like a broken record

John Linnell and John Flansburgh have been rattling around the back of my brain recently. First, they made a cameo over on Homestar last week. Then I realized it's been ten years since I started a mosh pit at their concert (prompting a public reprimand between songs). It still stings; it does.

When catchy TMBG songs are stuck in your head, you do funny things. In this case, I combined that neat sign-making service LetterJames with the new Hello picture server.

"When I was driving once I saw this painted on a bridge:

Posted by Hello

...I just want your half."

Reach Out and Annoy Someone

Blogborygmi was originally intended to give my freelance writing career a lift. That hasn't really happened -- blogging has become an end in itself -- but I still try to publish when I can.

The Worcester Telegram & Gazette (registration required) is running my latest op-ed today. It's about mobile phone number portability, and how this goverment-mandated consumer convenience may have unintended consequences down the road. Maybe it's just paranoid ramblings, but keeping one's phone number indefinitely could lose its appeal, if the number becomes a magnet for unsolicited text messages:

As barriers to communication drop, parasites emerge. The mobile market is approaching this vulnerability, just as e-mail did for spammers...

...I’m stuck with my e-mail account; it would be too difficult to change it. But how many marginal e-mail users got turned off by the cacophony of hucksterism arriving in their inbox every day?

...What seems like inexorable progress toward instant, universal communication has hit a snag with e-mail, and might suddenly stop with GPS-enabled tracking and [cell spam]. By mandating location services and number portability, the FCC may have actually made mobile phones less desirable.


How now, Newdow

Zachary Block has written a wonderful profile of a controversial figure who signs his legal papers as "Rev. Dr. Michael Newdow."

You might know him as the guy who argued before the Supreme Court against "under God" appearing in the Pledge of Allegiance. On this case, William Safire has written, "The only thing this time-wasting pest Newdow has going for him is that he's right."

He's got some other things going for him, too: He's an emergency physician who claims to have worked in 'hundreds' of ERs:
“I probably worked in more emergency rooms, conceivably, than anybody else, ever,” he says. Newdow still holds medical licenses in California, Florida, New Jersey, Michigan, North Carolina, and Virginia.

He then got his law degree from Michigan (like this future MD/JD is doing). Later on, he became a mail-in Reverend of the Universal Life Church and, in fact, started his own atheist church.

He's been much more successful with the "Under God" legal saga than he has been in the custody battle for his daughter.

An odd duck, to be sure, but I'm not going to give in to magazine psychiatry I've practiced before. Rather, I'm going to take solace that in this nation of ridiculous cases against medicine, in a world where the malpractice bus can visit your neighborhood ER, there's one doctor who having some success litigating something.

The decision will probably come in about a month.

UPDATE: That mobile lawyer / malpractice van link above is now host to a vigorous, fact-filled debate on malpractice and insurance boogeymen. Check it out.

Career differential

What's the best defense against hospitalism?

...maybe it's hospitalists!

I must admit, "a hospitalist" is climbing on the list of Things I Might Be When I Grow Up, or Finish School, Whichever Comes First.

(and if anyone knows any other opposed ist/ism pairs, I'd love to start a collection).

(and no, suggesting something like: "environmentalists are the worst advocates for environmentalism" doesn't count).

There's much more on the web regarding hospitalists, hospitalism, as well as list of other antagonyms.

Welcome to the Jungle

Susan Kruglinski writes a pleasant essay in today's NYTimes about how conceptualizing current math and physics research is damn near impossible, even for the researchers.

Talking about his recent pop-math book "Millenium Problems," Stanford mathematician Keith Devlin explained, "What the book was really saying was, 'You're not going to understand what this problem is about as a layperson, but neither will the experts,' '' he said, adding, "The story is that mathematics has reached a stage of such abstraction that many of its frontier problems cannot be understood even by the experts."

Columbia physicist Dr. Brian Greene, however, takes it one step too far:
"'Our brains evolved so that we could survive out there in the jungle,' he said. 'Why in the world should a brain develop for the purpose of being at all good at grasping the true underlying nature of reality?'"

I know what he's getting at, but Greene really contradicts himself. What evolutionary advantage do humans have, except for being good at grasping reality? (I'd thank the anthropologists out there to remain tactfully silent about long-distance running and being omnivores).

In fact, the only reason mathematicians and phycisists have pushed their fields into the realm of the unimaginable is because they've consistently applied the same tools -- conjecture and reasoning -- honed in studying simpler, more intuitive phenomena. These tools were first applied for survival, and later, comfort and enlightenment, before reaching a zenith of autoaffirming social and scientific commentary.

Damning Evidence

An old friend was in town this weekend. She's in residency now and mentioned the buzz around this JAMA story about how evidence-based medicine (EBM) was put on trial, and lost.

I was all set to blog about it, but found that new blogger Kevin, M.D., had beaten me to it. Check out his nice summary of the case, in which a resident (and residency program) was successfully sued for adhering to federal guidelines on PSA (prostate-specific antigen) testing.

What gets me is that those USPSTF guidelines are put in place, not just to save money but to save anguish, fear, and unnecessary surgery. There are false positives -- which can lead to biopsies and interventions that carry risks. There are true positives that lead to surgeries or radiation, also with risks. What's more, these interventions have not been shown to prolong or improve life.

But a jury (supposedly, a jury of the physician's peers) found that this pile of evidence and statistics means nothing -- any man over 50 should get the PSA blood test.

And yet, consider what a jury would say if the doctor neglected EBM and ordered PSA tests on people who didn't need to be screened. What if that doctor aggressively followed up a high PSA and started all kinds of interventions that did nothing but disrupt a patient's final years? Is that what they really want? or would they turn around and call it malpractice?

The title of the JAMA piece is "Winners and Losers", and it ends on a truly discouraging note (the winner = the plaintiff's lawyer). The only way I can deal with these miscarriages of justice is to believe that the defendant's lawyer dropped the ball. The author/defendant indicates that they never responded to the plaintiff's attack on EBM -- they seemed to rest on the facts of the case, and the national guidelines.

So, I hope that maybe a better defense lawyer could have responded to the attacks, persuaded the jury, and won the case. This is my wishful thinking, of course, and is increasingly unsupported by the evidence.

UPDATE: the link to the original post at Kevin, MD is fixed. And the original, original article is from the January 7th 2004 JAMA, "Winners and Losers".

Sing, Goddess

McBride's finished sulking in the tent of OB/GYN, and the epic struggle for universal health care takes a surprising turn.

Beware Greeks bearing gifts... and libertarians arguing compassion.

Beyond the pale

Hepatitis A can cause fulminant liver failure up to 1% of infected patients. I once saw a young patient who was at the brink (AST was 12,000 at one point) before her liver started to get better. After she came out of the ICU, all my team could really do was watch and offer supportive care.

We tracked her numbers as she healed. As expected, even as other liver markers start to decline, bilirubin levels show a mild, delayed increase. My patient became a little jaundiced.

Then, during morning rounds on the day of her planned discharge, her skin appeared bronze! The labs indicated her AST was now below 1000, and her total bilirubin was only 5.4, up a few notches the day prior.

I ran these trends by her, but added, cautiously, that I couldn't explain why she looked so much more jaundiced today.

She laughed and revealed, "I just put on my tanning cream."

Of course. Something to add to one's differential of painless jaundice: Nosocomial spread of tanning cream.

UPDATE: Tanning is apparently a common side effect of the phototherapy used to relieve neonatal jaundice. Who's an expert on this? Dr. Tan, naturally.


Daily Show host Jon Stewart's honorary doctorate speech to the grads of William & Mary is really very good (Hat tip: Grahamazon).

Stewart has a grander scope than Conan O'Brien did in his speech to Harvard four years ago, but then again, these are more trying times. Both comedians also drive home the point that taking risks, and failing occasionally, can lead to success, or at the very least, good comic material years down the road.

I suspect we won't get speeches urging risks -- and failure -- at med school graduation. For real nervous laughs, they might show us a slide of the malpractice van, parked outside a local hospital. Fear can be a powerful motivator, too.

Despite that -- or maybe because of it -- my definition of success is still in flux. Sometimes it seems there's nothing more rewarding than working up a case of Henoch-Schonlein purpura with pulmonary involvement. Other times, I get warm fuzzy knowing I host the #1 google result for the query "Dammit, Jim". I just hope I'm never forced to say, "I'm a doctor, not a blogger."

A cancer in the system

A story making the (grand) rounds last week involved the first case of malpractice, in London, 1424 AD. I can't find a record of this story online, and this book seems to suggest malpractice existed at least 75 years prior to the case below. Nevertheless:

A surgeon / barber was asked to close a cut on a thumb. He tried several times before succeeding, ultimately causing much bleeding, distress and scarring. The patient sued, and a panel of medical peers agreed with the plaintiff.

What did the surgeon do wrong, precisely? He failed to take into account the Gemini moon -- and its obvious associated coagulopathy.

Today, malpractice cases would never be decided by pseudoscience like astrology. Instead, we study mistakes and come up with powerful statistics about vocal inflections. Progress!


It was fifty years ago today that the Supreme Court ruled on Brown v. Board of Education. Earl Warren wrote that, when in comes to educational doctrine, separate is inherently unequal.

Today, in Massachusetts, this grand notion is applied to marriage.

In RI's Providence Sunday Journal (registration required), M. Charles Baskt writes:

As it happens, tomorrow -- May 17, 2004 -- also will mark another turning point in the nation's life: Because of rulings by the Massachusetts Supreme Judicial Court, gay marriage will become legal in the Bay State. Charlotte Whiting of the [RI] court's public information office says the overlap of dates is strictly a coincidence.
Lawmakers proceeded to ask if "civil unions" would be an acceptable substitute for marriage. On Feb. 4, the court said no:

"The history of our nation has demonstrated that separate is seldom, if ever, equal. For no rational reason the marriage laws of the Commonwealth discriminate against a defined class; no amount of tinkering with language will eradicate that stain."

The judges said civil unions would maintain a "stigma of exclusion that the Constitution prohibits."

It's May 17th -- a great day for a Union.

UPDATE: Andrew Sullivan, writing in the New York Times, says it better: it's Integration Day.

Can't buy a thrill

The medicalization of my vocabulary proceeds apace; I palpated my first thrill last week. This sounds more exciting than the reality: a 3/6 heart murmur jumps to 4/6 if you can feel its vibration on the chest wall.

Dave Barry would note that there's several good potential band names embedded in the paragraph above, and he'd be right. "Big Sur" -- the new single from the Thrills -- has been stuck in my head. This song sounds like Ivy, more lounge-ish and retro compared to the earnest, jangle-pop "One Horse Town" from last winter.

"One Horse Town," it must be noted, features no murmurs, rubs, or gallops.

UPDATE: Medpundit points out these sites, which will come in handy in due course.

The best of both worlds

Medpundit thinks the new Blogger interface isn't as friendly as the original.

In a presumably unrelated but sequential post, she goes on to describe how her "kids and husband have an intuitive grasp of things that I have to work very hard to comprehend" -- regarding the foreign language of math. She sets up an interesting contrast between her world, and that of the mildly austistic: Maybe everyone's doing dozens of calculations per second, but instead of math, most of us are calculating the meaning facial expressions, gestures, tone and inflection.

More in Mark Haddon's new book, the Curious Incident of the Dog in the Night-Time -- written from the perspective of an autistic teenager.

When we win

I've been wondering what, if anything, to say about Abu Ghraib. Commenting on the ups and downs of the war seems best left to the pros. I've been attentive to arguments that our security may not have been improved by invading, and could accept that the WMD intelligence was too flimsy to fully justify the war. But I've always bristled at the suggestion America had sinister motives for bringing democracy to the heart of the Mideast. I silently agreed with Toby Zeigler's blunt quote (from the West Wing last year) -- "they'll like us when we win."

But the atrocities at that Iraqi prison, I don't think I can believe that anymore.

Why is Abu Ghraib so much more devastating, in my mind, than setbacks in Fallujah or the WMD scandal or any of the bombings or mismanagement over the past 12 months? And what comes next? Andrew Sullivan has written an incisive, moving series over the weekend on these issues. Here's an except:

Yes, I know that the implications of this do not extend to our entire endeavor in Iraq; it is still a noble, important and worthwhile thing to accomplish. In fact, it is perhaps more essential that we get it right now and, by a successful end, remedy in part the unethical means of Abu Ghraib. But I cannot disguise that the moral core of the case for war has been badly damaged. It would be insane to abort our struggle there now because of these obscenities. But we will be changed even in victory. I believed the WMD rationale for this war and that still survives, though with greatly diminished credibility. But I believed in the war fundamentally on moral grounds. When doubts surfaced in my head before the conflict, I kept coming back to the inadequacy of the alternatives, i.e. keeping a crumbling Saddam in power, and to the moral need to replace a brutal dictatorship with freedom. By any objective standard, that rationale still holds. Iraq is a far better place today than it was as a police state, and its future immeasurably brighter. But what this Abu Ghraib nightmare has done is rob us of much of this moral high ground - and not just symbolically or in the eyes of others. But actually and in the eyes of ourselves...

...I want us to get over this but I also don't want us to get over this. The betrayal of our ideals is too deep to be argued away. Images in this media-saturated, volatile world can have more impact than any words. But the impact will, I think, be deeper on Americans than on an Arab street where hatred for this country runs high in any case. And that is how it should be. For these pictures strike at the very core of what it means to be America. We must expose, atone for, and somehow purge ourselves of this stain, while fighting a war that still must be fought. And it will not be easy.

This post is called "A Sleepless Night" but there are many others. Read the whole thing.

UPDATE: David Brooks delivers as well, complete with a shout-out to Reinhold Niebuhr!


The other day on rounds, I saw a patient with an oval pupil. She looked ... feline. I took it as an incidental finding (my mind was really on presenting the next patient, and finding some coffee) but it's possibly quite serious, according to several sources. Damned cool-looking, though: click on "oval pupilla" at this site for a glimpse, or check out this stunning view of the iris in Adie's pupil (which, I must say, is also on my differential).


I've been going back and forth with fellow med student bloggers about how to improve public awareness of health issues. Applying regulatory pressure on snack-food industries? In-your-face shock tactics? Free coupons for Tofutti?

I know how my class felt when we were handed a fragment of a 20-year old male's aorta, and got to feel the early atherosclerotic changes already underway. The sensation was a combination of queasiness, selfish concern, and resolve. How do you bottle and distribute that?

Slate's David Edelstein has a new movie review, with a potential answer:

For Super Size Me, Spurlock came up with a magnificent stunt - but one that seemed to leap from the collective unconscious of our fast-food nation. He would spend a month eating nothing but McDonald's food, three meals a day, and if they asked if he wanted it supersized, he's say, 'Yes, I would!'

What follows is apparently so vile, viewers may never look at a quarter-pounder the same way again. Is this why McDonald's has ended super-sizing? One thing's for sure: I'm lovin' it.

Accentuate the positive

Unlike the recent utensil tragicomedy, this one will probably have narrower appeal. Still, it was good for a chuckle when overheard at morning report:

    Latina resident: "The patient had no peripheral edema, but was noted to have jello skin."
    New England-bred intern: "Are you referring to the skin turgor?"
    Resident: "No."

Provincial jankee.

May is for...

...major surgery. Seems like a lot of people I know are going under the knife this month. Fortunately they're young and fit and will no doubt come through it with flying colors. Doc Shazam's already on the road to recovery, so stop over at Mr. Hassle's and wish her well, too.

Academic Revolt

John Wilson has written a fascinating piece on disgust in today's Globe.

He starts by saying "To dwell too much on disgust is to risk losing any sense of the object of study" -- and then proceeds to do just that. But what a ride! I'd never really equated the disgust one feels about poop, to the disgust one can feel about poverty statistics. Fortunately, people like Martha Nussbaum have, and she's addressed its suitability as a theory of morality.

Drawing on Rozin's theory of disgust and adding some wrinkles of her own, Nussbaum claims that disgust is fundamentally motivated by our "fear of our animal bodies" and our awareness of our vulnerability, above all our mortality.

... "It may even be," she writes, "that many, or even most, human beings need some form of [disgust] in order to live, because we cannot endure too much daily confrontation with our own decay and with the oozy stuffs of which our bodies are made." But it's an inhospitable world she imagines, in which most of us are consigned to live in delusion.

His choice of "inhospitable" may have been a coincidence, but through the whole article I was thinking about the nurses at my hospital. What happens when you deal with disgusting things on an hourly basis, every day? Do you become acutely aware of your mortality -- or at the other extreme, desensitized to moral outrages?

I'd venture: the former. Is it fair to compare Mother Theresa to that famous germophobe, Donald Trump? We might learn from those who embrace disgust, and those who run from it.

You can see where you fit -- take the quiz yourself (different scales for men and women!) and learn more about this revolting field of study.

Full Capacity

Gross Anatomy and 2md are on a roll lately -- which seems like the appropriate response to the mounting stress of second-year spring. Why else do class shows occur right before the Step I exam? It's creativity in the face of selective pressure; flowers do something similar this time of year.

Both sites have recently tackled the role of medicine in allowing self-destructive behavior.

2md asks, if anorexic patients can be hospitalized against their will, why not the morbidly obese?

Grahamazon wonders if double-stuffed oreos shouldn't include a picture of atherosclerosis on every box (among other things).

I remember this kind of idealism (or paternalism, more accurately) from my pre-clinical years, when the unhealthiness of the Western lifestyle was drummed home. There's a lot of backpedaling from this beginning with third-year, when armchair philosophy is forced to compete with tight schedules, long lists, and the already-atherosclerosed. Not to mention the elaborate denials, defenses, and patient enablers that flatly reject your appeal to reason.

Even so, there are times when patients lose their rights. My recollection from my psych rotation: patients can be said to have lost their medical decision-making capacity if they cannot meet Appelbaum's four criteria:

    1. Communicate and maintain a choice
    2. Demonstrate a factual understanding of the situation (diagnosis, prognosis, risks and benefits of therapy)
    3. Appreciate the siutation and its consequences (you could die without intervention, etc)
    4. Manipulate data rationally to arrive at this decision

I'm leery to post anything on anorexia, since they're a resourceful cohort that have used the web to sustain their pathology before. But I think it's safe to say they get tripped up on #3; anorexics simply don't think they're close to death, and they could still stand to lose a few pounds.

In my state, when a patient is found to lack medical decision-making capacity, a hospital representative takes it to a judge. If the courts find a patient to lack competency, a guardian is then appointed and given limited powers regarding the decision at hand. In the case of an anorexic patient, the guardian would approve resuscitation and psychiatric interventions.

The situation with capacity in the morbidly obese seems more ambiguous, mostly because their prognosis is less emergent, and the interventions more diverse. Unlike anorexia, I don't think many obese people are opposed to their doctor's recommendations. If anything, I suspect they get tripped up on criteria #1 -- they cannot maintain the choice to eat less. Do you appoint a guardian to follow them around, watching their diet and making them take the stairs?

The increasingly indicated therapy for a BMI over 40 is bariatric surgery, but I'm not aware if there are legions of obese patients refusing this option. Given the explosion of this field in recent years, it seems that many are amenable to it, when it's offered. No guardianship seems necessary in these cases.

Cooney once wrote that a competent person chooses to run risks, an incompetent person simply runs them. At first but it seems glib to me: plenty of competent people forget to put on their seatbelts, or ask for that extra helping of dessert. But Cooney's phrasing is growing on me. If there's a matter that's important to you, but you continually fail to treat it that way, well, yes, you lack capacity in that area. If your family and doctor are on top of things, they should call you on it, and see that you get help. This is how it should work for alcoholism, for eating disorders, and for other destructive behaviors.

What my fellow bloggers may be getting at, though, is intervening before overeating leads to morbid obesity. This, actually, is too paternalistic. Not all obesity is pathological, and the jury's still out on whether the health risks come from obesity or the sedentary lifestyle that accompanies it.

The issue in intervening in these destructive behaviors isn't the medical community's lack of vigilance or authority. Rather, it's a failing of human nature: many diseases move glacially, and inertia is a hard thing to overcome. There are plenty of people who come into the doctor's when a tiny mole changes, but there are others who can convince themselves that nothing's wrong even as half their face is eaten away by cancer.

How do you fight this facet of human nature? I don't know -- but I'm more disposed to raising awareness and fighting inertia in the people who need it, rather that taking away their rights.

As a postscript, I'd like to mention some published discussions of the consequences of Appelbaum's capacity criteria. For instance, one could argue that any patient who disagrees with a physician's recommendations hasn't, in fact, "appreciated the circumstances" of his or her illness (criteria #3). i.e., if they really did understand and appreciate the relevant facts, they'd go along with the proposed treatment, right? Contrastic views on this and other topics have been nicely addressed by Wenger and Stone.