Automatic for the people

In Complications, Dr. Atul Gawande visits the Shouldice Hospital in Toronto. They do hernia repairs there. In fact, that's pretty much all they do. Inguinal hernias all day, every day. Shouldice may mark the start of a new trend, the proliferation of health care "focused factories."

Not surprisingly, the Shouldice surgeons are the best in the world at hernia repairs. They have far fewer complications, and their hernia repairs are less likely to need revision ten or fifteen years down the road. What's more, they are faster than general surgeons. They can see more patients. And, not insignificantly to me, their 'surgeons' require a lot less training -- in some cases just a year, as opposed to five years of residency for an American general surgeon.

Doesn't the lack of variety get boring? Apparently, the doctors there take pleasure in the pursuit of perfection. And general surgeons here will tell you every operation gets to be routine after a while.

In fact, Gawande links the Shouldice operation with other 'routine' stuff requiring lots of training -- reading EKG's, diagnosing appendicitis, and the like. I used to think that giving someone lots of time to get the job done would help reduce errors and improve results. That's not true. Dr. Lucien Leape notes that "a defining trait of experts is that they move more and more problem-solving into an automatic mode."

This, I think, is why residency is so grueling. The goal is not just exposure to a wide variety of problems, but to force automatic decision-making. It's surprising to me, but as Gawande says, "Novel situations ... require conscious thought and 'workaround solutions' which are slow to develop, more difficult to execute, and more prone to error."

I think a lot of people go into medicine because they enjoy tackling interesting problems. And yet, the goal of medical training is to make these encounters routine and uninteresting.

I keep coming back to the airline industry, which I suspect is in agreement with Dr. Gawande. No one wants pilots who pause to enjoy the unique challenge of a foggy night landing. In research, it's not easy to get grants without using familiar techniques to tackle predictable, solvable questions. And in medicine, I guess, patients don't want their doctors to say "This is really interesting!"

Rise of the machines

Gawande takes it one step further -- if expertise means mind-numbing routine, can human judgment be replaced by computers? He cites a big EKG study pitting a world-renowned cardiologist vs. Lars Edenbrant's diagnostic algorithms (a pity Lars didn't call it Deep Red or ENIAKG or something).

The computer caught more abnormal EKG's than the cardiologist. And when it comes to things like appendicitis, where surgeons are expected to operate unnecessarily 15% of the time, computers can probably do better, too. Humans are distracted by things like "that memorable case last week" and "the patient's mom was really scared" ... computers know just the right weight to put on disparate data points like age and WBC and fever and vomit.

This leads to two scenarios for doctors: either factory-style expertise in one very narrow field like hernia repair, or acting as a liaison between the patient and the computer diagnostician.

On a second look, the liaison-scenario isn't so bleak, or so different from what goes on now. In family practice, a lot of visits are devoted to collecting information, going over test results, educating patients about different options, and counseling on health problems. In the future, we'll simply be adding computer diagnoses into the mix (my palm already has the Framingham Heart MI calculator -- just plug in cholesterol and age and blood pressure and other variables, then find the risk of heart attack over the next few years).

In fact, Gawande suggests doctors will have more time with patients this way -- more time to interact and explain things, less time spent coding bills and writing up differentials. I'm not sure that's true, but in terms of time spent with patients, it beats the focused-factory approach.

The bottom line is improved outcomes and patient ("customer") satisfaction. Who wouldn't go for more time with primary care docs, less time waiting for surgery, improved diagnoses, and reduced complications?

Maybe doctors will oppose it. I think my fellow med students and I still share a bit of the romantic notion of the generalist physician -- seeing all kinds of patients, diagnosing everything from papilledema to ankle fractures. If the idea of narrow factory-style specialization, or turning over diagnosis to the computer, is unsettling for us, imagine how tough it is for doctors already practicing.

No (job) satisfaction

There are so many songs exulting love and relationships -- are there any songs about a satisfying job? Going to work excited, coming home fulfilled?

Imagine it this way: no one has any trouble thinking of a love song. Cloying songs about parents, children, brothers and sisters are harder to come by, but certainly out there. Off the top of my head, I can think of a few semi-recent pop song about man's best friend (Sublime has at least one, and Suicide Machine's "Sometimes I Don't Mind" sounds like it's about a girlfriend ... but then takes a detour). There are also countless songs extolling cars and liquor.

But there are only a few dozen recognizable songs about work. A quick google search reveals this topic is being tossed around right now on the Boston Job Blog. Here are a few entries, from there and other sites:

Huey Lewis: Workin' for a Livin'
Tracy Chapman: Fast Car
Jim Croce: Working at the Car Wash Blues
Billy Joel: Allentown
John Lennon: Working Class Hero
Parton, Dolly: 9 to 5
Styx: Blue Collar Man
Donna Summer: She Works Hard for the Money
Creedence: Proud Mary
Rush: Working Man
Francis Dunnery: American Life in the Summertime
Elvis Costello: Welcome to the Working Week
Jon Bon Jovi: Livin' On A Prayer
Offspring: Why Don't You Get a Job
R.E.M. : Finest Worksong
They Might Be Giants: Minimum Wage
Bruce Springsteen: umm.... all of 'em
Dire Straits: Money for Nothing
Johnny Paycheck: Take this Job and Shove It
The Police: Synchronicity II
Kool Moe Dee: I Go to Work

The thing is, all these songs (and the others appearing when you google "songs about work") are kind of bluesy. Or angry. Work is hard, working for the man sucks, work is killing me, I'm not making ends meet, etc. This is still undoubtedly true for many Americans, but surely there should be some kind of "opposing view" -- just like there are love songs and breakup songs. I could compromise: maybe there's a tune about the ups and downs of owning a small business, somewhere.

How about the soundtrack to Rocky? "Gonna Fly Now" comes close to what I'm talking about, except there are only about 6 different words in the whole song. Also, I don't want to include vague inspirational stuff, otherwise "Faith of the Heart" and "I Believe I Can Fly" get lumped in.

UPDATE: Songs about the music industry don't count.

Tell me about your childhood...

I thought I'd like my psychiatry rotation, because I tend to enjoy interviewing patients. It turns out I like the rotation for completely different reasons. But the interviews -- whether it's with depressed patients or borderlines or even the occasional schizophrenic -- have not been what I expected.

DF once said that the reason he liked psych is because conversation with patients becomes diagnostic and therapeutic. And Dr. S says the mental status exam requires years and years of training to perfect. From what I've seen, I agree. And if regular conversation becomes so loaded with power and danger, it's no wonder there are so many restrictions on its use: Don't introduce yourself by your first name. Don't joke with the patients. Don't bring up aspects of your life. Don't clue the patients in on what you're thinking. Don't try to educate the patients.

Granted, there are very good reasons for these guidelines. I just hadn't realized how much I've come to rely on humor and personal examples on my other rotations. It makes sense that a third year would resort to these means, and now that it's prohibited, I'll probably develop new skills and end up a stronger interviewer. But I'm missing the give-and-take, and the bonds I used to make with patients.

Playing for Sweeps

A friend just emailed me a question -- is piercing the cartilage of the upper ear more dangerous than piercing the lobe? He asks, because it's going to be featured on tonight's 10 O'clock News Health Check. Since I got my PhD in chondrocyte mechanotransduction, he figured I'd be an expert.

Well, I'm not. I mean, I could guess that infection and damage to the upper ear is potentially more disfiguring than the lobe damage, but hey. They're teaching me stuff in medical school that's, well, much important to more people.

The other day I heard a radio promo for a Health Beat Special Investigation: pharmacies leaving OTC meds on the shelf for too long! Some are several months past expiration!! How can this be?? More at 11!!!

You only hear about this kind of Hard-Hitting Investigative Reporting during Sweeps months: February, May, and November. For some reason, this is when advertisers decide allocations and actually pay attention to ratings. So, in addition to all the best TV shows and TV movies airing at the same time, the local news stations go apeshit. In Boston, for instance, Channel 7 just introduced a traffic monitoring system that's so complex and expensive, it might actually be cheaper for them to ferry viewers into the city via helicopter.

And in Sweeps month, the Health Beat reporters put down their JAMA abstracts and head out into the community, where their Hard-Hitting Investigative Reporting will do some real good. God forbid your prilosec is only working at 90% max potency.

I could get worked up about this -- about how the money and time spent on these sweeps month Health Beat shows, or SARS coverage, is essentially wasted. About how no one's health will really be improved by these segments, whereas a widely-viewed one-minute diatribe against sugar or cholesterol or nicotine might get a few people out of 'pre-contemplative' mode.

Even the massive coverage of estrogen and HRT risks last summer will 'only' save a few hundred lives a year. That's huge, of course, but pales in comparison to medical errors, lung cancer, and other preventable forms of death and disease. Using equal-time arguments, public-service announcements about smoking or computerized error-checkering should run continuously, in prime time, from now until mid-October. And start up again next year.

I could get worked up about this, but I'm not so much railing against networks ignoring their civic duty as I am railing against human nature. What's more, I'm guilty, too. I'm studying Wilson's disease tonight (again) rather than diabetes or coronary artery disease. I may never see a patient who benefits from my vast knowledge of Wilson's disease, but I'll see DM and CAD every day.

I've commented more on public health priorities here, and here, and here. Even here. Bottom line: if we were really serious about saving the most lives per healthcare dollar, our lives would change catastrophically, and we'd probably end up as a bunch of soulless automatons, working from home, eating only a cellular peptide cake (with mint frosting). But that shouldn't prevent us from trying to make incremental, real improvements in people's lives, one Health Beat at a time.

Full Moon Fever

Atul Gawande's book Complications has lots that's worth commenting on. I'll tackle the shortest chapter first, the one in which none of his colleagues sign up for an ED shift on Friday the 13th. This was the bonus double secret Friday the 13th of March 1998, in which there was a full moon and eclipse.

Gawande scoured the literature, actually showing a mild protective effect for full moons: fewer overdoses. More recent studies have shown no full-moon correlation in ER admissions for cardiopulmonary arrest or maxillofacial emergencies, at least in Europe (Eur J Emerg Med. 2003 Sep;10(3):225-8 and Br J Oral Maxillofac Surg. 2003 Jun;41(3):170-2, respectively). But that 'protective' effect may be real, though: new moon cardiac arrest is slightly higher, as shown by a couple of other studies. Finally, an old (1978) study posits that psychiatric emergencies in Dade County do in fact cluster around full moons (J Clin Psychiatry. 1978 May;39(5):385-92).

As for Friday the 13th, there are some interesting stats. In Britain and in Finland, there were measurably more traffic accidents over several years. The British study went so far as to observe fewer cars on the road (compared to Friday the 6th), but more auto-related ED admissions. Thus, a large attributable risk (52%). The Finnish study, published in an American journal, found that all the extra traffic deaths on the 13th were coming from women, and blame their anxiety on the accidents. I'm not making this up. The references are: BMJ. 1993 Dec 18-25;307(6919):1584-6 and Am J Psychiatry. 2002 Dec;159(12):2110-1. Or just enter "Friday the 13th" at

An amusing survey, but Gawande misses a point: The surgery residents trying to avoid the full moon shift weren't quoting the above data. Nor were they observing pagan superstitions. What they were doing, I think, was participating in some groupthink, or bowing to peer pressure.

How many call nights have I commented "it's been quiet so far" -- only to be mildly reprimanded by a resident that my remarks will jinx the team? It happens often. It happens in the midst of discussions on physiology, or evidence-based guidelines.

This is, I think, a consequence of the OR mentality. Surgeons don't maintain a sterile field in the OR by reminding themselves of the risk factors for bacterial contamination. They do it by committing a regimented series of behaviors to memory. There are some aspects to the scrubbing and gowning that are clearly not evidence-based, but based on tradition and repetition. Deviating from this would be unsettling. So, too, is jinxing the team or signing up for a full moon shift.

Easterbrook invokes something similar in the Tuesday Morning Quarterback columns. In the midst of his play analyses, in which he often invokes probability and arcane NFL statistics, he'll also talk about offending ye Football Gods with poor etiquette or selfish behavior.

It seems the more complex the tasks, the thought processes, the more likely some kind of rigid codes of conduct appear. Actually, no, these codes are everywhere, regardless of the complexity of the job. It's just that, in the world of medicine and surgery, I'm surprised they're still there at all.

Full disclosure: I've yet to work in the ED on a Friday the 13th, but there was that memorable call last Halloween, when I put in my first chest tube. We were very busy. And Gawande got slammed on his shift, by the way. Tons of admissions.

Another Fine Film Idea

This is a regular feature on blogborygmi, having appeared once before.

This installment: A group of disgruntled Las Vegas Cirque du Soleil performers meets a bunch of disgruntled casino contruction workers. They improbably form a football team. They call themselves: The Vegas Odds.

I should rush this into pre-production, if only because Google keeps deflating my sense of creativity. Over the weekend I was trying to think of a fun catchphrase for the site. What common saying features words that rhyme with blog? Flog. How about: "The blogging will continue until morale improves." Heh. Perfect for a third year medical student, overwhelmed but looking to procrastinate.

But a quick google search revealed 19 different sites using this phrase, on over 1400 web pages.

This is the dark side of connectivity -- realizing just how many people have already thought your thoughts. At least, I suspect it will be hard to search for a football team called "the Vegas Odds". Take that, crummy information superhighway, connecting people with ideas from around the globe.

Evidence for Evidence-Based Medicine

One assigment in my family medicine rotation was to pick my 'favorite intervention' -- something like PSA or acyclovir, and document the evidence for and against it. It was supposed to be an opportunity to learn about absolute risk reduction, number needed to treat, etc... Instead, I tried to be clever.

I wrote that my favorite clinical intervention was the use of evidence-based medicine itself. Unfortunately, I had trouble finding good evidence to support it! Either it's not easy to search for this broad term, or there's no good study out there.

Ideally there should be some kind of comparison of patient outcomes in practices where EBM is rigorously practiced vs. matched practices where physicians treat employ mechanism-based therapies, symptomatic treatment, or just traditional therapies... I can't find this study anywhere, though I admit I'm no expert at these clinical searches and have been limiting most searches to the last 5 or so years (EBM first made its splash over 10 years ago, perhaps studies were done then...)

Old estimates were that only 20% of therapies were evidence-based, some now suggest 37% are based on RCT and 55% or more are based on some clinical trial. Is that enough to separate outcomes from EBM-practices from that of non-EBM practices? Moreover, why would such a study be necessary? EBM seems so obviously worthwhile that many have accepted on faith that it's good for patients. But then again, I assumed Zanamivir would disrupt the flu before the RCT was published. Furthermore, detractors of EBM claim that it erodes the doctor-patient relationship (among other things), which ultimately could lead to increased morbidity.

So, my searches on Ovid, Pubmed Clinical, and Google have turned up some anecdotal evidence on cost reductions and presecription reductions. The best search so far, "evidence for evidence based medicine" (with quotes) on google, which returns about 100 sites.

One of my pubmed searches turned up this gem, which is a simplistic but funny criticism of EBM excesses:

Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.
Smith GC, Pell JP.
BMJ. 2003 Dec 20; 327(7429): 1459-61.
Department of Obstetrics and Gynaecology, Cambridge University, Cambridge CB2 2QQ.

OBJECTIVES: To determine whether parachutes are effective in preventing major trauma related to gravitational challenge. DESIGN: Systematic review of randomised controlled trials. DATA SOURCES: Medline, Web of Science, Embase, and the Cochrane Library databases; appropriate internet sites and citation lists. STUDY SELECTION: Studies showing the effects of using a parachute during free fall. MAIN OUTCOME MEASURE: Death or major trauma, defined as an injury severity score > 15. RESULTS: We were unable to identify any randomised controlled trials of parachute intervention. CONCLUSIONS: As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.

Good laughs. Kudos to BMJ for running it. Other good links about this topic:

Evidence for Evidence-Based Medicine
David Maddison 2002 Lecture Transcript
Family Practice Vol 19 No 6 p 605

I eventually found one paper that treats EBM as an intervention in itself, frankly addressing whether the EBM guidelines used to treat acute low back pain are actually good for patients or just good for the bottom line.This paper was cited as the first rigorous answer to the question: "is there evidence for evidence based medicine?" compared to 'usual' care, in a transcript of a speech on EBM I unearthed on google. It was subsequently found on PubMed Clinical Queries by searching for "evidence based medicine" AND "usual" AND outcomes.

The paper is from McGuirk and Bogduk from University of Newcastle, Australia, called Safety, Efficacy, and Cost Effectiveness of EBM Guidelines for the Management of Acute Low Back Pain in Primary Care. SPINE 2001;26:2615-2622.

Evidence-Based Medicine is faced with a quandry in that it promotes clinical trials (particularly RCT) to evaluate therapies, yet cannot be easily evaluated itself by those same standards. The biases argued to be inherent in ECM, such as overreliance on binary pharm interventions, marginalization of harder-to-examine therapies, and ignoring multi-drug or multi-disease patients, are discussed in a series of short readable articles in Health Care Analysis, 2002 Vol 10 starting on p243. But the low back pain article I eventually found for the assignment does a good job of tackling some of those criticisms. The authors challenge others to examine EBM care within a randomized-controlled trial. In three years since publication, no one's been able to.

Low-carb journalism

A cardiologist at my school recently emailed us his deconstruction of Dr. Atkin's autopsy report. I'd credit him here, but I'm afraid of exposing him to the wrath of the Physician's Committee for Responsible Medicine, the vegetarian group that inappropriately obtained and disseminated the report.

Anyway, the cardiologist noted that Atkins died at 258 lbs after 10 days in the ICU, still had his swan ganz, and was jaundiced. The most important piece of info, though, was his pre-admission weight -- 195 lbs.

He put on sixty pounds in 10 days in the ICU. The jaundice and Swan suggest a multi-organ failure secondary to sepsis / SIRS, and difficulty maintaining blood pressure. His pre-admission weight was 195, but the press latched onto the 258 lbs figure and took the position it so often likes: exposing a hypocrite -- the diet guru who seemed to be fat. I'd call this low-carb journalism: easy to consume, but hard for people to gain anything from it.

There's a lot to dislike about the coverage on this matter. And those investigative reporters who went beyond the "258 lbs" figure ended up citing pathologist Dr. Baden, who incorrectly believed that accumulating 60 lbs of fluid in 10 days is impossible, or medical malpractice. It's a lot of fluid, to be sure, but even I knew Baden's estimate of 5-10 lbs of fluid as appropriate is too conservative.

I think there are real stories to be reported here. In the 10 months since his death, the Atkins logo has appeared everywhere, from Subway delis to candy bars. Is this what he was really planning? Or are profiteers exploiting his name and work? When you consider that his recommendations were first published 30 years ago, and the diet first made headlines about 7 years ago, it's odd that the marketing push would occur now, just months after his death.

Or, if a reporters ever used calculators, they'd learn that even his pre-admission weight of 195 lbs leads to a BMI of 26 (he's apparently 6'0"). That's slightly overweight, even before the bags and bags of IV fluids were pushed.

And finally, I'd like to hear more about the Physician's Committee for Responsible Medicine. If the press follows stories with a hint of hypocrisy, they might get a kick out of "responsible" docs publishing private medical records and apparently getting away with it.

Book blogging

I'm thinking that the last three interesting nonfiction books I've read -- Progress Paradox by Gregg Easterbrook, Short History of Nearly Everything by Bill Bryson, and now Complications by Atul Gawande, are so chock-full of useful info that they might be worth bookblogging.

Google returns about 18,000 sites with the word bookblog, but to me it means posting your impressions on each chapter, as you progress through the book. Obviously something like this works better for nonfiction, and particularly for mostly-unrelated collections of vignettes like Bryson and Gawande have written. But with running commentary from the blogger and their devoted readership, it'll play like a book club in motion, chapter by chapter.

Two things that have intrigued me so far about Gawande's book are his experience on Friday the 13th, and his thoughts to medical error. I'll tackle them tomorrow, methinks.

The Friday the 13th he describes had to be in March 1998 -- because it combined the 13th with a rare full moon AND eclipse. You don't see that much anymore.

Slick production values

My medical school's second-year Class Show was last night. I think it was pretty good, but I missed a lot of the references to other students, to the newer profs and classes, to certain events... I know about three first-years and five second-years, and the curriculum has been substantially revamped since I was a second year, in 99-00. The jokes I did get -- about squid axons, histology, MBB -- have gotten a little stale on my sixth viewing. There were some cringe-worthy jokes about gays and Asians, but also some impresive musical numbers. I'll never listen to "Brick" by Ben Folds Five without thinking of standardized patients in leg warmers.

It's like I'll never hear of "My Sharona" without thinking of "My Trachoma", or how I automatically change the words to "We are the World" to be about pathologists lamenting the decrease in autopsies. I look back on my class show with a lot of fondness. I staged managed, I wrote and appeared in a funny skit, and I worked with some very talented, smart people. The product was something we were proud of; but more than that, it signaled to many of us that we were interested in more than medicine, or research.

No idea what CD and DF are up to since the class show, except that they're PGY-2 and probably very busy. I've managed to try my hand at DJing and fiction writing before settling on freelance opinions, editing, and blogging as my avenue of expression. For a while, there was also an interest in geocaching, but there's a limited range of emotion you can express through a GPS and hiking boots.

Currency with a poor exchange rate

CNN reports on the NEJM "medical mystery" X-ray contest I participated in:
The 62-year-old man came to the emergency room of Cholet General Hospital in western France in 2002. He had a history of major psychiatric illness, was suffering from stomach pain, and could not eat or move his bowels... Dr. Lindsey Baden, an editor at the journal, reported that 666 readers in 73 countries -- mostly doctors or doctors-in-training -- contacted the journal to try to solve the mystery. Almost 90 percent settled on diagnoses consistent with pica, but only 8 percent correctly identified coins. "

Yay, me, in the top 8 percent (of readers with time on their hands). Of course, I had preparation last October, with a psych/surge patient who swallowed needles. Still, I was surprised by the sheer value of the coinage in the NEJM case: US$350, or twelve 'pounds' worth. This is one of the few occasions where "pay as you go" works well for doctors and patients.


a little help from my friendster

Writing about the woman in Kerry's almost-scandal, the New York Observer's Alexandra Wolfe observes:

"The point is that somewhere on the assembly line of media sausage production - whether it be in the land of Drudge, Fleet Street or ABC News the switch got flipped that identified Ms. Polier as a bona fide news story, one that would make the world forget about Janet Jackson's 40-year-old breast.
What happened next is what happens - and what will happen - to every child of the digital revolution who has ever filled out a user profile, I.M.'d her friends with idle gossip or programmed her browser to accept cookies: An army of reporters and gossip columnist went to their keyboards, called up their favorite search engines and began to construct a digital doppelganger of Alexandra Polier from her Friendster profile, her Associated Press and Columbia News Service bylines, and every little crumb and clue she had left behind in the bottomless storage vaults of the Internet. What cracks were left were filled in by the thick, spittle-moistened glue of dozens of bloggers who knew someone who knew someone, or didn't know anyone but had a great theory. "

In my article last summer in the Telegram, I hastily dismissed the bloggers' newsmaking capacity. In the wake of the Iraq war, my thinking was that armchair pundits can only comment on the news. But of course, more and more news is unearthed online -- going way back to the Heaven's Gate website. How much hard data on the Smoking Gun is actually stuff from other websites? Not much, but more every year.

Alex Polier has an online presence; this became news that bloggers can break from the comfort of their homes. Right now, there's not much to report -- other than that she presents herself rather unusually. But as today's twenty-somethings go on to make waves, their online proclamations, archived way back when, will come back in play.

Imagine it like this: Some bloggers are making much of Kerry's 1966 interview with the Harvard Crimson, and his post-Vietnam congressional testimony. What if Kerry had a website back then? Would he have rambled on a little longer, said some inappropriate things, linked to some dubious sites? Would he be friendsters with Jane Fonda?

I better shut up, lest all the publicity generated by this site suddenly backfire and destroy my career(s).

We like the moon's marketing potential

James Taranto of WSJ's Best of the Web Today is just learning about the Spongmonkeys:

"Are Cambodian eating habits the inspiration for the strange new ad campaign promoting the Quiznos Subs fast-food chain? The ads, which you can watch in Flash format at the Quiznos Web site, feature a musical pair of animated creatures--one sings, the other plays guitar--that look for all the world like wild-eyed mutant rodents. Mmmm . . . toasty!"

This reminds me of when "All Your Base" made it onto the front page of the Boston Globe. There's something very satisfying in discovering some silly web cult hit and watching big media editors catch on. Can they appreciate the absurdity? Do they publish it out of a sense of camraderie? The joy of spreading the silliness? That's why I showed the Spongmonkeys to my advisor and so many others. Big, infectious laughs.

But the Moon Song didn't make the leap that the Dancing Baby did. Not yet, at least. But the new Quinzos campaign may insert the Spongemonkeys high in our collective consciousness. Maybe as high as dirigibles or zeppelins or lightbulbs. Or maybe clouds. Or also puffins I think they go quite high too. Maybe not as high as the moon, 'cuz the moon is very high.

But I digress. The Houston Chronicle has a story on the new wave of flash animation (The Moon Song, The End of the World, and Homestar Runner) -- comparing it to the previous generation's Laugh-In and SNL.

The new web cartoons have several advantages over broadcast sketch comedy. It's easier and faster to spread the word about flash animation among peers, and keep the uninitiated, well, uninitiated. Sounds like an advertiser's dream, right? This method of propagation has some disadvantages, too. The ease of producing and transmitting 'flash' animation, the fickleness of the target audience, and the lack of mainstream penetration all suggest faster turnaround time between the latest catchphrases. Even has to keep at it, introducing more absurd characters (eh, Steve?) every week, or risk losing its audience.

Quinzos Subs will win in the short term by capitalizing on the Spongmonkeys... I'll betray my beloved Subway sometime next week to check out their new store on Park Ave. But I suspect that in a year or so, a mainstream Quinzos will have more mainstream ad campaign.

borborygmi, or grumblings from deep in my belly

I finally found a bunch of med student blogs. There's a list of medical blogs, broken down by author's education and slant, on and another one on

The first-year bloggers are woefully earnest. The intern bloggers are knee-deep in minutiae. And no third year with an eye on his transcript is wasting time blogging.

So much of the time, it's just not what I want to read, or write.

Lord knows there's enough going on in my psych rotation to fill a blog, but when I get home I'm anxious to switch gears. Usually the closest I'm willing to get is talk of medical error reform, which I find fascinating and of paramount importance. I suppose I might enjoy commenting on some patient and doctor encounters. And getting an ulcer about HIPAA.

Check out Mr. Hassle, started at the same time as this blog, with the same template. More gizmos, though, and more referrals. And tales from the ED! Going to follow that one for a while, see how that kind of writing fits me.

Everybody's a critic

The NYTimes: reports on the complex underworld of Amazon book reviews:

"'That anybody is allowed to come in and anonymously trash a book to me is absurd,' said Mr. Rechy, who, having been caught, freely admitted to praising his new book, 'The Life and Adventures of Lyle Clemens,' on Amazon under the signature 'a reader from Chicago.' 'How to strike back? Just go in and rebut every single one of them.'
Mr. Rechy is in good company. Walt Whitman and Anthony Burgess both famously reviewed their own books under assumed names. But several modern-day writers said the Internet, where anyone from your mother to your ex-agent can anonymously broadcast an opinion of your work, has created a more urgent need for self-defense."

The article suggests the obvious first step to remedy is to adopt something like eBay's reliability system. People are far more likely to buy from eBay sellers with good recommendations, so maybe Amazon customers will trust reviewers with solid track records.

What's striking is this Amazon situation shows that competitiveness is everywhere, even among what I thought was the small, congenial world of academic novelists. Maybe it's like road rage -- not seeing the face gives you license to act impolitely.

Something worth considering is that Helen Klauser, who has written more Amazon reviews than anyone, is reviled by some of her competitors. It's like the geocachers who hated CCCooperAgency or WaldenRun. If you don't have the time and the means, you can't compete -- this is true for business and research as well as online endeavors.

Another point: An anonymous review by a work's author may not be so malignant -- you can view it as an attempt to explain some of the motivation and technique that went into it, sort of like jacket-liner notes. The problem comes when reviewers are shoehorned into giving "thumbs up" or "five stars": That's when an auto-review becomes indefensibly biased. It may be worth looking into the distribution of Amazon ratings: on their five-star system, you'd expect the mean, median, and mode rating to be 3 stars. The mean may well be 3, but the mode could very well be 1 or 5 stars. I suspect there's an amost upside-down bell curve distribution of ratings, reflecting the polarization of reviewers that "loved it" or "absolutely hated it".

Life is but a meme

Every now and then Cecil Adams and the The Straight Dope rise above their self-adulation and write something insightful.

"What do memes add to the conventional understanding of the propagation of culture? Just this: They remove the element of conscious choice, making the process purely mechanical. Just as natural selection accounts for mankind's origins without invoking God, meme theory accounts for our cultural edifices without positing a 'self' or a 'soul.' That solves a long-standing philosophical conundrum: If we accept the idea of an unbreakable chain of cause and effect at the molecular level and take the materialist view that our brains are just complicated arrangements of molecules, there doesn't seem to be any room for free will. Susan Blackmore, in The Meme Machine (1999), argues that with memes there doesn't need to be. Free will and the sense of self are illusions. I'm not an independent actor, just an assemblage of memes (a 'selfplex'). Things happen not because 'I' make choices but because of interaction between the memes of which this 'I' is composed. One objects: So how did you write your book, lady? Blackmore's response: Creative types don't create; they're merely vehicles by which evolving memes manifest themselves. ('The book wrote itself.') Sounds like the woolliest college bull session ever, I know, but even if you don't buy it you've still got to think: Whoa. "

I bet in some of these books, people are working on Meme metrics, ways of rating which memes will proliferate. Then we could get into the realm of hypotheses and predictions. Of course, the reason I just thought of that is because the scientific method meme has been so successful. Right?

This stuff smacks of V's story about potatoes manipulating humans into growing them. A neat, late-night-college way to look at it, but not terribly useful. Potatoes and memes and technology will propagate, not because they're particularly catchy, but because they help us, improve us, make us happy. Even the pop-tune memes. Any meme metrics will show that Christianity and the Scientific Method proliferated because they improved people's way of life. In its own way, so did the Macarena.


Go public, but post less. What a winning formula. Thing is, I'm writing other stuff, so at least I can sleep easy. If I had the time.

Anway, I'd like to keep gathering data on the meme that media proliferation has only led to narrowcasting, with different ideologies and demographics becoming more isolated from each other and more of a closed-circuit with their sources. (It's important to remember the media is, um, a media, and not a true source, so if you're diagramming this, emphasize the moderate increase in newsmakers, actors, authors, etc but the dramatic increase in channels, magazines, internet and the straight, nonoverlapping circuits between demographics and their media.

Of course, I can't do graphics on this blog, but there is
an image
that's a pretty dramatic illustration of the same idea. I'm curious about the methodology, and I would be reluctant to generalize or even say it's a new phenomenon. But pretty dramatic. And who knew there were so many far-right or far-left books?

Or, take the Dean campaign. Please. This article by Ryan Lizza (if it was Rynn Liza I'd chuckle) describes the closed-circuit phenomenon, in this case with the "media" being replaced with "other Deaniacs" :

For the most part, though, the atmosphere on election night is oddly detached, as if everyone were watching a race in which they weren't actually participating. ...
We walk out of his office and hover over the clot of desks where the Internet team is busy posting to the blog and checking the temperature of the Deaniacs who are commenting online about the night's bloodbath. Nobody seems dispirited. Neel talks to Teachout about his appearance on her radio show that night and jokes about how his posts are being received by the Deaniacs. He raises his hands in the air and yells, "I want to blog!"

Yay, we finally have a candidate who interacts directly with his supporters, raising money from the little guys (still) and bypassing the fat cats and the biased media. But they alienate the unplugged masses everywhere they go. They haven't won any elections. And they persist, preseved in a vacuum, as the real world campaigns move forward.

Sports vs. Entertainment

Michael Holley reads my mind and has a partial response:

We are talking about a team that has won 14 games in a row and has managed to hold on to its humility. Can you imagine what a General Motor like Warren Sapp would do and say if he played on a team that had no losses since Sept. 28?
Most of the players have no desire to be American idols. That becomes a problem for them only when it's time for the biographies to be written. The Patriots are the most talented team in football, but they are a talented team stuck in a culture that obsesses over celebrity.
It's not enough to be talented. People want your talents to scream, shout, and do splits. The Patriots just bore you with competence and technique. So while a nation will be surprised when New England's 'no-name' offensive line controls the 'big-name' Carolina front four, the players will shrug.
They do it all the time. They have been doing it since early October. They have done it against the NFL's best teams and against both of the league's co-MVPs.
It always amazes me when I hear football fans -- and in some cases, ex-players and coaches -- who don't understand this. It's as if they want a football team to satisfy their sports and entertainment appetites. The Patriots will tell you to check out Chris Rock or 'The Lion King' for pure entertainment. For football, they are the best in the industry.

Holley, of course, made the Sportswriter's Pantheon with his fearless and accurate gameday column of how the Pats would stay ahead, and ultimately beat, the Rams in SBXXXVI. His writing is accesible to both fanboys and then general public (compare that to Shaughnessy, who writes for the mainstream but tends to bore the hardcore fans).
His argument about the Pats acknowledges what I've noted in a previous post: The Pats are efficient and competent and play great games, but lack that egomania that leads to crossover cultural appeal. Then again, Brady was at the SOTU and Vinatieri could probably run for Governor ("He'll kick ass on Beacon Hill"). Maybe competence will trump showmanship.

Up against a wall

Shipley writes about his op-ed job at the NYTimes:

These differences are important because Op-Ed, in some measure, is shaped by its neighbors. The Op-Ed editors tend to look for articles that cover subjects and make arguments that have not been articulated elsewhere in the editorial space. If the editorial page, for example, has a forceful, long-held view on a certain topic, we are more inclined to publish an Op-Ed that disagrees with that view. If you open the newspaper and find the editorial page and Op-Ed in lock step agreement or consistently writing on the same subject day after day, then we aren't doing our job.

Our decisions about which essays to publish aren't governed by a need for editorial variety alone. Among other things, we look for timeliness, ingenuity, strength of argument, freshness of opinion, clear writing and newsworthiness. Personal experiences and first-person narrative can be great, particularly when they're in service to a larger idea. So is humor, when it's funny. Does it help to be famous? Not really. In fact, the bar of acceptance gets nudged a little higher for people who have the means to get their message out in other ways — elected officials, heads of state, corporate titans. It's incumbent on them to say something forthright and unexpected. Op-Ed real estate is too valuable to be taken up with press releases.

After all, we don't have a lot of space. On a day with two columnists and an advertisement, Op-Ed has room for about 1,200 words of type. That's it. (Speaking of those advertisements: we have nothing to do with them. They're sold, placed and scheduled by The Times' advertising department.) These unyielding boundaries mean that Op-Ed cannot harbor any aspirations about being encyclopedic. ("All the views that are fit to print?" Not a chance, alas.) For this reason, important subjects, issues and ideas will go uncovered. Op-Ed will inevitably be subjective and idiosyncratic.

These space considerations can be frustrating for editors and contributors alike. Roughly 1,200 unsolicited submissions come to our office every week via e-mail, fax and the United States Postal Service. Many of these submissions are first-rate — and most get turned down simply because we don't have enough room to publish everything we like. How do we know they're good? Because all submissions are read; many are reviewed by the entire staff; some are hotly debated before a decision is made.

Sigh. USAToday told me they get something like 150 submissions per week. At least it's comforting to know someone read my station fire piece, before not contacting me.

What's particularly daunting is that I'm sort of planning for a regular post at some future regional paper. Something I can do in conjunction with seeing patients. Not sure if it'll be a Sci / Health / Tech Chet Raymo sort of column, or broader. But it still takes me the better part of a day to craft a publishable piece. (I suspect my problem is a reluctance to edit my own work so soon after writing it, thus, I ignore Lamott's advice about 'shitty first drafts' and take longer to craft something perfect).

I think pretty much anyone, with a few days' training, can do an H+P on an outpatient. To do twenty a day, years and years of schooling and training are necessary. I suspect it's the same with writing opinions. Which means it's a wide-open question whether any city paper will hire someone who can only churn out a few columns a month.

The good news: this blog has demonstrated there's no shortage of ideas. And there's plenty of opportunity for practice with Worcester Medicine, and maybe studentJAMA. Just like my first H+P's took forever, maybe someday I can crank out the columns. And every now and then, take a column, put some extra polish on it, and try for the NYTimes.