Annoying things about medical reporting

1. An article in Time magazine is headlined "It's Not You, Doctors Are Just Rude."

The first sentence of the article is " Doctors-in-training are in need of a dose of compassion."

It describes a paper from Johns Hopkins and the University of Maryland about intern communication behaviors. Interns were watched by trained observers.

Although interns were pretty good about touching patients and asking open-ended questions, they only introduce themselves 40% of the time and explained their roles only 37% of the time. They also sat down with patients just 9% the time.

Observations were made on 732 patient encounters, but only 29 first-year internal medicine trainees were involved.

The abstract did not explain whether these first-year interns had received any training in communication ("interpersonal skills and communication" is one of the 6 ACGMA core competencies), nor did it state at what point in their first year the study was done.

The headline of the piece in Time is a bit misleading since it suggests that all doctors are rude. Similarly, the first sentence of the article somehow brings in compassion.

The study was not about rudeness or compassion; rather it was about communication.

Maybe Johns Hopkins and the University of Maryland need to do a better job of teaching its interns, and maybe Time magazine needs to do a better job of reporting.

2. An article from a website called iMedicalApps gushes with excitement about the fact that Google Glass can be used by a surgeon to view continuous vital signs while operating.

It could be that Google Glass is going to revolutionize medical care, but I don't think it's going to be useful in the context of a surgeon looking at vital signs while she is operating.

You cannot concentrate on the operation and look at a Google Glass display of vital signs.

When I was operating, I was fully focused on the procedure. I depended on the anesthesiologist to alert me to any significant changes in the patient's vital signs.

If I wanted to know what the vital signs were, I simply asked the anesthesiologist. For me, that low-tech action was adequate.

3. Here's a headline from the Los Angeles Times. "Walk this way: Men slow down when sex is at stake."

This one is about a study from PLOS One that looked at 11 male and 11 female college students who walked around a track alone, with a significant other or with friends of the same or opposite sex. The study found that men walked significantly more slowly when they were paired with a female romantic partner compared to walking with another man or a woman who was simply a friend.

The authors concluded following: "Because the male carries the energetic burden by adjusting his pace (slowing down 7%), the female is spared the potentially increased caloric cost required to walk together."

This finding supports the idea that men are helping their romantic partners conserve energy and thus promote reproductive success. This is apparently a big issue in hunter-gatherer societies who walk long distances. It's not quite so clear why college students walking 400 meters would do the same thing. The authors speculated that it might be an evolutionary issue.

Regarding the article, a woman who follows me on Twitter said, "Not my hubby, tho we do have 2 kids."

Sorry LA Times, this one's not about sex, but I guess it makes for a better headline.

Lawyer tricks of the trade: Billable hours

Lawyers are hardworking people. That's for sure. Take this lawyer from Ohio who billed long hours for court-appointed cases. For instance, he billed for 21, 21.5, 23 and 29 hours of work for 4 different days. His lawyer said he did the work but was simply a poor record-keeper.

Right.

Not to be outdone, a lawyer from Iowa billed for more than 24 hours of work in a day on 80 separate days. He is being charged with a felony for receiving $178,000 for what are being called improper payments for work as a public defender.

Four other lawyers were terminated from the program for similar issues.

And you thought doctors worked long hours?

The president of the Iowa State Bar Association called the findings of the audit that discovered the problems "an isolated aberration, involving five lawyers. Simply put, a few bad apples do not spoil the barrel."

Are these isolated aberrations?

I'm not so sure. A lawyer friend of mine (yes, I do have friends and even relatives who are lawyers) tells me that this is not particularly uncommon.

He said that lawyers will often schedule 5 or 6 case conferences at a courthouse over a 2-hour period and bill each client for 2 hours worth of work.

At least one lawyer feels that the "billable hour" model should be scrapped because "The billable hour makes no sense, not even for lawyers. If you are successful and win a case early on, you put yourself out of work. If you get bogged down in a land war in Asia, you make more money. That is frankly nuts."

This meshes nicely with a story my lawyer friend told me. Shortly after he became a lawyer, he proudly walked into his boss's office to report that he had settled a case in record time. His boss then chastised him for doing so and pointed out that settling the case so quickly cost the firm a lot of money.

It's too bad that legal services are a "privilege"instead of a  "right." Then maybe someone other than I would be upset about how much it costs.

9-year-old boy flies to Vegas without a ticket. System error or human error?

Last week, a 9-year-old boy managed to fly from Minneapolis to Las Vegas by himself without a ticket on Delta Airlines.

According to a CNN report, Delta is reviewing its "policies and procedures to make sure something like this does not happen again." This is the predictable response by most organizations when a screw-up occurs.

Do you think this was a system error or a human error?

I favor the latter. And the errors weren't confined only to Delta employees.

How many people had to have not followed established procedures for the child to have pulled this off?

At most airports, you can't even enter the security line without showing your boarding pass and ID. Children under 18 are not required to carry identification, but someone from the TSA had to have overlooked the fact that the boy had no boarding pass to scribble on.

Another possible check might have occurred as he passed through the metal detector by himself.

At the gate when boarding starts, an agent either marks each boarding pass or scans its bar code to tally the number of passengers on board. Obviously, the boy didn't have a pass so that did not happen.

Once he got on the plane, he had to have picked a seat at random. He would not have known which seats were unassigned. It is highly likely that he had to change seats at least once or twice. Again no one noticed that he didn't have a boarding pass.

The story says the flight crew became suspicious when the plane was in the air. They eventually noticed that he was an accompanied minor that they had not been made aware of.

What happened to the head count prior to closing the door? Most flights I've been on do not leave the gate until the flight attendants have walked through the cabin and counted the number of seated passengers.

Rather than a review of policies and procedures, the airline and the TSA should "counsel" the personnel involved in this event.

For other examples of human errors being thought of as system errors, type "system errors" in the search field of this blog.

Squeezing breasts prevents cancer? How the media squeezes sensationalism out of research

Here's an example of the media taking a research study's findings completely out of context and confusing the public.

Researchers from the University of California at Berkeley found that compression of breast cancer cells grown in a laboratory made them assume a normal growth pattern.

Reports on this study may have been derailed by the university's own press release which was entitled "To revert breast cancer cells, give them the squeeze."

The study was presented at a meeting and has not been published. If you read the press release, it is very clear that the research involved only cells. The authors played down any practical use of the information, saying that even a compression bra would probably not be any value. Specifically, they said “Compression, in and of itself, is not likely to be a therapy.”

If you google "Squeezing breasts prevents cancer," you will find over 50 hits. Most of them prominently feature photos of women in various stages of undress and articles with sophomoronic (A word I just made up–a combination of sophomoric + moronic) commentary.

Here's one take on the subject from Elite Daily, the Voice of Generation-Y that cuts right to the chase: "You Can Now Help Prevent Breast Cancer By Squeezing Some Tits." [Contains NSFW photo.]

Cosmopolitan magazine's headline is "Can Squeezing Your Boobs Prevent Breast Cancer?" The brief article  [with obligatory NSFW photo.] completely misstates the findings of the research. Here's an excerpt. "A new study by a group of researchers in California proves that squeezing breast tissue can stop cancerous cells from growing. That's right, when your guy cops a feel, it's actually helping your tatas."

Here's another quote. "Scientists didn't go into deets [sic] about how your boobs should be squeezed, but said "physical pressure" was key." They didn't go into "deets" because there was nothing about actually squeezing breasts in the paper or the press release except mentioning that direct pressure on the breasts would probably not be of value.

A website called "Cancer Treatment Centers," has a rather demeaning video [NSFW beginning of video and side of page] discussion of the study by a man and a woman. Among the many stupid things, he asks her how hard he should squeeze, and she answers.

OK, "Nudge nudge. Wink wink. Say no more, say no more." [Monty Python sketch]

It was all in fun. What's the harm?

For one thing, breast cancer is not funny.

This sort of sensationalism is misleading and trivializes a serious problem.

I have no doubt that many casual or scientifically challenged readers of these sites are convinced that squeezing breasts prevents cancer.

That's too bad.

Reviewing three studies that question dogma

I like studies that question accepted practices. I also like to question studies that question accepted practices. [See this post about discrediting discredited practices.]

Here are three new studies with surprising and thought-provoking results.

A few years ago, the idea of rapid response teams surfaced. These teams were supposed to be called when patients on regular floors became unstable. It was thought that such teams would be able to intervene more rapidly than simply paging the patient's physician.

Every hospital established rapid response teams, and early studies tended to confirm that they were efficacious. So all is well.

But a paper from the journal Critical Care Medicine shows that rapid response teams increase costs and intensive care unit admissions without showing any improvement in risk-adjusted patient outcomes.

Naysayers will complain that it wasn't a randomized prospective double-blind study. But it was a large before-and-after cohort study from a respected institution, the Mayo Clinic.

The authors concluded that hospitals should at least evaluate their own experiences with rapid response teams.

Another study, this time in JAMA, questions the validity of using rates of venous thromboembolic events as markers of hospital quality.

It seems the more diligently one looks for VTEs, the more one finds them. Hospitals that did more imaging studies looking for VTEs had significantly higher rates of VTE. They also had significantly higher rates of adherence to prophylaxis guidelines.

So if a patient was looking for a hospital with high quality care in the area of venous thromboembolic events, the rate of VTE might be very misleading.

A third study, also from JAMA, looked at the use of universal precautions for all ICU patients in an effort to decrease the incidence of colonization or infection by antibiotic-resistant organisms.

This was a randomized trial in 20 American ICUs, 10 of which involved health care workers donning gowns and gloves for all patient contact and 10 where gown and glove use was required only for patients with established MRSA or VRE colonization or infection. Over 26,000 patients were included.

Although the acquisition of MRSA or VRE declined from baseline in both groups, the difference was not statistically significant. [Digression. This may have been due to the famous "Hawthorne Effect," which is that behavior improves when subjects are aware that they are being watched.]

When only MRSA was looked at, a barely significant difference in acquisition was noted for the ICUs in which all personnel took precautions for all patients.

Other interesting findings were that personnel in the gown and gloves for all patients ICUs entered patient rooms significantly less frequently. The rate of occurrence of the adverse events was not different in the two groups.

To review.

Rapid response teams may not be as useful as once thought. They may lead to increased costs and ICU admissions.

Hospitals with higher rates of VTE may actually be better quality hospitals than those with lower rates.

Observing gown and glove precautions for all patients ICUs does not appear to affect the rate of acquisition of antibiotic-resistant organisms.