All Saints' Day

The Dean's Letter goes out to residency programs tomorrow, November 1st. Our applications are complete at that time, and there's nothing left to do but sit and wait for more interview offers.

The Dean's letter, also called the Medical Student Performance Evaluation, is an overview of all our clerkship grades and evals. Most of the comments doctors and residents gave us in the past year find their way into this document. At our school, students are given a chance to correct grammatical mistakes and errors. It's a good thing, too -- I spotted one evaluator's comment that read:

Clearly, Nick was one of the students this past year.

I really hope an adjective was missing.

But in talking with my peers, many who are usually well-balanced and easy-going, we have discussions that George Orwell and Garrison Keillor could both enjoy. It's because we've become adept at reading between the lines of evaluations.

"Outstanding" is the best adjective to describe your candidacy for residency. It's nice to have it mentioned as often as possible, in fact: next to your people skills, your initiative, your knowledge base. "Excellent", by contrast, is really a let-down. It's the second-best adjective. Only in medical school can someone dread being called "excellent," but it happens. And don't get me started on "Very Strong" or "Very Good". That's damning by faint praise, as far as I'm concerned.

Maybe it's different at other schools, but I thought this was the code all program directors used. Actually, it's discouraging to think some of my graders might employ real English, and some are using eval-speak.

Fall classic

I slept for a long time last night, catching up on a deficit spent on the ALCS, the World Series, Halloween parties, and pediatrics call. This morning, I experienced the pleasant gift of an unearned extra hour.

I wrote about Daylight Saving in the spring. But it's a topic whose time has come again.

Bask

There's so much love in New England right now. Last night, for instance, I saw strangers share many a weepy embrace. Families strolled the eclipse-lit streets at midnight. I myself high-fived over two hundred people.

We took pictures with the man wearing a functional replica of the Fenway scoreboard. We cheered the cops and taxi drivers as they slowly rode by. There was even a guy handing out Baby Ruth candy bars in Central Square. It was perfect: don't just beat the curse -- eat it.

Yes, there's a spirit of magnanimity in the air, a generousity that comes naturally from a land that has produced this year's NFL and MLB champions.

With this in mind, here's a big thank you to my readers. October will break blogborygmi traffic records, which is kind of unexpected because 1) I think I'm posting less and 2) the Grand Rounds instalanche was back in September. But this has been a month of pleasant surprises...

Also, I have to thank the commenters, who have made so many posts more interesting and enjoyable by sharing their thoughts.

The mark of courage

Did I mention how great my readers are? Erin writes:

I'm desperately seeking a photo of the FrankenSchilling
sutures, due to a bargain I made with god/satan/whoever
regarding the World Series.

I can't find a picture anywhere, but I'm wondering
if any of you, with your expertise, could hazard a
guess as to what that must have looked like?
Vertical or horizontal? Above or below the ankle
bone? I promised the ghost of Babe Ruth that if
the Sox won this series, I'd tattoo those sutures
to my ankle.

First, take the time to get this right. Everyone will be talking about this magical month for the rest of their lives, but you'll have something to point to. Make sure it's accurate. Ask a surgeon blogger, or someone who's named his blog after a stitching technique. Or, hey, try asking Curt Schilling himself -- he posts to Sons of Sam Horn...

Failing that, at least print out a picture of a dislocated peroneal tendon and show it to your artist.

But from what I've gathered (and from Noah's input) I think you'll have four stitches total. They'll be in pairs over the outside knob of the right ankle (lateral malleolus). On each side of the forward-displaced tendon, two stiches, running lengthwise and parallel to the tendon, made a new groove for it to slide in.

I also heard Schilling had four sutures in Game 6 of the Yankees series, but Dr. Bill Morgan and company used only three in Game 2 of the World Series.

Good luck!

Calling a Code

Geena's the first nurse to host Grand Rounds, over at CodeBlog.* Go check out the latest and greatest in the medical blogosphere.

*(Not to be confused with CodeBlueBlog, cited below.)

A tale of two mobs

Bravo to CodeBlueBlog for asking a question that's somehow slipped everyone's mind:

How, exactly, did Victoria Snelgrove die?

This 21-year old fan took to the streets with thousands of others after the Red Sox beat the Yankees in Game 7 early Thursday morning. The police were called in, armed with new weapons purchased (but not used) for crowd control at the Democratic National Convention. Some poorly trained officers sprayed pepper-bullets into the mob. Snelgrove was struck in the eye and died hours later.

CodeBlueBlog is right to criticize the media's coverage of this sad event. At this point, no one in the press actually digging up facts anymore. The ratio of commentary to real news is so out of whack, you have to wade through hundreds of "me too" articles on Google News just to find out the smallest wrinkle in the story. The press has become just as unruly and misguided as the drunken revelers they're criticizing. The key questions -- mechanism of death, coroner's report, past medical history -- are not even being asked, as far as I can tell.

So, props to Code Blue for raising these questions. He performed an armchair literature survey of similar accidents -- above and beyond anything unearthed in the mainstream media. His findings? Among the hundreds of cases of paintball-to-eyeball injuries recorded, none resulted in death. Something's fishy here, and the truth may illuminate some of the polarized policy discussion now underway (Bostonians are being asked to either reinstate Prohibition or submit to the stormtroopers).

It's interesting though, that CodeBlue thinks the media's rush to commentary has led to an anti-police bias. I think the Boston press has been unconscionably pro-police, at a time when even the cops are admitting a major error. Either way, this debate needs more data, and journalists are failing us.

It's a sad coincidence that Snelgrove herself was a journalism student. I like to think she still has a story to tell -- if only her peers were asking the right questions.

Editorial

Malcolm Gladwell writes with an outsider's clarity and wit, which has served him well in such books as the Tipping Point, an excellent and readable introduction to phenomena in sociology and marketing. Hell, he can even make ketchup compelling.

But he's now tackling drug prices, and while he makes some excellent points, I wonder if his final conclusion isn't off the mark.

It is accurate to say only that the United States has a different pricing system from that of other countries. Americans pay more for drugs when they first come out and less as the drugs get older, while the rest of the world pays less in the beginning and more later. Whose pricing system is cheaper? It depends...

In fact, drug expenditures are rising rapidly in the United States not so much because we’re being charged more for prescription drugs but because more people are taking more medications in more expensive combinations. It’s not price that matters; it’s volume.

So true, and not emphasized enough. But then Gladwell focuses on a significant problem in prescription drugs: new meds with side-benefits that aren't cost effective or particularly efficacious. An example he gives is pravachol (one of many "me too" cholesterol-lowering drugs), which was shown to lower strokes in a small, select population but actually raises stroke incidence in a bigger, more vulnerable population.

He doesn't squarely blame the drug companies for advertizing these benefits, and he doesn't exclusively blame doctors for overlooking the caveats buried in the scientific literature. Instead, he implicates a new target: medical journal editors, for not doing their jobs and properly highlighting the advantages and drawbacks to new drugs. This criticism is all the more damning, since a powerful former editor, Marcia Angell of the NEJM, has just written a book about Big Pharm's duplicity (and, um, dropped the ball on pravachol).

I've edited some manuscripts myself (for publications with substantially smaller impact than the New England Journal of Medicine), but can still vouch for its difficulty. Clarifying the results and conclusions of some scientist-authors can be like herding cats. And even after I've done a spiffy job, I still can't be sure which section of the paper, which figure or conclusion, will be seized upon by other authors. Some data that I considered superfluous might be the puzzle piece that allows another lab to move forward.

I don't think it's different for clinical publications on drug efficacy. I'd bet that, no matter what results an author uncovers, and no matter how skillfully these results are arranged and highlighted by an editor, drug company marketers will still find material to work with. They'll always be able to find obscure, questionable benefits to justify new drug prescriptions over less-profitable generics. These results will make their way into Big Pharma handouts and presentations, where they'll be repeated ad naseum for years. They've got more money, and they've got more interest. The editors can't compete.

Via Medrants.

Social services

Kevin highlights a BMJ article about a male nursing home resident with a pressing need:

It seemed that Mr Cooper had persistently been asking female members of staff to have sex with him. The problems seemed to have begun when Mr Cooper's regular visits from an elderly female friend had ceased.

Although rather deaf and undoubtedly frail Mr Cooper did not have significant cognitive impairment. He volunteered that his visitor had been providing him with paid sexual services, and that since this was no longer possible he wanted to hire another prostitute. He said his deafness and poor vision had now made it difficult for him to do this for himself, and he had consequently sought help from the staff. He had been firmly refused. I gathered that after a stalemate of many months he could think of nothing to do other than proposition the staff.

As usual, Europeans have a very sophisticated approach to these matters. I recall a story earlier this year in which an unemployed German man asked his government to finance his sexual activities, since his wife was couldn't return to his country.

This case also reminds me of the uproar when health plans started covering Viagra but continued to exclude birth control pills. Why is restoring intercourse considered a medical necessity, but preventing its consequences is considered a lifestyle choice?

I never had a good answer, until I read of the havoc caused by this libidinous nursing home patient:

His situation deteriorated. An extra male staff member was hired, devoted solely to following him around all day to prevent him from making improper suggestions. Both the staff member and Mr Cooper found this constant observation trying.

Later, staff at the residential home obtained the telephone numbers of prostitutes, and one agreed to meet Mr Cooper at a neutral venue. The staff were still divided, although the man who had followed Mr Cooper's every tottering step for many weeks was reported to be relieved.

Read the whole thing.

Uncharted territory

So, um, the Sox beat the Yankees.

Here's a simple guide to peroneal tendon dislocations, like the kind that used to bother Sox ace Curt Schilling. Judging by his bloody red socks, and this Bill Morgan transcript, it seems the tendon was anchored out of its anatomical location, to a site anterior to the lateral malleolus:

JD: “I’m still not sure I understand how you create a wall, what did you attach the sutures to? Skin to skin and that created what, a barrier? Is that the deal?”

Dr.M: “Well the tendon is out of position and out in front of the bone and the problem is that it would slip back again to where it was supposed to be and then slip out again. And it was really just to create a barrier between the skin and the underlying tissue which is called facia so that there wasn’t let’s say a tunnel subcutaneously underneath the skin, it just kind of anchored the skin through the underlying tissue so it would stick the tendon where it was supposed… where it was, so it couldn’t sublux at all."

JD: “If I understand you correctly, you sewed this in a position with the tendon not where it eventually will be when it’s repaired, it’s out of position for the entire game last night?”

Dr.M: “Just for last night. Those sutures are out now.”

GC: “And you assure us he’ll be ready for the World Series correct? You’ll do this again and have him ready for the World Series…”

I think they should change the Red Sox logo to reflect this groundbreaking procedure. Can we get a photoshop on this?

And I expect anatomical gift programs in the Boston area will experience a boom when fans learn how cadavers were used to guide the Sox to victory:

Epstein spoke of how [Sox doctor Bill] Morgan practiced the procedure on cadavers (a common exercise for orthopedists) before using it on Schilling. After applying the anesthetic Marcaine to the area, Morgan sewed in three stitches directly through the skin and attached them to both ligament and deep connective tissue located next to the ankle bone itself. Schilling was satisfied that the procedure had worked during a light throwing session before Monday's Game 5. On Tuesday night, he was proven right.

They'll try it again before Game 2, apparently.

Stitched together

I'm going to continue these late-night ramblings because, as has been the case all week, the Red Sox Are Facing Elimination and in 24 hours I might be too depressed to share.

Bill Simmons, the Boston Sports Guy, pulls off the difficult job of relating the Fenway experience to both die-hard fans and perplexed outsiders:

For two straight days, I watched my beloved Red Sox stave off elimination against the Yanks, needing 26 innings over 27 hours to stay alive for Game 6 in New York. These weren't just baseball games. They were life experiences. They broke you down in sections. They made you question God, the meaning of life, whether sports should possibly mean this much. On Sunday night, I stewed in my seat vowing never to raise my kids as Sox fans. On Monday night, I skipped out of Fenway wondering if any other team could possibly mean this much to a group of people.

...Game 4 ended a little after 1:30 a.m. Fifteen hours later, I was sitting in my same seats in section 116 with my father, glancing around and wondering if we ever actually left. Apparently we did. There was only one major difference between the two nights: in Game 4, the fans were waiting for the Yankees to win the game. In Game 5, the fans were waiting for the Red Sox to come through. Now everyone in New England is pinning their hopes to the greatest comeback in baseball history. It happens that fast.

Emphases mine. Some of the best writing on the Red Sox is coming up at Surviving Grady. Start at the bottom and work your way up from the despair of the early Yankees drubbings, to the whiff of respectability when we won one, to the glimmer of hope Tuesday morning. Now? Chest-thumping and a dare to dream. On the ankle-sutured heroics of Curt Shilling, Red says:

The absolute fantastic-ness of this event is impossible to overstate. Two days ago, he was a gimp. A horrific footnote [pardon the pun] to the 2004 season. A million dollar horse that went tits-up when we needed him most.

But then the balls took over. And he was literally a one-legged guy at an ass-kicking contest. And his cleat did find ample ass to strike. And he turned in a one-run-over-seven-innings performance with blood soaking through his socks and sweat coating his back.

It was simply the gutsiest thing MLB has witnessed all year.

On the flipside, we had A-Rod resorting to schoolboy tactics, blatantly knocking the ball from Arroyo's glove on a close play at first, then whining incessantly when he was called out for it.

Maybe God's finally paying attention. Maybe he sees what's up.

Yeah, a little boisterous, but everyone who's up and blogging about this right now is drunk on something. Read the comments to those posts, as well, because the fans are writing poetry.

Penetrating Trauma

I'm writing this Red Sox story now, because I can't predict my emotional state this time tomorrow. After the Sox momentum these past few days, the tale feels distant, and receding, but I suspect it can never be too far from our thoughts...

Last year, during Game 7 of the epic 2003 American League Championship Series matchup between the Yankees and Red Sox, I was on call. Admitting patients. To the Surgery team. Every day was a long slog but call days especially so; this one was bearable only though occasional dispatches from the nurse's lounge: "Sox up 5-2!" "Pedro's looking strong!"

By the eighth inning, I was on the floor, admitting a middle-aged guy with alcoholic pancreatitis. Volume depletion is a big problem with pancreatitis -- we needed to know how much urine this guy was making. Precision required a foley catheter.

I tried to inform the patient of this as he looked over my shoulder, at his wall-mounted TV. He was watching our tired ace, Pedro Martinez, give up one hit after another.

Me: "So, uh, you're going to need a foley."
Patient: "Why is he still in the game? He's done!"
Me: "A tube will go through your penis."
Patient: "Whatever. Take Pedro out of the game!"

I slowly set up my foley kit (in retrospect, this was probably my second or third career catheterization). I glanced over my shoulder a few times, seeing Pedro give up a run and manager Grady Little come out to the mound.

Me: "Looks like Pedro's out."
Patient: "No! They're leaving him in!"

Pedro then gave up a ground rule double to Hideki Matsui -- there were two on with one out in the eighth. The score was 5-3, Red Sox. Jorge Posada came up to bat. I tuned everything out as I inserted the foley.

As the tube went in, I glanced up at the patient's face and saw an expression of abject horror and revolting pain. I will never forget that look, and I never want to see it again. I assumed at this point I had just obliterated the man's prostate.

Me: "What is it?! What is it?!"
Patient: "Posada doubled! The game's tied."

I looked up at the TV and saw the real damage. Pedro was pulled after that -- two hitters too late. The Yankees went on to win the game and move on to the World Series. The Red Sox manager was fired shortly thereafter.

The 2004 season brought a new set of memories and frustrations to the Sox/Yankees rivalry, but never doubt that the sting from that Game 7 lingers in the hearts of New Englanders. All I have to do is remember that face, and a pain far worse than any foley.

Reinforcements

The best and brightest in research, engineering, and medicine have been working nonstop to solve one of the most pressing problems facing the nation.

Of course, I speak of Red Sox Nation, and the problem of stabilizing Curt Shilling's right achilles tendon.

Reebok has built a custom high-top cleat to do the job. I expect to hear much more on this miracle of science soon, now that Game 6 has gone from "extremely hypothetical" to "Tuesday". For now, this story from the Globe will do:

The suspense surrounding Curt Schilling's possible return to the mound in the American League Championship Series intensified yesterday as the Red Sox indicated Schilling has found the footwear that would enable him to pitch if his injured right ankle permits it.

Manager Terry Francona said Schilling was experiencing normal soreness in his ankle the day after he tested a customized high-top cleat in his first bullpen session since his injury-shortened start in Game 1. The only problem was the shoe, built by Reebok, was too small and hurt Schilling's toes. He received a new pair of cleats yesterday.

"I think he's real comfortable with that high-top as long as he gets the right size," Francona said, indicating Schilling could pitch without an additional brace. "That was Plan A going out to the bullpen, and I think it worked pretty successfully."

The only remaining question was whether the footwear and a dose of the anesthetic Marcaine would permit Schilling to pitch effectively with a dislocated peroneal tendon. The tendon, whose protective sheath ruptured Sept. 26, runs around the back of his ankle.

"I think he kind of feels like we do, that the door isn't closed," Francona said. "Until it does [close], you keep the hope and faith, and try to work hard and do what you're supposed to do. We'll kind of see how it goes."

That attitude is slowly bringing us back from the brink, one game at a time. On a more personal note, residency matching has taken on an added dimension...

Vaccine fever

The flu vaccine shortage of 2004 has indirectly caused its first death:

LAFAYETTE, Calif. (AP) -- A 79-year-old woman who stood in line more than five hours for a flu shot collapsed and died after striking her head.

Marie Franklin and her husband, Robert, had been standing with hundreds of other seniors outside a Safeway supermarket on Wednesday when she became pale and weak. She collapsed as she walked toward shade.

Franklin, an award-winning local artist, died from those injuries Thursday. The Contra Costa County coroner's office ruled the death an accident.

"We see it as a fluke accident and choose not to blame anyone," said the Franklins' daughter, Ginni Poulos of Portland, Ore., who flew to her parents' home in the San Francisco Bay area city of Orinda. "We do think it could have been better organized. People wouldn't have had to wait so long if they had more workers or created a better system."

The daughter is exhibiting a fair and expansive attitude in a difficult time.

I wonder if the next victims' families will be so reasonable. Remember, you can't spell "fluke accident" without some of the letters in "flu vaccine shortage" (and when you have vulnerable patients waiting in lines overnights in October, you're bound to have more morbidity).

Why are patients being forced into this bizarre distribution system, anyway? If you're healthy enough to camp in line outside all night, you should be rewarded with concert tickets, not potentially lifesaving meds. At our pediatrics clinic, docs are making sure the infants with a history of lung disease get the influenza vaccine -- the most vulnerable, first. We're not having the kids arm-wrestle each other for it. So why are the elderly subjected to endurance tests?

Skin deep

Symtym's back with a spiffy new look. The custom skinning was implemented by Moxie. And that logo! A neat use of the icons behind medicine and law.

Anyway, he's got the goods on the VeriChip, the implantable RFID developed by Applied Digital Solutions and recently approved by the FDA. A transmissable past medical history would make my job in the emergency department a lot quicker... but maybe at a price (and I don't mean granulation tissue).

Spheres of influence

Galen's got some commentary on my post about influence and bias in journalism and medicine. And although he graciously identifies his political bent, he stays mum on his stance re: NoFreeLunch.

But hey, I'm staying quiet, too. I've got interviews coming up, and don't want to stake any positions more inflammatory than "the media could do a better job". (If a residency director ever quotes blogborygmi back to me in an interview, I will either rank that program #1 or claim someone has chosen my name as a pseudonym).

Anyway, I came across two interesting quotes about bias in journalism, and the state of the media:

"I think what happened to the media is ambition and stardom have overwhelmed purpose. People always talk about how there's a liberal bias and a conservative bias. But the main bias of the news is personal ambition, because a lot of choices are made based on not burning this source or not causing a conflict in an area that is your ladder upward.... the media is utilized purely as a strategy by people in power."

"Former CBS News-man Bernard Goldberg has written a best- selling book called Bias, in which he maintains that the real problem with the media is not a bias based on liberal vs. conservative or Republican vs. Democrat. It is a bias based on the sameness of worldview caused by social, intellectual, educational and professional inbreeding. These are folks who travel in the same circles, go to the same parties, talk to the same people, compare their ideas to people with the same ideas, and develop a standard view on issues that makes any deviation from them seem somehow marginal, or even weird."

The first quote is by Jon Stewart, host of the Daily Show, as told to Rolling Stone (sadly, the excerpt is only in the print version). The second quote comes from Pat Sajak.

In this era of celebrity journalists and fake news, we're lucky to have some entertainers with the insight and courage to call journalists to task.

Can I bring this back to medicine? Lemme try: Is there a medical equivalent to what Jon Stewart and Pat Sajak have done? Not unless the cast of ER starts giving interviews about the selfishness of doctors.

I don't think that's happened. The task of reigning in drug marketing's influence on doctors has been taken up by... doctors. And it's something to be proud of.

Update: Jon Stewart just went grapeshit on Crossfire today. Via metafilter. Some of the CNN transcript:

STEWART: What you do is not honest. What you do is partisan hackery. And I will tell you why I know it.
CARLSON: You had John Kerry on your show and you sniff his throne and you're accusing us of partisan hackery?
STEWART: Absolutely.
CARLSON: You've got to be kidding me. He comes on and you...
STEWART: You're on *CNN*. The show that leads into mine is puppets making crank phone calls. What is wrong with you?

and later:

STEWART: [after the presidential debates] you go to spin alley, the place called spin alley. Now, don't you think that, for people watching at home, that's kind of a drag, that you're literally walking to a place called deception lane? ...
BEGALA: ... They actually believe what they're saying. They want to persuade you. That's what they're trying to do by spinning. But I don't doubt for a minute these people who work for President Bush, who I disagree with on everything, they believe that stuff, Jon. This is not a lie or a deception at all. They believe in him, just like I believe in my guy.
STEWART: I think they believe President Bush would do a better job. And I believe the Kerry guys believe President Kerry would do a better job. But what I believe is, they're not making honest arguments. So what they're doing is, in their mind, the ends justify the means...
CARLSON: I do think you're more fun on your show. Just my opinion.
STEWART: You know what's interesting, though? You're as big a dick on your show as you are on any show.

And one point Stewart asks them to stop, stop, stop broadcasting, because they're hurting America. It's really something. The clip is available at Media Matters.

Differentiation

Over at Kill As Few Patients as Possible, Dr. Bradley and I have been going back and forth about embryonic stem cells, the public's perception of the issue, and how much Kerry should be castigated for a misstatement in the second debate.

I think we're coming to an agreement on the following:

1. Kerry's position is contorted
2. The media could do a better job
3. We're going to stay away from the 'is it murder' question

But you know, when I put it like that, it's sounds bland. Getting there is where the interest lies -- so go check it out.

Reflux

Back in July I asked, "Where are the Med Students?" -- specifically, why are there so few medical student bloggers compared to law students?

One quote I used came from Mary, a law student who brought up this subject in March.

Now the topic is revived again, thanks to some deep digging from Izzy. Check out his perspective on the question, and some of the comments it generated (including a fun cameo by the aforementioned Mary).

I do look forward to the time when people stop asking, "where are the med student bloggers?" -- because soon I hope they'll be ubiquitous. Until then, consider visiting some of the student sites collected on my sidebar.

Round 3 goes to Kevin

Kevin, MD is bringing us this week's Grand Rounds. He's done a great job rounding up the best posts from medical bloggers. Check it out!

Here's the schedule for upcoming editions of Grand Rounds:

October 19 Echo Journal
October 26 Code Blog
November 2 Medpundit
November 9 Grunt Doc
November 16 DB's MedRants
November 23 Shrinkette

Are you a medical blogger? Want to host? Drop me a line: nick -at- blogborygmi.com

Influence peddling

There's no shortage of opinions amongst medical professionals about the influence of drug companies on prescriptions and patient health. Some of my mentors and colleagues have made compelling arguments against accepting gifts from Big Pharm. Others have invited me to extravagant 'information sessions' at expensive restaurants and hotels.

Some examples of pharm influence are outrageous, while most are comparatively benign. And while there's evidence that free lunches and other perks that drug companies provide influence prescription-writing, I've argued in the past that no studies show these perks lead to actual harm to patients (yet).

I've wondered what studies have been done on bias in other fields -- say, the media. Because there's no shortage of opinions on liberal bias, or Fox News bashing, but precious little data. More underpowered contentions were made this weekend. The Ombudsman for the New York Times, Daniel Okrent, concluded after months of analyzing the Old Gray Lady's presidential coverage there is no systematic bias toward either candidate:

If there's a commissariat at The Times ordering up coverage to help or hurt a specific candidate, it's doing a lousy job; close reading shows bruises administered to each (and free passes handed out) in a pattern adapted from Jackson Pollock. Many people want to know why the other guy's position is in the first paragraph of a story, and their side doesn't weigh in until the sixth; they don't notice when it's the other way around. Sherrie Sutton of Manhattan, who describes herself as "the only possible Bush vote on the Upper West Side," asked why Times headlines consistently use "attack" when Republicans criticize Democrats, but not when Democrats criticize Republicans. Intrigued, my associate, Arthur Bovino, determined that in the past year, headlined Republicans attacked Democrats 12 times and Democrats attacked Republicans 22 times. Ms. Sutton replied: "Statistics don't lie, and you've got 'em. Interesting, that in the face of facts, I could still feel unsatisfied that campaign coverage by the NYTimes is balanced."

This is something, but hardly the in-depth analysis many bloggers were calling for. Okrent goes on to make a broadside against fact-checking blogs that urge readers to complain to the Times (the examples he picks of eggregious complaints, however, are effectively breathtaking).

Blogger Mickey Kaus counters:

Okrent denies that "because charges of bias come from both liberals and conservatives, the paper must therefore be doing things right"--but that doesn't stop him from using complaints from left and right to balance each other out and conclude the Times isn't "systematically biased toward either candidate." Might there be other large systemic biases, or biases within various departments?

There are some broader, systematic studies out there. A Yale group report on media bias was made available earlier this year. It's summarized nicely in the Rocky Mountain News:

Two researchers have ... come up with a measure of media bias that doesn't depend on journalists' own perceptions of where they fit on the political spectrum, or on subjective judgments about the philosophical orientation of think tanks. Tim Groseclose, of UCLA and Stanford, and Jeff Milyo of the University of Chicago used data comparing which think tanks various politicians liked to quote and which think tanks various media outlets liked to quote in their news stories to estimate two ADA scores for each media outlet in the study, one based on the number of times a think tank was cited, and the other on the length of the citation...

...The predominance of liberals (however identified) in major media is well-documented, but there remains a great deal of controversy over how much that fact influences news reporting (this analysis looks only at news reports, not editorials, reviews or letters to the editor). Most journalists I know say they work hard to keep their personal views out of their news reporting (again, excepting people like me who are supposed to be expressing opinions). And most of them, I'm sure, sincerely believe they succeed. This is evidence that what they succeed best at is sounding like Democrats.

Obviously there are problems with this method, and the authors address some of them. Other criticisms are discussed here. But the point was to develop an objective measure of ideological bias, which is not easy. Most people knows bias when they see it (triggering an involuntary roll of the eyes after a particular phrase or quote from Fox News or the NYTimes). But how to quantify it, and compare to some standard (in this case, Congress)? It's a start.

But comparing journalists' attitude toward bias to that of physicians is instructive The bias of reporters, left or right, isn't really financially motivated. It's about perception from colleagues, maintaining access to sources, and promoting a specific worldview. It's also partly about reader expectations, though polls suggest readers expect less and less.

Doctors, on the other hand, have a lot to lose by giving up pharmaceutical perks. You can count the value of free meals, conference fees, office supplies, etc. Plus, the doctor loses out on new drug developments (slanted as that might be, docs are usually good enough to read between the lines, and the reps can't outright lie). Finally, the doctor's patient pool stands to lose, as many clinics have an in-house pharmacy made up of free drug company samples.

So that's what each professional group -- doctors and reporters -- stands to gain or lose from their conflicts of interest. From that, you'd think it'd be straightforward to guess which group is acting responsibly, reflecting on what goes on, asking the tough questions, and proposing action on behalf of their consituents.

But the truth is surprising. Journalists, with less to lose, tend to deny bias. Medical professionals, with so much more at stake, are leading the charge against the influence of pharmaceuticals.

Sure, the problem of media bias is less likely to kill people (at least, not directly), and solutions aren't as easy to imagine (a "fair and balanced" review board?). But biased reporters are as repugnant to the code of journalism as corrupt doctors are to the oath of Hippocrates.

I just find it gratifying that doctors are trying to protect their patients from the possibility of bias, at their own measurable expense, while many journalists continue to insist they're not biased at all.

RTFM

Residency application season brings with it a bewildering array of new terms and acronyms. Here's my guide to some of the most commonly encountered:

LOR = Letter of Recommendation

ROL = Rank Order List (triply redundant term for organizing your program selections)

LOL = Laugh Out Loud (at the prospect of being an intern in 8 months)

AOA = Alpha Omega Alpha, the prestigious medical honor society

AOK = Your prospects to match well, if you're in AOA

ACLS = Advanced Cardiac Life Support (must be certified before graduation)

ALCS = American League Championship Series (if the Red Sox blow it again, I'll need ACLS)

EROAD = The "lifestyle" specialties (Emergency, Radiology, Ophthalmology, Anesthesiology, Dermatology)

TLAWROAD = The Long And Winding Road you must take to match in said specialties

USMLE = United States Medical Licensing Exam (pronounced 'you-smile' as in, "When we charge you a thousand dollars and force you to fly around the country to do physicals on fake patients, you just sit there and you smile.")

ERAS = Electronic Residency Application Service

RASH = Stressing about residency applications gives me hives

NRMP = National Residency Matching Program

NRBP = No Real Backup Plan

Putting the "med" back in medlogs

Jacob Reider is mulling ways to increase the signal-to-noise ratio of his emminently useful (but increasingly noisy) medlogs.com.

By his count, he just registered his 200th medical weblog. By other counts, there's really only a few dozen (the rest are long-defunct, or medical professionals who blog about nonmedical topics).

One really nice thing he's thinking of doing is archiving the Grand Rounds posts in a separate section -- along the lines of what Pharnygula's TangledBank does for their rotating research carnival. As it turns out, archives of Grands Rounds have already begun appearing ... at an Undisclosed Location.

I made some suggestions in the comments of Dr. Reider's first post, but have more of an idea about what he's getting at (printing that Usefulness Equation really helped):

The important idea here is that in the past .. when there were only a handful of medical weblogs ... they were truly useful. I wrote mine as an effort to provide to myself and my colleagues an important and useful source of information .. and .. yes .. an outlet for my thoughts and concerns.

Nick's commentary describes his appropriate concern for the "outlet" component of weblogs. I've always thought of medical weblogs as a way to provide transparency into the thoughts and actions of real physicians. This sort of transparency is rare, and patients who see how we think may understand more about how to interact with their physicians, how to critically assess the news reports, and ultimately how to care for themselves better...

...I suppose that the view of the usefulness of a post (or weblog) depends on the perspective of the reader. When I post a lot about technology or dry medical topics, my wife complains that she misses the reflections of the life of a family physician. But would Nick complain if I whine too much about life in my practice?

A good (useful) medical weblog will weave the clinical usefulness with the personal components -- just as any good teacher will weave the content they want to convey into an interesting an compelling tapestry.

Nick's not going to complain, especially when he starts internship and turns blogborygmi into a nonstop gripe session. And whatever Jacob Reider chooses to post, I'm very grateful for the work he and and David Ross have done in making medlogs.com -- and heartened to see they're thinking hard about making it even better.

I think I can counter his latest brainstorm -- which involves embedded ratings icons in all our posts, which would get counted up and tallied on Medlogs. Yow! Who will answer the helpdesk phones for that imbroglio? Why not take a hint from Google and use a simple pagerank-style hierarchy: When every starts linking to Kevin and Rangel great posts about Vioxx, Medlogs could tally our links and give their blogs Usefulness points. This system relies on our impressions of what's useful and worth reading, rather than trying to develop its own impression. It'll work, so long as we stop linking to doctors' cat-bloggings.

But until the robots and ratings scheme works, I'm putting my faith in our low-tech Grand Rounds hosts to separate the wheat from the chaff. So far, GR has highlighted a number of new medical blogs that I've been reading. And we've got no shortage of volunteers to host, which suggests medi-bloggers are willing to put in a few hours of reading through submissions in order to snag the spotlight for a week.

Bringing balance to the Force

Speaking of which, Kevin MD is hosting this week's Grand Rounds. And we'll soon be unveiling the list of hosts for the next few weeks. Interested in hosting? Mail me: nick -at- blogborygmi.com with a good hosting date for you (looking at Tuesdays in December or late November).

Also, Anjali mentioned in a comment on docnotes.com that the liberal perspective is underrepresented on Grand Rounds. I'm inclined to agree!

I once wrote that the internet has always been a haven of libertarians and Star Trek fans, and that's still true. Medical blogs, however, should counterract that tendency (medicine attracts more than its share of do-gooders and gluttons for punishment).

I wonder if the hosts and sponsors (Galen, Instapundit, other famous libertarians) have something to do with the paucity of liberal posts? I must say, when I was soliciting the web's biggest bloggers to link to Grand Rounds, only the right-wingers replied. Even my old acquaintance Atrios totally ignored my poignant appeal to balance and nostalgia. Maybe Anjali can flex some of her AMSA influence to recruit some new sponsors?

But this might be one of those problems of perspective. Those who agitate for institutional change might address this issue with the hosts and sponsors. A by-your-bootstraps individualist, though, might approach the lack of liberal posts on Grand Rounds by... submitting a liberal post?

All in your head

I'm starting my pediatrics rotation, and also starting this book written from the perspective of an autistic teen ("The Curious Incident of the Dog in the Night-Time", once mentioned by Medpundit).

Coincidentally, Metafilter points out an impressive compendium showing how a good chunk of what's on TV can be tied back to the musings of a single autistic child in St. Elsewhere.

In the final moments of St. Elsewhere, it was revealed that a character, autistic little Tommy Westphall, imagined the entire series' run. Because characters from St. Elsewhere crossed over with so many other shows (many produced by Tom Fontana), and because these shows had other crossovers, industrious web-inclined TV-watchers have catalogued the links... 164 series are involved, from Law & Order to Friends and Seinfeld, propagating backwards to I Love Lucy and Andy Griffith.

Some gems from this text list of crossovers (liberally trimmed here):

Diff’rent Strokes’ Arnold and Mr. Drummond considered buying the home of The Fresh Prince of Bel Air’s Banks family.
The Jefferson’s George and Weezie were also potential buyer of the Fresh Prince home.
E/R’s Nurse Julie Williams was related to The Jeffersons. And George Jefferson appeared on E/R
The first All in the Family spinoff character was Maude. Maude was Edith Bunker’s cousin.
Maude’s Florida Evans spunoff onto Good Times.
The Nanny's Fran Fine and Everybody Loves Raymond's Raymond Barone went to high school together.
Ellen meets Stanley Roper of Three’s Company while looking for a roommate.
Mad About You's Paul leased his old apartment to Seinfeld's Kramer.

Some of these links I knew, many I didn't. The connections are pretty random, but that fits into idea that all television is a child's stream-of-consciousness.

And from another site, which posits that every TV show falls into one of just 36 fictional universes, it's revealed that Knight Rider and Star Trek are linked, through the mad-scientist creator of NOMAD. They're apparently not counting James Doohan's appearance on KR2000.

I think the collectors of these crossovers may tend a little towards autism themselves. But I find it actually comforting to imagine much of our entertainment is connected. And now that William Shatner sings (speaks?) with my favorite musicians on "Has Been" (in what critics are calling in among the best albums of the year) we're moving toward consilience.

Evidence-based matching

So, I'm applying to Emergency Medicine residencies. And, just like with college and medical school applications, there's a little anxiety associated with the enterprise.

Fortunately, unlike the college and med school process, this time around I've got evidence-based interview advice.

Some residency applicants believe that the date on which they interview with a residency program influences how the program ranks them in the National Residency Matching Program (NRMP). Therefore, the authors studied whether interview date affects match list position in the emergency medicine (EM) residency match. METHODS: Forty-four Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency programs participated in this multicenter study. The interview date and match list position were collected for each interviewee for the 1997-98 season... RESULTS: Twenty-three programs, representing 1,997 interviews, reported potential bias in their interview date assignment... Two-sample t-tests for all programs, and programs with and without reported bias showed no significant difference in average interview date for ranked and unranked interviewees (both with p > 0.2). CONCLUSION: In this study, interview date for EM residency positions in the 1997-98 season did not affect match list position among ranked applicants. Moreover, interview date had nno effect on the decision to leave candidates unranked.

Thanks! That's a relief.

In fact, the previous post was inspired by studies like this. If people can pore over matching data to assuage the fears of the 1200 annual EM resident applicants, who knows what else dedicated statisticians could come up with?

METHODS: PDs of 120 EM residencies were mailed a 22 question survey immediately following the 1999 match... Forty-seven percent of PDs (always or frequently) told applicants to keep in touch if interested in the program. However, 88% of PDs were skeptical or did not believe an applicant's communicated intent to rank the program 'high,' nor did this communication influence an applicant's rank order (75%). Forty-two percent of PDs reported informal commitments by applicants. PDs frequently felt lied to by applicants (always (4%), frequently (42%), sometimes (42%)). Applicants often ask how the program intends to rank them. Highly ranked applicants receive positive responses from 61% of PDs vs. 33% of PDs who give negative responses to low ranked applicants. Ten percent of PDs offer residency positions outside of the match. CONCLUSIONS: Applicants who interview in >1 specialty are viewed negatively by PDs. Post-interview communications by applicants are viewed with skepticism. Gamesmanship is practiced commonly during the resident selection process.

Sheesh. Never mind.

Reversal of Fortune

All over the medical blogs this week, there’s been discussion of Merck’s withdrawal of rofecoxib (Vioxx) and the gathering storm of tort lawyers and class action suits (look at the ads to the right of this google search for some indication of what's coming).

Of course, many are gleeful that a greedy corporation will get what's coming to them. Others worry about the stifling effect on new drug research.

If this stifling effect is true, it should be quantifiable. The data can come in several forms: Measurable delays in drug approvals, or the abandonment of research projects following litigation involving similar drugs.

In other words: Are there instances where the development of a useful drug was delayed due to frivolous litigation, either by diverting company resources or forcing additional, unnecessary trials? Can we find answers to questions like "How many patients died of disease X, while the FDA held up approval on drug Y for unnecessary review?"

Because after we get some answers, some numbers, then we can go after someone to hold liable. (I realize this is the opposite of how it normally works -- these lawyers begin with a target, and then look for victims). It just seems like the regulators and trial lawyers are never held accountable, at least not to the standard that the pharmaceuticals firms are. The assumption with these lawsuits is always: 1) the drug company knew their product was unsafe and 2) rushed to sell it anyway.

This can be a persuasive argument for a jury, and has the benefit of being true sometimes. But a compelling argument can similarly be made if you change your assumptions, and gather some data.

If it can be shown that, with a little hindsight, livesaving drugs were 1) on the way to market and 2) delayed by regulatation or litigation, well, suddenly the burden is on the regulators and lawyers to explain why people were suffering. And suddenly, they're vulnerable to suits, too.

It seems far-fetched, sure, but ought to be easier to prove than McDonald's liability for America's obesity.

Of course, suing McDonald's wouldn't make Americans thinner. But targeting overzealous tort lawyers and stringent but ineffective regulators might make patients healthier.

I don't have many potential examples, because my school don't often teach us the history of the drugs we have to memorize (too bad, it might make it easier). But here's one story I've heard: Researchers knew since the early 70's that the antipsychotic drug clozapine (Clozaril) had fewer anticholinergic side effects (like odd, uncontrollable movements) than the mainstay therapy, haloperidol (Haldol). But Clozaril wasn't approved, because early trials on a small population showed an unacceptably high level of another side effect (agranulocytosis -- fewer white blood cells). The drug development was abandoned.

When reviewers repeated the trial years later, in a larger population, they found the incidence of this agranulocytosis was much lower than previously thought. The drug finally came to market in 1989. But how many Haldol patients developed debilitating movement disorders in the meantime? Could early lawsuits against antipsychotics have had a stifling effect on developing clozapine? And who can we sue to get these people some justice?

Another possibility is drotrecogin alfa (Xigris), a new drug to help patients with overwhelming infections (severe sepsis). Though Xigris is a recombinant form of a naturally occurring human protein (protein C, involved in clotting), the FDA held up its approval of Xigris pending the usual safety trials.... plus they demanded economic studies, as well.

Even now, Xigris is only approved for really sick septic patients. That's not because the drug doesn't work on healthier patients -- it does -- but treating these healthier patients is not deemed cost-effective. Of course, these septic patients could still crash and die, but too bad. Our courts have told doctors that using evidence-based cost-effective measures is malpractice, if the outcome is ever unfavorable. So critical care doctors may be vulnerable, though I'm not aware of any suits brought against FDA.

And when it comes to issues of liability, it seems like agencies charged with public safety ought to share in the blame. The FAA has been sued over airline accidents, for instance. So when a drug gets FDA approval and makes it to market, only to be voluntarily withdrawn years later when the company finds it's risky in some circumstances (as is the case with Vioxx), why not target the FDA? Some reports already indicate it was understaffed and lenient.

Of course, going after regulatory agencies, or individual trial lawyers, won't produce the financial windfall of suing pharmaceuticals. But like they say: this isn't about the money, it's about justice. Right?