the boys upstairs want to see

Both iPhone and Gmail were late entrants into established, crowded fields that nonetheless managed to change the way many people worked and organized information. The software was intuitive, clever, fast, and surprisingly frustration-free. I held out for a while at first, but when I finally adopted these new systems, I became evangelical in my support.

And for a while, things worked great. Tasks were accomplished so quickly and simply, there was a special satisfaction in using the software.

Then I got greedy and mucked it up.

This past spring, after owning my iPhone about a month, I decided the device wasn't achieving its full potential -- so I jailbroke it. At first I marveled at the third-party software (this was before the App Store) and the possibilities of customization. Moving backgrounds! Five icons in the dock! Tweaking elements of the title bar!

For Gmail, similar customizations were possible. Again, my justification for these hacks was improved functionality, such as the Remember the Milk sidebar integration. But after installing Better Gmail, I found the feature I customized the most were the skins. And then came Gmail Redesigned: a darker, gradient-crazy skin that transformed the airy, efficient Gmail into something seeming closer to SkyNet.

The novelty of these hacks lasted a while, but masked an inconvenient truth: they were buggy and slow. The rare freeze on my iPhone became more frequent, and switching between apps, which once took a moment, now took ten seconds or more (which may not sound like much, but is agonizing when you're trying to check the calendar from the phone, or look up a drug's pregnancy class in front of your attending).

And Gmail, with the Redesigned skin, began to lag, hang, and underperform. Not so much or so notably that I'd want to uninstall the changes, but enough that using the software was no longer a delight.

This week, though, Apple released firmware 2.2 for iPhone and Google upgraded Gmail with templates.

Firmware 2.2 is not such a milestone but it came at the right time for me -- there's enough useful apps in the iTunes store and the customizations that come with jailbreaking no longer mean so much. Upgrading from a jailbroken 2.1 was a breeze, and this week my iPhone's been so fast I no longer miss having five icons in a dock (plus, as a bonus, my title bar customization somehow survived the upgrade).

And the new Gmail templates are fun -- something for everyone, and all support a much zippier interface than Gmail Redesigned. RTM manages the transition in style, as well.

It impresses me how quickly and smoothly these companies have adapted. Or more precisely, that two giant firms have been taking notes from their most fervent users in order to keep their groundbreaking products fresh, for free. Their behavior stands in contrast to the common business practice and I can only hope other companies are watching Google and Apple as closely as they're paying attention to us. 

Thoughts arrive like butterflies

There's an irony here, because I found the following critique of Twitter while searching for a blogger-to-twitter solution. But I think the author is essentially right, based on his (and my) understanding of Flow. Excerpt below:

Worst of all, this onslaught is keeping us from doing the one thing that makes most of us the happiest... being in flow. Flow requires a depth of thinking and a focus of attention that all that context-switching prevents. Flow requires a challenging use of our knowledge and skills, and that's quite different from mindless tasks we can multitask (eating and watching tv, etc.) Flow means we need a certain amount of time to load our knowledge and skills into our brain RAM. And the more big or small interruptions we have, the less likely we are to ever get there.

And not only are we stopping ourselves from ever getting in flow, we're stopping ourselves from ever getting really good at something. From becoming experts. The brain scientists now tell us that becoming an expert is not a matter of being a prodigy, it's a matter of being able to focus.

This nearly two-year old critique hasn't really put a damper on Twitter's increasing popularity. Maybe there's some new data I'm not aware of, to show Twitter makes people more productive or creative.

I check Twitter updates almost exclusively via Twinkle, an iPhone Twitter client that's got a neat 'nearby tweet' feature. I really only am moved to use it when I'm in line for something, or stuck on a train. For all the talk of twitter in academia and medicine, I don't think the advantages would outweigh the frequent disruptions if I checked Twitter from my desktop.

Half a page of scribbled lines

Two full calendar months without a blog post? Yikes!

I don't want to end up on GruntDoc's Dead Blog list (even though it is Halloween) so let me just quickly link to my recent activity on Twitter.

While I'm not sure how often I'll use Twitter, it seemed helpful in communicating some of my impressions of this week's ACEP conference in Chicago.

And look! My twits will now appear on blogborygmi's sidebar, somewhere between RSS highlight and photo highlights.

Little souvenirs

One of the nicest perks of being an established-and-at-one-point-somewhat-prolific medical blogger is that really talented people send me really good books.

Two I'd like to highlight for you now are below.

Dr. Jay Baruch's Fourteen Stories: Doctors, Patients and Other Strangers. This award-winning collection of short stories from an ED physician had me pretty engrossed. Dr. Baruch does a good job of motivating his characters, and often the motivation is fear -- not just the sick patient but the student with an HIV needlestick, the doctor walking home late at night who encounters a dissatisfied patient. The dialogue is minimal, and often at odds with the situation -- but he's written these characters in such a way that it's easy to crawl into their thoughts and insecurities.

In his afterward, Dr. Baruch gives his take on the difference between getting to the truth of a medical presentation, and the truth of a short story. It's an informed and insightful essay -- required reading for aspiring physician-writers.

The other book I received recently is Laurie Edwards' Life Disrupted. I first read this author in the pages of the Boston Globe Magazine, then learned of her blog and finally, got to interview her for Medscape's Pre-Rounds.

Unlike Dr. Baruch's book above, Life Disrupted is decidedly nonfiction -- the subtitle is "Getting Real about Chronic Illness in your Twenties and Thirties." Medical blog readers will recognize many of the book's subjects, like Jenny Prokopy ( and Kerri Morrone ( Even some of the insleeve reviewers are longtime bloggers (Amy Tenderich, Paul Levy).

I'll confess, these familiar names actually helped me approach this book, which is an expert guide on empowering patients to get more out of life, and more out of the medical world. Why should I even be reluctant to read it? Because (though this has never been true of Edwards' earlier works) I've seen too many patient-empowerment books that read like self-help bromides or screeds against modern healthcare.

Not surprisingly, my reluctance was completely unfounded. Edwards is too smart, and has been through too much, to simply encourage her readers to distrust all medical professionals (although some of her readers and subjects have earned the right). Instead, she treats the physicians and nurses much like she considers her fellow patients: motivated, knowledgeable, but sometimes inflexible and afraid to adapt.

Her candid and conciliatory writing style quickly won me over. Her book is full of specific advice regarding relationships, socializing, career, and yes, navigating hospital stays and the healthcare system. I found it extremely practical and accessible, and learned a lot more than I had expected to. So, I heartily recommend it.

From the threshhold, what's to see

I love playing with Microsoft's new Photosynth but I'm still curious if it can handle this. Or this.

Grand Rounds: Change of the Guard

This week, GruntDoc hosted the 200th edition of Grand Rounds.

When this series started, the word "blogger" was just entering the public consciousness. The value of healthcare blogs -- to entertain, inform, and improve understanding -- this was clear to us, but we weren't really sure if anyone outside our group would ever notice.

Two hundred weeks later, every major media site has a blog on medicine and health, the industry is paying to access what physicians write online, and the transparency of blogging is transforming healthcare from the ground up (or, in some cases, from the top down).

Healthcare bloggers now have access to figures like the Surgeon General or AMA president. Healthcare bloggers write op-eds for major papers, appear on TV, and publish books.

Grand Rounds, I think, has had a role in this. This carnival has served as a weekly focal point, highlighting the most compelling voices and insightful ideas in this vibrant community. Grand Rounds made the world of healthcare blogging accessible and appealing to outsiders, and offered veteran bloggers and newbies a chance to touch base and rub elbows.

As the healthcare blogging landscape has changed, though, new challenges and opportunities have presented themselves. I've been unable to properly address these issues, however, since being named a chief resident at my program a few months ago. While the experience has been exhilarating so far, the task of organizing my department's Grand Rounds has left little time for planning Grand Rounds online.

But we're fortunate that our weekly roundup of medical blogging has attracted a number of dedicated benefactors. Beyond the hosts whose creativity and effort make each week so memorable and enjoyable, a few people have distinguished themselves with their belief in the concept and potential of Grand Rounds.

One such person is Colin Son, a medical student, longtime blogger, and previous host of Grand Rounds. He'll be taking over the Pre-Rounds series for Medscape and scheduling new Grand Rounds hosts. Working with him will be none other than Dr. Val Jones, the extraordinary blogger behind The Voice of Reason at Revolution Health.

They have the energy and enthusiasm to not only maintain this series but take Grand Rounds to new heights -- opening up the medical blogging world to new readers and venues. Please join me in welcoming them, and wishing them well. With your support and Colin and Val's stewardship, the quality and success of Grand Rounds will be insured -- for the next two hundred editions, and beyond.

Playin' with your food like it's some kind of game

Longtime readers (and really, that's the only audience, at this point) are well aware of my fascination with competitive eating. Beyond the awful, mesmerizing spectacle, there's the physiological aspect -- how can some people shovel so much into their gut, so fast?

At one point, I was actually thinking of making this into a research project. I spoke with a few contestants, and like to think my frequent phone calls to IFOCE chair George Shea in 2006 led to him bill that year's Nathan's Hot Dog Contest as, "The Mount Sinai of Mastication" -- but then again, he also dubbed it the Madison Square Garden of Gorging, and finally, the battleground where God and Lucifer fight for men's souls (such gifted hyperbole cannot be ascribed to any single influence).

But I digress. Since first blogging about the topic in 2004, offering some speculation on how elite eaters succeed in 2005, and calling for more research two years ago, well, I neglected to keep up with this topic. Even as a new champion was crowned, I overlooked this important addition to the body of evidence:

Competitive Speed Eating: Truth and Consequences
Marc S. Levine, Geoffrey Spencer, Abass Alavi and David C. Metz

OBJECTIVE. The purpose of our investigation was to assess the stomachs of a world-class speed-eating champion and of a control subject during a speed-eating test in our gastrointestinal fluoroscopy suite to determine how competitive speed eaters are able to eat so much so fast.

CONCLUSION. Our observations suggest that successful speed eaters expand the stomach to form an enormous flaccid sac capable of accommodating huge amounts of food. We speculate that professional speed eaters eventually may develop morbid obesity, profound gastroparesis, intractable nausea and vomiting, and even the need for a gastrectomy. Despite its growing popularity, competitive speed eating is a potentially self-destructive form of behavior.

Not Totally Rad's got a nice discussion of the paper, as well as some personal perspective:

After a few preliminary tests, these two subjects were asked to eat as many hot dogs as they could. The big burly dude ate 7 before feeling uncomfortably full. The champion eater then proceeded to down 2 dogs at a time for the next 10 minutes. After he ate 36 hotdogs, the investigators terminated the experiment.

Despite the speed eater’s insistence that he felt no sensation of satiety, fullness, bloating, or abdominal discomfort, we became concerned that further dilation of his already enormous stomach could be associated with a small theoretic risk of gastric perforation. Therefore, a decision was made to terminate the speed-eating test over the objections of our participant.

While all of this was going on, the radiologists asked the eaters to also ingest a barium sulfate solution so they could watch the stomach under fluoroscopy. The control dude's stomach showed a large mass of partially chewed hotdog bits, but only minimal gastric dilatation. The eating champion looked a bit different:

His stomach now appeared as a massively distended, food-filled sac occupying most of the upper abdomen, with little or no gastric peristalsis and emptying of a small amount of barium into the duodenum.

It's hard to generalize these findings to all eaters everywhere when one only has 2 subjects in one's experiment. However, the investigators concluded:

Our observations suggest that successful speed eaters expand the stomach to form an enormous flaccid sac capable of accommodating huge amounts of food.

Having seen the competitors up close, I still think there's something more at work, at least when you compare Takeru Kobayashi and Joey Chestnut to second-tier hot dog eaters like Tim Janus and Cookie Jarvis. Everyone seems to eat 3-5 or so hot dogs per minute in the first minute or two, but while the others visibly slow down, Chestnut and Kobayashi can keep up the pace throughout the 12-minute race. I think this happens too soon to be mediated by gastric dilatation. Rather, what separates the new champs from lesser eaters is an ability to relax and really open the gullet. I found an old WaPo article that discusses this:

Stanford's Triadafilopoulos has another theory. When the muscles that line the esophagus initiate swallowing, they alternately relax and contract in a rippling pattern that pushes food downward. It typically takes 9 to 15 seconds for a swallow to convey food to the stomach, he said. This makes the esophagus the real bottleneck in competitive speed eating, with a mouth full of food waiting for traffic to clear in the tunnel.

Some people can relax all those muscles at once, momentarily turning the esophagus into a hollow pipe. "That's how people in circuses can swallow swords," Triadafilopoulos said. Some eaters may do the same thing, and literally pour food down the hatch.

"These people have somehow developed the ability, probably through some kind of training, to relax everything at the same time," he conjectured.

Metz doesn't buy that idea...

Metz, it should be noted, is one of the study authors cited above. I'd like his next fluoroscopy study to include a look at swallowing, and compare hot dog champions who can eat 50+ dogs in 12 minutes to those that top off around 30.

And my original questions to George Shea remain unanswered: What is the IFOCE's stand on performance enhancing substances (like glucagon, or even just topical anesthetics). What if a gastric bypass patient wanted to compete -- would that be fair? If Shea is looking to legitimize and mainstream this activity, he may have to answer these questions. But my hunch, as years go by and disturbing evidence begins to accumulate, is that IFOCE will remain the stuff of traveling sideshows.

So that's today's memory lane

The Scene: An ICU, on an early July morning. A well-dressed man is standing at the nurses' station, scribbling notes. Our main character walks in.

Me: Hey, where's the post-call intern?
Intern: That would be me. Would you like me to tell you about the overnight admissions?
Me: Sure, sure... Say, if you're post-call, why are you wearing a shirt and tie?
Intern (defensive): I... I wore scrubs overnight. I just changed back.
Me (with genuine admiration): Wow. Good luck with that.

The scene: A Welcome Fete. The new interns are meeting the residents.

The mature, confident resident (to a group): Hi, I'm Nick.
Intern A: Hey! I read about you. You're that blog guy.
Me: Oh, ha. Um, yes. But, you know, that's just kind of a computer thing I do... on the side.
Intern B: Hey, I remember you from interview season. But the website you were talking about, it had something to do with free drinks.
Me: Hmmm...
Interns A, to Intern B: I love this town.

Cover me

After more than a few years of schooling and training, the day is approaching when my erudition and skills may be of some value. So, I recently applied for a disability insurance policy.

These insurers, they ask a lot of questions. When they got to the part about traffic citations over the past five years, I had to stop and think. It's been three years since I've even owned a car (but what a car it was). And I know I had a speeding ticket at some point in the early part of this decade. But was it 2002 or 2003?

I was reminded of Michael Moore's documentary, SiCKO, where a health insurance company denied coverage to a young cancer patient because she had forgotten to disclose an old, easily treated yeast infection. They called it a pre-existing condition.

And suddenly, it's became very important that I dig up old car documents from another state, even though I don't drive. God forbid I'm denied coverage at some point because of a misrepresentation in my original application (after talking to enough insurance agents, "God forbid" is a phrase that has worked its way into heavy rotation).

Does anyone know if I'm being paranoid about pinning down the date of an old speeding ticket?

Another question: I've often wondered why health insurance companies don't push harder for DNR status on elderly, moribund patients with dense dementia. Find and talk to the next of kin, work with the guardian, adjust expectations and prepare everyone for the inevitable.

Yeah, it's unseemly, but so much of what they do is already unseemly. And having seen too many of these unfortunate resuscitations, it seems that getting more aggressive about DNR status is more humane than trying to cheat otherwise healthy, active people out of coverage for out-of-the-blue health problems.

One that won't make me nervous

I used to read Andrew Sullivan's blog a lot in grad school. He's bounced around several times over the years -- both on the web and on major issues -- but I rediscovered him this primary season. I was drawn to his optimism and enthusiasm, even as some of his opinions are difficult to defend.

Anyway, he was recently musing about the latest ketamine-for-depression research, and wondering if this notorious drug could someday have a clinical use.

I wrote in to tell him I use it (clinically) quite often -- not for depression but for procedural sedation.

To my surprise, he printed the letter. And now I wish I had included more from my informed consent spiel, mentioned the sialorrhea, and maybe talked about that one time I pushed it too fast...

Far-Flung Correspondence

As I was always fond of his writing in high school English class, I was happy to see H. L. Mencken's name come up in this NYTimes piece on handling a large volume of correspondence:

We all can learn from H. L. Mencken (1880-1956), the journalist and essayist, who was another member of the Hundred Thousand Letters Club, yet unlike Edison, corresponded without an amanuensis. His letters were exceptional not only in quantity, but in quality: witty gems that the recipients treasured.

Marion Elizabeth Rodgers, the author of "Mencken: The American Iconoclast” (Oxford, 2005), shared with me (via e-mail) details of her subject’s letter-writing habits. In his correspondence, Mencken adhered to the most basic of social principles: reciprocity. If someone wrote to him, he believed writing back was, in his words, "only decent politeness." He reasoned that if it were he who had initiated correspondence, he would expect the same courtesy. "If I write to a man on any proper business and he fails to answer me at once, I set him down as a boor and an ass."

Whether the post brought 10 or 80 letters, Mencken read and answered them all the same day. He said, "My mail is so large that if I let it accumulate for even a few days, it would swamp me."

Yet at the same time that Mencken teaches us the importance of avoiding overnight e-mail indebtedness, he also reminds us of the need to shield ourselves from incessant distractions during the day when individual messages arrive. The postal service used to pick up and deliver mail twice a day, which was frequent enough to permit Mencken to arrange to meet a friend on the same day that he extended the invitation. Yet it was not so frequent as to interrupt his work.

Today’s advice from time-management specialists, to keep our e-mail software off, except for twice-a-day checks, replicates the cadence of twice-a-day postal deliveries in Mencken's time.

Ms. Rodgers said that Mencken was acutely disturbed by interruptions that broke his concentration. The sound of a ringing telephone was associated in his mind, he once wrote, with "wishing heartily that Alexander Graham Bell had been run over by an ice wagon at the age of 4."

Mencken’s 100,000 letters serve as inspiration: we can handle more e-mail than we think we can, but should do so by attending to it only infrequently, at times of our own choosing.

Sage advice. And -- you know you're in trouble when Mencken thinks you're an ass. But, truthfully, the Times writer is focused on the volume of correspondence -- 100,000 letters -- but I don't think Mencken's or Edison's volume of correspondence is what's truly noteworthy.

Even if you only count emails of more than two sentences, you only need five or six emails a day, every day, to hit 2000 a year. I think I'm at about that level, and I don't even work in an office (though the vast majority of these emails, I'm sorry to say, are not as timely or well-written as a Mencken letter, but they seem to be about as long). Still, if I live another fifty years (and if we're still corresponding with written words in the 2050's) I should make it to the hundred-thousand club -- and I think many of my peers will, too.

But correspondence today is undeniably more result-driven ('how is this project coming along?' -- 'are you free this weekend?' -- 'will you host Grand Rounds?') and virtually necessitates a reply (I hope). I can't imagine carving out the time to reply to five or six unsolicited emails a day. And that's what makes Mencken's achievement all the more remarkable.

Host Defense Activation

Ok, so, remember when those outrageous subway ads asking passengers to "demand a CAT scan" appeared, and prompted me to suspect, offhandedly, that the group behind the ads was receiving funding from GE or another CT-scanner manufacturer?

And when the awful truth came out, that the Lung Cancer Foundation was actually funded by a tobacco company -- a firm likely invested in the notion that smoking-related cancer is preventable and thus limits their liability -- well, I fretted that I wasn't cynical enough -- that it would be a far more straightforward and relatively benign conflict of interest if the funding just came from GE.

Well, here's some comforting news -- members of the Lung Cancer Foundation was also receiving money from GE! From WSJ comes news that the lead authors of a controversial 2006 NEJM report on CT-detection of lung CA were getting royalties from a major CT scanner manufacturer (these same authors are prominent members of the Lung Cancer Foundation, the group behind the dangerous advertisements):

In today's correction, the New England Journal acknowledges that the study's lead authors, Claudia Henschke and David Yankelevitz of Cornell University's Weill Medical College in New York City, received royalties from GE, a big maker of CT scanners, for pending patents on ways to manipulate and interpret CT scans and other medical images. The Wall Street Journal's Health Blog reported the royalty payments last October. Dr. Henschke said then that the royalties were small and declining.

A spokesman for both doctors said they had told the New England Journal that Cornell had licensed the pending patents to GE before the study was printed in 2006, but not that they were personally receiving a share of the royalties. Jeffrey Drazen, the New England Journal's chief editor, said the publication had learned of the royalties only recently.

I call this news 'comforting' because it suggests people behave predictably, that a truly disturbing action can be thwarted by the by lesser, more mundane transgressions. Al Capone getting busted for tax evasion is the first example that comes to mind, but there are probably more fitting precedents.

The NEJM article now carries a "correction" up front that addresses the GE conflict.

Cornell issued a press release clarifying the conflicts of interest:

The original $2.4 million pledge to the Foundation -- and the work funded by the Foundation at Weill Cornell -- was publicly disclosed at the time through a press release, and was covered in the lay media, including USA Today...

The gift was unrestricted, which means that, unlike industry-funded research agreements, it allowed for research to be conducted independently and without restriction in areas of significant but uncertain promise, without the gift-recipient being held accountable in any way to the gift-giver. Significantly, there were no restrictions on publication of results or data; WCMC was not required to keep the donor informed of how the funds were used; and the donor was not entitled to have access to any of the research results.

It is very important to note that the I-ELCAP project -- which comprises more than 50 institutions in nine countries and in 26 states -- has been funded only, in part, by this Vector/Liggett unrestricted gift. The basic research concepts behind the screening project have been developed by Dr. Henschke and Dr. Yankelevitz since the early 1990's, long before the Vector/Liggett gift. I-ELCAP has obtained considerable funding from other sources, and has been able to recruit additional screening centers which, in turn, have developed their own funding resources.

The gift was originally made as part of a grand plan and vision on the part of public health and lung cancer advocacy groups and Vector/Liggett to provide screening research centers throughout the country. The Foundation was organized by Dr. Claudia Henschke and Dr. David Yankelevitz and other advocacy-individuals associated with the I-ELCAP program, with the expectation that other major tobacco companies, in addition to Vector/Liggett, would contribute to this national effort. The initial decision to establish a foundation was thought by them to be the most appropriate and effective fundraising vehicle to achieve such a national research plan...

It is noteworthy that, like Weill Cornell, many of our peer institutions and medical schools do accept funding from tobacco companies and from institutions that manage funds from tobacco settlements for responsible research, and do establish legitimate foundations to manage the administrative and financial aspects of grants and gifts. We recognize, due to the extreme concern about tobacco companies' attempts to misuse research to the detriment of public health, that broader and continuing disclosures could and should have been made. But Weill Cornell strongly rejects the thesis of The New York Times article that any omission was deliberate.

Regarding the matter of allegedly undisclosed patents and patent applications by Dr. Henschke and Dr. Yankelevitz, Cornell Research Foundation, Inc., a subsidiary of Cornell University, licensed technology to General Electric (some of which is now patented) related to detection and measurement of nodules developed by Henschke, Yankelevitz and others. As is generally required at academic medical centers, the royalties were distributed to Cornell, which, in turn, provided a share to the inventors under Cornell's intellectual property policy, which is based on the Bayh-Dole Act. NIH Conflict of Interest regulations currently do not require individual disclosure of royalties paid to them by the employer institutions. Nonetheless, the royalties from the GE licensing agreement, the issued patent, and the patent applications were typically disclosed to journals and at CME meetings, when such disclosures were deemed relevant by Dr. Henschke and Dr. Yankelevitz.

Some of those publications have disagreed with Dr. Henschke and Dr. Yankelevitz's judgment on these, and corrections and apologies have been published in those journals...

NIH disclosure rules are surprising. Someone could patent a device or technique, and a university tech transfer office could license the idea to a big firm, which finds the idea so valuable they pay the university royalties for it. That money finds its way back to the original scientist, who can conduct research showing how great his idea is... and yet never be forced to disclose that he's making money off it, and could make a lot more if everyone believes his research.

It's got to be better to just fully disclose the potential conflict from the outset. That is, I think, what many successful scientists do, and it doesn't stop their research from being accepted.

I don't know why this process wasn't followed with the lung cancer research, and I don't know why the foundation instead chose a dangerous and misleading advertising campaign to advance their cause. These actions make the protestations about their level of disclosure being mischaracterized that much tougher to stomach.

The Lung Cancer Foundation has been mum on the entire debacle, save for two brief blog entries that, curiously, makes no mention of the fact that the 'tainted' researcher is the founding board member of the organization that produces the blog.

On the plus side, I don't recall seeing any new subway ads urging me to "demand a CAT scan," and I believe a few older ones have disappeared.


Last month, when I (and others) noted the ominous ads appearing in NYC subways, urging riders to "demand a CAT scan" -- I looked into the foundation that supported the ads. While the mass-market message was completely irresponsible (the use of CT scans for lung cancer screening has only been tested in smokers over 40, so there's no apparent reason for most riders to 'demand a CAT scan' from their doctors) I was nonetheless impressed by the credentials of their medical advisory board:

I see a medical advisory board full of oncologists, thoracic surgeons, and indeed, the author of the aforementioned 2006 NEJM study touting early detection via CT. Several board members are themselves lung cancer survivors.

I can't doubt this group's dedication or integrity (I originally expected "" would be backed by GE Lightspeed scanners or something similar).

But I must ask, were these board members behind the subway ad campaign? Do they really want the general public demanding a CT scan? Because it's hard to believe such an informed and experienced group could endorse this approach.

Well, it turns out I wasn't cynical enough. The Lung Cancer Foundation is not backed by CT scanner manufacturers -- it's backed by cigarette companies.

Today's NYTimes drops the bomb:

In October 2006, Dr. Claudia Henschke of Weill Cornell Medical College jolted the cancer world with a study saying that 80 percent of lung cancer deaths could be prevented through widespread use of CT scans.

Small print at the end of the study, published in The New England Journal of Medicine, noted that it had been financed in part by a little-known charity called the Foundation for Lung Cancer: Early Detection, Prevention & Treatment. A review of tax records by The New York Times shows that the foundation was underwritten almost entirely by $3.6 million in grants from the parent company of the Liggett Group, maker of Liggett Select, Eve, Grand Prix, Quest and Pyramid cigarette brands.

The foundation got four grants from the Vector Group, Liggett’s parent, from 2000 to 2003.

Dr. Jeffrey M. Drazen, editor in chief of the medical journal, said he was surprised. "In the seven years that I’ve been here, we have never knowingly published anything supported by" a cigarette maker, Dr. Drazen said.

An increasing number of universities do not accept grants from cigarette makers, and a growing awareness of the influence that companies can have over research outcomes, even when donations are at arm’s length, has led nearly all medical journals and associations to demand that researchers accurately disclose financing sources.

Dr. Henschke was the foundation president, and her longtime collaborator, Dr. David Yankelevitz, was its secretary-treasurer. Dr. Antonio Gotto, dean of Weill Cornell, and Arthur J. Mahon, vice chairman of the college board of overseers, were directors.

So, after decades of denying the link between smoking and lung cancer, now a cigarette company has chosen to fund research in cancer detection. That's a good thing, right? It's even charitable, isn't it? Again it's necessary to ratchet up the cynicism:

Dr. Jerome Kassirer, a former editor of The New England Journal of Medicine and the author of a book about conflicts of interest, said he believed that Weill Cornell had created the foundation to hide its receipt of money from a cigarette company. "You have to ask yourself the question, 'Why did the tobacco company want to support her research?' " Dr. Kassirer said. "They want to show that lung cancer is not so bad as everybody thinks because screening can save people; and that’s outrageous."

Dr. Henschke’s work, while controversial among cancer researchers, has been embraced by many lung-cancer advocacy organizations, which have pushed for legislation in California, New York and Massachusetts to create trust funds to pay for lung cancer screening — often with language tailored to benefit Dr. Henschke’s group.

From this perspective, a mass-market campaign for lung cancer screening, instead ads targetted to smokers over 40, makes much more sense. What better way to build the association, in the public mind, that lung cancer is detectable and treatable if caught early? You could even imagine tobacco companies trying to limit future medical liability by pointing to the research they funded. "Everybody knows smoking causes cancer," they'd say -- "but everybody also knows a screening CT would have caught this early, while it was treatable."

So, the millions Liggett gave to Dr. Henschke wasn't motivated by charity or guilt, but rather, looks like a wise investment. Similarly, the misleading subway ads were never designed to protect the public -- the exist to protect cigarette company interests.

Blood Makes Noise

I recently heard US Army Major (and emergency medicine physician) report on his research, conducted in a major trauma center in Iraq. To give some context to his investigations on Factor VII and clotting, he mentioned a number of incredible statistics about the volume his hospital sees, the throughput his ER achieves, and even the turnaround time for lab results.

But one thing he said really stayed with me: all the hospital personnel have their blood typed and crossmatched. When a wounded soldier or Iraqi civilian requires a massive transfusion in the OR, they'll summon someone with the right blood and just hook them up to the patient, in the OR. He said, "There's nothing like transfusing warm, fresh whole blood to a patient -- it's like a magic bullet. Too bad we could never do that in the States."

(Another Iraqi hospital, one not run by the US Army, has apparently adopted different techniques).

But more data is accumulating on the inadequacy of current blood products practices. We already knew banked blood has poorer oxygen carrying capacity and is immunosuppressive (at best). Now, the NEJM just published a paper from Koch et al that demonstrated more post-operative complications from older blood transfusions. Cardiac surgery patients were significantly more likely to stay intubated, to have their kidneys fail, to develop sepsis, and to die -- when they were transfused packed red cells that had been stored more than two weeks.

Blood transfusion has come a long way and the practice of whole-blood transfusion has fallen out of favor, at least among US civilian institutions. But military studies have shown, at least, non-inferiority of the practice fresh whole blood transfusions, compared to frozen blood products (and patients requiring FWB required more blood, which is typically associated with worse outcomes). And others are looking at ways to mitigate the risk of infection.

It will be interesting to see this military practice finds some applicability in stateside trauma centers, and if the pendulum swings back towards whole blood transfusion in certain cases. If reviews bear out the benefit of fresh whole blood, hospitals should set up some kind of system where volunteer employees can be summoned to the OR to donate. It somehow seems more immediate and personal than current blood donation and banking. And when you consider all the expensive, marginal interventions we use in emergency medicine, it's nice to think we're sitting on something that could make a dramatic difference for a critically ill patient.

More, Now, Again

If, for some reason, you haven't read enough about me in the past few months, you can read my profile (html, pdf), by Dr. Tiago Villanueva, in this month's Student BMJ.


Christine Miserandino (of recently asked me some questions about Grand Rounds, and my thoughts on use of the emergency department, and the web, by the chronically ill. The interview is now posted to her site.

My interview of her, as well other Grand Rounds host interviews I've been privileged to conduct, is available on Just register (free) and search for "Pre-Rounds" (you can sort by date to see the most recent, first) or browse the Pre-Rounds column index.


I hardly ever use my record player. Nevertheless, I would like to own this record, featured recently on the website of New York's WFMU:

There is absolutely no information printed on this 10" record except the word Borborygmi, which is the medical term for stomach-gurgling sounds.

A fitting name for this collection of jaunty piano-and-vocals medical parodies, apparently sung by real doctors. Only real doctors could have gotten away with singing such explicit material in the '50s / early '60s period these songs were probably recorded. Assuming this is the same bunch who did this, this record was produced to benefit the Greene County, MO Medical Society's Scholarship Foundation. It definitely wasn't for the general public - only other medical industry professionals would understand all the references.

Looking for graphics, I was just typing in mildly appropriate phrases like "singing doctors," not really expecting to find anything, and I came across this (the album cover to the right). I'd say it's a different album judging by the song titles, but they mention Greene County in their lyrics. How many Green County singing doctors could their be?

It's nice to think these clever tunes (you can sample them on the WFMU site) helped fund the education of physicians. Another one of their albums has made it to online auction. They also recorded Medic Emetics, Keep You In Stiches, and Thanks for the Miseries. After a few minutes of web sleuthing, I found a different listing, for the Greene County Boys. Borborygmi sells for $9; they also had an album called Placenta Preview.

Early Detection of an Invasive Mass-Marketing Campaign

I was taken aback by a new subway advertising campaign, imploring the public to demand a CAT scan. With lines like "5 out of 5 lung cancer survivors recommend a CAT scan", the idea is a familiar one: early detection saves lives.

Of course, early detection of lung cancer by chest x-ray was shown, decades ago, to have no impact on mortality and is often the example of "lead time bias" taught in evidence-based medicine lectures.

But now we've got computer-aided tomography scanners, with their improved resolution (and higher doses of radiation). Can they find lung cancer soon enough to treat? Will they find "incidentalomas" that prompt dangerous, useless workups? Will this intervention do more harm than help?

These are serious questions, and research is ongoing. Some provocative recent results suggesting CT scans of asymptomatic at-risk individuals (mostly smokers over 40) can improve lung cancer mortality, but others offer some words of caution going forward.

Sadly, the folks at think they've got all the evidence they need. On their front page, it's written:

The availability of early detection for lung cancer is widely unknown, inexcusably underencouraged, underfunded, and underinsured. Just ask five-out-of-five lung cancer survivors. “While we wait for the cure, the biomarkers, the blood and saliva tests, we will use the early detection imaging and diagnostic tool we have available, right now. The 64-slice low dose CT scan."

One of the participating hospitals, linked from the site, is honest about the trial:

Sequoia’s lung cancer early detection program is a participating member of the International Early Lung Cancer Action Program (I-ELCAP).

I-ELCAP is the first research study of its kind involving a large number of hospitals that are evaluating the effectiveness of screening for lung cancer with low-dose CT Scanning...

...Who should get screened? We currently do not know what defines the ideal population for lung cancer screening (that is one of the goals of the study). Our screening program includes people 40 and over with a history of smoking or second hand smoke exposure.

Reasonable words. And looking around the site that demandaCATscan points to,, I see a medical advisory board full of oncologists, thoracic surgeons, and indeed, the author of the aforementioned 2006 NEJM study touting early detection via CT. Several board members are themselves lung cancer survivors.

I can't doubt this group's dedication or integrity (I originally expected "" would be backed by GE Lightspeed scanners or something similar).

But I must ask, were these board members behind the subway ad campaign? Do they really want the general public demanding a CT scan? Because it's hard to believe such an informed and experienced group could endorse this approach.

I could have supported ads targeted to smokers over 40, encouraging them to enroll in a lung cancer screening trial. But the way it's currently executed, these ads will plant a lot of misconceptions in peoples' minds, and lead to a lot of fruitless conversations with already time-crunched physicians. Plus, the money spent misguiding young healthy subway riders could've been spent better -- on researching screening, therapies, or just enrolling appropriate subjects.

It seems like this intervention will cause more harm than benefit.

Full Disclosure

Remember that recent study about doctors talking about themselves during patient encounters? It received a lot of attention from the media and patients...

But now (at last!), you can hear three doctors talking about it -- me, and my esteemed Medscape Roundtable colleagues, Dr. Robert Centor and Dr. Robert W. Donnell. I tried to critique the study, and advance another reason why physicians would 'self-disclose.' Check it out, and let your own voice be heard in the comments section.

You can write, but you can't edit

I'm thoroughly enjoying this month's edition of Annals of EM -- partly because of some challenges to current practice, with some research that's up my alley... but mostly because it arrived on my day off.

One article on lab turnaround times has a brilliant editorial accompanying it. Some background: I've been fascinated by charting since medical school, and this memorable post from MedPundit on the evolution of charting stayed with me as I tediously documented findings and thought process on my patients.

Nowhere is documentation more verbose than in the electronic ED. The late, great Cheerful Oncologist blog once hilariously remarked upon this problem:

It was the most amazing thing I had laid eyes on all summer. I sat mesmerized, scrutinizing page after page until finally I heard a voice asking if I was alright...

Later, while driving home, my thoughts drifted back to that emergency room report. It wasn't the facts in the case that captivated me; the patient's illness was serious but manageable, and he had improved since his admission.

It was the macros used by the E. R. doctors and nurses in their typewritten report that were stunning. They spilled over the pages, neatly stacked into parallel lines, all created to prove conclusively to any skeptics that at no time while physically present in the emergency room did the patient receive anything less than perfect care. The result was a repetitive - nay, interminable, tedious, irksome collection of about a hundred paragraphs that contained just under ten percent factual information.

The rest was just a pile of crap that I inferred was placed there for the sole purpose of vexing malpractice lawyers.

Don't get me wrong - I understand the importance of careful documentation of the events of the day inside a hospital or medical office. I get it when I'm told to leave good records of what I say to my patients. It's just that in this particular case the result is an unintentionally hilarious narrative. Let me illustrate by providing an example of a visit to a local hamburger joint, as chronicled by the restaurant's risk management team:

"The client, who walked into the lobby on his own power, had no signs of distress. He was promptly escorted to the nearest counter by staff member One. He completed this ambulation without injury. The client was asked how he felt before the Staff Member departed. The client said he felt fine, but did complain of a feeling of hunger in the vicinity of his abdomen. He was promptly examined by the staff member and found to not contain any foreign objects protruding from his abdomen or chest.

"The client placed his order for a hamburger, large fries and medium coffee. He did not show any signs of distress while waiting for his order, and was checked on by staff members One and Two at 1457 hours and again at 1502 hours. The client did not fall down at any time during his wait, but he did show brief signs of distress upon hearing the score of the Cardinals-Cubs baseball game, which was being broadcast from a nearby radio...

It goes on and on. Some ED information systems are better than others in shielding practitioners from the malpractice malarkey that creeps into charts (by highlighting freetext material, key findings, assessments and plans -- while pushing the checkbox stuff off to the periphery, at least while the patient is still in the ED).

But while we bemoan this excess verbiage, it's not often we wonder what else is at risk. That's why I enjoyed Dr. Peter Viccellio's editorial piece on hidden costs of computer systems, excerpted below:

The electronic medical record has become a tidal wave in emergency medicine. Templates. Checklists. Computerized physician order entry. Time stamps. All entries ending with "side rails up." When one walks into such an ED, it is rather typical to see most of the staff with their nose in a computer. With many hospital systems, there’s a wonderful opportunity to take a minute to chat with your colleagues as you await completion of your sign-on, to check to see if labs are back yet, knowing that you’ll be back to your seat to check again in a little while. (At my institution, the simple act of logging on consumes about 30 to 45 minutes per physician per shift.) Of course, much of this is improved by a robust tracking system (which, uniquely, is a system that works for the physician, rather than vice versa). Many places have implemented computerized physician order entry, or some tortured version of it, and would do well to adopt suggestions such as the ones outlined in the Guss et al article.

The human transaction costs of all these interactions with the computer have, oddly, been largely ignored.
Large groups of health care practitioners typically spend countless hours devoted to the design and maintenance of the system. Time spent at the computer writing notes, entering orders, and looking up lab results is time away from the bedside. The burden of clerical activity has shifted to the nurse and physician. We enter the orders. We seek out the results, often buried in multiple systems. We type our notes. We print out our discharge instructions and prescriptions.

From personal review of a number of templated charts, several things are readily evident. First, there is a struggle between free texting (which is very time consuming) or simply fitting the patient to the template and ignoring the variances. Second, a lot of sprained ankles are curiously getting their pupils checked and their bellies examined by both the physician and the nurse. Some evidently believe that any box left unchecked is an invitation to a supervisory reprimand. The third, and most important, has to do with the ultimate content of the chart. It no longer tells a story (yet, at the same time, takes pages and pages to do so).

The explosion of information in the record, much of which is drivel, succeeds in defeating the primary purpose of an electronic medical record, ie, to tell the story in a meaningful way. It is ultimately a record designed for coding and compliance, not to portray the battle of the patient. When an ED visit for a cough, with diagnosis of pneumonia, consumes 17 pages of print, something has gone awry. (Or perhaps things went awry when pulmonary edema was no longer considered an emergency unless there was a documented family history, social history, and 10 reviews of systems.) Unstudied is the impact a template may have on critical thinking. Being led through a series of checkboxes is very different than the unrestrained and loosely structured improvisation between the physician and the patient. Will the physician have more or less "Aha!" diagnostic breakthroughs when guided and constrained by a template? Will it alter content, the exchange, the clues of body language, the personal interaction, and the diagnostic considerations for better or for worse? Where will we find the time? Whatever its impact, we can at least be sure that more boxes will be checked.

What do these comments have to do with the Guss et al work? Improving flow is centerpiece of their efforts. Although these interventions decreased lab turnaround time for specific labs, were the patients any better off? Did they get out any faster? The article is unfortunately silent on these matters. The context of the study is one in which all efforts are channeled through a computer, and most of this effort depends on those on whose time the patient would consider most valuable. After a pound of flesh for the coder and a pound for the compliance officer, what’s left for the patient? It’s great for the clerk that we now log on, enter orders, type notes, get results, print discharge instructions, and even carry our own telephones. Some of us are doing our own billing as we work.

We need to critically measure the true value of systems that potentially double or triple the amount of work required away from the bedside. Like the electronic medical record, computerized physician order entry itself has not quite been the Grand Panacea as originally envisioned, with production of its own set of errors and time-consuming processes. We don’t really have it "right" yet.

Agreed. But while ED information systems have so far been geared toward maximizing documentation (with an eye toward limiting liability and maximizing billing) new efforts are underway to make computer charting more efficient, and at the same time support decision-making. It will take effort and much trial-and-error, but fortunately, computerized charting is a platform that, by its very nature, lends itself well to research.

How Do You Sleep at Night?

Getting emergency department signout on a Monday evening is as close as I've come to drinking from a firehose. Whatever late afternoon activities I've been engaged in, they seem impossibly placid when I walk into the ED at its most crowded and chaotic.

The patients peer at the gaggle of white coats at signout, trying to size up the night team. The outgoing team has already welcomed us as liberators. And they tell us about the ongoing workups, the lab results and consults still pending, and the patients already dispositioned but still waiting for a bed.

In signout, the essentials are all there, but some nuance is inevitably glossed over. And so it was on one particularly busy Monday, when I received at least a half-dozen patients, including a hypotensive febrile encephalopathic young man who had been rejected by the MICU. My mind was still preoccupied with him when an outgoing intern started telling me about the simple, straightforward elderly woman with back flank pain and hematuria who was "probably in the CT scanner even as we speak." Just get the read, confirm the stones, give her some 'scripts and she'll be on her way.

Not surprisingly, it only took a few minutes for that neatly-bundled package to unravel (though enough minutes passed for the intern to be on well the way home). I got a call from radiology that my new patient was requesting pain meds (the scanning table was too stiff) and something for her nerves (she didn't like moving through that heavy donut of a machine).

I checked the record, and was amazed to see the patient had already received three generous rounds of opioids and benzodiazepines before signout. Combined, it was enough for procedural sedation in a young adult -- and my patient was well past retirement age. Her outpatient summary mentioned a xanax prescription, but none of this had been covered in signout.

A nurse, grappling with her own monstrous signout, graciously provided me with round four of this patient's morphine-and-ativan regimen. I scurried down to radiology, myself pretty anxious to meet this new patient, and to return to the encephalopathy case in the resuscitation bay.

When I got to radiology, which seemed so serene in comparison to the ED, I was greeted by a tech who directed me down a near-deserted hallway, to a distraught woman in a stretcher. By her side was an affable husband, holding their coats, bags, and various papers. He smiled broadly and asked, "are those her medications?"

His wife was hyperventilating and clutching her side. After introducing myself and confirming the story, I pushed the meds and reconnected her IV fluids. I apologized and hurried back to the busy ED.

The code was called overhead, about ten minutes later. Every doc's ears perked up in the ED -- we're responsible for the coding patients in some part of the hospital, but not others, so we waited to hear if we'd need to gather our gear and run.

As it turned out, the code was in radiology. We were covering. And I started to run, worried -- really panicked -- that I had just killed a patient.

I was the first from the ED to arrive, but there were already some long white coats surrounding a stretcher. And, to my eternal relief, it was not the stretcher of my patient.

Even better, this was not even a real code -- the long white coats belonged to neurosurgeons, who were concerned their head-bleed patient from upstairs was breathing funny, and wanted anesthesiology to tube him. I volunteered, but they held out for the anesthesia team, who arrived a minute later. My services were not needed, so I slung some gear over my shoulder and trudged back, stopping along the way to talk to the woman with flank pain, and her husband.

"I've got to confess," I remarked, tapping on the airway equipment, "I thought we were called to use this on you."

"She's alright," the husband responded.

"No I'm not!" the woman exclaimed. "All this activity has made me very anxious..."

Everywhere you sing your smile

Seeing this funny video reminded me of the time the Google StreetView van stopped outside my apartment. I asked the driver what was wrong, but he was not very forthcoming -- despite the fact he was photographing absolutely everything and everyone around him (on second thought, this might explain his evasiveness).

Next to these excellent photos of the Google Van and hardware (including some self-portraits and a glimpse of the Google Beetle) I add my own blurry cameraphone pic, on the right.

More Google Van pics and coverage at, you guessed it,

Program Note

I'll be calling in tonight to the Dr. Anonymous Show on BlogTalkRadio. We'll be talking about medical blogs, and blog awards, and the blogging of blogs. If this interests you (and honestly, why wouldn't it?) you should tune in, or even call into the show. Hopefully some of my colleagues from Medgadget will join us.

If Political Pundits Covered an Emergency Department Shift

This long, rambling dialog took shape while I walked home from the ED just now, to yet another night of surprising election results. To follow the analogy, just substitute "doctors" with "voters," "patients" with "primaries" ... and the causes of abdominal pain... as major US presidential candidates:
Jeff Greenfield: If you’re joining us from home, this is a very special night in the ER. After hearing about diseases for so long, a group of doctors is finally going to step up and decide what's ailing a waiting room full of patients.

Wolf Blitzer: It’s a big night, no doubt, and let’s see how doctors are evaluating their first patient.

Dan Rather: She’s a young woman with several hours of periumbilical pain. Now it seems to hurt a little more on the right. She’s vomited. That's all we've been able to uncover.

Chris Matthews: I was talking with some of the doctors tonight. While they've obviously given this a lot of thought, many seemed ready to back appendicitis.

Anderson Cooper: Appendicitis has received major endorsements from several surgeons, and it clearly has the name-recognition among the general public. It’s a heavy hitter.

Jeff Greenfield: The ER docs are conferring. I wonder what they’re discussing?

Keith Olbermann: Maybe they want to know if the patient pregnant? Afebrile? I think they’re ordering labs of some kind.

Doris Kearns Goodwin: Well, it hardly seems to matter at this time, Keith. Appendicitis has a well-honed message of fear. These doctors, facing uncertain times, can’t afford to back a dark horse diagnosis now.

Larry King: I think I heard one doc mention torsion. What do you think of that?

Jeff Greenfield: Torsion is very popular among this demographic.

George Stephanopoulos: You know, torsion has surprised me a lot recently. Women *and* men seem pretty impressed by the pain and damage from gonads twisting on a stalk. This is one diagnosis they don’t want to overlook.

Larry King: Well, here we go. The patient’s getting a CT scan. And there’s the wet read! We are calling it appendicitis!

Wolf Blitzer: Amazing. You know, grassroots organization really carried appendicitis in this first key patient of the night. Everybody knows somebody who's lost their appendix -- and that kind of familiarity with the disease really figured into the doctor’s decision-making.

George Will: And, you know, as I look across the waiting room at all the patients clutching their bellies, I really think appendicitis is going to run the table tonight.

Jeff Greenfield: You think everyone with abdominal pain has appendicitis?

Anderson Cooper: Appendicitis has the momentum, Jeff. Its brand is strong.

Chris Matthews: Appendicitis has reached the top of the differential by borrowing from so many other diseases. It's like a chameleon. And these doctors are just blown away by its broad appeal across so many key demographic groups. They're true believers.

Jeff Greenfield: Here’s another patient. The doctors are evaluating him. How do you think this one’s going to turn out?

Ted Koppel: A wise man once said, if you want to know what’s ailing the patient, you ought to ask the patient. And measure vitals, do a physical exam, and consider some imaging and labs – and also, spend some time building an appreciation of pathology.

Chris Matthews: I don’t know, I’m ready to just call this one for appendicitis.

Sean Hannity: Appendicitis is a *juggernaut*. The other diagnoses should just *give up*.

Dan Rather: You know, the other day I was talking with an agent of Yersinia... From a certain point of view, Yersinia and appendicitis have a lot in common.

Chris Matthews: Yersinia’s time has passed. It’s embarrassing that Yersinia is still on the differential diagnosis.

Larry King: The doctors are looking up something... prior visits, it would seem. And now, orders are going in.

Dan Rather: I don’t see any calls to surgery, nor is there a CT scan ordered. We may be looking at a major upset.

Larry King: They’ve given their fluids, pepcid... and some reglan! And they’re moving on!

Tim Russert: Gastroenteritis! The doctors have spoken.

Jeff Greenfield: Unbelievable. This is a huge setback for appendicitis.

Wolf Blitzer: But what an amazing comeback for an old standby. Lately gastroenteritis didn’t really seem to have the vision, or the ability to reach doctors on a visceral level anymore. Tonight it seemed almost like an afterthought, especially with that first patient.

Dan Rather: Acute gastroenteritis has pulled itself back from the diagnostic abyss.

Tim Russert: I have to wonder what the doctors are basing their decision-making on. It’s almost as though there are factors besides momentum that play into their thought process.

George Stephanopoulos: I think doctors were trying to send appendicitis a message – appy’s got to earn its spot at the top. The doctor's aren't so enamored with it anymore, that's for sure.

Anderson Cooper: Well, it just goes to show, doctors are a fickle bunch. There’s still a long way to go in this shift, and now the ER is a battleground for disease.

Dan Rather: This is where the fun starts.

Forgive the length. And I don't mean to imply that the presidential candidates cause upset stomachs. Just that voter's decisions, like medical decisions, are a good deal more sophisticated than the talking heads give them credit for. If pundits spend time on fundamentals, like policies and platforms, instead of canditates' momentum and maneuvering, they might improve their accuracy -- and at the very least, render more of a service to their viewers.

Informed Review

I know it's January, but that somehow makes this IRB appraisal of Santa's activities more timely. Excerpts below (via Grahamazon):

1. You propose to study "children of all ages". Please provide an exact lower and upper age limit, as well as the precise number of subjects. Provide a statistically valid power calculation to justify this large of a study.

7. The database of good and bad children will be kept "on a scroll at the North Pole." Please describe the security provisions you have in place to protect the research data. Is the scroll kept in a locked cabinet in a locked room? Who has access to the scroll? Are there backup copies of the scroll and how often are they compared to the original?

10. As this study involves prospective data collection and is more than minimal risk without prospect of direct benefit to the subjects, informed consent signed by both parents will be required. Please have the consent form translated into every language spoken by children.

In googling for more IRB rants, I found this thoughtful blog post that points to a number of papers considering the ethics of IRB regulations. A 2003 report on IRB Mission Creep seems like an evenhanded approach to addressing some faults in the system.

Making Modern Music has an interesting story on the Death of High Fidelity. Of course we've known since the beginning that MP3 sampling is a poor substitute for CD quality sound, which itself pales next to vinyl on a high-end system. But what this article tells us is how the music industry is adjusting to the new milieu, mixing 'louder' songs with less detail that are designed to play well on iPods, car stereos, and bars. RS talk about 'ear fatigue' in relation to new albums (so that's why I can't tolerate Arctic Monkeys) and includes a lamentation from Steely Dan's Donald Fagen, whose music isn't translating well on my iPod.

Rolling Stone prints a damning comparison of songs waveforms -- past, present and reissued. And a link to a technical wikipedia discussion (with more examples, and some possible solutions).

But there is one marriage of technology and music I can enthusiastically endorse: Air Karaoke, available on Channel 1017 in New York City (the Oxygen network's On Demand channel). Apparently this has been available for ble years, but I was unaware until the week hours of 2008. Already, this new technology has impacted my life, and certainly, the lives of everyone within earshot.

Check it out

Much has been said about this excellent New Yorker article on checklists in medicine, by Atul Gawande, in which he talks with two checklist gurus -- intensivist Peter Pronovost from Hopkins (he wrote the Tintinalli chapter on ABG interpretation) and Markus Thalmann, an Austrian surgeon who led some truly incredible hypothermia arrest resuscitations.

The article gives a historical perspective to the concept of checklists -- from engineering to pilots -- and how it's moving into medicine. Checklists standardize complex activities like sterile line placement, leading to fewer complications, shorter ICU stays, and more lives saved. It's engagingly written and very relevant to ED practice.

Key grafs:

If someone found a new drug that could wipe out infections with anything remotely like the effectiveness of Pronovost’s lists, there would be television ads with Robert Jarvik extolling its virtues, detail men offering free lunches to get doctors to make it part of their practice, government programs to research it, and competitors jumping in to make a newer, better version. That’s what happened when manufacturers marketed central-line catheters coated with silver or other antimicrobials; they cost a third more, and reduced infections only slightly—and hospitals have spent tens of millions of dollars on them. But, with the checklist, what we have is Peter Pronovost trying to see if maybe, in the next year or two, hospitals in Rhode Island and New Jersey will give his idea a try.

Pronovost remains, in a way, an odd bird in medical research. He does not have the multimillion-dollar grants that his colleagues in bench science have. He has no swarm of doctoral students and lab animals. He’s focussed on work that is not normally considered a significant contribution in academic medicine. As a result, few other researchers are venturing to extend his achievements. Yet his work has already saved more lives than that of any laboratory scientist in the past decade.

I emailed the residents about this a month ago, but since then, the article has taken on additional significance, as I've committed to an informatics project on decision support. Not surprisingly, Gawande has covered this territory, as well.

So, there's not much more nuance I will add to what's already been said about Gawande's piece, other than to speculate that the Dr. Markus Thalmann that Gawande interviewd is the same man Austrian doctor listed as the winner of the 2003 Spartathlon. Runners like their checklists, too.