Wednesday, May 28, 2014

Oh, no. Not another medical TV drama

A show called "The Night Shift" has surfaced on NBC. The pilot is available for viewing on line. I'll post the link in a minute.

But first, let me warn you. Here's what happened in the first 13 minutes of the show.

The hero doctor, named TC, awakens in jail after a bad night, and while riding his motorcycle to work he comes across a roadside accident.

A man impaled by a tree branch is in shock. Paramedics are in attendance, but don't know what to do.

The doctor suggests removing the branch, which he promptly does. Blood pours out of the wound.

ED Doc clamps renal artery at accident scene
The medic says, "He's gonna bleed out."

TC says, "No, he's not. His renal artery is cut. I'm gonna clamp it." How he knows it's the renal artery I couldn't tell you. He places a clamp through the 3" long impalement wound and the bloody field.

Then he makes an incision at the umbilicus and puts in a peritoneal dialysis catheter, which fortunately the ambulance crew has handy. They also have an empty IV bag, which is used to collect the blood for auto-transfusion.

Did I tell you that this is all taking place on the ground by the highway?

On to the ED.

A two-week-old baby arrives in presumptive renal failure. Another ED doc subdues a large violent man with a "sleeper hold" reminiscent of Worldwide Wrestling. A man positioned on his hands and knees is having a scrotal laceration sutured.

Of course, there's a blossoming love affair between TC and a beautiful female colleague who both pretend they aren't hot for each other.

A new intern was juggling some things he picked out of the "lost and found" box to try to impress a woman doctor when he found out the box actually contained objects removed from people's rectums.

The hospital is having financial trouble. At a meeting, our hero insults a realistically smarmy administrator who told him a patient could have been transferred by pointing out that he wasn't a doctor.

While on break, the docs pass the time by playing basketball just outside the ED where a number of hospital personnel seem to be socializing. Perhaps this could be why the hospital is losing money.

TC puts the two-week-old baby on hemodialysis without consulting pediatrics or nephrology, mentioning how vascular access was obtained, or speaking to the parents, who apparently were not present.

That's about all I could take.

If after all that, you really must have the link, it is here.

Friday, May 23, 2014

Cows or Sharks? Which are more likely to kill you?

Give me a minute, and I'll get to the cows and sharks.

You would be surprised at how few doctors are familiar with even the most basic statistics. Medical journal articles often have statistical errors which are missed by manuscript peer reviewers and readers alike.

Most medical students have taken a course in statistics, but it is usually taught in the first or second year of school. By the time they start residency training when they could really use the information, they have forgotten most of it. Statistics should be taught during the clinical years of medical school and reinforced throughout residency training.

Hospital administrators are even more clueless than physicians. I have blogged before (here and here) about the irrational responses of administrators to miniscule changes in poorly constructed surveys of patient satisfaction. When scores go down by insignificant percentages, all hell breaks loose with task forces, ad hoc committees and browbeating of staff.

Here’s a fun exercise involving statistics. It's OK. No formulas will be discussed.

Which animal kills more people per year in the United States, cows or great white sharks?

Although not long ago a German tourist was killed by a shark in Hawaiian waters, the answer is overwhelmingly "cows."

How can this be? You rarely hear about a cow killing a human but it happens about 20 times every year. Between 2003 and 2008, 108 people died from injuries caused by cattle across the United States, according to the Centers for Disease Control and Prevention. That's 27 times the whopping 4 people killed in shark attacks in the United States during the same time period, according to the International Shark Attack File.

Guess how many cows there are in the US.

According to the Drovers Cattle Network, there were 96.5 million head of cattle here as of mid-2013. The cattle population dwarfs the number of great white sharks. The New Ecologist estimates that the number of great whites in the entire world is about 3500.

The Guardian recently reported that there have been 1,085 recorded shark attacks in the US since the year 1670 for an average of only 3.5 shark attacks each year for the last 342 years.

Although not as dramatic or as newsworthy as a shark attack, it is far more likely that a person will be killed by a cow than a shark.

So keep your statistical radar turned on. Be skeptical.

And if you see an udder in the water, get to shore as fast as you can.

Thursday, May 22, 2014

Google Glass in the OR: Not ready for prime time

The Royal London Hospital and the Barts and The London School of Medicine and Dentistry presented the first live-streamed surgical procedure in the UK. The operation was an extended right hemicolectomy with resection of a metastatic liver lesion.

I was able to view the entire broadcast portion of the surgery live, and you can see it if you click  [2/27/15 Addendum: The link to the video has been taken down. Sorry.]

Here is what I thought about the event.

Tuesday, May 20, 2014

Does anyone really read anything online?

Not long ago, I tweeted a link to a very long story. Within 60 seconds, it received three retweets. Since the article would have taken at least 10 minutes to read, it is highly likely that those who retweeted it did not read it.

This phenomenon is not limited to Twitter. A couple of recent articles revealed some interesting data about what people really do online.

From Time magazine in early March: "A stunning 55% [of those who clicked into an article] spent fewer than 15 seconds actively on a page. [emphasis theirs] The stats get a little better if you filter purely for article pages, but even then one in every three visitors spend [sic] less than 15 seconds reading articles they land on."

Analysis of 10,000 articles shared on social media "found that there is no relationship whatsoever between the amount a piece of content is shared and the amount of attention an average reader will give that content."

A Slate article noted that about 5% to 10% of those who open an article leave it immediately and 38% of people who click on it "bounce" [leave it] before the end of the first paragraph.

At a few hundred words into the article, about half of the remaining readers have left, and very few of the rest make it through to the end.

The amount of scrolling can also be tracked. "There’s a very weak relationship between scroll depth and sharing. Both at Slate and across the Web, articles that get a lot of tweets don’t necessarily get read very deeply. Articles that get read deeply aren’t necessarily generating a lot of tweets."

On April Fools' Day, NPR published a story called "Why Doesn't America Read Anymore?" There was no article [emphasis mine]—only the headline and an explanation of the fact that they wanted to see if people would comment anyway. They were not disappointed as many brainless comments rolled in. This Gawker post has the best of them.  

The Washington Post noted that in addition to diminishing attention spans, we are developing into a nation of superficial readers. “It’s like your eyes are passing over the words but you’re not taking in what they say,” said a graduate student in creative writing.

Attempting to stay with the trend, last week both the Associated Press and Reuters directed their reporters to limit stories to fewer than 500 words.

If anyone is still reading this, what it means is that I should not feel slighted that people are retweeting me without necessarily reading what I so carefully and lovingly select for dissemination. 

It's not me. It's you.

PS: I am aware that some people retweet things and plan to read them later. But how do they know that what they have retweeted is worthy? Or does it matter?

Friday, May 16, 2014

What do students do on third-year surgery rotations?

On my other blog, "Ask Skeptical Scalpel," a woman who has been accepted to a few medical schools wants to know how she can find out what sort of hands-on experience medical students get during their third-year rotations.

To view that post, click here.

Wednesday, May 14, 2014

Crowdsourcing medical advice

A website called "CrowdMed" offers "crowdsourcing" of medical diagnoses. You enter a narrative about your illness and the crowd, which may not necessarily all be MDs, comes up with a diagnosis for you. Patients are supposed to discuss the most likely diagnoses with their own physicians. Via a somewhat complex system, the medical detectives can win money if patients offer cash rewards, which are not mandatory.

CrowdMed takes 10% of any money put up by patients as its commission. They claim they and anyone who offers an opinion are not legally liable since all medical opinions are anonymous, patients are told that only their real doctors can provide a definitive diagnosis, and all diagnoses are based on the pooled input of many contributors.

I have a friend who has knowledge of medical crowdsourcing that antedates CrowdMed.

He knows someone who is into self-abuse like marathons, triathlons, etc. She always has some ache or pain and goes to a massage therapist or a chiropractor, who offers a diagnosis. Then it’s off to the natural food market for some organic potion. The person behind the counter does the prescribing and maybe a bit of fine-tuning of the diagnosis. Friends and acquaintances are also free to lend their expertise. The most highly prized diagnosticians are wives of doctors, especially those who belong to the garden club. The patient would never consider a recommendation to see an actual doctor.

He has no data on the accuracy of the diagnosticians or the outcomes of the patients.

I was going to ask who in their right mind would ask a bunch of anonymous strangers for medical advice, but then I remembered that I had recently written a post about the people who ask me about their undiagnosed abdominal pain. It turns out there are a lot of such people. 

On the CrowdMed website, most of the cases described are indeed true mysteries. Take this one for example:

Keturah, 39 years old, Oregon, United States—who describes symptoms in 11 different areas of the body using a mere 1689 words.

I wouldn't know where to begin to solve that one.

Unlike the combination of the massage therapist, chiropractor, natural food market clerk, and the doctors' wives, CrowdMed claims it has an 80% success rate in achieving a correct diagnosis.

When I started writing this post, I had intended to ridicule CrowdMed, but I have changed my mind. They may have found a way to monetize what I've been giving away for free. They also have a classically good business model which involves having other people do the work.

Saturday, May 10, 2014

Why do today's college students riot?

I wish I knew.

I realize I am a dinosaur, and many things have changed since I went to college, but at least when students rioted in the '60s, it was about a war.

Students at the University of Kentucky rioted after their team lost in the finals of the NCAA basketball tournament. I suppose you could say they were disappointed and decided to vent outdoors.

This article says at least 17 couches were burned. Why is it that people in the South burn couches when they riot? Where do they get these couches? Are there a lot of living rooms without couches in the South? Is there a market for asbestos couches?

Not to be outdone by the Wildcats, students at the University of Connecticut rioted because they won the NCAA title. I can understand celebrating, but rioting?

College students riot when they lose and riot when they win.

Lacking powerhouse basketball teams, students at the University of California Santa Barbara and Santa Barbara City College apparently have to invent a reason to riot. Every spring they take to the streets for a weekend called "Deltopia." This year's event resulted in 100 arrests and 44 injuries requiring treatment at a hospital. Last year there was a death when a woman fell off a cliff.

Instead of rioting, maybe they should spend more time studying. The UCSB student newspaper published a piece called "An Open Letter in Defense of Deltopia" written by a student who wisely chose to remain anonymous. The letter is stunningly stupid in both syntax and theme and must be read firsthand to be fully appreciated.

In case you don't have time, here are some excerpts from that apologia:

Do not forget the student activism that has taken place within this community over the course of its inception.

I assure you, the urge to rage will long outlast the budget of Santa Barbara to keep sending in large numbers of police.

They treat the UC students as if they didn’t have to work hard to get here, and they treat the CC students like they’ll never amount to anything of substance. Contrarily, SBCC and UCSB are beacons of the educational process in their own respects.

To those lobbied against the students, you should definitively decide how much animosity, brutality and prejudice you are going to harbor and exert on the students who call this place home.

If this is an example of what these "beacons of the educational process" are turning out, rioting about the faculty and the curriculum might be justified.

Thursday, May 8, 2014

Prelim GS resident needs advice

On my other blog, "Ask Skeptical Scalpel"

A US citizen, who is an international medical graduate and a current general surgery PGY-2 preliminary resident, wants to continue his quest for a categorical position.

My advice is here. What would you tell him?

Tuesday, May 6, 2014

What you need to know about some open access journals

The other day I received this email.

Invitation to Review Manuscript: HJEHS-14-013

Dear Colleague,

We received a manuscript titled:


We will be most grateful if you could find time to review the manuscript. Please find the Abstract below: 

This investigation was carried out to determine the armspan to lower limb length ratio amongst adult males in Rivers and Bayelsa States of Nigeria. A total of 500 apparently healthy males were used which cut across several age groups ranging from 20 to 60 years. Data were collected through one on one interview after which the individuals arm span and lower limb length were taken using a flexible metre tape. Results showed that arm span correlated well with the lower limb length and significant difference exist between the arm span and lower limb length ratio of adult males in Rivers state (2.06) and Bayelsa State (2.04) with p > 0.05 [sic]. The result also showed that a significant difference exist between arm span to lower limb length in all the age groups p > 0.05 [sic]. From the results we concluded that the arm span to thigh-foot heigth [sic] ratio of adult males in Rivers and Bayelsa States varies, with that of adult males in Bayelsa state closer to the estimated normal value of 2.
Key words: Arm-span, Thigh-foot, South-south, Nigeria

Kindly send us send a mail indicating your acceptance to review this manuscript to enable us forward to you the full manuscript.

Thank you.

Faith Lily
Editorial Assistant,
Herald Journal of Environmental and Health Science

Those are some really important findings. They suggest that either the authors or the journal's editors (or both) don't know what a significant p value is. (For you non-statisticians, a significant p value should be < 0.05, not > 0.05.) At the very least, the number of typos suggests they aren't very careful.

Why send this to me? I've never dealt with this journal before, and I have no interest or expertise in "the armspan to lower limb length ratio amongst adult males in Rivers and Bayelsa States of Nigeria" or anywhere else.

From the journal's home page: "Why Publish with HJEHS - Quality Peer Review."

Some quality. Reviewers like me are apparently selected at random.

Note also that the journal's "Archive" is empty and dated 2012.

Much as I would love to see the full manuscript, I'm going to pass on the opportunity.

"Herald Journal of Environmental and Health Science" appears on Beall's List, a compilation of suspected "predatory" journals. The criteria for identifying a predatory journal are found here.

The good news is that at least it's cheap, with a stated "processing fee" of only $400. In a previous post about open access journals, I noted fees as high as $5000.

Faculty, residents, and students should be aware that any journal that promises open access and charges a fee for publishing a paper should be thoroughly vetted before submitting any work or especially any money.

Friday, May 2, 2014

Antibiotics instead of surgery for appendicitis? I'm still not convinced

Two recent papers have added more fuel to the debate about whether appendicitis can be managed without surgery.

The first paper is a prospective observational study from Italy involving 159 patients over the age of 14 who were thought to have uncomplicated appendicitis. Nonoperative management with oral antibiotics was planned for all of the patients.

Nonoperative management failed within 7 days in 19 (11.9%) patients, all of whom underwent immediate surgery. Appendicitis was found in 17 patients, and 2 had tubo-ovarian abscesses

The abstract says "After 2 years, the overall recurrence rate was 13.8% (22/159)." This is blatantly misleading. The overall recurrence rate was 19 recurrences within 7 days plus 22 more recurrences between 7 days and 2 years for a total of 41 (25.8%) recurrences with 27/159 (17%) of the patients requiring surgery.

If you look at this paper more carefully, you will find the following from Table 3: