Intel Inside

I've been fascinated by recent research out of Brown, Caltech and Duke in neurological control of prosthesis and software. Earlier posts (10/03 and 7/04) detailed the experiments with monkeys, when chips in their brains enabled them to move robotic arms with just the power of thought.

Today, via Drudge, a Guardian report on the human trials:

There's a hand lying on the blanket on Matt Nagle's desk and he's staring at it intently, thinking "Close, close," as the scientists gathered around him look on. To their delight, the hand twitches and its outstretched fingers close around the open palm, clenching to a fist.

In that moment, Nagle made history. Paralysed from the neck down after a vicious knife attack four years ago, he is the first person to have controlled an artificial limb using a device chronically implanted into his brain...

...There are huge hurdles ahead. No one knows how much information we can usefully decipher from the electrical fizz of the brain's 100bn neurons. More importantly, scientists are still in the dark as to what effect, if any, long term implants will have on the human brain, or how its circuitry will cope with the new tasks demanded of it.

Nagle got involved in the latest trial after hearing about John Donoghue, a professor of neuroscience at Brown University on Rhode Island, whose company Cyberkinetics has developed an implant called BrainGate.

The reporting seems pretty good (I can forgive the UK writer for saying Brown University is "on" Rhode Island). Unlike earlier breathless news articles, this one seems grounded in a healthy skepticism, and notes the significant limitations and hurdles ahead.

Implants suffer from a number of drawbacks, the first being that they demand invasive surgery, with attendant risks. Second, implanted electrodes cause at least some inflammation of the brain tissues they push into. As well as obvious medical concerns, if the inflammation is significant, it can smother any signals the electrodes might pick up.

"Every one you put in gives some inflammation, but it's minor. We're still working on making electrodes more biocompatible, but we've got monkeys who have so far survived for nearly five years with implants and they are fine," says Nicolelis. "The thing is, to do what we want to do, to get that level of control, you have to get into the brain."

It's always been a matter of concern -- the human inflammatory response is a good deal more vigorous than that of even closely related primates. However, noninvasive techniques for mapping brain activity to mechanical devises are under development. The only question is, will brain chip implants, with their greater risks and greater control, win out over the safer and less precise (but potentially trainable) electrode caps? Regardless, this technology seems to be moving faster, and overcoming more obstacles, than tissue-engineered approaches to repairing severed spinal cord.

Barriers

I recently attended a talk by pediatric endocrinologist, and former Surgeon General, Jocelyn Elders. She's not a particularly gifted speaker, but delivered an enlightening presentation, with a lot of statistics and advocacy recommendations, and a little biographical context.

I had been curious if she had regrets about her outspokenness, which ultimately led to her resignation. She brought this up early on, when she reflected on how much she loved her job as Surgeon General, and how she feels she conducted herself exactly right. She said she'd do it again the same way, promoting the same measures, saying the same things.

Well, I'm glad she's sleeping easy. But the rest of her talk was about the numerous problems and setbacks facing teenagers -- poverty, limited access to healthcare, and ultimately, trouble getting access to abortions. These are difficult challenges, to be sure. And I don't think Elders' message is misdirected. But I can't help wonder that, if she had been a little more savvy in her tenure, if she had better marshalled political will and produced the appropriate studies, teens might be in better shape now.

Certainly, after the terms of C. Everett Koop and Jocelyn Elders, the public role of the Surgeon General as an advocate for health matters has decreased dramatically. I can't remember the last time I heard anything about current SG Richard Carmona's speeches or initiatives.

We certainly haven't heard anything about the preponderance of data suggesting teen sexual habits don't change, from country to country, with or without sex education, with or without abortion access. Elders reveals that, given the global constant of teen sex, the only variable seems to be unwanted teen pregnancies that keep poor people mired in poverty.

In light of this, it's unfortunate that American teens, and their healthcare providers, have to contend with abstinence-only sex education. Elders had one rhetorical zinger in her speech, when she criticized proponents of the stark 'abstinence-only' sex education curricula. In this age of teen pregnancy and increasing teen STD rates, she quipped, "They say condoms break, but we all know the vows of abstinence break more frequently than any condom."

Elders also said something really interesting, something that doesn't get said enough in the debate about sex education: The age of menarche (first menstruation) in U.S. girls is dropping. The age of marriage is rising. The two used to roughly coincide, in the late teens. But now menarche occurs, on avergage, at age twelve (she said eleven in her speech, I can't find that datum). Conversely, marriage is being postponed. If sex educators are trying to keep sex within marriage, without using condoms, without allowing abortions, they're facing a widening time gap.

She doesn't tie it together as tightly in her speech, but I think this is the crux of the matter. The push in recent years to promote sex for procreation, in married couples only, something at odds with a century's worth of changes in human society and human biology.

UPDATE: Dr. Quinn was there, too! It's a small blog world.

Grand Rounds Update

Our movable collection of the week's best medical posts, Grand Rounds, is celebrating its half-year anniversary. Many hearty thanks and congratulations to our hosts and contributors. I've been genuinely dazzled by the writing and creativity of the medical bloggers, and it's been an honor scheduling you. I can only hope that funneling traffic from healthcare professionals, and lay readers, has resulted in new fans of our medical blogs.

So, as promised, I've got some news:

First, after six months of rotating hosts, it's time to begin recycling. While a lot of new medibloggers have emerged since we started, there still aren't more than a few dozen of us out there writing with frequency. Recycling will keep the quality of hosting high, and will fortify the voices of established medical writers. New medical bloggers will still be featured frequently, of course -- I imagine old hosts will come back once or twice a month for the forseeable future.

Second, I'm launching a private Grand Rounds discussion forum on Google Groups. It's my hope that tips and ideas for promoting and improving Grand Rounds can percolate among the former hosts. And I'm always receptive to suggestions from anyone via email.

It's worth reflecting on what from Medlogs.com founder Dr. Reider said, when musing about the next wave in medical news delivery:

... If we're talking about medical information - and perhaps even medical news - there is still an author of the story - and an editor - and if I know a little about them - I am better prepared to judge what it is that I am reading. "Personality" may be the means to the "transparency" end. Humor, even in "news" is appropriate and maintains the attention of the reader. Makes everyone more human. Sometimes when the author says WHY something is important - or offers an editorial summary - they are providing a framework for the reader.

Dr. Reider wasn't talking about our weekly roundup, or even blogs as they now exist. But I think that the format of Grand Rounds, with its mix of familiar and new contributors and hosts, goes a long way toward his vision of an accessible, useful health publication with transparency and personality.

Browse through the archives and see for yourself. The past editions of Grand Rounds can now be accessed on this site, but will also remain at Izzy's Undisclosed Location. I'd like to thank Izzy, and also Interested-Participant and Galen for their early guidance and suggestions.

Collateral Damage

One of the clinics I rotated through had posters on the walls of elderly folk working out. The photos of buff seventy-something-year old men pumping iron, and toned elderly women swimming, were meant to inspire the patients to take care of themselves.

The pictures gave me hope, too -- that my meticulously honed physique need not fade away (note: readers who've met me can decide, quietly and to themselves, whether or not I'm being sarcastic).

Which is why today's photos of Arnold Schwartzenegger on a beach are a little disheartening.

While he still looks like he's in good shape, he's clearly let himself go a little. His pecs have atrophied. His deltoids, while toned, have lost mass. And he's acquired some love-handle type structures. Also, I could swear he's got a ventral hernia (though I'm reserving judgment until CBB's blockbuster investigative report).

Oh well. He's still only in his fifties -- there's plenty of time to return to form, and maybe his comeback will serve to motivate his cohort.

XXVII

Grand Rounds has gone tabloid! Now with more exclamation points than ever!! And gratuitous celebrity name-dropping! What hath Graham wrought? As he says, get it while it's hot. And be sure to check out next week's installment at Politedissent.com.

I'll have more news about Grand Rounds later today!

Objectors, revisited

An alert reader pointed out this piece in today's Washington Post:

Some pharmacists across the country are refusing to fill prescriptions for birth control and morning-after pills, saying that dispensing the medications violates their personal moral or religious beliefs...

..."There are pharmacists who will only give birth control pills to a woman if she's married. There are pharmacists who mistakenly believe contraception is a form of abortion and refuse to prescribe it to anyone," said Adam Sonfield of the Alan Guttmacher Institute in New York, which tracks reproductive issues. "There are even cases of pharmacists holding prescriptions hostage, where they won't even transfer it to another pharmacy when time is of the essence."

I blogged about this in September, when the issue provoked a good discussion on metafilter. I had just submitted my application to residencies, and resolved to try and find problems with both sides of the argument, in case any program directors were reading. An attempt at objective commentary though motivated self-interest -- and it's for a good cause! I ended up putting the patients' concerns first (and poking fun at a small religious group):

Already, primary care docs know which drugstores around town don't carry oxycontin (for fear of burglaries) -- and they pass this information along to patients when precribing pain meds. Will the docs have to learn which pharmacists won't fill prescriptions for emergency contraception? For birth control? STD's? Addictions?

Maybe. Of course, it'll be easy to remember to avoid the Christian Science Pharmacy (it's the one with all the empty shelves). But either we force druggists to honor prescriptions for all that's legal, or we memorize their morals, quirks, and biases.

One can only hope patients don't get sicker as they race around town, trying to find someone who believes in treating them.

An interesting discussion ensued.

Inspirational News

While digging up references for this post, I came across another gem, which straightforwardly suggests atmospheric air is mildly anesthetizing:

Nitrogen has recognized narcotic potential at hyperbaric pressures. No narcotic effect of helium has been demonstrated at any pressure. We evaluated the effect of nitrogen in air at one atmosphere on human performance by comparing it with helium-oxygen using a four-alternative divided-attention task that requires rapid response to auditory and visual signal changes. There was a 9.3 per cent decrease in response time when subjects breathed helium-oxygen, a signigicant change (P less than 0.001). This change could not be ascribed to practice since the order of presentation of gases did not have a significant effect. It concluded that the nitrogen in ambient air slightly but measurable impairs human performance compared with a non-anesthetic gas such as helium.

Wow. Air has been holding me back all this time.

Minder Binder

Aren't medical bloggers ambitious? Galen's formed a company and has a useful new product: the Medi Binder for patients to keep track of meds, docs, allergies, labs...

As Galen originally wrote:

think of the hapless octogenarian with who is supposed to remember about 14 medications and an extensive history of conditions and surgeries. Damn near impossible.

I'm sure your thinking the information should be in the chart, right? Yeah, like you can read your partner's handwriting. Hard enough to read my own. Plus if you're a specialist, you've got a snowball's chance in hell of getting any information prior to the consult.

Now this may be a minor annoyance in the office, but in an ER it can be downright dangerous. As continuity of care becomes the exception rather than the rule, something has to be done to fill the communication gap.

He's selling to patients, but I hope he also targets hospitals, GPs, any health care facility. They should just be handing out the MediBinder to complicated patients. I bet in the long run, hospitals would come out ahead in terms of time saved, faxes and phone bills decreased, and mistakes averted.

Wakeup Bomb

Via Gizmodo, a review of the new Sleeptracker Alarm Watch, designed to wake you at the optimal point in your sleep cycle. The idea is to avoid grogginess and wake up feeling refreshed.

Now, I had no doubt that the SLEEPTRACKER would perform just fine as a digital watch, which it did. Setup was simple, and after it was done, I could tell the time and date. However, this watch sells because it wakes you up like you have never been woken up before. I went to bed that evening at the time that I told the SLEEPTRACKER that I would be in bed by. During the night, my baby woke up crying, which in turn woke me up. I remember getting up at about 2:10 AM to calm him down and get him back to sleep. In the morning, I heard the alarm go off. I checked the watch, and it was 5:47 AM. Oh, and yes – I felt perfectly awake and satisfied with the amount of sleep I got. I didn’t feel the need to hit a snooze button of any sort.

After I got up, and did the toothbrush thing, I checked the sleep data. It was very interesting to see the times that the SLEEPTRACKER had recognized as my light sleep/awake moments. Most intriguing though, was that it marked 2:11 AM as one of those moments – right after my son woke up crying!

When I was in college, friend and fellow pre-mudphud Matt D used to recommend sleeping in 90 minute increments, because that was the approximate timing between REM cycles. The trouble was always individual variation -- if your cycles are 95 minutes, or fluctuate throught the night, setting the alarm properly becomes impossible.

This watch seems to do the trick. It's not clear how the Sleeptracker works -- whether the underside sensors are monitoring the sleeper's pulse, or arm movements, or temperature, or some combination. But, as the reviewer mentioned, you can review your night's sleep and tally the "almost awake" periods. Maybe you can reverse-engineer their sensors with a Holter monitor or insomniac partner.

(A good primer to the physiology behind waking is Akerstedt and Shulz's review article.)

Under pressure

Every first year anatomy student learns about Saturday night palsy:

The patient ... presents holding the affected hand and wrist with his good hand, complaining of decreased or absent sensation on the radial and dorsal side of his hand and wrist, and of inability to extend his wrist, thumb and finger joints...

...This neuropathy is produced by compression of the radial nerve as it spirals around the humerus. Most commonly it occurs when a person falls asleep, intoxicated, held up by his arm thrown over the back of a chair. Less severe forms may befall the swain who keeps his arm on his date's chair back for an entire double feature, ignoring the growing pain and paresis.

Saturday Night Palsy inspired an Australian rock song. And, I should note that an interesting alternative explanation for the term has been proposed.)

Now, in my final weeks of med school, I've come across Thursday afternoon palsy, more commonly known as Lateral Femoral Cutaneous Nerve Entrapment, or meralgia parasthetica:

The lateral cutaneous nerve of the thigh passes from the lateral border of psoas major across the iliac fossa to pierce the inguinal ligament. It travels in a fibrous tunnel medial to the anterior superior iliac spine and enters the thigh deep to the fascia lata before continuing distally into the subcutaneous tissues.

Compression of the nerve as it passes through the inguinal ligament or as it pierces the fascia lata causes meralgia paraesthetica.

Characteristically, the patient complains of a burning or stinging sensation in the distribution of the nerve over the anterolateral aspect of the thigh. This is aggravated by walking or standing; it is relieved by lying down with the hip flexed.

It was apparently called Thursday afternoon palsy because that was the time of the week women would gather, sit, have tea, eat crumpets, play bridge, I don't know. The combination of sitting with the legs crossed, in a corset, would cause the entrapment symptoms.

It's only a matter of time before someone describes generalized post-match palsy.

Vital signs

A little while back, MedGadget reports a new device for noninvasively measuring carbon monoxide levels in blood, the Masimo Rainbow SET Pulse CO-Oximeter. This is potentially great news, as carbon monoxide poisoning symptoms are vague and often attributed to other causes, especially when a clear history of exposure isn't available.

Also, in the past, to confirm carbon monoxide, arterial or venous blood had to be drawn and sent to the lab, costing valuable time and delaying therapy. Worse, the standard noninvasive test of blood oxygenation, the pulse oximeter, can't distinguish between oxygenated hemoglobin and CO-hemoglobin -- sometimes fooling docs (or, let's say, med students) into thinking oxygenation was adequate (ie, the pulseox could read 95% saturation, even if it was 80% HbO2 and 15% Hb-CO.

So, this new device should save lives and improve outcomes. But don't take my word for it, read the breathless press release:

Now, with Masimo Rainbow SET, Masimo ushers a new era where carbon monoxide and potentially other vital parameters can be safely and accurately monitored continuously and noninvasively... Rainbow technology is based on system theory and adaptive signal processing algorithms first introduced to the medical community with Masimo SET in 1996. Rainbow technology goes further with the ability to analyze information from a sophisticated new sensor technology that employs eight wavelengths. The Rainbow sensor generates an extraordinarily rich physiological data stream, which opens the door to monitoring additional parameters that presently require costly, inconvenient blood gas measurements that are often unavailable when the information is needed most.

Eight wavelengths! Current pulse oximeters employ two wavelengths to detect blood oxygenation, as discussed in this report:

The pulse oximeter calculates the absorption based on two physical principles: the two wavelengths of light are absorbed differently by oxygenated hemoglobin and deoxygenated hemoglobin; and tissues such as bone and fat and venous blood absorb a relatively constant amount of light, producing a relatively constant rate of light absorption.

I wish there was more information available about how the new CO-oximeters work, particularly, how they overcome the limitations of the O2 meters. Masimo's first of the line, the Rad-57, debuted at EMS Today in Philadelphia last weekend, so materials developed for the demo may be forthcoming.

Still, it's important to remember that, whatever readout these CO-oximeters show, the level of carboxyhemoglobin does not always correlate with severity of symptoms or neuropsychiatric sequelae.

And, just like the pulse-ox's SpO2 readout is just a proxy for oxyhemoglobin content, an output of carboxyhemoglobin in grams per dL is more reproducible and medically significant than a percentage (full disclosure: I've worked with one of these authors, he's the same one who punctured the myth that nail polish tarnishes pulse oximetry readings).

Particularly interesting will be how many cases of chronic, low-level carbon monoxide exposure this new detector picks up. This device could be a big step forward for emergency care and public health.

Vigor and Calmness

CodeBlueBlog is hosting the 131st Carnival of the Vanities this week. I think he may be the first medical blogger to run the show, and yes, it's a really big show.

Up near the top of the carnival, under "My Med Buds", he's put up a little guide to the medical blogs. It's a good introduction for neophytes. And he makes note of my Whitman reference! It's a poem which, coincidentally, has some bearing on his collection of Terri Schiavo posts, and his question of the week: what is life?

Drink it down

Today is World Water Day. It's a good opportunity to take a moment and learn about some of the fluids, and misinformation, we've been consuming.

One of the contributors to the Medical Informatics Student Blog has laid to rest one of the most frequent, stubborn medical claims I've come across:

The 8 glasses of water rule began when the Food and Nutrition Board recommened approximately "1 mm of water for each calorie of food" which would average about 64 to 80 ounces a day. However, the next part of the recommendation was "most of this quantity is conatined in prepared food." So, it seems that America only listened to the first half of this recommendation.

According to Family Practice News, 8 Glasses of Water a Day is no longer the Mantra. Most healthy individuals remain adequately hydrated by allowing their thirst to dictate their intake.

Additionally, I found that caffeinated drinks (coffee, tea, and soda) DO count towards your daily total.

The student provides the links are there to back it up, like this IOM report. But it can't be said any more emphatically than this pubmed abstract I'm excerpting:

The search included not only electronic modes but also a cursory examination of the older literature that is not covered in electronic databases and, most importantly and fruitfully, extensive consultation with several nutritionists who specialize in the field of thirst and drinking fluids. No scientific studies were found in support of 8 x 8. Rather, surveys of food and fluid intake on thousands of adults of both genders, analyses of which have been published in peer-reviewed journals, strongly suggest that such large amounts are not needed because the surveyed persons were presumably healthy and certainly not overtly ill. This conclusion is supported by published studies showing that caffeinated drinks (and, to a lesser extent, mild alcoholic beverages like beer in moderation) may indeed be counted toward the daily total, as well as by the large body of published experiments that attest to the precision and effectiveness of the osmoregulatory system for maintaining water balance.

This "8 glasses of 8 ounces" fallacy has undoubtedly contributed to the runaway bottled water industry, which is fundamentally ineffecient and surprisingly unsafe.

Cycles

The 26th Grand Rounds is up at The Well-Timed Period. Go check out the best posts from medical bloggers, including extensive commentary on the Terri Schiavo case. And consider perusing the menstruation and birth control resources that TWTP has collected.

Next Tuesday's host is a fellow med student, Graham Walker.

This week's edition marks half a year of Grand Rounds. Stay tuned for some announcements later this week, regarding tweaks and changes planned for the next six months and beyond.

Healthy, Wealthy and Wiser

I'm a big fan of high-tech doodads. It's especially nice when I can justify using them. Hence, MedGadget has become must-read blogging goodness.

And today they've got something I can afford, new PDA software for identifying and managing hazmat exposures:

WISER (Wireless Information System for Emergency Responders) is a system designed to assist First Responders in hazardous material incidents. Developed by the National Library of Medicine, WISER provides a wide range of information on hazardous substances, including substance identification support, physical characteristics, human health information, and containment and suppression guidance.

Future versions will have wireless networking capability for coordinated responses. And you can't beat the price (free).

I Sing the Body Electric

Via Drudge, a new story from Paul Rubens about using human electric fields to transfer data:

Using RedTacton-enabled devices, music from an MP3 player in your pocket would pass through your clothing and shoot over your body to headphones in your ears. Instead of fiddling around with a cable to connect your digital camera to your computer, you could transfer pictures just by touching the PC while the camera is around your neck. And since data can pass from one body to another, you could also exchange electronic business cards by shaking hands, trade music files by dancing cheek to cheek, or swap phone numbers just by kissing.

NTT is not the first company to use the human body as a conduit for data... But RedTacton is arguably the first practical system because, unlike IBM's or Microsoft's, it doesn't need transmitters to be in direct contact with the skin -- they can be built into gadgets, carried in pockets or bags, and will work within about 20cm of your body. RedTacton doesn't introduce an electric current into the body -- instead, it makes use of the minute electric field that occurs naturally on the surface of every human body. A transmitter attached to a device, such as an MP3 player, uses this field to send data by modulating the field minutely in the same way that a radio carrier wave is modulated to carry information.

I'm sure their scientists have considered this, but radio carrier waves don't vary to the same degree as people do. I'm curious how that notoriously unreliable piece of engineering, the human body, will causes glitches in this system.

Take the MP3 scenario mentioned above -- say you're on a treadmill listening to tunes coveyed through your body. What happens as you work up a sweat? Does the resistance of the skin affect the speed or quality of transfer? How about muscle activity?

Or say you're transferring data to a colleague via handshake. Is it possible we'll someday hear comments like, "This download's taking longer than usual -- have you put on some weight?"

I'm also not enthusiastic about a world where computer viruses are transmitted in the same manner as natural viruses. Crowded subways are disturbing enough already.

However, if this technology should work out, there are important health monitoring implications. It wouldn't take much additional effort, for instance, to program an MP3 player to detect cardiac arrhythmias (you'd know you were having V-tach if your iPod cued up "Kickstart My Heart").

Having grappled with EKG leads, and the tracing errors introduced by patient breathing, coughing, sweating, and simple movement, I'm skeptical that these machines could use subtler electric fields for precise tasks like data transfers. I'd love to be proven wrong, though -- for doctors, this technology could give new meaning to the "laying on of hands."

Start Spreading the News

The NRMP match algorithm takes, I'm told, about 90 seconds to assign this year's 16,500 medical students and 10,000+ FMGs to one of hundreds of programs in dozens of specialties. On Monday, we were informed whether or not we matched. The program directors learned the neames of their new trainees yesterday. The medical schools got the list of programs this morning.

And, just after noon, as results were posted on the NRMP website, our Dean handed the each applicant an envelope with our match results.

YES.

People cheered, clapped, and hugged when they returned with the envelope to their loved ones and friends. I celebrated with my parents, and enjoyed more than a few high-fives with my classmates. Later, many of the current and graduating MD/PhD students huddled together. We've known each other for the better part of a decade, and have waited a long time for this.

I'm going to an awesome program in a spectacular city, and I'm very, very excited. At this moment, I really wish we started internship tomorrow.

Across the medical blogosphere, it looks like everyone did great. I think Matt Shook actually phoned in a blog entry from the match, which ought to be commemorated in the annals of medicine. The Push Fluids group "rocked the match", and Izzy and his roommate are thrilled. Jatser's ceremony sounded a lot like ours, but they chose to sit it out, as did a fair number of my classmates. Every year there are a few unpleasant surprises or disappointments, and regardless, I can understand the desire to celebrate away from the crowd and the press cameras.

But I'm glad I had the opportunity to reconnect with old friends, and marvel at all the children my classmates are producing. Given the nature of fourth-year, today might be the last chance I have to catch up with some of these wonderful, talented people.

Telegenic

Respectful Insolence has posted the twenty-fifth Grand Rounds. Check out the best of the medical blogosphere -- this week, creatively formatted to resemble TV Guide listings.

This should come as no surprise to regular readers, but medical writing isn't all TLC and Discovery Channel. Ever ask yourself which medical blogger should end up playing opposite William Shatner? Ever wonder whether these ramblings conform to Hannity and Colmes, or Comedy Central? Others wonder, but Orac Knows.

Tune in next week, when the Well-Timed Period is scheduled to host the sixth-month anniversary of Grand Rounds.

The Kids Are Alright

Thanks to all the friends and well-wishers who dropped me a line yesterday. I matched. Izzy and Anjali have updated their pages with good news, too. In addition, two new fourth-year med student bloggers have come to my attention: Tanfastic, and Prognosis: Negative, both with positive results in their respective specialties.

While we spend the next few days wondering where we're headed, the umatched begin the scramble today at noon. Good first-hand descriptions of the process are available on the Student Doctor forums.

In my chosen field of emergency medicine, as of this morning, there were just 24 unfilled spots, out of 1188 positions in over a hundred U.S. programs. It's not yet clear how many people applied to EM, though some estimate around 1400 med students this year.

What, me worry

Today is unMatch Day. Black Monday. It's the day when most medical students in the U.S. find out IF they're going into a residency in July. The question of WHERE is revealed on Thursday (as I've mentioned before, some specialties have already conducted their matches, with unnerving results).

After the six-month process of applying, interviewing, and ranking, Match Week can be an abrupt exclamation point.

Those unfortunate enough to get bad news today will be pushed into what's affectionately called "The Scramble" -- cold-calling programs that have a few unfilled spots, faxing the application, and hoping for some mercy. I know doctors who've actually changed their careers during the scramble (ie, not matching in dermatology and deciding, oh well, anesthesiology's nice, too).

But that's still pleasantly hypothetical, at least for another few hours. Besides me, other fourth-years include Anjali, Trent, Izzy, and the crew from Push Fluids. It's not evidence-based, but be sure to send some good vibes across the ether.

Acro-batics

The clinical trials of new drugs and interventions are unwieldy beasts. They can span many years, multiple hospitals, and thousands of patients. The trials generate reams and reams of data, and drawing the proper conclusions requires painstaking statistical interpretation.

Each trial has the potential to be noteworthy, to change practice and save lives. But how do you encapsulate that promise, how can you keep the study on your colleagues' minds during the long slog before publication?

A catchy study title helps.

A little digression: I was commenting on Intueri's post about the lack of evidence-based guidelines in psychiatric interventions. I suggested such protocols often grow out of the acute care experience, but she pointed out many psychiatric sitations are indeed acute.

I was going to suggest a study, along the lines of some memorable clinical trial acronyms, like PIVOT and CASANOVA. I came up with CALM: the Clinical Acuity-Lessening Medication trial. Unfortunately, it's already taken: Candesartan and Lisinopril Microalbuminuria study.

Damn. And I soon learned just how many clinical trials have contrived acronym, browsing this extensive list. Sure, these massive studies can seem boring, and lead investigators -- like anyone -- need some amusement to spice things up. But I think some of these scientists were trying too hard:

AWESOME -- Angina With Extremely Serious Operative Mortality Evaluation

BATMAN -- BiodivYsio® BATiMastat SV stent versus balloon ANgioplasty

HeADDFIRST -- Hemicraniectomy And Durotomy for Deterioration From Infarction Relating Swelling Trial

IMPRESS -- Inhibition of MetalloProtease by BMS-186716 in a Randomized Exercise and Symptoms Study;

PROVE IT -- PRavastatin Or atorVastatin Evaluation and Infection Therapy;

SHOCK -- SHOuld we emergently revascularize occluded coronaries for Cardiogenic shocK

Seriously, how can people keep a straight face at cardiology conferences?

"Oh yeah, Bob, it's easy enrolling candidates for the AWESOME study."

"Great, John. But we're under a lot of pressure in the PROVE IT trial to, you know, prove it. Hey, over there -- who's that guy?"

"That's Batman."

As ridiculous as that sounds, you have to pity the clinicians participating in trials that just didn't try hard enough, namewise:

ACME -- Angioplasty Compared to MEdicine

CASH -- Cardiac Arrest Study, Hamburg

REVERSAL -- REVERSal of Atherosclerosis with Lipitor™

or look at the 7 (!) trials that lay claim to "SMART".

The best scenario comes when an acronyms strikes just the right balance, appearing both clever and fun, maybe spelling a word at least tangentially related to the study:

AT LAST -- Antiretroviral Trial Looking At Sex and Treatment

MAGIC -- MAGnesium In Coronary arteries

PEACE -- Prevention of Events with Angiotensin Converting Enzyme inhibitor

RHYTHM -- Resynchronization for Hemodynamic Treatment for Heart failure Management

SIESTA -- Snooze-Induced Excitation of Sympathetic Triggered Activity

Scroll through the list, find your favorite. It's comforting to see our best minds are studying LIFE and LIMB, MIRACLE and MIRAGE. The aforementioned CALM is balanced with EXCITE. You can also learn the difference between SYMPHONY and OPERA. As for more conventional names: ADAM, DAVID, MONICA, RUTH, and SONIA are all ALIVE, with VIGOR and GUSTO.

There are too many more to mention, though I was a little dismayed to find the really memorable ones were often sponsored by pharm companies. Though they're catchy, I have no idea if the studies are well-conducted, or tell us anything important. For this reason, I'd like to organize a study examining whether clinical trials with fancy acronyms have higher impact than serious studies denoted by plain collections of letters. We'll call it ABSURD -- Acronym Behavior overShadowing Useful Results and Data.

Talking Points

So, I've been mulling over CodeBlueBlog's coverage of Bill Clinton's decortication. Like with the Yuschenko / dioxin poisoning and other CSI: Medblogs cases before it, I'm slowly being won over to his line of thinking. What can I say? I'm still reluctant to question attending physicians, even when I have all the records of a case. Their experience and familiarity with particular patients dwarfs my own. I tend to give them the benefit of the doubt.

But it's even more difficult to second-guess media reports on medical cases. We never have all the facts of a case, or even a tenth of the details in a patient's chart. We're going on vague answers from press conferences, and photos shot from the crowd.

For those trying to piece together the truth, it's especially frustrating to dig for more data amongst the 1,277 nearly-identical stories on Google News. When you consider the basic questions that are consistently unasked, while reading the same parroted talking points over and over... it can either lull you into complacency or make you give up altogether.

CBB doesn't do either. He takes what the doctors have disclosed, throws in some observations, checks against the literature and his own experience, and draws up a list of possibilities as to what's really going on. Often, his differential includes malpractice, addictions, sexually transmitted diseases, and feeble attempts to cover them up.

CBB's motivation behind his CSI Medblogs posts is explained well on his site and in comments to this blog (more below). He'd invoke holding reporters accountable for viewer conclusions, raising the bar of journalism... Sometimes I think even more is at stake. The blogging activity around Clinton's surgery is not the best example -- I think the sad death of Red Sox fan Victoria Snelgrove is more appropriate. Her death by a police officer's pepperball gun has never been adequately explained, and has clear implications for the future of crowd control in America.

The family is entitled to privacy, but the public is entitled to safe demonstrations. We need to know what happened. And you'd learn a lot more relevant details from reading the CBB and blogborygmi discussion of this case than you'd learn in the 1000+ mainstream media reports that were filed.

But we don't have the access that these reporters do. And we've got, well, day jobs. The best we can do is try to steer the reporting in the appropriate direction. As CBB said in a prior comment, responding to my contention that medical blogs haven't produced a Rathergate:

These same reporters and editorialists will pontificate thousands of words on why the entire health care system should be overhauled YET THEY DON'T KNOW A VENTRICLE FROM A FEZ. They are INCAPABLE of reporting a story that follows a medical case in a way that makes sense so I AM ALMOST ALWAYS ABLE TO REMAKE THEIR REPORTING to come to ANOTHER conclusion!

See the issue?? If they say poison, I can say alcoholism. If they say pepperball I can say malpractice. But they can't do the same to me, because I'm reporting the same thing that they are (using their data) but putting it together in the proper order and sequence so that one is left NOT with answers but a DIFFERENTIAL DIAGNOSIS, from which we have to draw the MOST LIKELY diagnoses.

If I can win THIS point and THIS idea gets across, THAT will be my Rathergate.

I'm starting to think that, if this were to occur, it wouldn't be a Rathergate (a blogger-spurred correction in mainstream reporting) but instead, a sea change in medical journalism.

Let's say a reported read CBB's posts and cornered Clinton's doctors: "How could you have let him go five months with this easily anticipated post-CABG effusion? Or is this a new effusion unrelated to his bypass, but possibly related to his new gaunt appearance? Maybe it's cancer? AIDS lymphoma?"

The doctors would have to either admit they goofed in waiting (which would sink them), or admit they're hiding something (which would sink them, their patient, and generate a hundredfold increase in questions), or open up the chart and explain each decision, piece by piece (which could still leave the doctors and Clinton vulnerable to more questions, and would require responsible reporting to avoid headlines like, "Clinton docs were worried about AIDS!" -- and, I should add, this would require a responsible audience).

In short, I wonder if doctors, patients, reporters, or the general public are ready for this level of inquiry and access.

CodeBlueBlog argues (again, from an earlier comment):

I really don't think I am pushing a conspiracy at all. Just like with Teddy Bruschi (who is more likely to have had a stroke from snorting cocaine as anything else)the PATIENTS are HURT by incompetent reporting because it leaves open the types of deductions I have made in thewse cases.

Yushcheko an alcoholic?
Bruschi a cocaine freak?
Clinton with AIDS?

All these items are open without adequate, intelligent, comprehensive reporting.

My sense is, these issues would be more "open", "in play", "fair game" or whatever the parlance is, if they passed from the caregiver's lips. It might be better, from the high-profile patient and physician perspective, to ignore certain diagnostic evaluations, for fear of what the lay audience would conclude.

Trial lawyers and police PR have learned to manage the press in high-profile cases. Same with the NTSB after a plane crash. They control the amount and rate of information disclosure, they give some food for thought each day, they steer the conversation while they go about their investigations. CBB and I have more or less assumed that doctors were not playing this game -- that if someone were asking the right questions we'd have a story that made sense.

But maybe the docs are managing the press with the savvy of a PR agent. In the case of Clinton, they're not going to spend one second talking about the chance of HIV or malignancy, even if it's on their differential, even if they're testing for it. From their perspective, it's simply not worth bringing up other options at this point. Better to stay on message and not encourage more questions.

So is this a failure of good reporting? Or have the doctors and patients decided in advance just how much they're going to reveal to journalists? And would more aggressive, educated reporting actually give us more information in these high-profile cases, or would it turn the sources against the media and bloggers alike?

Double Down

Like Emergency Medicine personnel before them, MD / PhD students are now glaringly overrepresented in the medical blogosphere. I count six: Janel of Synthesis and Output was first, then myself, then Morning Retort, and now mudfud.blogspot.com ... Through her I've found two others. Also, doctorsquared.blogspot.com seems to be a mudphud student whose site is defunct.

When you consider how few medical student bloggers are online, the amount of MD/PhD students is substantial.

It was easy to explain the preponderance of EM blogging: patient encounters are easily translated to blog posts, the practioners tend to be extroverted, and the lifestyle of insomnia and downtime helps, too.

But why all these new MD/PhD students? I'd like to say that the same qualities that lead one to seek a physician-scientist training program also drive one to blog -- a good mix of analysis and articulation, and a familiarity with explaining things to disparate groups.

I wonder, though, if there's also a component of isolation -- that MD/PhDs never really fitting into their MD or PhD classes. Anyway, the blogs below are as diverse a group as you can find. Check 'em out and see what you think:

Synthesis and Output

Morning Retort

Mudfud

Two Terms Later

Mudphud Chickness

Memory Lapse

I was reading about this potentially groundbreaking research occuring under my nose, linking brain-secreted insulin deficits to Alzheimer's. I didn't even know the brain could make insulin.

Dr Suzanne de la Monte and colleagues now believe it is down to what they are calling type 3 diabetes.

By looking at rodents and post-mortem brain tissue from people with Alzheimer's disease they have found that insulin and its related proteins are actually produced in the brain, and that reduced levels of both are linked to Alzheimer's disease.

Credit the BBC for finding a good skeptic:

Professor Greg Cole, from the University of California Los Angeles' Alzheimer's Disease Research Center, said: "This is a new finding. It is interesting that the brain makes very low levels of insulin.

"But its significance is unclear. The levels are so low that they have not been detected with less sensitive methods. I don't think we can say they are high enough to matter.

"I suspect that the brain insulin itself is not very significant and neither is its deficit in Alzheimer's disease and, therefore, I wouldn't call it type 3 diabetes."

I wouldn't call it Type 3 diabetes either, but mostly because the name's already taken. So's Type 4 diabetes (aka Gestational Diabetes, occasionally called type 3).

De la Monte's ability to name diseases is positively insipid. This group doesn't even deserve the bronze! But I suppose they wouldn't have received as much attention if they hailed the possibility of Type 5 diabetes.

Cuddle up to Ebola

I've been steered towards a new line of plush infectious organisms. Giant Microbes is making stuffed playthings of rhinovirus, strep pneumo, influenza, and the gang. What can I say? The bugs are cute, and curious kids might want to know what's making their noses run and ears hurt.

Their "professional" series features HIV and Hepatitis C, because, I suppose, those aren't as amusing as necrotizing fasciitis (the "flesh-eating" bacteria comes with a sewn-in knife and fork).

You can test your diagnostic accumen by comparing the plushie to the light microscopy in the "Coming Soon" section.

I think this is a pretty neat product, especially since each critter comes with some educational information. This company walks a fine line, however, and maybe could ensure good will by donating some proceeds to an infectious disease foundation.

Cry Wolf Blitzer

I was just telling a friend that the medical blogosphere hasn't had it's first Rathergate or Trent Lott effect yet -- there's been no story where medical blogs broke news or dictated mainstream media coverage.

Then I read CodeBlueBlog's take on Clinton's thoracoscopy (two posts):

If Clinton's pleural problem is secondary to his bypass surgery then either they failed to do appropriate follow-up and MISSED it for six months (unlikely); or, they have been hiding his problem while they exhaust all nonsurgical treatment options; OR ... Bill Clinton's exudative pleural effusion is from something else.

CBB suggests the possibilities: malignancy, bacterial infections, and HIV, among others.

Sensational stuff, right? Well, CBB's case flows logically, and is a good primer on the pleura. But it's based on two premises: 1) Clinton's looking pretty old and 2) we're just hearing about this effusion now. To me, it seems very likely that noninvasive workup proceeded quietly for months, the effusion persisted, and now the surgeons are going in.

As for his appearance, who knows? Some people look a little frail when they've lost a good amount of weight in a hurry, and Clinton's changed his habits. Comparing today's photos from a decade ago (as CBB has done), or even a few years apart, is a recipe for errors -- even for a radiologist.

Look at Clinton's contemporary, Michael Douglas -- in pictures from ten years ago, and now. Throw in a surgery and some weight loss, and ask yourself, is this really a conspiracy?

Sometimes CBB can sound like one of Douglas's directors, Oliver Stone. But when and if we see a medical coverup (whether it's Ukranian poisonings or pepper-balled Red Sox fans), I expect Code Blue Blog will be the one to break it. And that will be a great day for journalism, especially in this age of Martha and Michael.

Until then, I'll keep waiting for Sanjay Gupta tp patiently explain Light's Criteria for pleural effusions to an eager television audience.

Gallows Humor

I've been reading about the cervical spine, specifically the first two vertebrae under the skull. The atlas and axis have a unique geometry compared to other vertebrae, facilitating the freedom of motion our heads enjoy.

Knowledge of these bony articulations has important clinical applications:

Most cervical vertebrae have articular facets that permit extension-flexion and rotational movements; the joint between the atlas and axis however is specialized and permits only rotational movement; in accurate hanging, a large knot is placed posterior to the joint between the atlas and the axis and the weight of the body forcibly flexes the joint, driving the dens into the medulla, resulting in instantaneous death; in inaccurate hanging, the knot is placed behind other cervical joints, resulting in flexion of the neck, prolonged agony and death by strangulation; amateurs should not attempt hanging people.

Fortunately (or sadly, depending on one's perspective), there aren't too many hanging experts anymore.

Note: the death caused by brainstem impaction involves a cruciate ligament tear but is distinct from the Hangman's fracture. Further morbid reading is available from Wikipedia, including reports of fracture and even decapitation from hanging when the "long-drop" is too long.

XXIV

The Hospice Guy is hosting this week's Grand Rounds. Go check out the latest and greatest posts from the medical blogosphere, and get a sampling of Hospice Guy's important job (and plain-spoken delivery).

Next week's host is Orac from Respectful Insolence. Izzy has archived the old Grand Rounds posts. If you're interesting in hosting Grand Rounds, drop me a line.

Powers that Be

I'm still thinking about that new new Hands On: ER game coming out next month. visiting the company's web site and found, lo and behold, you can actually play a mini-ER game online -- it's really dull, but the voice of Noah Wylie kept me going.

What I'm really interested in, however, are those medical super-powers. I think that could be the game feature that attracts thousands of frustrated health care professionals. What powers would you pick?

X-ray vision, or the ability to be in two places at once, are too over-the-top for this game. Photographic memory, already mentioned, seems just right: not too ostentatious, but genuinely useful. I'd put foreign language skills in this category, as well. What about speed-charting? Sway over the CAT-scanning queue? Acquiescent cardiology attendings for chest-pain admissions?

Troubled relationship

Over the weekend, Kevin posted about a new effort to reverse a trend, and encourage medical students to once again choose primary care.

Trainees and students often don't recognize the gratification of building relationships over many years, said Steven Weinberger, M.D., senior vice president for medical knowledge and education at the ACP. He said he hopes that by redesigning student and resident training, medical school faculty can demonstrate to students that primary care offers the potential for long-lasting relationships with patients."

As Kevin notes, the ACP is ignoring the bottom line. Students don't -- they know which fields promise long, stressful hours with dwindling reimbursement.

I'm at a school that historically sent a huge fraction of its class into primary care, but this year should produce record-breaking numbers of radiologists, orthopods, and emergency medicine specialists. I don't think this would've changed if we'd been tracking the same patients across many years.

Truthfully, across the medical blogs I survey, I can't recall many posts extolling the virtue of these long-term relationships. I think "continuity-of-care" can be tremendously rewarding in pediatrics, in OB-GYN, and a few other fields. But during my medicine rotation, most outpatients visits could be described as "managing the decline" -- brief encounters with diabetics, heart patients, and COPD'ers where prescriptions were renewed and lab values were relayed. The grinding nature of these diseases means the patients get sicker and sicker, and time crunch puts a premium on friendly chit-chat or answering questions.

A friend in residency at an esteemed hospital reported that, when the internal medicine program made outpatient continuity-of-care a priority, the number of residents going into primary care actually shrank. Instead, they chose to subspecialize in cardiology, GI, or any number of fields with more desirable lifestyles.

Primary Source

Dr. John D. Gartner has commented on my earlier post on hypomania in America. He brings an interesting perspective to this issue, since, well, he wrote the book I was talking about. He invites us to check out his book's website., where many of the points I and other commenters raised have already been addressed.

The book's introduction is excerpted online. It's accessible reading, starting with some memorable anecdotes that motivated him to write the book.

He goes on to discuss the prevalence of mania and hypomania, both in the general population and in families of entrepreneurs. He draws a nice correlation between the incidence of bipolar disorder in various countries, and their immigration rates. He acknowledges the difficulty of measuring hypomania in a population, but provides more statistical proxies than had occurred to me, including relocation and job-switching.

Another nice touch is when Gartner lets Alexis de Tocqueville make his point for him, quoting the Frenchman's impressions of early Americans. De Tocqueville, it turns out, might as well have been describing hypomanics -- you can compare his remarks to the DSM-IV definition, also covered on Gartner's introduction.

Fine points

I imagine it might be frustrating for an author to see people discussing points already covered in the book. So, thanks to Dr. Gartner for tactfully directing readers to his book's site.

I do still wonder if the American bipolar rates are in some way related to the U.S. psychiatry apparatus (Gartner points out, for instance, that manic-depression is less prevalent in Taiwan, but it's not clear to me if psychiatric hospitalizations are classified similarly there. This is guided by my (admittedly limited) experience in school with immigrant Asian families and psychiatric illness. Maybe that's something covered inside the chapters of his book.

Virtual Television

Via medgadget, a review of the new video game based on ER:

ER is at its core a social simulation game, possessing ingredients of titles like The Sims with traditional role-playing elements thrown in for good measure... In addition to fulfilling these game objectives, players must also keep tabs on relationships with their patients and fellow physicians, energize and nourish themselves by eating regularly (or at least grabbing a can of soda for a quick jolt of caffeine), washing up to maintain their hygiene and getting into the gym now and then to keep fit.

...In addition to the perks, ER also allows players to make use of special abilities, which are status boosts that can be stacked three at a time to improve performance. One might choose to use a Photographic Memory ability, which would allow them to gain a certain amount of experience points just from observing and being in the presence of other doctors as they handle their patients. The special abilities are swappable, so players can freely switch between whichever abilities are available to them and best suited to complete their current tasks.

Based on the review, the game seems more about character development than it is about medical simulations and correct diagnoses (which is featured heavily on Step III). So, from my perspective, it's hardly test prep, and the ER setting may be too familiar to enjoy spending free time in. But, in terms of escapist wish-fulfillment, it could be fun to play an all-knowing attending when mired in the depths of intership.

Letters in the Mail

Upon receiving another solicitation for a Master's or PhD, by mail, no doubt with credit for life experience, Cullen Murphy proposes the new science of exaltametrics. This measurement of a society's propensity to bestow titles (yeah, we're on an upswing) is further justified in the March issue of the Atlantic:

Does title inflation (or deflation) have any historical correlation with the more general decline (or advance) of civilization? One could cite some suggestive evidence... Our own Founding Fathers, seeking to establish a more perfect social order, rejected various baroque suggestions for the title of the nation's chief executive ("His Majesty the President" and "His Highness the President of the United States of America and Protector of the Rights of the Same") in favor of something more homespun.

...By the same token, epochs in which people betray a grasping appetite for status are often times of decadence and decline. Think of the ancien régime's array of ever more finely sliced noble distinctions, which the guillotine's blade brought to an end. Recall Edward Gibbon's description of the desiccated nobility in early-fifth-century Rome: "They contend with each other in the empty vanity of titles and surnames, and curiously select the most lofty and sonorous appellations … which may impress the ears of the vulgar with astonishment and respect." We know what happened next: the barbarians were at the gates (and they all wanted titles).

It would be going too far to assert any hard-and-fast correspondence between title inflation and social decay. But surely it's worth knowing whether the titles of our age are the equivalent of gold bullion or of Weimar banknotes.

Murphy is trying to account for the proliferation of Senior Vice Presidents and Endowed Chairs. But I'm also reminded of Kurt Vonnegut's Player Piano, a novel about a future where the automation had left the masses idle. All the people still working (designing bigger and better machines) had doctorates, though in ubiquity the term had become meaningless.

This occurred to me about this on rounds a few weeks back -- one of our patients was a retired physician. The nurses, who are only too happy to call me "Doctor", often addressed him as 'Mister.'

He didn't correct them, and that sat well with me. Maybe it's because Dr. Evil's remark ("I didn't spend six years in Evil Medical School to be called 'Mister'") has driven home to me the narcissism of insisting on the title. Or, more likely, titles seem best kept to the professional realm, amongst colleagues. In this case, the interaction was nurse/patient, not nurse/doctor, and the appellation was appropriate.

I wonder if this interaction-specific restraint would appease Murphy, who seems to bristle at title-holders' sense of... entitlement... outside their sphere of work. Keeping the ranks at the office, or in formal communications, is a suitable compromise as post-graduate education becomes more common, even as the topics of study become narrower.

Driven

There was a neat article in the Boston Sunday Globe about American Hypomania. Yeah, it sounds like the latest craze, but a new book suggests it may have been going on for centuries:

In his new book "The Hypomanic Edge: The Link Between (A Little) Craziness And (A Lot of) Success In America" (Simon & Schuster), John Gartner contends not only that most of today's successful entrepreneurs and businesspeople are hypomanic, but that many of our history's leading figures, such as Alexander Hamilton, Andrew Carnegie, and Henry Ford, had the condition as well. The United States has more hypomanics than other countries, Gartner claims, and these people are largely responsible for the nation's power and prosperity.

I remember learning about hypomania in the context of bipolar disease (manic-depression) in med school. Many of my classmates suspected they were hypomanic, or would need to be in order to graduate. Indeed, when you read the DSM-IV criteria for a hypomanic episode, it doesn't sound half bad:

A distinct period of persistently elevated, expansive or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood...

...inflated self-esteem or grandiosity, decreased need for sleep (e.g., feels rested after only 3 hours of sleep)... flight of ideas or subjective experience that thoughts are racing...increase in goal-directed activity (at work, at school, or sexually)...

...The mood disturbance not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.

Sounds great, right? Well, I'm leaving out the undesirable features -- distractability, irresponsible spending sprees, pressured speech -- and condensing the APA legalese. It's worth noting that, according to DSM, hypomania differs from full-blown mania only in that it can last just four days (mania requires a week) and that it doesn't markedly impair functioning. That's it. Follow the link above to see the rest, and learn how hypomanic episodes are a component of bipolar disorders.

It's sufficient to say that preclinical med students aren't the only people a little enamored with this disease. Even psychiatrists with a lot more experience treating bipolars think there's something attractive about hypomania. It's a small step from that, to assigning hypomania a role in making this nation great. But Dr. Kay Jamison, who herself is bipolar and has some fond memories of it, sounds aword of caution:

"Certainly there have been studies, long before his book, suggesting that there is a disproportionate rate of bipolar illness in immigrant populations, which is not surprising, really, when you think about the energy and the optimism and impulsiveness that drives people to immigrate," she said in a recent telephone interview. "Now, does that mean that most Americans are hypomanic? No, that means - at least from my point of view - that a very real minority may be hypomanic, though perhaps a very important minority."

Gertner apparently acknowledged that his book has no reasonable proof, just a provocative correlation. He elaborates:

"What I'm doing is putting certain things together, drawing an inference," he says. "I'm saying: 'Look, isn't it interesting that the countries that have been havens for immigrants also have the highest rates of bipolar disorder? And isn't it interesting that those are the countries that have the highest rates of new company creation?' Yes, it could be coincidental - but in science, we say that the simplest explanation is usually the right one."

It seems far simpler, to me, to say the following: the American system, with its lack of tradition, its relatively trustworthy institutions, and its extensive natural resources, encouraged the citizenry to take risks. Many did, leading to an unparalleled prosperity. Their wealthy decendants are now able to obtain psychiatric diagnoses that their counterparts in the Old Country cannot, and thus Americans lead the world in a number of disorders, including bipolar.

Jamison thinks that immigrants tended to have bipolar traits, compared to those left behind. But really, why not obsessive-compulsive traits? After all, one would need to be meticulous about planning to leave home, and those traits would serve one well in American business. And I wouldn't be surprised if Americans lead the world in OCD diagnoses, too. But no one's yet ascribed our economic state to that disease -- perhaps it's not as glamorous.

Anyway, any attempt to prove this hypomania hypothesis will be tough. It's easy enough to measure spending habits, and bankruptcies, but hard to attribute that to hypomania when there are so many external forces involved. Same with hours slept (Americans do work more and sleep less than others), and frequency of sex (Durex says we're #1). But again, is U.S. culture reinforcing these behaviors, or hypomanic behavior creating the culture?

They'd have an easier time explaining our high oil consumption with the obsessive-compulsive fear of public transportation. Much easier to study. I really think someone should look into this. I would, but I have too many other ideas to follow up on right now...

Movable Feast

This week's Grand Rounds -- the best recent posts from the medical blogosphere -- is being hosted by Maria from Intueri.org. She's taken hosting to a new level. I recommend the Tumor with Three Spices.

Maria's been blogging for years now, and her archives make for engrossing reading about her journey from student to physician. Another fascinating perspective on health care comes from next week's host, Hospice Guy.

Check 'em out, and get your medical posts submitted to hospice_guy at yahoo dot com by Monday afternoon. If you're interesting in hosting Grand Rounds, drop me a line.

Black Cloud

My internal medicine sub-internship is over, and, like the first sunny days after a long winter, I feel a buoyancy and optimism I've been missing.

Don't get me wrong -- I've enjoyed all my rotations, and even this sub-I had its merits. The residents and attendings at my hospital were very supportive, and effective teachers. The patients have been largely friendly and appreciative. And, when it comes down to it, I'm still a blessed student, and though my responsibilities are growing, my stress level is benign compared to the interns.

But this past month was the closest I've come to refusing to get out of bed in the morning. There's an inescapable dread factor in medical ward months -- the Short Call and Long Call days where you're admitting new patients. The pressure comes from wanting to keep your patient list short going into call. And it's always a day away.

Some residents are described as "white cloud" or "black cloud" depending on whether they bring good luck and short patient lists, or bad luck and endless complicated admissions. I think it's either a polite way of pointing out who's efficient, or a silly superstition. Because the truth is, during medicine ward months, everyone has a black cloud over their heads -- pressuring us to discharge, discharge, discharge.

I remember pitying my fellow sub-intern, who was on Long Call on Superbowl Sunday. He ended up enjoying the game in the lounge, as the admitting team got just one new patient that day (I'd be curious to see what admissions were like in Philadelphia). As a consequence, his workload was light all week. As for our team, we were on call the next day, and we capped (and most came in within four maddeningly stressful hours at the end of the day). What's worse, we had to frantically work to unload these patients all week before short call (where we also capped) and the next long call (also capped).

When your list is long, there's no joy in anything. The patients always have too many questions, the learning opportunities always seem to be a distraction.

The days began with rounds, which are the most awkward and unnatural of human interactions. Then you've got a crucial period to get notes written, labs ordered, and consults arranged. If a discharge is being planned, you've got to get the ball rolling early in the day. But most days of the week, our work is interrupted with teaching attending lectures, morning conference, noon conference, and Grand Rounds (I much prefer the web-only version).

There's nothing more frustrating than being forced to watch a presentation on a rare, rare case of sarcoid cardiomyopathy when you're trying to manage the paperwork for your patients with common, common COPD exacerbation.

I found myself saying, often, "Thank goodness I'm going into Emergency Medicine." In EM, the didactic sessions actually seem to matter -- you learn stuff you'll actually use (in Medicine, the take-home message of these rare case presentations always seems to be, "consultants order more tests than you can possibly remember.")

One of the big drawbacks to EM, they say, is the lack of continuity. Well, this much-touted "continuity of care" seems overrated and overestimated. I've had attendings tell me "I've known this patient for years, I'd discount her anginal symptoms" and then blanche as the patient gets quintiple-stented. Meanwhile, with the weekly personnel changes of residents, students, or consultants, and the elusive weekend coverage, there's not a lot of continuity to begin with.

What got me down the most about this month was this: seeing the same patients on rounds every day rarely engenders positive feelings. Usually it was guilt or frustration or, at worst, suspicion. Guilt for not curing the patients immediately. Frustration because the consultants disagree or the biopsy results aren't back or the nursing home is refusing the patient. And suspicion, when the patient looks improved enough to go home but won't.

All that continuity seemed to generate resentment (both ways) and erode the patient-healer bond, not strengthen it. I contrast that to my experience in the ED, where in brief encounters I was able to connect with all but the most abusive patients, and often help relieve all but the sickest.

People talk about burnout in Emergency, and the time-honored ways of the medical wards. But I have a different idea about which field suits me, and which could drive me mad. Thank goodness I'm going into Emergency.