Hyperresonant

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 demandaCATscan.org 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 demandaCATscan.org 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, thelungcancerfoundation.org, 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 "demandaCATscan.org" 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, GoogleVan.com.

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

RollingStone.com 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.

Briefly Noted

Another year is slipping by, and I haven't read nearly as much (non-medical) literature as I would have liked. Still, a number of noteworthy books have come to my attention, and if you're looking for a medically-themed gift for someone on your list, consider some of the following:

The Man with the Iron Tattoo: Two neurologists, John Castaldo and Lawrence Levitt, recount their lives in medicine, with interesting cases, memorable patient interactions, and some mild pontification about the importance of reaching out to one another. Well-written, and an interesting look at how medicine and standards have changed in a generation.

The Diagnosis of Love, by Dr. Maggie Leffler. I must say, this book was much better than the title or blurb (about a young female physician resolving family and relationship crises) would lead me to expect. The book featured snappy pacing and dialog, well-developed characters, and captured some of the frustration and opportunity inherent in a scientifically-trained physician interacting with some of the stubborn and less rational people around her.

Know Your Numbers, Outlive Your Diabetes by Dr. Richard Jackson and noted journalist and blogger Amy Tenderich of DiabetesMine. When I think of all the diabetic patients I see with repeat visits to our emergency rooms, I can only hope some of newly diagnosed pick up this book before it's too late. With straightforward text, and easy-to-read bullet points and tables, this book can give patients a strategy on to manage this challenging disease. And it might give the patients, and their caregivers, some hope as well.

The Alchemy of Grief by Emily Ferrara. One of my former professors has produced a book of poetry, borne of a parent's worst pain, the loss of a child. One review reads:

This is excellently controlled craftsmanship, conveying deeply felt emotion. The grief of loss is sharply poignant and real, yet never maudlin or self-indulgent. The music of the lines is subtle and fine. The tension between the controlled craft and the poignancy of the theme makes the reader participate in the poems and feel with the poet, sharing the human despair and transcendent emotions that bring us through to survival. - Daniela Gioseffi

Brought to you by Carl's Jr.

Although it's by no means a great film, there's no recent movie imagery that has lingered with me as much as Mike Judge's Idiocracy, a dystopian black comedy in which the dim-witted have conquered the planet through their fecundity.

Maybe this movie resonated with me because I'm too far removed to really 'get' MTV culture anymore. Or working in NYC emergency rooms has made me a little discouraged about our future. In any case, a reviewer has nicely captured the humor and horror when our modern hero, Joe, wakes up five hundred years in the future, and heads to St. God's Memorial Hospital:

Because language has deteriorated throughout the centuries, when Joe speaks, Dizz can barely understand him (imagine a man from the 1500s trying to speak Elizabethan English in modern-day Amarillo, Texas). Scared by Dizz's hostile grunts and disoriented from his hibernation, Joe stumbles across the hellish garbage-covered city to a hospital, still somehow convinced that he's just hallucinating.

The hospital sequence is one of the funniest parts of Idiocracy, gleefully showing how complex bureaucracies can develop even in the dumbest of societies. Joe finds that hospitals are now set up like Jiffy Lubes - you stand in line until a technician hooks you into a machine that loudly offers a pre-recorded diagnosis ("You've got hepatitis!"). When Joe finally gets to see a doctor (who offers the diagnosis "your shit may be retarded"), he begins to realize what's happened.

But I also enjoyed the little things, like the movie's clever adaptations of modern logos (NSFW), and how coarseness has become commonplace in civil institutions.

If you can't wait for that future, at least now you can drink Brawdo, the Gatorade-like beverage that threatens to destroy American civilization in 2505. Why would you want to drink it? Well, for starters, it's got electrolytes.

We will float into the mystic

The latest edition in Medscape's Roundtable series features Drs. Robert Donnell, Roy Poses and me, talking about Integrative Medicine and EBM in today's med school curricula.

I really enjoyed participating, and give thanks again to series editor Christine Wiebe for corralling us and arranging the pieces. I think we all made good, well-referenced points, and our views frame a provocative debate. See for yourself with whom you agree, and join in on the discussion.

Fluorescent and Starry

I receive several academic journals in the mail, and after browsing the articles of interest, I enjoy flipping through the 'letters to the editor' section at the end. Controversial topics are reconsidered from another viewpoint, which is always valuable to the physician in training. And even early in your career, you'll see some familiar names, from conference speakers or from the places you've trained.

And, sometimes, you might see your own name.

Allen Roberts and I were mentioned in a letter to Annals of Emergency Medicine, penned by none other than Jen Jen Oh, the founder of Lingual Nerve (who I finally had the pleasure of meeting, when she recently visited NYC and my hospital). The topic was blogging (what else?) -- specifically, Eric Berger's article on EM blogging (subscription req'd) this past spring. An interesting excerpt from Jen Jen's letter is below, sanse the effusive praise:

I too have a personal blog, located at www.spacefan.blogspot.com, which began in 2002. Although it started out by covering more social aspects of my life, its direction changed in 2003, when I reported on the SARS epidemic in my country. It was eventually mentioned on The Guardian’s Web site and garnered a favorable review. SARS-related entries from that year can be accessed via the archive links on the main page of my blog.

The pros and cons highlighted in the article, though cited by US-based doctors, are also applicable in other parts of the world. With regard to the ethical and administrative dilemmas, I’ve had my share of closed-door meetings, stern e-mails and other warnings over the years, first about revealing too much in my SARS-related posts, then about being too vocal in my frustrated rants on emergency department (ED) crowding (which the powers-that-be contend will tarnish the hospital’s image, ED staff’s sanity and morale be damned).

Preserving patient confidentiality is rarely an issue, but with our younger generation of doctors and doctors-to-be jumping on the blogging wagon, there have been times when too much was divulged, with dire consequences....

...Despite all the precautions taken, medical blogging remains a tenuous pastime, with few doctors making any form of profit from it. I personally do not know any doctor who does it primarily for money or fame. Instead, we are driven by a passion for the written word which, when combined with the adrenaline rush and emotional rollercoaster ride of the medical profession, makes for compelling — almost addictive — reading.

Aside from helping doctors connect on a national and global scale, medical blogs also provide invaluable insight for the general public, who know little about our small, exclusive community. While there will always be the occasional heckler, the majority of non-medical readers harbor a deep interest and respect for what we do, and express these sentiments when they comment on our entries. My posts on SARS elicited responses offering encouragement and sympathy from all over the world, providing a great source of comfort to myself and my fellow colleagues during our darkest days.

Last but not least, medical blogging can prove instrumental in raising the profile of various specialties, emergency medicine included. As recently as 5 years ago, few residents in Singapore applied for traineeship positions in emergency medicine, but this number has surged in the past 2-3 years, with many applicants mentioning that they read my blog on a regular basis and developed an interest in this field because of the information I provided. Medical students choose to do elective postings with us because they know where "Dr. Spacefan" works, and quite a number of them have already decided to make emergency medicine a long-term career choice...

Wow. I thought it was from all the American Idol posts, but Jen Jen always had that rock-star cachet about her. The illustrious Truman J. Milling responded to her letter.

Program Note

I'll be appearing on the Dr. Anonymous internet radio talk show this Thursday night, live at 10 PM EDT.

Listeners can phone in questions, or comment in the accompanying chat session. If you can't catch the live version, don't fret -- the show will be archived for later enjoyment.

Served up by Sermo

Sermo's founder and CEO, Dr. Daniel Palestrant, sent me an invitation to dinner last week. At first I thought it was because of the Medgadget brouhaha, but no. I was singled out simply by geography, as part of his larger plan to informally sit and meet with more Sermo users across the country. Fellow Medgadget scribe Joshua Schwimmer was invited, too.

We didn't know what to expect. I suspected he'd be polite, if only from his previously published correspondence. But what about the rest of the Sermo community, some of whom have distinguished themselves with their comments?

It turns out, we had nothing to fear, and a lot to learn. The Sermo users who showed up to the Midtown restaurant were a diverse mix of academic and private practice physicians, from internal medicine to neurosurgery, men and women, and -- get this -- older. There was no one under 30 in the crowd, and a good number of folks over fifty (plus a septuagenarian professor).

They had some of the same concerns we did about the integrity of the site, and especially about the new deal with Pfizer. Mostly, though, they were curious to hear from the founder about his plans for the community.

Daniel Palestrant impressed us. For all our questions, he was honest about what he knew and didn't know, and he was often able to disclose market research, survey data, and how legal and programming constraints influenced his decisions.

I'd read stuff about the founding of Sermo before, but this was the first time I heard that Sermo's partnership with the FDA stems from negotiations dating back to Sermo's inception. They've also been involved with the bioethicists at Penn, referring questions of conflict since the beginning to people like Art Caplan.

I'd thought that Sermo's business model was essentially to create a forum for doctors, and then sell their aggregated opinions about drugs to investment firms. While that is still fundamentally true, Daniel pointed out a doctor's forum can provide other valuable functions. Already, physicians have started to compare notes about different insurers' reimbursement rates, and a forum like Sermo can bring about more efficient information exchange without risking collusion and anti-trust. The doctors at the negotiating table might not have such a disadvantage next time.

Plus, Sermo forums have been on the forefront of identifying some adverse events that eventually led to FDA advisories and recalls. Granted, they discuss a lot on those forums, so it's easy to be prescient sometimes... but I was thrilled to hear just how they're studying the forums -- which threads generate useful clinical pearls, and how to minimize useless flame-wars (Medgadget has contributed much data to this endeavor). They've brought aboard Paul Resnick to help sort the wheat from the chaff and improve discourse. They're really thinking how to optimize design, and yet are firmly committed to keeping hands-off and not moderating, once the discussion's begun.

When it comes to Pfizer, or for that matter, the AMA -- posts from their representatives will always be clearly marked and well-differentiated from the regular physician comments. And when the docs savage an AMA or drug rep, Sermo won't delete or edit a thing. It's been an eye-opening experience for these 'clients,' but they're determined to adapt, in order to have some interaction with the community. Thankfully, Sermo has determined that client posts can't make up more than 2% of the total, if the community is to flourish.

I was wary that drug reps would find new ways to disarm and undermine comments (and commenters) critical of new drug data -- but Daniel told me I'm underestimating the power of the online physician community.

Moi? But perhaps he's right. I thought I knew a lot about this community, stemming from my blogging activities... now close to four years ago. But while I've been preoccupied with my training, another kind of doctor has ventured online -- one that's a decade or more removed from residency, and eager to recreate that camaraderie and intellectual exchange.

I thought independent bloggers could get the job done, and easily recreate the feel of the physicians lounge -- after all, it's worked for thousands of our readers. But I understood Daniel's meaning when he remarked, "I tried blogging once, but it was too hard."

Practicing alone, doctors have been outmatched by the insurance industry, regulations, and slick pharma reps. But now they're looking to engage these entities, as a group. Sermo quickly figured that out, and capitalized to facilitate the exchange.

That bodes well for Sermo, and probably for physicians as a whole.