Advocacy in Disguise

I often wondered what life would be like when my generation started to assume responsibility. Then I read this headline (via mefi):

Optimus Prime Dies of Prostate Cancer
Popular Transformer’s Death Calls for Annual Screening

I have a lot of conflicting emotions about this. First, it's sad to see Prime die, again. And yet, I'm always a fan of creative marketing to reach new audiences. Make no mistake -- this is a real press release from a real organization -- the National Prostate Cancer Coalition. They have a staff and budget and stuff. The press release goes on to describe how the leader of the Autobots succumbed to cancer on a Cartoon Network show called Robot Chicken. The release continues:

“When it comes to prostate cancer, there’s more than meets the eye,” National Prostate Cancer Coalition CEO Richard N. Atkins, M.D. said. “Often times when one has symptoms for prostate cancer it’s already in its late stages, that’s why early detection is so important.”

Above the text is a photo of several men with latex gloves prominently displaying their index fingers.

At first I thought the tone of this site was pitch-perfect -- using a little absurd humor and capitalizing on male squeamishness to raise awareness. But as I kept browsing, I realized the authors of the site weren't kidding when they said "more than meets the eye." In fact, I'm inclined to think the NPCC can identify with Optimus Prime's enemies, the Decepticons.

On the issue of PSA testing, the advocacy group writes:

There are some who say that because of false positives and false negatives early detection is not worth it. These individuals or institutions are misguided. While there is no perfect test for prostate cancer, PSA and the physical exam (in our opinion) do more good than harm for men’s health and long lives.

One institution this group characterizes as "misguided" is the United States Preventative Services Task Force. This is an organization of medical experts, charged by law to make evidence-based recommendations to clinicians on matters such as screening for illness. They do this by thoroughly examining peer-reviewed literature and government statistics.

In short: the USPSTF is as impartial an organization as we're likely to see. Their funding is transparent and their mandate is clear. Unlike NPCC, they base their recommendations on extensive, readily available citations. And when it comes to PSA screening, USPSTF was not as enthusiastic as those mourning the dead Transformer:

The USPSTF found good evidence that PSA screening can detect early-stage prostate cancer but mixed and inconclusive evidence that early detection improves health outcomes. Screening is associated with important harms, including frequent false-positive results and unnecessary anxiety, biopsies, and potential complications of treatment of some cancers that may never have affected a patient's health. The USPSTF concludes that evidence is insufficient to determine whether the benefits outweigh the harms for a screened population.

It's so tempting to do a simple blood draw for PSA in an a healthy patient and, if it's high, congratulate yourself for finding early cancer and go about treating it. But the truth is more complicated. Most forms of prostate cancer are really slow-growing. So slow, in fact, that most men diagnosed with prostate cancer actually live long enough to die of something else. And most treatments for prostate cancer aren't simple, either.

Consider it this way, using the stats collected by USPSTF: if you give this PSA test to 1000 people without any sign of the disease, maybe something like 150 or so will have a positive test. Those 150 will get poked and prodded and biopsied and might get worried, probably for nothing. They might seek treatment they don't need, suffering complications such as incontinence and erectile dysfunction. Of those 150 who test positive, only a few dozen will actually have prostate cancer. And even then, even after all that, we can’t tell if treatment is worth the harm and the stress, or actually prolongs life.

None of these figures appear on the NPCC web site. Instead, there's a self-contradictory barrage of unreferenced stats, many of which mislead readers into thinking PSA is unambiguously helpful. It's not. Their conclusions about a drop prostate cancer mortality are wrong -- deaths aren't down because PSA is helping men beat cancer, but because PSA is uncovering many cases of slow-growing, nonlethal cancer.

Sadly, I think Optimus Prime's death is being used to advance an agenda, and that the motives of the NPCC are not in the best interests of patients. I'm going to trust the bland, dry presentation from USPSTF over the kitschy hipsters from NPCC, whose idea citing references is namedropping 80's cartoon heroes.

Rank and File

As of 9 PM tonight EST, the main National Resident Matching Program is closed to changes. For students and programs alike, the rank list is fixed. There's no more tweaking the positions, no more re-reading of emails for hidden meanings.

Interviews are over, the decisions have been made, and there's nothing to do but sit and wait. I look forward to the time where I can look back on this and sigh at the uncertainty, the tedium, the angst.

Most everyone who's gone through this process (ie, most physicians I know) seems to downplay this period. But that may just be human nature: from the perspective of the matched, everything fits. There's a re-casting of the narrative leading up to Match Day.

I hear things like, "Of course I thought I'd end up at Program X. I had such a great interview, and their program director trained with my advisor." Sure, in retrospect, it seems inevitable. But the truth is, no one knows until until they open the envelope. And no matter where you go (assuming you match in your top four) you're going to be pretty happy, right?

I can only hope. And wonder -- is there is any other career when your future employer, your future city of residence, is decided in secret and revealed to you, 90 days before you start work?

Maybe the military?

At least now that rankings are certified, I can breath a little easier, blogwise, knowing nothing I write can change a program's ranking of me. The past few months have featured more lip-biting and nervous glances at SiteMeter than I care to admit (and, hey, what was that flurry of activity from penn.edu?)

It's all over but the shouting: Match Day is March 17th. As luck would have it, that's also St. Patrick's Day, which is splendidly efficient since I planned on drinking, anyway.

More on the intricacies of the match algorithm can be found on the NRMP site.

And, for a tale of high drama that spawned a blog of its own, check out my post on the Urology Match last month. Be sure to read the thoughtful comments from Jeffrey Huo, a former student member of the NRMP board who puts a very human face on this black box process.

XXII

Catallarchy's Trent McBride has done a stellar job putting together this week's Grand Rounds.

This is a bit of a departure for our weekly medical blogosphere roundup. Unlike other hosts, much of what writers post on Catallarchy is not medical. But I've always been impressed by McBride's work (going back to his days at The Proximal Tubule) and I hope he gets a wider audience.

Catallarchy, by the way, is a libertarian-leaning blog collective (I just enjoy puzzling over that.) Next week, a very different kind of host: Maria from Intueri. Submit your medical posts to her, and if you're interested in hosting, contact me.

Blog will eat itself

Actually, maybe I do know where "this blog thing" is heading. In 2003, in the pages of the Worcester Telegram, I wrote:

There's no doubt blogs will continue to grow, both in audience and in influence. They will force more transparency and accountability in government, media and other institutions... We'll know they've truly arrived when blogs feature glitzy production values, big staffs, and use their resources to expose the hidden motives of ... other blogs.

I don't know about the big staffs or glitzy production, but the currentcommotion over blogger Jeff Gannon's hidden past suggests we've reached a milestone. If you don't believe me, Steve Colbert says about as much, at the end of this hilarious bit with Jon Stewart (Colbert, as it happens, has a hidden past as well.)

Connections

More than a few times, I've been asked, "Hey, this blog thing -- where will it lead?" I'm no closer to knowing than I was a year ago, but Jacob Reider's thoughts on the matter seem to make sense, and he's been medical blogging longer than anyone.

As for me, I've always been partial to print, and so I'm happy to have been involved with a local medical journal with deep roots, read by a lot of doctors and patients in my area. The first issue to which I've contributed is now on the web.

Specifically, I edited two wonderful pieces, by local writers Susan Tarrant and Emily Ferrara.

Both deal with their experiences facilitating medical communication. Ferrara's piece is adopted from a chapter in a recent academic book on 'reflective practice' -- she shares her gleaned insights from teaching creative writing to medical students. Tarrant draws on her sometimes difficult experiences as a hospital's patient representative.

These authors have an intimate view of a demanding field, yet they've managed to retain an outsider's perspective. It was a pleasure working with them.

Tales from Third Year

Cameron's back and posting some wonderful tales from his surgery rotation. I recall those months vividly, from the combination of fatigue, fear, and obstinate personalities. Cameron writes a disturbingly funny post is about a practical-joke surgeon from Argentina.

Another post is about 'framing doctors', the process by which some docs jump to conclusions about a patient and ignore contradictory evidence. This can be an invaluable skill for an experienced physician in an emergency situation -- I've previously mentioned some of the lessons of Blink on how extraneous data can cloud a diagnosis. But as Cameron points out, snap judgements can be ugly, too.

Courtship

As the deadline nears to certify rankings, the governing agency of the residency match sends medical students this reminder:

"One of the purposes of the Matching Program is to allow both applicants
and programs to make selection decisions on a uniform schedule and without
undue or unwarranted pressure. Both applicants and programs may express
a high degree of interest in each other and try to influence future ranking
decisions in their favor, but must not make statements implying a commitment."

I, for one, have never had difficulty complying. But I've got to ask: Is this the Residency Match -- or match.com?

Nonlinear

The term genius gets thrown around a lot. James Gleick wrote
that there seem to be two classes of geniuses: one, typified by Enrico Fermi, is wicked smart but in ways you can predict and anticipate -- it's a genius of speed and productivity, somehow just out of reach:

"An ordinary genius is a fellow that you and I would be just as good as, if we were only many times better." You and I would be just as good ... Much of what passes for genius is mere excellence, the difference a matter of degree. A colleague of Fermi's said: "Knowing what Fermi could do did not make me humble. You just realize that some people are smarter than you are, that's all. You can't run as fast as some people or do mathematics as fast as Fermi."

The other kind, exemplified by Richard Feynman, is a genius out of left field. You have no idea what he's going to come up with, it's completely surprising and unprecedented.

"Genius is the fire that lights itself," someone had said. Originality; imagination; the self-driving ability to set one's mind free from the worn channels of tradition. Those who tried to take Feynman's measure always came back to originality. "He was the most original mind of his generation," declared Dyson. The generation coming up behind him, with the advantage of hindsight, still found nothing predictable in the paths of his thinking.

Coleman chose not to study with Feynman directly. Watching Feynman work, he said, was like going to the Chinese opera:

"When he was doing work he was doing it in a way that was just -- absolutely out of the grasp of understanding. You didn't know where it was going, where it had gone so far, where to push it, what was the next step. With Dick the next step would somehow come out of -- divine revelation."

I've been meaning to collect these quotes and mull them over. But there's always some topical tie-in, of course. In this case, it's a film nominated for Best Picture, written by someone who many have called a genius.

If he is one, then Charlie Kaufman must be a genius like Fermi. Each of his three movies has similar elements of self-reference and frustrated love. If you dwelled in these circles long enough, and mixed in some TNG plots and self-help notions along the way, it might be possible to come up with a Kaufmanesque script. It's almost within reach, like Fermi's math.

But that shouldn't take anything away from Kaufman's writing. Just soak up part of this Alexander Pope poem, Eloisa to Abelard:

Dear fatal name! rest ever unreveal'd,
Nor pass these lips in holy silence seal'd.
Hide it, my heart, within that close disguise,
Where mix'd with God's, his lov'd idea lies:
O write it not, my hand — the name appears
Already written — wash it out, my tears!
In vain lost Eloisa weeps and prays,
Her heart still dictates, and her hand obeys.
...
How happy is the blameless vestal's lot!
The world forgetting, by the world forgot.
Eternal sunshine of the spotless mind!
Each pray'r accepted, and each wish resign'd.

You can almost imagine making a movie from this. Almost. But Kaufman did! And the movie informs the poetry, and vice-versa, in infinite recursion.

Believe it

Orac writes to inform me he's hosting a new biweekly round up of posts called Skeptics' Circle. It was created by St. Nate. Think of it like a "Carnival of the Incredulous." Or, Grand Rounds with more evidence.

Maybe someday I'll submit a post to them about the Mickey Mantle liver transplant story. Many patients and potential donors think the transplant process is fixed because of that tale; the record should be set straight. Anyway, I think that's the kind of writing Orac's crew is looking for. Check it out.

(...and if someone hasn't started a Carnival of the Carnivals, the recent explosion in weekly roundups suggests an opportunity...)

(UPDATE: I was foolish to think this hadn't been seized upon, long ago.)

Read between the lines

Here's a good example of a research tool so accessible, so appealing, that scientists are clamoring to put it to use. From University of Bath professor Mark Brosnan, via this month's Atlantic:

The digits under investigation are the second digit (2D – next to the thumb) and the fourth digit (4D – next to the little finger). 2D divided by 4D (2D: 4D ratio) provides an index of exposure to testosterone while in the womb. The HOX gene family is required for the growth and patterning of digits and the differentiation of the genital bud. Hoxd and Hoxa genes are strongly expressed in the gonads and are also required for the growth and differentiation of digits. This sharing of causal factors in digit and gonad differentiation allows patterns of digit formation to be a marker for prenatal sex hormone concentration (Manning et al., 1998)

This was surprising to me -- the hormones we're exposed to in the womb affect our finger lengths in statistically significant ways. OK. It's tempting to wonder if our prenatal environment can leave other lasting marks:

Prenatal testosterone slows the growth rate of the left side of the brain while enhancing growth of the right side (Geshwind and Galaburda, 1985). The right hemisphere is associated with better visual-spatial and mathematical abilities, as is the 2D: 4D ratio (Manning and Taylor, 2001). Handedness may also be affected (Manning et al., 2000). Thus, traditional sex differences in visual-spatial and mathematical abilities can be attributed to differences in exposure to prenatal testosterone, indexed by a sex dimorphic pattern in digit ratio.

Bronson goes on to try to show that prenatal testosterone exposure, as assessed by digit ratio, is correlated with science department membership at a university. I know, I know -- most people would never think to examine such a relationship. Yet this kind of intellectual leap is common inside academic departments! Either these people are really bright or really self-absorbed.

As the levels of testosterone decrease in males, performance upon visual-spatial measures increase whereas comparable cyclical declines in female testosterone result in decreased performance upon visual spatial measures (Moffat and Hampson, 1996; see also Sanders et al., 2002). Thus those with the greatest visualisation skills will be females with the lower male-typical digit ratio (0.98) and males with the higher female-typical digit ratio (1.0). Additionally, an extreme digit ratio (0.94) has been associated with Autism, suggesting that excessive prenatal testosterone may play a causal role in the development of autism (Manning et al., 2001). Using some of the visual-spatial measures described above, Dyslexia has been cast as the opposite end of the continuum to Autism (Brosnan et al., 2002).

So interesting: High testosterone exposure in men leads to low index-to-ring ratio (relatively small index fingers) and, also, poor visiospatial skills. There's a few wrinkles -- high T seems to improve visiospatial skills in women, and really high T seems, cyclically, to strengthen visiospatial skills in men.

Armed with this knowledge and some calipers, Bronson's team measured the faculty -- focusing on the science and engineering types, and comparing to the humanities and business school types:

…An ANOVA was conducted to statistically identify whether there were differences between different groups (sex, faculty or pay scale) that related to differences in digit ratio... This shows that there was a significant difference between the faculties in digit ratio (F=3.519, p=0.034). A Tukey HSD post hoc analysis revealed that the significant difference was between the Science faculty and the HASS/Management faculty (p=0.02), with the Engineering faculty averaging between the other two faculties.

Brosnan's data is not yet in publishable form, so I imagine we'll eventually see histograms or breakout data sets by gender. It might clarify this link, or totally eliminate any relationship (one physicist with Asperger's could skew everything!)

But before you go lining up your fingers, kind readers, note that the ratios Brosnan is talking about have a variance of about 5%. So, a mismeasured millimeter or two could lead you to abandon your science career and become a testosterone-addled middle manager. Surely this is a choice we've all contemplated, but never with hard data to back it up. So be careful. And then go ahead and do what you've always wanted to, anyway -- confident in the knowledge that you are more than the lengths of your fingers.

Not surprisingly, there’s been finger-length controversy before, concerning the link to homosexuality. This might be a more intuitive link to examine than science department faculty membership, but ultimately, just as muddled and equivocal.

Someday, this line of thinking might lead to better predictors of future careers, better explanations for our desires and preferences. Until then, we muddle through weak correlations and heavy overlap. But cocktail party science marches onward! Next up: Thoughts from the future influence random number generators.

Comfortably Numb

In December, commenting on Atul Gawande's NEJM piece on the advances in trauma surgery underway Iraq, I wrote:

One comes away with a greater appreciation of what the tiny number of army physicians and surgeons have accomplished in Iraq. There are implications for our civilian trauma management, as well (lengthy stabilization in the field or community hospital may not be in the patient's best interest).

Now it's clear the potential for changes in civilian surgery aren't just limited to transport management. Steve Silberman has an eye-opening article in this month's Wired on potentially far-reaching progress in anesthesia. Some wounded soldiers are receiving hi-tech regional blocks instead of general anesthesia:

The blocks used by Buckenmaier and his team are made possible by the recent invention of small, microprocessor-controlled pumps which bathe nerves in nonaddictive drugs that discourage the transmission of pain signals. The pumps also can be used for weeks after surgery, enabling soldiers to adjust the level of medication themselves as they need it.

For soldiers evacuated from the battlefield, the advantages of nerve blocks over traditional methods of pain control are clear. The wounded troops flying in and out of Landstuhl are often in misery or a narcotized stupor, while those treated with blocks remain awake and pain-free despite massive injuries.

He goes into some excrutiating detail about setting up a regional block at the scene of a trauma:

Wilhelm had been carried into the OR for debridement, the harrowing process of removing dirt and dead tissue from a wound. Buckenmaier got out his bag and went to work.

First he used a millivolt stimulator to probe for leg nerves that were still functioning. The soldier's ankle flexed - a sign that the stimulator had found the nerves serving the injured area. Then Buckenmaier placed two blocks by inserting ultrafine catheters into Wilhelm's back and thigh to bathe his sciatic and lumbar nerves in a drug called mepivacaine.

Throughout the 85-minute operation, Wilhelm remained awake and talking. At one point, a technician lifted his wounded leg to clean it, and the weakened tibia fractured with a sharp crack that sent shudders through the surgical staff. But the blocks were so effective, Wilhelm didn't even feel it.

The typical scene in the recovery tent is a somber one: friends touching the sides of the bed around an unconscious soldier in a silent show of support. By contrast, when Wilhelm's operation was over, 15 of his buddies crowded around, laughing and joking with him.

Later, Wilhelm's catheters were connected to pumps, each about the size of a TV remote control and weighing only about 6 ounces, with tiny LCD screens. Hooked up to a supply of ropivacaine, they would provide continuous anesthesia for 48 hours on two AA batteries. The entire apparatus fit in a fanny pack.

And finally, if one accepts the research that chronic pain can be nipped in the bud, by quickly covering short-term pain, then the regional blocks will improve outcomes down the road, as well.

XXI

Be sure to check out Sumer's Radiology Site, the host of this week's Grand Rounds. This edition might feature a little more medical terminology than previous Grand Rounds, but hey, there's also cartoons.

Tune in next week when Catallarchy's Trent McBride hosts. He asks that you email your submissions to him at this address.

Previous editions of Grand Rounds, and the upcoming schedule of hosts, are kept at an undisclosed location. And if you're a medical blogger who's thinking about hosting Grand Rounds, drop me a line.

XX

Head on over to Enoch Choi's Medmusings to see Grand Rounds, his collection of the best of the week's medical bloggings. And give him credit -- he went really out of his way to do a fabulous job...

Next week, Sumer's Radiology site plays host. Submit your medical-themed posts to him (you don't even have to be in the field!) And if you're interested in hosting, drop me a line.

HotSync

Old PDAs can be put to good use again, helping doctors in Africa:

In honor of World AIDS Day, December 1st, Skyscape and SATELLIFE are asking you to donate your used PDAs to health practitioners in Africa to enable them to access the latest medical information - and help fight the spread of AIDS.

Skyscape will equip these handheld devices with mobile medical references enabling health practitioners in the developing world to access to the latest medical information while working in rural areas.

SATELLIFE will distribute the PDAs to doctors in Uganda and other East African Countries as part of its existing initiative to fight the spread of AIDS in Africa and improve medical care by providing doctors the most current treatment guidelines and references.

This program started in honor of last December 1st's World AIDS Day -- but still seems to be going strong. Most medical students / residents I know are on their second or third PDA (then again, many of the ones I know started school in the 90's).

What happens to the old ones? With the black-and-green screens? And the quaint AAA batteries? At last, there's a good alternative to gathering dust.

Flashback to back

On rounds this morning, one of my patients was sporting a Superbowl cap. After a minute of the usual chit-chat ("Did you sleep well? How many pillows? Can I listen to your lungs?") I realized that he was wearing a Patriots Superbowl XXXIX Champions cap, which had only been available to the public for about an hour.

It was then that I realized: Here's a real fan. And: I am taking this victory far too lightly.

I think my roommate from out-of-town sensed this complacency; it's part of the reason she rooted for Philly (another reason: she has a death wish). But she has a point, and I need to remind myself of the New England tradition of losing.

Here's something I wrote in haste and disgust, the morning of ALCS Game 4 (October 17, 2004) against the Yankees. For those who haven't had this series seared into memory, Game 3 was an utter blowout and the Yankees were one game away from eliminating the Red Sox. On that Sunday morning after Game 3, I ran some errands. Everyone I encountered looked like they'd been punched in the gut. We were facing another winter of inferiority. I wrote (bear with me, for the flashback-in-a-flashback):

A year ago, faced with a crushing playoff loss against the Yankees, I wrote this:

I think how your view the 2003 Red Sox says a lot about how you view relationships. There were highs and lows, it was a good ride, it didn't have to end like it did, and it would have been great to go all the way...
...Obviously, I was shocked when the Sox managed to blow it. And the worst part is knowing -- as the Pats have shown us -- just how happy the town would have been if we had beaten the Yankees and won the championship. There will be no spring in my step for a few days, but c'mon people, get over it.

With the benefit of perspective, I realize now I was writing in denial. It hurt like hell then. It hurts now. And there's no getting over it, ever.

Sheesh. I waited for the Red Sox to lose the series before I clicked "Publish" and, as luck would have it, they never lost again. I just can't put myself in that frame of mind anymore. The Sox won it all in October, the Pats won again yesterday. And I can't quite remember what it was like, before. But writing like this almost captures it -- a time-travel dialogue between a fan from 2004 and his 2003 self.

Future Red: Well, there'll be some personnel changes, but it's all good. Like I said, the Red Sox win the World Series! And there's a huge ass parade and the entire city goes nuts. Alan f--king Embree goes on the Tonight Show. It's unbelievable.

Red [wiping his eyes as he watches Gammons interview Boone]: What about the Yankees?

Future Red: Buddy, you won't f--king believe what we do to them.

Red: Please tell me it involves blow-torches.

Future Red: Even better. Let's just say we hand them the single most devastating loss in their franchise's history. Hell, in baseball history.

Red: No way.

Future Red: Listen, it hurts now. I know it does. And although it seems absolutely impossible to contemplate this right now, the Red Sox are going to have their greatest season ever next year. You absolutely will not believe how good it feels.

The reruns on NESN sure help.

"Let Your Fingers do the Walking"

http://a9.com/-/company/YellowPages.jsp

A few months ago I wondered aloud:

... Through the concerted action of smart mobs, we're getting closer to the day when we'll have an indexed, street-level view of every block, every store, every dorm. Even later, perhaps, a chronological view ...

I was surprised to see that Amazon's A9 search engine has already accomplished a lot of this, for ten US cities:

The most powerful technology A9.com invented for Yellow Pages is “Block View,” which brings the Yellow Pages to life by showing a street view of millions of businesses and their surroundings. Using trucks equipped with digital cameras, global positioning system (GPS) receivers, and proprietary software and hardware, A9.com drove tens of thousands of miles capturing images and matching them with businesses and the way they look from the street.

You can see a list of Greek restaurants, for instance, near your specified zip code, and what they look like from the outside. You can even wander up and down the street and see what's nearby. It doesn't quite seem like it's worth the monumental effort, but for dense cities, it might pay off. And it's pretty cool.

When you couple this with Google's new TV search, it's shaping up to be a genre-expanding year for the search engine business.

CME

Continuing Med Ed guru Sue Pelletier is hosting Grand Rounds XIX. Continue your medical education by paying a visit! And tune in next week, when noted phsyician and wine aficionado Enoch Choi hosts Grand Rounds: Dos Equis.