Resident Alien

I've given two talks this year: one in November and one just a few weeks ago. Both were "Joint Conferences" with mixed audiences.

In November, as I reviewed the PowerPoint slides before I presented, I remember going back to the title slide, and removing the references to my doctorates. In their place, after my name, I entered "PGY-1" -- thinking that maybe the attendings and residents of other department would go easier on the intern.

When I was preparing my talk two weeks ago, hiding behind the "PGY-1" label seemed a little absurd. I didn't think I needed to, anymore, and besides -- my internship's days were numbered. What was the difference between the me of mid-June and the me of July 1st, anyway?

But tomorrow, I think I'll miss that shield of internship. Though the increase in responsibility for EM residents is not as dramatic as in, say, internal medicine, more is nontheless expected of us: To take the sickest patients. Manage our section of the ED. Nail the tricky procedures on the first try -- hell, not just do them but teach along the way.

I recently led a simulation in which I made some mistakes -- I failed to give antibiotics to the sim-patient as soon as I could have; I let him go to the CT scanner with unstable vitals. Afterwards, a resident told me not to beat myself up about the case too much -- "after all, you're still an intern."

Not anymore.

Post-Exposure Pronouncements

Rabies is no laughing matter, but I did chuckle a bit upon reading today's NYC DOH alert. The email subject was:

Rabid Kitten Confirmed on Staten Island

We've come a long way from ominous headlines like "Anthrax in New York" -- unless, of course, that kitten's got some nasty, big pointy teeth...

Goals and Objectives

I'm working on a project for my residency's journal club -- a website to archive the papers we discuss, along with our analyses (if you're wondering about the format -- it's a blog! Just call me Johnny One-Note).

But the project's got me thinking about my approach to scientific literature, and just how much has changed since my research days. I've already quoted that axiom -- "The role of the physician is to express confidence. The job of the scientist is to express doubt."

That quote just deals with the way information is presented and projected, however. I'm now experiencing a fundamentally different mindset when first evaluating the literature -- I'm now asking myself, "will this change my practice?" from the outset, and organizing my assessment of the paper around that question.

It occurs to me that many of my peers have already been doing this, but I recall a time when I was more interested in novel methodology, or surprising conclusions, whether or not it was immediately relevant to urban academic emergency medicine.

Researchers, I think, squirrel away such data for future reference -- you never know when it might prove useful, in explaining a quirky lab result, or building a case for your next grant. Physicians, on the other hand, tend to discard a lot clinical information that they come across -- as though we can't afford to expend mindshare on articles that aren't going to influence decision-making.

The trio of fun articles I covered a few weeks ago on GruntDoc's site has already been boiled down to one high-yield question I can ask drunk college-aged patients (in case you're wondering, my request for handheld lasers in the ED is not expected to go through).

It's too bad -- because reading about a clever experiment, or unexpected finding, can be a true delight. This kind of thoughtful reflection and recollection defines what a scholar is, to me. I hope I can retain some of that, and enjoy the intellect and creativity that goes into many underappreciated manuscripts.


Last week I saw yellow tape go up along my street. Cops were shouting at passersby to turn around. Anyone who emerged from their apartments was asked to go back inside or make their way, escorted, to Third avenue. Without the constant sounds of traffic, things became eerily quiet.

I sought refuge in the cleaners next door; the unflappable woman who works there was ironing behind the counter. "Bomb threat," she told me, offhandedly.

She was right -- I later learned a man had left a suitcase in a trashcan on my corner. It said "A BOMB" in big, taped-on letters. The NYPD closed four blocks within 30 minutes. When they determined the package was no threat, they quickly carted the suitcase away and reopened the streets. Within a few minutes, everything was back to normal. The story didn't even made the evening news, or the paper.

* * *

This morning, I saw yellow tape going up, along my street. A man was setting up red cones along the open parking spaces. Two towtrucks were busily hauling cars away.

"Excuse me," I said, to the man with the yellow tape. "Why are all these cars being towed?"

"Filming a movie."

Oh, yes, we've been here before (though this is shooting literally outside my front door.) I got some details on the movie -- called "The Brave One", starring Jodie Foster... There was one more thing I wanted to know:

"Why move all the cars? What's happening in the scene?"

"A traffic jam."

I love this town.

On a related note: Grand Rounds is up, with a movie theme.

Update: The Reeler's got the lowdown on this morning's towing, and some investigative reporting on how much NYPD is paying to accomodate the filmmakers and inconvenience the car-owners of my fair street.

Agent Provocateur

On the topic of my dear old buddy, who visited this weekend for an MSF meeting, and, as is his habit, made some mischief and provocative conversation with everyone he encountered:
GF: So, your friend, he's, uh, really something.
Me: Of course, he's a member of Doctors Without Borders... but it's also true he's a doctor without boundaries.

I miss him already.

Fat Arguments on Thin Ice

Via Kevin, MD comes news of MedGenMed's latest video (registration required), featuring Dr. Michael Dansinger, excerpted below:
Is that white-coat feeling a little tight? Many physicians are overweight or obese for the same reasons our patients are.[1] Many of us do not eat right and get enough exercise.[2] We work long hours, making it seemingly impossible to squeeze regular exercise into our busy daily routines. We eat on the run and unhealthy food (often served in our own hospitals) is commonplace.

Physicians rally against obesity, and yet, we are not doing all we can. Sadly, those of us who fail to embrace lifestyle recommendations in our personal and professional lives promote a public perception that lifestyle change is ineffective or unrealistic.[3] Despite dramatically increasing obesity rates, we have failed to improve our dismal obesity counseling rates.[4] The physicians who fail to recognize and treat obesity are often the ones who personally fail to heed lifestyle recommendations,[5] and these doctors may sometimes lose credibility with their own patients.[6]

I know we can do much better. First, we must recognize that the human body needs at least an hour of exercise daily for optimum health, and every able-bodied physician should strive to achieve this...

Sigh. Does anyone keep track of all these mandates, to sleep more, eat better, exercise an hour a day, build strong, healthy relationships, etc? Because it adds up to about a 33-hour day, by my calculations.

Go look at the comments to my earlier post -- the physicians who wanted me studying on a Saturday night in residency, rather than having a beer with my new colleagues. Maybe they would allow me an hour a day to exercise -- not for my health, of course, but so I can better counsel my obese patients. I'm guess I'm fortunate we live in an era where I can listen to lectures on my music player at the gym (and, by the way, I drink lite beer when circumstances warrant).

Anyway, back to the video -- I'm not impressed with Dansinger's citations. #5, for instance, seems to imply that doctors with obesity issues are less likely to bring those same issues up with patients. Well, it's based on a mailed survey to 355 pediatricians (!) in North Carolina. If I were a fat pediatrician, I might be a little reluctant to counsel a fat child, myself, because, you know, little kids can't abstract like adults can. But then again, maybe Dr. Dansinger was hoping his viewers couldn't abstract, either.

The important study that Dansinger cites, #6 -- the lynchpin to his whole argument -- is this small survey study from three years ago. Patients from five (5) doctors in Georgia were surveyed about their counseling and recommendations. Two were obese. The patients from the two obese physicians had less confidence in their recommendations about illness and health advice. Fine. What's interesting, and invalidates Dansinger's whole argument, is that there was NO significant difference in patient's confidence on their obese doctor's weight and fitness advice.

Kevin MD's commenters said it best:
I would rather have an overweight Dr. try to educate me about obesity, than some litle skinny guy who never had to watch anything he has eaten in his life.

...Well, who can better explain obesity than one who is suffering?

I don't know many obese physicians, but all of them are working on losing weight. Accusing these struggling doctors of somehow hurting their patients, by citing some ridiculously underpowered and inappropriate studies, is completely unwarranted.

I think Medscape treated this complex issue with more sophistication when they ran my Pre-Rounds interview with Fat Doctor. Yeah, it's anecdotal evidence, but it's honest in a way that Dr. Dansinger's video is not.

Hematogenous Spread

It's been quiet here recently, but that's not to say I haven't been writing.

Aside from the usual medical device love-fest over at, I've been guest-blogging this week over at GruntDoc, which has been fun -- it's a pretty interesting audience, a different group from the fans of Medgadget and Blogborygmi.

I also wrote an article for AAEM's Common Sense (pdf), about how students interested in emergency medicine should arrange their fourth-year curriculum.

There's always Pre-Rounds, with now thirty columns profiling your favorite medical bloggers.

And there are some projects in the works, exciting projects involving over-eating and over-exposure...