Brief Defence of the FDA

I was at the doctor's office today, and for no apparent reason they have The Wall Street Journal. The editorial page is sort of like watching Prime Minister's Questions - a bunch of people who appear to speak the same language look at the an issue in this country and come at it from a completely perverse direction.

Witness Arcoxia! (etorcicoxib)! that ASTOUNDING wonder drug from Merck. The WSJ Op-Ed guys are in a snit because the FDA won't allow the drug to be marketed. Brief summary:

The FDA explained that it didn't see the need for another drug like this. Robert Meyer, director of the FDA's Office of Drug Evaluation II, told reporters that, "simply having another drug on the market" wasn't "sufficient reason to approve the product unless there was a unique role defined." The FDA is supposed to judge whether a drug is safe and efficacious and that's all.

OK. The authors then rip apart the FDA based on this quote. I say the quote is irrelevant.* The question is, is the drug safe and effective for its stated purpose? Answer: Define "Safe and Effective." Some percentage of people taking warfarin will suffer a fatal bleed into their brain. On the other hand warfarin may prevent them from developing fatal clots. There's a balance depending on the purpose. One is more willing to tolerate side effects from potentially lifesaving treatments from those that merely make life more comfortable.**

So, what does etorcicoxib do? Well, it merely makes life more comfortable (who didn't see that coming?). Etorcicoxib is, for civilian purposes, a pain killer. More specifically, as the 'coxib suffix implies, a COX-2 inhibitor. You may remember the COX-2 inhibitors from such debacles as VIOXX!!!

"Wait," Cara said, "didn't Merck also make Vioxx and get sued for a bunch of money."
"Indeed," said I.
"What a bunch of morons," she noted, then dozed off.

To give you the 60 second caricature, when you pop an Aspirin, or Tylenol, or ibuprofen, or Aleve, the drug inhibits two enzymes, COX-1 and COX-2 which are involved in synthesizing a lot of different molecules called prostaglandins that have different effects in different parts of the body. This broad distribution explains the broad effects of the so-called Non-Steroidal Anti Inflammatory Drugs or NSAIDS - a baby Aspirin thins the blood preventing heart attacks and strokes. Tylenol reduces fevers and relieves pain. Step back a moment andc onsider how odd it is that those effects are linked.

Unfortunately, NSAIDS are also a leading cause of gastric ulcers. This effect is presumably because they block COX-1 in the gut, which results in less secretion of protective mucus (mmmm, protective mucus). Also, the anti-coagulating effect is also due to COX-1, perhaps making the ulcers more difficult to heal. Thus were born, THE COX-2 INHIBITORS!!!. Unfortunately, COX-2 inhibitors kill. All of them. And the degree of killing is related to the degree of COX-2 inhibition. It's late, and I'm studying for boards, so I'm just going to have to take what my pharm professors said and whack you over the head with it. I'm sorry. PubMed will work for you as well as me, and is non-essential to my continuing points. Also, the COX-2 inhibitors don't really prevent ulcers, if you look beyond 6 months of use.

Even before the whole Vioxx thing, I was a big hater of the COX-2 inhibitors, because the things were like, three bucks a pill, and I said, "heck, for three bucks a pill, you could take a truckload of Tums." New, older and wiser, I say, "heck for three bucks a pill, you could buy a cratefull of Prilosec OTC" (unsurprisingly this works).

There I go, tarring etorcicoxib with that rofecoxib brush. Why don't we just see how it stands up on its own? As the WSJ says, there was a trial of over 37,000 people that showed that etorcicoxib was safe. I think they're referring to this trial (PubMed ID 17113426 if that doesn't work), which shows that etorcicoxib is about as safe as the NSAID diclofenac, and had fewer ulcers. Diclofenac? Yes, it's a real drug. I'd never heard of it either 'til I came to med school. In my limited exposure, I have yet to meet anyone taking it. Why the comparison with diclofenac, then? It's a stacked deck.*** As the Wikipedia article linked above indicates, diclofenac has 10:1 inhibition of COX-2 versus COX-1, i.e. it is, essentially, a COX-2 inhibitor (note that even the classic COX-2 inhibitors like rofecoxib, celecoxib, and etorcioxib have some COX-1 inhibitory effect). 'Classic NSAID' indeed.

How does etorcicoxib stack up against stuff that people actually take? Well, there's no significant difference there either. Wait, let's actually read a bit of the abstract:

The RRs for thrombotic events were 1.11 (95%CI: 0.32, 3.81) for etoricoxib (N = 2818) versus placebo (N = 1767);

Let me try and translate this: People taking etorcicoxib were somewhere between one third as likely and three times as likely to get a clot as people taking sugar pills. In other news, I weigh somewhere between an Oxford English dictionary and a Honda Accord. My intelligence is somewhere between a ground squirrel and Da Vinci. George Bush's approval ratings are somewhere between 7 and 70%.

Here's the real "money quote."

1.70 (95%CI: 0.91, 3.18) for etoricoxib (N = 1960) versus naproxen (N = 1497).

Translation number 1: The risk of developing a clot was somewhere between a little less than 1 and 3 times as likely in people taking etorcicoxib versus Aleve. Translation number 2: If the study had gone on 3 months more, we would have succinctly demonstrated that our drug kills people.

So, if I'm the FDA, I bounce the drug, not because there's not a marketing niche, but because it's not safe and effective for purpose. On the other hand, I suppose the study has demonstrated a "unique role" for the drug - expensive AND deadly, woo-hoo.

It's past my bedtime, so I'm going to take a final parting broadside at the WSJ, specifically this anecdote:

One patient, Kathleen Slocum, said that her life without Vioxx or other COX-2 inhibitors was "misery." She also pointed out that while over-the-counter analgesics work well for pain relief, the main problem she has had with her severe arthritis is joint swelling and stiffness; OTC analgesics haven't helped her with these problems. Ms. Slocum knows more about her specific needs than the FDA does. Isn't it possible that at least some segments of the population would find that Arcoxia addresses their needs? And remember that the people choosing are self-interested patients and their highly educated and trained physicians.

I should note that 'over the counter analgesics,' with the exception of Tylenol, will take out COX-2 as effectively as any 'coxib, so from a pathophysiologic standpoint, her argument is meaningless. I also note that 'joint swelling and stiffness' are rather vague terms that would be quite susceptible to placebo effect. Perhaps if naproxen were prescription only and 5$ a pill it would be more effective for her. Finally, there's the dodge about knowledgeable patients and highly educated physicians. I would argue that patients don't know what they need, hence they go to doctors and request drugs they saw advertised on TV.**** And I would argue that physicians, my future self included, are vulnerable to the claims of leggy drug detailers, and busy enough that we won't do the legwork that could save out patients. We will assume that if it's FDA approved, it's benefit essentially outweighs its risk in the intended use. So that's what FDA approval had better mean.

*: Key difference between science (or scientistic fields like medicine) and journalism. In journalism, it's all about getting different authorities to give quotes and bash them against each other. Medicine is supposed to be about the evidence.

**: Look, you can argue this, you can say, "But Jeff, isn't there some pain so bad that it makes life not worth living?" And I would say yes, and then I would say, "If you're so concerned about the pain, why not go for narcotics? Or something to address the underlying problem like joint replacement (for osteoarthritis) or REAL immunosupressants (e.g. steroids, methotrexate, cytoxan... for rheumatoid arthritis)?"

***: I'm as pro-pharma (probably more pro) as the next guy. If you look at a pharma trial, you will find that it has been conducted superbly. However, a trial is only as good as the question is asks. Too often, the comparison is against older drugs with known side effects, or they will test higher doses of the company drug versus lower doses of a competitor drug. This isn't always the case, but it's worth looking out for. It also gives me an excuse to stick to reading the abstracts.

****: This makes me think about all the adds Apple keeps putting out for iPods. It's like, everyone that was going to buy one already has one, but they need to keep advertising so people still think that what they bought is cool. I wonder if you could do a study about some drug in a placebo-ey category like anti-depressants and see if it's apparent efficacy waxes and wanes with the amount of advertising surrounding it.

The problem with Watson-Crick base pairing

Is that W and C don't base-pair. You know what works? Goldstein-Crick base pairing.

(Why this should be funny but probably isn't to you: In addition to the A, T, G, and C of normal DNA sequences, other letters of the alphabet are used to designate possiblities, e.g. W = weak, which could be either A or T, so named because they make only 2 hydrogen bonds, as compared to the Strong G-C base pairs which are held together by 3 bonds.)

Psychiatry

We get conflicting accounts of medicine in popular media, in undergraduate biology, and in more research oriented basic science lectures. But it's always good to get the single consensus answer. In CPP this comes from the mouths of practicing physicians specializing in the disease being discussed. Their answer has the advantage of having survived contact with reality, and being relatively accepted by a lot of other medical types you might talk to.

Psychiatry is an area where the gap between popular accounts and practice appears to be the widest. Civilians* throw around diagnoses, or sub-diagnoses or outdated diagnoses with great freedom, assigning fairly serious conditions to (say) celebrities they have never met. As described in psychiatry, life is more complicated. Diagnosis consists of large lists of criteria that patients have to fulfil, e.g. in order for you to be depressed, from this list:

Depressed mood
Energy loss
Anhedonia (lack of pleasure)
Death thoughts
Sleep changes
Worthlessness
Appetite
Mentation changes
Psychomotor

You must have depressed mood or anhedonia and five of the others for most of the day every day for two weeks to qualify those weeks as a depressive episode. This sort of formal rigor is much more appealing than saying, "Hey, this guy is sad, let's give 'im some Prozac."

One of the best parts of this section was that in lab, instead of only reading cases, we had actual patients come in to talk to the class so we could see what it was like. And that's where the nice neat system vanishes. Our bipolar patient was being treated for anxiety, our obsessive-compulsive disorder patient had depression. Our schizophrenic patients seemed to have well behaved disorders, but our recovering alcoholic physician had his ADHD misdiagnosed as anxiety, and got addicted to his Xanax. And if depression was such a difficult diagnosis to meet, antidepressants would not be among the top-selling drugs.

They do teach some things that are pretty easy for me to swallow:
Psychodynamic psychotherapy ("And how does that make you feel?") is reserved for those with lots of time and money.
Cognitive behavioral therapy is pushed, especially for certain disorders where medication is not helpful.

It seems to me that the reliance on medication is partially about efficacy and partially about cost. Consider that you can get a month's supply generic prozac or paxil (fluoxetine and paroxetine) for $4 from Wal-Mart, but that a month's supply of cognitive therapy is $400.




* I realize that this is my first use of this potentially derogatory term to describe non-medicos and another step on my long journey to becoming and asshole physician. Further I recognize that this blog began as an attempt to stymie said journey, and has instead served as a record of it.

More Veiled Conceit*

Peruse this wedding announcement:

"Unknown to Ms. Luft, her skirt had somehow become tucked into her pantyhose. When the elevator door opened, she realized there was a problem. 'I only noticed when everyone in the elevator was staring at my backside,'"

Obviously, this woman is very enamored of her sweet, tight buns or she wouldn't have related this tidbit to the whole planet. Or at least she was enamored of her 16 year old buns. Let's see what Wechter has to say about it:

''I was very attracted to Sara when I first met her... She's got a very engaging personality. I thought about her all the way home.''

Sweet, tight, engaging.

Couples write their own wedding announcements, so one can only wonder why the couple chose to write it this way. Do they want us to read between the lines? Do they figure they have a better shot of getting in if they have a bit of salacious summer camp gossip?

Doing an O&P (That's occupations and parents) we find that their jobs are investment/portfolio types, as are their parents, so, they're standard fare for the NYTWCA. They live in New Jersey, he works in Greenwich, and she works in New York. How miserable. Each of them spends at least 3 hours a day in the car or in transit.

Other than the meeting story, this couple is so aggressively boring that they would normally fly under the VC radar, except for the bride's heavily aftershadowed closing line, '''It was Josh, making sure I got home safely from my flight,'' she said. 'That was when we were 16 years old, and we've pretty much stayed together since.'''


pretty much [prit-ee muhch] adv. 1. After dating for two years dating long distance, they agreed to 'see other people at college.' His banana face

doomed him to four years of sucking face at closing time at the Copabanana. (Slogan: Where ugly girls go to cop banana faces.


I just realized that this icon is probably for an establishment where ugly girls go to cop other sorts of bananas, but I think the point is made). His bitterness increased when in a desperate, drunk dialing rage he called her voice mail and got: "Hi, this is Sar, please leave a message after the tone. If you're calling because you saw my name above the urinal at Tongue and Groove (click for awesome music), please send a head and a body shot to luftballoon@emory.edu. I'm totally stoked to hear from you, bye-ee." His sobbing description of a strange sore on his penis drew out her compassion, and she agreed to get back together... after the penicillin kicked in.

2. He demanded that they stay together through college, but then one day that girl in his Management 318 class showed up with her skirt tucked in her pantyhose. She flew in unexpectedly to surprise him, and found the pantyhose draped over his doornob. "Wechter?" He said over the phone, "I hardly knew 'er." Six years, 14 breakups, and numerous heartfelt conversations later, they give up on dating other people and show the whole world their orthodontic work on the NYTWCA.

3. In order to stay together in college, they lived in Rocky Mount, VA (exactly halfway between University City and Atlanta) and commuted 6 hours in either direction, which makes their current 3 hour commute look like crossing the street. Once she got really sleepy and stayed in a rest stop in North Carolina, so they spent the night apart.

Which do you think is most likely?



*Veiled Conceit is the original idea of 'Zach' at Veiled Conceit
With special help from Cara.

A Little Veiled Conceit*

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

Before we begin this week's edition of Veiled Conceit, I'd like to give small public service announcement:

Do not, under any circumstances let your picture look like this:











Seriously. She's either ridiculously smug, or giving every pretentious male in the U.S. a 'come-hither' look. Maybe both. She was in the Peace Corps. I would say that ex-Peace Corps folk are usually highly pretentious about it, but the one's I know are actually quite nice. damn. She used to fight child trafficking in Nepal, but then she started working for Planned Parenthood, and you know what inappropriate trafficking joke goes here. As for the groom, Bob, he's totally oblivious, although his gaze is oddly mesmerizing.

Update: I just noticed the bride is 35. I swear officer. I know she looks 17, but at least she's old enough to know to lie, right?


Let's go to this week's vows couple, fine art photographer Alex Heilner and his bride to be Amy Scott. Let's look at some of his work, eh? I immediately went for the collection called 'microbes.' The best I can say is that the landscape photos are much better.


a colony of Penicillin Resistant E. statebuilding

It seems that Mr. H is known for his alphabetizing ability, and his annual scavenger hunt. He's also known for his list of desired girlfriend qualities, "An abridged version" said the Sunday Stylez Crew, "would include: brainy, creative, humble, funny, confident and energetic enough to go out every night. And one more thing: 'Hot. That was important.'" Translation: Hot. Re-translation: Hot, and willing to always put Queen II in front of Queen on Fire: Live at the Bowl because I comes before O, or U.

Let's look at the man himself...

Objects in mirror are closer than they appear.

Any middle class pig can photograph himself in the bathroom mirror. But, the car mirror! Genius. Every car commercial every written satirized in a single, digital moment! Couldn't we get a better head-shot, you ask? Well, no. He's a small, Beetle-like figure in wedding picture A, and an out of focus cheek in wedding picture B.


He's definitely "small enough to fit in a guitar case"

According to the article, the couple married themselves, as is legal under Colorado law. What sort of pretentious yuppie Napoleon bullshit is this?



Napoleon: Also small enough to fit in a guitar case.




Buyers Remorse

As always, the real story is in the background...

He and Alex gaze at the same thing far to the right. Is it the open bar? The air conditioner? Or the next item on Alex's scavenger hunt of love? Only time will tell, but statistics say...



Finally, I'm going to try to convince Cara to help me out with a video, which may get updated in below.
Update:


*Veiled Conceit is the original idea of 'Zach' at Veiled Conceit

Top residency choices this week:

1 allergy & immunology 46
2 hematology 44
3 radiology 44
4 aerospace med 43
5 dermatology 43
6 neurosurgery 43
7 neurology 42
8 emergency med 42
9 general surgery 42
10 pediatrics 42

The 3PPS Test

How to do it: Visual examination of the proximal phalanx of the third "ring" finger of the left ("sinister") hand.

Possible findings - documentation:
1. Nil.
2. Ring - describe ring.
3. Ring callus - note.


The upshot is that my frequent failure to perform this simple task has resulted in mockery from my physical diagnosis comrades,

Tofu Cube... OF DEATH!!!

I had a charming case of food poisoning last quarter, which I was able to (thanks to Medical Micro) identify as heat stable staph toxin. I don't want to go into it now, but at the time, I asked my friends who had been at the same restaurant if anyone had the same symptoms, and a friend wrote back that she can't get food poisoning since she doesn't eat any meat.

Contra that, today I noticed a report in the CDC's Morbidity and Mortality Weekly Reports, and they talk about this Chinese couple that got botulism from their fermented tofu.

Anyway, I have extracted below the recipe for TOFU OF DOOM.

The tofu was a commercially packaged product purchased at a retail market. In the home, the tofu was boiled, towel dried, and cut into cubes. The cubes were placed in a bowl, covered with plastic wrap, and stored at room temperature for 10--15 days. The tofu was then transferred to glass jars with chili powder, salt, white cooking wine, vegetable oil, and chicken bouillon to marinate at room temperature for 2--3 more days. Finally, the fermented tofu was stored and eaten at room temperature.


*
Note that I cite MMWR below.

After I dressed this morning...

C: You look like you're going clubbing.
I: Not so much, but I am going to go study clubbing.

The image to the side is of clubbing - bony expansion of the tips of the fingers caused by long-term lack of oxygen, e.g. that caused by smoking or other lung damage.

AIDS drugs cause AIDS I

Yesterday, I was puttering through the hospital when I came across a J, pathologist friend of mine. Whenever I see a pathologist, I always ask to see whatever slide they're working on, which usually results in an interesting story.

J told me about a case from his residency in 1994. A 20 year old man presented to the morgue with multiple Kaposi's Sarcomas in his GI tract. KS is a cancer of an unknown, probably blood vessel cell which is caused by the Kaposi's Sarcoma Herpes Virus (KSHV, HHV8). Prior to 1981, the stereotypical patient with KS was an 85 year old Italian male.

In '94 the stereotypical patient was this patient, a young gay man. Since the cancer was in his digestive tract instead of the skin, he didn't have a chance to get treatment.

Not that there was much treatment.

J kind of breaks off and says, "We don't really see cases like that anymore, not since '96."

Boards question:
A 37 year old male heroin user has noticed multiple 0.5- to 1.2-cm plaque-like, reddish-purple, skin lesions on his face, trunk, and extremeties. Some of the larger lesions appear to be nodular. These lesions have appeared over the past 6 months and have slowly enlarged. The most effective treatment for his condition is:

A. Vincristine, irinotecan, and cisplatin.
B. Valcyclovir, gancyclovir, and foscarnet.
C. Indapamide, metoprolol, and prazosin
D. Zidovudine, lamivudine, and efavirenz.
E. Ticarcillin, clavulanate, and gentimicin.


Tick
Tick
Tick


Correct answer: D. The common thread in all of this is the Human Immunodeficiency Virus, and the cocktail indicated is an ideal treatment. The release of protease inhibitors in 1996 meant that the number of patients with full blown AIDS and AIDS defining illnesses cratered, hence the dearth of KS biopsies.

This brought to mind a story on badscience.net about South Africa's stand against providing AIDS drugs to AIDS patients. For instance at an international HIV/AIDS conference, the South African booth featured that infamous reverse transcriptase inhibitor, the African Potato. Anyway, part of the South African government's argument is that, as the title of my piece indicates, AIDS drugs cause AIDS.

How can we reconcile J's observations with this claim?

Prior to 1987, there were no AIDS drugs in general circulation. One can only conclude that gay men, injection drug users, and hemophilliacs were secretly stealing AZT and snorting it starting in the mid 1970s. Of course the world's known supply was sitting on some lab shelf in Research Triangle Park. The only reasonable explanation is therefore that the Columbian cartels must have stolen the structure and synthesized a bunch of the stuff, and used it to cut the blow.

Explaining the sudden drop of KS after 1996 is relatively trivial. As it turns out, AZT causes AIDS, but the 3TC and Efavirenz are actually antidotes, so as long as people take them as a cocktail, nothing too horrible happens.

Essential resources:
AIDS reappraisal - Wikipedia (it's almost painful how hard they worked to keep this article neutral)
A little piece of history. Check the date.
Hopefully I'll get to address other aspects of the 'reappraisal' in a later piece.

Among my many flaws:

I: I seem to be missing the gene that makes you want to go to a bar, have one drink, and say, "Hey, let's go to a different bar!

She: SRY?

A problem possibly solved

Yesterday we started anemia, particularly the iron, B12, and folate deficiencies. It reminded me of a patient I saw last year who had a very confusing constellation of symptoms, but which I now realize were all anemia caused by a rash that had appeared on his chest 3 years earlier. The rash contained, presumably, rapidly proliferating skin cells and immune cells, which would suck of the folate and B12, both of which are involved in DNA synthesis. This was compounded by the patient's poor eating habit. Now if I could just figure out what the autoimmune condition was.

Something sort of similar is maybe in this paper.

Problem Solving Skills Dos

We're doing CPP&T this quarter, which is the part of medical school where they actually teach medicine. Each lecture takes the following format: "Here's a disease, here's how you get it, here's how you recognize it, here's how you treat it." Then we have lab twice a day, which is a series of cases where patients have the illness and we have to establish differentials and suggest labs and such.

We're also taking Physical Diagnosis, part of which is to run around the hospital, interviewing patients and doing as much of the physical we have learned, then trying to do diagnosis and present them to an attending physician.

It occurred to me today that medicine is very much like school problem solving - you are presented a patient/problem, you attempt to solve it in a stereotyped way based on practice problems of a similar appearance. You either get it right or wrong, but either way, you quickly move on to the next problem. If you do a good or bad job overall, it will definitely matter, but success on one problem, or even one type of problem is not necessary.

This is unlike other areas of work, which I can't think of right now, where either you can't move on, or all your problems are interrelated in ways that are simply impossible to entangle.

Anyway, that makes medicine comparatively comfortable, as opposed to, say, research, where you may be stuck on a problem for years, never knowing if you have the right answer.

The Second Eval

To: Office of Medical Education
Re: Work load of fall quarter

I would like to clarify my position on the course load for this quarter. I strongly believe that the work load for this quarter is appropriate. Therefore, I would have said "Strongly Disagree," but I'm concerned someone would take that as a request to load more work into the quarter, which I feel would be inappropriate.

Keith Ellison and the Hot Tub

Reviewing this I worry that some people will take it the wrong way, but I worry that throwing more words at it will make it worse. So, please interpret my remarks to be inoffensive to Christians, Muslims, and Jews, and if your worldview is relatively close to mine, we will have achieved communication.

As an aside, I do, in real life, know how to pronounce 'coup.'

Overly extensive coverage at... Wikipedia, where else?

Look there's a moose

My friend Sancho began working at Garmin recently and is justifiably proud of their winter ad campaigns. Observe:

"The moose"


Sancho prefers the moose, but I find it's scare tactic ways a little troubling. More realistic of what I would use a NuVi for would be:

"The unibrow"

Why Rumsfeld stuck around so long

On the top, Leo Thomas McGarry, the wise chief of staff cum vice presidential candidate on the West Wing
On the bottom, Donald H. Rumsfeld, the secretary of defense cum ex secretary of defense on CNN.

Scary it took me so long to figure this out.

Matchmaker matchmaker: A little veiled conceit

Recently, my mother asked whether people actually meet on JDate. Well mom, if the December 3rd vows couple is to be believed, not only JDate, but also SawYouAtSinai.com and JRetroMatch.com are smoking. Yes, mom, I'm sure they're full of nice Jewish girls.

But what's with Jews and constantly fulfilling stereotypes (and using that classic Seinfeld construction?)?

The bride, Rebecca Benjamin (oy!) is a matchmaker from Chappaqua, home of those other famous Jews, the Clintons. Alas, she is doomed never to fall in love, until she does. Maybe it's because she's so bossy, what with her always having to get the appetizer that she wants and getting a seat next to the groom at a singles event. She's quite picky though, "surmis[ing] from his height and appearance that he was potentially the one for her." From the pictures it looks like those qualifications were, "taller than me" and "cheeks you can grab while calling someone a little punim."

Not that his judgement of hotness is that great either. When visiting a friend, he saw a picture of that friend, former Vice President Dan Quayle, and Ms. Benjamin - focussed on her! Maybe it was recent and Danny boy has lost his hotness... sigh. Oh Dan.

I'm sure her heart jumped when she found out he worked at the law firm of Goldstein (no relation), Goldstein (no relation), Rikon, and Gottlieb, but must have descended a bit when she discovered he was only an associate. This means one of two equally troubling things: Either there are a lot more Rikons running around than I thought, or the groom is working for his father at the age of 30.

Finally they danced and formed an "instant relationship." They were "inseperable" But three weeks later the little Punim went on another singles cruise.

Why did he go?

"I booked in advance, and it was non-refundable..."

It was non-refundable.

IT WAS NOT REFUNDABLE!!!

Way to make the race look bad, buddy. *

The rest of the piece continues in its typical sappy fashion with additional bits of sterotypical Jewishness, but nothing can match the enormity of this confession, so I think I'll leave you with that.

As always, I must give credit to the originator of this concept, "Zach" of Veiled Conceit.

* Among the commandments that Jews are required to follow is to not commit Hillul ha-Shem, which is shaming the name of God. Indeed, there is a commandment against bad PR. Of course there's also a commandment against shaving with a razor, but being the modern Jew that I am, I continue to see the historial reason for the former commandment while gleefully violating that latter.

Continuity

So, linking in the pictures and the videos means that there will be some continuity errors with what was previously published, id est, I lied. But you were expecting that, right?

The new idea is to provide a mix of multimedia content that is unashamedly comprised to incomplete thoughts, why? because I don't have time to complete them.

That is all.

Video Archive

My video channel is:
http://www.youtube.com/profile?user=lostea

It's, video-ish and what I've been doing.

Circular Reform II

The meat.
The Poobah feeds us what he thinks good curricular reform looks like. We need to get away from spoon-feeding lecture material and move toward problem based learning. We neeed to encourage life-long learning. We need to promote horizontal and vertical integration, i.e. I need to talk to more 4th years. We need to get away from the 2+2 formula of medical education where there are two years of preclinical class-work and two years of clinical apprenticeship in the hospital. We should replace it with a 2x2 formula that promotes more integration between the preclinical and clinical worlds. I wonder if he's aware that, on a stricly mathematical level, 2x2 = 2+2? Obviously, this is deeper than math. Of course, I have no idea how 2x2 might work, and Poobah gives no pointers.

Poobah also encourages our initiative to promote good teaching and our huge push for professionalism. Little does he know that our professionalism teaching actually includes (see Hubris). Finally, he says that we shouldn't be seduced by false outcomes, things like standardized exam (board) scores, student satisfaction, and residency results (the Match). After all, we're amazing students, so we should do well on the boards regardless.

He talks about the need for humanism and the goodness of having a standardized patient interview as part of the 2nd step of the boards. He talks about the possibility of changing pre-medical requirements to start out with better trained students, or other larger reforms. In response to questions, he complained about the loss of low-income students who don't understand that they'll be able to pay their way out of the enormouse debt burden that medical school entails, and speculates unproductively about how medical schools can decrease their costs.

Ahem.

1. There's no data. I complained about this on the way out, and another student said, "There is data, he just didn't show it to us. If he had, it would have taken six hours." Maybe, but without the data, the hour speech is a waste of time. As Poobah said, one of the major obstacles to curriculum reform is student opposition.

2. I have very little to say to a fourth year, thank you very much. I mean, we can talk, but when we do I don't learn things that I need to know. Unlike undergraduate, there's not stuff that you need to start right now or you'll be screwed, because all that stuff is built into the curriculum.

3. 2+2 is not on the table. Sure, the inspiration for this system (The Flexner Report) is almost 100, but that doesn't automatically make it wrong. More significantly, the dean's office told the MSTPs that this is unlikely to change. Since we do 2+4+2, a major disruption of the 2+2 system will affect us deeply. This isn't to say that they would never do anything to inconvenience us, but they gave no details on what the reform would be, other than to say 2+2 was unlikely to change, which makes me feel more confident that it will be protected.

4. The reason DMS couldn't tell us what the reforms would be is that they pitched them as being student originated and student driven, so I resent the possible implication of this meeting that reform will be centrally designed and executed.

5. Problem based learning is not a panacea. For the non-medical types, PBL is a system where, rather than sitting in lecture, students are put in small groups and assigned problems to deal with. In medicine, these normally take the form of cases. The varied parts of the case serve as teachable moments, e.g. we have a patient with poor circulation and use it as an excuse to talk about hemoglobin. At the same time, we can talk about the physiology of circulation, how to interview this patient, what parts of the history are significant, how to deal with this patient's access to care etc. etc.

This sounds great, right? Kind of. This environment isn't the best environment for everyone. Some people love lecture (I go back and forth). If you don't learn from lecture, you just don't show up. If you don't learn from small group, they still take attendance, so you get to suffer through however many hours of groupthink, then go home and try to learn it your way. Regardless, some things are just better lectured. The tie-ins can be somewhat contrived. Each small group has to be led by someone, who will either be a professor (expensive) or a TA (useless). There's also no way to standardize what a small group will cover. Do you want to be treated by someone whose group shortchanged the hemoglobin, or the history taking? What happens when they have a patient that isn't a case? There are thousands of pathogens and drugs that 2nd years have to know cold - how is that case-able? Switching to case-based learning would also require Dupont to build us a huge new expensive building to accomodate the numerous small groups, making the transition that much more expensive.

Every generation has its own educational fads. Whole language. Integrated Math. International Baccalaureate. Self Esteem (ugggh). How do we know that PBL is a real advance and not a random gyration or cul-de-sac of edu-bureaucra-somethingorother?

6. My last question is not solely rhetorical. How do assess whether a pedagogy works? It's not trivial. One way is to look at internal grades. Early in Harvard's New Pathway program, for instance, rather than teaching students the names, origins, insertions, and actions of the muscles, they just taught them that muscles have names, origins, insertions, and actions. These students were quite noticeable in their 3rd and 4th years as they were the ones that had no f'ing idea what they were doing. We don't really have internal grades, so this won't work too well.

Since medical school involves a lot of material, one simple and obvious way to test multiple pedagogies is a standardised test, like the US Medical Lisencing Exam, and see whether a pedagogy improves scores. But Poobah said that board scores don't matter because we're such stellar students that we'd do well anyway. No. Look at Baylor. They teach to the boards to an outrageous degree, and their board scores are significantly higher than say, ours, since we basically ignore said boards. Thus, pedagogy can have an impact on board scores. Second, it's ridiculous for a person that is (somewhat) involved in running the USMLE to say that it doesn't measure anything. Emphasize touchy-feely all you like, but there is a body of knowledge that doctors MUST posses. The degree to which a school imparts that information is relevant, even if it is not the whole story.


MBA programs are ranked by how much money their graduates make after 3 years. The analogous system for medical schools would see where people go for their residency. This seems more reasonable than board scores - the application process involves interviews, recommendation letters and descriptions of our performance in clinical clerkships. If I've learned nothing, continued my unprofessionality, and turned into a peronality-free robot, they'll notice. There are problems with this, obviously. It's less quantifiable than boards, unless you want to assign points based on how prestigious the specialty and location of the residency are, which would itself be arbitrary. Since residency is a matter of matching, in which students rank their preferences, you could see what percentage of students get their first choice, but what if I rank a place first because I know they're the only place that will take me? Finally, part of the reason I'll get into a specific residency is because I went to Dupont. The system is sticky - difficult to change. Still, looking at the change in our performance, relative to ourselves, provides some quick feedback.

One could argue that the true definition for success lies in the future, some 10 years hence, when they see what kind of doctors we are. This is horribly non-quantifiable. How are they going to assess our competence then if they admit it's impossible to measure competence now? Is it going to be outcomes, in that our school is better if we place more professors? That ignores the fact that most people don't want to be professors. Should we do take-home pay? How uncivilized. It does however, have the advantage of being a realistic assessment of your value to society.

Once you eliminate ways to compare programs, the relative value of programs is dependent entirely upon reputation. For instance, we have a reputation as a "Top 10 medical school," when, in fact, we're not. Not even close. But the strength of the Dupont brand is such that we seem that way. Or something. The whole 'not top 10' is based on US News's rankings (http://www.usnews.com/usnews/edu/grad/rankings/med/brief/mdrrank_brief.php) which, in the absence of better data, will be the way med schools are ranked (which should be incentive for developing alternate rankings). Let's look at the rankings and methodologies (http://www.usnews.com/usnews/edu/grad/rankings/about/06med_meth_brief.php): Reputation. Reputation. (This counts for 40% of the score, btw). NIH grants total, and per researcher. How this affects the quality of my MD-only colleagues education, I couldn't say. Note that the total is more heavily weighted than the per-researcher, thus encouraging schools to add mediocre scientists.

The next part is hillarious. Acceptance rate - what this has to do with quality, again, is unclear. Plus it encourages schools to drum up applications. Also, is this based on primary applications, or secondaries? A primary application costs $30 and all you have to do is check another box on the common app. To do a secondary, you actually want to go to the school. MCAT - yes, let's replace using board scores for a test that wonders whether you remember your cyclohexane chair conformations (http://www.cem.msu.edu/~reusch/VirtualText/sterism2.htm) from OChem. Undergraduate GPA - . Enourages schools to accept people that avoided PChem and/or classes that they thought would prove difficult - these are precisely the sort you want for your physician, no?

Faculty/student ratio is interesting. Note that's faculty members per student. We're not in undergrad anymore, dorothy. And while I would appreciate getting picked apart by 9.5 professors if I went to Harvard, I'm not sure I would notice if it was only the 4.5 that would be after me at Hopkins. Again, this encourages schools to hire more crappier professors, or relabel reserach assistants and other non-helpful people as 'teaching faculty.' Next to these metrics, board scores and %1st pick for residency seem downright brillant.


Satisfaction
The third criterion rejected by Poobah is student satisfaction. I've heard the argument before: I have no basis for comparison. I don't know whether my level of knowledge is actually good or competitive, only how it measures in the eyes of the very people I'm rating. Just because I had a good time in class doesn't mean I got anything out of it. But, as Poobah says, we're good students. We went to top schools. We take out knowledge and try to think about problems. We have a basis for comparison - it's called undergraduate. I've been taught physiology before, and I know when they're doing a bad job. We're here to learn, and we can tell the difference between when the professor is imparting useful information, imparting details about their research, and goofing off, and we rate them appropriately.

Circular Reform I

Obviously, Dupont needs to change the way it educates its students. I'm not talking about obvious, low risk, and brilliant moves, like rehiring Dr. X. That's far too petty. Rather, DuPont needs to completely rejigger its curriculum, and in doing so leapfrog ahead of other medical schools and have:

THE CURRICULUM OF THE 21ST CENTURY

We got a speech on this matter from one of the GRAND POOBAHs of the medical establishment.^1 It occured at noon, after a morning's worth of classes. Lunch, paradoxically, was not served. One of the constants of medical school is that when they want you to do something, there's free food. Nonetheless, the entire 250-seat auditorium was filled, with numerous upperclassmen sitting on the stairs. First, the dean got up and introduced the poobah. They went through this guy's whole pedigree (Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard)^2 Note that he's ~60 years old. Is that philosophy conversation he had with Chas during the Eisenhower administration really this important? Fortunately, they also went over all the crap he's done since then.

About midway through the resume, I was struck by a thought, "How cool is it that we live in the age of empiricism, where all the resume in the world does no good if the data is against you?" And I resolved that I wouldn't believe a thing unless I got the data. I have a grad class where people will refuse to give any credence to a paper because there's a shadow in one of the gels. Should we require the same standard before we muck up a generation of Dupont grads?

1 Saying who would be too much, but this was one of the top 20 people in medical education. Think deans of medical education, AAMC apparatchiks, medical education 'experts,' psychology types etc.
2 That's preschool, grade school, high school, undergraduate, post-baccalaureate research, MD, PhD, residency, fellowship, professoriate, chairmanship, initiative directorship, and deanship. As I wasn't taking notes, my rendition may be slightly innnacurate.

Has it been this long

And nothing has really gone on? The honest answer is yes. I am of the opinion that in order to write, you must have something you want to say. This is part of the reason I got out of writing as a field - I don't think that my ideas, in and of themselves, are of much originality or value. In my case, I've got nothing to push against.

The pressure of summer is basically gone. I no longer study every night. If I did, I would be so far on top of everything it would be ridiculous.* I try to amuse myself with pathology conferences or radiology visits, but scheduling for them is inconvenient given the amount of class I have. It's becoming obvious that I can improve my day immesurably by simply skipping the first lecture of any given day.

Why is the pressure of summer basically gone? It's simple. Anatomy and histology are two large concept areas where I had no previous knowledge. Zero. We receieved bone sets our first day, and I couldn't identify squat. Histology didn't start out as pinkish bluish ovals, it started out as 'can't focus on the image 'cause I don't know how to use a microscope.' Contrast that with physiology. Our med physio class is 100 'hours,' long, whereas my junior level physiology was 75 'hours' (Or 90 or 105, depending on how you want to count the lab) and taught on the same, if not a higher technical basis. The prof at Norbert, for instance, did us the courtesy of assuming we understood metastable kinetic states, and how they related to sodium channel opening (in a purely qualitative way, but still informative). For grad courses, Cell Biology and Proteins (my biochem course) are concepts I've heard before, just slightly embelished. Cell Death can surprise, like when we learned about mitochondrial calcium absorption, but it's more of an integrative class that stitches together what we already know than one which introduces big volumes of new data.

One might wonder why Physio is such a waste of time. Is it the variety of incoming preparations? My physio experience is certainly not representative, so this may have something to do with it. Is it the professors insistence on not telling us things, even in outline, that other people will teach us, and recapitulating how patch-clamp works 50 times? I'll give an example: Two weeks ago, we were lectured on the various membrane proteins involved in Long-QT syndrome, and then tested on what they were. I surveyed about 10 people in my class, including a few MSTPs, and no-one knew what QT referred to, or why it would be bad for it to be long.** It takes me about 5 minutes to explain this in simple terms any beginning med student can understand. Why don't the profs do this? Finally, the first years have a lot of other stuff to do. Physio has a rep for being an easy class where you just study the old tests, which is basically true. Our anatomy-heavy curriculum doesn't give it sufficient time to elaborate to the point where it would be revolutionary for me.

I guess I do have some stuff to say, though admittedly it is just dumb griping. We did get a lecture from a medical bigshot on how to reform our curriculum, so that will be a lot of fun if I ever do write about it.



* Why would being on top of everything be ridiculous? First, it would make classtime a complete waste. Second, I need to recouperate and save my powder for when it really counts. Third, I'm a gist kind of learner, sloppy intellect with a long memory for concepts. Hard work would just clean up the details, which would ultimately blur anyway.

** QT refers to a measurement done on EKG. It works like this, on EKG, each heartbeat has 3 big waves. The P wave is the electrical signal from the atria contracting and priming the heart. The QRS complex is 3 waves clustered together that represent the ventricles squeezing blood out into circulation. The T wave represents the ventricles relaxing. The QT interval is the amount of time (x-axis) between the beginning of the QRS complex and the end of the T wave, that is, how long the heart is contracted for. If this is too long, it means that the heart will still be contracting after all the blood has been squeezed out. It would be far more efficient to relax and let in the next round of blood. Failure to do so means that less blood gets pumped. This is 'bad.'

Powerful Medicines I

At the White Coat Ceremony the Gold Foundation for Humanism in Medicine gave us two books. One of them is On Doctoring, a collection of stories, poems, and essays about medicine. It's unobjectionable. The other is Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs. 70% of primary care medical visits result in a prescription, and thus it's important that we get it right.^1 The conceit that this book is essential or useful needs to be examined more thoroughly.

This is going to be a fairly lazy book report. The first thing I'm going to do is take a poke at the author. Actually, the only thing I have on him is that he's been at Harvard since 1969 (p 231), and he's still only an associate professor. This is probably because he's too busy running the Pharmacoblahblahblah divisions at The Brig so it probably doesn't signify.^2

I would, however, like to take aim at Bernard Lown, M.D., winner of the Nobel Peace Prize and possibly one of the biggest malpracticers in medical history. A bit of background: Your heart has a normal rhythmic beat. In some people, a heart attack or other some such causes the heart to become very a-rhythmic. These people are at high risk of keeling over with no warning, a phenomenon known as "Sudden Cardiac Death." As it turns out, if you study most people, we have a few arrhythmic beats per day. Lown (and many others) figured that if a lot of arrhythmic beats are bad, a few are still a problem. Lown proposed that treating mild arrhythmia would prevent Sudden Cardiac Deaths. With no evidence other than Lown's say-so, thousands of physicians began prescribing the treatment for mild arrhythmias. When a clinical trial was finally conducted, they found out that the treatment caused sudden cardiac deaths, rather than preventing them.^3,4 The whole story appears in Deadly Medicine: Why Tens of Thousands of Heart Patients Died in America's Worst Drug Disaster. Deadly Medicine calculates that around 50,000 excess deaths occurred because of Lown's conjecture. However, a 1997 paper argues that no extra deaths appear in the epidemiology as a result of doctors trying to suppress mild arrhythmias.^5 Regardless, Lown hectoring about the need for evidence-based medicine is pretty rich.^6 It's also interesting to note that Lown is a (the?) senior physician at The Brig, and thus in some way Avorn's boss.


Next post: The problems with the content (as opposed to the dust jacket).


1a. What this means: You have a problem that you decide needs medical attention. You visit your family doctor, pediatrician, internist, woman doctor. There is a 70% chance that this individual will prescribe you something. This doesn't include getting referred to the dermatologist and the derm. giving you something.

b. Factoid from Clinical Skills - 75% of diagnosis are made on the basis of history alone, and 90% are made from a combination of history and physical exam. History is everything the patient says. Physical exam is where you take weight, height, blood pressure, get your knee tapped etc. etc. This seems to imply that most prescriptions are given on the basis of minimal information. You may argue that for someone with high-blood pressure, not many tests are necessary besides taking their blood pressure during the physical exam. I would counter that a lot of people are getting prescriptions for antibiotics without getting a culture taken to see if they actually have a bacterial infection. Over-prescription of antibiotics leads to antibiotic resistance, so this is not an academic problem.

2. The Brig (and indeed any of the Harvard Hospitals) is considered one of the most desireable places to go for residency.

3. Everyone was so convinced that arrhythmia suppression worked that they wouldn't enroll their patients in a trial and risk them getting a placebo. At a conference where the primary investigator was describing the results, one of the attendees stood up and said, "You are immoral!" (this is from Deadly Medicine).

4. Pratt CM, Moye LA. The Cardiac Arrhythmia Suppression Trial: background, interim results and implications. Am J Cardiol. 1990 Jan 16;65(4):20B-29B. PubMed

5. Anderson JL, Pratt CM, Waldo AL, Karagounis LA. Impact of the Food and Drug Administration approval of flecainide and encainide on coronary artery disease mortality: putting "Deadly Medicine" to the test. Am J Cardiol. 1997 Jan 1;79(1):43-7. PubMed

I know nothing of epidemiology, but their method seems rather unsophisticated, especially given what Avorn says about epidemiological research.

6. Lown's quote is actually about "the corrosive effects of commerical influence... Thus, to poke fun at him for this, I have to go into how his arrhythmia suppression hypothesis required the development of new, more easily tolerated, drugs to give to patients that didn't feel ill. It was because of this theoretical market that the drug companies chose to develop the new drugs. Lown's hypothesis provided the rationale under which they were able to sell their drugs to more patients, including those outside the category for which the drugs were initially improved. Thus, Lown arguing about the need for evidence-based medicine is rich, as is Lown arguing about the corrosive effects of commercial influence.

Hubris

We had a professionalism day. This is the day where they tell us that professionalism is difficult to define, invite us to dialogue about professionalism, lecture us for five hours about professionalism, then tell us that we're ready to be professionals.

Anyway, Dean Hillary* is asking us about the merits provided by professionalism. Then she asks, "These merits may bring on a tragic flaw... does anyone have any idea what that is?"

Hubris. It's always hubris. Life as a Greek tragedy. I raise my hand.


*Not their real name.

Clinical Skills: The science of communication

This class, the whole "you're a doctor now" class is pretty boring. Our first lecture was on how important communication is. Then we had a lecture on how to talk to people, "Ask open ended questions... Give non-verbal reinforcement (mmm-hmmm, head nodding etc.)... Summarize what your patient says." This is mostly good for a few bad jokes.

I: This summarizing thing is so stupid. Won't people just get annoyed?
C: So what you're saying is that summarizing is annoying.

S: So how old are you?
I: I'm 25
S: How long has this been going on for?
I: Couple months.

I: Why did you come in today?
S: My knee hurts.
I: No. NO NO NO NO NO! You're getting it all wrong. It's supposed to be your knee.

Anyway, research indicates that first year medical students take a better history than upperclassmen, who take a better history than residents, and so on up the medical ladder. The solution ot improving patient-doctor communication? ABOLISH MEDICAL SCHOOL.

The whole communciation thing is unsurprising to me because even in normal conversation I try to do the same things, have ever since I un-gave-up on the non-supernerds. I've been accused of trying to make stilted and controlled something that should come naturally. On the other hand, it's transformed a lot of anemic conversations, so I'm willing to work with the science of communication. In principle.

An excess of normality

Something strange happened this week - it was dull. Dupont over the summer was like nothing I've done previously. Conversely, this week has felt like part of another year at Norbert. Lots of sitting in lecture and paper reading. I even had to write a critique adjudicating between two different viewpoints of a single phenomenon which were articulated in readings - just like an English class. The material was also much more comforting. I have much more experience with ion channels and lipid bilayers than I do with cranial nerves and brachial plexi. There two exceptions thus far - autopsy conference and clinical skills, which I'll post on... maybe.

Orientated

Orientation is finally finished. All programmed time, all day, every day. More tiring than actually going to class, I think.

Decompression IV

4. Finally, and probably most important. I spent a lot of time this summer trying to fit in with my class. Ultimately, I think I wore myself out and didn't leave a good taste in my classmates mouths. Hopefully over the winter I'll be able to make actual friends at Dupont, and if I can't, I'll just have to range farther, because spending time pretending that I can be whoever people want me to be is simply a bad idea.

We interrupt this whiny series...

To present an item from The Guardian's series "Bad Science."

One of the things that happens when you're a science graduate is that people always ask about these things - is red wine good? Why? What about white? How about chocolate? Of course, I haven't read the paper, so the honest answer is, "I don't know."* This is an extremely difficult answer to give when you've just spent the last half hour hearing about baseball stats, or that one time that this one guy got, like, so trashed, and you know that if you don't take the bait, it's right back into the box scores, or...

My urge is to bash anything too radical, mostly because it's unlikely to have been reported correctly, or to be a poor trial design (one that's small or doesn't consider alternate hypothesis that are more reasonable, e.g. children with MS are unlikely to have younger siblings because the parents are too busy dealing with the sick child to produce or care for another child). Of course, my cavalier treatment does cause the appearance that scientists are high priests flinging rhetorical missiles at one another, based on totally arbitrariness etc. etc.

One of my teachers at Norbert U, a lab instructor, told me not to get a PhD. She said there were too many of them and that I should instead take up science writing. I guess that means that if my work is incorrectly portrayed, I have only myself to blame.

*In fact, I barely read the abstracts linked to above. They're simply some of the first abstracts that came up on PubMed

I originally clicked over to the Bad Science post because of a post on: Instapundit

Decompression III

3. It doesn't have to be that way. I don't have to be a single PI, solely responsible for myself. I can find collaborators and set up something permanent. Being the sole professor interested in a single area in a university can give you some crazy ideas, but a good partner can help you balance them out. This is something my advisor has done, and it works well for her. Similarly, I can do something other than research. I can go work for the FDA, or a tech company, or even just teach.

Decompression II

2. Success has many definitions. My classmate S____y says that MSTPs tend to be unsuccessful. What does he mean by this? Very few people are amazing physicians and amazing scientists simultaneously. "We all think we can beat the odds." I finally realized that I don't really plan on playing those odds. On my way back from DMS, I swung by Norbert University,* my undergraduate, and had lunch with my advisor. She has a single paper in PubMed, which is over 11 years old. She has no graduate students. She does not appear to have received any NIH grants. And yet, she's very successful, at least by my lights. She changed my life. She is an amazing mentor, mother and a courageous human being (for reasons I'd rather keep private). I'll bet you Hannon doesn't come close. She's also one of the co-creators of the research project that inspired me to get into research in the first place, which brings me to my next point...

* After the Norwegian Ridgeback from Harry Potter and the Sorcerer's Stone

Decompression I

You may have noticed that summer has ended. Summer session ended a couple of weeks ago, and thus I haven't had many relevant thoughts. Actualy, I had quite a few.

1. I dislike anatomy. I've always thought that gross anatomy is like Clue. By the time the game begins, the fun part is already over.* I'm much more of a physiology man. But, Dr. X was so charismatic, and I was so wrongfooted and afraid I was going to get tossed that I confused Stockholm Syndrome for true like. On reflection, it is a bunch of really boring memorization whose exact function for most medicine, most of the time isn't really obvious. I have a better memory than most, and my particular specialty is long-term retention (rather than volume). But you know what? Anatomy is falling out of my head faster than... ummm... (un?)fortunately, most of my hackneyed metaphors have fallen out of my head as well. I had incredible difficulty studying for anatomy, and no wonder - I have a lot of trouble doing things I dislike.


* Blatantly stolen from the tagline for Kill Doctor Lucky, a rather neat product from Cheapass Games, "Why do all mystery games start just after all the fun is over?"

Blogging downside

It burns me to the core when I see blogs talking about themselves. However, much as I hate to admit it, the first Google search result for "patientetherised" is this website. I hate the fact that I'm saying it, or even that I noticed. It's like a circle jerk with only one participant. I'm so so sorry. Substantiative posting will resume... eventually. I'm doing something major and medical related on the 18th of September, so hopefully I will have a thought about that before it happens. If not... I would say I'm sorry, but S____y says we Americans apologize to much, so... deal.

My least favorite part

One of the basic organizing principles of medical school is that in the first year they explain how things work (physiology), and in the second year, they explain how things break (pathology). One downside to this is that pathology, and the ensuing treatments, are a lot more interesting than physiology, so as part of our first year, we get introduced to some basic ailments and their treatments, both to illustrate why things are important, and to keep us from getting bored.

From time to time, we look at various types of imaging studies, such as x-rays, CAT scans, MRI, and contrast studies like angiography or barium studies that look at the GI tract. Dr. X will often ask us, "What's wrong?" As in this example:



So, this is a plain film x-ray.* Bone and metal are white, soft tissue is gray, air is black. At first glimpse, there appear to be a lot of bone fragments, little white cirles that don't seem to go with anything. In fact, this is a child. Her bones have not yet finished ossifying, so in some parts they are composed of cartlidge, which doesn't block x-rays the way the calcium in real bone does. The big thick bone coming up form the bottom of the image is the femur (thigh bone) articulating with the three bones of the pelivs. The trick with looking at pediatric images for fractures is that you have to know where it's normal to have breaks in ossification, and where it's not. One easy way is to compare the left versus right sides. A simple analysis is below:


O.K., so the left pubic bone is fractured (x-rays are read as if the patient were facing you). The disrupted pubic symphysis and very slight dislocation of the left femur are results of this. Why is this my least favorite part? The answer is found in the answer to this question - what's the differential diagnosis for a pediatric fractured pubis? This is a complicated way of asking, "What could be the cause?" If you're lucky, thre's a car accident in the near past. If not, the most likely cause is child abuse.




*I don't know who this is, or the age. There are no identifying marks, therefore I consider this sanitized for the purpose of privacy. The image is a picture I took of a plain film, so it is not form any case online.

Survey Part II

The second survey I took recently (see below for Part I) was a course evaluation of the anatomy class whose final is this Friday. Three questions stand out to me:

Please indicate the degree to which you agree or disagree with the following statements from 1 (Strongly Disagree) to 5 (Strongly Agree).*

6. Encouraged critical, independent thinking.
7. Stimulated and facilitated questions and discussions.
8. Motivated independent study in the topic area.

When I got to this point, I said, "Wait, these are course objectives?" It's objectively true that the course didn't encourage these things. It's objectively true that when a controversy came up, our professor would say things like, "We can argue all day about this - Moore says 5 muscles, Clemente says 7, Grant has 4, Grey has 10, Hollinshead says something else entirely. Ultimately, when you think about abducting your arm, it's really only two muscles - supraspinatus and deltoid."** So thinking, discussing, and searching for alternate explanations were never on the plate.

Could this be some kind of crazy form borrowed from the English department because the School of Medicine didn't want to write their own evaluation form? Nope - the forms are different, and the school of medicine one even has our little crest in the corner.

So then, what's going on? I'm not sure, but my next question is - are these things actually course objectives, and should they be? Turning back to Volume I, Page 1 of the syllabus, the course objectives seem to be to:

1. Provide a course of study that will not only be inspiring but efficient and economical.
2. Integrate basic anatomical facts and concepts into a framework of clinical thinking.
3. Be a positive and defining experience - interesting, challenging, and enjoyable.*

No mention of discussion, critical thinking, or independant study. This exonerates the course from false advertising, but the inevitable followup is to wonder whether these course objectives (to the extent that they were fulfilled) form the basis of a viable course. My answer is yes. My impression in this course, as in many science courses, is that the principles of efficiency and economy require us to ignore many controversies, nits, and details, simply because they would distract us from our course of study. Given the choice between covering the material we have, and discussing what makes a "fact" a fact, a 'fact,' a "scientific fact," a 'scientific fact' or what have you, actually talking about something is far preferrable. I can quibble with the best of them, and I don't need more practice.

What about inspiration, acting as a defining experience? Surely I don't go for that crap? Actually, I do. The problem with this blog is that I'm normally only motivated to write when I'm pissed off and partisan, but you can see the chink in my thinking in Survey Part I where I said, "That's why I'm putting up with you people in the first place." There's a big distance between writing an essay about how I want to help people and actually doing it. Somewhere in there is the moment when I stop thinking "How cool is it to be here"" and start thinking "How can I use this to improve the world?" There is the moment when I decide that saving lives is more important than collecting data. There is the moment that I realize that someone's life will be in my hands, the moment it actually is, and moment what I let it slip. One of the outcomes of my interview odessy is that I realized medical training changes you, and I decided that this change is part of my mission in life.

So it's been amazing, nerve-wracking, boring, fascinating, long, grueling, vital, and unique. That's more than enough for any course. Best course I ever had? I'm not sure. Dog Lab was probably the most life changing, Molecular Bio and Physiology are also up there. Let's say Top 7 at least. And despite my last post, just because we don't haggle about the embryological origin of the Sinoatrial Node doesn't mean I'm a soulless technocrat, or that I've lost my ability to dissent. It means I've learned the ability to hold my fire.


* As always edited for brevity and clarity.
** Made up, but representative. The names are names of common anatomy texts. If you really really want to read them, go search for them on Amazon yourself.
P.S. What I can't figure out is why SOM has these objectives on the evaluation sheet if they're not actually objectives for the classes.

Nearing the end

I've finished the content part of anatomy. I've learned the name of most every part of the body, and what connects with what. I know the signs of certain textbook illnesses. I can make sense of studies made with various imaging Devices, such as plain-film x-ray, CT, magnetic resonance, and the images made using various contrast agents.* I have been indoctrinated in simple Procedures used to influence the Sphere of Life. My Genius has been praised. I have sat in on research Symposia, and been introduced to the modern medical Paradigm...

"A mage with this level of Conditioning has been Processed. Substitute a technological focus for each of his Spheres. He is now a Technocrat."**



*Actually, I seem to be surprisingly good radiology - things tend to make sense, and it's the one area where I'm definitely better than my peers (whereas in everything else I'm about average)

**Brucato P, Campbell B, Long S, deMayo T, Taylor S. Guide to the Technocracy. White Wolf, 1999. p90

What this means, to you non-Mage players is that I've been indoctrinated and inducted. I'm one of the brotherhood now, with a diminished tendency to question received wisdom, and the accompanying increase in my perception of self importance and authority.

The Spanish Brandy

I burst into my Program Director's office last week.

I: What does Dr. X drink?
PD: What?
I: Well, our anatomy prof? Dr. X? He's really good. We want to get him a nice bottle of alcohol, and I figured you knew him.* So, what would be an appropriate gift?
PD (Gets out from behind his desk, reaches into his office cupboard, takes out a bottle of Spanish brandy): Give him this.
I (surprised): Is it any good?
PD: Of course.
I (put the bottle in my bag): OK. ... Thanks!
PD: Just don't drink it, OK? And don't tell him I gave it to you.

*The prof in question got this stint by being competant, but also because he crossed paths with our PD, who offered him the job of teaching us.

Surveys I

I took a pair of surveys today. One of them is the AAMC Matriculating student questionaire. Briefly, the American Association of Medical Colleges is the cabal of most every med school in the country (and some Canadians as well, perhaps). AAMC administers the test (MCAT) and the admissions system (AMCAS). They also keep track of what we, the students, think. I filled out a similar survey when I took the MCAT - this lets them compare matriculating students (those going to med school) vs the cohort that takes the test. It's confidential, thank God.

I had to enter my AMCAS ID#, which I probably typed several times a day every day for about six months, but has since completely fled my mind. I had hoped that I might stop being a number at some point...

1. When did you definitely decide that you wanted to study medicine?*

I remember this question from back in the day, because my answer "Dude, I haven't" wasn't one of the options. I guess now it would be "during senior year." Though, my decision of whether to actually practice is still up in the air. My desire to practice is kind of like Stockholm Syndrome. The more time I spend around physicians, the more I want to be one. Conversely, since I started thinking about graduate courses, my desire to practice is receeding.

6. Indicate how important the following factors were in your choice of medicine as a career goal by selecting one of the five options to the right of each factor: (Options are Not at all Important ... Very Important)

a. Profession provides opportunity for research
Very Important

b. Profession provides opportunity to develop expertise in a specialized area
What? I could develop expertise in the specialized area of guessing people's ZIP codes from their addresses... but why? Not at all Important

c. Profession provides opportunity to make a difference in people's lives
Where's the circle for: "That's why I'm putting up with you people in the first place" ?

d. Profession provides opportunity to use manual dexterity skills
I'll let this pass.

e. Physicians can have significant control of their work hours
I dunno AAMC, are you glad you stopped beating your wife?

f. Doctors can find practices that limit their amount of work stress
See e.


7. How important were the following individuals and experiences in your decision to study medicine?

g. Particular book, article, film, television program
No, as a matter of fact, I was not one of those geeks who ran home early from Dog Lab to watch ER.

8. How important were the following factors in your choice of this particular medical school?

a. General reputation of school
Yes, I was so excited Dupont was ranked #3 I set my house on fire.**

b. Amount of financial support offered
Very Important.

c. Nature of school's curriculum
As opposed to its demeanor? Not Important.

d. Ability of school to place students in particular residency programs
I didn't know I wanted to go to fancy-schmancy residency programs until I knew I could go to fancy-schmancy residency programs if I went to fancy-schmancy places. Of course, MD/PhD obviates the need for F/S med school, but still. Somewhat Important.

e. It was the only school to offer admission
But then again, it was the school I most wanted to go to. Very Important.

f. Friendliness of the administrator, faculty, and/or students
This is why.

32a. Regardless of your dependency status, please indicate your parents' combined gross income for last year (a rough estimate is sufficient).
Riiight. "$0"

35. How do you plan to finance your medical school education? Please enter a percentage for each applicable category to total 100%.
Now, is this "Work study" or "Award/Scholarship"? Some of my classmates list their occupation as 'indentured servant.' Split the difference.


I consent to have personally identifiable information released to my medical school. I understand that the medical school will not distribute this information to organizations or persons in any form that will permit personal identification of me.

You've got to be kidding me.

~~~~~
So, what does this survey mean? To me, it implies that medicine thinks rather positively of itself, and expects us to think positively of it as well. I left out some issue questions that ask about what we think about the future of medicine, but they struck me as grist for AAMC publications - "87% of incoming medical students think that physicians will be less well paid in the future - we must do something about it!"

It also tells me that the profession isn't ready for me, or that I'm not ready for the profession. Many of the questions asked about things that never even crossed my mind. I wonder what has changed since then. Have some of the questions become more relevant? Was the old survey sitting in my file, screaming, "ZSN has no business being in medicine"?


* Questions are edited for brevity, many are removed entirely.
** Dupont University, borrowed from Tom Wolfe, does not exist. I exist. Therefore, I do not attend Dupont Univeristy. Twit.

External genetalia - awesome

We're almost done, only the pelvis and perineum remain. In keeping with that theme, I give you the following image. This image is part of a series designed to contrast the simplicity (and overall awesomeness) of the cock and balls with the overwrought and complicated female reproductive tract. Unfortunately, the penis drawing (which consisted of a penis with many regions that were all labelled 'awesome') has been lost, only the vaginabeast remains:

Persistence

There is a quote in the anatomy lab:

Nothing in the world can take the place of persistence.

Talent will not; nothing is more common than unsuccessful men with talent.

Genius will not; unrewarded genius is almost a proverb.

Education will not; the world is full of educated derelicts.

Persistence and determination alone are omnipotent.


The implication is obvious - we need to work like crazy, or else we will fail, or at least fail to make our mark on the world. From here, my thoughts go in several directions. First, the whole quote, then a close reading of the quote as written (which is boring as hell), then how it relates to my thinking (also very boring).

Turns out, the remainder of the quote is, "The slogan 'Press On' has solved and always will solve the problems of the human race." This doesn't sound too bad, just a call to take control of your life. More significant (I think) are the speaker and the date, those being Calvin Coolidge and 1932.

Calvin Coolidge was president during the late 1920s. The stories of wealth , lack of foresight, and belief in unlimited prosperity from this period should have been ground into your mind in the 11th grade (as they were into mine). Reread Gatsby for a refresher. My PhD will not be in economics, but my understanding is that at least some of the causes of the greatness of the great depression were created or allowed to fester during Coolidge's administration. Wikipedia states, "Even in 1929, after nearly a decade of economic growth, more than half the families in America lived on the edge or below the subsistence level—too poor to share in the great consumer boom of the 1920s, too poor to buy the cars and houses and other goods the industrial economy was producing, too poor in many cases to buy even the adequate food and shelter for themselves." You may recall that the great depression began in Europe prior to it's American begining in October 1929. The European nations, understandably hard-up for cash asked Coolidge for relief and he replied, "They hired the money, didn't they?" You can see, he was not exactly a compassionate person. Telling somebody that was laid off because of a global depression and is incapable of feeding their family that they need to "Press on" is a kick in the teeth, plain and simple.


What does this actually say? I'm not talking AP English style close reading, I'm talking what's the meaning. The first sentence says that only persistence can be persistence. This in and of itself is meaningless. Nothing in the world can take the place of ice cream. Nothing in the world can take the place of road tar. Nothing in the world can take the place of some woman's dead husband on Law & Order. What is more common, unsuccessful men with talent, or bacteria in the colons of the unsuccesful men with talent? Perhaps we should read that as saying that the most common outcome for talented men is to be unsuccessful, in which case I would be better off sticking Crayons in my head Homer Simpson style than going to anatomy lab. I suppose I could always hope I'm one of the lucky ones (truly nothing in the world can take the place of luck), but unfortunately I'm pretty smart... It seems odd that an institution that exists to promote and sell (for an impressive price) education is claiming that the world is already stuffed with "educated derelicts." I'm reading the last line to say that the combination of persistence and determination combine to do... something. The concepts are omnipotent, but does that mean that potence is proportional to persistence x determination, or is it an all or nothing thing? What happens when two persistent people come into conflict?

Fortunately, this isn't a scientific pronouncement, so such close reading, while annoying, is not necessary.

This seems like a fairly benign, somehwat overwrought call to keep buggering on (or KBO as Churchill might say). It does make one want to reach for the Demotivators (this one and this one seem quite appropriate), but this in and of itself is more a reflection of my cynicism. I said before that this is "a call to take control of your life," but that's incorrect. The reason that I made that particular leap is that I conflated this recipe for success with my own. Mine is simply to internalize my locus of control. What does that mean? It means that I believe I am in control of my life. I realize that I can't control everything that happens, but I can control the probabilities that they will happen. I can't guarantee that I won't lose my keys (or cell phone, or mp3 player or any other small item), but I can do things that will greatly decrease the probability of that occuring, things like checking my pockets before I leave somewhere.

The same is true of grades. You can't control what will be on the test, but you have a pretty good idea what the questions will be, and you know how to study for them. A lot of work is required, yes, but also talent, genius, previous education, and a host of other traits - the wisdom to know when to ask for help, and the humility to actually make the request, for instance.

So what bothers me most about this statement is the idea that I am not in control off my success, and that the only way to attain success or power is to submit to a regime of persistence. As WSC might say, "Never give in--never, never, never, never, in nothing great or small, large or petty, never give in except to convictions of honour and good sense. Never yield to force; never yield to the apparently overwhelming might of the enemy." That is, know when to stop beating your head against the wall.

Head and neck anatomy joke

After finishing the practical exam.
I: Do you know why God gave us V1?
TA: Umm... why?
I: So you can tell when you're banging you head on the wall.



This won't make it funny, but the explanation for this joke is that sensation to your forehead is provided by the 1st division (1) of the fifth cranial nerve (V), thus V1. Yeah...

Sideline into the real world

According to Frank Foer of The New Republic, there is a broad international consensus that it will take Iran about 5 years to complete a nuclear weapon. Then he reports that the CIA says it will take Iran a decade.

Funny thing - the Jerusalem Post reports that the Israeli army (IDF) estimates that Iran will have nuclear weapons in 2008, that is 3 years. Consider the CIAs failure to predict the first atomic tests run by India and Pakistan. Consider their estimates, all their estimates, about Iraq. Recall who bombed the Osirak complex in 1981. Now, who are you gonna trust?

If I wasn't freaking out about anatomy, I'd be freaking out about this.