Analysis of a rather odd paper on cancer of the penis

Yesterday a Tweet by @DrVes caught my attention. It was a link to an abstract of a paper, published ahead of print in the Journal of Sexual Medicine, entitled “Sex with Animals (SWA): Behavioral Characteristics and Possible Association with Penile Cancer. A Multicenter Study.” Subjects were interviewed and completed questionnaires about their sexual experiences. The paper is from the Department of Pelvic Surgery, Hospital A.C. Camargo, São Paulo, Brazil and has 20 authors. I will leave the fascinating subject of multiple authors and what 20 people could have done to meaningfully contribute to the authorship of any paper for another time.

Instead, let’s focus on the findings of this study. I was unable to obtain a full text version of the paper but in this case, the abstract may be enough. The paper concerns the difference between men with and without penile cancer.

The abstract states, “SWA [sex with animals] was reported by 171 (34.8%) subjects, 44.9% of PC [penile cancer] patients and 31.6% of controls (P<0.008).” I know economic issues exist in Brazil and times may be bad. But ONE-THIRD of the nearly 500 men questioned HAD SEX WITH ANIMALS! And that represents just the ones who admitted it.

There is more. From the abstract: “SWA with a group of men was reported by 29.8% of subjects and SWA alone was reported by 70.2%. Several animals were used by 62% of subjects, and 38% always used the same animal. The frequency of SWA included single (14%), weekly or more (39.5%), and monthly episodes (15%).” It is not clear why the frequency numbers do not add up to 100%.

That SWA is a risk factor for penile cancer was confirmed on multivariate analysis.

Not to downplay the seriousness of penile cancer, but I think we have even bigger problems in Brazil. One, having lived exclusively in the USA, I may be naïve but one-third of men admitting to having sex with animals seems quite high to me. Two, what about the fact that 30% of the sexual activity with animals involved groups of men? Could it be that the animals are not always willing participants? Three, almost 40% had sex with animals on a “weekly or more” basis. Four, what about the integrity of these men? Only 38% were faithful to their animal partners.

I wish to thank the authors for sharing this with us. I look forward to their next study.

More Stuff Contaminated with Germs!

Squads of people are culturing every inanimate object in sight. Here’s the latest from a microbiologist at the University of Arizona as published in USA Today. [There is no link to the actual study.] It seems the worst thing you can touch (this week) is a gas pump, with 71% of them contaminated with “germs most associated with a high risk of illness.” Next in line are corner mailboxes, ATM buttons, escalator rails, parking meters, crosswalk buttons and vending machines.

An expert, Ashley Templin, 26, a hair stylist at the Ezelli Salon in Detroit, was quoted. She said that the thought of germs is such a problem for her that she doesn’t “use public rest rooms.” She does not say what she does when she has to urinate. Perhaps she never drinks beer or like many women, she holds it forever.

I have blogged before about the burgeoning culture of culturing everything. I continue to point out that no one has linked outbreaks of disease to gas pump handles, neckties, cell phones or the myriad other inanimate objects that are being cultured left and right. If this were truly a huge problem, we would all be continuously incapacitated by infectious diseases.

The article recommends handwashing, which of course is good advice.

What should we culture next? I suggest elevator buttons, movie theater seats, newsstands, car door handles, petting zoos and sewage treatment plants. Can you think of other things to culture?

Med School Applications at Record High. What Does It Mean?

MedPage Today featured a report released by the Association of American Medical Colleges (AAMC) stating that first-time medical school applications have reached a record high. There were 32,654 applicants for 19,000 first-year positions this year. Including people who have applied before, the number of applicants was 43,919.

My initial reaction to this news was, “I wonder why?” Physicians are taking hits from all sides. We make too many mistakes; we make too much money; we work too many hours; malpractice insurance premiums keep rising; reimbursement rates are falling; we don’t follow guidelines. I could go on.

But then I scrolled down to the comments section and found this from someone named “paramedic_t”:

You can't go to law school! The market is supersaturated with unemployed lawyers. Where else do you look?

I realize this is only one comment and there were almost 44,000 med school applicants. But should medical school be a career choice based on, “Where else do you look?”? I predict that this applicant, should he be accepted, will neither be happy with nor enthusiastic about his situation. I know a lot of people who love medicine with a passion who are disillusioned and burned out. I can’t see how “paramedic_t” will succeed. Even if he does, would you want him as your doctor?

Let’s put this medical school application business in perspective. While med school applications are increasing, the ratio of applicants to slots pales in comparison to applications the undergraduate college of US News’s #1 school Harvard University [94,000 applicants, 6641 (7%) in freshman class] or even #50 George Washington University [32,368 applicants, 10358 (32%) in freshman class].

So I’m not sure what it means. Does it mean that medicine is such an attractive career that people just can’t wait to spend a minimum of seven years after college, making peanuts and working hard to enter a career with an uncertain future? Or is it simply about, “Where else do you look?”

Media Distortions, OWS & the Wealthy

I have been tweaking the folks at Occupy Wall Street over the last couple of weeks and have received many passionate comments. Some accuse me of taking isolated examples and holding them up as representative of the whole. It looks like I’m not the only one. Yesterday’s New York Times Magazine featured a pair of OWS protesters in its “What Were They Thinking?” section. From the looks of it, they weren’t thinking anything coherent.

Here are some quotes [in italics] from the piece with my comments [in bold].

Core [a young woman]: But when I get out of broadcasting college, what job am I really going to get? I may have to go to Kansas just to get a normal job with low pay, and that frustrates me. I want to stay in New York. I was born and raised here. Please tell me who gets a broadcasting job in New York right after college? You need to go somewhere, maybe even [shudder!] Kansas, to get some experience before you appear on Channel 7 Eyewitness News.

Core: I took a photo of a guy crying while playing the drums. That touched me. Brandon lost his virginity today — not to me. I don't know who the girl is. But I want to have a party for him. What about her? At least Brandon accomplished something.

Brandon [a young man]: I drank six Four Lokos with Core, a beer or two. And then we ordered an iced mocha and two chicken fingers and large fries. I lost my virginity today. I was amped for it. I’m not sure how this is going to bring about sweeping social change.

Don’t blame me. Blame the New York Times.

In the interest of fairness, I’ll turn to the Wall Street Journal. In a story from October 22, 2011 the Siegel family of Florida was profiled. Mr. Siegel made and lost a lot of money in the timeshare business. When he had the money, he started building what was to be, at 90,000 square feet, the largest single-family dwelling in the United States. But the house is unfinished and on the market for $75M. The family has fallen on some hard times. They even have to send their eight children to PUBLIC SCHOOL!

Here are some quotes from the article.

Mrs. Siegel: "This is the grand hall," she says, opening her arms to a space the size of a concert hall and surrounded by balconies. "It will fit 500 people comfortably, probably more. The problem with our place now is that when we have parties with, like, 400 people, it gets too crowded." Now this is a real problem.

Mr. Siegel: "I was cocky and I didn't care what the house would cost because I couldn't spend all the money I was making," There are other options. You could have helped some other people with all the money you couldn’t spend. For example, there are entities known as charities.

The family had to give up their private jet. Recently, the family boarded a commercial flight for a vacation, making for some confusion. One of the kids looked around the crowded cabin and asked, "Mom, what are all these strangers doing on our plane?" How’s that for a reality check?

To overstate the obvious, this is the kind of thing that provokes people to protest corporate and personal greed.

So we have two examples of the media taking isolated cases and exploiting them. Are all the OWS protesters as shallow and vapid as the two in the New York Times story? I don’t think so. Are all wealthy people as shallow and vapid as the Siegels? I don’t think so.

Personal Accountability and Opportunity in the U.S.

The death of Steve Jobs has been discussed for several days. He apparently regretted his decision to postpone surgery for his surgically curable uncommon type of pancreatic cancer choosing “alternative medicine” instead. But another aspect of his life also caught my attention.

Steve Jobs was, to use a quaint term no longer in vogue, an “illegitimate” child. He was given up for adoption. He was raised in a middle class home in California and dropped out of college after one semester. He was poor for a while but worked hard and became a very successful man.

This got me thinking about other people who made the most of their lot in life.

When I was running a surgical residency, every year it seems I interviewed at least one applicant to my program who had this sort of story.

My parents fled Viet Nam in 1974. I arrived in the US at the age of 15 and spoke no English. My parents worked several jobs and I went to high school. At age 21, I graduated from college with honors and a degree in physics. I scored a 31 [good score] on my MCAT and was accepted at six medical schools. I scored in the 230s [good score] on my USMLE exams, Parts I and II.

These applicants got good grades in medical school and had excellent letters of recommendation. They often did extracurricular projects resulting in published research.

Why am I telling you this?

I get tired of hearing people whining about the lack of opportunity in this country. How is it that a kid from Southeast Asia who couldn’t even speak English when he got here can be so successful? Yet people who are born and raised here can’t see any possible avenue to success. It must be the government’s fault, Wall Street’s fault or someone else’s fault.

I don't get it. Can you explain?

Publish or Perish? But Where?

One of the drivers of the proliferation of journals, both online and print, is the requirement of most Residency Review Committees that faculty of residency training programs must engage in research. This rule is not “evidenced-based,” as there is no proof that a surgeon has to do research in order to be a good teacher or role model. Sometimes the opposite is true; the researcher can’t teach at all.

Residents choose to train at community hospitals because they do not want to participate in research. [Anecdotally, I think many residents at university hospitals would rather not do research too.] As is the case with faculty, there is no proof that forcing a resident to do research will result in important discoveries or make her a better surgeon.

Look at this language from the RRC forSurgery.

Some members of the faculty should also demonstrate scholarship by one or more of the following:

II.B.5.b).(1) peer-reviewed funding;

II.B.5.b).(2) publication of original research or review articles in peer-reviewed journals, or chapters in textbooks;

II.B.5.b).(3) publication or presentation of case reports or clinical series at local, regional, or national professional and scientific society meetings

Since I dropped out of the business of training residents, I have been actively blogging and not cranking out mindless publishable research. Here is an interesting fact. I have no doubt that far more people have read what I have written in my blog for a year and a half than ever read all of my 95 published works combined.

For example, I wrote a blog entitled “Statistical vs. Clinical Significance: They Are Not the Same” in August of 2011. To date, it has been viewed 4466 times. I would guess that one post alone has been read by more people than ever have read my combined published papers. I have 1070 followers on Twitter. Again, it is likely that more people have read what I tweet than ever read my scholarly works.

So what’s the point? Although I have written that individuals who participate actively in social media like Twitter have very little influence when one looks at the big picture, the same can be said of publishing a journal article. Who really reads the 25 or so critical care journals that are currently being published online and in print? [See my blog about this.]

Did I have more influence with my published writings or do I have more influence now with my blogging and tweeting? What do you think?

PS: Just like a journal article, I have cited myself three times.

Journals, Open Access Journals and More Journals

I recently received an email inviting me to join the editorial board of a relatively new online, open access journal. I am not aware of how I was chosen for this honor. I either am or have been a manuscript peer reviewer for five different journals and currently serve as an associate editor of one of them. But that information is not widely known. I have a decent bibliography, much of which is relevant to the journal’s subject matter. Maybe that’s it.

Manuscript peer reviewers and associate editors do not receive compensation for their work. Most of us view it as pro bono work for the benefit of advancing science and it is somewhat career-enhancing to be involved in the editorial process. One also can learn a lot about how journals deal with manuscripts that are submitted. This results in one becoming a better writer.

The email had a link to a list of the members of the editorial board. Of some 30, it contained only one name that I had heard of in the field. The website said the journal has an impact factor of 1.5. I could not verify that claim.

In case you aren’t familiar with open access journals, they generally do not charge the reader for a subscription or a fee to view some or all articles. Instead the authors pay an “article processing charge” which can be substantial.. A comparison of article processing charges lists fees up to $5000.00.

I am at the stage in my career where doing extra work for nothing to beef up my curriculum vitae is no longer a need. In reply to the email offering me a position of the editorial board of the open access journal, I asked if there was going to be any payment to the members of said board, who are the people doing the actual work of peer reviewing and re-reviewing manuscripts. I was told that no reimbursement would be possible.

Let’s say that an open access journal publishes 40 articles per month at $2500.00 per article. That’s $100,000.00 per issue times 12 issues or $1.2M per year. Not a bad gross income when one realizes that except for copy editing the papers and posting the finished product on the journal’s website, the intellectual work is being done by editorial board members and manuscript reviewers for free.

One of the largest open access publishers is BioMed Central [BMC]. I am not sure whether it pays any of its editorial board members or manuscript reviewers. However, BMC publishes 221 scientific journals, some of which charge the reader for accessing certain types of research. You can do your own math and see that this is big business. 

And here is another question. How many journals are needed? For example, the Thomson-Reuters Science Citation Index Expanded - Critical Care Medicine - Journal List shows 23 journals primarily devoted to the rather narrow field of critical care. This does not include other journals like Chest and Anesthesiology, which have sections on critical care. Two new critical care journals have appeared, TheScientificWorldJOURNAL [Critical Care] and Annals of Intensive Care.

Who has the time or interest to read 25 journals? What is the quality of the articles in all these journals? Does anyone read this stuff? Does anyone really care?