangers)

This #EMR talk degenerated into scaremongering. Just heard: "the lawyers are savvy, but the AMA is active." guess we're doomed

favorite #SA11 exhibit slogan? So far QuickClot leads with "the bleeding stops here" (from the makers of Combat Gauze) picMy goodness, the T-ring people have the best exhibitor poster (warning: not safe for lunch) pic

At Newman's #SA11 talk on the NNT for common EM therapies... Always eye-opening how limited our interventions really are

Newman stresses absolute risk reduction, over relative. And shows mortality scales from 0-100% to really put benefit in perspective

NNT for rhogam in threatened AB: infinite!? Not a single case report of isoimmunization in 1st trimester, some in 2nd.

Newman's covered some of this lit on his smartEM podcast, and http://theNNT.com

Newman on NNT for packing after abscess I&D: no recurrence benefit, hurts more, prevents good cosmesis.

Steroids for meningitis? NNT of 20 to prevent hearing loss... Better than mortality benefit of lytics/PCI for STEMI (NNT 40) Newman #SA11

Antibiotics in COPD exacerbation? NNT = 3 to prevent bounceback. As good as Mg++ for asthma to prevent admission. Great interventions

Newman got passionate, urging EM doctors treating arrest patients to think about etiology rather than blindly following ACLS cookbook

After Newman laid down evidence-based but counter-culture facts, he urged action plan: educate pts, prioritize interventions

At @M_lin's talk, she suggests fragile elderly lac repairs be improved by suturing through steri-strips, to prevent new skin tears

Wise suggestions from @M_Lin: tegaderm to limit spread of tissue adhesive, and tissue adhesive to affix avulsed fingernails

@M_Lin: Fast-absorbing gut suture plus tissue adhesive is perfect for wounds that need a little extra tension (like on chin)

Ooh clever: Sono tough-to-reach extremity lacerations to look for foreign bodies by placing hand/foot in water bath.

Off to hypertension lecture, mostly because I need a better way to reassure well patients that have no emergency

Bresler starts Rx for ED HTN if diastolic > 100 persistently. JNC recommends HCTZ (but what about K+?)

2010 AHA guideline: lowering systolic to 140mmHg in hemorrhagic stroke is probably safe. Big change

Show of hands at hypertension lecture: who's ever used fenoldopam? Mine was the only hand that went up #SA11 #practiceoutlier

Bresler treats his asymptomatic HTN ~220/110 pts with Clonidine x1, no Rx, which seems like treating numbers, not patient.

As I did this cutting and pasting, I had a few Twitter-like thoughts come to mind:

Someday, academic speakers may be evaluated on Tweeted comments, and on the quality of Twitter discussion they stimulate, as opposed to those Likert evaluation scales handed out at the end of talks.
Tweeting (with geo-location enabled) lectured pearls may also be a way for students to demonstrate understanding / attendance to teachers / administrators.
It's great that academic promotion boards are looking at social media influence alongside journal publications and other printed works. I wonder if the time-honored academic practice of double-dipping will find use, here. Just look at the mileage I'm getting from these tweets.

Going to California

2011-10-19T16:00:00.000-04:00

I'll be speaking at BlogWorld Expo in LA on November 4 at 4pm, on how social networks can influence patient outcomes.

I'll be joined by two distinguished physicians and social media pioneers, Dr. Jen Dyer and Dr. Val Jones. We'll make a few brief presentations and then field questions. The session will be immediately followed by happy hour.

Also, be sure to check out all the other great topics in the social health track, spread throughout the conference. The speakers with Twitter accounts (approximately all of us) are listed here and tweets about the conference have the #BWELA hashtag.

If you're on the fence about attending the conference, consider: promo code BWEVIP20 to knock 20% off the registration fee.

Goin' Mobile

2011-10-04T07:30:00.000-04:00

Long before my colleagues knew me as "that guy who sewed a pocket into his white coat so he could use his iPad in the ED" ... but sometime after they knew me as "the guy with the blog" ... I like to think they knew me as "that guy who helped edit many editions of EM Practice, the evidence-based, presentation-focused journal of emergency medicine."

With this post, I can be all three guys at once, and recommend the wonderful, iPad-optimized PDF of of many fine flowcharts featured in EMPractice in recent years, now available for free.

Every issue of EMPractice has a flowchart to help guide emergency decision-making with the best available evidence. We've taken a bunch of recent flowcharts and bundled them into a useful, navigable document that will bring the best evidence to the point of care.

Of course this PDF works well on paper, and the hyperlinks will work on other computers or devices, but it's sized and designed with the iPad in mind. It's really great for teaching or reviewing, on shift.

NB: I'm on the editorial board for EMPractice and had a small role in developing this PDF.

Falling farther from just what we are

2011-09-28T15:23:00.000-04:00

I like asking patients about their jobs. Sometimes it may seem relevant to the complaint. Other times, it could potentially help the therapeutic bond. Mostly, it's just interesting.

Occasionally, I'll hear a patient is not working; that he or she is on disability.

This can surprise me, especially when the patient's interview responses and examination seem quite appropriate and unremarkable.

Now, I'm not in an ED where this happens too often (or maybe I don't ask enough). At any rate, I haven't been compelled to blog about this phenomenon, like, for example, Edwin Leap recently did. And I'm certainly not of the mind that disability payments are responsible for the debt crisis, or that the vast majority of folks on disability don't deserve it.

But I was recall my training in smoking cessation counseling; we were taught that every time a doctor elicits a smoking history but doesn't discourage the practice, a patient takes notice. Maybe the patient doesn't walk away thinking, "my smoking habit is healthy," but perhaps he or she ends up concluding it can't be such a big deal, if the doctor didn't dwell on it.

As a consequence of this training (and the research that backs it up) I do tend to dwell on smoking history. I have all kinds of statistical and anecdotal pearls to trot out, depending on the situation (wound healing, viral URI, heart disease, etc).

I wonder if the same thinking can be applied to those unexpectedly disabled that I see every now and then. Is there a phrase a physician can ask, that expresses some surprise at the incongruence of their presentation and disability status, without coming across as confrontational, or opening up a can of worms?

Perhaps it's just a variation of my formulation, a few paragraphs back: "You're on disability? That's surprising to me; you seem so capable."

And then, just listen.

Comin' down on the nightshift

2011-09-01T10:00:00.000-04:00

I was contacted by the folks at RN Central about running an infographic about the dangers and errors associated with hospital night shifts.

They thought I should publish it, "since you run a site about nursing."

Since that statement is an error, and since the email was sent at night, I assume the sender had to be overworked or undertrained. That off-the-cuff assumption, it turns out, may be more rigorous than anything in the infographic.

As I wrote in an exchange with the excellent Michelle Lin, this info graphic is horrible -- proclaiming lots of undocumented "facts" that you can't be sure about (are they pulled from the pre-work-hours reform era?) and "tips" no one can follow (such as "avoid going to the hospital during Spring Break" -- what?).

Other "pearls" just reflect reality: 50-70% of hospital admissions happen at night or on weekends! Well, hey, nights and weekends make up the majority of the week.

The chart is capped it by highlighting 5 bad outcomes across the US (world?) over the past 22 years. Does that enlighten anyone? My ED alone sees 100,000 patients a year.

The thing is, I've generally been a fan of this new wave of infographics. As Steven Davidson has pointed out, charts and graphs used to be designed with journals and powerpoint in mind; today's colorful and long infographics are built for the social media / Prezi age. And through web-surfing, I've definitely come across some nicely-distilled points in various economics and political infographics. Perhaps I like those kinds of infographics because I'm not versed enough in that field to catch the simplifications or misdirections, or to mind the lack of true citations.

Still, I think an infographic should make a succinct and compelling case, like "boost overnight staffing with more experienced providers" ... this one seems to be lashing out at all kinds of problems, from overnight staffing to residency training to preventable errors, and fails to make any compelling cause/effect relationship or implementable policy recommendation.

Worse -- if I wanted to learn more about that stat, "babies born at night are 16% likelier to die" (seriously, think about how ridiculous that number is without confidence intervals or ARR) where would I go? The Halifax Medical Malpractice Lawyer Blog? (that's one of the sources, next to WSJ and NEJM).

I just can't figure out who this infographic is trying to educate or warn. I think it's mostly a promotional tool for RN central. In the process, though, it's spreading fear and confusion. Be sure to only look at the chart during the day, when the muddled thinking and errors are less likely to harm you.

Since Canada came along

2011-08-09T15:16:00.000-04:00

Over email, some far-flung EM colleagues and I were discussing a case, where an elderly but generally healthy man developed a fever, went to an emergency department, had blood cultures drawn (as well as other labs, films and urine). Ultimately the old man was discharged home.

A few days later, on a weekend, a positive blood culture report (gram negative rods) prompted another ED attending on duty to call the patient at home. Over the phone, the patient said he felt fine; back to normal, no worse for wear. The ED attending considered the matter closed.

On Monday, the primary care doc reviewed the case, and, with ID, admitted the patient (who still felt fine) to the hospital for monitoring and IV antibiotics. Apparently a nastygram was sent to the weekend ED attending, as well, citing some kind of policy that gram negative rods can't be ignored.

My friend, the Canadian Doctor, commented:

This is ridiculous. Because of the "unique" medico-legal climate in the US, there will never be an incentive for any physician to endorse conservative, less aggressive management. Without the support of colleagues from other specialties for anything but aggressive knee-jerk responses, patients suffer the consequences of a peer-pressured physician environment where we must all cave to the most conservative (brainless) approach. While I am comfortably protected in Canada (and its different set of imperfections, of course), I hope that this American death spiral of false logic and spineless non-decision making is arrested soon by some tort reform and financial accountability.

In the past I've really tried to shy away from policy discussions on this blog. There are already great sites for that sort of thing, and I don't want my words taken out of context or brought back to haunt me.

But I did tell my Canadian friend that his emailed paragraph was delicious enough to deserve a wider audience. With a few minor alterations, he's ok'd its appearance, here.

Signal in the sky

2011-07-01T14:22:00.000-04:00

Notable figures such as Atul Gawande and Captain Sullenburger have, when discussing safety in medicine, drawn comparisons from the world of airline operations. Lots of people, actually, have made comparisons to these disparate fields.

If healthcare were more like aviation, the thinking goes, there would be fewer errors, greater transparency, and more uniform ways of doing things (and thus, presumably, lower costs). Gawande and Sully both talk about the egos of doctors, who view checklists as beneath them, who view their patients and practice as worthy of exceptions to guideline-based practice, who view their gestalt as superior to cookbooks and calculators.

No doubt, that's part of the problem. But consider: New York magazine publishes a list of top doctors, but not top pilots. Lots of people brag about the acclaimed specialist they see, but no one brags about the pilot that they've booked for their trip to Paris. I think society's expectations of physicians have never been in line with their expectations of air travel. The relationship between passenger and pilot is nothing like the relationship between patient and doctor, except that we rely on pilots and doctors to get us from point A to point B safely and smoothly.

US healthcare has maddening inefficiencies and rituals. But so, too, do airlines. I'm not even talking about TSA security theater (at least, not this time). Just consider the flight attendant preamble about using your seat as a flotation device in the event of a water landing, or the rules about electronics below 10,000 feet. These always seemed to me to be put in place by cautious administrators, years or decades ago, with a "better safe than sorry" rationale that's hard to study or rescind, once put in place.

These speeches and restrictions always reminded me of the over-the-top, out-of-date rules about cell phones in hospitals. Sure, there's one confirmed case that I'm aware of, years ago, where a mobile phone caused an IV infusion pump to malfunction. But it never seemed reasonable to extrapolate from that event, to banning personal communications at a time when patients and families are most inclined to get in touch.

Recently, the IATA issued a report on passenger-generated electronic interference with flight systems. Via TechCrunch:

The reported incidents were based on 125 airlines’ responses submitted between 2003 and 2009, noting that flight controls, autopilot, auto-thrust equipment, landing gear, and the communications kit were all allegedly affected by electronics use. Of course, not one of the seventy-five incidents were verified to be caused by electronic devices. Instead, the IATA reports that crew-members and pilots believed that electronics were the culprits in those cases.

In one instance, with two laptops being used nearby, the plane’s clock spun backwards and GPS readings began going off. In another example, altitude details were jumbled until the pilot asked passengers to turn off their gizmos. A Boeing advisor, Dave Carson, believes that the signals radiating from portable electronics can mess with sensors hidden in the passenger areas of a plane, and that those signals are far stronger than what Boeing considers acceptable during a flight.

I didn't know some sensors were in the passenger area, where nearby device signals could interfere. Still, the article goes on to say a true cause/effect relationship between portable electronic devices and malfunctioning sensors has not been demonstrated by any of these IATA incidents.

What I found particularly interesting were the outraged comments, in response to the "scofflow" writer who admitted to keeping his phone on during landing. He was attacked for jeopardizing the lives of everyone on every plane he's flown on. With 4000 flights a day in the US alone, and a lot of forgetful or sleeping passengers on each flight, I have a hard time believing that electronic interference poses any measurable risk. Even if all 125 citations over 6 years were really due to electronic interference, there were still no "bad outcomes" (to borrow from medical QA parlance) and the event rate, as commenters point out, was approaches zero and is far less than the odds of being struck by lightning.

Would these same outraged commenters angrily force a patient's family member to hang up their mobile phone, if they saw them talking in the ED near a stretcher? Would they yell at a car driver who's not wearing a seatbelt? Or do these commenters feel people who keep their devices on during plane takeoffs and landings are not just jeopardizing themselves, but perhaps the commenters as well?

This seems like yet another example of our attitudes and behaviors toward risks being poorly aligned to the actual danger. It's more David Ropiek's territory -- though I'm sure Sullenbuger and Gawande would agree, getting the public's perceptions to match the true hazards in aviation would make air travel a good deal more smooth and productive.

As for healthcare, it seems almost impossible to calculate how much money, time, and stress would be saved if patients' risk perceptions were brought into better agreement with true health risks. Yet I'm more optimistic that the culture of aviation -- with its transparency, uniformity, and lack of ego -- is more likely to lead to progressive policy changes and successful public education, when compared to the culture of medicine.

Paranoia strikes deep

2011-06-14T14:49:00.000-04:00

You know, I already thought that someone at Apple shared my taste in music, as they've highlighted Goldfrapp albums on their site, on several occasions.

But sometimes, while surfing the web, some examples hit a little too close to home. For instance, here's an article on iPhone tracking, that happens to show my neighborhood in the Maps app.

Sure, you say, lots of iOS screenshots feature Central Park. Lest you think this is just Manhattanite navel-gazing, here's a new Medgadget post with a screenshot of the iPhone app called FindER that just happens to show the town I grew up in, and the hospital where my scalp lac was stapled (twenty years ago).

Maybe I'm reading too much into this. Or maybe I'm reading too much about iOS apps.

Best practices

2011-05-27T20:11:00.001-04:00

Grand Rounds needs you.

Val Jones and I have recognized that GR works better when we invest in a higher profile --

e-mail blasts about the next host's deadline and address.
daily tweets through the @grandrounds account, highlighting links from that week's edition
identifying and guiding new bloggers through the hosting process
coordinating with other online health networks

Trouble is, neither Val or I are in a position right now to do this ourselves.

If you've got the time and inclination to tackle at least a couple of these items, contact us.

Through their vocations

2011-05-20T15:00:00.000-04:00

According to this reputable source, (and backed up a little by this source) the concept of the modern grocery store was once laughable. Customers used to walk up to clerks with their shopping lists, and the clerks would fetch the items for them.

No one thought people would want to do the work of picking their own fruits and vegetables.

I think the same is true for CPOE -- computerized physician order entry.

I try to remember this when I encounter opposition to CPOE and electronic medical records (EMR). Sure, I learned for the oral board exam how to rattle off a long list of lab tests to order, medications to give, based on a clinical scenario. But I trained, and practice, with order sets on EMRs. It's just more natural for me to pick among preselected agents and doses, and prompts me to consider alternatives I might not have. I like perusing the items listed in front of me, or a few clicks away, just as I like to feel a few avocados before picking one to purchase.

CPOE is a hot topic, right now. I spent months with my colleagues creating and refining order sets for our new ED information system. I'm watching ACEP's informatics section settle on a policy statement on scribes, who many ED physicians rely on to interface with computerized systems. Here's my own recent piece for EPMonthly about drug-drug interaction warnings and coming era (hopefully) of smarter, more context-aware clinical decision support.

I suppose the analogy to decision support would be expiration dates, or nutrition labels, to help consumers shop. I'd also allow the comparison that modern EMRs are like a confusingly organized grocery store that requires hours of training, and federal incentive plans, before people shopped there.

Maybe the news that NIST is convening an EMR usability workshop should be interpreted in this light -- we've acknowledged that we're heading away from clerks and toward picking out our own items, but the store aisles are going to have to be laid out more intuitively.

Nothing Much to Lose

2011-04-13T16:54:00.000-04:00

Reading the ER Stories blog is often a guilty pleasure for me. Today's post, however, struck a nerve:

Very often I ask patients about their recent visits to other doctors. While I am taking a history, it’s important for me to know if you’ve recently been seen by another provider for the same or similar complaints and what they did, what they diagnosed you with, what they prescribed, etc.

I often get a kind of irritated response such as “Oh, he didn’t do anything” or “he said it was nothing” or “he didn’t say anything to me”. Although I know my share of layzee doctors, I bet the vast majority of times, the doctor DID do something and DID say something.
Just not what the patient either wanted to hear or that their perception or comprehension was wrong. ...

... Now, maybe he is not a good communicator. Maybe he doesn’t have the time to sit there and explain the pathophysiology of viruses or something like benign peripheral vertigo – and thus you feel short changed. After all he “just asked me a few questions, listened to my lungs and told me to go home and rest”.

Early on in my training I was fortunate to be taught that proper communication is the responsibility of both doctor and patient. So when a patient shows up in my ED and says their last doctor "did nothing" -- when I can see with a few clicks that they got labs, a CT, and two prescriptions -- well, there's a failure to communicate. And the other doctor carries at least some of the blame for this.

Certainly, the patient is dissatisfied (because they're still seeking care, in an ED). You could argue that they're consciously downplaying what was done elsewhere in the hopes we enthusiastic ED docs can take a fresh look at the case. Maybe that's it -- but I bet from the patients' perspective, since they've still got a complaint, they've figured that nothing successful was done.

From the ED physician's perspective, however, ruling out a bunch of life threatening conditions is a success. Or at the very least, not nothing. Same with providing symptomatic relief until clinic followup.

Communicating this to patients takes time, and constant effort. So many things in the department are working against a meaningful conversation about the visit -- the interruptions, the stress, the duty to document. Even discharge, which should be a chance to clarify and communicate, is often a rush job. A colleague of mine has a first-author paper in Annals this month, on what gets said when discharge instructions are provided. The sobering stat:

"Only 22% of providers confirmed patients' understanding of instructions."

I would have thought that the emergency medicine, which is gifted with so many talented bloggers and podcasters, would do better at communicating with patients. If comprehension of discharge instructions is so infrequently done (and there's supporting evidence), it's not hard to imagine how hours of complex diagnostic workup gets interpreted by the patient as "the doctor did nothing."

What can help reverse this situation? I don't want to be Johnny-One-Note with my espousal of technology, but the iPad is proving helpful in reviewing a visit with a patient, at the bedside. You can go over lab reports, show x-rays, and clarify prescriptions before they're printed. I think it seems more tangible to the patient than just saying "everything came back normal."

Even the iPad, efficient as it is, requires time. And there are certainly some shifts where time isn't readily available. So another thing some of my friends in EM have done is share their email addresses in discharge summaries, and invite followup questions on their care.

This used to give me pause, for a lot of reasons. But when I think about the fair chunk of my non-clinical time I spend on quasi-medical communication -- to colleagues, in print, and on blogs and social media, I've got to ask: what kind of communication is most important? Wouldn't some of that time be better spent going clarifying care, with my patients?

After all, while composing this blog post, plenty of people could say "this doctor did nothing."

Present Tense

2011-04-03T16:30:00.000-04:00

I made my first PowerPoint presentation in 1997, and actually used Microsoft's application to prepare 35mm Kodachrome slides for a carousel projector. Since then, I've seen thousands of PowerPoint presentations (and a few dozen Keynotes), and had a hand in creating many, myself.

Not since a conference a decade ago have I needed to make Kodachrome slides. Yet almost everyone still uses software built around printing slides, making a linear progression of topics. The impact of this format on human thought is substantial -- PowerPoint was fingered as contributing to the Columbia disaster and has spawned a lot of discussion and linkage, even here, regarding effective communication (probably all conceived of during dull PowerPoint presentations).

While compelling presentations are possible with Powerpoint (using the Lessig Method, for example) those kinds of talks require planning, and a mastery of the material. And some great stock photos. My experience in school and training is that the PowerPoint is often made as the presenter is learning the content and so is bound to lack the organization and expertise necessary for a Lessig-style presentation. People procrastinate about public speaking, and when crunch time comes it's just too easy to flip through a a textbook, call up a Pubmed abstract, and churn out another verbose PowerPoint slide. With practice, it's possible to whittle down the number of words and bullets per slide -- but who has time for that? Much easier to read the talk from the slide itself.

While I strive for Lessig-like clarity and impact in my talks, it's rare that I can eliminate all the slides with three or more bullet-points on them. PowerPoint, even though it's based on making Kodachromes for obsolete carousel projectors, is just too much of a crutch.

Which is why I was relieved to see Prezi come along. If you could imagine what presentations should look like with modern computers and digital projectors, Prezi is pretty much that -- more like a mind map than a slide deck.

Prezis can still be a linear progression of images, text, bullets, etc. But even linearly, it's easy to make big concepts stand out, and parenthetical points diminutive and aside from the main progression. Tangents can literally be tangential. Related ideas can be visually grouped, and you can easily give your audience the bird's eye view, for perspective. Most significantly, though -- Prezis needn't be linear. A presentation can go in various directions, based on audience input or presenter's whim. I think this will ultimately lead to much more interactive, engaging presentations.

Furthermore, Prezis just look great. I was always trained to avoid flashy animations and effects -- my grad school advisor wisely counseled, "Let your data do the dazzling." And I agreed with him, especially whit PowerPoint's cheap, tacked-on effects. But Prezi's more fluid animations have purpose -- they are literally moving the audience's focus along, from one concept to another, or to multiple ideas.

I gave my first Prezi presentation last week (here's the public version, stripped of many incriminating screenshots and some diversions). It was a challenge, and I still have a lot to learn, but I think it was more compelling than I could've made the material, in PowerPoint. And coming at the end of a long conference, I think people were ready for something different.

It wasn't easy, though. It took a while to get the hang of the zebra circle controller. There are still some things about frames that baffle me (no resize option? really?) But the greatest hurdle was old habits: Prezi forced me to think much more about the outline of my talk, up front. I couldn't just churn out some slides to get the ball rolling, but really had to plan where I'd take the audience.

Other thoughts:

A poorly planned PowerPoint will bore the audience. A poorly planned Prezi could make the audience violently ill.
PowerPoint encourages and even rewards procrastination. With Prezi, it's hard to make (as many) last-second rearrangements without disrupting the carefully-laid path.
Getting videos to reliably display in Prezis is easier than in PowerPoint. Images should be as easy, but there are quirks -- .png files look pixelated, and pdf's don't yet display on the iPad app.
We are pretty close to the point where a presenter can walk around with an iPad and control (or let an audience member control) a Prezi projected on the big screen (this may already be possible with extra hardware, but the Prezi iPad app doesn't faithfully reproduce the Flash-based web Prezis, and doesn't yet allow Prezis over AirPlay).

Even though my talk was (mostly) linear, I'm looking forward to trying some choose-your-own-adventure style presentations, which could be especially useful for talks on medical decision-making. When you think about how many hours people spend looking at PowerPoints, it's easy to get excited about the potential for Prezi. Other Academic EM types are experimenting with Prezi -- and someone has gone and made a Prezi touting its advantages. Finally, inevitably, there's now a blog about Prezi tips.

Land of a Thousand Words

2011-01-04T14:04:00.000-05:00

I've spent some time recently working with our new ED information system vendors on verbiage.

That's what the industry calls the result of all the boxes we check when filling out an electronic chart. Those checked boxes develop into a narrative, with the help of software:

The patient's chief complaint is abdominal pain. The onset was described as gradual. This episode began 6 hours ago. The problem is localized to the RLQ. The complaint is associated with fever and nausea and vomit. This is no association with diarrhea or constipation. The problem is persistent.

Chekhov, it ain't. But there's a lot of pertinent positives and negatives that need to make it into the record, from a galaxy of possible complaints, modifying factors, and associated symptoms. I'm not aiming for art; just trying to maintain subject-verb agreement (though some phrases have had a certain poetry -- my favorite so far is, "The presence of foreign bodies is uncertain.")

Some thoughts on this process:

I will generate more chart verbiage than I could ever match with research publications, columns, blog posts and tweets. By this metric, I am finally a prolific writer (though my compensation per word is probably below industry standards).
The (considerable) amount of time we're spending on the verbiage is still not nearly commensurate with the amount of times we'll see it (even understanding that any single chart is unlikely to ever be read again once the encounter is over, the phrases will come up over and over, in multiple encounters).
While it's regrettable that circumstances force me to decrease the signal-to-noise ratio in our charts, I consider it worthwhile to try to make the noise a little less jarring.
While there are a lot of ED metrics worth streaming to the web or twitter (wait time, chief complaints for biosurveillance stats) I would really enjoy seeing (deidentified) brief excerpts -- sort of like @GiggleMed but artful.

Does your EMR have any noteworthy stock phrases? Good or bad? I think we'd be happy to cite your system as an influence.

Grand Rounds in the New Year

2010-12-31T14:34:00.000-05:00

Grand Rounds took a break this week, for the first time in its history. We probably should have done it on earlier occasions, but in the past there was no shortage of willing hosts or participants.

Now is a different story. Recent hosts have remarked to me about sparse submissions and a decline in traffic -- it seems to vary week-to-week, and there are notable exeptions, but the trend is unmistakable. One new blogger (and recnt host) asked, "Does blogging even matter anymore?"

I don't have a great answer. It seems like most everyone still has a blog, if only to have something to link back to on tweets. Blog traffic and comments don't seem to motivate writers as much as followers, fans and retweets.

For years I've considered Twitter and Facebook as less flexible, and more lacking in meaningful content, compared to blogs. But it's clear that this is how the vast majority of online readers prefer to learn about quality health writing. And since the mission of Grand Rounds has always been to showcase excellent medical writing and creative writers, we're going to have to do more with these new platforms.

They might be giants

2010-12-22T07:38:00.001-05:00

This year, I learned about the death of two physicians that were pretty important to me.

The first was my pathology teacher, Dr. Guido Majno. In addition to just being a tremendous person, kind and curious... He and his wife wrote the best textbook I've ever read.

The second death was that of my pediatrician growing up, Dr. Thomas Peebles.

Funny, although he followed me from birth to high school, my family never knew about his incredible research background. We learned it in the many obituaries.

It's worth reflecting on their accomplishments and the manner in which they conducted their lives and practice -- especially in this era, when doctors are encouraged to develop their social media presence and be proactive about online reviews.

Would they have used these new tools? Would they even have needed them? Would they have found the idea of trading links to medical stories on Twitter to be interesting? Stimulating? Or maybe distressing, or distasteful?

I never thought to ask them.

Time won't let me go

2010-12-17T15:00:00.004-05:00

Before the App Store, way back in the spring of 2008, I jailbroke my refurbed first generation iPhone. I claimed it was for the cool native apps but also liked the customization that was possible (even now, animated backgrounds and control over device sounds is not allowed through official channels).

The innovation came at a price -- the phone became slower and more crash-prone.

When the App store was available, I quickly upgraded to the Apple-approved iPhone OS 2.0 and all my jailbreak hacks and apps disappeared.

Except, strangely, one hack.

Erica Sadun, who writes for TUAW and really makes use of Ping, wrote a bit of code that let me change the clock in my taskbar to text. The text I chose, on one fateful day 2.5 years ago, stayed with me through the upgrade back to an official Apple OS.

Stranger still, the clock-to-text hack stayed active when I upgraded to the iPhone 3GS, last year (when I restored my backed up data and apps, the text came with it).

Newer OSes were released, I never went back to jailbreaking, but still the hacked text remained. It followed me to the iPhone 4 this summer and iOS 4.1 this fall.

Yet surprisingly, upon upgrading to iOS 4.2, the clock returned, and my little bit of text was gone.

I'm sure there's a good explanation for this, rooted in code that's well beyond my understanding. And, truthfully, Apple was right: having the time displayed on my taskbar is a lot more useful than my little bit of personalization.

I'm just reporting this in the same spirit as my bizarre case reports: it's good to notice and share unanticipated findings in complex systems, so that others may learn and maybe use that information, going forward.

There must be some kind of bad connection

2010-12-14T15:49:00.000-05:00

A reader of my EMPractice LLSA review on paracentesis (still available, buy yours today!) wrote my editor with a question. Not, thankfully, on anything factual in my writeup, but rather on an issue of word usage.

This is picayune but a start. 2010 LLSA 4 paracentesis refers to a \"Z tract\" as a technique to avoid leakage. When I learned this years ago I thought it was Z track-as the pathway (track) left when the needle was removed. I thought using tract was just sloppy language. Checking Roberts for procedures I read Z tract-OK-solved. BUT then Roberts' Illustrative Guide calls it Z track. So, evidenced-based mavens which is it?!!!

Our editor referenced the original NEJM article on which my review was based. The NEJM uses the term “Z-tract.” But further Googling turned up varied usage, and "Z-track" was far more popular.

Is there a definitive answer?

Of course not. This is medicine, after all.

I favor "tract" because it feels more consistent with other biological tracts -- a 3D tunnel system like the GI tract.

I've always felt "track" was reserved for more linear or 2D systems, like a race track or tenure track.

This isn't the first time this question has come up. But what I find puzzling is so many online dictionaries and language sites all state that "tract" can refer to organ systems -- but I've never heard the phrase "cardiovascular tract" or "musculoskeletal tract" -- it's always GI or reproductive tracts. Mostly, I suspect, because these are organ systems based around a single tubular structure.

Thus, it's my assertion that the Z shape we're making in paracentesis has more in common with a tracT than a tracK, and is more in keeping with the original definition of tract:

Tract: 1350–1400; (in senses referring to extent of space) < L tractus stretch (of space or time), a drawing out, equiv. to trac-, var. s.of trahere to draw + -tus suffix of v. action; Track: 1425–75; late ME trak (n.) < MF trac, perh. < ON trathk trodden spot; cf. Norw trakke to trample; akin to tread

Still, despite favoring the tracT side of this debate, I can't say it's completely unreasonable to call it a tracK and so I'm not planning on annoyingly correcting my colleagues who refer to it as such. The other big K-for-T switch in medicine, however -- vomicking for vomiting -- must be corrected at every opportunity.

When all is well and well is all

2010-12-12T12:14:00.000-05:00

Slate's Juliet Lapidos recently reviewed a new book by Allan Metcalf on the story of OK ("America's Greatest Word"). Key graf:

The only etymology with hard evidence behind it, he says, is that OK began as a joke—a joke so bad, so boring, that I won't cover it in detail. Briefly: In the spring of 1839, the Boston Post ran an article tweaking the Providence Daily Journal, which included the phrase "OK—all correct." Get it? OK started as an intentionally misspelled abbreviation of all correct (oll korrect). It sprang, more generally, from an 1830s fad for abbreviations, like NG for no good and OW for oll wright or all right.

I've heard about this silliness before, and in fact referred to it whenever someone around me bemoaned the spelling of, say, "Gorillaz" or "Flickr." The current trend in spelling hijinx doesn't portend the end of civilization or reflect a decline in education, but rather, continues a longstanding English tradition.

But the part about the review that I really liked focused on the inscrutability of "OK" (more below):

Metcalf gives less weight to the relativist OK, or the "noncommittal"OK, as he calls it, which "affirms without evaluating." The word's passivity, to Metcalf, is merely one of its many aspects, rather than an encapsulation of a third, less glamorous American philosophy: the shrug....

...Throughout, Metcalf stresses OK's clarity over its opacity. He does not linger on its potential for unintentionally confusing exchanges...

He may be missing the usage of the future, it seems to me, in downplaying the baffling OK, deliberate or otherwise. When used in speech, the word benefits from facial and tonal and social contexts. As our conversations move increasingly into a textual arena, OK gets stripped of these supports. The lone OK in an otherwise blank e-mail tells us only one thing for certain: Our initial message did, in fact, fly successfully through the ether and land in the intended inbox. Whether the OK surrounded by white space is also meant to convey emotion—positive, negative, or something in between—we just can't tell. Whether that uncertainty is positive, negative, or something in between is purely a matter of opinion. On the giving end, I rather like it—in fact, I couldn't do without it.

I only wish Lapidos or Metcalf knew the many ways I get to hear (and use) "OK", in the emergency department.

Because, sure, there's an element of that affirmation-without-evaluation, like when a patient is explaining why she thinks she's coughing ("It's not my smoking -- it's that my grandson was sick last week" -- "Okay".)

There's plenty of similar OK deployment when attendings are listening to residents's case presentations unfold. The attending's OK in this situation is used to further the narrative without biasing it; I try to hear the resident's plan emerge without injecting too much approval or disapproval (that comes later).

There's OKs with extra meaning, like the reassuring, professorial kind of OK, when frightened patients can take comfort that their symptoms are familiar to their doctor (it's also heard when interns are being coached through their first central line).

But there's another OK -- one that I didn't see Lapidos or Metcalf mention -- a slightly aggressive, belittling OK. I still hear it occasionally, when explaining a case to a consultant or (thankfully rarely) hearing a resident take a patient history.

The aggressive OK is a perversion of the reassuring OK, really distinguished by just a matter of timing and tone. The aggressive OK means to imply, "Nothing you've said so far has justified why we're having this conversation, so what else have you got to say?"

Call it the professional cousin of the teenager's sarcastic OK. The aggressive OK comes as close to signalling disinterest, boredom, or hostility as convention allows. Its use is, simply, not OK -- but survives, I think, because this versatile word can disarm us with its commonness.

You made me like it

2010-11-23T09:02:00.002-05:00

Grand Rounds, the weekly rotating carnival of healthcare blogs, is in its seventh year.

This week we're trying something different.

Grand Rounds will be hosted on a blog, as usual, but this time it's a Facebook site (The fact that this is our first veterinarian host is noteworthy as well).

Earlier this year we launched an online presence for Grand Rounds on Facebook (and Twitter). The justification? Facebook is now the #1 website in the US, accounting for one in four pageviews. This is simply where a lot of people spend a lot of time online. Facebook already drives more traffic to media sites than Google; it stands to reason that smaller sites like blogs would also benefit from FB's social referrer approach, alongside the Grand Rounds showcase or Google's PageRank valuation.

But what about blogs that make their home in Facebook's Pages? It was really just a matter of time. The original blog carnival model guaranteed a weekly spotlight and flood of traffic to the host. Some people would visit, maybe browse the archives, and add the host blog to their bookmarks or RSS readers. There's nothing about that scenario that's not possible with Facebook blogs, and their "Like" feature is arguably more intuitive and manageable than earlier ways of subscribing.

I had said before that Facebook, by virtue of its accounts being tied to real names, would encourage an era of more reasoned and responsible blog commenting. I expected that quantity of comments and posts might fall, the quality would rise -- an antidote for the trolling and choir-preaching that substitutes for real conversation at many sites today. This week's host, however high-quality her posts, is not a real person. The team behind "Amanda Brown, DVM" can write at will, and leave comments on other pages, with some level of professional protection.

What that means for the future of online healthcare discourse is not clear, but the I suspect this degree of anonymity, plus the ease of "Liking" and the fact that so many of people visit FB regularly already, will encourage more people to use Facebook as a platform for their healthcare musings. And they'll be welcome to host Grand Rounds.

1010 Wins

2010-10-10T16:08:00.000-04:00

Calendar trivia has always interested me. And we've lived though some special dates, from the turn of the millennium to 9-02-10 day last month.

Today is no exception. And like 1/2/03 at 4:56, today we could experience a couple of memorable minutes.

But a few moments' thought on the matter leads me to believe that the high frequency of notable dates we've been enjoying is going to come to an end soon.

Another endangered calendric item: those plastic eyeglass-like frames that attain ubiquity every New Year's Eve, since the 1990 (or even earlier). In fact, for most of my life, each year has featured at least two bulbous numbers, ideal for making zany celebratory glasses (if I'm not explaining this well, see here).

I think this comes to an end for 2011. The impact on the economy is difficult to estimate.

Common disaster

2010-09-07T14:43:00.000-04:00

I love this town. In the event of another disaster in NYC, I want to be able to help. So, years ago, I signed up for the NYC Medical Reserve Corps.

While I thought my services as an emergency physician might be of benefit someday, now I wonder if the most pressing need was for an interface & usability expert. Either that, or years of Google and Apple interfaces have spoiled me to the point where navigating forms online is pretty much unbearable.

The way I understood NYC Medical Reserve Corps (MRC) is this: you sign up. You give some details about yourself and your skill set. You give contact info. The city calls or emails you periodically to verify your info. We all stand ready to help.

Members recently got a flurry of emails about some kind of upgrade. New logins would be necessary, more features, etc.

Here's one small section of the process:

Scroll down to “To become a volunteer, click on the Join Now button.”
Enter NYC MRC ID and ServNY password, Click on ‘Log In’.
When prompted, enter NYC MRC PIN, Click on ‘Continue’.
To “Confirm your identity”; Enter last 4 digits of phone number or 5 digit zip code.
Click on ‘Continue’. You have now ‘claimed’ NYC MRC records. Continue to Step 3.

But first you've got to get a ServNY userID:

Change drop down box “NYC MRC ID” to ‘Yes’.
Enter NYC MRC ID and NYC MRC PIN from Go Live/Welcome letter. Case-sensitive. NOTE: PIN is listed as “password” in Go Live/Welcome letter.

It goes on and on like this, forcing you to refer to info from multiple websites and emails. As you fill in the fields, there's often no indication when something worked or didn't. I thought I completed the process on several occasions, only to be unable to login later, or receive a reminder email asking me to repeat the same steps.

To be fair, NYC MRC has offered to help, and set up phone numbers and better step-by-step guides. But I'm also not sure why we're even being forced to re-register. Don't they already have my contact info? Isn't that pretty much all that's needed?

I think, like with many systems and institutions, something got lost along the line, and a simple volunteer network became a massive bureaucracy. The simple act of offering to help, and providing contact information, is now insufficient. There's too many hoops to jump through, for the privilege of helping New Yorkers.

Brothers in arms

2010-09-02T07:25:00.004-04:00

It's happened again.

Almost every day, I get a brochure or three about courses, credentialing, or some educational opportunities for doctors. I thought it would let up when I passed the boards, but no.

On many of them, there's stock photography like this:

http://www.fotosearch.com/UPC005/tre01014/

http://www.fotosearch.com/RBL008/a01394/

http://www.fotosearch.com/BLD131/cb0408awh_0528/

http://www.123rf.com/photo_3193578.html

http://www.istockphoto.com/stock-photo-8149905-lady-doctor-standing-with-her-arms-crossed.php

http://www.fotosearch.com/OJO105/pe0007596/

http://www.istockphoto.com/stock-photo-11943832-female-doctor-smiling-with-arms-crossed.php

http://www.istockphoto.com/stock-photo-10361626-happy-mature-doctor-with-his-arms-crossed.php

http://www.istockphoto.com/file_closeup.php?id=12217867

If you're too lazy to click the link, that's ok, I'm too lazy to import the pics. I'll save you some time:

Everyone one of these pictures, and most of these brochures, feature a doctor with his or her arms crossed. Often, they're looking at the camera, with an air of seriousness and, I daresay, a trace of disapproval.

I can understand maybe patients seeing us this way -- we have some experience and education, and a lot our workload comes from theoretically preventable disease. So a doctor with arms folded might work if you're trying to sell treadmills or grape nuts.

But is this an image that works on other doctors? Are we more likely to sign up for a board review course if it's offered to us by a stern, standoffish colleague?

Then I think back to medical school, and realize: of course.

Get it together

2010-08-29T15:43:00.001-04:00

Bill Simmons sometimes pokes fun at the journalism cliche of collocated words that rarely appear apart from each other -- you don't often see the word 'ruffled', and when you do, you know the word 'feathers' is likely to be close by.

There's a similar phenomenon in medicine, though I stubbornly have refused to acknowledge it.

Consider the followed dialog that transpired during a recent overnight ED shift:

Resident: "I have a 32 year old woman with hyperemesis. I'd like to start antiemetics and IV fluids."

Me: "Is she pregnant?"

Resident, befuddled: "Um, yeah? I said she has hyperemesis."

Of course, the resident was using hyperemesis to denote hyperemesis gravidarum. But really, hyperemesis just means lots of vomiting. Just because it's rarely used outside the context of pregnancy, it doesn't mean it's not a useful term (indeed, cannabinoid hyperemesis is another entity we sometimes see in the ED.)

What other terms get truncated like this? Anorexia nervosa comes to mind -- saying "the patient has anorexia" literally just means there's a lack of appetite, not a lethal eating disorder.

I'm sure there are countless others, but I'm wondering: could any of these medical terminology shortcuts lead to particularly dangerous misunderstandings?

I don't think anyone would mistake a triad for a joint if a colleague said, "they've got Charcot..." On the other hand, abbreviating the confusing term "superficial venous thrombosis" could lead to a mixup in therapies...

Program Note

2010-08-27T13:09:00.001-04:00

Bora's back hosting Grand Rounds this coming Tuesday at his site, Blog Around the Clock -- but I'm going to help him collect submissions over the weekend. Please email me a link to your best recent material at nick /at/ blogborygmi.com (a little blurb is helpful, too)! Deadline is Monday night.

How'd you get to be happiness

2010-08-24T21:54:00.000-04:00

Somebody at Apple likes Goldfrapp.

They've used her latest album for this tutorial (scroll down) and the sublime Seventh Tree was pictured on the first Apple descriptions of the Remote app.

It's nice when a monolithic institution shows a little personality.

Of course, my interest in Goldfrapp is mostly professional -- who else has sung as well about ending up in an emergency department?

Independent point of view

2010-08-22T11:45:00.051-04:00

Here's a confession: Despite my steadfast advocacy of medical blogging as a means to promote understanding and education, I continue worry a lot about professional liability. Not just whether the things I write could hurt my career, but, in terms of academic output, is blogging a waste of time? What view does my department's leadership take on blogging?

Still, I've continued to support medical blogging as a useful academic endeavor, hoping that someday this support would be borne out. When sites like Sermo and Facebook came along, I despaired that more physician opinions were going to be hidden behind walled gardens, available only to select colleagues or friends.

Then, last week, some revelations -- I discovered a member of my department's leadership was blogging, or at least, had commented on a blog. How about that!

The other revelation? Facebook may be the last great hope for academic discussions to flourish on blogs.

This all arose from a pretty academic question, about emergency department implementation of electronic medical records. Does the degree of implementation (full, partial, or none) impact patient wait times in the emergency department?

This is a good question, and has been asked many times by doctors, administrators, vendors, and researchers. And naturally, the answer depends. Some implementations of ED electronic systems have been very successful -- here's a nice example that I helped write. Of course, skeptics can point to a lot of disastrous implementations (Over at EPMonthly last year, Kevin Klauer summarized the skeptic's viewpoints very well, and I've covered some stylistic objections to EMR in the past).

While ED adoption of electronic medical records was always an expensive question, with last year's ARRA's provisions for stimulating health IT spending by tying medicare reimbursements to meaningful use of electronic medical records, this has become a political issue, as well.

Enter the medical blogosphere. Specifically, the WSJ blog post covering this new paper by Furakawa on electronic information systems and emergency department wait times.

Furukawa's retrospective analysis of ED length-of-stay and other metrics was based on a 2006 database of 364 hospital EDs, and a separate assessment of degree of EMR implementation (how many functions had been turned over to electronic systems). He found that the 1.7% of EDs that had the most robust implementation of EMR had 22.4% shorter length-of-stays than those with no or minimal electronic records. This was statistically significant.

Interestingly, he also found a statistically significant increase in time-to-physician (which he calls wait times) in EDs with basic (not full, not minimal) implementation of electronic medical records. This effect was more pronounced among lower acuity patients, but it was present among even the very sick patients.

Got that? Both are interesting findings, inviting a lot of questions. The academic in me wants to dive into how time-to-physician was measured, how variations between sites were normalized, what wait times were like at these centers before partial EMR implementation, how these changes in length-of-stay compare to other interventions or factors in ED crowding, etc. I would love for this to be what discussion centers around, though that kind of discussion remains rare in the blogosphere.

What we got instead was this:

The reports on adversity from HIT are being stifled by the HIT industry. They are not being posted fast enough to convince the White House that it is a collossal waste of money and time to conduct an unregulated experiment using unconsented patients at the behest of the HIT industry and vendors. Tuskegee Project was similar, except for the race factor. They took the downtrodden and subjected them to disease.

With EMR HIT, they are taking the downtrodden (sick patients) and subjecting them and their care to HIT medical devices that have no proof of safety and effectiveness.

Wow, huh? If you had told me Tuskegee would come up in a discussion of medical records, I would have assumed the comparison was between staying with paper charting in 2010 to leaving syphilis untreated in 1972. And I would've said that's an awful, hyperbolic comparison that doesn't advance the debate.

But to hear Tuskegee invoked against electronic records? Well, I don't know where to begin, other than to note Godwin's Law states that any web debate will eventually degenerate into one side comparing the other's to Nazism. So I guess we have that to look forward to, and Tuskegee is just a waypoint on that journey. Or maybe this is a calculated attempt to move the Overton window, so that an idea that seems quite reasonable is suddenly perceived as unthinkable...

Another element to this "debate" is that other commenters let anonymous posts like the one above slide without criticism, but when an ED informaticist chimes in with their real name and opinion, they're immediately pressed to disclose conflicts of interest, and cite their sources. That's all well and good, but where's the parity? These demands seem like they're coming from other physicians but oddly enough, when I google these commenters' names I only find... other WSJ blog posts.

Anyway, the poor quality of blog comments has been lamented for years, on many forums. It's just the first time I've seen the ugliness come to my area of research.

It's particularly discouraging, because if trolls and narrow-minded partisans can hijack and debase a blog discussion (and, presumably, discourage participation from more sources) in one of the few areas I've actually studied, what hope is there for learning from the comments on other topics? And has this stifled the development and legitimacy of academic blogging?

I find myself wondering, for the first time, if networks like Facebook might actually be helping foster online discussion, by tying people's online comments elsewhere back to their account.

Facebook founder and CEO Mark Zuckerberg was derided this spring when he described having different online personas as "a lack of integrity." And I understand the critic's perspectives -- there's real value in keeping some characteristics or interests private, and in keeping one's public comments anonymous, or at least, separate from other realms. And I've always liked that it's the discretion of the blogger or publisher to allow comments at all, to let them stay anonymous, or to force commenters to use a real email address or name.

From a different perspective, however, I think it's generally assumed that, if commenters were forced to use real names (or tie their comments to, say, a Facebook account), that the quantity of comments would plummet, but the overall quality would probably rise. My question is: Does this rise in quality offset the decline in quantity? In the past I would've said no, but now I'm not so sure.

Citations from Edelman's New Media Academic Summit

2010-06-24T20:11:00.000-04:00

I spoke today at the panel on transparency at Edelman's New Media Academic Summit. Ben Boyd was the moderator and Ellen Miller from the Sunlight Foundation was my fellow panelist.

Reviewing some of the #nmas10 tweets from the audience, I figured I should provide some links for the anecdotes I mentioned:

BID CEO Paul Levy's blog is still the starting point when talking about transparency in medicine today. I had the chance to speak with him, a few years ago.
Ed Bennett has done an extraordinary job following hospital social media adoption and highlights effective new media policies, as well.
Hospitals are using twitter and billboards to broadcast ED waiting room times. This is not without risk, as billboards may not clarify the triage process, where seriously ill patients will be seen right away
ACEP president Angela Gardner's Twitter feed and ACEP's blog.
A recap of Better Health bloggers' meeting with Rep. Jack Ryan last summer during the healthcare reform debate.
Recent articles from NEJM and JAMA articles on med students and social media.
A lot of the developments in openness in peer review, and the world of grant funding, are chronicled at Nature's Peer-to-Peer blog. Bora Zivkovic has been and active and articulate defender open publications, as well.

Special thanks to Dr. Val Jones of Better Health for getting me involved with this group.

Warm impermanence

2010-06-08T14:00:00.001-04:00

I'm back from SAEM's Annual Meeting, and catching up on a boatload of emails and unread items in my RSS feed. Something's gotta give when social media use goes into high gear, but one of the things I missed was my own article in EPMonthly on using technology to keep current. Kind of embarrassing.

Anyway, some of the resources I highlighted were the same that Graham Walker mentioned in his comprehensive review of E-learning for EM. We're definitely entering a golden age for electronic resources in our specialty, and the tools to archive this material and make it quickly accessible are also coming along nicely. It's also reassuring, when others point out the mental risks from internet info consumption, that I've met so many accomplished and sharp people taking the plunge into this new media. What is it with early adopters, anyway? This quote comes closest to explaining the phenomenon, among any I've read:

I find that the early adopter mentality is widely misunderstood: Journalists going for a sociological angle on the people in line for iPads, for example, focus on a desire for status or attention, or to be first on the block. They completely miss the point. They don't understand that the desire is for the thing itself and for what it can do; that we imagined this device before it was announced; that we're constantly bumping up against the limitations of what's available today; and that when these things finally appear in stores, we say "At last!" And then we buy them, and use them, and immediately get frustrated with its shortcomings and start waiting for the day when the next model comes out.

This text was waiting for my in my RSS reader, and when I came across it I naturally tweeted the link, as well as added it to Evernote, before reprinting it here.

Can't buy a thrill

2010-05-02T12:10:00.000-04:00

Many of the peculiar terms and phrases we learned in medicine have found a new use in cyberspace, as titles of websites (consider 10 out of 10, The Central Line, or this blog -- and that's just emergency medicine sites).

But that's the virtual world -- what about the real world? This past week I saw a couple of products that make me think medical parlance could sell physical products. Consider:

This is Spinal Tape (via Joshua Schwimmer)
Drug of Choice coffee (via Rob Lamberts)

OK, fine, it won't really be a trend until Wendy's is selling STEMI-burgers or we see Throckmorton-branded condoms. But I wonder if this could someday happen, given the improving economics of niche marketing. Or maybe the general public, through realistic TV shows and, yes, blogs, has picked up on enough of our lingo to make this work?

I can't say. But I'd like to remind readers that you can enjoy your Drug of Choice in a lovely, professionally-designed mug, on sale now in storeborygmi.

Pad & Pen

2010-04-08T14:54:00.001-04:00

My piece on the iPad's potential in emergency departments is now up at EP Monthly. Check it out -- especially the ambitious developers who've left comments.

The speculation about this device in healthcare has gotten a little more detailed -- and optimistic -- as people have had the chance to use it this week. Other insightful comments are available from Larry Nathanson, Chilmark Research, and John Lynn.

A new kind of tension

2010-02-12T09:49:00.007-05:00

There's an adage I often think about: "A physician's job requires the expression of confidence. The researcher's role is to express doubt."

This was never more apparent than when I transitioned from the research environment into the clerkships of medical school. The language of decision-making had abruptly changed -- in the lab, a year's worth of experiments is summarized with "seems" and "suggests," and every assertion is carefully calibrated to acknowledge uncertainty and a high standard for proof.

As a student on clerkships, I couldn't quite wrap my head around the residents' ambitious plans for patients:

"Check CBC, electrolytes, chest X-ray, EKG, oh, and, he needs a head CT."

This use of "need" too often seemed careless to me, as if any patient could need a test that was almost certainly going to be normal, that in most parts of the world would never even be considered.

But in the residents' perspective, I came to understand the head CT was just an expected component of the patient's management -- it had nothing to do with likelihood ratios or pertinent life-threatening conditions that must be explored -- it was simply part of the story for certain patient scenarios, and couldn't be omitted without raising a lot of questions.

"We should also check a TSH level."

Few patients ever needed a TSH level, as far as I recall -- this wasn't something that would hold up discharge, for instance. But checking thyroid function was often something that should also be done. Again, not because the residents had a firm grasp of the prevalence of thyroid disease in certain populations, but rather, because it demonstrated a thorough workup and, while not an essential or expected part of management, was nice for the attendings to see.

Over time, I gradually adjusted to this very nosocomial interpretation of "need" and "should." Now that I'm an attending, and the students' and residents' plans are a lot more hypothetical (until they get my approval), I'm hearing a little more "want" and "think" and "maybe." For me, it's a welcome return -- a language more in line with my background, and one that acknowledges the uncertainties of medicine.

Some inner truth of vast reflection

2010-01-28T15:11:00.000-05:00

I've seen a couple of examples of this now, so I've decided it's a trend. Naturally I'm going to excerpt something from which to base this post:

This sentence claims to follow logically from the first sentence, though the connection is actually rather tenuous. This sentence claims that very few people are willing to admit the obvious inference of the last two sentences, with an implication that the reader is not one of those very few people. This sentence expresses the unwillingness of the writer to be silenced despite going against the popular wisdom.

I've got further evidence to back this up from this humerous video (though I won't embed it for stylistic reasons).

A pithy observation is shared, and of course, a link to a prior discussion on Metafilter.

After all this deliberation, I've got to conclude this trend has pros and cons, and a lot of unappreciated nuance. I just hope it turns out alright.

Into a void we filled

2010-01-19T11:14:00.006-05:00

I had a bunch of difficult shifts midweek last week and a lot of charts to complete, afterward. That, plus some other obligations, and I had fallen behind on emails -- to say nothing of the news. So while I had heard a little bit about the earthquake in Haiti, I hadn't really reflected on it.

Gmail had grouped the following messages last week from CNN -- all sent within a few hours of each other -- into a thread:

CNN Breaking News: Hundreds of thousands of people have died in Haiti's earthquake, the prime minister told CNN today.
CNN Breaking News: President Rene Preval tells CNN that Haiti lacks capacity to hospitalize quake victims, asks for medical aid.
CNN Breaking News: R+B singer Teddy Pendergrass has died at age 59, CNN has confirmed.

So forgive me, I knew something terrible had happened but I was having difficulty putting it into context.

This isn't necessarily new territory. But, much like with Katrina, the enormity really only sinks in, for me, when I read physician's accounts from the front lines. Something about comparing the challenges of working in my electronic ED with the endless supplies, state-of-the-art equipment, and an army of readily available specialists, to what these doctors are going through, conveys the horror more than a thousand breaking news updates or footage of crumpled buildings.

Some informative, and responsible, medical accounts are available online (1,2).

Here's a dispatch from a former colleague with ties to the area:

My husband and I hitchhiked it to port au prince from the domincan republic; the devastation is of incredible magnitude; [X] and I both have family here; his father was pulled from the rubble alive after having been trapped for 16 hours; fractured ribs hand and leg ; his brother and stepmother killed; we are still looking for 2 nephews; [X] and I stay on opposite sides of town since food and water are scarce; we are helping our families to ration; at night we sleep on the roads the only safe place since after shocks are still being felt daily; hospitals have turned away thousands so I care for whomever I can in the meantime; I delivered a baby on the sidewalk this morning; please send this email out to our colleagues and ask them to send whatever resources they can; the various teams deployed have still not covered a large portion of the city that is in need of assistance; I have still not been able to get in contact with my medical mission group for lack of communication.

People have been bellyaching about disaster journalism cliches for close to 40 years, but the physician-as-reporter is a new wrinkle that's coming under some scrutiny. From my perspective, I find the physician dispatches very helpful for contextualizing the disaster -- at least, until these doctors' heroics start to become the focus of the story, instead of the lens from which to view it.

Comment te dire adieu

2010-01-15T07:10:00.003-05:00

A longtime reader wrote to ask if I had removed comments because they were a relic in this age of facey-spaces and tweety-pages.

That's when I realized my comments had disappeared.

Haloscan, which had faithfully been providing free commenting to this site long before Blogger.com could, is now under the control of another company. There was a warning sent to my email before the holidays that I promptly forgot about. And then sometime after Grand Rounds last week my comments were gone; not with a bang but a whimper.

There was a brief period of panic but fortunately, my login still worked on Haloscan.com and they let me download the 1279 comments blogborygmi has accumulated over the past six years. Folks are working on ways to import these old comments to Blogger. In the meantime, I've enabled Blogger's new (to me, at least) comment features.

Of course I understand after a growth phase, there's a need to convert resource-intensive services into sources of profit, even if it means charging for something that used to be free. I just wonder if the new owners of Haloscan (JS-Kit? Echo?) carefully thought this through:

They had a small group of early adopters who wanted comments on our blogs, long before a major platform offered them.
We were happy enough with their service to stick with it, for the better part of a decade, even after more robust (and free) versions were offered by competitors.
For various reasons, they needed to move us to a flashy new system.

Were they really counting on us to start paying for this unnecessary new service? Or, put it this way: was there no other way to offset the cost of making a few blog veterans happy? It seems like they could upgrade us to the new platform for free and maybe get some positive, genuine word-of-mouth publicity, which I'm told is something bloggers have a knack for. Or, I don't know, maybe they could offset the cost by including advertising -- I've read there's some money in that.

Oh well. An opportunity for them has been lost, and for me, some old lessons have been reinforced. What about you? Feel free to leave a comment below.

My one lucky prize

2010-01-10T23:58:00.001-05:00

GruntDoc's got a neat little post up how he infers his hospital's census:

My way to work goes through one of our myriad basement areas, the one where empty beds are stored. I’ve seen literally none, and a lot.

The other night there were so many I couldn’t believe it. Our count is down. This, too, shall pass.

Follow the link for dramatic photo evidence.

These sorts of indicators are fun -- almost as elegant as the Ambient Orb sitting on the desk of Beth Israel Deaconess CEO Paul Levy, gently alerting him to the status of the emergency department waiting room.

Though I can access my emergency department's information system from home, and thus check ED crowding before my shift (if I see lots of admitted patients waiting for upstairs beds, the hospital's pretty full), I rarely do so. I'd much prefer the Orb's distilled, wordless updates to the information overload from our EDIS.

The other day, I got a new kind of indicator about the hospital's census. I had admitted a patient with a history of MRSA to an isolation bed, only to learn a short while later he was ready to go upstairs. This was surprising, as isolation beds are in short supply and patients frequently wait many hours in the ED for one (if not a day or more). In fact, the floor nurse was suspicious I had listed him incorrectly to a regular room, with a vulnerable roommate.

I called our bedboard to make sure they got the right listing. They told me the census was low enough to permit them to turn double-bed rooms into single isolation rooms (in college we called these "dingles"). I don't think I'd ever heard of that happening in our hospital, before -- though like GruntDoc I realized this, too, would pass.

Grand Rounds Volume 6, Number 15

2010-01-05T08:00:00.004-05:00

Welcome to Grand Rounds, the weekly collection of the best in medical blogging, featuring works from physicians, nurses, researchers, students, patients and healthcare professionals.

It's a new year and I'm very happy to be involved again in organizing this "carnival of the caregivers." Many thanks to Dr. Colin Son for his role in scheduling hosts, and for writing the Pre-Rounds column for Medscape.com over these past 18 months. Special thanks to Dr. Val Jones of Better Health who will continue to promote and plan GR.

This is the 327th edition of Grand Rounds, and navigating web is pretty different compared to when I first hosted. I've been stubbornly resisting social media to help spread the word about each week's location for Grand Rounds, figuring quality writing will find a way to reach interested readers. But when you consider that the Grand Rounds community of patients, providers and pundits is its own kind of social network, it only makes sense to adopt these new tools.

And so, this week, in addition to the RSS feed and Google Calendar, we're rolling out the @grandrounds twitter account, and a Grand Rounds fan page on Facebook.

These (still comically underdeveloped) resources are hardly groundbreaking innovations in 2010, but then again, the blog carnival concept wasn't new when Grand Rounds started in 2004. Your suggestions to keep Grand Rounds accessible and relevant are always welcome, and your continued participation -- as readers, contributors, and hosts -- is essential. Thank you for your involvement over the years, and be assured, even with this expanded social presence, the purpose of Grand Rounds will always be to showcase excellent writing from independent voices in the medical field.

I've loosely organized bloggers' contributions in the categories below, but first wanted to take a moment to highlight my favorite post of the week:

Editor's Choice

Evan Falchuk of See First blog brilliantly deconstructs the popular new National Geographic chart on health care spending and life expectancies across the world, bringing clarity and nuance to a gross oversimplification.

Medical News and Reviews

In a timely post for air travelers, Dr. Ves Dimov of the amazing CasesBlog website examines the radiation exposure from full-body scans used for advanced airport security screening.

The Blog That Ate Manhattan has the definitive take on the new mammography guidelines.

What killed Franklin Delano Roosevelt? Dr. Ramona Bates sifts through the photos and reviews the evidence behind "FDR's Deadly Secret" over at Suture for a Living.

Healthline's Teen Health 411 blogger (and recent GR host) Nancy Brown, PhD, reviews new data and concludes parents shouldn't panic about "sexting."

Smile! Inside Surgery looks at tetanus, part of the continuing series of concise summaries of commonly occurring medical conditions.

What just happened? Doc Gurley condenses all the medical news of the past year into a hilarious recap: Top 10 Health Lessons of 2009. Read it, lest you be doomed to repeat that bizarre year.

Healthcare Policy Views

If you're concerned about a nursing shortage, David Williams of Health Business Blog wants to reassure you, by welcoming robots and immigrants to fill the nursing shortage.

In the latest from his Careful What You Wish For series at InsureBlog, Henry Stern contrasts his wife's recent mammography scare in the US to shortcomings in the UK's NHS system.

In the US, electronic health record adoption is getting a boost from the government -- providers will receive incentives for "meaningful use" of EHRs. David Harlow of HealthBlawg thoughtfully reviews of the new definitions for meaningful use – a must read for those of us in health care informatics.

You've heard about patients in Canada or the UK who endure long waits to see specialists -- but did you know that less-educated patients wait longer? Over at Colorado Health Insurance Insider, Louise looks at why socioeconomic status influences wait times.

Dr. Val has a call to action for preventive health, asking readers to channel their frustrations over healthcare reform into staying fit and trim for the new year. That'll show 'em!

Case Reports / Notes from the Front Lines

What happens when a son tries to 'drop off' his father, and treats a hospital like the adult Humane Society? The Happy Hospitalist becomes unhappy, and is forced to explain hospital admissions.

Emergency Medicine blogger Chris Nickson at the Life in the Fast Lane blog writes about an unexpected ending to a family meeting about a dying patient, in his post: Bad News Broken.

In a very personal post, Todd C. Williams reflects on his wife’s medical care and draws comparisons to his own work in project management.

Dr. Charles has examined his recommendations for exfoliating soap -- we can scrub off dead skin, but those little plastic microbeads from the soap will come back to haunt us, in surprising and sad ways.

At a blog called Own Your Health, medical journalist Roanne Weisman reflects on lifestyle choices and a family member's death, and concludes: she didn't have to die.

Good Medicine for the New Year

Sad that the holidays are over? You can still give the gift of information (and peace of mind). Paramedic, author and businessman Greg Friese describes four methods people can use to compile medical history and emergency contact info.

A blogging therapist named Will Meek (prediction: large inheritance) reflects on some common blurred thinking from a psychotherapeutic perspective, and offers some simple checks to keep folks grounded.

Julie from The Doctor’s Rheum brainstorms some creative and inexpensive ways to address excuses for lack of exercise in the new year.

Dr. Jolie Bookspan recaps readers' success stories from the past year in her Fitness Fixer Reader Hall of Fame.

Thank you for checking out this first Grand Rounds of 2010. Please visit DrRich at the Covert Rationing Blog for next Tuesday's edition!

Call for submissions -- Grand Rounds @blogborygmi on Tuesday January 5

2010-01-01T20:29:00.002-05:00

The first Grand Rounds of the year will appear here, at blogborygmi.com, on Tuesday morning.

The deadline for submissions will be Monday 1/4/0910 at 11:59 PM EST.

Please review the ancient but still relevant submission guidelines and email a link to your best recent writing to nick -at- blogborygmi.com, with a short description.

Also, please -- if you'd like to try your hand at hosting, or know of a blogger who'd make a great Grand Rounds host, please let me know. It's a wide-open year ahead of us.

Finally, if you've got suggestions for improving Grand Rounds -- social media integration, organization, anything -- I'm happy to listen.

Sleepwalking

2009-12-15T03:47:00.000-05:00

Today the NY Times printed a piece pokes fun at, and highlights the dangers of, the new habit of texting-while-walking:

This summer, the American College of Emergency Room Physicians released a statement expressing concern about the issue, citing a Chicago doctor who was seeing a lot of face, chin, eye and mouth injuries among young people who reported texting and tumbling.

Hmm... I'm a member of ACEP, but I've never heard of ACERP. Is it some rival organization of emergency physicians whose practice is confined to four walls? Or, in its rush to condemn new technologies that enable communication on-the-go, has the New York Times abandoned the traditional practices of editing and fact-checking?

More play time than money

2009-12-10T16:40:00.000-05:00

Much has been written about health care reform, but there's something that's gone unremarked upon, as far as I know:

I don't think I've ever seen this much attention to legislative procedure.

And it's kind of remarkable, really -- just look at some of these mainstream news stories from Slate or the New York Times. And it's been like this for months now.

I remember briefly some discussion of the constitutionality of filibustering in relation to Bush judicial nominees a few years back -- the trivia around the nuclear option and all. But in all the big legislative debates I can recall, from the Brady Bill to NAFTA, DMCA, McCain-Feingold, the PATRIOT Act, Medicare part D and TARP, I don't think there's been such coverage of rival committees, proposed amendments and procedural maneuvers. I can't recall a time when so many different senators and representatives were regularly featured in the news.

There's probably some way to measure this -- counting mentions of the term "cloture" in the news over the years, perhaps, or determining the frequency of senators' names appearing in print.

Who knows? Maybe I'm just paying more attention this time around. But I'd bet the proliferation of punditry, speculative markets and blogs has spawned more detailed reporting.

It's not at all clear whether this increased reporting on legislative procedure translates to a populace more informed on policy options, although I'd wager that's the case. And while I'm sure there are still plenty of back-room deals and shady lobbyist rewrites, this increased public engagement and scrutiny of the legislative process has got to be a good thing, overall.

What I'm wondering is: What would have happened to all the vitriol over healthcare reform, if we didn't have all these frequent, detailed updates? Would we have seen less heated rhetoric, or could more have been possible?

Protect your language

2009-12-08T16:28:00.002-05:00

The Efficient MD's eyes are opened by the nasty thoughts Google Suggest offers up when someone starts typing "Doctors are..." Since Google Suggest lists only common results with which to complete your queries, it seems that the most common thing people think about doctors online is that we're "overpaid" or "jerks" or "dangerous" or, most commonly, "sadists who like to play god."

Surveys show people consider doctors to be among the most respected professions. So what gives?

Well, I've been paying attention to what Google can tell us about ourselves (the first Google Talk was a lot less useful, but arguably more interesting) for some time. But even before I knew Google Suggest was a weird and limited tool, I knew this:

Declarative sentences are the only kind of sentence that can be proven or disproven. Yet the people who use them most -- and favor the short, simple variety of declarations --are often those least interested in arriving at truth.

That's my guess why those "Doctors are..." statements seem so unfriendly to doctors.

You can find more head-scratching or downright funny Google Suggest screenshots here... It seems that questions from school assignments often find their way into Google Suggest. Finally, here's an analysis suggesting the way the start of a question is phrased implies a certain sophistication of query.

While you're deciding

2009-11-21T17:52:00.003-05:00

I took my board exam this week, and I think I liked it.

Which is not to say it was easy, or even altogether fair. And though I felt a little bit better upon finishing than these folks, I could be grossly deluded in my estimation of the number and trickiness of truly tough questions.

But there was a point in the exam, three or four hours into it, when I was overcome by the sheer variety of extraordinary patient presentations -- the environmental catastrophes, bizarre overdoses and bites from creatures great and small. Overcome, not because I've never seen patients like this (for the most part, I haven't) or because I didn't know how to diagnose and manage them (I think I did), but really because these questions underscored what an amazing specialty I've chosen.

I like that my specialty board expects a mastery of emergency topics on which there's no consultant to turn to, and that they expect me to be able to work in any part of the US -- places where snake bites or diving complications or altitude sickness is more common than my neck of the woods. Too often in emergency departments, we get caught up in managing patients with existing, complex diagnoses -- transplants, hereditary disorders, and the like -- who present with a list of specialists to notify. It's nice that our board has crafted a curriculum and though their exam, reminds us that at least occasionally, our medical input is indispensable.

Favorite parts of the exam (that I can mention in an open forum):

Taking the exam at 500 Fifth Avenue, an overlooked gem of a New York City skyscraper. In any other city, this 60-story art deco tower would be celebrated, iconic. In midtown, however, people's attention is drawn to the nearby New York Public Library and Grand Central Terminal, just a block or two away, as well as the other towers along 42nd Street -- Chrysler, Grace, and the new Bank of America building. But 500 Fifth is worth a closer look, if only to draw a comparison to the tower its developers built immediately after, a little farther down the street.

I recently co-authored a short "chapter" in a review book about a rarely-encountered (by me, at least) ophthalmological emergency. It was on the board exam!

When you walk into this Pearson testing center, you take a number -- and that's the testing station you're to which you're assigned. I took Number 14. The lady behind the desk called Number 12 to snap his picture and get him registered. Then, she called on me. When I jokingly asked what happened to Number 13, she replied something to the effect of: "You doctors may not be superstitious but we know better than give someone that number."

Of course, I do have a few gripes:

For an electronic exam that's criterion-referenced (not curved), it seems odd that it'll take so long (usually 40-50 days, I think they reserve the right to take 90 days) to score it.

A huge fraction of the exam -- by some estimates, a third of all questions -- are experimental. I recognize the examiners' need to know how challenging or fair new questions are before making them "count" -- but when so much of a test is, well, untested, the examination process becomes an exercise in confusion and frustration, and it becomes impossible to gauge one's performance. By the time the scores come, months later, an opportunity for constructive feedback has been lost. Maybe this is ABEM's way of simulating the actual practice of emergency medicine? As a recent grad, let me suggest: why not experiment more on the residents? There's a lot of them, and their inservice exam is free (yes, I spent nearly $1000 for the privilege of taking a largely experimental test -- shouldn't it be the other way around? Maybe ABEM could offset some of the cost by letting us choose how much of the exam day will be spent giving them data on future questions).

For a specialty that prides itself on recognizing zebras and considering the life-threats for even the most benign presentations, the exam has an unseemly predilection for "most common" questions -- the most common bug responsible for a given infection, the most common age group affected by a given disorder, etc. I know some demographic information and context is important, but these questions arise so often, it's almost as though the board doesn't want us to use broad-spectrum antibiotics, for instance, or work up younger adults with chest pain.

All in all, though, the exam experience was ok -- and not as bad as I was dreading. I just hope I don't have to repeat it.

Look at my circumstance

2009-10-15T14:45:00.000-04:00

Here I am at the medblog track at Blog World Expo '09. I'm finally meeting some of the authors I've been reading for years. Then GruntDoc, one of my 'blogfathers', gives me grief for not posting more.

Well, to sate his appetite for new junior faculty sticking their necks out, here's some thoughts on the mandatory H1N1 vaccine that I put together for EPMonthly.

More to come, after the panels, dinners, and afterparties...

Can Web 2.0 improve this post?

2009-10-07T06:12:00.000-04:00

If you were curious about some of the Web 2.0 sites or services I mentioned today in my talk, links are available below:

Here are the EM ultrasound resources I mentioned:

A peak you reach

2009-07-24T10:35:00.004-04:00

Friends visiting New York City this summer keep asking if it's safe. As in, will they be catching and suffering from novel H1N1 (swine) flu.

I like to think my friends are pretty sharp, discerning folks (after all, they're choosing my company) so I have to attribute these inappropriate questions to a wider problem.

For reference, here's the latest though probably not last NYC DOH guideline on H1N1, which notes about 900 hospitalization and 45 deaths in H1N1+ patients over three months. About three quarters of these patients had at least one risk factor such as existing lung disease.

This deaths and hospitalizations are concerning, naturally, but some perspective is in order: as many as half a million New Yorkers have been infected with H1N1, and this spring in US cities, we actually saw a smaller fraction of deaths due to infectious respiratory illness, compared with 2008. Also, for reference, based on data from a few years ago, I'm guessing that any given three month period, there are between 10,000 to 15,000 deaths in New York City.

So why were ED's swamped in May? Why are my friends still afraid to come to NYC? Dr. David Newman has some thoughts in EPMonthly:

...with constant messages of swine flu lethality on the nightly news, it is little surprise that ED’s in New York City, departments in a chronic state of over-crowding and crisis, were soon bursting at the seams with record volumes. In some institutions daily ED volumes doubled, as EP’s worked through third-world conditions of extreme crowding, questionable hygiene, extended wait times, and swarms of infectious, coughing congregates all within arm’s reach of each other.

The impact is clear: lives were lost. High quality studies have shown repeatedly that when ED’s experience crowding patients in need of rapid, high intensity care are identified later, treated more slowly, and devoted fewer resources. Mortality goes up during crowding in virtually every condition that has been studied, including MI, sepsis, and others. The irony is stark: Once a critical mass is reached, the more that come to be saved, the fewer we can save.

...The overall management of information during the swine flu of 2009, despite some progress in our access to information, was misguided and dangerous. Frantic media outlets drove a nation to fabricated fears, while state-level institutions not only failed to contain or counteract these messages, but also used expensive, fruitless, prescription-only pills, available to most only in their local ED’s, as a means of false comfort. Instead of using honest information to provide safety, comfort and education, the approach created panic, cost money and resources, and took lives.

All of this was preventable and is reversible for the future. There is no reason why the media cannot be recruited into the information dissemination process...

Unfortunately, there is a good reason why: Responsibly framing public health risks is no longer a role that suits traditional media. They've decided it's just not in their interest.

I remarked on this years ago with West Nile virus, which never will never kill as many as, say, food poisoning or swimming pool accidents.

There are many factors driving the public appetite for health risk information -- and that's understandable. I think it's even ok for news organizations to shuffle around reporting to some extent, to satiate those desires.

But what happened in NYC this spring was media malpractice -- night after night, opportunities to put the risks of swine flu in perspective were passed up for breathless reporting. I recall one occasional, a phalanx of reporters were camped outside a hospital I worked at, providing next to no detail about an infant who died it respiratory distress. It turns out this child did not have H1N1, but communicating that was not a priority -- by the next day the lead story was ED's are overcrowded and schools are closing.

EPMonthly ran a nice sidebar from Dr. Jim Augustine, enumerating the ways in which ED docs can engage the media to get the right message out.

But I'm more encouraged by approaches to bypass traditional media and reach patients directly. Yesterday I heard some encouraging news from the CDC: their emergency twitter feed has over 500,000 followers. Millions saw their videos. This is amazing reach, for public health communication.

It wasn't enough to help ED's this spring. But individual hospitals and the CDC is ramping up their use of social media, even as traditional news sources decline in influence. It's really the first good viral news I've heard in a while.

Under my skin, redux

2009-07-24T09:41:00.004-04:00

Here's a followup to that recent post about the frustrations involved with patient-reported allergies.

Somehow I missed this before now, but a group from Cincinnati actually started testing patients who reported penicillin allergies... in the ED!

Our results are supportive of the feasibility of conducting penicillin skin testing in the ED and demonstrate the potential influence of conducting skin testing in the ED. The rate of false-positive reports of penicillin allergy in our patient population was high: more than 90% of patients reporting a penicillin allergy did not have a positive skin test result. These findings are consistent with previous reports from other non-ED patient populations...

...The introduction of penicillin skin testing to the ED environment could help decrease the overuse of broad-spectrum antibiotics in the ED...

It took little time to train the ED docs to administer this common skin test used in clinics, and results were available withing 30 minutes. No special background or skills were required to perform this trial -- it's a great example of tackling frustrating problems with straightforward research design.

A small step

2009-07-18T16:47:00.000-04:00

When you have a singular achievement of historical magnitude, well, I imagine it's hard to go back to regular life. And it's hard to resist the temptation to cash in on said achievement.

Buzz Aldrin was on TV the other night, giving yet another interview, and I just got done telling my girlfriend that Neil Armstrong never does that sort of thing -- no celebrity biographies, very few interviews, and certainly no endorsements. I figured he realized that the first man to walk on the moon ought to be above that sort of thing.

Turns out I was wrong. Here's a TV spot featuring Neil Armstrong for... Chrysler. (Armstrong's also had a biography released recently, as well.)

Oh well. The next order of business is tracking down this short film that appeared on SNL nine years ago, an imagined vignette of Neil Armstrong's quiet life now in Ohio, walking around town, minding his business but unable to concentrate on much -- because every few seconds his mind seizes on the fact he was first to walk on the moon.

Until that clip surfaces, we'll have to make do with this other imaginative film: the unedited version of Neil Armstrong's moonwalk (NSFW).

Meeting in the aisle

2009-07-17T00:01:00.001-04:00

I have a lot of ways to save or share web pages of interest. There's Evernote, ReadItLater, and good old bookmarks. Plus, bookmarklets make Twittering a page easy, and Note in Reader lets you now star, share or 'like' any page.

With so many ways of highlighting good content, it's kind of sad that I rarely go back to look at the material I select, tag, and archive.

But there was a page I kept coming back to, after I saw it online over the weekend. It's a transcript of an interview between an ex-health insurance exec and Bill Moyers.

I've excerpted just a tiny bit and rearranged it a little here, but it's really excellent and deserves a full read (or watching) if you have the time. via Metafilter.

WENDELL POTTER: ... I went home, to visit relatives. And I picked up the local newspaper and I saw that a health care expedition was being held a few miles up the road, in Wise, Virginia. And I was intrigued.

BILL MOYERS: So you drove there?

WENDELL POTTER: I did. I borrowed my dad's car and drove up 50 miles up the road to Wise, Virginia. It was being held at a Wise County Fairground. I took my camera. I took some pictures. It was a very cloudy, misty day, it was raining that day, and I walked through the fairground gates. And I didn't know what to expect. I just assumed that it would be, you know, like a health-- booths set up and people just getting their blood pressure checked and things like that.

But what I saw were doctors who were set up to provide care in animal stalls. Or they'd erected tents, to care for people. I mean, there was no privacy. In some cases-- and I've got some pictures of people being treated on gurneys, on rain-soaked pavement.

And I saw people lined up, standing in line or sitting in these long, long lines, waiting to get care. People drove from South Carolina and Georgia and Kentucky, Tennessee-- all over the region, because they knew that this was being done. A lot of them heard about it from word of mouth.

There could have been people and probably were people that I had grown up with. They could have been people who grew up at the house down the road, in the house down the road from me. And that made it real to me.

BILL MOYERS: What did you think?

WENDELL POTTER: It was absolutely stunning. It was like being hit by lightning. It was almost-- what country am I in? I just it just didn't seem to be a possibility that I was in the United States. It was like a lightning bolt had hit me.

BILL MOYERS: People are going to say, "How can Wendell Potter sit here and say he was just finding out that there were a lot of Americans who didn't have adequate insurance and needed health care? He'd been in the industry for over 15 years."

WENDELL POTTER: And that was my problem. I had been in the industry and I'd risen up in the ranks. And I had a great job. And I had a terrific office in a high-rise building in Philadelphia. I was insulated. I didn't really see what was going on. I saw the data. I knew that 47 million people were uninsured, but I didn't put faces with that number.

Just a few weeks later though, I was back in Philadelphia and I would often fly on a corporate aircraft to go to meetings.

And I just thought that was a great way to travel. It is a great way to travel. You're sitting in a luxurious corporate jet, leather seats, very spacious. And I was served my lunch by a flight attendant who brought my lunch on a gold-rimmed plate. And she handed me gold-plated silverware to eat it with. And then I remembered the people that I had seen in Wise County. Undoubtedly, they had no idea that this went on, at the corporate levels of health insurance companies.

...

WENDELL POTTER: ...there's a measure of profitability that investors look to, and it's called a medical loss ratio. And it's unique to the health insurance industry. And by medical loss ratio, I mean that it's a measure that tells investors or anyone else how much of a premium dollar is used by the insurance company to actually pay medical claims. And that has been shrinking, over the years, since the industry's been dominated by, or become dominated by for-profit insurance companies. Back in the early '90s, or back during the time that the Clinton plan was being debated, 95 cents out of every dollar was sent, you know, on average was used by the insurance companies to pay claims. Last year, it was down to just slightly above 80 percent.

So, investors want that to keep shrinking. And if they see that an insurance company has not done what they think meets their expectations with the medical loss ratio, they'll punish them. Investors will start leaving in droves.

I've seen a company stock price fall 20 percent in a single day, when it did not meet Wall Street's expectations with this medical loss ratio.

For example, if one company's medical loss ratio was 77.9 percent, for example, in one quarter, and the next quarter, it was 78.2 percent. It seems like a small movement. But investors will think that's ridiculous. And it's horrible.

BILL MOYERS: That they're spending more money for medical claims.

WENDELL POTTER: Yeah.

BILL MOYERS: And less money on profits?

WENDELL POTTER: Exactly. And they think that this company has not done a good job of managing medical expenses. It has not denied enough claims. It has not kicked enough people off the rolls. And that's what-- that is what happens, what these companies do, to make sure that they satisfy Wall Street's expectations with the medical loss ratio.

...

WENDELL POTTER: Right. Right. And they're Democrats. And my executives wanted to meet with — and when I say my, the people I used to work for--

BILL MOYERS: At Cigna.

WENDELL POTTER: Yeah, wanted to meet with Hillary Clinton, when she was still in the Senate and still a candidate for president. Well, that's hard to do. That's hard to pull off, but she did. That just shows you that you can, through the relationships that are formed and that the insurance industry pays for, by hiring these lobbyists, you can your foot in the door. You can get your messages across to these people, in ways that the average American couldn't possibly.

BILL MOYERS: So it's money that can buy access to have their arguments heard, right?

WENDELL POTTER: That's right.

BILL MOYERS: When ordinary citizens cannot be heard.

WENDELL POTTER: Absolutely right. It's the way the American system has evolved, the political system. But it does offend me, that the vested special interests, who are so profitable and so powerful, are able to influence public policy in the way that they have, and the way that they've done over the years. And the insurance industry has been one of the most successful, in beating back any kinds of legislation that would hinder or affect the profitability of the companies.

BILL MOYERS: Why is public insurance, a public option, so fiercely opposed by the industry?

WENDELL POTTER: The industry doesn't want to have any competitor. In fact, over the course of the last few years, has been shrinking the number of competitors through a lot of acquisitions and mergers. So first of all, they don't want any more competition period. They certainly don't want it from a government plan that might be operating more efficiently than they are, that they operate. The Medicare program that we have here is a government-run program that has administrative expenses that are like three percent or so.

BILL MOYERS: Compared to the industry's--

WENDELL POTTER: They spend about 20 cents of every premium dollar on overhead, which is administrative expense or profit...

So, yeah. I don't usually share or post much on healthcare reform. There's a lot of stakeholders in US healthcare, they make a lot of good points, and it's difficult for me to reconcile the proposals and theory with the forces at work in the emergency department. Plus, the risk of alienating some prospective employer with my forever-googlable opinions always seemed to outweigh the benefit of trying to persuade some anonymous readers.

But I was interested in what Wendell Potter had to say. I know, he's got a new job and a blog and therefore, undoubtedly, an agenda of his own. Maybe it's just his skill in PR but he seemed like an honest guy, and that's something I've been looking for in this debate for a long time.

Today, some other bloggers head to DC to discuss healthcare reform -- Dr. Val, Dr. Rob, Dr. Wes, Kevin MD, Emergiblog, Kerri and others.

I've read these people's words for years. Interviewed them all for Medscape. Some, I've met in person. One, I almost met, but my hospital caught fire, and then I recovered his iPod and earned a llama.

Yes, many of them have forged ties to industry and agencies. And many of them are advancing an agenda of their own, or at the very least, a podcast. But unlike the Potters and Moores and Becks of the world, well, I know these folks, and they seem like honest and good people. Even the guy giving out the llamas. So I recommend you all listen to them, and bookmark Better Health, and retweet, and Note in Reader, and save to Evernote, and whatever else you do with thoughtful material.

Update: The #patientsfirst hash will get you the twitterfeed of the event. A helpful blogger has generated this pdf transcript of the conversation.

To leave me here on shaky ground

2009-07-14T06:25:00.004-04:00

So, five years ago, I wondered if the delays in approving, and obstacles in administering, drugs like clozapine (Clozaril) could actually be used to hold parties liable for deaths that occurred while deserving patients weren't getting their meds.

This was kind of a thought exercise, as I understand it would be extremely difficult to measure. But I thought the notion of holding administrators, bureaucrats and lawyers as accountable for their decisions as physicians was one worth exploring.

So I was intrigued to reports of a new study in the Lancet that started like this:

"Thousands of people with schizophrenia worldwide could have been saved if doctors had prescribed them the anti-psychotic drug clozapine, a new study says."

Wow.

This was the largest study yet to look look at mortality and antipsychotic use. The authors' aim was to examine the mortality gap between the general population and those with schizophrenia, on or off meds. The accompanying editorial phrased the study's findings succinctly:

"Tiihonen and co-workers address a crucial question—to what extent do second-generation antipsychotic drugs contribute to excess mortality in people with schizophrenia? This question has loomed large since reports of raised risk of weight gain and diabetes associated with some of these drugs. Even the earliest studies of weight gain and incident diabetes suggested substantial heterogeneity across second-generation antipsychotics for adverse metabolic effects. Subsequently, large clinical trials, including the CATIE study, have confirmed that different drugs have different metabolic liabilities. Now, differences in mortality also seem to exist between drugs. In today's study, current use of quetiapine was associated with the highest risk of death, with a hazard ratio of 1·41 (95% CI 1·09–1·82) compared with current use of perphenazine. Current use of risperidone was also associated with a (34%) increased risk of death, compared with current use of perphenazine.

Analyses of cumulative use of antipsychotics did not show an increase in cardiovascular mortality in patients taking olanzapine and clozapine over the 11-year study. This finding is surprising in view of the substantial evidence of heightened cardiovascular risk associated with these two drugs. Clozapine was, in fact, associated with a much lower risk of death than was any other antipsychotic treatment, and a substantially lower risk of suicide than with any other medication. Even though people with clinically significant medical comorbidities might be excluded from clozapine treatment and the eventual burden of cardiovascular mortality could take decades to emerge fully, this finding is still striking. Furthermore, these results mean that the reports of under-use of clozapine in African–American patients with schizophrenia are of even greater concern."

The authors make a suggestion:

"...our results raise the issue of whether clozapine should be used as a first-line treatment, because it seems to be the safest antipsychotic in terms of mortality and it is also the most effective.

However, clozapine is inexpensive, and hence it is unprofitable for the pharmaceutical industry to market compared with other second-generation antipsychotic drugs. Additionally, monitoring schedules are a drawback that would be encountered with heightened use of clozapine,and physicians and other hospital staff might therefore be reluctant to initiate clozapine treatment. However, clozapine is associated with a lower discontinuation rates than is any other antipsychotic, and monitoring is not likely to be a major difficulty for patients after the initiation of treatment."

So, after all these years, even with the much-emphasized risk of agranulocytosis and weight gain, clozapine is the safest atypical antipsychotic? At least, in Finland? I'm no psychiatrist, and the only time I order atypicals are when I'm caring for boarded patients already taking these drugs. The docs over at Furious Seasons seem appropriately skeptical.

Still, it's interesting that the media is making this leap, and framing the study in terms of 'lives that could have been saved' -- a step the authors and editorialists weren't willing to take, and one that I don't recall seeing during the news from, say, the WHI hormone replacement reversal. It's an interesting way to frame results because, unlike 'number needed to treat' or 'likelihood ratios,' 'lives that could have been saved' implies liability -- not just for doctors but for bureaucrats and drug marketers. It's a metric that lends itself well to ... thought exercises.

Via @PharmaGuy (forum post)

Under my skin

2009-07-12T09:01:00.002-04:00

There's a satisfying post on WhiteCoat where he rants against patient-reported allergies. A sample:

When I ask patients about their medical allergies, more often than not patients suffer from at least one. During a recent shift, I had 17 people who told me that they had medication allergies. When someone has an allergy, I always ask what the allergic reaction is. The responses I received included the following:

* Seven people had allergies to various medications (most often penicillin) because their parents told them they had a reaction as a child. They didn’t know what the reaction was, but they have never taken the medication since.

* Four people had nausea and vomiting with medications that typically cause nausea and vomiting as one of their side effects...

He's right -- a lot of people have unwarranted concerns about mild or entirely predictable reactions, and sometimes this can be frustrating on a busy shift. But I also like the commenter who wrote:

I’m not sure how you think the patient is supposed to know which things actually require medical attention, especially when doctors and nurses refuse to give any guidelines over the phone. 'Come on in, and if you aren’t seriously ill, then we can make fun of you on the blog tomorrow.'

Patient perceptions of allergies is a subset of a larger issue facing all of emergency medicine -- patient perception of disease. We don't expect patients to triage themselves, or figure out which symptoms are worrisome and which are benign. That's our job. I try to look at proper allergy reporting as another opportunity for patient education (my favorite is explaining why someone can't be allergic to the iodine atom).

More importantly, from the informatics perspective, allergy reporting is a big frustration as well (and one we can actually do something about, ourselves). Patient-reported allergies find their way into every EMR, and trigger the most inane alerts and stops, forever. If a patient reported vomiting once after codeine, every subsequent doctor who sees this patient will have to jump through electronic alert hoops just to order IV morphine. It doesn't matter if the patient is taking oxycontin and wears three fentanyl patches. The same goes for antibiotics -- I think most lay folks would be surprised that we have to wrestle, years later, with the inherited family warning of about penicillin reactions, even when ordering a 4th-generation cephalosporin with essentially no cross-reactivity...

There's no intelligence built into the system, yet, I think because everyone's afraid that if a patient has a bad outcome because that 14th medication alert was eliminated, they'd be liable. This line of thinking ignores the notion that bad outcomes are probably happening because there are so many useless alerts, they all tend to be ignored.

Someone told me recently (perhaps it was Dr. Reider?) that non-clinical folks involved in setting up electronic health information exchanges thought that communicated allergies to new providers would be the top priority, and were surprised when physicians considered allergies to be less important than, say, recent EKG's, imaging, current med lists, and the like.

I wonder if this attitude toward allergy records is because we don't think most allergies are that serious, because we can most often treat whatever arises... or because we're overcome with alert fatigue.

Whatever the reason, there's no doubt in my mind that if we had an intelligent, efficient system to process patient-generated allergy reports, we'd be less frustrated with this information, and more sympathetic to the patient's concerns.

Movin' on up

2009-07-10T12:15:00.002-04:00

Congratulations to Drs. Graham Walker and Liam Yore, who've made the leap from home-grown bloggers to big-time, institutional blogging over at ACEP's The Central Line.

Also, an excellent development in the other direction: Longtime columnist for ACEP News, Dr. Michelle Lin, now has her own blog: Academic Life in Emergency Medicine. She's providing DVD-like bonus material behind each new Tricks of the Trade column, and also describing her experiences balancing teaching, research and clinical responsibilities.

And bonus: The Examining Room of Dr. Charles is back open for business!

Sleep to Dream

2009-07-10T12:04:00.000-04:00

I enjoyed NYC Dr. Kent Sepkowitz's column in Slate the other day -- Paging Dr. Feelgood -- where he recaps the careers of some celebrity docs and tries to imagine the pathway to enabling addicts. Key part:

In a strange way, I actually stand in awe of these guys. I have taken care of a few celebs in my career, and for me it was an awful experience. If you fuck it up, you're toast. Once I took care of a very important person, a person you have heard of and are very interested in, someone you would be shocked to know had the problem—asthma—that I treated him for. Well, almost treated him for. His complaints and his recollection of near death last time he had the identical symptoms so unnerved me that I asked a colleague to assume his care.

But the Dr. Feelgood experiences no such hesitancy... Perhaps it all starts innocently—a rich, famous guy with a tiny problem walks into the office. He can't sleep at night. He's so friendly, sincere, not stuck up like some celebs. Then he comes back a week later because of a sore ankle, wanting a little codeine and bearing an autographed photo or a CD. Other patients notice and figure you must be a pretty good doctor if Mr. Showbiz is coming in....

I once wrote about that concern over VIP complaints, in a medscape column. And, like the author, the only thing that impresses me about these celebrity docs is their creativity -- Sepkowitz describes how the first Dr. Feelgood used solubilized placenta. And, while the risks of propofol dosing are drummed into our heads in training, it never occurred to me a doctor-to-the-stars might use propofol outside the hospital on an unmonitored patient.

While it didn't surprise me that propofol has been considered in
palliative care and even implicated in a murder, it turns out propofol (diprivan) abuse and dependency is not unheard of and, as this review by Roussin shows, some IRB actually permitted trials:

Normal healthy volunteers (n = 12) were exposed in a blind fashion to acute bolus injections of 0.6 mg/kg of propofol and to a similar volume of soy-based lipid emulsion (similar to the vehicule of propofol) twice. After these sampling sessions, they were asked to choose which drug they preferred to be injected with. Propofol was chosen by 50% of the subjects, and seemed to have been based on the pleasant subjective effects. In contrast, the choice of placebo (Intralipid®) seemed to have been based on either non-intense subjective effects during the propofol sampling session (increased dizziness, confusion) or residual effects (fatigue) after the sessions. These results suggest that, in some healthy volunteers, propofol functioned as a reward.

...From a psychopharmacologists' standpoint, propofol shares properties in common with many drugs that are abused. In particular, the onset of the effects of propofol are rapid and this drug makes people 'feel good' and feel relaxed [45]. The mood-altering effects of subanaesthetic doses of propofol delivered via an infusion or by an acute bolus injection have been assessed in human healthy volunteers [44,52]. Subjects reported feeling high, lightheaded, spaced out and sedated....

I read up on propofol use a lot a year ago, in preparation for a talk on procedural sedation. At that point I think its only foray into pop culture's collective consciousness was a poem by Karl Kirchwey called "Propofol" that ran a year ago in the New Yorker. It began:

Moly, mandragora, milk of oblivion:
I said to Doctor Day, "You bring on night."
"But then," he said, "I bring day back again,"
and smiled; except his smile was thin and slight.

Now everyone's talking about propofol. The ASA is using this opportunity to reintroduce talk of restricting propofol to their specialty alone (despite abundant and mounting evidence that it's used safely in ED procedural sedation). Reporters are wondering why propofol administration is not as closely logged as, say, opiates.

All this activity suggests it soon will be. And while keeping this drug out of the hands of abusers and enablers is a worthy goal of regulation, I hope those who've demonstrated a safe track record are not prohibited from using this unique medication.

One that won't make me nervous

2009-06-30T23:39:00.003-04:00

I'd been meaning to get rid of some comment-spam on this blog, from dubious web hucksters selling percocet and vicodin... but an FDA advisory panel may have solved my problem in a different way, today recommending to ban painkillers that contain acetaminophen (this was part of a series of decisions to limit overdoses of tylenol, in the hopes of preventing what is now the #1 cause of liver failure in the US).

The panel's decision let to my first front page post on Metafilter which recapped some of tylenol's history and its popularity (because of their rigid self-link rules, I couldn't highlight my Medgadget post on Tylenol at 50).

The Metafilter discussion was intelligent as usual, though unfortunately I couldn't stick around to address some misconceptions that arose. Some highlights for those who don't want to sift through 100+ comments:

Meehawl wrote:

you could just mandate that all paracetemol be combined with a sufficient dose of methionine to replenish the liver's glutathione levels and so lower the probability of a runaway toxic fulmination. This would of course make the pills more expensive to manufacture so that's not really going to happen. The argument against it, using the high NNT of 999 people who would be pre-treated with methionine so that the 1 overdoser can benefit seems lacking given the severity of the outcome, the cost of the post-exposure treatment, and the lack of side effects of the pre-treatment.

homonculus wrote:

Also, it is important for pain patients to be heard by the FDA about this: if they are thinking of pulling something like getting rid of Vicodin and Percoset *without* offering replacements without the acetaminophen that are the same level controlled substances, it would be very bad for pain patients.

There does appear to be a hydrocodone (Vicodin) which is schedule III and an oxycodone (percocet) with ibruprofen instead, which is schedule II, which would be existing options but schedule II's are more of a pain in the butt.

I just read a bit about that. From MedPageToday:

In a far less decisive vote, the committee voted 20 to 17 in favor of a more extreme recommendation to pull all prescription products containing acetaminophen from the market.

Because the split was so close, it is unclear whether the FDA will adopt the recommendation, but if it did, some options would be eliminated for pain patients. For instance, patients taking Vicodin would not have an acetaminophen-free option because there is no hydrocodone-only formula.

In addition, removing the acetaminophen from the Vicodin would move the drug into the more-strictly regulated "class II" schedule of narcotics from its current classification as a class III drug, creating additional barriers for physicians prescribing the drug to patients.

That makes me think it's unlikely the FDA will ban them. The outcry would be too great.

stopgap looked up the other drug use mortality data and compared it to tylenol's 56,000 OD presentations and 1000-1600 liver failures:

For the others, the following stats are from 2005. I saw some reports that suggest MDMA might be around 50, and I also saw marijuana as 0.

Heroin: 2,011
Cocaine: 6,228
Ecstasy/MDMA: no data
Marijuana (Cannabis poisoning): 112
Cars: 45,343

Clearly, we need to reduce the standard dosage of motor vehicle use.

But the most spot-on comment may have been the first one, by inigo2:

Sweeeet - my medicine cabinet's gonna be worth a ton in a few months.

Thanks to our collective number crunching, we now have a handle on the problem -- 56,000 acetaminophen overdoses, with 1600 progressing to liver failure. It sounds unacceptable until you realize there were 124 million prescriptions of tylenol combined with opiates, and untold numbers of OTC Tylenols taken as well. Suddenly the number of complications looks manageable, compared to the amount of patients that rely on these drugs. That, plus the UK's mixed results in managing this problem, suggests to me that banning percocet and vicodin is not the solution.

I'm looking forward to reading more from medical bloggers in the days to come about this practice-changing recommendation. But for now I just want to reflect on a rite of passage: tomorrow, graduated medical students become interns and start ordering and prescribing their first drugs. I remember receiving advice about this transition, hearing that 'in July, when you're first adapting to responsibility for patients, you'll think twice before even ordering Tylenol for a fever.' Well, with a likely black box warning to come and increased scrutiny on dosing, tomorrow's interns will be anxious about ordering Tylenol long past July.

Get back to the basics for you

2009-06-23T19:01:00.001-04:00

Folks with writer's block have no end of excuses-- I'll just offer up as a defense that even as output on blogborygmi trickled to nothing, I was blogging a lot on my residency's website. And, honestly, I didn't want anything I wrote to be misinterpreted during interview season, which has a stifling effect on creativity.

But there's another possibility that's been rattling around my brain, more since Farhad Manjoo phrased it so succinctly a few weeks ago in Slate. What if I stopped contributing to the medblog community because I had changed the way I accessed it, in moving from bookmarked websites to RSS? Quoth Manjoo:

RSS started to bring me down. You know that sinking feeling you get when you open your e-mail and discover hundreds of messages you need to respond to—that realization that e-mail has become another merciless chore in your day? That's how I began to feel about my reader. RSS readers encourage you to oversubscribe to news. Every time you encounter an interesting new blog post, you've got an incentive to sign up to all the posts from that blog—after all, you don't want to miss anything. Eventually you find yourself subscribed to hundreds of blogs, many of which, you later notice, are completely useless. It's like having an inbox stuffed with e-mail from overactive listservs you no longer care to read.

It's true that many RSS readers have great tools by which to organize your feeds, and folks more capable than I am have probably hit on ways to categorize their blogs in a way that makes it easy to get through them. But that was just my problem—I began to resent that I had to think about organizing my reader. Moreover, I hated the software's bland interface; when you read blogs through RSS, you're only getting text, not design, so every blog looks like every other blog. But I didn't want Gawker to look like the New Republic; I needed a visual difference, in the same way that I want the National Enquirer to look distinct from the New York Times

He goes on to describe his new system for perusing websites, which sounded a lot like my old bookmark hierarchy. Since reading his article, I've started trying to recreate that old system, but now using Speed Dial groups for firefox. With any luck, I'll soon feel that vibrant sense of community that I enjoyed so much, years ago...

Social coteries, that's me

2009-06-23T13:07:00.003-04:00

I'm helping my hospital draft a policy on The New Media. Is there anyone out there who's worked on something similar, or can point me to another institution's document?

If so, please leave a comment below, or email me, or give me a tweet, or contact me via LinkedIn or Facebook...

He's just resting

2009-06-23T12:43:00.004-04:00

The report of my [blog's] death is... an exaggeration.

Which is to say: some responsibilities have come to an end, others have yet to begin, things have come into focus, and now's a good time to return to blogborygmi.

the boys upstairs want to see

2008-11-23T22:54:00.001-05:00

Both iPhone and Gmail were late entrants into established, crowded fields that nonetheless managed to change the way many people worked and organized information. The software was intuitive, clever, fast, and surprisingly frustration-free. I held out for a while at first, but when I finally adopted these new systems, I became evangelical in my support.

And for a while, things worked great. Tasks were accomplished so quickly and simply, there was a special satisfaction in using the software.

Then I got greedy and mucked it up.

This past spring, after owning my iPhone about a month, I decided the device wasn't achieving its full potential -- so I jailbroke it. At first I marveled at the third-party software (this was before the App Store) and the possibilities of customization. Moving backgrounds! Five icons in the dock! Tweaking elements of the title bar!

For Gmail, similar customizations were possible. Again, my justification for these hacks was improved functionality, such as the Remember the Milk sidebar integration. But after installing Better Gmail, I found the feature I customized the most were the skins. And then came Gmail Redesigned: a darker, gradient-crazy skin that transformed the airy, efficient Gmail into something seeming closer to SkyNet.

The novelty of these hacks lasted a while, but masked an inconvenient truth: they were buggy and slow. The rare freeze on my iPhone became more frequent, and switching between apps, which once took a moment, now took ten seconds or more (which may not sound like much, but is agonizing when you're trying to check the calendar from the phone, or look up a drug's pregnancy class in front of your attending).

And Gmail, with the Redesigned skin, began to lag, hang, and underperform. Not so much or so notably that I'd want to uninstall the changes, but enough that using the software was no longer a delight.

This week, though, Apple released firmware 2.2 for iPhone and Google upgraded Gmail with templates.

Firmware 2.2 is not such a milestone but it came at the right time for me -- there's enough useful apps in the iTunes store and the customizations that come with jailbreaking no longer mean so much. Upgrading from a jailbroken 2.1 was a breeze, and this week my iPhone's been so fast I no longer miss having five icons in a dock (plus, as a bonus, my title bar customization somehow survived the upgrade).

And the new Gmail templates are fun -- something for everyone, and all support a much zippier interface than Gmail Redesigned. RTM manages the transition in style, as well.

It impresses me how quickly and smoothly these companies have adapted. Or more precisely, that two giant firms have been taking notes from their most fervent users in order to keep their groundbreaking products fresh, for free. Their behavior stands in contrast to the common business practice and I can only hope other companies are watching Google and Apple as closely as they're paying attention to us.

Thoughts arrive like butterflies

2008-10-31T13:46:00.003-04:00

There's an irony here, because I found the following critique of Twitter while searching for a blogger-to-twitter solution. But I think the author is essentially right, based on his (and my) understanding of Flow. Excerpt below:

Worst of all, this onslaught is keeping us from doing the one thing that makes most of us the happiest... being in flow. Flow requires a depth of thinking and a focus of attention that all that context-switching prevents. Flow requires a challenging use of our knowledge and skills, and that's quite different from mindless tasks we can multitask (eating and watching tv, etc.) Flow means we need a certain amount of time to load our knowledge and skills into our brain RAM. And the more big or small interruptions we have, the less likely we are to ever get there.

And not only are we stopping ourselves from ever getting in flow, we're stopping ourselves from ever getting really good at something. From becoming experts. The brain scientists now tell us that becoming an expert is not a matter of being a prodigy, it's a matter of being able to focus.

This nearly two-year old critique hasn't really put a damper on Twitter's increasing popularity. Maybe there's some new data I'm not aware of, to show Twitter makes people more productive or creative.

I check Twitter updates almost exclusively via Twinkle, an iPhone Twitter client that's got a neat 'nearby tweet' feature. I really only am moved to use it when I'm in line for something, or stuck on a train. For all the talk of twitter in academia and medicine, I don't think the advantages would outweigh the frequent disruptions if I checked Twitter from my desktop.

Half a page of scribbled lines

2008-10-31T11:55:00.000-04:00

Two full calendar months without a blog post? Yikes!

I don't want to end up on GruntDoc's Dead Blog list (even though it is Halloween) so let me just quickly link to my recent activity on Twitter.

While I'm not sure how often I'll use Twitter, it seemed helpful in communicating some of my impressions of this week's ACEP conference in Chicago.

And look! My twits will now appear on blogborygmi's sidebar, somewhere between RSS highlight and photo highlights.

Little souvenirs

2008-08-24T14:08:00.002-04:00

One of the nicest perks of being an established-and-at-one-point-somewhat-prolific medical blogger is that really talented people send me really good books.

Two I'd like to highlight for you now are below.

Dr. Jay Baruch's Fourteen Stories: Doctors, Patients and Other Strangers. This award-winning collection of short stories from an ED physician had me pretty engrossed. Dr. Baruch does a good job of motivating his characters, and often the motivation is fear -- not just the sick patient but the student with an HIV needlestick, the doctor walking home late at night who encounters a dissatisfied patient. The dialogue is minimal, and often at odds with the situation -- but he's written these characters in such a way that it's easy to crawl into their thoughts and insecurities.

In his afterward, Dr. Baruch gives his take on the difference between getting to the truth of a medical presentation, and the truth of a short story. It's an informed and insightful essay -- required reading for aspiring physician-writers.

The other book I received recently is Laurie Edwards' Life Disrupted. I first read this author in the pages of the Boston Globe Magazine, then learned of her blog and finally, got to interview her for Medscape's Pre-Rounds.

Unlike Dr. Baruch's book above, Life Disrupted is decidedly nonfiction -- the subtitle is "Getting Real about Chronic Illness in your Twenties and Thirties." Medical blog readers will recognize many of the book's subjects, like Jenny Prokopy (chronicbabe.com) and Kerri Morrone (sixuntilme.com). Even some of the insleeve reviewers are longtime bloggers (Amy Tenderich, Paul Levy).

I'll confess, these familiar names actually helped me approach this book, which is an expert guide on empowering patients to get more out of life, and more out of the medical world. Why should I even be reluctant to read it? Because (though this has never been true of Edwards' earlier works) I've seen too many patient-empowerment books that read like self-help bromides or screeds against modern healthcare.

Not surprisingly, my reluctance was completely unfounded. Edwards is too smart, and has been through too much, to simply encourage her readers to distrust all medical professionals (although some of her readers and subjects have earned the right). Instead, she treats the physicians and nurses much like she considers her fellow patients: motivated, knowledgeable, but sometimes inflexible and afraid to adapt.

Her candid and conciliatory writing style quickly won me over. Her book is full of specific advice regarding relationships, socializing, career, and yes, navigating hospital stays and the healthcare system. I found it extremely practical and accessible, and learned a lot more than I had expected to. So, I heartily recommend it.

From the threshhold, what's to see

2008-08-24T13:21:00.004-04:00

I love playing with Microsoft's new Photosynth but I'm still curious if it can handle this. Or this.

Grand Rounds: Change of the Guard

2008-07-28T11:06:00.003-04:00

This week, GruntDoc hosted the 200th edition of Grand Rounds.

When this series started, the word "blogger" was just entering the public consciousness. The value of healthcare blogs -- to entertain, inform, and improve understanding -- this was clear to us, but we weren't really sure if anyone outside our group would ever notice.

Two hundred weeks later, every major media site has a blog on medicine and health, the industry is paying to access what physicians write online, and the transparency of blogging is transforming healthcare from the ground up (or, in some cases, from the top down).

Healthcare bloggers now have access to figures like the Surgeon General or AMA president. Healthcare bloggers write op-eds for major papers, appear on TV, and publish books.

Grand Rounds, I think, has had a role in this. This carnival has served as a weekly focal point, highlighting the most compelling voices and insightful ideas in this vibrant community. Grand Rounds made the world of healthcare blogging accessible and appealing to outsiders, and offered veteran bloggers and newbies a chance to touch base and rub elbows.

As the healthcare blogging landscape has changed, though, new challenges and opportunities have presented themselves. I've been unable to properly address these issues, however, since being named a chief resident at my program a few months ago. While the experience has been exhilarating so far, the task of organizing my department's Grand Rounds has left little time for planning Grand Rounds online.

But we're fortunate that our weekly roundup of medical blogging has attracted a number of dedicated benefactors. Beyond the hosts whose creativity and effort make each week so memorable and enjoyable, a few people have distinguished themselves with their belief in the concept and potential of Grand Rounds.

One such person is Colin Son, a medical student, longtime blogger, and previous host of Grand Rounds. He'll be taking over the Pre-Rounds series for Medscape and scheduling new Grand Rounds hosts. Working with him will be none other than Dr. Val Jones, the extraordinary blogger behind The Voice of Reason at Revolution Health.

They have the energy and enthusiasm to not only maintain this series but take Grand Rounds to new heights -- opening up the medical blogging world to new readers and venues. Please join me in welcoming them, and wishing them well. With your support and Colin and Val's stewardship, the quality and success of Grand Rounds will be insured -- for the next two hundred editions, and beyond.

Playin' with your food like it's some kind of game

2008-06-12T07:21:00.007-04:00

Longtime readers (and really, that's the only audience, at this point) are well aware of my fascination with competitive eating. Beyond the awful, mesmerizing spectacle, there's the physiological aspect -- how can some people shovel so much into their gut, so fast?

At one point, I was actually thinking of making this into a research project. I spoke with a few contestants, and like to think my frequent phone calls to IFOCE chair George Shea in 2006 led to him bill that year's Nathan's Hot Dog Contest as, "The Mount Sinai of Mastication" -- but then again, he also dubbed it the Madison Square Garden of Gorging, and finally, the battleground where God and Lucifer fight for men's souls (such gifted hyperbole cannot be ascribed to any single influence).

But I digress. Since first blogging about the topic in 2004, offering some speculation on how elite eaters succeed in 2005, and calling for more research two years ago, well, I neglected to keep up with this topic. Even as a new champion was crowned, I overlooked this important addition to the body of evidence:

Competitive Speed Eating: Truth and Consequences
Marc S. Levine, Geoffrey Spencer, Abass Alavi and David C. Metz

OBJECTIVE. The purpose of our investigation was to assess the stomachs of a world-class speed-eating champion and of a control subject during a speed-eating test in our gastrointestinal fluoroscopy suite to determine how competitive speed eaters are able to eat so much so fast.

CONCLUSION. Our observations suggest that successful speed eaters expand the stomach to form an enormous flaccid sac capable of accommodating huge amounts of food. We speculate that professional speed eaters eventually may develop morbid obesity, profound gastroparesis, intractable nausea and vomiting, and even the need for a gastrectomy. Despite its growing popularity, competitive speed eating is a potentially self-destructive form of behavior.

Not Totally Rad's got a nice discussion of the paper, as well as some personal perspective:

After a few preliminary tests, these two subjects were asked to eat as many hot dogs as they could. The big burly dude ate 7 before feeling uncomfortably full. The champion eater then proceeded to down 2 dogs at a time for the next 10 minutes. After he ate 36 hotdogs, the investigators terminated the experiment.

Despite the speed eater’s insistence that he felt no sensation of satiety, fullness, bloating, or abdominal discomfort, we became concerned that further dilation of his already enormous stomach could be associated with a small theoretic risk of gastric perforation. Therefore, a decision was made to terminate the speed-eating test over the objections of our participant.

While all of this was going on, the radiologists asked the eaters to also ingest a barium sulfate solution so they could watch the stomach under fluoroscopy. The control dude's stomach showed a large mass of partially chewed hotdog bits, but only minimal gastric dilatation. The eating champion looked a bit different:

His stomach now appeared as a massively distended, food-filled sac occupying most of the upper abdomen, with little or no gastric peristalsis and emptying of a small amount of barium into the duodenum.

It's hard to generalize these findings to all eaters everywhere when one only has 2 subjects in one's experiment. However, the investigators concluded:

Our observations suggest that successful speed eaters expand the stomach to form an enormous flaccid sac capable of accommodating huge amounts of food.

Having seen the competitors up close, I still think there's something more at work, at least when you compare Takeru Kobayashi and Joey Chestnut to second-tier hot dog eaters like Tim Janus and Cookie Jarvis. Everyone seems to eat 3-5 or so hot dogs per minute in the first minute or two, but while the others visibly slow down, Chestnut and Kobayashi can keep up the pace throughout the 12-minute race. I think this happens too soon to be mediated by gastric dilatation. Rather, what separates the new champs from lesser eaters is an ability to relax and really open the gullet. I found an old WaPo article that discusses this:

Stanford's Triadafilopoulos has another theory. When the muscles that line the esophagus initiate swallowing, they alternately relax and contract in a rippling pattern that pushes food downward. It typically takes 9 to 15 seconds for a swallow to convey food to the stomach, he said. This makes the esophagus the real bottleneck in competitive speed eating, with a mouth full of food waiting for traffic to clear in the tunnel.

Some people can relax all those muscles at once, momentarily turning the esophagus into a hollow pipe. "That's how people in circuses can swallow swords," Triadafilopoulos said. Some eaters may do the same thing, and literally pour food down the hatch.

"These people have somehow developed the ability, probably through some kind of training, to relax everything at the same time," he conjectured.

Metz doesn't buy that idea...

Metz, it should be noted, is one of the study authors cited above. I'd like his next fluoroscopy study to include a look at swallowing, and compare hot dog champions who can eat 50+ dogs in 12 minutes to those that top off around 30.

And my original questions to George Shea remain unanswered: What is the IFOCE's stand on performance enhancing substances (like glucagon, or even just topical anesthetics). What if a gastric bypass patient wanted to compete -- would that be fair? If Shea is looking to legitimize and mainstream this activity, he may have to answer these questions. But my hunch, as years go by and disturbing evidence begins to accumulate, is that IFOCE will remain the stuff of traveling sideshows.

So that's today's memory lane

2008-05-25T23:27:00.002-04:00

The Scene: An ICU, on an early July morning. A well-dressed man is standing at the nurses' station, scribbling notes. Our main character walks in.

Me: Hey, where's the post-call intern?
Intern: That would be me. Would you like me to tell you about the overnight admissions?
Me: Sure, sure... Say, if you're post-call, why are you wearing a shirt and tie?
Intern (defensive): I... I wore scrubs overnight. I just changed back.
Me (with genuine admiration): Wow. Good luck with that.

The scene: A Welcome Fete. The new interns are meeting the residents.

The mature, confident resident (to a group): Hi, I'm Nick.
Intern A: Hey! I read about you. You're that blog guy.
Me: Oh, ha. Um, yes. But, you know, that's just kind of a computer thing I do... on the side.
Intern B: Hey, I remember you from interview season. But the website you were talking about, it had something to do with free drinks.
Me: Hmmm... Myopenbar.com?
Interns A, to Intern B: I love this town.

Cover me

2008-05-15T14:42:00.001-04:00

After more than a few years of schooling and training, the day is approaching when my erudition and skills may be of some value. So, I recently applied for a disability insurance policy.

These insurers, they ask a lot of questions. When they got to the part about traffic citations over the past five years, I had to stop and think. It's been three years since I've even owned a car (but what a car it was). And I know I had a speeding ticket at some point in the early part of this decade. But was it 2002 or 2003?

I was reminded of Michael Moore's documentary, SiCKO, where a health insurance company denied coverage to a young cancer patient because she had forgotten to disclose an old, easily treated yeast infection. They called it a pre-existing condition.

And suddenly, it's became very important that I dig up old car documents from another state, even though I don't drive. God forbid I'm denied coverage at some point because of a misrepresentation in my original application (after talking to enough insurance agents, "God forbid" is a phrase that has worked its way into heavy rotation).

Does anyone know if I'm being paranoid about pinning down the date of an old speeding ticket?

Another question: I've often wondered why health insurance companies don't push harder for DNR status on elderly, moribund patients with dense dementia. Find and talk to the next of kin, work with the guardian, adjust expectations and prepare everyone for the inevitable.

Yeah, it's unseemly, but so much of what they do is already unseemly. And having seen too many of these unfortunate resuscitations, it seems that getting more aggressive about DNR status is more humane than trying to cheat otherwise healthy, active people out of coverage for out-of-the-blue health problems.

One that won't make me nervous

2008-05-06T06:50:00.002-04:00

I used to read Andrew Sullivan's blog a lot in grad school. He's bounced around several times over the years -- both on the web and on major issues -- but I rediscovered him this primary season. I was drawn to his optimism and enthusiasm, even as some of his opinions are difficult to defend.

Anyway, he was recently musing about the latest ketamine-for-depression research, and wondering if this notorious drug could someday have a clinical use.

I wrote in to tell him I use it (clinically) quite often -- not for depression but for procedural sedation.

To my surprise, he printed the letter. And now I wish I had included more from my informed consent spiel, mentioned the sialorrhea, and maybe talked about that one time I pushed it too fast...

Far-Flung Correspondence

2008-04-22T05:04:00.003-04:00

As I was always fond of his writing in high school English class, I was happy to see H. L. Mencken's name come up in this NYTimes piece on handling a large volume of correspondence:

We all can learn from H. L. Mencken (1880-1956), the journalist and essayist, who was another member of the Hundred Thousand Letters Club, yet unlike Edison, corresponded without an amanuensis. His letters were exceptional not only in quantity, but in quality: witty gems that the recipients treasured.

Marion Elizabeth Rodgers, the author of "Mencken: The American Iconoclast” (Oxford, 2005), shared with me (via e-mail) details of her subject’s letter-writing habits. In his correspondence, Mencken adhered to the most basic of social principles: reciprocity. If someone wrote to him, he believed writing back was, in his words, "only decent politeness." He reasoned that if it were he who had initiated correspondence, he would expect the same courtesy. "If I write to a man on any proper business and he fails to answer me at once, I set him down as a boor and an ass."

Whether the post brought 10 or 80 letters, Mencken read and answered them all the same day. He said, "My mail is so large that if I let it accumulate for even a few days, it would swamp me."

Yet at the same time that Mencken teaches us the importance of avoiding overnight e-mail indebtedness, he also reminds us of the need to shield ourselves from incessant distractions during the day when individual messages arrive. The postal service used to pick up and deliver mail twice a day, which was frequent enough to permit Mencken to arrange to meet a friend on the same day that he extended the invitation. Yet it was not so frequent as to interrupt his work.

Today’s advice from time-management specialists, to keep our e-mail software off, except for twice-a-day checks, replicates the cadence of twice-a-day postal deliveries in Mencken's time.

Ms. Rodgers said that Mencken was acutely disturbed by interruptions that broke his concentration. The sound of a ringing telephone was associated in his mind, he once wrote, with "wishing heartily that Alexander Graham Bell had been run over by an ice wagon at the age of 4."

Mencken’s 100,000 letters serve as inspiration: we can handle more e-mail than we think we can, but should do so by attending to it only infrequently, at times of our own choosing.

Sage advice. And -- you know you're in trouble when Mencken thinks you're an ass. But, truthfully, the Times writer is focused on the volume of correspondence -- 100,000 letters -- but I don't think Mencken's or Edison's volume of correspondence is what's truly noteworthy.

Even if you only count emails of more than two sentences, you only need five or six emails a day, every day, to hit 2000 a year. I think I'm at about that level, and I don't even work in an office (though the vast majority of these emails, I'm sorry to say, are not as timely or well-written as a Mencken letter, but they seem to be about as long). Still, if I live another fifty years (and if we're still corresponding with written words in the 2050's) I should make it to the hundred-thousand club -- and I think many of my peers will, too.

But correspondence today is undeniably more result-driven ('how is this project coming along?' -- 'are you free this weekend?' -- 'will you host Grand Rounds?') and virtually necessitates a reply (I hope). I can't imagine carving out the time to reply to five or six unsolicited emails a day. And that's what makes Mencken's achievement all the more remarkable.

Host Defense Activation

2008-04-04T06:00:00.004-04:00

Ok, so, remember when those outrageous subway ads asking passengers to "demand a CAT scan" appeared, and prompted me to suspect, offhandedly, that the group behind the ads was receiving funding from GE or another CT-scanner manufacturer?

And when the awful truth came out, that the Lung Cancer Foundation was actually funded by a tobacco company -- a firm likely invested in the notion that smoking-related cancer is preventable and thus limits their liability -- well, I fretted that I wasn't cynical enough -- that it would be a far more straightforward and relatively benign conflict of interest if the funding just came from GE.

Well, here's some comforting news -- members of the Lung Cancer Foundation was also receiving money from GE! From WSJ comes news that the lead authors of a controversial 2006 NEJM report on CT-detection of lung CA were getting royalties from a major CT scanner manufacturer (these same authors are prominent members of the Lung Cancer Foundation, the group behind the dangerous advertisements):

In today's correction, the New England Journal acknowledges that the study's lead authors, Claudia Henschke and David Yankelevitz of Cornell University's Weill Medical College in New York City, received royalties from GE, a big maker of CT scanners, for pending patents on ways to manipulate and interpret CT scans and other medical images. The Wall Street Journal's Health Blog reported the royalty payments last October. Dr. Henschke said then that the royalties were small and declining.

A spokesman for both doctors said they had told the New England Journal that Cornell had licensed the pending patents to GE before the study was printed in 2006, but not that they were personally receiving a share of the royalties. Jeffrey Drazen, the New England Journal's chief editor, said the publication had learned of the royalties only recently.

I call this news 'comforting' because it suggests people behave predictably, that a truly disturbing action can be thwarted by the by lesser, more mundane transgressions. Al Capone getting busted for tax evasion is the first example that comes to mind, but there are probably more fitting precedents.

The NEJM article now carries a "correction" up front that addresses the GE conflict.

Cornell issued a press release clarifying the conflicts of interest:

The original $2.4 million pledge to the Foundation -- and the work funded by the Foundation at Weill Cornell -- was publicly disclosed at the time through a press release, and was covered in the lay media, including USA Today...

The gift was unrestricted, which means that, unlike industry-funded research agreements, it allowed for research to be conducted independently and without restriction in areas of significant but uncertain promise, without the gift-recipient being held accountable in any way to the gift-giver. Significantly, there were no restrictions on publication of results or data; WCMC was not required to keep the donor informed of how the funds were used; and the donor was not entitled to have access to any of the research results.

It is very important to note that the I-ELCAP project -- which comprises more than 50 institutions in nine countries and in 26 states -- has been funded only, in part, by this Vector/Liggett unrestricted gift. The basic research concepts behind the screening project have been developed by Dr. Henschke and Dr. Yankelevitz since the early 1990's, long before the Vector/Liggett gift. I-ELCAP has obtained considerable funding from other sources, and has been able to recruit additional screening centers which, in turn, have developed their own funding resources.

The gift was originally made as part of a grand plan and vision on the part of public health and lung cancer advocacy groups and Vector/Liggett to provide screening research centers throughout the country. The Foundation was organized by Dr. Claudia Henschke and Dr. David Yankelevitz and other advocacy-individuals associated with the I-ELCAP program, with the expectation that other major tobacco companies, in addition to Vector/Liggett, would contribute to this national effort. The initial decision to establish a foundation was thought by them to be the most appropriate and effective fundraising vehicle to achieve such a national research plan...

It is noteworthy that, like Weill Cornell, many of our peer institutions and medical schools do accept funding from tobacco companies and from institutions that manage funds from tobacco settlements for responsible research, and do establish legitimate foundations to manage the administrative and financial aspects of grants and gifts. We recognize, due to the extreme concern about tobacco companies' attempts to misuse research to the detriment of public health, that broader and continuing disclosures could and should have been made. But Weill Cornell strongly rejects the thesis of The New York Times article that any omission was deliberate.

Regarding the matter of allegedly undisclosed patents and patent applications by Dr. Henschke and Dr. Yankelevitz, Cornell Research Foundation, Inc., a subsidiary of Cornell University, licensed technology to General Electric (some of which is now patented) related to detection and measurement of nodules developed by Henschke, Yankelevitz and others. As is generally required at academic medical centers, the royalties were distributed to Cornell, which, in turn, provided a share to the inventors under Cornell's intellectual property policy, which is based on the Bayh-Dole Act. NIH Conflict of Interest regulations currently do not require individual disclosure of royalties paid to them by the employer institutions. Nonetheless, the royalties from the GE licensing agreement, the issued patent, and the patent applications were typically disclosed to journals and at CME meetings, when such disclosures were deemed relevant by Dr. Henschke and Dr. Yankelevitz.

Some of those publications have disagreed with Dr. Henschke and Dr. Yankelevitz's judgment on these, and corrections and apologies have been published in those journals...

NIH disclosure rules are surprising. Someone could patent a device or technique, and a university tech transfer office could license the idea to a big firm, which finds the idea so valuable they pay the university royalties for it. That money finds its way back to the original scientist, who can conduct research showing how great his idea is... and yet never be forced to disclose that he's making money off it, and could make a lot more if everyone believes his research.

It's got to be better to just fully disclose the potential conflict from the outset. That is, I think, what many successful scientists do, and it doesn't stop their research from being accepted.

I don't know why this process wasn't followed with the lung cancer research, and I don't know why the foundation instead chose a dangerous and misleading advertising campaign to advance their cause. These actions make the protestations about their level of disclosure being mischaracterized that much tougher to stomach.

The Lung Cancer Foundation has been mum on the entire debacle, save for two brief blog entries that, curiously, makes no mention of the fact that the 'tainted' researcher is the founding board member of the organization that produces the blog.

On the plus side, I don't recall seeing any new subway ads urging me to "demand a CAT scan," and I believe a few older ones have disappeared.

Metastasis

2008-03-27T17:28:00.002-04:00

Last month, when I (and others) noted the ominous ads appearing in NYC subways, urging riders to "demand a CAT scan" -- I looked into the foundation that supported the ads. While the mass-market message was completely irresponsible (the use of CT scans for lung cancer screening has only been tested in smokers over 40, so there's no apparent reason for most riders to 'demand a CAT scan' from their doctors) I was nonetheless impressed by the credentials of their medical advisory board:

I see a medical advisory board full of oncologists, thoracic surgeons, and indeed, the author of the aforementioned 2006 NEJM study touting early detection via CT. Several board members are themselves lung cancer survivors.

I can't doubt this group's dedication or integrity (I originally expected "demandaCATscan.org" would be backed by GE Lightspeed scanners or something similar).

But I must ask, were these board members behind the subway ad campaign? Do they really want the general public demanding a CT scan? Because it's hard to believe such an informed and experienced group could endorse this approach.

Well, it turns out I wasn't cynical enough. The Lung Cancer Foundation is not backed by CT scanner manufacturers -- it's backed by cigarette companies.

Today's NYTimes drops the bomb:

In October 2006, Dr. Claudia Henschke of Weill Cornell Medical College jolted the cancer world with a study saying that 80 percent of lung cancer deaths could be prevented through widespread use of CT scans.

Small print at the end of the study, published in The New England Journal of Medicine, noted that it had been financed in part by a little-known charity called the Foundation for Lung Cancer: Early Detection, Prevention & Treatment. A review of tax records by The New York Times shows that the foundation was underwritten almost entirely by $3.6 million in grants from the parent company of the Liggett Group, maker of Liggett Select, Eve, Grand Prix, Quest and Pyramid cigarette brands.

The foundation got four grants from the Vector Group, Liggett’s parent, from 2000 to 2003.

Dr. Jeffrey M. Drazen, editor in chief of the medical journal, said he was surprised. "In the seven years that I’ve been here, we have never knowingly published anything supported by" a cigarette maker, Dr. Drazen said.

An increasing number of universities do not accept grants from cigarette makers, and a growing awareness of the influence that companies can have over research outcomes, even when donations are at arm’s length, has led nearly all medical journals and associations to demand that researchers accurately disclose financing sources.

Dr. Henschke was the foundation president, and her longtime collaborator, Dr. David Yankelevitz, was its secretary-treasurer. Dr. Antonio Gotto, dean of Weill Cornell, and Arthur J. Mahon, vice chairman of the college board of overseers, were directors.

So, after decades of denying the link between smoking and lung cancer, now a cigarette company has chosen to fund research in cancer detection. That's a good thing, right? It's even charitable, isn't it? Again it's necessary to ratchet up the cynicism:

Dr. Jerome Kassirer, a former editor of The New England Journal of Medicine and the author of a book about conflicts of interest, said he believed that Weill Cornell had created the foundation to hide its receipt of money from a cigarette company. "You have to ask yourself the question, 'Why did the tobacco company want to support her research?' " Dr. Kassirer said. "They want to show that lung cancer is not so bad as everybody thinks because screening can save people; and that’s outrageous."

Dr. Henschke’s work, while controversial among cancer researchers, has been embraced by many lung-cancer advocacy organizations, which have pushed for legislation in California, New York and Massachusetts to create trust funds to pay for lung cancer screening — often with language tailored to benefit Dr. Henschke’s group.

From this perspective, a mass-market campaign for lung cancer screening, instead ads targetted to smokers over 40, makes much more sense. What better way to build the association, in the public mind, that lung cancer is detectable and treatable if caught early? You could even imagine tobacco companies trying to limit future medical liability by pointing to the research they funded. "Everybody knows smoking causes cancer," they'd say -- "but everybody also knows a screening CT would have caught this early, while it was treatable."

So, the millions Liggett gave to Dr. Henschke wasn't motivated by charity or guilt, but rather, looks like a wise investment. Similarly, the misleading subway ads were never designed to protect the public -- the exist to protect cigarette company interests.

Blood Makes Noise

2008-03-20T19:14:00.002-04:00

I recently heard US Army Major (and emergency medicine physician) report on his research, conducted in a major trauma center in Iraq. To give some context to his investigations on Factor VII and clotting, he mentioned a number of incredible statistics about the volume his hospital sees, the throughput his ER achieves, and even the turnaround time for lab results.

But one thing he said really stayed with me: all the hospital personnel have their blood typed and crossmatched. When a wounded soldier or Iraqi civilian requires a massive transfusion in the OR, they'll summon someone with the right blood and just hook them up to the patient, in the OR. He said, "There's nothing like transfusing warm, fresh whole blood to a patient -- it's like a magic bullet. Too bad we could never do that in the States."

(Another Iraqi hospital, one not run by the US Army, has apparently adopted different techniques).

But more data is accumulating on the inadequacy of current blood products practices. We already knew banked blood has poorer oxygen carrying capacity and is immunosuppressive (at best). Now, the NEJM just published a paper from Koch et al that demonstrated more post-operative complications from older blood transfusions. Cardiac surgery patients were significantly more likely to stay intubated, to have their kidneys fail, to develop sepsis, and to die -- when they were transfused packed red cells that had been stored more than two weeks.

Blood transfusion has come a long way and the practice of whole-blood transfusion has fallen out of favor, at least among US civilian institutions. But military studies have shown, at least, non-inferiority of the practice fresh whole blood transfusions, compared to frozen blood products (and patients requiring FWB required more blood, which is typically associated with worse outcomes). And others are looking at ways to mitigate the risk of infection.

It will be interesting to see this military practice finds some applicability in stateside trauma centers, and if the pendulum swings back towards whole blood transfusion in certain cases. If reviews bear out the benefit of fresh whole blood, hospitals should set up some kind of system where volunteer employees can be summoned to the OR to donate. It somehow seems more immediate and personal than current blood donation and banking. And when you consider all the expensive, marginal interventions we use in emergency medicine, it's nice to think we're sitting on something that could make a dramatic difference for a critically ill patient.

More, Now, Again

2008-03-05T19:27:00.002-05:00

If, for some reason, you haven't read enough about me in the past few months, you can read my profile (html, pdf), by Dr. Tiago Villanueva, in this month's Student BMJ.

Dialogue

2008-02-26T11:10:00.003-05:00

Christine Miserandino (of butyoudontlooksick.com) recently asked me some questions about Grand Rounds, and my thoughts on use of the emergency department, and the web, by the chronically ill. The interview is now posted to her site.

My interview of her, as well other Grand Rounds host interviews I've been privileged to conduct, is available on Medscape.com. Just register (free) and search for "Pre-Rounds" (you can sort by date to see the most recent, first) or browse the Pre-Rounds column index.

Hyperresonant

2008-02-18T05:48:00.004-05:00

I hardly ever use my record player. Nevertheless, I would like to own this record, featured recently on the website of New York's WFMU:

There is absolutely no information printed on this 10" record except the word Borborygmi, which is the medical term for stomach-gurgling sounds.

A fitting name for this collection of jaunty piano-and-vocals medical parodies, apparently sung by real doctors. Only real doctors could have gotten away with singing such explicit material in the '50s / early '60s period these songs were probably recorded. Assuming this is the same bunch who did this, this record was produced to benefit the Greene County, MO Medical Society's Scholarship Foundation. It definitely wasn't for the general public - only other medical industry professionals would understand all the references.

Looking for graphics, I was just typing in mildly appropriate phrases like "singing doctors," not really expecting to find anything, and I came across this (the album cover to the right). I'd say it's a different album judging by the song titles, but they mention Greene County in their lyrics. How many Green County singing doctors could their be?

It's nice to think these clever tunes (you can sample them on the WFMU site) helped fund the education of physicians. Another one of their albums has made it to online auction. They also recorded Medic Emetics, Keep You In Stiches, and Thanks for the Miseries. After a few minutes of web sleuthing, I found a different listing, for the Greene County Boys. Borborygmi sells for $9; they also had an album called Placenta Preview.

Early Detection of an Invasive Mass-Marketing Campaign

2008-02-17T21:39:00.005-05:00

I was taken aback by a new subway advertising campaign, imploring the public to demand a CAT scan. With lines like "5 out of 5 lung cancer survivors recommend a CAT scan", the idea is a familiar one: early detection saves lives.

Of course, early detection of lung cancer by chest x-ray was shown, decades ago, to have no impact on mortality and is often the example of "lead time bias" taught in evidence-based medicine lectures.

But now we've got computer-aided tomography scanners, with their improved resolution (and higher doses of radiation). Can they find lung cancer soon enough to treat? Will they find "incidentalomas" that prompt dangerous, useless workups? Will this intervention do more harm than help?

These are serious questions, and research is ongoing. Some provocative recent results suggesting CT scans of asymptomatic at-risk individuals (mostly smokers over 40) can improve lung cancer mortality, but others offer some words of caution going forward.

Sadly, the folks at demandaCATscan.org think they've got all the evidence they need. On their front page, it's written:

The availability of early detection for lung cancer is widely unknown, inexcusably underencouraged, underfunded, and underinsured. Just ask five-out-of-five lung cancer survivors. “While we wait for the cure, the biomarkers, the blood and saliva tests, we will use the early detection imaging and diagnostic tool we have available, right now. The 64-slice low dose CT scan."

One of the participating hospitals, linked from the demandaCATscan.org site, is honest about the trial:

Sequoia’s lung cancer early detection program is a participating member of the International Early Lung Cancer Action Program (I-ELCAP).

I-ELCAP is the first research study of its kind involving a large number of hospitals that are evaluating the effectiveness of screening for lung cancer with low-dose CT Scanning...

...Who should get screened? We currently do not know what defines the ideal population for lung cancer screening (that is one of the goals of the study). Our screening program includes people 40 and over with a history of smoking or second hand smoke exposure.

Reasonable words. And looking around the site that demandaCATscan points to, thelungcancerfoundation.org, I see a medical advisory board full of oncologists, thoracic surgeons, and indeed, the author of the aforementioned 2006 NEJM study touting early detection via CT. Several board members are themselves lung cancer survivors.

I can't doubt this group's dedication or integrity (I originally expected "demandaCATscan.org" would be backed by GE Lightspeed scanners or something similar).

But I must ask, were these board members behind the subway ad campaign? Do they really want the general public demanding a CT scan? Because it's hard to believe such an informed and experienced group could endorse this approach.

I could have supported ads targeted to smokers over 40, encouraging them to enroll in a lung cancer screening trial. But the way it's currently executed, these ads will plant a lot of misconceptions in peoples' minds, and lead to a lot of fruitless conversations with already time-crunched physicians. Plus, the money spent misguiding young healthy subway riders could've been spent better -- on researching screening, therapies, or just enrolling appropriate subjects.

It seems like this intervention will cause more harm than benefit.

Full Disclosure

2008-02-01T17:28:00.000-05:00

Remember that recent study about doctors talking about themselves during patient encounters? It received a lot of attention from the media and patients...

But now (at last!), you can hear three doctors talking about it -- me, and my esteemed Medscape Roundtable colleagues, Dr. Robert Centor and Dr. Robert W. Donnell. I tried to critique the study, and advance another reason why physicians would 'self-disclose.' Check it out, and let your own voice be heard in the comments section.

You can write, but you can't edit

2008-01-29T14:53:00.000-05:00

I'm thoroughly enjoying this month's edition of Annals of EM -- partly because of some challenges to current practice, with some research that's up my alley... but mostly because it arrived on my day off.

One article on lab turnaround times has a brilliant editorial accompanying it. Some background: I've been fascinated by charting since medical school, and this memorable post from MedPundit on the evolution of charting stayed with me as I tediously documented findings and thought process on my patients.

Nowhere is documentation more verbose than in the electronic ED. The late, great Cheerful Oncologist blog once hilariously remarked upon this problem:

It was the most amazing thing I had laid eyes on all summer. I sat mesmerized, scrutinizing page after page until finally I heard a voice asking if I was alright...

Later, while driving home, my thoughts drifted back to that emergency room report. It wasn't the facts in the case that captivated me; the patient's illness was serious but manageable, and he had improved since his admission.

It was the macros used by the E. R. doctors and nurses in their typewritten report that were stunning. They spilled over the pages, neatly stacked into parallel lines, all created to prove conclusively to any skeptics that at no time while physically present in the emergency room did the patient receive anything less than perfect care. The result was a repetitive - nay, interminable, tedious, irksome collection of about a hundred paragraphs that contained just under ten percent factual information.

The rest was just a pile of crap that I inferred was placed there for the sole purpose of vexing malpractice lawyers.

Don't get me wrong - I understand the importance of careful documentation of the events of the day inside a hospital or medical office. I get it when I'm told to leave good records of what I say to my patients. It's just that in this particular case the result is an unintentionally hilarious narrative. Let me illustrate by providing an example of a visit to a local hamburger joint, as chronicled by the restaurant's risk management team:

"The client, who walked into the lobby on his own power, had no signs of distress. He was promptly escorted to the nearest counter by staff member One. He completed this ambulation without injury. The client was asked how he felt before the Staff Member departed. The client said he felt fine, but did complain of a feeling of hunger in the vicinity of his abdomen. He was promptly examined by the staff member and found to not contain any foreign objects protruding from his abdomen or chest.

"The client placed his order for a hamburger, large fries and medium coffee. He did not show any signs of distress while waiting for his order, and was checked on by staff members One and Two at 1457 hours and again at 1502 hours. The client did not fall down at any time during his wait, but he did show brief signs of distress upon hearing the score of the Cardinals-Cubs baseball game, which was being broadcast from a nearby radio...

It goes on and on. Some ED information systems are better than others in shielding practitioners from the malpractice malarkey that creeps into charts (by highlighting freetext material, key findings, assessments and plans -- while pushing the checkbox stuff off to the periphery, at least while the patient is still in the ED).

But while we bemoan this excess verbiage, it's not often we wonder what else is at risk. That's why I enjoyed Dr. Peter Viccellio's editorial piece on hidden costs of computer systems, excerpted below:

The electronic medical record has become a tidal wave in emergency medicine. Templates. Checklists. Computerized physician order entry. Time stamps. All entries ending with "side rails up." When one walks into such an ED, it is rather typical to see most of the staff with their nose in a computer. With many hospital systems, there’s a wonderful opportunity to take a minute to chat with your colleagues as you await completion of your sign-on, to check to see if labs are back yet, knowing that you’ll be back to your seat to check again in a little while. (At my institution, the simple act of logging on consumes about 30 to 45 minutes per physician per shift.) Of course, much of this is improved by a robust tracking system (which, uniquely, is a system that works for the physician, rather than vice versa). Many places have implemented computerized physician order entry, or some tortured version of it, and would do well to adopt suggestions such as the ones outlined in the Guss et al article.

The human transaction costs of all these interactions with the computer have, oddly, been largely ignored. Large groups of health care practitioners typically spend countless hours devoted to the design and maintenance of the system. Time spent at the computer writing notes, entering orders, and looking up lab results is time away from the bedside. The burden of clerical activity has shifted to the nurse and physician. We enter the orders. We seek out the results, often buried in multiple systems. We type our notes. We print out our discharge instructions and prescriptions.

From personal review of a number of templated charts, several things are readily evident. First, there is a struggle between free texting (which is very time consuming) or simply fitting the patient to the template and ignoring the variances. Second, a lot of sprained ankles are curiously getting their pupils checked and their bellies examined by both the physician and the nurse. Some evidently believe that any box left unchecked is an invitation to a supervisory reprimand. The third, and most important, has to do with the ultimate content of the chart. It no longer tells a story (yet, at the same time, takes pages and pages to do so).

The explosion of information in the record, much of which is drivel, succeeds in defeating the primary purpose of an electronic medical record, ie, to tell the story in a meaningful way. It is ultimately a record designed for coding and compliance, not to portray the battle of the patient. When an ED visit for a cough, with diagnosis of pneumonia, consumes 17 pages of print, something has gone awry. (Or perhaps things went awry when pulmonary edema was no longer considered an emergency unless there was a documented family history, social history, and 10 reviews of systems.) Unstudied is the impact a template may have on critical thinking. Being led through a series of checkboxes is very different than the unrestrained and loosely structured improvisation between the physician and the patient. Will the physician have more or less "Aha!" diagnostic breakthroughs when guided and constrained by a template? Will it alter content, the exchange, the clues of body language, the personal interaction, and the diagnostic considerations for better or for worse? Where will we find the time? Whatever its impact, we can at least be sure that more boxes will be checked.

What do these comments have to do with the Guss et al work? Improving flow is centerpiece of their efforts. Although these interventions decreased lab turnaround time for specific labs, were the patients any better off? Did they get out any faster? The article is unfortunately silent on these matters. The context of the study is one in which all efforts are channeled through a computer, and most of this effort depends on those on whose time the patient would consider most valuable. After a pound of flesh for the coder and a pound for the compliance officer, what’s left for the patient? It’s great for the clerk that we now log on, enter orders, type notes, get results, print discharge instructions, and even carry our own telephones. Some of us are doing our own billing as we work.

We need to critically measure the true value of systems that potentially double or triple the amount of work required away from the bedside. Like the electronic medical record, computerized physician order entry itself has not quite been the Grand Panacea as originally envisioned, with production of its own set of errors and time-consuming processes. We don’t really have it "right" yet.

Agreed. But while ED information systems have so far been geared toward maximizing documentation (with an eye toward limiting liability and maximizing billing) new efforts are underway to make computer charting more efficient, and at the same time support decision-making. It will take effort and much trial-and-error, but fortunately, computerized charting is a platform that, by its very nature, lends itself well to research.

How Do You Sleep at Night?

2008-01-29T12:12:00.000-05:00

Getting emergency department signout on a Monday evening is as close as I've come to drinking from a firehose. Whatever late afternoon activities I've been engaged in, they seem impossibly placid when I walk into the ED at its most crowded and chaotic.

The patients peer at the gaggle of white coats at signout, trying to size up the night team. The outgoing team has already welcomed us as liberators. And they tell us about the ongoing workups, the lab results and consults still pending, and the patients already dispositioned but still waiting for a bed.

In signout, the essentials are all there, but some nuance is inevitably glossed over. And so it was on one particularly busy Monday, when I received at least a half-dozen patients, including a hypotensive febrile encephalopathic young man who had been rejected by the MICU. My mind was still preoccupied with him when an outgoing intern started telling me about the simple, straightforward elderly woman with back flank pain and hematuria who was "probably in the CT scanner even as we speak." Just get the read, confirm the stones, give her some 'scripts and she'll be on her way.

Not surprisingly, it only took a few minutes for that neatly-bundled package to unravel (though enough minutes passed for the intern to be on well the way home). I got a call from radiology that my new patient was requesting pain meds (the scanning table was too stiff) and something for her nerves (she didn't like moving through that heavy donut of a machine).

I checked the record, and was amazed to see the patient had already received three generous rounds of opioids and benzodiazepines before signout. Combined, it was enough for procedural sedation in a young adult -- and my patient was well past retirement age. Her outpatient summary mentioned a xanax prescription, but none of this had been covered in signout.

A nurse, grappling with her own monstrous signout, graciously provided me with round four of this patient's morphine-and-ativan regimen. I scurried down to radiology, myself pretty anxious to meet this new patient, and to return to the encephalopathy case in the resuscitation bay.

When I got to radiology, which seemed so serene in comparison to the ED, I was greeted by a tech who directed me down a near-deserted hallway, to a distraught woman in a stretcher. By her side was an affable husband, holding their coats, bags, and various papers. He smiled broadly and asked, "are those her medications?"

His wife was hyperventilating and clutching her side. After introducing myself and confirming the story, I pushed the meds and reconnected her IV fluids. I apologized and hurried back to the busy ED.

The code was called overhead, about ten minutes later. Every doc's ears perked up in the ED -- we're responsible for the coding patients in some part of the hospital, but not others, so we waited to hear if we'd need to gather our gear and run.

As it turned out, the code was in radiology. We were covering. And I started to run, worried -- really panicked -- that I had just killed a patient.

I was the first from the ED to arrive, but there were already some long white coats surrounding a stretcher. And, to my eternal relief, it was not the stretcher of my patient.

Even better, this was not even a real code -- the long white coats belonged to neurosurgeons, who were concerned their head-bleed patient from upstairs was breathing funny, and wanted anesthesiology to tube him. I volunteered, but they held out for the anesthesia team, who arrived a minute later. My services were not needed, so I slung some gear over my shoulder and trudged back, stopping along the way to talk to the woman with flank pain, and her husband.

"I've got to confess," I remarked, tapping on the airway equipment, "I thought we were called to use this on you."

"She's alright," the husband responded.

"No I'm not!" the woman exclaimed. "All this activity has made me very anxious..."

Everywhere you sing your smile

2008-01-28T14:30:00.000-05:00

Seeing this funny video reminded me of the time the Google StreetView van stopped outside my apartment. I asked the driver what was wrong, but he was not very forthcoming -- despite the fact he was photographing absolutely everything and everyone around him (on second thought, this might explain his evasiveness).

Next to these excellent photos of the Google Van and hardware (including some self-portraits and a glimpse of the Google Beetle) I add my own blurry cameraphone pic, on the right.

More Google Van pics and coverage at, you guessed it, GoogleVan.com.

Program Note

2008-01-10T06:39:00.001-05:00

I'll be calling in tonight to the Dr. Anonymous Show on BlogTalkRadio. We'll be talking about medical blogs, and blog awards, and the blogging of blogs. If this interests you (and honestly, why wouldn't it?) you should tune in, or even call into the show. Hopefully some of my colleagues from Medgadget will join us.

If Political Pundits Covered an Emergency Department Shift

2008-01-09T01:15:00.000-05:00

This long, rambling dialog took shape while I walked home from the ED just now, to yet another night of surprising election results. To follow the analogy, just substitute "doctors" with "voters," "patients" with "primaries" ... and the causes of abdominal pain... as major US presidential candidates:

Jeff Greenfield: If you’re joining us from home, this is a very special night in the ER. After hearing about diseases for so long, a group of doctors is finally going to step up and decide what's ailing a waiting room full of patients.

Wolf Blitzer: It’s a big night, no doubt, and let’s see how doctors are evaluating their first patient.

Dan Rather: She’s a young woman with several hours of periumbilical pain. Now it seems to hurt a little more on the right. She’s vomited. That's all we've been able to uncover.

Chris Matthews: I was talking with some of the doctors tonight. While they've obviously given this a lot of thought, many seemed ready to back appendicitis.

Anderson Cooper: Appendicitis has received major endorsements from several surgeons, and it clearly has the name-recognition among the general public. It’s a heavy hitter.

Jeff Greenfield: The ER docs are conferring. I wonder what they’re discussing?

Keith Olbermann: Maybe they want to know if the patient pregnant? Afebrile? I think they’re ordering labs of some kind.

Doris Kearns Goodwin: Well, it hardly seems to matter at this time, Keith. Appendicitis has a well-honed message of fear. These doctors, facing uncertain times, can’t afford to back a dark horse diagnosis now.

Larry King: I think I heard one doc mention torsion. What do you think of that?

Jeff Greenfield: Torsion is very popular among this demographic.

George Stephanopoulos: You know, torsion has surprised me a lot recently. Women *and* men seem pretty impressed by the pain and damage from gonads twisting on a stalk. This is one diagnosis they don’t want to overlook.

Larry King: Well, here we go. The patient’s getting a CT scan. And there’s the wet read! We are calling it appendicitis!

Wolf Blitzer: Amazing. You know, grassroots organization really carried appendicitis in this first key patient of the night. Everybody knows somebody who's lost their appendix -- and that kind of familiarity with the disease really figured into the doctor’s decision-making.

George Will: And, you know, as I look across the waiting room at all the patients clutching their bellies, I really think appendicitis is going to run the table tonight.

Jeff Greenfield: You think everyone with abdominal pain has appendicitis?

Anderson Cooper: Appendicitis has the momentum, Jeff. Its brand is strong.

Chris Matthews: Appendicitis has reached the top of the differential by borrowing from so many other diseases. It's like a chameleon. And these doctors are just blown away by its broad appeal across so many key demographic groups. They're true believers.

Jeff Greenfield: Here’s another patient. The doctors are evaluating him. How do you think this one’s going to turn out?

Ted Koppel: A wise man once said, if you want to know what’s ailing the patient, you ought to ask the patient. And measure vitals, do a physical exam, and consider some imaging and labs – and also, spend some time building an appreciation of pathology.

Chris Matthews: I don’t know, I’m ready to just call this one for appendicitis.

Sean Hannity: Appendicitis is a *juggernaut*. The other diagnoses should just *give up*.

Dan Rather: You know, the other day I was talking with an agent of Yersinia... From a certain point of view, Yersinia and appendicitis have a lot in common.

Chris Matthews: Yersinia’s time has passed. It’s embarrassing that Yersinia is still on the differential diagnosis.

Larry King: The doctors are looking up something... prior visits, it would seem. And now, orders are going in.

Dan Rather: I don’t see any calls to surgery, nor is there a CT scan ordered. We may be looking at a major upset.

Larry King: They’ve given their fluids, pepcid... and some reglan! And they’re moving on!

Tim Russert: Gastroenteritis! The doctors have spoken.

Jeff Greenfield: Unbelievable. This is a huge setback for appendicitis.

Wolf Blitzer: But what an amazing comeback for an old standby. Lately gastroenteritis didn’t really seem to have the vision, or the ability to reach doctors on a visceral level anymore. Tonight it seemed almost like an afterthought, especially with that first patient.

Dan Rather: Acute gastroenteritis has pulled itself back from the diagnostic abyss.

Tim Russert: I have to wonder what the doctors are basing their decision-making on. It’s almost as though there are factors besides momentum that play into their thought process.

George Stephanopoulos: I think doctors were trying to send appendicitis a message – appy’s got to earn its spot at the top. The doctor's aren't so enamored with it anymore, that's for sure.

Anderson Cooper: Well, it just goes to show, doctors are a fickle bunch. There’s still a long way to go in this shift, and now the ER is a battleground for disease.

Dan Rather: This is where the fun starts.

Forgive the length. And I don't mean to imply that the presidential candidates cause upset stomachs. Just that voter's decisions, like medical decisions, are a good deal more sophisticated than the talking heads give them credit for. If pundits spend time on fundamentals, like policies and platforms, instead of canditates' momentum and maneuvering, they might improve their accuracy -- and at the very least, render more of a service to their viewers.

Informed Review

2008-01-04T02:40:00.000-05:00

I know it's January, but that somehow makes this IRB appraisal of Santa's activities more timely. Excerpts below (via Grahamazon):

1. You propose to study "children of all ages". Please provide an exact lower and upper age limit, as well as the precise number of subjects. Provide a statistically valid power calculation to justify this large of a study.

7. The database of good and bad children will be kept "on a scroll at the North Pole." Please describe the security provisions you have in place to protect the research data. Is the scroll kept in a locked cabinet in a locked room? Who has access to the scroll? Are there backup copies of the scroll and how often are they compared to the original?

10. As this study involves prospective data collection and is more than minimal risk without prospect of direct benefit to the subjects, informed consent signed by both parents will be required. Please have the consent form translated into every language spoken by children.

In googling for more IRB rants, I found this thoughtful blog post that points to a number of papers considering the ethics of IRB regulations. A 2003 report on IRB Mission Creep seems like an evenhanded approach to addressing some faults in the system.

Making Modern Music

2008-01-02T12:18:00.000-05:00

RollingStone.com has an interesting story on the Death of High Fidelity. Of course we've known since the beginning that MP3 sampling is a poor substitute for CD quality sound, which itself pales next to vinyl on a high-end system. But what this article tells us is how the music industry is adjusting to the new milieu, mixing 'louder' songs with less detail that are designed to play well on iPods, car stereos, and bars. RS talk about 'ear fatigue' in relation to new albums (so that's why I can't tolerate Arctic Monkeys) and includes a lamentation from Steely Dan's Donald Fagen, whose music isn't translating well on my iPod.

Rolling Stone prints a damning comparison of songs waveforms -- past, present and reissued. And a link to a technical wikipedia discussion (with more examples, and some possible solutions).

But there is one marriage of technology and music I can enthusiastically endorse: Air Karaoke, available on Channel 1017 in New York City (the Oxygen network's On Demand channel). Apparently this has been available for ble years, but I was unaware until the week hours of 2008. Already, this new technology has impacted my life, and certainly, the lives of everyone within earshot.

Check it out

2008-01-02T12:16:00.000-05:00

Much has been said about this excellent New Yorker article on checklists in medicine, by Atul Gawande, in which he talks with two checklist gurus -- intensivist Peter Pronovost from Hopkins (he wrote the Tintinalli chapter on ABG interpretation) and Markus Thalmann, an Austrian surgeon who led some truly incredible hypothermia arrest resuscitations.

The article gives a historical perspective to the concept of checklists -- from engineering to pilots -- and how it's moving into medicine. Checklists standardize complex activities like sterile line placement, leading to fewer complications, shorter ICU stays, and more lives saved. It's engagingly written and very relevant to ED practice.

Key grafs:

If someone found a new drug that could wipe out infections with anything remotely like the effectiveness of Pronovost’s lists, there would be television ads with Robert Jarvik extolling its virtues, detail men offering free lunches to get doctors to make it part of their practice, government programs to research it, and competitors jumping in to make a newer, better version. That’s what happened when manufacturers marketed central-line catheters coated with silver or other antimicrobials; they cost a third more, and reduced infections only slightly—and hospitals have spent tens of millions of dollars on them. But, with the checklist, what we have is Peter Pronovost trying to see if maybe, in the next year or two, hospitals in Rhode Island and New Jersey will give his idea a try.

Pronovost remains, in a way, an odd bird in medical research. He does not have the multimillion-dollar grants that his colleagues in bench science have. He has no swarm of doctoral students and lab animals. He’s focussed on work that is not normally considered a significant contribution in academic medicine. As a result, few other researchers are venturing to extend his achievements. Yet his work has already saved more lives than that of any laboratory scientist in the past decade.

I emailed the residents about this a month ago, but since then, the article has taken on additional significance, as I've committed to an informatics project on decision support. Not surprisingly, Gawande has covered this territory, as well.

So, there's not much more nuance I will add to what's already been said about Gawande's piece, other than to speculate that the Dr. Markus Thalmann that Gawande interviewd is the same man Austrian doctor listed as the winner of the 2003 Spartathlon. Runners like their checklists, too.

Briefly Noted

2007-12-17T16:18:00.000-05:00

Another year is slipping by, and I haven't read nearly as much (non-medical) literature as I would have liked. Still, a number of noteworthy books have come to my attention, and if you're looking for a medically-themed gift for someone on your list, consider some of the following:

The Man with the Iron Tattoo: Two neurologists, John Castaldo and Lawrence Levitt, recount their lives in medicine, with interesting cases, memorable patient interactions, and some mild pontification about the importance of reaching out to one another. Well-written, and an interesting look at how medicine and standards have changed in a generation.

The Diagnosis of Love, by Dr. Maggie Leffler. I must say, this book was much better than the title or blurb (about a young female physician resolving family and relationship crises) would lead me to expect. The book featured snappy pacing and dialog, well-developed characters, and captured some of the frustration and opportunity inherent in a scientifically-trained physician interacting with some of the stubborn and less rational people around her.

Know Your Numbers, Outlive Your Diabetes by Dr. Richard Jackson and noted journalist and blogger Amy Tenderich of DiabetesMine. When I think of all the diabetic patients I see with repeat visits to our emergency rooms, I can only hope some of newly diagnosed pick up this book before it's too late. With straightforward text, and easy-to-read bullet points and tables, this book can give patients a strategy on to manage this challenging disease. And it might give the patients, and their caregivers, some hope as well.

The Alchemy of Grief by Emily Ferrara. One of my former professors has produced a book of poetry, borne of a parent's worst pain, the loss of a child. One review reads:

This is excellently controlled craftsmanship, conveying deeply felt emotion. The grief of loss is sharply poignant and real, yet never maudlin or self-indulgent. The music of the lines is subtle and fine. The tension between the controlled craft and the poignancy of the theme makes the reader participate in the poems and feel with the poet, sharing the human despair and transcendent emotions that bring us through to survival. - Daniela Gioseffi