Briefly Noted

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

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

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

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

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

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

    Brought to you by Carl's Jr.

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

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

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

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

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

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

    We will float into the mystic

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

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

    Fluorescent and Starry

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

    And, sometimes, you might see your own name.

    Allen Roberts and I were mentioned in a letter to Annals of Emergency Medicine, penned by none other than Jen Jen Oh, the founder of Lingual Nerve (who I finally had the pleasure of meeting, when she recently visited NYC and my hospital). The topic was blogging (what else?) -- specifically, Eric Berger's article on EM blogging (subscription req'd) this past spring. An interesting excerpt from Jen Jen's letter is below, sanse the effusive praise:
    I too have a personal blog, located at, which began in 2002. Although it started out by covering more social aspects of my life, its direction changed in 2003, when I reported on the SARS epidemic in my country. It was eventually mentioned on The Guardian’s Web site and garnered a favorable review. SARS-related entries from that year can be accessed via the archive links on the main page of my blog.

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

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

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

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

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

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

    Program Note

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

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

    Served up by Sermo

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Refer Madness

    A few years ago, when blogs were new, James Lileks wrote about an experience after his domain's registration expired. He learned about it by accident, while surfing the links at

    Anyway, there’s a message on Instapundit telling me my site cannot be found. This is a bit like picking up the New York Times and reading a headline that says JAMES, YOU LEFT YOUR KEYS AT STARBUCKS.

    I was reminded of this tonight, when Joshua Schwimmer emailed his new colleagues at Medgadget to let us know about the National Library of Medicine's guidelines for internet citations. Someone at the NLM has helpfully provided some examples for formally citing blogs. They include:

    3. Blog with optional full names for authors/editors

    Ostrovsky, Michael; Genes, Nicholas; Odell, Timothy; Ostrovsky, Gene, editors. medGadget [blog on the Internet]. El Granada (CA): Medgadget LLC. [2004 Dec] - [cited 2007 May 16]. Available from:

    11. Blog title with upper/lowercase letters, special characters

    Genes N. blogborygmi: a digest of developments in the life of an emergency medicine resident [Internet]. [place unknown]: Nicholas Genes. [2003 Jun] - [cited 2007 May 16]. Available from:

    There are others -- Matthew Holt, Kevin Pho, Kim from Emergiblog, Amy Tenderich, Sid Schwab, Jacob Reider, Thomas Boyle from Code Blue Blog, the aforementioned Joshua Schwimmer, and more -- all make the list (there are many, many ways to cite blogs).

    To borrow from Lileks, it's a bit like thumbing through Strunk and White, and seeing the notes you used to pass to classmates held up as the paragon of good grammar.

    The flip side of that is, in just a few years, blogs have gone from nerdy novelty to stuffy institution. At least I can take comfort in knowing someone at the NLM reads the same blogs I do.

    Spare Us the Cutter

    When I was a fourth-year med student, one of my favorite things was to wake up on an noncall Sunday, read the newspaper(s) and blogs, and find something to write about.

    Fast forward a few years: I've got a boatload of assignments I should be tackling, I'm working a shift tonight... and yet.

    CNN's got a list of Five Operations You Don't Want (hat tip: Clinical Cases). They are: Hysterectomy, episiotomy, angioplasty, Nissen fundoplication, and lower back surgery.

    The article is written by an ex-patient who talked with "25 experts involved in various aspects of surgery and surgical care" and reviewed some data from the government and think tanks. It's well-referenced, and provides many disadvantages and alternatives for each procedure. But, while I know that writers don't often pick their headlines, but in this case "want" is the wrong word -- I've never really seen a patient "want" one of these procedures (with the possibly exception of episiotomy and lower back surgery, and then, only because of extreme pain possibly clouding their judgment).

    The only surgery patients seem to really want (besides cosmetic) is gastric bypass surgery. I'm really surprised it's not on the list -- probably because surgeons know better than to perform gastic bypass unless absolutely necessary.

    Still, patients often mention it to me in the ED -- regardless of the reason they came in. I could be suturing a laceration, when an obese patient could ask me out-of-the-blue for a referral. Or an asthmatic with shortness of breath will wonder aloud if gastric bypass will prevent future exacerbations.

    I don't really know how to view these situations. I'm not an expert on this procedure, but these patients often have limited access to health information. So I try to address some misconceptions and steer them in the right direction.

    Gastric bypass carries a 30 day mortality between 0.3% - 1.9%, which ought to prompt some reflection. Common sequelae include iron and calcium deficiency, ulcers, hernias, infection, and the dumping syndrome. Plus -- this seems to gets patient's attention -- they become more sensitive to alcohol, often unpleasantly so.

    Everyone gets a referral to a primary care doctor for more information -- though I don't know how many follow up. I do think CNN and the media would do readers a service with more reporting on the risks of gastric bypass.

    In the meantime, the above CNN article would be a good deal more helpful to lay readers if it were simply titled "Five Operations You May Not Need." And if the author is thinking of starting a series, I'd be interested in reading something like, "Five Operations You May Someday Need, But Really Don't Want".

    Different Strokes for Different Folks

    The latest Medscape Roundtable, featuring Robert Centor, Graham Walker, Theresa Polick and me writing about the 'VIP' treatment, has been posted.

    Special thanks to our editor, Christine Wiebe, for getting this idea off the ground... and for mercifully, tactfully killing my attempts at VIPoma humor.

    The Stroke's The Word

    In May, when the new ASA stroke guidelines came out, this table's title caught my eye. Now I'm copyediting a piece on stroke management in the ED, and this phrasing is probably the clumsiest part of the manuscript:

    Suggested Recommended Guidelines For Treating Elevated Blood Pressure In Spontaneous Intracerebral Hemorrhage

    My issue is with the unecessary hedging built into the title -- "Suggested Recommended Guidelines."

    Why not just call it, "Some Ideas You Might Want to Consider, if That's OK -- I Know You've Got Strong Opinions About This" ?

    He Helps You To Understand recently linked to a WikiHow post, about maximizing the efficiency of a patient's time with his or her doctor. The article is pretty good, with tips like:

    Describe your basic reasons for the visit in one or two sentences.

    Recall the onset and timing of your symptoms. Include starts, stops and frequency.

    Explain what makes the pain better or worse.

    ...Do not wait till the end of the meeting to say "...and, by the way, I have this other pain".

    Good advice. I never really knew this, before medical school -- I was naive enough to think my physician would love to hear a pre-med's theories about his ear pain. But now I can't believe we don't hand this out, pamphlet-style, in the waiting room.

    The one item on the list that Lifehacker should have paid closer attention to was this one:

    Start talking to the doctor about your symptoms, not what you think your diagnosis is...

    Because a few days ago they linked to WebMD's symptom checker, which is an arbitrary mix of commonsense medicine and diseases lifted from the Hypochondriac Hall of Fame (that back pain could be a muscle strain... or dermatomyositis... or kidney cancer! Ask your doctor about starting chemo).

    What'd be great is if Lifehacker editors read each other's posts, or, better yet, web-based symptom checkers were based on the same cardinal questions doctors ask patients (the Revolution Health checker is a step in that direction).

    That's What Makes Our Town the Best

    Yet another boost to New Yorkers' sense of superiority:

    Americans have gained an extraordinary 33 years in average life span over the past century. A baby born today can expect to live an average of 78 years, compared with 45 years back in 1900. But those gains have not been uniform across the nation. Columbia University economist Frank Lichtenberg reports in a new study that, while average life expectancy increased by 2.33 years nationwide from 1991 to 2004, the increase varied widely among states. Residents of New York gained 4.3 years, the most of any state, during the 13-year period studied and can expect to live 79.2 years. Oklahomans, however, gained only 0.3 years over the same period, to 75.4. (For a table listing all the states, click here.)

    (He's talking about NY state, but recent data on the city is equally encouraging. With the drop in gun violence and AIDS mortality, and, I suspect, before the diabetes epidemic starts cutting into life expectancy, Gotham dwellers are among the longest-lived in the country. Even the smoking prohibitions and revolutionary trans-fat ban aren't yet reflected in this data).

    So what's our secret? I had some theories:

    1. Franklin said that death and taxes are the only certainties in life. But what if more taxes can stave off death? Then New Yorkers would approach immortality.

    2. With so many hospital emergency rooms close by, maybe the nonchalant, inappropriate use of emergency medical services has actually led to some benefit.

    3. Greed is good for you. Also, rudeness and narcissism function like vitamins and fiber, respectively.

    4. We walk everywhere. We walk our way to fitness, and indeed, we walk faster than ever. Even in the dog days of July, when you'd expect others to slow down, the heat just causes New Yorkers to pound the pavement faster. Maybe it's because of the unlocked odors hovering in the air. But it's dramatic.

    Alas, Lichtenberg's work supported other conclusions:

    Lichtenberg measured a number of variants that might explain this gap, including obesity, smoking, income, health insurance coverage, and the incidence of AIDS. He discovered that a primary reason for greater gains in life span is access to new drugs and other medical innovations. For each state, he determined the year that commonly prescribed drugs won Food & Drug Administration approval, and found that those states that skewed toward newer drugs tended to have above-average increases in longevity, when adjusted for other factors.

    Frankly, I'm skeptical. Lichtenberg is an economist, not an epidemiologist (dammit, Jim). He has previously dismissed some fundamental tenets of public health in favor of his theories. According to his recent WaPo op-ed, he's using econometric models to explain mortality, which is (I like to think) ultimately a medical question.

    His work has been funded through the pharmaceutical industry, and a longtime collaboration with a free-market advocacy group called the Manhattan Institute (when I put it that way, it's no surprise he concluded free-market pharmaceutical innovations benefit New Yorkers).

    Also in the WaPo piece, Lichtenberg states that the biggest gains in life expectancy came in NY, NJ, DC, and California -- can it be that other factors he didn't account for, such as health initiatives for immigrants, improvements in infant mortality, or the introduction of more robust state-level health plans -- increased lifespan more than, say, the rapid adoption of the latest statin?

    And if there's merit to Lichtenberg's underlying hypothesis (that access to medical innovations drives changes in life expectancy) then why has the US fallen behind 44 other countries? Has Andorra shot to the top because their drug-approval process is more laissez-faire?

    BusinessWeek said full study should be available at the Manhattan Institute site, but it doesn't seem to be there. So, without true stats or methodology to pour over, I'll do a very New York thing, and trust my gut: The activity level and disposition of New Yorkers (and the strong civic services in the community) has more to do with our longevity than the fact our doctors were prescribing Zocor a year or two before docs elsewhere.

    *The title of this post, as with most of my posts lately, is lifted from pop music lyrics. In this particular song, the noted longevity expert Mick Jagger listed other attributes of Manhattan that he found redeeming, besides the access to cutting-edge medical care.

    The Deranged Millionaire

    A fellow resident physician in the NYC area was updating me about his jury duty stint. I mentioned that John Hodgman (who is an author, writer for the New York Times magazine, comics critic for the NYT Book Review, contributor to McSweeney's, correspondent for the Daily Show, and also, the "I'm a PC" guy) was recently blogging about his jury duty experience here in the city.

    "I know," my friend said. "I saw him. While I was eating pho noodles during the lunch break, I saw him doing the same, two tables down."

    I was thunderstruck, for John Hodgman seems like a tremendous person. I must reconsider pho noodles.

    An interview (on, no less) pretty much proves why Hodgman is so worthy of idolatry. An excerpt is reprinted below (best appreciated if his responses are read in a mild-mannered, erudite tone):

    CC: You once said, "Comedy always tells the truth. That's why it's funny." Can you elaborate on that?

    JH: Not without sounding pompous and stupid, no. The fact is, no one has ever properly figured out why anything is funny. It just is, or is not. Does that evasive little koan suit you better? Because I've got a million of them.

    Alas, his story about the Battlestar Galactica reception is too long and enlightening to reprint here. A more thorough CV of Hodgman is available on wikipedia.

    Originally via Metafilter, which counts Hodgman among its earlier members.

    May Be Unsuitable

    It's almost July 1 -- a natural point for medical folk to take stock of things. The senior residents are working their final shifts with us, packing up for their new attending positions. The rising interns are getting trained in ACLS. And on the blogosphere, we're sizing up the new rankings.

    This site, with its anemic posting frequency, and a layout that steadfastly proclaims its allegiance to 2003, was recently ranked in eDrugSearch's Top 100 healthcare blogs. Blogborygmi made the top 50, and Medgadget, for a brief period, was king of the hill.

    Over on Medgadget, I wrote:

    Let's just say we're not bowled over by the rigor of [eDrugSearch's] system -- too many important blogs are missing, some defunct blogs are included, and a closer look at individual numbers just makes us scratch our heads...

    Nor do we think ranking blog influence is as useful or necessary as, say, ranking hospitals or colleges. The medical blogosphere is a growing community of vital, insightful voices. We have an opportunity to fundamentally change the way health information is communicated. Medical blogs should be surveyed, scrutinized, categorized... but not ranked.

    But... If someone is going to rank them... We're glad we're at the top.

    Shortly afterward, added to their list the incredible British EMS site, Random Acts of Reality, and we promptly became Number Two.

    Alas. Perhaps more amusing than these rankings (which was ultimately a clever PR stunt for a site I initially suspected would install malware), was a movie-style ratings for blogs, that GruntDoc pointed out.

    By counting certain keywords -- like 'pain' and 'sex' -- this service decides if you're PG-13 or rated R.

    Blogborygmi, it turns out, is G-rated -- family fare. But I'm in good company: even HealthCareBS was rated G (and no, it doesn't stand for 'Bachelor of Science'). Mighty Medgadget, with our ongoing coverage of reproductive technology and plastic surgery, was only PG-13. If only we covered drugs (a ratings watchword) we'd be considered more adult: The pharmaceutical development blog, In the Pipeline, was slapped with an NC-17.

    (An aside: It just occurred to me that Bachelors of Science would make a great blog name. But a quick search reveals, unfortunately, a band swept in and claimed it. Makes sense; almost all band names have been taken.)

    Oh well. For years, other bloggers have set up hierarchies and categories based on traffic, links, votes, and other characteristics -- it's only natural, given the easily accessible technology, and our underlying touch of narcissism. Why should medical bloggers be any different? It's in our nature.

    Free for all

    Michael Moore's new documentary on the shortcomings of American healthcare, Sicko, has been pirated and is available on various P2P torrent networks. Last weekend, it appeared on Google Video as well.

    When his film Fahrenheit 9/11 was pirated, Michael Moore said:

    "I don't agree with the copyright laws and I don't have a problem with people downloading the movie and sharing it with people as long as they're not trying to make a profit off my labour. I would oppose that," Moore told the Scottish Sunday Herald. "I do well enough already and I made this film because I want the world to change. The more people who see it the better, so I'm happy this is happening."

    Say what you will about the man, but Moore has put his money where his mouth is (between snacks, presumably). The film reveals Moore donated $12,000 to an anti-Moore site so the webmaster could keep it operational while taking care of his ailing wife (the webmaster thanked Moore).

    For a guy who's advocating unfettered access to something as expensive and important as healthcare, it's nice to see Moore's not shy about making his work freely available, as well. Or, like his critics say, maybe the extra buzz is just good for ticket sales.

    Could Have Lied

    I was ready to come back from a conference in Chicago and write about the rosy state of medical blogging. I'd describe how my presentation on an EM journal club blog was received, and report how physicians are finally becoming comfortable with sharing their opinions online.

    But then I had to work a ton of shifts. And then I saw Kevin MD's post about Black Wednesday, and realized I'd have to write a more balanced entry. And then I saw that others were already doing that, surveying the landscape and summarizing the viewpoints.

    I would have added that the alleged blogger-in-hiding, Fat Doctor, had in fact gloriously returned, and then would try to synthesize this week's news -- that Wall Street's listening in on Sermo's physician forums, and the AMA will endorse this, finally legitimizing what we'd known all along -- doctors' online musings make for compelling reading.

    But then today, the Boston Globe revealed the identity of Flea, and that his activities as a medical blogger prompted his legal team to settle a malpractice trial. Kevin has the coverage, with some great insights from readers in the comments section.

    As I kept reading, I noted that, once again, the comments devolved into a stalemate over doctor's compensation, malpractice liability, and society's expectations.

    Why do so many threads on so many blogs end this way? It's tiresome, and I used to think it was just trolls and newbies... but now I wonder if trading barbs about money and risk is just a natural response to medical blogging.

    A physician's opinion is always worth something. Everywhere these opinions are expressed -- in the clinic, in M+M, in scholarly journals -- regulations and standards have sprung up, to ensure we're not abusing this privilege, and are acting with the noblest of intentions.

    It seems the same forces have begun to act upon medical blogging.

    I'd like to write more about this... Really. But after this week, it's clear -- there's more incentive to share my thoughts in protected communications with graciously appreciative clients.

    The Waiting is the Hardest Part

    Recent events, a new Gap commercial, plus the discovery of a British pop band -- it's got me thinking. Just like Seinfeld had an entire episode where the gang was waiting to be seated at a Chinese restaurant, I propose a musical that consists of nothing more than a woman waiting to be seen in an emergency room.

    Think of it. It'd be a little like Waiting for Godot, but set to music, and with a bigger payoff. There'd be pain, suspense, heartbreak, and the promise of an end to suffering. Everything you'd expect in a musical!

    I further suggest the woman be named Annie. I'd like the enterprising producer who options this project to know, the music will be based on these three songs:

    1. Annie Waits (Ben Folds)
    2. Annie, Let's Not Wait (the Guillemots)
    3. Annie, Get Your Gun (Squeeze... and, uh, the musical)

    We could easily work in The Band's The Weight with its commonly misheard lyric, "Take a Load Off, Fanny" (bonus relevance: the song may actually be about an STD).

    Further inspiration could come from the Annie soundtrack, or Wikipedia's Songs with Annie in the title.

    A show like this prompts lots of unique considerations -- the length of the show could be stretched arbitrarily (Monday shows and matinees, for instance, would always run longer).

    Actors and actresses could be forgiven for sounding flat or moving sluggishly -- they're playing sick! Also, costuming and set design couldn't be simpler.

    Best of all, a show like this wouldn't need a big Broadway opening. It could play in hundreds of sites, in cities large and small, every day. I predict our first year could play to a captivated audience of 100 million.

    Survival of the Sickest

    There was a Daily Show episode last month, where Jon Stewart interviewed Dr. Sharon Moalem about his new book, "Survival of the Sickest." The topic of his book -- that many human diseases persist because they actually confer a survival advantage -- is a recurring theme in medical school, and always something fun to ponder. Stewart asked some straightforward questions, Moalem gave answers designed to flabbergast the lay audience (along the lines of,"Our bodies can rust with iron overload! But we should be thankful we sequester iron so fastidiously, because otherwise bacteria would feast on it, like they did during the Plague!")

    Unfortunately, Moalem didn't have much time to flesh out his ideas, because Stewart, mindful of the audience, kept jumping around.

    I noticed that Moalem wore a yarmulke during the interview, and wondered if he worked at my hospital. Indeed, he does. The very next day, a publishing agent contacted me, offering to send a copy of Moalem's book if I'd review it online . I agreed, and made a mental note to finish the last two books that were sent to me under similar arrangements (yes, blogging's been good to me, Howard).

    But Survival of the Sickest had something going for it that those other books did not -- a long bus trip in which I could sit and read the thing. And it's a quick read, chock full of tidbits and groan-inducing puns.

    Others have pointed out similarities to last year's cocktail-party companion, Freakonomics. Levitt and Dubner's book was about how clever approaches to problems can yield surprising answers. There was no overarching hypothesis. Sickest is a little more organized -- but not much more.

    Moalem uses a few big examples to support the idea that some long-term diseases can provide short-term benefit -- hemochromatosis as a way or warding off bacterial infection, diabetes as a defense against frostbite, and thalassemia, sickled cells, and G6PD deficiency as protection from malaria. All these subjects are treated airily, with a smattering of supporting evidence, and no real consideration of criticism.

    That's ok. This book isn't really about proving a hypothesis. In fact, it truly shines in its asides and extraneous information. One chapter, "The Cholesterol Also Rises," tries to build the case that Africans experience high cholesterol (and its associated risks) because that's nature's compensation for developing darker skin. Darker skin means it's harder for the body to make Vitamin D, but extra cholesterol building blocks would help the process along.

    What makes the chapter really memorable, though, are little tidbits about race, skin color, how light can trigger sneezes, and the explanation for the Asian flush when drinking alcohol. One aside featured the pituitary gland, which ultimately triggers the melanocytes that tan the skin. The pituitary responds to the optic nerve's sensation of light -- so tanning with sunglasses is actually less effective than keeping your eyes wide open to the sun.

    I love that stuff, and dog-ear pages with factoids that I'll want to recall. Sickest had over two dozen dog-ears by the end, which is right up there with Freakonomics and Gladwell's books.

    It was enough to make me overlook the really tenous evidence Moalem uses to support his most contentious theory -- that diabetes' prevelance is an adaptation to the last ice age. Sure, it's more common in among Northern Europeans. And sure, some frogs use hyperglycemia as an antifreeze during hibernation season.

    But he also invokes the fact that rats become insulin-resistant in the cold, and that human fibrinogen levels rise in winter (which he also links to our higher rate of MI and stroke). These may not be so much cold responses as a simple molecular kinetics -- a lot of biochemical reactions don't work as well in cold temeperatures. Besides, he says high fibrinogen in winter is evolution's way of protectiong against ice-crystal damage, but he fails to note that clotting is impaired by hypothermia -- clotting factor levels are not correleted with activity.

    Moalem cites the fact that type I diabetes is most often diagnosed in the autumn, when "temperatures start to fall." Well, I've heard this tidbit before, but it was used to support the viral theory of type I diabetes -- and frankly, that theory has a lot more support. Moalem doesn't mention it.

    The book's final chapters don't even try to support his idea that chronic disease may help in the short term. The chapters just funnel Moalem's extensive knowledge of evolutionary biology trivia to the reader. And it's entertaining. I'd heard some stuff on the blogosphere about toxoplasmosis influencing rat behavior, and potentially human behavior, too -- but Moalem is able to expand upon it and put it in context. Also, he includes a nice section on the Aquatic Ape hypothesis, which I plan to share with my friend's wife before she gives birth in a spa this summer.

    So, this book certainly gave me some things to think about and file away. But in an anecdote that's fairly typical, Moalem notes that in times of societal stress (such as former East Germany in 1990 and the US in the fall of 2001) women are more likely to miscarry -- but only the male fetuses. Interesting, isn't it? Is it because males are more demanding on resources? Or because in a crisis, it's better to have more females around to ensure survival?

    It turns out no one knows. It's not even clear how it's happening. Evolutionary biology can give us some possible explanations, all of which can be satisfying from a teleologic perspective. But unfortunately, none of them may be the right answer. None of them may advance our understanding or treatment of disease. Still, it makes for great conversation.

    Sitting in a Tin Can

    Pushing tPA feels a lot like coordinating a space shuttle launch. There's such a long checklist to work through before this powerful clotbuster can be administered -- and the drug is so dangerous that if any contraindication is found, the show's off.

    The other day, our little corner of the ER sounded like mission control:

  • The patient's family reported that stroke onset was within our three hour window.

  • The medical record revealed no recent surgeries or history of intracranial bleed.

  • The nurse noted the systolic blood pressure had fallen below 185 mmHg.

  • The radiologist phoned in the negative head CT results.

  • The neurologist confirmed our patient's weakness and lopsided smile weren't improving.

  • The emergency medicine resident emerged from behind the curtain to proclaim, "guaiac negative!"

  • And we were go for tPA.

    The only difference is, compared to the fire and noise of a NASA launch, the stopcock and syringe of tPA is a little anticlimactic. Ten percent of the drug goes in as a bolus, then the remaining 90% as a drip over an hour.

    During that hour, the neuro resident made arrangements for our patient, upstairs in the stroke unit. I went back to seeing other patients.

    When the tPA drip ended, as the nurses set up the portable monitor, I checked in again on our patient. Her pupils were still equal and reactive , but her left side was still weak. As far as I could tell, the medication hadn't done any harm, but didn't seem to have done any good, either.

    I wheeled her out of the department, into the elevator, and we glided up to the unit. Her family members rode along, silently.

    The elevator doors opened, and the neuro resident greeted us. I handed over her chart and said goodbye to the patient. Her family thanked me, and she acknowledged me -- with a bright, symmetric smile.

    Where Everybody Knows Your Broth

    In the past few months I've eaten at some unique places:

  • a restaurant that only serves macaroni and cheese (S'Mac)

  • a yogurt bar (Pinkberry)

  • a rice pudding bar (Rice to Riches)

  • I'm still hoping to go to that secret cookie shop (mmm... secret cookies), and the popcorn place on the west side. The next time I'm in Philly, I'll check out Cereality.

    But a few weeks ago, I found myself in Hoboken, eating some beef stew in celebration of St. Patrick's Day (yes, they do it early and often over there). The food was splendid, but our party ran out of plates -- and so people started eating their stew in a cup.

    And that's when my idea for StewBar was born.

    You know, a place to get your stew on-the-go. Meat, vegetable, chili -- many varieties. Enterprising franchisers can even apply for a liquor license, to become a "Stew & Brew" for the late night crowd... or tired residents looking for a square meal and a way to take the edge off.

    My question now is, is a stew bar enough of a gimmick? Because if not, we thought up aanother: The Stork, a combination straw / fork for your stew-in-a-cup.

    If You Leave, I Won't Cry

    Have you ever really invested in writing a comment on someone's blog, then decided to double-dip and convert your text into a post on your own blog? I used to do this a lot -- and frankly, if I'm ever going to post more than twice a month, I need to start doing it again.

    So, here's a nice thread that Future EM Resident Graham Walker started about telling patients, nicely, that they don't have an emergency:
    "Hey, good news! I talked about your case with the attending, we reviewed your story and physical exam findings, and we both agree that you don’t need any blood tests drawn, or a trip down to the radiology department for some xrays. In fact, what you’ve got will almost certainly get better on its own, though here are the warning signs to watch out for..."

    Then later (or earlier) you can mention, "You know, we triage patients so that complaints like yours today aren’t seen as fast as the life-or-death cases. You might save time, and get seen faster, in a primary care clinic. What? You don’t have insurance? You can still be seen in the resident clinic... And as you build up a relationship with these clinic doctors, they can give you more information on your condition, do routine testing to nip new problems in the bud... it really saves time and peace of mind, in the long run..."

    This won't please everyone (especially in Manhattan, where no patient likes to think they overestimated an "emergency.") Some people feel entitled to testing because they waited forever. Some patients want a medical-sounding diagnosis for every ache or sniffle.

    I tell them I see emergencies all the time, I love them, I go out of my way to look for them, but hey, it's *a good thing* I don't think they're crashing -- they should be happy and reassured. And while it’d be great to pin a diagnosis on every little thing, I'm not a rheumo-neuro-psychiatrist... my job is to find emergencies, and they don't have one.

    I like the comments from a mom who didn't exactly know what 'a good sat' was, and the reader who added that a minor cold might get worse in an ED full of germs.

    Further reading: a brief discussion of the origin of the name Gomer (were there ERs in the Biblical times?)

    Master of the House

    Emergency Medicine programs have the most "off-service" rotations of any specialty, and emergency departments feature the most rotators from other specialties.

    So it was not unusual for me, an EM resident rotating through Surgery, to receive a emergency consult from a medicine resident, rotating in the ED:

    "An elderly man fell and broke his hip. Pain's under control, vitals stable, ortho will see him -- but what concerns me is his giant inguinal hernia. His scrotum is the size of a volleyball."

    I came down to the ED to evaluate the hernia. It was indeed large, but nontender. The patient was too demented to tell me much about it, but a family member showed up and informed me he'd had the hernia for many years. Furthermore, he had no trouble eating, voiding, or ambulating.

    As I presented the case to the surgery chief, he interrupted me and said, "This seems like an inappropriate consult. Who called it in? One of your colleagues?"

    "Well, actually, a medicine resident."

    The surgeon shook his head and said, "Loss of domain."

    "Excuse me?" I asked.

    "When that much bowel has relocated outside the abdomen, for so long, it'll never go back. It's called loss of domain."

    "Oh, ok" I said. "I thought you were referring to the difficulty emergency programs have ensuring consistency, with so many rotators coming and going."

    "Well, that too."

    The Noise Made By People

    My first thought upon reading this New York Times piece was, "Thank goodness Dan didn't film me in Mr. Palumbo's study hall."

    Schoolyard scraps, spectacular skateboard spills, puppy-love quarrels, goofy antics like placing a slice of American cheese over the face of a snoring buddy, and bruising stunts like hurling one's body through a neighbor's wooden fence — these and other staples of suburban teenage life have taken on a new dimension as online cinéma vérité. Instead of being whispered about among friends and then fading away, such rites of ridiculousness are now routinely captured on video and posted on the Internet for worldwide perusal, and posterity.

    "Teens have been doing inappropriate things for a long time, but now they think they can become celebrities by doing it," said Dr. Andrew Adesman, chief of developmental and behavioral pediatrics at Schneider Children’s Hospital at Long Island Jewish Medical Center.

    "In the past, you’d brag to your friends in the locker room about doing something stupid or crazy or daring," Dr. Adesman said. "Now the Internet provides additional motivation. But these things can just as easily lead to criminal prosecution as broad celebrity."

    Then I had another thought: Someday, a mangled teen will roll into my ED, we'll ask ourselves, "How did this happen?" ...

    ...and then EMS will give me a URL.

    Completions and Connections Left from Last Year

    Ah, New Year's. Resolutions are being made, abstract deadlines are pending. The senior residents are interviewing for jobs, medical students are touring through our ED. Yes, there's ambition in the air, and I'm certainly doing my part -- committing to new projects at a dizzying rate.

    But that's not to say old projects will wither! In fact, I've been meaning to point out two entries to my recent Grand Rounds edition that somehow ended up on the cutting room floor (I blame the egg nog).

    The first is actually a trio of posts from my closest blogging consigliere (at least, geographically). New York nephrologist Dr. Joshua Schwimmer compiles KidneyNotes, his helpful collection of useful links and news clippings, punctuated by some striking photos. He has an extensive list of medical podcasts, for those of us who got iPods for the holidays.

    But what he really wants to draw our attention to is a new tool he developed for Dissect Medicine, the medical version of the Digg popularity aggregator. Though still small (and in beta), Dissent Medicine could easily become a huge destination for medical news and opinions. Kinda like Grand Rounds, without the soul.

    Another entry came from Dr. Ves Dimov at the Clinical Cases & Images Blog -- the leading blog for highlighting web practice resources. He sent in his impressions from the American Society of Nephrology (ASN) Renal Week 2006 -- which will go down in history as the first medical conference where data on medical blogging was presented. Unless we missed one already.

    For the record: Pubmed now lists one article with the word "weblog" in the abstract, and 32 articles with the word "blog" (though four papers predate the Web 2.0 era, and include an author named "Blog" -- is that Swedish?)

    If you're interested on the emerging impact of blogs in medicine (and who isn't?) here are a few noteworthy references: A blog for residents' dermatology education, PACS IT guys using a blog to good effect, and a neurologist in Japan using a blog to teach the public about epilepsy surgery.

    Some people are already drawing conclusions and making recommendations:
    Therefore, research should be conducted to determine the best ways to integrate these tools into existing e-Learning programmes for students, health professionals and patients, taking into account the different, but also overlapping, needs of these three audience classes and the opportunities of virtual collaboration between them. Of particular importance is research into novel integrative applications, to serve as the "glue" to bind the different forms of Web-based collaborationware synergistically in order to provide a coherent wholesome learning experience.

    The wheels, they are turning.