Primal emotions

Has this ever happened to you? Too often, someone's telling me a sad story, maybe something that happened to them a long time ago. I'm moved, and compelled to empathize with a heartfelt "sorry."

Then the object of my sympathy replies, "Oh, it's not your fault."

Of course it's not, you pitiable dolt.

This irritates me to no end, because it turns me from generous giver to guarded defender. Sorry has several shades, but most people can recognize "sorry I'm responsible" from "sorry for your misfortune" based on context.

For those that can't, I recommend the "sorry-prime" terminology. Sorry-prime (also written as sorry') is the derivative of sorry feeling; the slope of the emotion, if you will. It's not regret for your role in your friend's suffering, it's just general regret. Sympathy.

This can work with other emotions, too. Angry-prime, envy-prime... if you can feel it, you can probably feel the derivative. The only exception may be jealousy-prime.

Try it, because this is the kind of thing that needs to catch on in order to work. At least think of it this way: the next time you say you're sorry-prime, the object of your sympathy may still not know what you mean, but he probably won't correct you, either.

Handling the truth

The other day, with the warm weather upon us and hospital responsibilities at an ebb, I partook in a chat with some colleagues over lunch about the Scientific Method. Spring and heady ideas were in the air; all that was missing was my absinthe and my swizzle-stick.

Nevertheless, we concluded that, as far as modes of thought go, the Scientific Method has met with considerable success. One dissenting compatriot noted that, for many, intuition and 'gut feeling' weigh more heavily on decision-making than objective data. I thought this wasn't entirely regrettable, for as Gawande has pointed out (see below), even gut feelings and intuition have more basis in observation than is generally appreciated.

Which brings us to the current debate on evidence and medicine, now making its way around in the medical blogosphere. Writing in Tech Central Station, Medpundit has asserted that, in the wake of some shoddy peer-reviewing in the Lancet, and some questionable data-manipulation by the CDC, 21st-century medicine is on shaky ground:

These are but two of the most recent and glaring examples of just how soft medical science has become, or perhaps remained. There's no shortage of marginal hypotheses that appear in the medical literature and are passed on to the lay press as solid fact. That's why one day hormone replacement therapy is good for you and the next it's bad. Why one day fish is a health food, and the next it's a toxin. We may have better technology, better drugs, and a better understanding of many disease processes than our forefathers did a hundred years ago, but we're no more sophisticated than they were in sifting the bad science from the good.

Over at MedRants, DB brought her to task:

We have made much progress both in scientific inquiry and the careful criticism of published articles. Medicine progresses not in a straight line, but rather through fits and starts, in a jagged line. But it does progress, and our patients benefit regularly from that progress.

Returning to the Medpundit excerpt above, it seems to me that having "better technology, better drugs, and a better understanding of many disease processes than our forefathers did" would be impossible without a more sophisticated ability at "sifting the bad science from the good."

Indeed, the examples Medpundit uses may be the exceptions that prove the rule: doctors employ reasonable therapies based on a tested understanding of biology and physiology. She herself has pointed out this out before, in distinguishing mainstream medicine from its 'alternatives'.

Trent McBride at Proximal Tubule remarks that Evidence-Based Medicine is really just a restatement of the Scientific Method. This is superficially true, and explains Medpundit's frustration that some therapies, like hypotheses, must be occasionally rejected in light of new evidence.

McBride is essentially right to compare EBM and science, though it's more often conceived that EBM is an evaluative layer on top of the scientific method. It's commonly used like this: basic scientists develop therapies based on physiological processes, and then clinical scientists check those therapies to see if they really improve patient outcomes.

This is why EBM is susceptible to its own its own evaluation by evidence, ie, one can ask if
EBM really leads to better outcomes
. You can't do this with the Scientific Method -- it's one of many ways to arrive at truth. Just one that seems to work reliably well.

Another way of arriving at the truth is remarked upon in Complications. Gawande tells the story of a fire fighter lieutenant who, in a fairly route kitchen fire, suddenly sensed the floor was going to collapse and ordered his men out. His intuition was right, and the crew barely escaped in time. How did the fireman arrive at this conviction? Upon reviewing the scenario with a cognitive psychologist, the lieutenant realized he had subconciously processed two unsettling cues -- the warmth of the living room, and the unexpected quiet of the kitchen fire. These signals didn't jibe well with his considerable experience, so he got the 'feeling' something was very wrong, and ordered the retreat.

There was no hypothesis, no controlled experiments -- just some subtle observations and a fortunate outcome. The scientific method and EBM are the best ways to improve lives on a large scale; I'm betting my career on that. But if I'm ever in a burning kitchen, I'm not going to bet against a firefighter's intuition, either.

Taste: the Final Frontier

I suggested before that NASA wasn't hip enough to do self-consciously geeky promotions, like Brain Awareness Week (you just missed it). But at least they're not quashing this:

"This is the big announcement that Long John Silver's has been waiting for since January - that there is evidence of a past salty sea on Mars," said Mike Baker, Chief Marketing Officer for Long John Silver's, Inc. "We can't wait to celebrate NASA's out-of-this-world success, and there's no better way to recognize their giant accomplishments than with free Giant Shrimp for America."

On Monday, May 10, between the hours of 2 p.m. and 5 p.m., customers can stop by any participating Long John Silver's restaurant and enjoy a free Giant Shrimp (one piece per customer).

Long John Silver's President Steve Davis sent a personal letter to NASA Administrator Sean O'Keefe, congratulating NASA on their discovery.

"We've been following the Mars Exploration project since the beginning," Davis wrote, "and we've been anxiously awaiting word of evidence of an ocean on Mars. The rovers have been extremely busy since they arrived on Mars - they've had 'plenty of things on their plate.' Now, with the discovery of ocean water, America can add one more thing to its plate - free Giant Shrimp."

Really, it won't be long before we realize the Onion's prediction of the Coca-Cola Rover finding evidence of Desani on Mars. Whatever it takes to fund the moon base.

(thanks to Feet First)

Hard to swallow

Austrian lung specialist Friedrich Bischinger is encouraging better living through nose-picking:

Dr Bischinger said: "With the finger you can get to places you just can't reach with a handkerchief, keeping your nose far cleaner.

"And eating the dry remains of what you pull out is a great way of strengthening the body's immune system.

"Medically it makes great sense and is a perfectly natural thing to do. In terms of the immune system the nose is a filter in which a great deal of bacteria are collected, and when this mixture arrives in the intestines it works just like a medicine...

He pointed out that children happily pick their noses, yet by the time they have become adults they have stopped under pressure from a society that has branded it disgusting and anti social.

He said: "I would recommend a new approach where children are encouraged to pick their nose. It is a completely natural response and medically a good idea as well."

There's solid stuff, way back in the literature, that suggests Bischinger is all wet... The tissue of the GI tract isnot invulnerable to infection... I hanker that he's blown an opportunity to wipe out a major source of disease... If Bischinger had a nose for research, he'd pick a less congested field of study.

Had enough? Even I can't touch this one:

Rhinotillexomania: psychiatric disorder or habit?
J Clin Psychiatry. 1995 Feb;56(2):56-9.
Jefferson JW, Thompson TD.
Dean Foundation for Health, Research and Education, Madison, WI 53717-1914.

BACKGROUND: Conditions once considered bad habits are now recognized as psychiatric disorders (trichotillomania, onychophagia). We hypothesized that nose picking is another such "habit," a common benign practice in most adults but a time-consuming, socially compromising, or physically harmful condition (rhinotillexomania) in some. METHODS: We developed the Rhinotillexomania Questionnaire, mailed it to 1000 randomly selected adult residents of Dane County, Wisconsin, and requested anonymous responses. The returned questionnaires were analyzed according to age, sex, marital status, living arrangement, and educational level. Nose picking was characterized according to time involved, level of distress, location, attitudes toward self and others regarding the practice, technique, methods of disposal, reasons, complications, and associated habits and psychiatric disorders. RESULTS: Two hundred fifty-four subjects responded. Ninety-one percent were current nose pickers although only 75% felt "almost everyone does it"; 1.2% picked at least every hour. For 2 subjects (0.8%), nose picking caused moderate to marked interferences with daily functioning. Two subjects spent between 15 and 30 minutes and 1 over 2 hours a day picking their nose. For 2 others, perforation of the nasal septum was a complication. Associated "habits" included picking cuticles (25%), picking at skin (20%), biting fingernails (18%), and pulling out hair (6%). CONCLUSION: This first population survey of nose picking suggests that it is an almost universal practice in adults but one that should not be considered pathologic for most. For some, however, the condition may meet criteria for a disorder - rhinotillexomania.

(For those without the Greek or medical background, trichotillomania is hair-pulling, and onychophagia is nail-biting.)

After this, no one can tell me that blogging is a bad habit...

Traumatic choices

Cut-to-Cure's back from a Trauma conference in Vegas, and has some observations:

On the last day, half of the morning was spent on discussions of "ethical issues" the most interesting one was related to the presence of family members in the trauma bay during resuscitation. Objections included the lack of space in the ED, having family members "fall out" during a resuscitation, family member interference and criticism (that's not how Dr. Carter did it on ER last night!) and of course, fear of litigation if things don't go well. Those that support the presence of family members during resuscitation cite reports (mainly related to ICU codes) that state the emotional benefits and "closure" that having family members present provides. The speaker polled the audience asking who would want their family member to see them with all of the accessories that go along with a complicated trauma resuscitation, very few said yes. I think that the presence of families in the trauma bay can only be a hindrance.

Meanwhile, over at gruntdoc, there's polite disagreement (also see codeblog's commentary):

I do resescitations for a living, and can say that only in VERY limited circumstances would I NOT allow a family into the room. (One or two, not the extended family).

There is, when present, no doubt in their mind that everyone is doing everything to "save" their loved one. I would say that the family of the chronically ill "do the best", as they've been around medicine and hospitals for a long time, and the environment isn't overwhelming. Those who aren't hospital aware are frequently comforted by the fact that all those people are working so, hard, which is the absolute truth.

I support letting the family in. If they're disruptive, let them go (with the Chaplain, or your equivalent), but most will understand. It's what I'd want. I wouldn't insist reluctant observers be forced to attend, but were it me, and my family is on the table, I want to be there.

I'm all for giving people choices, but am curious what the literature says is best for closure and bereavement in these cases. I suspect that with sudden or unexpected deaths (ie, trauma), family members might need to see more of the process to accept what's happened. This could be less necessary in patients with chronic illness.

I also wonder about the layout of the trauma bay -- where I work, there's not a lot of room for family to be shuffled in and out. They'd also be either way too close to the action, or off in the corner. Maybe the expansion plans call for a small viewing area.

Quest for a diversion

I generally dislike online flash animation games -- I don't find them engaging, or addictive, or stimulating of my reward centers. But for some reason I can't stop playing Quest for the Crown. Is it the retro-cool? The absurdity of the challenge? The detailed, bizarre cheat guide? The killer soundtrack? I don't know, but this game's got it all.

It doesn't hurt that I'm pretty good at it, either.

Not gelling

Atul Gawande has an article in this week's NEJM about hand washing. He was disturbed to learn that the adoption of those alcohol-gel dispensers outside patient rooms has not reduced nosocomial infections, despite the fact that it bumped hygeine compliance up from 40% to 70%.

I'm surprised, too -- I love those gels, and really thought they might stem the tide of MRSA and VRE sweeping the hospitals (now more than 10% of hospital patients have one or both). Gawande compares the success Lister had in promoting OR sterility, to the heckling and nagging employed by Semmelweis to staff to wash their hands -- and notes that, 130 years later, operating rooms remain vigilantly sterile, but floor beds could still use someone to nag the staff.

Gawande suggests something akin to an OR circulating nurse for the ICU or floor, but dismisses the idea as too expensive and running counter to the culture. I suspect that the problem will have to get even worse before people are ready to invest in comprehensive changes. But you could say this about other problems in health care, too.

Big picture

Much has been made of the Top 200 Influential Authors list - which adds up citations from bloggers and columnists to see who’s on the most widely read. Is it NYTimes pundit Paul Krugman, or These things matter to people with site meters.

Many have savaged the Blogrunner ranking methodology, but surprisingly, no one hass blinked at the notion of lumping newspaper and magazine columnists together with amatuer bloggers. Many, like James Lileks and Andrew Sullivan, do both. But many others have day jobs completely unrelated to writing. It's fanciful to think some hack in her bathrobe is jockying for attention alongside the publishing elite, but the truth isn't far off.

A recent CNN story pegged the number of US bloggers at 2-7% of the websurfing population – hundreds of thousands, in other words. (Another blogger pointed out there are more bloggers than there are CNN viewers on a given day). Granted, a lot (CNN says 90%) of these blogs are defunct or updated infrequently, and many others are vehicles for high-school gossip or just blowing off steam, ie, not for mass consumption. But it's heartening to think that the best bloggers now compete with the best writers in the best papers... although they get paid less.

As for us little people, World As a Blog shows a map of the planet. Every few seconds, a red dot lights up and a text box appears, showing what a blogger has just posted. The (mostly English) content wasn't particularly enlightening, but it's the best representation I've yet seen of the blogging phenomenon.

Raw material

Dr. Van Hee was having a hard time unloading a psych ward patient to the medical floor. But he had no trouble finding fans of his writing:

The charge nurse was incredulous. "You want to send us a patient from the locked psychiatry ward?"

"Look, he's no trouble. He's an old guy with a hip fracture and urosepsis. He's not going anywhere. He doesn't even need restraints. He yells a lot, but he doesn't thrash at all. He just lies there and yells at you when you try to stick IVs in him."

I was again denied. "Maybe he needs to go to the ICU. Sounds like he requires more nursing care than we can provide. By the way," she said, "I like your blog, Dr. Van Hee." I was speechless.

Now I had to get another resident involved, the ICU resident... When she came to admit the patient, I was expecting to bear some disgust that this guy had to go to the ICU. Instead, I heard, "So how do you decide what to write on your blog?" The screams of three psychiatry patients were still echoing through the hall. "...This?"

"Yes, definitely this."

Maybe he should just wear this t-shirt.

Gender bender

For those who were good at distinguishing the boys' handwriting from the girls', now the Gender Genie claims to distinguish male prose from female.

As featured in the July 18th Nature:

A new computer program can tell whether a book was written by a man or a woman. The simple scan of key words and syntax is around 80% accurate on both fiction and non-fiction1,2.

The program's success seems to confirm the stereotypical perception of differences in male and female language use. Crudely put, men talk more about objects, and women more about relationships.

Female writers use more pronouns (I, you, she, their, myself), say the program's developers, Moshe Koppel of Bar-Ilan University in Ramat Gan, Israel, and colleagues. Males prefer words that identify or determine nouns (a, the, that) and words that quantify them (one, two, more).

Crude, but effective. And interesting , especially amongst writers. Of course, I was confident that this blog ... would be a masculine blog ... and the computer agrees.

This kind of technology may well lead to offspring -- are there rules to distinguish female painters from males? How about filmmakers ? Can you look at a CEO's record of decisions and draw conclusions about about gender?

The point is the same, as always: trends and tendencies are kind of interesting, but not terribly instructive or predictive. There will always be exceptions -- women who write in bold, declarative statements and men who paint in the style of Cassat. Also, the jury is out on categorizing homosexual prose, as well as female writers who claimed to be men (George Elliot), or those sometimes misunderstood as such (Mr. Hassle).

Aside from its utility in lit crit term papers, and possibly espionage, the usefulness of the Gender Genie seems limited. It seems obvious, but writers should be judged by the content of their prose, not the idiosyncrasies of their syntax.

Drama behind the shelves

Last week Lileks noticed that GE bulbs are no longer on sale at Home Depot. His mind imagined the drama and strife that that likely accompanied this corporate maneuver:

I’m guessing it may have had to do with shelf fees – maybe Home Depot wanted a certain amount of money up front to stock GE products, and GE didn’t want to pay that much, and someone decided to walk away from the partnership for a year, or forever. This drama probably occupied the lives of several dozen middle-level execs for a year or so – sleepless nights, missed dinners, contentious teleconference calls, all ending in a few guys sitting in the kitchen at 2 AM with an Amstel wondering if this was going to cost them their job…

...I don’t know why there aren’t more novels written about the business world. Probably because most people inclined to write about the anxieties of a man caught up in a ballpoint pen launch would be inclined to see it as an example of conspicuous consumption, a comedy whose empty moral reminds us how hollow life is in this vast machine of production and consumption. But it says more about the world we inhabit than yet another miserable account of growing up with an alcoholic father and dysfunctional siblings and how they were affected when the vermiculite factory laid off seven percent of its workforce in 1996.

He’s right, and it’s not just novels. I wrote an earlier post lamenting the lack of music that extolls fulfilling job experiences. Even TV gives little insight into daily jobs – except for maybe police work, trial law, and some fields of medicine.

Reality TV could change this -- I think half the success of The Apprentice is that people enjoy watching contestants in business situations, and seeing them come up with clever solutions to problems. The advertising pitches, and even the bottled water sales negotiations, was something I found surprisingly interesting.

The Apprentice sequel shouldn’t be about selecting another apprentice – it should follow the first Apprentice as she (it’s got to be Amy) manages one of Trump’s companies. I’d watch.

Going back to high school English class, I recall debating the strategies for tragedy and catharsis. The old view, espoused by Aeschylus and Shakespeare and many in between, was that good drama must involve royalty or nobility. Newer playwrights like Ibsen, Miller and others rejected that notion, and used average joe salesmen types or their housewives as protagonists. They all agreed, however, that catharsis came from a character's overreaching, stumbling on their tragic character flaw, and watching everything unravel.

Now, however, careers grow more and more diverse, and failure can take subtler forms. Curious people already go for books about behind-the-scenes product introductions (Mary Walton's "Car", the story of the jellybean '96 Taurus, was riveting ). Maybe in the future, the masses will seek drama and catharsis, not from noblemen or housewives, but by watching design teams struggling to meet a deadline, or learning about software with a tragic flaw.

Up next: iron curtains

Gizmodo is reporting the invention of translucent concrete!

“Thousands of optical glass fibers form a matrix and run parallel to each other between the two main surfaces of every block,� explained its inventor Aron Losonczi. “Shadows on the lighter side will appear with sharp outlines on the darker one. Even the colours remain the same. This special effect creates the general impression that the thickness and weight of a concrete wall will disappear.�

The hope is that the new material will transform the interior appearance of concrete buildings by making them feel light and airy rather than dark and heavy.

This is all well and good, but we're now 18 years overdue for transparent aluminum. The good news is they're apparently getting closer.

Blooming narcissus

My textbooks say personality disorders are characterized by inflexible, maladaptive traits that cause people functional impairment. But one oft-noted point is that some traits usually associated with disorders are, in the right line of work, not maladaptive, but rather useful. Schizoid personality types do well on the graveyard shifts, for instance. Obsessive, meticulous types make good accountants. Sitcoms need schizotypals. And so on.

One wonders if there's ever a good time for narcissism. (At this point, it would be tactful for readers to overlook the narcissism of blogging). Putting it another way: what happens when a narcissistic personality has a job where arrogance is encouraged?

With this in mind, I read an article about a well-publicized case in this area. A few years ago, a Boston surgeon left a patient in mid-operation to cash a check across the street. I didn't follow the story too closely, and thought it ended there. But there's always more, and this Boston Globe Magazine profile of that surgeon really brings it to light:

There's an intensity to David Arndt that never seems to slacken, a way in which he seems both hyper-aware of his very public collapse and oblivious to it. Overnight, the high-octane, Harvard-trained Arndt became the doctor who left his patient on the operating table so he could go to the bank to cash a check. In an instant, that summer of 2002, the news went national. But the profound professional embarrassment would turn out to be only the beginning. Within two months, Arndt would be charged with statutory child rape, indecent assault, and drug possession. He would file a "poverty motion," the surgeon in one of medicine's most lucrative specialties asking the court to pay his costs. And then, in a separate case nearly a year later, he would face one more charge, this one for possessing methamphetamine with intent to distribute.

"His downfall is almost operatic in its tragedy," says Grant Colfax, a Harvard-trained doctor who was once one of Arndt's closest friends.

As Arndt prepares to stand two separate criminal trials, Colfax is like many of the people who knew him well and are now left scratching their heads. Their emotions oscillate between two poles: There's the lingering disbelief that such a brilliant and compassionate doctor - some say the most brilliant and most compassionate they had ever known - could seem to self-destruct in such a spectacularly public way. Then, perhaps more troubling, there's that voice inside them, which had been muffled deep for so long, the one that kept telling them it was only a matter of time before David Arndt's self-absorption and sense of invincibility finally got the best of him.

Dr. Arndt seems like a surgery cliche at times: oblivious to any personal defects, but incisively questioning the credentials of everyone around him. At one point in the narrative, Globe writer Neil Swidey, asks:

If David Arndt sounds a little too intense, a little too arrogant, ask yourself this: Aren't those exactly the qualities you want in a surgeon? Because this is what his arrogance looked like for most of his time in the operating room: An intolerance for error. An eagerness to take on the toughest cases. A fearlessness about confronting anyone - be it an orderly or a chief of surgery - who he thought was underperforming.

Swidey gets more insight from former classmates and friends:

Remmler says that Arndt was funny, charming, and "really smart. I felt lucky to have him as a classmate." But, she adds, "he was also really narcissistic, and I guess I knew there was this compulsive streak about him - addictive almost. And so deciding his needs are more important than his patient's life - that sounds narcissistic to me."
...and later...
"David wanted people to pay attention to him and notice him," says Saiya Remmler, the psychiatrist and former med school friend. "To me, it sounds like a gradual, maybe even lifelong, struggle between greatness and tragic flaws." And what might be at the center of this Greek tragedy? She and other physicians who knew Arndt but haven't seen him in years suggest narcissistic personality disorder, where an exaggerated sense of self-importance masks a chronic emptiness.

The point, which is often stressed to me on the wards, is that it's not a disorder until it causes impairment. Personality disorders typically begin in young adulthood, and Dr. Arndt had a protracted adolescence, bumming around the San Fran art scene in his early 20's. Afterward, the scrutiny and supervision of medical school and residency can keep a lot of maladaptive behaviors in check (and reward behaviors that would be maladaptive elsewhere). It's only when he took on real responsibility, in his year as a chief and thereafter, that his life deteriorated. I suspect that if he hadn't been so talented, and in a field where his narcissism less appropriate, his personality would have crashed into reality far earlier, and far more quietly.

An honor just to be nominated

I took my psychiatry OSCE the other day, my "objective structured clinical exam". It's no coincidence that OSCEs sound like Oscars, because both involve some serious acting. At the OSCEs, you have actors pretending to be patients, students pretending to be doctors, and faculty pretending the exam is 'objective'.

It's been said that OSCEs are the worst kind of exam, except for all the others (apologies to Winston Churchill). Despite the drawbacks -- artificial time constraints, inability to review past records, and patients who hide facts unless certain 'trigger words' are used -- the OSCEs are probably a good thing. Otherwise, we'd spend all our time studying diseases, with no emphasis on interviewing or conveying this information.

The OSCE experience is not unlike my first exposure to standardized patients, the Seinfeld episode called "The Burning":

[Mt. Sanai Hospital. Kramer is on the table surrounded by med students.]

STUDENT #1: And are you experiencing any discomfort?

KRAMER: Just a little burning during urination.

STUDENT #1: Okay, any other pain?

KRAMER: The haunting memories of lost love. May I? (signals to Mickey) Lights? (Mickey turns down the lights and Kramer lights a cigar) Our eyes met across the crowded hat store. I, a customer, and she a coquettish haberdasher. Oh, I pursued and she withdrew, then she pursued and I withdrew, and so we danced. I burned for her, much like the burning during urination that I would experience soon afterwards.

STUDENT #1: Gonorrhea?!

KRAMER: Gonorrhea!

(The lab breaks out in spontaneous applause as Mickey turns up the lights and Kramer takes a bow.)

OSCEs aren't quite like this, but they're not different enough. By the way, one of our professors suggested Cosmo Kramer as an example of someone suffering from schizotypal personality disorder.

Big Brother is weighing you

Maybe you’ve heard about the “internet everywhere� concept, or Project Oxygen at MIT. The idea is to put interactivity and connectivity all over the place -- in refrigerators, cars, walls. The goal is convenience and efficiency -- your house will automatically turn down the heat and lights for rooms lacking movement or noise, for instance. Another example: when your car pulls into the grocery store, you get an alert from the fridge telling you the milk expires soon.

Some critics point out the expense-to-convenience ratio is a little skewed, here – a lot of these “problems� could be solved with post-it notes or simple conscientiousness. But Gizmodo, which has been on a health-kick lately cites this brief article from the Houston Chronicle on nursing-home applications for pervasive technology.

The simplest devices automatically turn on a light when a person gets out of bed and track motion to see how well someone slept…
Other prototype devices monitor weight and blood pressure continuously, help Alzheimer's patients recall names, faces and recent conversations, and listen to footsteps to see how steady people are on their feet and broadcast an alarm if they fall.
The elder-tech industry says its devices are cheaper than hospital or institutional care.
"We don't have enough caregivers to work with all the seniors. When their population triples, it's going to be more difficult," said Dr. Laverne Joseph, the president of the Retirement Housing Foundation, a California-based nonprofit group.
At Oatfield Estates, described as "an alternative to assisted living," computers record the location of every resident, and sensors under residents' bedposts -- with permission -- tell caregivers whether residents are losing or gaining weight or having trouble sleeping. (emphasis added )

It’s not surprising that this technology would find use first in populations where post-it notes and conscientiousness is no longer possible, or too expensive to delegate to others. The next target might be children, and Wherify has already made some inroads into kid-tracking with GPS.

Eventually, things will become cheap enough for sick adults – people with severe asthma, advanced heart disease, or sleep apnea. Eventually, doctors might be able to monitor a patient's alcohol or tobacco abstinence with these technologies.

Cut-to-Cure just posted about the need for gyms to carry defibrillators, but pervasive technology take emergency health care farther. The day is coming when, if someone’s vitals start to fluctuate -- at home, or the gym, or even in a mall -- the call and coordinates will automatically goes out to EMS. Maybe the nearest hundred cell phones would get a text message with the news, and a primer on basic life support techniques.

More devices are profiled at the Center for Aging Services Technologies (CAST). It's a little scary, but pretty cool, too.

Night float

One of the floor managers at our hospital is a gem. Peg, as we'll call her, always has a snack handy for the students, and a bit of gossip to go with it. She's seen it all, and still brings vitality and style to what she does. What's more, she speaks with a piercing clarity and earnestness, like a 1950's commercial voiceover.

Late one night while on call for surgery, I was sitting in the charting area writing a post-op note. Several other nurses and doctors were around, working quietly. At the floor manager's central desk, a buzzer went off, indicating a call from a floor patient. Peg flipped the microphone on.

"Hello?" she asked, in her crisp, clear voice.
From the patient's room, the only sound that could be heard was the percolating chest-tube apparatus.

Peg waited a few moments, cocked her head and announced, "Oh, it's Mr. Bubbles!" as she off turned the call light.

I smiled to myself and resumed my note. A few minutes later, the silence was interrupted when the same patient buzzed in again.

"Hello?" Peg asked, with a preternatural cheeriness.
Again, the sound of percolating bubbles. Then, finally, a man's harried voice came on and exclaimed: "Is leaking! Is leaking!"

Everyone in the charting area looked up from their work, and wondered: Was the patient's chest tube leaking? What was going on?

Peg paused for a moment and reflected. She turned to a colleague and remarked, "I do believe he called me Sweet Pea."

I started giggling, and a few others joined in. One of my residents let out a big belly laugh, and everyone just lost it. I hadn't laughed so hard in a long time. Someone got up to check on the patient, while the rest of us slowly calmed down and got back to work.

For so much of my time in third year, I've felt this constant background anxiety and uncertainty. For that moment in the charting room, the confusion and fear came face to face with Peg's self-assured, maternal simplicity. Peg won, and there was much rejoicing. Certainly, some late-night giddiness contributed, too. It's one of my favorite moments from surgery.

You're joking

Donald Trump has filed to trademark the phrase "You're Fired". Check out the details on The Smoking Gun, including a shot of The Hair in full effect.

I guess this isn't as outrageous as it first seems. He's just looking to slap the phrase on some clothes or casino games. Trying to copyright the phrase, I guess, would be cause for alarm.

The big money, though, would come from trademarking his hair. Already, people are attempting to duplicate the hairstyle under controlled, reproducible conditions. It's like when Compaq was trying to clone the PC: only a matter of time before someone gets it.

Over on, they've got an explanation and some commentary. What does Trump himself think of the look Dave Letterman described as "Trumpy" ? According to USA Today:

"It's been good for me over the years," Trump told USA TODAY Tuesday. "No," he says, he has never had a stylist. "Maybe that's my problem."
And take note, Queer Eye for the Straight Guys: Trump says he wouldn't let them make him over. "I'm not particularly thrilled with the way they look."
Then he slyly adds, "But that would get good ratings, wouldn't it?"

He really could cash in with a line of Halloween wigs, or fashionable bike helmets.

Day of reckoning

Tomorrow is Match day for American medical students. Around the hospital today, the tension was palpable. Everyone was a little irritable and distracted. Maybe it's because our school didn't do so well on Black Monday. Or maybe it's a reaction to the snow. Either way, I'm glad I've still got a year to go.

The Chicago Sun-Times has a brief article on the Match process, as well as the anti-trust lawsuit against it.

Students have ranked, in order of preference, the teaching hospitals where they hope to do their residencies. Hospitals in turn have ranked the students. A computer will match each student with one hospital.
More than 80 percent of students get one of their top three choices. Match Day "benefits students as well as institutions," said Jeffrey Miller, an associate dean of Northwestern University medical school.
But a lawsuit is alleging that Match Day exploits students and violates anti-trust laws. Match Day "is part and parcel of a scheme by hospitals to keep residents' salaries artificially depressed," said Chicago attorney Sherman Marek, one of the lead plaintiff counsels.
A resident matched to a single hospital is in no position to negotiate salary and working conditions, because there's no other place to go, Marek said. First-year residents wind up working 80 hours a week for about $40,000 a year. That amounts to about $10 per hour for an M.D. who has gone through eight years of college and medical school.

Medical students are a diverse bunch. If you count summer jobs in high school, and research rotations, or even post-college jobs, I know a few who can say that $10 an hour is the most they've ever made. And there are plenty who have never made less. Finally, there are some who've never had a job at all.

There's a discussion on the merits of the Match underway over at A Chance to Cut.

UPDATE: Glorfindel of Gondolin is an MD pursuing a JD, and has some thoughts and links on the Match and the suit. And I finally figured out this trackback feature.

A winters' tale

I've been trying to achieve this effect for a while, but early attempts were too awkward (fortunately, readers were spared). Yet now it's clear that brief, absurd humor is possible in a blog.

I wonder, though, if the act of linking to it disrupts the delivery of the funny.

The M.C. Escher Bill

I don't think any of the law blogs (blawgs) I browse have remarked on this, probably because it's too nutty:

U.S. Rep. Ron Lewis of Kentucky introduced a bill yesterday that would allow Congress to override Supreme Court rulings. Lewis' legislation would let lawmakers reverse Supreme Court decisions if the court rules that laws passed by Congress are unconstitutional... But legal scholars say Lewis' bill is itself unconstitutional.

I'm no authority on constitutional law, or astrophysics, for that matter. But it's a safe bet that if this bill were to pass, and the Supreme Court ruled it unconstitutional, something significant would happen to the fabric of space-time.

UPDATE: Volokh weighs in, and TPT has more, too.

Conflict of some interest

Another day, another well-written, thoughtful med student blog: "2md" is, as you might have guessed, written by a 2nd year medical student.

One of his posts mentions the No Free Lunch movement, designed to

"encourage health care practitioners to provide high quality care based on unbiased evidence rather than on biased pharmaceutical promotion." In other words, no free pens, no free pads, no free stethoscopes, no free Chinese dinners, no free trips to "educational" conferences in Fiji... The relationship between the pharmaceutical industry and the medical profession is a stark example of culture failure. Cultures are supposed to reflect the values of the community, and the medical profession values patient care above profit.

The blogger then cites articles here and there that indisputably claim that pharm giveaways affect prescriptions.

I'm haven't really decided which side of the fence I'm on. But I'm always happy to point out that the issue is less clear-cut than people think. And, just as some people work themselves into a tizzy about banning free drug company lunches, well, I tend to be irked by excessive self-righteousness... especially when my lunch is at stake.

The abstracts linked to above show correlations between pharm-company interventions and drug prescriptions. Is this horrible? It would be great if the papers showed something obviously wrong: doctors with Lipitor pens unable to stop prescribing Lipitor to hepatitis patients, for instance. But instead, we're given correlations and a vague warnings that doctors are susceptible to advertising.

They're also susceptible to education. I bet if someone polled students finishing their 3rd year psych clerkships, they'd find we're a lot more comfortable recommending Zyprexa or Remeron than before. No one's clammoring to ban psych clerkships (well, almost no one).

Ah, but medical schools don't have a conflict of interest when teaching about drugs. Or do they? I would argue they have less of a conflict of interest than drug companies, as opposed to zero. Residents feeling the crunch to discharge patients or lower costs, for instance, may prescribe well-tolerated drugs with fewer side effects, rather than the drugs with the best efficacy. And students learn from the residents while helping them out (a "free lunch" scheme if there ever was one).

I think many are opposed to the free pens and free lunches simply because it's unseemly to them. One of my professors suggested that when patients see my Lipitor pen (or something similar), it contributes to the erosion the doctor-patient relationship. Patients sense the conflicts of interest, and wonder if we're really putting their best interests first.

It's a mistake for patients to over-interpret the presence of drug-company paraphernelia given out at these education sessions. Someday I hope my public-university med school diploma will hang in my office -- but since taxpayers helped subsidize my education, should patients assume I'll take the side of the government when it comes to Medicare allocations?

Conflicts of interests are everywhere. Big Pharm advertising campaigns have influence, but so do the studies they tout. Until there's evidence that these free lunches actually hurt patients, save me a seat at the table.

Fed up down under

Like me, The Helix is med student currently on a psychiatry consult / liaison service.

The big difference is that he's in Australia, and I'm in a place expecting a foot of snow tomorrow.

Browsing through some of his recent posts, you can appreciate other differences, too. Our EKG is called an "ECG" over there. And they get a paltry 20 minutes for their exam/interview at the end of the block.

We get 25 minutes.

Another difference is he can't wait for his rotation to finish, and wonders how I'm getting along with my team. The truth is, they're really, really good. So good, in fact, that they have me believing that 25 minutes is actually enough time to establish rapport, get the narrative, get neuroveg symptoms, get a quality mental status exam and a Folstein.

Color me impressed, they've given me something to shoot for. I think they pull it off with gentle interruptions, smooth transitions between patient answers and examiner questions, an empathetic demeanor, and a ton of experience-guided intuition.

Plus, having the med students collect all the collateral info in advance... helps.

Maybe I've been lucky, but my C/L team has also been wonderfully medical-minded, thoroughly exploring (and explaining) organic causes for the psychiatric illnesses we've seen. It doesn't hurt that we've seen steroid psychosis, HSV encephalitis, frontal-lobe strokes, Wilson's disease, and a rule-out for Diogenes syndrome (among others). Neat stuff.

One of the residents said it best: "Psychiatric problems nowadays are as managable as other medical problems. And interviewing someone with mania is a lot more interesting than someone with chronic hip pain."

UPDATE: Helix has the best psych presentation I've ever heard.

Use it and lose it

Ready to face the week ahead? Would it help if you knew it was Brain Awareness Week? Be sure to print out the poster, lest you forget to "Just Use It" this week or any other time.

At last, a week in to be conscious of our brains. What's next, Alertness Month? Water Safety Week? Actually, yes, those are coming up.

At first this just sounds like a misguided attempt to promote research. But then again, the Brain Awareness page has a pagerank of 7, pretty high on the Google's scale of web importance (equal to Drudge and Andrew Sullivan). Smirk if you will, but they're getting the word out about neuroscience research. Have there been other instances of self-consciously retro or hokey science initiatives like this? (I'm not counting those Enzyte commercials.) If popularizing science means resorting to this kind of detached, ironic marketing, we're in more trouble than I thought.

Anyway, under the detached irony, it seems like a serious and legitimate cause. You can read about last year's Brain Awareness Week, and be sure to check out the testimonials.

UPDATE: The Mars rovers, Spirit and Opportunity, have blogs. This kind of fits in with hokey marketing, if only NASA was hip enough to think of it themselves.

Mind the Gap

I heard the Soup Dragons song "I'm Free" the other day, on a TV commercial (for the Gap). It's stuck in my head now. This Stones cover is really perfect for mass media -- bits of guitar and raggae and an energizing chorus. Seems kind of wild, but really pretty safe.

When was the last time you heard this song? I can't remember. For a while I thought it had been on ads pretty much continuously, and that I must have heard the song at least a few times in recent months. Upon reflection, however, I think it's been years and years (AT&T wireless used it a while back, I think).

I bring this up because we had a confabulating patient a while back. He had anterograde amnesia (he could not make new memories, kind of like the guy in Memento ). When you'd ask him what he'd been doing this morning, or yesterday, he'd make stuff up. Reasonable stuff, to be sure, delivered in a matter-of-fact way. But he could go into great detail of what he'd been watching on TV, or what he'd seen when he went for X-Rays -- even if the TV was off, and no X-Rays were taken.

There are two takes on this kind of confabulation in patients:

Barbara Wilson et al notes that confabulation tends to be an acute reaction to the loss of new memories. After some months or years, patients more freely admit they don't know what they've just been doing. But some story-telling seems to persist; she had a patient who insisted, every few minutes, that he just woke up. He couldn't be convinced otherwise, even when confronted with hard evidence. She compared it to the delusions of schizophrenic patients, as "an attempt to provide a rational and acceptable solution to strange and dramatic experiences." (In light of this, it's interesting to note that most amnesiacs do not report this waking sensation).

Whitlock observes that amnesiac confabulation cannot be a reaction to embarassment. He cites an old paper suggesting that confabulation occurs when patients forget that they can't remember (which was really a plot hole in Memento). Interviews suggest the patient believes what he or she is saying, and really can't evaluate the correctness of the narrative. They don't know what they're saying is wrong, and moreover, they don't know that they don't know.

Maybe the key to resolving these two takes on confabulation is measuring (through EEG, or fMRI, or through facial expression?) whether there's a flicker of fear or uncertainty before the amnesiac patient responds to a question. Then, I'd be more likely to believe the brain generates some kind of "rational and acceptable" solution to calm the patient and answer the question (though, to be clear, even in this case the patient can't recognize the falsehood).

More interestingly, I wonder if the brain's first response -- for all people -- is to make something up, and this gets edited a few moments later by the input of memories. In amnesiacs, that input never comes.

Would this explain why people sometimes start to answer a question, then abruptly stop? I've been party to several post-call pimpings on the wards, when I think I know something I truly don't. It takes a second before I realize that I had no idea what was about to come out of my mouth.

This phenomenon might also explain my Soup Dragons lapse. Until next time.

Blame the Baklava

More fuel for the fire against Big Food comes from Lissau et al, quoted in this month's Atlantic. The US has the highest fraction of obese teens, by far. It's almost 14% of boys and over 15% of girls.

Who's number two? Greece, the home of my parents and extended family.

At this rate, soon all the Greek weddings will be big, fat ones.

To be clear, it's actually just the Greek boys that are the fattest of Europe; Danish and Israeli girls are heavier than the Greek girls. But then again, the investigators relied on self-reporting of heights and weights... And in my experience, Greek women tend to be modest about these things.

Furry little pill

Medpundit can't bring himself to dislike a new pop-psychiatry book with a really long name:

"...But pills, and even talk therapy, can't obliterate the horror of facing your mortality, the pain of a lover's rejection, or the loneliness of old age, let alone erase the emotional scars inflicted by man's general inhumanity to man.

Dr. Servan-Schreiber knows this all too well. He has spent a lot of his time doing psychiatric liaison work. That is, he helps other doctors deal with the repercussions of their illnesses. It's these sorts of patients who modern psychopharmacology fails the most. And it's these sorts of patients Dr. Servan-Schreiber has in mind when he talks about the instinct to heal.

Take the example of the lonely old person. Many's the time Dr. Servan-Schreiber was consulted by other doctors to recommend therapy for them. He knew from experience that no amount of psychotherapy, no potent anti-depressant, was going to cure their loneliness. So, he often made sensible recommendations instead. Recommendations like 'get a pet.' The response of his colleagues was not kind...

This strikes me as a little dangerous. Granted, I'm being reckless by quoting, possibly out-of-context, a book I haven't read. But then again, I'm on a psychiatry consult-liason service right now, so that's got to count for something.

We get a few bogus consults from docs who see "bipolar disorder" on the Past Medical History and instinctively throw their hands in the air. But most of my depression consults have had merit -- ie, major depression that was interfering with the patient's recovery from surgery or illness.

What troubles me is the popular notion, out there, that Western doctors tend to overdiagnose and overmedicate. Hyperactive kids get a pill, old people get a pill, but really all we need is love (via pets or traditional families or something). Critics of overmedication will point to this book by one of those "sensible doctors" who's blowing whistles and ruffling feathers in that heartless, moneymaking healthcare industry.

I used to be skeptical of ADHD and depression until I saw what some families deal with. I still don't know if these drugs are given out too easily. But the bigger problem now, in my mind, is not overmedication -- rather, it's getting people to realize that depression is its own, real disease. An old person with cancer who speaks less than ten words a minute, and doesn't lift her head off the bed all day, is probably suffering from something more than just cancer.

That extra "something" is a disease, with diagnostic criteria and proven remedies. These medications got popular, by the way, because they tend to work. But in the interest of full disclosure, I have to admit: my cat has gotten me through some rough times.

We like the toast

I'm not just writing about Quiznos because Google, in their infinite wisdom, sends lots of searchers to my earlier post about the Spongmonkeys (or is it Spongemonkeys ?).

I'm also writing because Quiznos just opened a sub shop near me. The guy behind the counter at my local Subway clued me in to the appeal: he loves Quiznos more because they toast the subs. Ingredients-wise, he says, Subway has the edge. But the toasting puts Quiznos on top.

But he added, "Right now, Subway is field-testing toasted bread in one of their stores -- we might have it here soon."

Ah, field-testing a toaster. Someday, maybe that technology will filter down to the masses. I'm all for field-testing new flavors or sandwiches -- Lord knows McDonald's wouldn't have gambled on McGriddles if focus groups didn't love 'em -- but the toaster seems like a proven fan favorite already.

The counter guy explained the testing: if Subways just started adopting toasters willy-nilly, the lines at lunch would go nuts. I imagine employees need to be trained, certain subs should be classified as toast-eligible, protocols must be worked out...

But the Subway I frequent is struggling, customer-wise. They've tried every discount they can think of, but the place is often deserted (poor parking situation, apparently). In short, toasting wouldn't cause long lines here, it might bring more people in, and it cuts into the up-and-coming Quiznos Spongmonkey juggernaut (those teeth aren't just for singing).

I suspect toasting is not allowed because of some kind of corporate uniformity clause. Subway owners can have some freedom and flexibility with the drinks and decor, but messing with the food might cause the "brand" and "experience" to be less uniform. Chaos.

Some people think that corporations are lean, fast-adapting animals. Subway is apparently a well-regarded company... but this toaster situation just makes me sad inside.

That's just fool talk

Glenn Reynolds weighs in on a new term for the Iranian "Mullocracy", : "I should also note that I prefer the term 'mullarchy' for the Iranian political scene, since it's shorter, and has the advantage of rhyming, more or less, with 'malarkey.' It seems to be catching on."

He's right. "Mullarchy" has 102 hits on google and counting. I think I noticed Andrew Sullivan use the term a few months back, and liked it immediately. It's rare that I'm ahead of the curve on these things (the last time was with "dis" -- which was big at my school way before Arsenio popularized it).

The 'mullarchy' trend may benefit these people.


Medpundit can't bring himself to dislike a new pop-psychiatry book with a really long name:

"...But pills, and even talk therapy, can't obliterate the horror of facing your mortality, the pain of a lover's rejection, or the loneliness of old age, let alone erase the emotional scars inflicted by man's general inhumanity to man.

Dr. Servan-Schreiber knows this all too well. He has spent a lot of his time doing psychiatric liaison work. That is, he helps other doctors deal with the repercussions of their illnesses. It's these sorts of patients who modern psychopharmacology fails the most. And it's these sorts of patients Dr. Servan-Schreiber has in mind when he talks about the instinct to heal.

Take the example of the lonely old person. Many's the time Dr. Servan-Schreiber was consulted by other doctors to recommend therapy for them. He knew from experience that no amount of psychotherapy, no potent anti-depressant, was going to cure their loneliness. So, he often made sensible recommendations instead. Recommendations like 'get a pet.' The response of his colleagues was not kind.

This strikes me as a little dangerous. Granted, I'm being reckless by quoting, out-of-context, a book I haven't read. But then again, I'm on a psychiatry consult-liason service right now, so that's got to count for something.

We get a few bogus consults from docs who see "bipolar disorder" on the Past Medical History and instinctively throw their hands in the air. But most of my depression consults have had merit -- ie, major depression that was interfering with the patient's recovery from surgery or illness.

What troubles me is the popular notion, out there, that Western doctors tend to overdiagnose and overmedicate. Hyperactive kids get a pill, old people get a pill, but really all we need is love (via pets or traditional families or something). Critics of overmedication will point to this book by one of those "sensible doctors" who's blowing whistles and ruffling feathers in that heartless, moneymaking healthcare industry.

I used to be skeptical of ADHD and depression until I saw what some families deal with. I still don't know if these drugs are given out too easily. But the bigger problem now, in my mind, is not overmedication -- rather, it's getting people to realize that depression is its own disease. An old person with cancer who speaks less than ten words a minute, and doesn't lift her head off the bed all day, is probably suffering from something on top of cancer.

These medications got popular because they tend to work, by the way. But in the interest of full disclosure, I have to admit my cat has gotten me through some rough times.

Morbidity and Mortality at UCLA

Ted William's son died of leukemia a few days ago, at UCLA Medical Center. John Henry Williams was most noted for having his legendary father's severed head sent to Alcor for cryogenic storage. Like father, like son: John Henry has arranged to be frozen at Alcor, as well.

Of all the fates for the posthumous body, freezing is among the most selfish and misguided. On the other hand, donating the body to medical schools is possibly the noblest. Anatomical gift programs had trained generations of medical students, and thus turn tragedy into a cause for optimism.

Which is why the other medical story out of UCLA is so disturbing. Parts of donated cadavers were allegedly sold to researchers. Up to 800 bodies were involved over six years.

Cadavers have been treated with disrespect before. Michael Chricton writes of his adventures on the Mass Pike with a severed arm at HMS in Travels. You could argue that the donators sign a contract, but breaking this contract is essentially a victimless crime.

Still, it's the thought that counts. These bodies were all somebody's children, someone's parents. Could you do this to the body of a family member? These criminals act like (forgive me) their head's not attached right.

'Roid rant

There's a provocative post up on The Proximal Tubule about athletes taking steroids. The post summarizes and undercuts the traditional objections to to hormones and steroids, including this one:

They force otherwise clean athletes to undertake unhealthy measures to keep up (even though the "natural" measures to become a world-class athlete are just as unhealthy - do you think becoming a 300-pound NFL lineman or dedicating your life to one solitary thing is healthy?)

This is echoed by the article from the 9/10/01 New Yorker that TPT links to. The author of the piece, Malcolm Gladwell (who also wrote the Tipping Point), describes the meeting of two great milers: Roger Bannister, the laid back med student who was first to break the 4 minute mile, and today's champion, Hicham El- Geurrouj.

El Guerrouj ... trains five hours a day, in two two-and-a-half-hour sessions. He probably has a team of half a dozen people working with him: at the very least, a masseur, a doctor, a coach, an agent, and a nutritionist. He is not in medical school. He does not go hiking in rocky terrain before major track meets. When Bannister told him, last summer, how he had prepared for his four-minute mile, El Guerrouj was stunned. "For me, a rest day is perhaps when I train in the morning and spend the afternoon at the cinema," he said.

As more people are free to join the pursuit of excellence, what's needed to compete moves farther and farther from what's mainstream.... even going beyond what's healthy. It's easy to sit on the sidelines and shake one's head at the spectacle: female skaters and gymnasts with stunted development, or biathletes with cardiomegaly that will kill them in their fifties.

And the fact that many of these athletes have freakish traits and proportions to begin with doesn't seem fair, either.

But using this to justify steroids for pro athletes is a big leap. To be fair, the folks at the Proximal Tubule don't explicitly make the case for steroids or hormones. They're just pointing out that media coverage is pretty slanted, steroids aren't all harmful, and the issue is more nuanced than what's being reported.

They're right on those counts. But on the issue of whether it's cheating, there's no contest. I think what confuses a lot of people is the mixing of athlete's goals with those of the audience and the organizers. The athletes want to win, so they train hard and feel the urge to bend the rules. The public, on the other hand, wants to see who's the best. So they make rules about eligibility for competing, just as they make rules about triple axels and free throws. No one in the audience wants to see a team win because the officials blew a call, but I think the athletes would say they trained hard, the other team got breaks too, and a win is a win. I think athletes make similar excuses about steroids.

TPT points out the dichotomy between 'natural' and 'unnatural' is artificifial -- and they're right. But the designated hitter rule for half of Major League Baseball is kind of arbitrary, too. If the media reports on steroids with on a scolding, superior tone, it's because dozens of baseball's best players are, be definition, cheating. The media's entitled to be critical: they're disappointed, too. It's no different than Sammy's corked bat.

As for the big picture, though, there's no denying that the world of pro athletes is out of control. I'm just happy I'm in an field where there's no spotlight or intense competition, the gifts you're born with don't matter, and the quest for excellence doesn't drive people to chemical dependency.

Ha. Please don't touch my coffee.

Notes vs. Chords

There is a lot of navel-gazing on the web. Blogging about Blogs, Do's vs. Dont's, and a new searing (and funny) indictment of the blog culture. I just hope I don't cross the guy at Annoyed -- in a very short time, he's tackled blog cliches, blinkies, and Nana Mouskouri.

Lileks indulged in some introspection this week, too:

"Variety is necessary to any blog. If you demonstrate a certain amount of monomania, you'll reduce your audience down to those who share your worldview, which might be smaller than you suspect. I think readers of general-interest sites will tolerate the occasional patch of monomania, but not if it's Fevered Monomania. Long stretches of Fevered Monomania drive people away. "

There's been some perseveration here with medical postings, as I tried to establish my bona-fides amongst med bloggers. But just as there are many pitches and rhythms of borborygmi, so too must there be variety on blogborygmi. Now that gizmodo's back, with a new editorial focus, there can be more technology grumblings on the site.

And politics again, soon. Maybe the ideal situation would be the intersections of medicine and politics, like the Kerry Botox scandal. But I didn't have the stomach for it, and sat it out.

How about this: AMG and other sites claim that Nana Mouskouri was born with only one vocal cord. WTF? I don't think they mean unilateral vocal cord paralysis, because she'd be barely audible. Maybe I haven't heard of this congenital anomaly because it doesn't really hurt one's singing career. I bet she's at increased risk of aspiration, though.

Dances with HIPAA

It's a full moon, a Saturday night, and I'm blogging from my call shift with the Emergency Mental Health service.

The waiting room is empty. Consider this more anecdotal evidence for the phenomenon noted earlier...

UPDATE: It picked up. And when I got home, I saw that Linus (the cat) had been in a fight.

Bilious Humor

This is probably Psych 101 material, but I didn't come across it until deep in graduate training. It's an excerpt from "the Mature Defenses," adapted from Semrad 1967, Bibring 1961, and Vaillant 1971:

Humor is the overt expression of feelings without personal discomfort... and without unpleasant effect on others. Humor allows one to bear, and yet focus on, what is too terrible to be borne. This stands in contrast to wit, which always involves distraction or displacement away from the affective issue.

Hmmm. It's never pleasant to think that such a big part of one's personality is considered a 'defense mechanism' (albeit a more developed defense than: "I know you are, but what am I?" -- which may be what they mean by 'projection').

But the psychiatrists have a point; there clearly are times when a joke is pathological. Shouldn't psychiatrists be more precise, however, and call this defense 'gallows humor' ?

Sure, Tom Green's bout with testicular cancer, immortalized in the funny show, "Tom Green's Testicular Cancer Special", can be construed as a humor defense. But does that mean that everything else that's funny is wit? Steven Wright, yes. Gallagher, no.

If Gallagher isn't witty, and he's not, then his watermelon-smashing routine must be shielding us from something too terrible to be considered. The psychiatrists may be on to something: I recently heard of a man who only laughed when planning morbid pranks. One such plan was to put clothes on a watermelon and throw it off a building, confusing and horrifying the people below. This, indeed, would be too disturbing to contemplate without Gallagher having paved the way.

On a more serious note: if humor is a defense, why isn't it invoked immediately after a trauma? Why do we have to wait a few days, weeks, whatever, before we can "look back and laugh at it"... it seems the best time for the defense would be when the stimulus is most painful.

Circumstantial Evidence

Got a great comment yesterday on my evidence-based medicine post, but it's kind of buried down below so I'll reprint it here:

Is EBM an intervention, or is it an organizing principle about interventions? You can write a prescription for acyclovir, but not for EBM. The teacher may have been put out by the confusion of logical levels rather than by the proposal to examine EBM. Its proponents so far as I know are not so woebegone as to insist on RCTs for interventions with very large effects (like insulin for diabetic ketoacidosis or parachute use for skydiving), but for those with small to moderate effects, which are the rule in medicine. Growth by small steps happens much more often than by great leaps...

This comment, from someone who goes by Pontificator-In-Chief, raises a good point. Of course I'll acknowledge that Randomized Controlled Trials aren't always insisted upon, and that EBM as an organizing principle is really quite reasonable.

My point, however, is that lots of things are really quite reasonable. Antivirals for viral infections, for instance. The beauty of EBM is that it ignores mechanisms and looks at the bottom line: does the antiviral reduce the duration of illness? Severity of symptoms? Or, more broadly, for things like lipitor -- sure, cholesterol numbers fall, but does lipitor cut down the number of heart attacks? Extend life?

Evidence-based medicine should really examine its own bottom line. It hasn't been proven that the rigid application of evidence-based guidelines actually improves patient outcomes. It probably cuts costs, sure -- by reducing the number and choice of prescriptions. But using EBM brings some side effects, listed below. One problem I didn't dwell on previously is erosion of the doctor-patient relationship. By inhibiting patient autonomy and forcing adherence to certain guidelines, EBM might damage them to the point where patients are less inclined to go to the doctor, less likely to self-medicate, etc.

After a couple of sore throats in which no antibiotics are prescribed, will a patient become less likely to have that fever checked out? Or ask about that lump? I can't say. Either way, it's probably hard to assess. But the bottom line is worth examining, and EBM proponents should be finding ways to measure it. After all, PSA testing seems quite reasonable at first glance, but now no one balks at multi-decade, multi-million dollar trials of PSA testing on mortality.

And, by the way, lots of non-prescribable interventions are measured and assessed all the time. Check this one out:

Evidence-based physicians' dressing: a crossover trial.
Med J Aust. 2002 Dec 2-16;177(11-12):681-2.
Nair BR, Attia JR, Mears SR, Hitchcock KI.
Department of Geriatric Medicine, John Hunter Hospital, Hunter Region Mail Centre, NSW.
OBJECTIVE: To describe the effect of physicians' dress on patient confidence and trust. DESIGN: A prospective crossover trial involving physicians dressed in "respectable" versus "retro" attire. SETTING: A general medicine ward at a tertiary hospital. PARTICIPANTS: 12 male general physicians and 1680 patients. MAIN OUTCOME MEASURES: Patient trust and confidence as measured by a questionnaire mailed after hospital discharge. RESULTS: Formal attire was correlated with higher patient confidence and trust. Nose rings were particularly deleterious to patients' reported trust and confidence. A minimum threshold of two items of formal attire (dress pants, dress shirt, tie, or white coat) were necessary to inspire a reasonable amount of confidence; this is the NND (number needed to dress). CONCLUSIONS: We highlight the need for more research into the effects of physician dress, and coin the term "evidence-based dressing".

It's a small step (made during a silly walk) from this kind of research, to the kind of EBM vs. 'traditional medicine' comparison that I'm proposing. EBM's been around for over a decade -- why hasn't anyone done it?

Bad News is No News

Yesterday's post was about countries that only report positive results: The New Intervention That Works Better, the New Drug with Fewer Side Effects, etc.

One might speculate why it might be that China and Russia don't report bad news. Is it because they pick projects likelier to succeed? Or is there intense government pressure to fudge the data?

Maybe it's because they didn't know about JNR -- the Journal of Negative Results.

From The Power of Negative Thinking in Harvard Magazine:

Although ball players can't win with bad batting averages, scientists often learn from a good whiff, says Hersey professor of cell biology Bjorn R. Olsen. Many experiments fail, or produce controversial, ambiguous, or unexpected results. For those who bravely—or accidentally—go where few have gone before, Olsen and Christian Pfeffer, a visiting research fellow in pediatrics at Dana Farber Cancer Institute, have created the Journal of Negative Results in Biomedicine to push such outcomes into the mainstream.

There was a guy in my lab, we'll call him JP, who actually proposed this idea a few years back. I don't think he planned this so much as a peer-reviewed journal but as a repository for bad data. Each month, I envisioned sections like "Results People Couldn't Achieve" and "Overstated Conclusions That Are Actually Meaningless". JP dreamed of sending invitations to selected labs: "Based on your recent works, we encourage you to submit to JNR." Ah, the kiss of death.

You'd think business at a journal like JNR would be booming. Our lab alone could have filled a double-sized issue. Yet, their top ten articles list only goes to 6 -- because they've only published six articles in two years.

Investigators may be worried about the stigma of publishing "negative." Or, more likely, they hide their negative results from competitors and use them as a springboard for experiments that will work.

Maybe JNR should retool, and focus on dead-end projects that will never, ever see the light of day: Summer research rotations for college and med students. The kids win, because they get their name in print. The labs win, because all the time and money spent on training and supplies results in a tangible publication. And JNR wins, because their summer issue would be huge. I wish this had been around in my day.

PubMed's greatest hits

Hot on the heels of the randomized parachute trial!

Do certain countries produce only positive results? A systematic review of controlled trials.
Control Clin Trials. 1998 Apr; 19(2): 159-66.
Vickers A, Goyal N, Harland R, Rees R.
Research Council for Complementary Medicine, London, UK.

OBJECTIVE: To determine whether clinical trials originating in certain countries always have positive results. DATA SOURCES: Abstracts of trials from Medline (January 1966-June 1995). STUDY SELECTION: Two separate studies were conducted. The first included trials in which the clinical outcome of a group of subjects receiving acupuncture was compared to that of a group receiving placebo, no treatment, or a nonacupuncture intervention. In the second study, randomized or controlled trials of interventions other than acupuncture that were published in China, Japan, Russia/USSR, or Taiwan were compared to those published in England. DATA EXTRACTION: Blinded reviewers determined inclusion and outcome and separately classified each trial by country of origin. DATA SYNTHESIS: In the study of acupuncture trials, 252 of 1085 abstracts met the inclusion criteria. Research conducted in certain countries was uniformly favorable to acupuncture; all trials originating in China, Japan, Hong Kong, and Taiwan were positive, as were 10 out of 11 of those published in Russia/USSR. In studies that examined interventions other than acupuncture, 405 of 1100 abstracts met the inclusion criteria. Of trials published in England, 75% gave the test treatment as superior to control. The results for China, Japan, Russia/USSR, and Taiwan were 99%, 89%, 97%, and 95%, respectively. No trial published in China or Russia/USSR found a test treatment to be ineffective. CONCLUSIONS: Some countries publish unusually high proportions of positive results. Publication bias is a possible explanation. Researchers undertaking systematic reviews should consider carefully how to manage data from these countries.

This is similar to the parachute RCT in that it takes a step back from all this evidence-based data and instead raises some interesting questions about methodology. Plus, I'm always partial to manuscripts published without ever leaving the computer.