Can You Hear Me Now?

I used to wonder why Gizmodo et al are always taking jabs at Verizon. To me, they've always been friendly, with good plans and coverage. Sure, Verizon disables some cool features thge manufacturers put on their phones, but that just makes hacking them more rewarding, right?

Then I got a text message from the company, noting that I hadn't visited my "Pix Place" (online repository of my camera phone pictures) in 150 days, and if I didn't log in within 30 days, all my pictures (approximately fifteen, in total) would be deleted.

Cheerful, huh? Because these blurry photos must be taking up about 200 kb on Verizon's servers, and clearly, a competitive company in a cutthroat industry can't afford to give out free memory...

Then, when checking my voicemail a few days later, I heard a disturbing new automated message. Instead of informing me I had my regular three saved messages, I learned I had "three saved messages, whose retention time is about to expire."

A confession: I saved some messages for a long time. One, for instance, dates back to when the Sox beat the Yankees in the 2004 ALCS, and a friend called me up and made some kind of drunken hooting noise that I thought was worthy of repeated listens. Every 21 days, Verizon would play the message to me and ask if I wanted to delete it, and I'd always smile and press no.

Well, I guess they'd had enough, or maybe Verizon is run by a Steinbrenner acolyte, because in a few days those treasured messages were erased.

I think someone at the Onion is also frustrated with this company:

Verizon Introduces New Charge-You-At-Whim Plan
August 21, 2006 | Issue 42•34

NEW YORK—Verizon Communications, Inc. announced a new service package for its wireless and residential customers that would charge them widely varying, but always high, fees every month depending how the communications giant feels at the time. "Our Charge-At-Whim packages offer the same mediocre quality and insufferable level of customer service you’ve come to expect," a Verizon spokesman said Tuesday. "But it adds an unjustified, arbitrary and, if you’ll allow us to boast, frankly unjustifiable method of determining just how much you’ll pay for them." Packages start at "oh, $69.99 a month, let’s say?" and went into effect about three or four months ago.

Feels about right.

Lost my Driving Wheel

I just concluded the best, hardest month of my residency thus far.

I've taken call many, many times before this, but never with the same potential for frenzied activity, 27 hours straight (24, for my readers on the Bell Commission). After the first few calls for the medicine ICU, I grew efficient enough to get in an hour or two of sleep. But, unlike floor medicine, where the overnight intern is awoken a dozen times for generally trivial concerns, all my pages in the ICU were genuine problems.

I performed more emergent intubations, more lines, more spinal taps, and about a thousandfold more ABG's than in any single rotation before this. Running a code no longer paralyzes me with fear. Most incredibly, from my perspective, was that I was making so many of these critical decisions.

Because of the crazed sleep schedule, in which I'd be unconscious for about 15 of my 21 free hours post-call, life outside the hospital became filled with malaise and dysphoria. My apartment has never been messier. So many obligations got punted to September -- relationships, phone calls, emails, workouts, blogging.

Nothing was getting done -- nothing was worth doing. I didn't get out much, and when I did, things seemed unbearably slow or purposeless. I never felt really alive until I was on call again. Isn't that a lark? Maybe I was so conscious of my agency because most of the people around me were heavily sedated.

I did call my parents a lot, often to thank them for happy childhood memories that would surface at odd times. This was likely prompted by the wrenching conversations I would have with families about their sick loved ones. Until now, too often, talking with families in the ED was been a chance to gather history and transcribe medication lists, or explain why someone is going to be admitted / discharged (when all the family wants is for them to be discharged / admitted). But this month had more than its share of conveying painful news, of asking families to make difficult decisions.

It's remarkable, how thoroughly and abruptly lives can be disrupted, how strong people are forced to be, at their most vulnerable.

I can see clearly now

If you want to simulate the development of visual cognition in newborns, take a course in ultrasonography. I remember when I was a med student, and a resident showed me my first blurry, shaky FAST images (focused assessment of sonography for trauma).

Resident: See that? That's Morrison's pouch, showing no free fluid between the kidney and liver.

Me: I think that's just static, and you're playing a trick on me. Can we adjust the image?

Resident: No, actually, see, this echogenic area is the renal pelvis...

Me: Really, just stop, you're not fooling anyone.

A few years later, and here I am, identifying venous thrombi and peri-pancreatic stranding, the common bile duct and the superior mesenteric artery. It's unbelievable what you can see in that static-y window. I especially like how, the better I get with ultrasound, the more it seems to help (compare that with sub-subspecialties like toxicology, where the effort of accumulating greater expertise finds diminishing returns for patient aid...)

Other observations:

In my surveys, whenever I apply the ultrasound probe over the male bladder, the men always crack a smile and ask me if they're pregnant. It never gets old. (The women, they don't ask out loud).

There is a striking correlation with EM ultrasound expertise and a past life as a disc jockey. In fact, it turns out I used to listen to one of my U/S mentors, on the radio. Different frequencies now, but same catchy appeal.

The Secret of Acronyms

I've received some great feedback from my post the other day, on acronyms in medical research.

I soured on the whole field of "research on research" when I learned articles like Stanbrook's weren't just bar-room talk that led to an afternoon browsing pubmed, but rather, institutionalized bodies of research with conferences, grants, endowed chairs, etc.

Don't get me wrong, I love cocktail-party research like this (where would Blogborygmi be, without it?) Papers like Stanbrook's make us think, and keep us mindful of influences. Even if that's all it can accomplish, well, it's something.

But look at some of the output of one of the ART in Medicine authors, Dr. Donald A. Redelmeier. Over the years, he's produced such gems as "Oscar winners live longer than other actors" and "Why cars in the other lane really do go faster."

If you're going to get funding for producing a series of provocative but disconnected pop-science pieces, that are fun to talk about but hard to act on, you ought to eliminate the middle man and work directly for NPR.

But I don't mean to single out Dr. Redelmeier, who in addition to his occasional cocktail diversions, has a distinguished career as an investigator. In fact, he was one of the authors on an influential CHAMPS study (not the same Avonex / MS study a commenter mentioned, but hey, even six-letter acronyms need to be reused).

Is Redelmeier cynically manipulating doctors with his catchy titles? Or is he just one of those "exemplary investigators" who "generate both clever acronyms and important research" ? I'm inclined to say the latter, but I wish he had fully disclosed his ties to the acronym industry. Maybe he missed those talks on conflict-of-interest at the last conference.

Operation SMARM

It's always nice when a topic can be both funny and worthy of serious thought. Such is the case with the use of acronyms in medical research.

Inspired by an exhaustive list of medical trial acronyms, last year I wrote wrote a post that still makes me smile (the part where my mind's eye conjures Batman at a medical conference). Here's an excerpt:

It's comforting to see our best minds are studying LIFE and LIMB, MIRACLE and MIRAGE. The aforementioned CALM is balanced with EXCITE. You can also learn the difference between SYMPHONY and OPERA. As for more conventional names: ADAM, DAVID, MONICA, RUTH, and SONIA are all ALIVE, with VIGOR and GUSTO.

There are too many more to mention, though I was a little dismayed to find the really memorable ones were often sponsored by pharm companies. Though they're catchy, I have no idea if the studies are well-conducted, or tell us anything important. For this reason, I'd like to organize a study examining whether clinical trials with fancy acronyms have higher impact than serious studies denoted by plain collections of letters. We'll call it ABSURD -- Acronym Behavior overShadowing Useful Results and Data.

Well, last week, the NEJM (um, the New England Journal of Medicine) published such research -- Acronym-named Randomized Trials in Medicine - The ART in Medicine Study (I like my proposed title better). An excerpt is reprinted below:

As compared with studies without acronym names, acronym-named studies had higher Jadad methodologic quality scores, enrolled five times as many patients, had follow-up periods half as long, but were not more likely to report positive results. Acronym-named studies were four times as likely to be funded by the pharmaceutical industry and eight times as likely to be authored by an industry employee.

Acronym-named randomized trials were cited at twice the rate of trials that were not named with acronyms (13.8 vs. 5.7 citations per year)...

Although other explanations are possible (for example, exemplary investigators may generate both clever acronyms and important research), these results support the hypothesis that naming randomized trials with an acronym may enhance the citation rate. ...

Enhanced attention to and recall of studies through the use of acronyms may facilitate the appropriate translation of research findings into clinical practice. If acronyms exert influence independently of normative markers of clinical credibility, however, such influence is not rational scientifically, even if it is understandable psychologically. Consequently, this subtle linguistic tool could undermine evidence-based practice. The observed close association between acronym use and sponsorship by the pharmaceutical industry amplifies this concern.

Stanbrook et al deserve credit for sifting through the literature, quantifying 173 studies and drawing some important conclusions about article quality and citation rate.

But these authors's work is part of a burgeoning field of research ON research, a meta-analysis, if you will, on how science is conducted and disseminated. There are now whole conferences studying peer review, bias, and the impact of "impact factor" (Stanbrook originally presented this research at one such event).

Thus, we can expect more research into this topic. Is it easier to apply an acronym scoring system like APACHE, or an eponymous one, like Ranson's criteria? Do patients fare better when they're told they suffer from POEMS, or the Crow-Fukase syndrome of polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes?

I wish to contribute to such research, but right now all I can offer is another title: the Study of Medical Acronyms in Reinforcing Memory. It may be unfairly catchy, but I think its very acknowledges something overlooked: the attractiveness of meta-research may well be disproportionately higher than its actual usefulness. There are more important to study, debate, and get sanctimonious about.

"Everybody falls, the first time"

It's the intern's first day. We're walking down the hallway from the ED, so I can show him the lounge.

"Are you ready? You know, the computer system here is pretty complex," I said.

"Yeah, they gave a lecture on it, but it was pretty confusing," he replied

"The system can do absolutely everything -- charting, orders, prescriptions, admissions, discharges... but's got so many features, it takes a while to master. At first you'll be like Neo looking confused at the green streaming letters in the Matrix, but eventually you'll transcend it.. and just start moving faster than you thought possible."

"But wait," the intern interjected. "Didn't Neo have to die before he could do all that?"

I stopped walking, turned, and faced my young charge. "We all had to... It's very painful."

We continued walking down the hallway, in silence.

An Inappropriate Truth

This month's Annals of Emergency Medicine has a series of articles on ED usage, plus an editorial entitled, "Frequent ED Visitors: The End of Inappropriateness." Given the tenor of posts from seasoned ED bloggers, I expected this editorial would be about denial-of-care protocols, full of anecdotes about abusive patient freeloaders.

But in fact, this editorial is based on evidence. The one anecdote included is a doozy, about a father who took his infant to the ED, got a diagnosis of OM, but his insurance denied payment due to the "inappropriateness" of the visit. The father, of course, was the board-certified EM physician who wrote the editorial.

He goes on to delineate the separate but related complaints of overcrowding, frequent flyers, and inappropriate ED use, which he defines as follows:

Generally defined as an ED visit by someone with a nonurgent or less-urgent condition treated more efficiently and cheaply in an office or clinic setting. In its more malignant form, inappropriate ED use has been characterized as visits by people of lower socioeconomic status who are "gaming" the system by claiming benefits and services to which they are not entitled...

...In this issue of Annals, 2 articles provide compelling evidence that the "inappropriate" ED visit is nothing of the kind.

Dr. Bernstein concludes his piece:

The notion of the "inappropriate" ED user is largely apocryphal. Fuda and Immekus and Hunt et al convincingly demonstrate that frequent ED users are sicker, with considerable mental illness and substance use, than infrequent or nonusers. Frequent ED users come to the hospital because they need care. Infrequent users may avoid the ED with expanded access to primary care, but this is not at all clear. Constructive policy change will not result from a blame-the-victim analysis.

Perhaps a wiser health policy goal would be to focus on the delivery of high-quality, convenient, accessible care to all patients in all clinical settings, ambulatory, emergency, and inpatient. Intensive case management of frequent ED users and expanded off-hours access to facilities delivering primary care, especially mental health and substance use treatment, may decrease the frequency of ED recidivism, but additional work is needed to test the efficacy of these interventions. In health care's current political climate, which emphasizes cost containment and personal responsibility, it is difficult to see this happening. But for now, let us put to rest future conversations about "inappropriate" ED use.

Sadly, I don't think Dr. Bernstein's recommendations will be heeded in ED conference rooms and EM blogs. I, too, have been guilty of letting the stress get to me, generalizing from one encounter to an entire waiting room. But I've also made a conscious effort to adopt well-conducted new research into my practice, and these findings should be no different.

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.

Action

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 Medgadget.com, 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...

CME Credit

It was a warm weekend evening, and the new interns were completing some of their first shifts in the ED. We were drained, but exhilarated, and a little punchy. One of the senior residents was sitting in the corner of the lounge, by himself. He was reading our textbook -- Tintinalli -- and by the looks of it, he'd made it to page 1675 or so.

One of the interns approached him. "Hey, buddy, we're got the rest of the weekend off. We're thinking about going out for some drinks tonight -- you want to come?"

The senior waved him off, "No, I've got a lot of reading."

Undeterred, my fellow intern pushed, "Come on, what for? You have boards coming up or something?"

The senior looked up from the book, and said something I'll never forget: "I'm reading to become a better doctor."

I don't remember what we ended up doing that night, but whatever it was, the senior's comment had lowered our enthusiasm for it by more than a few notches. In those heady days after graduation last year, nothing else would make the point so succinctly to this newly-minted intern: We were done with medical school, but we weren't done being students.

"I'm not the man they think I am at home"

So, I went out this morning at the crack of dawn for my brioche and coffee, and I saw a rocket ship on the curb, by the trash.

The model looked like it was out of 1950's sci-fi features: a silver metal cylinder with riveted wings, and a thick antenna nose. It was about a foot and a half long, angled upward on a metal pedestal with a thick base. There was a loose electric cord dangling from the base; it was not immediately apparent what electricity would do for the model.

I stood for a moment on the sidewalk, flummoxed over the model (remember, I still hadn't had my coffee). The rocket, almost certainly, would not fit in with my apartment decor. But dammit, it was practically on my doorstep, and I was curious about the plug.

I resolved to get my breakfast, then pick up the rocket on the way back. Just to try it out, of course -- and if it didn't work, or didn't fit, it'd go back to the sidewalk.

When I returned, ten minutes later, the rocket was gone.

It was not yet 5 AM. Once again, I have underestimated the depth and breadth of geekdom in this town.

---

Speaking of which, I shouldn't have made that mistake, so soon after the Fifth Avenue Apple Store opening. I went, mostly because there was a rumor on teh internet about a big-name concert outside the cube. That, and I thought I might finagle a free T-shirt during the opening and giveaway, Friday at 6 PM.

After all, it had been raining that afternoon, and who really goes to these things, anyway?

It turns out, a lot of people go to these things. This, for instance, is the blog of a guy who travels the world, going to Apple stores. The line wrapped around the GM building, from Fifth to Madison and back. There was no concert, no Steve Jobs speech, but a mob scene nonetheless.

I quickly gave up on the free-T-shirt idea, or even getting into the store. Instead, I wandered around the cube. I found a nice roped-off spot near the northern fountain, where spectators were speculating on the identities of the honchos moving in and out of the store's entrance.

After a few minutes, one of the young, all-black clad Apple employees walked over to our area. He asked, politely, "Are you ready to come in?"

It turns out he wasn't talking to me, but rather to Elizabeth Berkley, who had appeared right behind me. Maybe she was in town for this. Or maybe everyone's a geek, now.

My patient, the car

I misinterpreted the title of a Polite Dissent post -- Doctor or Auto Mechanic? -- which immediately conjured a version of this classic game in my mind.

And since, well, some doctors are called "auto mechanics of the body," I started making a list of tools and terms that sound like they could go in either profession -- medicine or car repair.

So far my list includes the peak flow meter, front fascia, nebulizer, curing lamp, 4x4, clean-catch, head gasket, pacer leads, valve grinder, hepatic duct, surgi-lube, colposcope, universal joint, and of course, a Hemi.

I'm sure there are many more such terms, especially within the realms of orthopedics and ... emissions.