Monday, August 10, 2009

A bit of veiled conceit, 3AM edition

"A glimpse into that haven of superficial, pretentious, pseudo-aristocratic vanity: The NY Times' Wedding & Celebration Announcements "*

Cailin O'Connor and James Weatherall

"Hello! We might be as upset that you are that our picture wasn't online and you were forced to take a picture of your own newspaper, then remember how to use the rotate tool in GIMP.** Or maybe we just like teeth."

The bride! Likes teeth, not T's. Look at her first name more closely and feel the shame of a hundred substitutes while the rest of the class snickers on.

The bridegroom! Getting a PhD in philosophy, ATM machine FAIL! He already has a PhD in physics from here - never heard of it, won't make fun of it, guess he didn't like the program at his undergrad. He's appears to have been an experimentalist. Now, he's pursuing both that doctorate of philosophy in philosophy, and an MFA in creative writing - something terrible happened. The boson is a lie.

Mary Ziegler and John Roberts III

"I knew that I was seeing a very beautiful woman at her frumpiest"

When they first met, she was wearing her 'beater glasses.' I, too, have beater glasses. Coincidentally, they are also my nice glasses.

This would be a perfectly ordinary couple were it not for the couch. Actually, an "uncomfortable," "ugly," "stain-spotted" love seat. Very romantic. She was sick of it, and New York, so she sold it to him so that his female visitors wouldn't have to sit on the bed.

Then she laid beater-glasses-corrected eyesight on him and it was she that ended up back on the couch and back in New York.

As for the couch itself, it makes a cameo on the couple's wedding cake:

It's smaller than I expected. Also, fewer stains. Just let me run the blacklight over it before I hand over the cash.

*This quote and concept are stolen from 'Zach's' original Veiled Conceit

**GIMP - Photoshop for people that haven't got $1000 lying around and think they might be getting a little old to steal everything. Really, when was the last time you used it for anything but crop and autocontrast (don't answer Hippity, Westy, or Milensomthingsomthing).

Tuesday, March 24, 2009

Primary care - good and good for you!

Abraham Verghese thinks there aren't enough primary care doctors. Perhaps he's right.

Primary care doctors - internists, pediatricians, and family practice docs - are patients' first point of contact. There are two ways to think about primary care. I would argue that because primary care doctors need to be able to distinguish between tension headaches and brain cancer (for instance) that primary care physicians should be The Best doctors, while people working in a specialty need less diagnostic expertise due to the smaller disease spectrum they see. Curmudgeons, like V, would argue that because you have virtually no way to distinguish between tension headaches and brain cancer without an MRI (or similar) that primary care should be done by flowchart wielding nurse practitioners.*

Verghese wants more primary care physicians because:
Real patients want someone whose examining skills, when combined with common sense and sound judgment, can spare us the costly, blind, shotgun, ‘tick-all-the-boxes” kind of testing and imaging that has come to be the American brand of medicine. We want a doctor who orders tests judiciously, who calls in specialists sparingly, and who rides herd on them and weighs and translates what they say. What we want, in other words, is a primary-care physician.

Now, I agree with this entirely.** However, if V were to read this, he would point out patients, with the exception of Abraham Verghese (note the they -> we switch mid-paragraph), do not know and are not particularly interested in the formal status of the person caring for them. An M.D. does not increase, and likely decreases compassion. Becoming a primary care physician does not make one conscientious, similarly specialization does not remove that characteristic.

Since I agree with Verghese entirely, though, let's look at why there aren't enough primary care physicians. Verghese lists several reasons, summarized as: Primary care doesn't pay enough relative to the degree of training and the debt level most M.D.s graduate with.*** That's it. Secondarily to this, because primary care physicians are paid on a per-patient basis, they have to work long hours and don't get to spend much time with patients, so the work-style isn't much fun.

The above paragraph carries three completely plausible suggestions in it. Verghese clips one of them and misses the others completely. Instead he suggests an Peace Corps style program in which recent med school grads would be forced**** to work for a year doing primary care in an underserved area, in exchange for lowered student debt. Students exposed to the joys of primary care would abandon their future plans and switch to primary care in droves.

Students are already exposed to the joys of primary care, in the form of (at Dupont) 12 weeks of medicine (1/3 outpatient), 6 weeks of pediatrics (1/2 outpatient), and 4 weeks of family practice (all outpatient). One might argue for adding more to the curriculum, but if a student is offered primary care in at least 3 different flavors and likes none of them, what are the chances that a fourth will change their mind? Treating the students like grunts to be worn down in the toughest areas is also likely to leave a sour taste in the mouth.

Verghese does hit one nail on the head - debt forgiveness. Unfortunately, his program is begging to be ripped off. What's that you say, it will help me get a dermatology residency, and it will decrease my debt? A more straightforward plan would be to pay off the debt of students that go into primary care and practice in it for at least 5 years after their residency is over.

Consider the two other problems Verghese identifies - excessive training times, and reimbursement. Adding a year to training will only exacerbate the problem. Conversely, switching to a more nurse practitioner-based system (i.e. fewer years of training) could increase the number of primary care providers without provoking bitterness. Finally, why not suggest a tweak in the reimbursement system?

Funny conclusion goes here.

Is the headache new or old?
New -> Consider headache characteristics
Thunderclap headache -> Head CT / LP
Signs of infection -> Consider meningitis
Headache with neurologic signs -> Neuroimaging
Morning headache -> Consider broad differential (including brain cancer)
Else -> New onset primary headache (give up)

Stern SDC, Cifu AS, Altkorn D.

**: See answer #9 here, except replace "NBME" with "Abraham Verghese"

***: Note that the difficulty of acquiring a residency 'slot' in a given specialty directly proportional to the future compensation of that residency. Surprise, M.D.'s are human!

****: He says it is voluntary, but says that competitive specialties (particularly dermatology) would use it as a criterion for entering physicians. Let me translate that into med studentese: Unless you want to end up as a [least favorite specialty] practicing in [a state you hate], you WILL do this program.

Thursday, February 12, 2009

Roger Cohen meet Stanley Kubrick

So there's an Op-ed where some guy went to Iran and discovered:
Iran's inner America

I'll hold my tongue, except for one quote from Full Metal Jacket

We are here to help the Vietnamese,

because inside every

gook there is an

American trying to get out.

Saturday, February 07, 2009

What's in _The Atlantic_'s library?

Red Arrow - Harrison's Internal Medicine, 14th Edition. Next to it, Physician's Desk Reference. Should come in handy if healthcare ever comes up.

Image: The Table.

Thursday, February 05, 2009


People need to stop talking about the stimulus as being this many Bbbbbbbbillion or that many bbbbbbbbillion dollars. To the government, a billion dollars is like 100 dollars to you or me. In order to get anything done, a billion is the right amount of money to spend. I understand you all went to diction school and have to ENunCiAte so people don't get confused about billion versus million, but there's a difference between, "Obama plans to add 3 Billion to the NIH budget" and "Obama plans to add... B-b-b-b-billion dollars..."

Sunday, January 04, 2009

Bruce Ivins is still getting published

In the Journal of Infectious Disease.
But also in the NY Times.
Basically, the evidence against Ivins is that he was a mentally troubled guy that drank too much. Also, he had the technology and expertise available to produce the anthrax spores sent out. Also, he really creeped out one woman when she was in grad school. Seriously.
Nancy Haigwood knew Bruce Ivins when she was in grad school and decided he was creepy. Then her house was vandalized, and a letter was written to the local newspaper in her name defending a campus sorority. She decided that Ivins had done both those things. There's no evidence, as it was 30 years ago, but because she was creeped out by Ivins, she assumed that he did these things. Later, in e-mail conversations, Ivins mentioned things to Haigwood about her children that she hadn't told him. This is rendered as evidence of stalking, but it seems to me like evidence of gossip.**
Flash forward to after the anthrax attacks. She receives an e-mail from Ivins with a picture of him in an anthrax lab working without gloves. She decides that this demonstrates an unnerving hubris - a very odd conclusion to make from a single photograph.*

o.k. o.k. some of the defenses that I've thrown up of Ivins in the past - that he may not have known how to make dried spores, that he was just a bit eccentric. Obviously, Ivins was in an excellent position to make the anthrax, and he was in some way mentally outside the normal range. You might argue that alcoholism and psychiatric hospitalization, even voluntary, should disqualify someone from working with anthrax. That seems a bit harsh.

But the evidence actually linking Ivins to the anthrax attacks is nonexistant. He worked late prior to the attacks, but on what? The FBI must have asked him, but I don't have his answer. They couldn't match him to the envelopes, the stamps, or the post office in New Jersey. The fact that he takes long drives does not, in fact, mean that he was in Princeton lo that mailing morning.

Remember Steven Hatfill. The FBI's positioning of him as Mr. Anthrax was very convincing for a while.*** As the NYT says, "Dr. Hatfill, too, was eccentric. He, too, had begun drinking heavily as he came under scrutiny. He, too, had grown depressed and erratic under the FBI's relentless gaze. What if Dr. Hatfill had committed suicide in 2002, as friends feared he might? Would the investigators have released their evidence and announced that the perpetrator was dead?"

The reporter is too polite to provide an answer. I'm too worried about a future FBI investigation into me to be honest.**** But you aren't. And you know the same answer applies to Bruce Ivins.

*: There is definitely bacteria growing on some of the plates, and they are definitely blood agar or similar, invalidating any suggestion that he was just looking at media or working with a non-anthrax bug (like E. coli). On the other hand, the initial investigation of anthrax was done by Robert Koch working in an upstairs bedroom of his house with zero protective gear - caution and a lifetime of working with the bug might be protection enough.

**: BTW, if I can find your home address or details about your kids with a single search on Google or Facebook, it's not stalking. It's hardly even research.

***I particularly like that the 'damning evidence' brought over to this article was that Hatfill bragged about having a "working knowledge" of biowarfare pathogens. Imagine, someone actually bragging on their resume. That's amazing. Also, if I can have working knowledge of Drosophila genetics and vector construction, why can't someone else have working knowledge of biowarfare pathogens {presumably he enumerated them, NY Times said biowarfare pathogens}

****: Dressed up in a fly costume. Drank tea from a mason jar (repeatedly!). Liked Iowa. Secretly devout. A momma's boy. History of binge drinking. Once messaged a woman on facebook mere hours after meeting her at a party and knowing only her first name and major. Worked late hours. Worked odd hours. Occasionally handled hazardous materials without gloves. Struck some people as weird. Laughed at odd times in medical school classes. Once came to medical school class with a mowhawk hair cut. Longstanding interest in synthesis of methamphetamine from commercially available products. Previous interest in synthesis of chemical warfare agents from commercially available products. Interest in home microbiology. Interest in home distillation. Reputation for attempting techniques merely to see if they work. Occasionally angry. Hubristic. Questions medical hierarchy. Questions findings of the FBI...

Also, 'working knowledge' of multiple (2) human pathogens (E. coli and a 5 week stint of Hepititis C work).

Friday, January 02, 2009

Sent to Andrew Sullivan

Glenn Greenwald asks:

Is there any other significant issue in American political life, besides Israel, where (a) citizens split almost evenly in their views, yet (b) the leaders of both parties adopt identical lockstep positions which leave half of the citizenry with no real voice? More notably still, is there any other position, besides Israel, where (a) a party's voters overwhelmingly embrace one position (Israel should not have attacked Gaza) but (b) that party's leadership unanimously embraces the exact opposite position (Israel was absolutely right to attack Gaza and the U.S. must support Israel unequivocally)? Does that happen with any other issue?

The answer: Immigration. The Republicans. 2005. oh crap.

via Andrewsullivan