Now it can be told

Keeping with this week's theme of premature debuts, our new group blog -- called The Lingual Nerve -- is up and running.

It's a few hours before the planned July 1st launch, but hey, it's past midnight somewhere (namely, in Singapore, where the blog's originator lives and works).

As you might have guessed, Lingual Nerve will sport an international flavor, with other bloggers based in the UK, Australia, and the US. But we plan to keep writing the insightful medical commentary and stories that our readers have come to expect.

I'm thrilled to be working with this talented group, and eager to see how this unfolds. Bookmark us and come along for the ride...

The silence of the stats

Rangel points out a positively morbid WSJ column by Larry Eastland in which he attempts to make a point about abortions. He examines what fellow WSJ editor James Taranto politely calls the "Roe Effect":

The number of abortions accumulate in size and political impact as the years roll along. Like an avalanche that picks up speed, mass, and power as it thunders down a mountain, the number of Missing Voters from abortion changes the landscape of politics. The absence of the missing voters may not be noticed, but that doesn't mean its political impact disappears.

Eastland goes on to cite statistics that liberals are more likely to abort than conservatives. Assuming kids will vote like their parents, he reasons, America has lost more Democrats to abortion than Republicans in the decades since Roe v. Wade. This demographic shift was enough to give George W. Bush the margin of victory he needed in 2000.

It's fascinating, disturbing concept, which I think Eastland has pursued it. He's collected a lot of data, to his credit, but not nearly enough to clinch the case. Eastland acknowledges he's making an assumption about children voting like their parents. He doesn't, however, acknowledge another key assumption he's made: that abortion means fewer children. I'm not sure that's true.

I can think of a few examples of colleagues and friends who had a child very early, and as a consequence, haven't had other kids. On the flip side, those who wait until they're financially secure, older, married, etc, might be more inclined to raise a large family.

Is the effect I noted above enough to reverse the missing voter trend? It doesn't even have to be: Another Eastland assumption is that these missing voters would have voted like their parents. But how many adults switch parties as they age and start families? I remember that adage, "if you vote Republican at 18 you've got no heart, and if you vote Democrat after 40 you've got no brain."

In other words, growing responsibility, home ownership, and I think, starting a family -- all tend to make people more conservative. And I suspect conservatives have larger families, but which came first: the political leanings or the SUV full of kids?

As for Democrats and abortion, are they damned if they do, damned if they don't? And is the answer the same among Volvo-driving New Englanders as it is among poor Southern Baptists?

Eastland has stumbled onto a dissertation-sized topic. He needs to examine the assumptions that babies born in a world without Roe wouldn't cost their parents children down the line, wouldn't change their parent's political leanings, and would, in fact, vote like their parents. Further, I think each assumption's truthfulness varies by geography, religion, and socioeconomic class... even family size. It's not an easy question, and certainly Eastland's facile first analysis fails to convince me.

The one point Eastland is trying to prove is: liberal policies are costing them elections. Of course, this is true, but probably not in the convoluted, ghastly way he suggests.

And Rangel's got more -- about some liberal policies that might be saving pregnancies.

UPDATE: A thorough analysis is up at the Church of Critical Thinking. The comments include stats on infant mortality and voter rates for twentysomethings, further minimizing the "missing voter" effect.

Tabula Rasa

It's getting harder to defend the drug companies. Despite mounting evidence that pharmaceutical company gifts and lunches influence physician prescriptions, I've argued in the past that this is beside the point -- there's no evidence that free lunches harm patients. Besides, there are many financial considerations influencing doctors' decision-making, from Medicare reimbursements to preferred drug lists to the curricula of state-run medical schools. It almost seems like corporations are being unfairly singled out.

But then you hear stories from the Sunday New York Times, like the doctor who received an unsolicited check for 10 grand:

Schering-Plough's tactics, these people said, included paying doctors large sums to prescribe its drug for hepatitis C and to take part in company-sponsored clinical trials that were little more than thinly disguised marketing efforts that required little effort on the doctors' part. Doctors who demonstrated disloyalty by testing other company's drugs, or even talking favorably about them, risked being barred from the Schering-Plough money stream...

...In return for the fees, physicians were supposed to collect data on their patients' progress and pass it along to Schering-Plough, the doctors said. But many physicians were not diligent about their recordkeeping, and the company did little to insist on accurate data, according to Dr. Pappas and the others.

One of the nation's most prominent liver disease specialists, who spoke on condition of anonymity for fear of angering big drug makers, called the trials "purely marketing gimmicks."

...Six specialists in liver disease said Schering-Plough also paid what it called consulting fees to doctors to keep them loyal to the company's products. The letter accompanying a check for $10,000 explained that the money was for consulting services that were detailed on an accompanying "Schedule A," said a doctor who insisted on anonymity. But when the doctor turned to the attached sheet, he said, "Schedule A" were the only words printed on an otherwise blank sheet of paper.

It seems we're getting closer to scenarios from a bad Robin Cook novel (I can't remember which one had the doctors get brainwashed on a pharm-sponsored cruise).

So, this leaves me in a fix. I can either throw out the argument that conflict-of-interest doesn't necessarily mean harm to patients, or I can wait for new evidence that it does. Maybe I can conduct one of those corporate pseudo-studies to find out.

Or maybe all the proof I need is already out there -- written on a sheet of paper marked "Schedule A."

UPDATE: Chase raises a good point (in the comments below and on PoorMedicalStudent: it takes two to tango, so doctors should also be held accountable for taking a bribe. Anjali recently noted that doctors are on trial in Italy for just such an offense. Still, there is such a thing as extortionary pricing, and I think the law -- and ethics -- demands more of rich corporations than of poor medical practitioners.

Consilience, part 2

Hot on the heels of his triumph in Dodgeball, William Shatner continues to collaborate with my favorite entertainers -- in this case musicians Ben Folds, Aimee Mann and Joe Jackson.

If you heard Shatner's soliloquy on Ben Folds "In Love" (Fear of Pop, 1998) then you've probably been waiting for their next collaboration. That is, if your head didn't explode right then and there.

The new album is called "Has Been." So far it reminds me of "We Are the World", but smaller, featuring only aging ironic hipsters, for no greater good other than kitsch. Is this how my parents interpreted the Dean Martin roasts?

Cat's in the cradle

I've yet to meet another blogger, though I correspond with several and follow the posts of many more. It's tempting to believe I know what these people are really like, especially those that write with clarity and passion. Grafting elements of the personalities of my friends and family to these ethereal blogs seems almost natural.

So, when I see a blog change direction over time, it makes me wonder. Has the writer found a new voice? A new passion? Is this who she really is, or always was? I question my first impressions, and review older posts. And I think of my own past, and my friends' experiences, and the detours we've taken in the name of love, charity, or philosophy.

And I remember the friendly-but-concerned inquiries I've made -- and received -- over the years: "You seem different, is everything ok?" and its variations. It's a tricky question, which could be answered with a scowl, a smile, or utter denial. So it's not easy to ask. It's even harder when one clumsily tries to frame the question in terms of "missionary zeal" and the downside of an Instalanche...

...So when the answer comes back, with the warmth and grace of this post, it's humbling. I'm comforted that all's as it should be, and relieved that my awkward overture across the miles was understood -- by someone I've never met.


I've resisted aggregators for so long, but in the past few weeks has become a fixture. It's partly because some of my regular must-see sites have been dormant lately, and partly because there's so much new material to be covered.

Medlogs reminds me of my school's holiday parties, or convocation cocktails, or any occasion where we mix the normally separate divisions of the hospital. A quick peek at the medlogs categories is like mingling at one of these get-togethers, catching bits and pieces of conversations from familiar faces and new voices.

Most of the attendings and administrators are talking about malpractice and hospital policies. Some slick businessmen are milling around -- are they selling something? The residents are often venting, and passing along suggestions. The nurses are swapping stories. The students are spread out all over the place, looking for more free food.

It's easy to keep within one's familiar circles and conversation topics, but you'll find some students bravely mingling in the attending section. Others will be going on and on about non-medical things, but it's interesting enough to make you listen in, even as you wonder who they are and how they got into the party.

Some new finds:
  • At last, another MD/PhD student! Only, Synthesis and Output has been blogging much longer than I have.

  • Practice Makes Perfect, a career-oriented doc with a penchant for words.

  • When in doubt, Push Fluids. Clinical-years students in New York City, with all that entails.

  • Justin Tsai. You can't say he's tackling the big topics, but it's compelling reading nonetheless.

  • The thing about mingling, though, is it's tougher to settle down and contribute to a conversation. One concern with is that it'll stifle reader comments -- ya can't see 'em from their site, and you're less likely to visit a blog if you've just read the latest post on an aggregator. (Something's gotta explain the dearth of opinions lately). And it seems kind of arbitrary which blogs are indexed in toto, and which get the blurb treatment.

    But is currently the best bet for one-stop shopping -- that is, until group blogging catches on...

    Three-way collision

    To the teeth is on a roll (and I even agree with her on a few things).

    But where does she stand on the all-important seatbelt debate? I think it's enlightening to see how Trent, Cameron and I responded to Cut-to-Cure's soul-searching over seatbelts. The PT used study data and principles to arrive at a reasonable, consistent conclusion. 2md waxed poetic about how personal interconnectedness must outweigh abstract principles. And I made a puerile observation. One issue, three blogs in a nutshell.

    And now that Cameron's a third year, 2md is no more. Be sure to visit the new site, called "ThreeMD" ("3md" was already taken, and choosing a word that looks like it should rhyme with "reamed" seems appropriate).

    Incredible Bulk

    There must be an advantage to myostatin, the gene that keeps our muscle bulk in check. But right now, it looks like there's a lot of upside in life without myostatin. Blocking myostatin could be great for astronauts, cancer and AIDS patients, and people too busy to work out. Just look how ripped this myostatin-negative boy is (NEJM, subscription required). Pics of him as an infant are reprinted at Apostropher. Now age five, he is more than seven standard deviations above age-matched boys for quadriceps CSA.

    Will we learn someday that Schwarzenegger, Charles Atlas, or other bodybuilders / athletes were myostatin mutation heterozygotes (carriers)? After all, the boy's mother is, and she was a professional athlete herself. Will athletic regulators have to look out for a new class of performance-enhancing substances? It might depend on what cardiomyopathy or bony abnormalities awaits this young boy. His vigilant doctors have found no cause for concern, yet.

    UPDATE: Medpundit looks at the boy's pedigree chart and surmises, "one night stand." But she says it more poetically, I think.

    UPDATE: A breathtaking overinterpretation of this story is underway at Gene Expression. But at least some of it is grounded in the historical context of gene therapy for muscle wasting -- a topic I recall fondly. What's so encouraging about this myostatin news isn't that we can knock out genes to create superhumans (!) -- it's that this protein regulates notoriously hard-to-fix structural proteins, and since it's secreted, it can be easily blocked. If you've seen cachexia or Duchenne's, this news is plenty to get excited about -- even without our tendency to invoke Marvel superheroes.

    UPDATE: CNN has picked up the story, and there are more comments and links at Metafilter. I mentioned this at the gym today, thinking they might be interested. I told him how Wyeth was working on antibodies to myostatin. The Supplement Man was not impressed, and directed me to MyoZap and said it's been available for a while now, "and does whatever those drug companies are trying to do." Funny, it's not on our hospital's formulary...

    Godspeed, Scaled Composites

    How do you know it's the 21st Century? The FAA has just licensed the first US inland spaceport, at Mojave. It's in anticipation of Scaled Composite's suborbital test launch today.

    How do you know the 20th Century casts a long shadow? The spaceport's site prominently asks visitors to "Dispose of trash appropriately. Foreign Object Debris, FOD can pose a serious hazard."

    So we've got private spaceships, yes, but they're still a wee bit delicate. And there are other hazards to watch out for:

    Running a spaceport also means keeping a watchful eye out for Gopherus agassizii. For those of you still living in your shell, that’s the desert tortoise, found in the Mojave and Sonoran Deserts of southern California. This tortoise was listed as threatened under the California state Endangered Species Act in 1989.

    "Ironically…at 300 takeoffs and landings a day, nobody asked us to ever do a tortoise check. But before I can clear a spaceship to land, I have to do a tortoise check of the primary runway," Witt said.

    The future is a lot like the present, only moreso.


    Blogborygmi will never delve into movie reviews, but heed this recommendation: if your childhood concepts of 'hero' came from Captain Kirk and Michael Knight, then, as you grew up, you found yourself enjoying into the bizarre buddy humor of Swingers or awkward timing of Mystery Men, and then, you unknowingly craved some kind of harmonization of these diverse spheres of entertainment...

    ... then you owe it to yourself to see Ben Stiller, Vince Vaughn, David Hasselhoff and William Shatner share the screen in Dodgeball.

    And Jason Bateman is thrown in there too, as the color commentator for ESPN8: "The Ocho".


    What's easier to understand, google pageranks or the clotting cascade? Both seem based on well-defined, well-studied mechanisms but are, in fact, frequently unpredictable. Try dosing someone's coumadin after a course of azithromycin and a diet heavy on leafy vegetables. Their INR could be 2 or 8 and I'd believe it.

    It's the same with Google's pagerank. A mediblog from a certain rising second year had a page rank on 7 last week -- the highest of any medical blogger, anywhere, and equal to the PR of some of the most popular blogs on the web. Today, his site is down to 3. (At least, that's what's reported on my google toolbar. The real PR used by google could been different. But the proof is in the traffic -- I wonder if he noticed a boost, and now a decrease, in visitors arriving from searches).

    And that's just pagerank. As for actual search enging results position (SERP), I'm just as confused. For instance, for a few weeks after this post, my blog was the #1 site for the phrase "dammit, jim" -- Then it dropped to #14, and now it's #5 or so. The recent movement up is likely due to blogborygmi's new pagerank, transient as that might be. But there appears to be a time-sensitivity to search terms, as well. Terms in recent posts get a leg up on other returned google results. I've searched, but haven't found this noted elsewhere.

    Also, as a point of pride, blogborygmi had been the sole returned site for the google search of "grapeshit." Then, for a few weeks, all references to this fabulous word vanished. Then, google returned six results from all over. Now, two. How am I supposed to monitor progress as this term sweeps the nation?

    Based on these examples, it's hard to believe I'm trying to make a point. Bear with me! I just met a toxicology student who, when confronted with a novel patient ingestion, has more luck with google than pubmed. And he's not the only scholar using Google results for urgent patient care.

    Google is a private company, of course, and they provide a free service that works very well. But if the internet is becoming the central repository of human discourse, and Google is the indespensible guide to the internet, there should be more transparency about how it works. Why do some terms rise and fall, while others disappear and come back? The answers might be of trivial importance now, but someday it could be lifesaving.

    Yes, disclosure of the pagerank and SERP algorithm allow for exploitation and duplication of Google's functionality. Even without the disclosure, people have tried to manipulate the system, only to see their sites seemingly punished. Is Google really this petty and arbitrary? Is this what's necessary to make and maintain such a good search engine?

    The bottom line is, will scientists and scholars remain content if their reference librarian pulls books and journals out of a black box and says, "trust me, this is what you want" ? Maybe... But only if they're always, always right.

    High density factoids

    At my school, the outpatient medicine rotation students take a break from the clinic once a week for class. Today we had a dazzling presentation on cholesterol management. Really! Every slide had blockbuster stuff. Some pearls that I can recall, off the top of my head:

  • How low is too low? Aside from low LDL potentially causing myelination problems in children, there's really nothing but benefits the lower you take your (LDL and total) cholesterol. Right now the guidelines are to keep LDL below 160 if there are no other cardiac risk factors, but it's really a compromise so that we don't start the whole nation on meds.

  • Fish oil gets no love from the press or drug companies, but it's great for raising HDL. In clinic I've noticed it's good for skin, too. Maybe also schizophrenia.

  • Via the 4S study, from the perspective of mortality and cholesterol medical management, a patient with newly diagnosed diabetes should be treated as aggressively as a patient who's already had a heart attack.

  • Women's cholesterol rises more or less linearly through their adult life. There's no change in the increase during menopause. Cholesterol in men, on the other hand, plateaus and actually starts to decline after midlife. No one knows why.

  • Zetia! It's fun to say, and it works well in combination with statins.

  • At the end of the lecture, I asked the presenter if he had seen a recent report on seasonal variations in cholesterol, and if so, would he start factoring that into his management strategies.

    He replied that he was already taking seasonal variation into account, because he wrote the report I was citing. I love it when that happens.

    The skinny on his data: total cholesterol is, on average, 4 points higher in men, 5-6 in women, in winter. There's greater variation in hypercholesterolemic patients, though. This variation is largely due to seasonal changes in plasma volume (even as we lose weight in the winter, we retain more water in the blood).

    So, if a doctor starts a patient on cholesterol-lowering regimen in January, and checks the lipid panel again at a 6 month follow-up, the successful decline could be artificially inflated. Likewise, one shouldn't get discouraged by what appears as meager progress from June to December.

    Note: Hat tip to Medpundit with bringing the cholesterol variation report to my attention originally, and I should add that any transcription or interpretation errors in this post are my own, and not the fault of today's lecturer.

    Binding legislation

    Cut-to-Cure's worried that his advocacy of mandatory seatbelt programs is at odds with his advocacy of government noninterference. I've grappled with this, too. One weasely way out: say that you're for full autonomy on private roads, but support any old legislative intervention on public roads! They paved 'em, so let them look after their perceived interests. And sleep easy, slim.

    A valuable question

    Glorfindel's talking about this piece on Michael Porter in the Boston Globe. The gist of both authors is: Porter is has a lot of credentials, so his assessment of US healthcare could cause real change.

    Porter and Teisberg have a deceptively simple diagnosis: Healthcare competition today works on the wrong level. The players -- health plans, payers, providers, and doctors -- engage in what the authors call ''zero-sum competition," dividing value rather than creating it. They seek to transfer costs onto one another, limit access to care, hoard information, and stifle innovation, all to the detriment of patients.

    The right kind of competition should occur at the level of preventing, identifying, and treating patients' conditions and diseases, Porter and Teisberg assert.

    Oh! Ok. I agree; it's deceptively simple. So deceptive, and so simple, that it really doesn't answer anything. I haven't read Porter's HBR paper, though neither of the reviewers above seem to have, either (it costs $495 to download the pdf -- how's that for runaway costs?). Otherwise, they'd have discussed just how Porter's idea for encouraging competition to treat diseases will create savings in excess of, say, excluding the uninsured, the old, the sick. There's value in treating this people, yes, in very human terms. But monetary savings?

    I remember Bill Clinton asking, ten years ago, why market forces do such a good job generating value in many industries, but fail so thoroughly in healthcare and education. He called it the most pressing question facing America. I don't think Porter has come up with the answer.

    Newdow standing down

    I observed in an earlier post that Michael Newdow was having more success with his Pledge of Allegiance case than his child custody case. The Supreme Court, however, saw these cases as intertwined; they decided that Newdow did not have standing to bring a case on behalf of his daughter, and threw out the argument 8-0.

    Couldn't they have figured this out before all the hype and preparation, which culminated in a presentation before the Court that observers called, "dazzling?" Did they have to wait to hear Newdow's argument before they decided it couldn't be made?

    Eugene Volokh and Jacob T. Levy have also weighed in. But any comment (other than that old standby, "feh") seems to be treating the decision with more care and thought than the Court has demonstrated.

    Headlines readers like to read

    The Boston Globe Sunday Ideas section continues to impress blogborygmi. First, the deputy editor called me to confirm some corrections to one of last week's articles. This act proves, once again, that the blogosphere does keep Big Media honest. At least, until Big Media comes calling, at which point bloggers start stammering and praising effusively.

    Second, however, is this week's Jan Freeman column, in which she addresses a topic dear to me: cliches in headlines.

    The reader who raised this issue, Jeff Smith, was complaining of too many uses of the same tired phrases (his Lexis search of "what's in a name" turned up 900 references in the past two years).

    I wonder: how many citations did Smith encounter, on his own reading, over the past two years? No more than a dozen, I'd wager. And even though a dozen might seem like a cliche to some dedicated readers, it's the kind of subtle reinforcement of literature that binds a people together. Freeman explains:

    E.D. Hirsch, that energetic crusader for a common culture, provides a neat illustration of the problem in his "New Dictionary of Cultural Literacy," the 2002 edition of his compendium of words and concepts literate Americans should know. Naturally, Juliet's "What's in a name" is here, along with "star-crossed lovers" and Hamlet's "The lady doth protest too much" and "to the manner born." ...

    ...In Hirsch's view, these are not junk cliches but essential elements of a shared American culture. If we swore off all our proverbs and familiar quotations, they would no longer be familiar -- they'd be back in cold storage with more obscure allusions like "perfidious Albion" and "Belshazzar's feast," familiar only to a well-read elite. That won't happen, of course: These phrases are well-worn precisely because they still have force in contemporary contexts; they make up one part (however threadbare) of the cultural fabric, recognized (however vaguely) by many speakers of English.

    That still leaves the practical question -- how much use adds up to overuse? Editors make that calculation every day, judging whether a quotation, proverb, or turn of phrase is annoyingly or reassuringly familiar, used up or still amusing. Sometimes a fad gets out of hand, and warning flags fly around a newsroom: No more "kinder, gentler," or "'Tis the season," or "mother of all" anything!

    ...A cliche-checker could be set to ration a publication to, say one "Horatio Alger story" a month, or two Macbeth quotations, or six uses of "Orwellian." The job might be Herculean, or even Sisyphean, but hey -- if it's worth doing at all it's worth doing well.

    Damn, she's good. Freeman gives insight into the minds of writers and editors, defends a practice we're all accustomed to but rarely question, and drops a lot of references, to boot.

    I think she could go further and deny that these phrases are really cliche at all. Sure, all these phrases are indexed on the nifty cliche finder, but if you're using a common phrase in a new context, it ceases to be tired and instead, validates. These phrases serve as bona-fides that the writer's no hack; he or she demonstrates a command of the canon, which lends authority to what's being argued.

    Also, I think these well-worn phrases act to familiarize and comfort readers, making them receptive to whatever new ideas are coming across. Readers need this kind of coddling! Check out this old dictum from an interview with fabled editor and headline-writer John Shea (via Romanesko):

    Keep it conversational and never underestimate the pleasure derived from a doo-dah headline.

    People don't just process printed matter in their heads, Shea would tell me. An inner voice reads them aloud, so it's important to consider how a headline sounds as well as what it says. Which is why conversational is so much better than those awkward, overpunctuated, language-of-their-own headlines that populate a lot of papers.

    Headlines that follow the cadence of "Camptown ladies sing this song" are particularly popular. This point was driven home on an old Brunching Shuttlecocks entry: Twelve Actual AP Headlines Which, When Followed By 'Doo-Dah, Doo-Dah,' Can Be Sung To The Tune of 'Camptown Races'. My favorite example? "Man in Wheelchair Hit By Train."

    Doo dah, doo dah. It's harder than it looks, as my own attempt (above) shows.

    Impossible to ignore

    I remember the commute into Longwood every morning, the exhilaration of being paid to think, to analyze, to experiment. It was my first summer doing research, and I felt my career taking shape.

    On the radio, I was listening to Francis Dunnery sing about "American Life in the Summertime." And that Cranberries song. Cheesy pop, but that somehow made it more poignant. Mountains were climbed, movies were watched, and friends converged at the all-nite Burger King. Through it all, a Greek pined for a Turk. It was a strange time, but it set the tone for many summers to come.

    My favorite sportswriter just took a break from the humor and coverage of the Olde Town Team to look back at other memorable moments of June, 1994.

    When health freezes over

    From the May 2004 Wired, Wil McCarthy writes on the latest in cryonics:

    "Right now, we can easily bring animals back from two hours of absolute clinical death," says Hal Sternberg, BioTime's VP of research. "No pulse, no respiration, no measurable brain activity."

    The astounding thing is that the animals show no sign of physical or neurological damage. Over a period of weeks, the animal returns to its cute and cuddly self.

    The FDA hasn't approved BioTime's procedure for humans yet, but with Hextend already on the market as a blood-volume replacement, Sternberg expects the green light in as little as three years. And when that happens, it will not only improve surgical safety, but also make way for longer procedures that no surgeon would dare attempt at room temperature, such as separating adult conjoined twins fused at the head.

    BioTime has other cool stuff in the pipeline, including HetaFreeze, a solution called a cryoprotectant. This substance makes it possible to freeze tissue grafts - BioTime has tested it with skin and hair - without disrupting their cellular structure. It may allow whole organs, such as hearts, and even intact (but brain-dead) organ donors to survive partial freezing.

    I got into a debate or two after this post in which I described participants in modern cryonics as "selfish and misguided." I still believe that's true, but it seems the day might come when cryonics is medically prudent.

    (tip of the hat to Transterrestrial's Andrew Case).

    More facts, less fear

    The new blog from the American Council on Science and Health, called Facts & Fears, is up and running. Add it to the list of sites doing a good job clarifying health news, dispelling misconceptions, and calling the media to task. The medical section is too sparse, and is too broad. Hopefully Facts & Fears will be just right.

    Their writers have even weighed in on the obesity crisis that made the blog rounds last month, including a new take on the movie, Super Size Me. Check it out.

    Out-Cold Play

    Eighth-graders in Cape Elizabeth, Maine are conducting extra-curricular physiology experiments:

    Teachers and parents in Cape Elizabeth are warning middle school students about the dangers of deliberately making themselves pass out, a developing trend among youngsters in the community...
    ...The process of inducing the fainting, which the students do to themselves, involves deliberately hyperventilating, bending over and standing up quickly, then holding the neck to restrict blood flow to the brain. Possible injuries include falling from fainting, and brain damage from oxygen deprivation.

    I went to college with a guy from Cape Elizabeth; if this is the kind of stunt Mainiacs are pulling these days, then we can all breathe easy.

    And though it's a touchy subject, the local science faculty should seize this as a teaching moment. Kids could have a lot of fun with a blood-pressure cuff and pulse oximeter, in a supervised setting. And maybe learn something more about autonomic vasomotor control.

    Sic transit gloria mundi

    Saw Venus cross the sun this morning...

    ...but this celestial body is going to be tired later today...

    Reach Out, redux

    In last week's Newsweek, Stephen Levy wrote more about the convergeance of cell phones and GPS tracking.

    The prospect of being tracked "turns the freedom of mobile telephony upside down," says Marc Rotenberg of the Electronic Privacy Information Center. His concern is government surveillance and the storage of one's movements in databases. In fact, if information from the GPS signals is retained, it would be trivial to retain a log of an individual's movements over a period of years (just as phone records are kept).

    This is in agreement with my Telegram piece on 5/28, though I thought the movement tracklog would be of more use to marketers than to the government.

    Levy goes on to write that the loss of privacy won't be immediately apparent, until the novelty of cell-based location services wears off:

    Sooner or later, though, it will dawn on us that information drawn from our movements has compromised our "locational privacy"—a term that may become familiar only when the quality it refers to is lost. "I don't see much that will bring it about [protections] in the short term," says Mark Monmonier, author of "Spying With Maps." He thinks that that we'll only get serious about this after we suffer some egregious privacy violations. But if nothing is done, pursuing our love affair with wireless will result in the loss of a hitherto unheralded freedom—the license to get lost. Here's a new battle cry for the wireless era: Don't Geo-Fence me in.

    I think those 'egregious violations' may be something as innocuous, but annoying, as location-based text-message spam -- call it stalkmail, if you will (more in an earlier post).

    Truth and / or Beauty

    The Boston Globe magazine today surveys new developments in the interface between science and art. Harvey Blume's article includes a talk with a Harvard particle physicist, Eric Heller, who tinkers with his subatomic flow diagrams with photoshop (with startling effectiveness).

    Blume also interviews MIT's Felice Frankel, who's carfeul to call her scientific images a "craft" and not "art":

    "What's primary for me about my photographs," she said, "is that they communicate scientific information. If by chance they also happen to be beautiful, I'm very happy about that. But I feel I'm revealing the beauty that's already there."

    ...Frankel believes that abstraction is a useful element of scientific photographs. "I think a lot of my images are successful because they are abstract," she explained. "That allows the viewer to participate." As she describes it, abstraction is a sort of come-on, "a seduction" that prepares the viewer for "another layer of meaning" -- a bedrock scientific layer that, in the case of microcantilevers, involves the physics of microelectrical systems. For her, abstract beauty is not an end in itself; it leads viewers to the nuts and bolts of scientific truths that underlie the image, and then it peels away -- leaving, she hopes, a readiness to recognize other such representations of nature.

    Frankel's insistence on -- almost a fiercely protective attitude toward -- scientific truth, makes her impatient with artists who ransack science for imagery and metaphor without taking time to understand it. "I get angry," she says, "at artists who create one-liners, who take a sentence from a textbook and make an installation out of it."

    I appreciate her stance. Yet these one-liners might at work with in a different new science-art book Blume mentions:

    In her recent book "The Molecular Gaze: Art in the Genetic Age," coauthored with Dorothy Nelkin, [Suzanne] Anker looks at disconcerting outcomes, real or imagined, of the biological revolution -- for example, a mouse engineered to grow a human ear on its back. This trick was pulled off several years ago by researchers at the University of Massachusetts at Amherst, who later harvested the tissue in order to replace damaged tissue on the ear of a child....

    Anker discusses the mouse with a human ear as an example of what is known among biologists -- and their fellow travelers in the arts -- as transgenics, the cutting and pasting together of elements from two different beings to produce a third. She notes that in Greek mythology, that third was known as a chimera. She also points out that the technique of cutting and pasting was much in vogue among early 20th-century artists, such as Picasso and the Dadaists. "With the advent of the 20th century," Anker explained, "new ways of looking at the world arose in parallel in the arts and in science."

    So it doesn't really matter that UMass researchers weren't thinking about Greek myth or art history when they grew an ear on that mouse. Now that humans can read and rewrite genetic code much as we do computer code, biology may well be the source for the next iconic image. If so, it may not be anything like the graceful double helix.

    The author is incorrect on some of the facts -- the UMass scientists were at the Worcester campus, not Amherst. And, as far as I know, the engineered ear was a proof-of-concept and was not re-implanted in a human.

    But Anker, an art history professor, might be an example of what Frankel was worried about. Why include the mouse with a human ear (shown below) in a book on molecular biology? The human cartilage cells were mixed into the scaffold ex vivo and inserted into the mouse surgically, subcutaneously (the mouse acted as an incubator). Molecular genetics isn't involved at all, unless you count the use of a nude mouse (which has a defective immune system, unable to reject the human chondrocytes). So why is it in her book on molecular biology?

    I don't have the book, so I don't know if they give it the appropriate caveat. One molecular biologist seems to have liked it. The image they probably used is shown below --though the original 1995 CNN health brief has another another iconic image (mice do certain things when they're frightened).

    Posted by Hello

    But calling this mouse a "chimera" is misleading -- the term should be reserved for true genetically engineered chimeras. Otherwise, you could say I'm a chimera because I've got some cat fur on my lap.

    The mouse with a human ear could have been photographed a hundred years ago, if someone had shaved a rodent and slipped an ear under its skin. In other words, the significance of the UMass photo isn't that mice can sprout new parts, but that we can grow cartilage in certain shapes. Yet the under-informed have latched onto this image as heralding the apocalypse.

    Stephen Milloy has tried to enlighten people about this issue in the past. The fact that it's still misunderstood, almost a decade later, implies his work isn't done. And that the image should be discussed as art, comparable to Picasso's minotaurs, is just specious.

    Not too many people are going to hang up a photo of this mouse in their living rooms. But someday, someone whose arthritic cartilage was replaced by these techniques might be able to walk over to Anker's office and discuss the real significance of the mouse experiment. That's the truth, and the beauty, of the UMass photo.

    Update! Harvey Blume responds:

    as to the question of transgenics, though you're clearly right, this mouse was not a product of genetic reprogramming (& i hope i did not imply it was), anker does, in fact, discuss it in that context, though she would probably agree with you fully that she was using that term -- and the term "chimera" -- loosely to make her point. she then goes on talk about phenomena that are transgenic in the technical sense. i think she's simply trying to open our minds to the idea.

    In and Out

    Just started my month of outpatient internal medicine, after a long stint of inpatient. It took the better part of a day to adjust my priorities...

    Me: Did you notice that small lesion on the patient's hand?
    Attending: Yes, I think it's actinic keratosis but I don't like the induration and surrounding erythema. I'm tempted to start a course of 5-FU, but will arrange a derm referral.

    Whereas the same conversation on morning rounds in the hospital might go something like:

    Me: Did you notice that small lesion on the patient's hand?
    Resident: Feh.

    The beauty of this contrast is that future doctors can pick what kind of problems they manage, and in what setting. Feh? Or no feh?

    UPDATE: Feet First illustrates this concept with a nice anecdote. And she points to this wry bit of reporting about a man ... who is "said to be very popular in Germany."

    Click it

    The still-tiny medical student blogosphere is composed mainly of beleaguered twentysomethings posting their disconnected thoughts on what they're learning in the classroom, experiencing on the wards, and hearing from the media.

    Then, there's Trent McBride, who seems well on his way toward writing the book about paternalism in medicine. The third installment is up now. Once again, it's meticulously researched, well reasoned, and forces readers to challenge some basic assumptions.

    I'm not agreeing with his conclusions about the War on Drugs and its relation to prescriptions and infectious disease, but I find myself arguing from the position of, well, inconsistently applied paternalism and intuition-based medicine and policy.

    If I were to research an evidence-based reply, it might start with the BMJ series in 1996 and the running NEJM series throughout 1994 (search "war on drugs" in pubmed). In a NEJM book review on "Illicit Drugs in a Free Society", edited by Bayer and Oppenheimer (registration required), Ernest Drucker wrote:

    A chapter by Harry Levine and Craig Reinarman (both sociologists) examines the lessons of the prohibition of alcohol, our earlier "great experiment" in drug policy. It was claimed at the time that Prohibition was needed because alcohol was "so addicting and dangerous . . . that it could never be regulated." But 60 years later, we do regulate alcohol (and tobacco), and more effectively each year, judging from declining rates of death in alcohol-related auto accidents. Levine and Reinarman suggest that "most if not all psychoactive substances could be similarly regulated." Twelve major scientific commissions on drug-policy reform (in the United States, Great Britain, and Canada) have recommended regulatory alternatives to drug prohibition, but all have been ignored.

    Legalization, in other words, does not imply deregulation. Could McBride abide an end to the war on drugs if it meant increasing the range of the D in FDA?

    Looking at it another way: this weekend's click-it-or-ticket checkpoints haven't done anything for my appreciation of government regulation. I've vacillated on seatbelts before, even though the data on this issue seems clear.

    The lesson from this weekend's checkpoint gridlock is that Americans will put up with infringements in personal liberties if they think it's saving lives. Evidence trumps principle in a lot of these cases. So until there's a better-designed experiment than 1920s Prohibition, drug legalization will still seem like a risky proposition. A slow roll-out of legalization, maybe one drug at a time, with emphasis on data collection and new safety regulations, could go a ways toward easing fears.

    But this is just the disconnected musings of a beleaguered med student. Check out Trent McBride's earlier installment on paternalism, and its responses. I'm especially looking forward about the upcoming sections on HIPAA and Organ Donation.


    Classmate and friend John Harris was on local NPR last week, recounting an interview with a Parkinson's patient. Give it a listen on RealAudio.

    Our school encourages these home visits with sick, elderly patients. I embarked on my first, very self-consciously. I thought my patient might resent my intrusion -- young, healthy, privileged, but still asking for more.

    I walked away humbled. John's experience is somewhat similar, I think.