like a broken record

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

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

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




...I just want your half."

Reach Out and Annoy Someone

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

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

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

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

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

Indeed.

How now, Newdow

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

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

He's got some other things going for him, too: He's an emergency physician who claims to have worked in 'hundreds' of ERs:

“I probably worked in more emergency rooms, conceivably, than anybody else, ever,” he says. Newdow still holds medical licenses in California, Florida, New Jersey, Michigan, North Carolina, and Virginia.

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

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

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

The decision will probably come in about a month.

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

Career differential

What's the best defense against hospitalism?

...maybe it's hospitalists!

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

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

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

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

Welcome to the Jungle

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

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

Columbia physicist Dr. Brian Greene, however, takes it one step too far:

"'Our brains evolved so that we could survive out there in the jungle,' he said. 'Why in the world should a brain develop for the purpose of being at all good at grasping the true underlying nature of reality?'"

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

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

Damning Evidence

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

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

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

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

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

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

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

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

Sing, Goddess

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

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

Beyond the pale

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

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

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

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

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

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

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

Commencement

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

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

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

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

A cancer in the system

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

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

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

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

Unseparated

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

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

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

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

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

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

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

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

Can't buy a thrill

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

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

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

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

The best of both worlds

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

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

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

When we win

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

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

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

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

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

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

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

Cattiness

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

Grimace

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

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

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

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

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

Accentuate the positive

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

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

Provincial jankee.