Brain Trauma Blood Test Shows Promise But Report of Findings Is Flawed

USA Today reports that US Army doctors have discovered a blood test that can reveal whether a trauma victim has had a concussion. The test measures the level of proteins released when brain cells are damaged. If these findings are confirmed in a larger study, it would be a major advance in the treatment of traumatic brain injury [TBI]. However, the article is mostly an uncritical look at the subject.

A major question not answered is how was the blood test validated? A quote from the report “Doctors can miss these injuries because the damage does not show up on imaging scans…” is correct, but how then did they verify that a patient with a positive blood test indeed had a concussion? In medicine, before a new diagnostic test can be accepted for general use, it must be compared to a so-called “gold standard.” If the new blood test was not measured against the results of head CT scanning, then what was the gold standard used?

Only 34 subjects were included in this apparent pilot study, which has not been subjected to the peer review process. I would like to call the new blood test by the name of the protein or proteins being investigated, but the article did not provide that information.

The article referred (without a link) to a Rand Corporation study that, according to the USA Today article, stated “About 300,000 troops in Iraq and Afghanistan have suffered concussions…” I accessed that study and found that what it actually said was

“A telephone study of 1,965 previously deployed individuals sampled from 24 geographic areas [found that] 19 percent reported a probable [emphasis added] TBI during deployment...”

The author of the USA Today piece apparently then assumed that 300,000 or 19% of the 1.64 million deployed troops had in fact experienced concussions, a rather large leap of faith on three levels. The following assumptions are invalid: one, a “probable” TBI is the same as an actual concussion; two, a telephone interview is an accurate way to acquire clinical information; three, the results of a telephone sample of 1,965 people, which is 0.1% of those deployed, can be extrapolated to represent the experience of the entire population of troops.

A larger study of the unnamed protein is planned. Let’s hope it does prove to be an effective test. As the article points out, a TBI blood test would be useful in many areas such as sports, child abuse and others.

Resident Work Hours: The Solution

I don’t know why I didn’t think of it sooner. Or like many great ideas, why didn’t someone else come up with it? This morning at 4:30 as I lay awake having just received a consult from infernal medicine for an elderly lady being admitted with gallstones, atrial fibrillation and acute dehydration which could have waited until 7:00 a.m. today or even tomorrow, it hit me. I have the solution to the resident work hours controversy.

A few years ago, I was in the Navy and served on a ship. Crew members “stood watch” which consisted of a rotations of four hours on duty and eight hours off duty. Thus, each crew member worked eight hours per day but the work time was divided into two four hour shifts. To me this would be the perfect solution to the resident work hours dilemma.

I know, you are saying, “But Skeptical Scalpel, wouldn’t that mean six patient hand-offs per day?” Yes, of course it would. But according to the proponents of reduced work hours for residents, hand-offs are not a problem for continuity of care or patient safety. So if two or three hand-offs per day are OK, why not six?

There are a few issues that need to be worked out. For example, surgical residency training would have to be increased to 8 or 9 years duration. Operations would have to be scheduled carefully to enable a resident to participate from start to finish. All operations would have to last fewer than four hours. Each residency position currently filled by a single individual would require three people. Who is going to pay for that? Well, no one is concerned about who is going to pay for the newly adopted regulations limiting first-year trainees to 16 hour days. Then there are weekends, vacations and holidays which would mean that extra residents would be needed to cover.

Since I wrote this rather hurriedly, I may have overlooked something. I will give you 45 days to comment and then I will implement these new and improved work hours as stated.

Medical Student Whining and Resident Work Hours

For those of you who may not have heard, the Accreditation Council for Graduate Medical Education [ACGME] recently approved further restrictions on the number of hours that residents can work. The rules take effect in July of 2011. While many appreciate the fact that the ACGME was forced to do something to at least appear to rein in what has been portrayed as draconian working conditions for trainees lest Congress or OSHA or the ACLU enact even more onerous rules, the ACGME changes were met with mixed responses. Directors of residency training programs were most upset about the rule that restricts first-year residents to a maximum of 16 consecutive hours worked followed by a minimum of 10 hours off.

Even the mathematically challenged can see that 16 + 10 = 26, which will make scheduling interesting since last time I checked [I love that cliché], a day consists of 24 hours. The new trainees also are mandated to receive more supervision. What is not spelled out is how these new doctors are to learn to work independently the following year when they will be less supervised and stay awake for 24 hours never having done it before. As a practicing surgeon, I am here to testify that after working a full day, I am often called to see patients in the middle of the night. So far, we don’t have a mandatory 10 hours off, although it wouldn’t shock me if that is on someone’s agenda. Also, someone will have to take care of the patients when the first-year residents go home after 16 hours. Who that will be and how they will be funded is not clear.

The American Medical Student Association [AMSA] Thinks the restrictions did not go far enough. "We're going to keep pushing" for stronger limits "because it involves both patient safety and our safety and well-being," Sonia Lazreg, the group's health justice fellow [Wow!*], told The Associated Press. "The fight for safer work hours is not over."

Never mind that the jury is still out regarding the effect of the current work hours restrictions on patient safety, whether more frequent “hand-offs” of patients leads to more errors in patient care than tired doctors, what the long-term impact of these restrictions will be and many other aspects of the issue.

To the AMSA I say, stop whining about work hours. Why did you apply to medical school if you didn’t want to work hard? No one said it was going to be easy. Don’t tell me you didn’t know that doctors work long hours. This reminds me of the type of complaining that people do when they buy a house near an airport and then bitch about the noise. So AMSA members, get over yourselves. If you don’t like it, go to law school.

*(Comment by Skeptical Scalpel, who has applied for a health justice fellowship)

The “Straw Man” Is Back

A rather breathless posting on Science Daily today extols the virtues of the “scarless” or single incision laparoscopic cholecystectomy compared to the standard four small incision technique. Single incision, or laparoendoscopic single-site surgery [abbreviated LESS (a catchy acronym is mandatory)], utilizes one incision in the navel through which the entire surgical dissection and removal of the gallbladder are done. LESS cannot usually be done when the surgery is for an acute gallbladder attack or if the patient has had previous upper abdominal surgery. The study was done at Mt. Sinai Hospital in New York.

According to the article “The Mt. Sinai group did find two advantages to the LESS procedure: these patients required less pain medicine after the operation than their counterparts who had the traditional minimally invasive operation; and LESS patients typically reported higher satisfaction scores: —4.7 on a scale of 1 to 5 (5 equals highest score) versus 3.6 for the conventional laparoscopic surgery group.”

Available in the abstract of the paper but not reported by Science Daily were the following: the study was retrospective and involved only 26 LESS patients and 50 conventional laparoscopic cholecystectomy patients; 31% of the LESS patients required additional incisions; the average age of the LESS patients was significantly younger than the conventional group [37 vs. 49 years respectively]; follow-up data were unavailable for over half of the conventional group.

The Science Daily piece quotes one of the authors. "What's really exciting is how these patients would recommend the procedure to a friend or family member," Dr. Chin said. "Seventy-four percent of the patients who had the single-incision operation would strongly recommend the procedure to someone else versus 36 percent of those who had laparoscopic surgery."

Here is where the “straw man” is introduced. A “straw man” is defined [see The Skeptic's Dictionary] as creating a fallacious argument and then refuting it with one’s own position. If you believe this article, only 36% of those who had standard four-incision laparoscopic surgery would recommend it to someone else. However, in the early days of laparoscopic cholecystectomy, papers reported patient satisfaction rates of 94-95% after conventional laparoscopic cholecystectomy.

Patients in both groups had obviously undergone only one of the two procedures making the recommendation data rather difficult to interpret. If 64% of patients who had undergone conventional laparoscopic cholecystectomy would not recommend it to someone else, what then would they recommend? Keep your gallbladder despite the pain? Old fashioned large incision open surgery? Suicide?

The straw man is an old friend. It’s good to see that he is still around.

Stretching Before Exercise: The Facts

Despite evidence dating back over a decade indicating that pre-exercise stretching has no value, I continue to observe joggers in my neighborhood and people in the gym going through elaborate stretching routines.

Recent systematic reviews show that stretching before exercise neither prevents soreness nor injury. Regarding soreness, a Cochrane Review looked at 10 studies in young, healthy adults and found no significant difference in muscle soreness up to three days post-exercise in those who stretched before working out and those who did not. Similarly, another Cochrane group reviewed strategies for hamstring injury prevention and noted no difference in injury rates between those who did specific hamstring strengthening exercises or stretching and those who did neither. There is also some evidence that pre-exercise stretching may result in decreased muscle strength and power.

It appears that a few minutes of warm-up focusing on the same movements that will occur during the period of exercise is sufficient. So please stop with the ritualistic stretching and get on with the exercising.

Skeptical Scalpel’s Guaranteed Weight Loss Program

Every day you must burn more calories than you eat.

Suboptimal Outcomes for Medical School Matriculants

In the annual JAMA education issue of September 15, 2010, Drs. Andriole and Jeffe address the topic “Prematriculation variables associated with suboptimal outcomes for the 1994-1999 cohort of US medical school matriculants.” The paper is a comprehensive and scientifically sound look at what factors that existed prior to medical school enrollment were associated with students who achieved less than optimal outcomes. Poor outcomes were defined as failure to pass the United States Medical Licensing Examination (USMLE) Step 1 or 2 on the first attempt and withdrawal or dismissal from medical school for academic or non-academic reasons. The study involved over 84,000 matriculants from 1994-1999 with just over 11% falling into the suboptimal outcome category.

Major variables associated with first-time failure to pass the USMLE or academic withdrawal/dismissal were low Medical College Admission Test scores, race (Asian or Pacific islander), under-represented minority or debt of more than $50,000 before entering medical school.

But the most interesting part of this paper is that 178 matriculants in the group who started medical school from 1994-1999 had to be excluded from the study because they were still in medical school. In case you don’t get it, this means they had been in medical school for at least 10 years. [Medical school usually takes four years to complete.] I was apparently prescient in my blog post [rant] on medical education of August 10, 2010 in which I marveled that I once had received an application for a residency training position from a student who had been in medical school for 10 years, and I speculated that it must be very difficult to flunk out of medical school. This was confirmed by the prematriculation variables study which states that only 1049 (1.2%) of students withdrew or were dismissed from medical school for academic reasons.

To be fair, it is possible that some of the 178 long-term medical students could be taking 10 or more years to finish for reasons other than failure to advance because of academic difficulties. I asked Dr. Dorothy Andriole, the lead author of the study, if she knew why these individuals were in school for so long. She did not have specifics but speculated that “…some students enrolled in dual advanced-degree programs (such as MD/PhD, MD/JD, etc.) may be engaged in research-related or other degree-related activities that can substantially lengthen the time from medical school matriculation to medical school graduation [and] some students, unfortunately, experience very serious, life-threatening medical illnesses personally or within their families and must take a prolonged leave of absence from medical school.”

I hope to see a follow-up article on the fate of those 178 medical students. Maybe it could focus on such issues as how was the 10 or more years of tuition funded, how did these people perform on the USMLE, what specialties did they eventually wind up in and how competent were they?

Question: What do they call the person who finishes last in his/her class in medical school?
Answer: “Doctor”