I can see clearly now

If you want to simulate the development of visual cognition in newborns, take a course in ultrasonography. I remember when I was a med student, and a resident showed me my first blurry, shaky FAST images (focused assessment of sonography for trauma).

Resident: See that? That's Morrison's pouch, showing no free fluid between the kidney and liver.

Me: I think that's just static, and you're playing a trick on me. Can we adjust the image?

Resident: No, actually, see, this echogenic area is the renal pelvis...

Me: Really, just stop, you're not fooling anyone.

A few years later, and here I am, identifying venous thrombi and peri-pancreatic stranding, the common bile duct and the superior mesenteric artery. It's unbelievable what you can see in that static-y window. I especially like how, the better I get with ultrasound, the more it seems to help (compare that with sub-subspecialties like toxicology, where the effort of accumulating greater expertise finds diminishing returns for patient aid...)

Other observations:

In my surveys, whenever I apply the ultrasound probe over the male bladder, the men always crack a smile and ask me if they're pregnant. It never gets old. (The women, they don't ask out loud).

There is a striking correlation with EM ultrasound expertise and a past life as a disc jockey. In fact, it turns out I used to listen to one of my U/S mentors, on the radio. Different frequencies now, but same catchy appeal.

The Secret of Acronyms

I've received some great feedback from my post the other day, on acronyms in medical research.

I soured on the whole field of "research on research" when I learned articles like Stanbrook's weren't just bar-room talk that led to an afternoon browsing pubmed, but rather, institutionalized bodies of research with conferences, grants, endowed chairs, etc.

Don't get me wrong, I love cocktail-party research like this (where would Blogborygmi be, without it?) Papers like Stanbrook's make us think, and keep us mindful of influences. Even if that's all it can accomplish, well, it's something.

But look at some of the output of one of the ART in Medicine authors, Dr. Donald A. Redelmeier. Over the years, he's produced such gems as "Oscar winners live longer than other actors" and "Why cars in the other lane really do go faster."

If you're going to get funding for producing a series of provocative but disconnected pop-science pieces, that are fun to talk about but hard to act on, you ought to eliminate the middle man and work directly for NPR.

But I don't mean to single out Dr. Redelmeier, who in addition to his occasional cocktail diversions, has a distinguished career as an investigator. In fact, he was one of the authors on an influential CHAMPS study (not the same Avonex / MS study a commenter mentioned, but hey, even six-letter acronyms need to be reused).

Is Redelmeier cynically manipulating doctors with his catchy titles? Or is he just one of those "exemplary investigators" who "generate both clever acronyms and important research" ? I'm inclined to say the latter, but I wish he had fully disclosed his ties to the acronym industry. Maybe he missed those talks on conflict-of-interest at the last conference.

Operation SMARM

It's always nice when a topic can be both funny and worthy of serious thought. Such is the case with the use of acronyms in medical research.

Inspired by an exhaustive list of medical trial acronyms, last year I wrote wrote a post that still makes me smile (the part where my mind's eye conjures Batman at a medical conference). Here's an excerpt:
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.

Well, last week, the NEJM (um, the New England Journal of Medicine) published such research -- Acronym-named Randomized Trials in Medicine - The ART in Medicine Study (I like my proposed title better). An excerpt is reprinted below:

As compared with studies without acronym names, acronym-named studies had higher Jadad methodologic quality scores, enrolled five times as many patients, had follow-up periods half as long, but were not more likely to report positive results. Acronym-named studies were four times as likely to be funded by the pharmaceutical industry and eight times as likely to be authored by an industry employee.

Acronym-named randomized trials were cited at twice the rate of trials that were not named with acronyms (13.8 vs. 5.7 citations per year)...

Although other explanations are possible (for example, exemplary investigators may generate both clever acronyms and important research), these results support the hypothesis that naming randomized trials with an acronym may enhance the citation rate. ...

Enhanced attention to and recall of studies through the use of acronyms may facilitate the appropriate translation of research findings into clinical practice. If acronyms exert influence independently of normative markers of clinical credibility, however, such influence is not rational scientifically, even if it is understandable psychologically. Consequently, this subtle linguistic tool could undermine evidence-based practice. The observed close association between acronym use and sponsorship by the pharmaceutical industry amplifies this concern.

Stanbrook et al deserve credit for sifting through the literature, quantifying 173 studies and drawing some important conclusions about article quality and citation rate.

But these authors's work is part of a burgeoning field of research ON research, a meta-analysis, if you will, on how science is conducted and disseminated. There are now whole conferences studying peer review, bias, and the impact of "impact factor" (Stanbrook originally presented this research at one such event).

Thus, we can expect more research into this topic. Is it easier to apply an acronym scoring system like APACHE, or an eponymous one, like Ranson's criteria? Do patients fare better when they're told they suffer from POEMS, or the Crow-Fukase syndrome of polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes?

I wish to contribute to such research, but right now all I can offer is another title: the Study of Medical Acronyms in Reinforcing Memory. It may be unfairly catchy, but I think its very acknowledges something overlooked: the attractiveness of meta-research may well be disproportionately higher than its actual usefulness. There are more important to study, debate, and get sanctimonious about.

"Everybody falls, the first time"

It's the intern's first day. We're walking down the hallway from the ED, so I can show him the lounge.

"Are you ready? You know, the computer system here is pretty complex," I said.

"Yeah, they gave a lecture on it, but it was pretty confusing," he replied

"The system can do absolutely everything -- charting, orders, prescriptions, admissions, discharges... but's got so many features, it takes a while to master. At first you'll be like Neo looking confused at the green streaming letters in the Matrix, but eventually you'll transcend it.. and just start moving faster than you thought possible."

"But wait," the intern interjected. "Didn't Neo have to die before he could do all that?"

I stopped walking, turned, and faced my young charge. "We all had to... It's very painful."

We continued walking down the hallway, in silence.

An Inappropriate Truth

This month's Annals of Emergency Medicine has a series of articles on ED usage, plus an editorial entitled, "Frequent ED Visitors: The End of Inappropriateness." Given the tenor of posts from seasoned ED bloggers, I expected this editorial would be about denial-of-care protocols, full of anecdotes about abusive patient freeloaders.

But in fact, this editorial is based on evidence. The one anecdote included is a doozy, about a father who took his infant to the ED, got a diagnosis of OM, but his insurance denied payment due to the "inappropriateness" of the visit. The father, of course, was the board-certified EM physician who wrote the editorial.

He goes on to delineate the separate but related complaints of overcrowding, frequent flyers, and inappropriate ED use, which he defines as follows:

Generally defined as an ED visit by someone with a nonurgent or less-urgent condition treated more efficiently and cheaply in an office or clinic setting. In its more malignant form, inappropriate ED use has been characterized as visits by people of lower socioeconomic status who are "gaming" the system by claiming benefits and services to which they are not entitled...

...In this issue of Annals, 2 articles provide compelling evidence that the "inappropriate" ED visit is nothing of the kind.

Dr. Bernstein concludes his piece:

The notion of the "inappropriate" ED user is largely apocryphal. Fuda and Immekus and Hunt et al convincingly demonstrate that frequent ED users are sicker, with considerable mental illness and substance use, than infrequent or nonusers. Frequent ED users come to the hospital because they need care. Infrequent users may avoid the ED with expanded access to primary care, but this is not at all clear. Constructive policy change will not result from a blame-the-victim analysis.

Perhaps a wiser health policy goal would be to focus on the delivery of high-quality, convenient, accessible care to all patients in all clinical settings, ambulatory, emergency, and inpatient. Intensive case management of frequent ED users and expanded off-hours access to facilities delivering primary care, especially mental health and substance use treatment, may decrease the frequency of ED recidivism, but additional work is needed to test the efficacy of these interventions. In health care's current political climate, which emphasizes cost containment and personal responsibility, it is difficult to see this happening. But for now, let us put to rest future conversations about "inappropriate" ED use.

Sadly, I don't think Dr. Bernstein's recommendations will be heeded in ED conference rooms and EM blogs. I, too, have been guilty of letting the stress get to me, generalizing from one encounter to an entire waiting room. But I've also made a conscious effort to adopt well-conducted new research into my practice, and these findings should be no different.