A yearly welcome

July 1st is when most US residency programs let their new interns loose after a week of corporate compliance training and ACGME-mandated talks about burnout.

If you are a medical student or a new intern, read this.

And this short post of mine still applies.

In addition, remember that it is easy to become very cynical very quickly. That is not the best of defense mechanisms, but it is better than substance abuse, domestic violence, or suicidal ideation. So, if you have to be cynical, do it up the chain of command, not down or laterally. That way you will avoid preconditioning medical students, observers, and your fellow interns. The senior residents will either support you in your jadedness, or will get to feel smug when they tell you that you are too young for that much cynicism. Your attendings should, ideally, teach you why you are wrong—though the younger they are the more likely it is they will behave like senior residents. So it’s a win for everyone, really, unless someone dings you for lack of professionalism.

Also, please remember to eat.

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The overhead

There are many misnomers in American medical English. Patients walk into your clinic (from Greek kline, bed) to learn whether their scan was negative (good) or positive (bad). Those who have severe chronic pain may ask for their pain medicine (that relieve pain, not cause it), usually opioids. Some physicians would call them pain-seeking (though what they are seeking is relief). If they don’t get a prescription, they may rate their doctor poorly on a patient satisfaction survey, which is a big thing if you are into quality improvement. Quality improvement. There’s a misnomer.

Quality improvement in medicine is by definition limited to improving things you can measure, i.e. quantify, i.e. judge by criteria that are the ying to quality’s yang. Those measures may be valid or not, and may improve patients’ lives, longevity, etc. (or not) but they are not quality. Because they are measures. Numbers. You know, quantities.

The movement is dangerous in at least three ways. Firstly and most obviously, many of the things being measured haven’t been validated in prospective trials. They are either (poor) conjecture—like tight glycemic control for type II diabetics assumed to help because of good outcomes in type ones (since, you know, a skinny teenager and a morbidly obese 60-year-old are similar that way.) Or they came out of a corporate think-tank cocaine-fueled outside-the-box brainstorming session, like patient satisfaction scores1.

Secondly, even if they were the best measures in the world, tying them to promotion and compensation would have the unintended consequence of having practitioners loose sight of all other aspects of medicine, including the patient. There are many accounts of how it can happen—this one from Dr. Centor comes readily to mind—but since (1) identifying and (2) addressing the patient’s actual problem is difficult to measure objectively, it is not one of the benchmarks.

And finally, wherever there are numbers and money, techniques will evolve to game the system. David Simon’s account of how this happens in law enforcement is applicable. Want fewer central line infections? Enact a policy not to draw blood cultures from central lines! Too many nosocomial urinary tract infections? Urinalyses on admission for everyone! Hospitals create teams with dozens of people whose only job is to find new and better ways to do this. And they have to—because everyone else is doing it. A depressing amount of time, money, and effort wasted because of pointless exercises of anonymous pencil-pushers.

This is how you get to a near 3000% increase in the number of hospital administrators over 30 years. I am sure they are all good people, with good salaries, but they are, for the most part, insignificant. An epiphenomenon induced by someone’s desire to turn healthcare into an industry, forgetting that the six sigma ideology that works so well for toaster ovens can’t be forced onto moist, squishy, and fragile humans.

Which is also a good working definition of quality improvement.


  1. Some speculation on my end there. They might have been on LSD

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Zbogom, Nemanjino

Prošle godine u ovo vreme sam, i ne primetivši, prešao značajan životni miljokaz—moje dalje usavršavanje neće zavisiti od dobre volje srpske birokratije.

Stranci koji žele specijalizaciju u Americi a nemaju zelenu kartu mogu birati između dve vrste lanaca—H1B i J1 vize. Ova prva je radna viza, skuplja, i većina akademskih programa je ne sponzoriše. J1 je poznata studentima iz Srbije koji dolaze u SAD preko work and travel programa. Postoji posebna verzija J1 vize za lekare, koja je zasnovana na sledećim pretpostavkama:

  • u zemlji iz koje dolazite postoji potreba za lekarima određene specijalizacije, ali
  • ne postoje kapaciteti za školovanje tih specijalista, tako da
  • strana zemlja šalje lekara u Ameriku, ali
  • pod uslovom da se nakon završetka specijalizacije vrati u svoju zemlju na bar dve godine.

Ako neko želi da ostane u Americi nakon završetka specijalizacije, to može uraditi:

  • nakon što provede bar dve godine u matičnoj zemlji, ili
  • tako što radi dve do pet godina u delu SAD sa manjkom lekara te specijalnosti.

Prve četiri stavke su vrhunsko licimerje sa američke strane, jer su baš njima potrebni lekari generalno, a naročito specijalizanti. Broj medicinskih fakulteta je decenijama bio ograničem zbog straha lekarskog lobija da će hiperprodukcijom doći do pojeftinjenja radne snage (khmSrbijakhm). Iz moje perspektive—hvala im.

Na žalost, to znači da od države morate dobiti potvrdu da je sve gore navedeno tačno. Za Srbiju, ovo je čist kabuki. Ako i postoji potreba za nekom specijalnošću, nema se para za plaćanje svršenog specijaliste—naročito ako vam veći deo posla obavljaju volonteri. A svakako vam niko ne može reći kakva će biti situacija nakon četiri-pet godina (da li se u Srbiji bilo šta može planirati na tako dugi rok?)

Procedura je haotična. Najbolje se može uporediti sa umrtvljivanjem zubnog živca pri kojem vam zubar ne kaže koliko će zuba stradati. I ne koristi anesteziju. A zubarska stolica je istovremeno i električna, sa satom koji otkucava.

Karakterišu je četiri momenta:

  • službenici i službenice koji ne znaju o čemu se radi;
  • osoba do koje dođete nakon tridesetog telefonskog poziva zna šta vam treba, ali ne sme to da napiše jer ne može da vam garantuje posao (iako nigde u potvrdi ne treba da stoji bilo šta o garantovanom zaposlenju); kada božanskom intervencijom ipak sastavi potvrdu,
  • osoba koja treba da je potpiše ne može to da uradi jer je na odmoru, službenom putu, operacionoj sali, ili lebdi iznad Sahare u balonu, izgubljena i bez kompasa;
  • vaš budući poslodavac, koji vam svake nedelje šalje podsetnik da ističe vreme za dobijanje vize.

Nakon uljudnih molbi, svakodnevnih telefonskih poziva, preklinjanja na kolenima, i pretnjama zaštitnikom za ljudska prava i—ključni momenat—medijima, izaćićete iz zgrade u Nemanjinoj isceđeni kao krpa, ali sa dovoljno snage da otrčitite do Fedeksa kako biste to parče papira poslali kome treba u 26 milisekunde do dvanaest.

Nije tako svakome i svaki put, ali se desilo dovoljno puta meni i ljudima koje znam da je malo verovatno da je u pitanju nečija loša sreća.

Tema za razmišljanje: zašto Ministarstvo zdravlja ne bi pojednostavilo i ubrzalo proceduru, ali i počelo da naplaćuje taksu od ljudi koji su se (uglavnom) besplatno školovali, a sada idu negde gde će u bliskoj budućnosti imati za srpske uslove više nego pristojna primanja? Indija, najveći svetski izvoznik lekara, pre izdavanje potvrde traži od budućih specijalizanata koji su završili državnu školu da potpišu obavezu da će, ukoliko se ne vrate kući nakon specijalizacije, platiti oko $5.000 u rupijima.

Naravno, lako mi je to da predložim kada mi potvrda više ne treba. Ali mi je neverovatno da je srpskoj birokratiji lakše da izvodi gore opisane burleske nego da radi svoj posao i pošteno zaradi pare; i da se država Srbija bez ikakve nadoknade odriče intelektualnog kapitala u koji je prethodno uložila finansijski.

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Talk therapy

She makes the mistake of talking to patients.”

Overheard from a fellow discussing the consult attending’s rounding habits

Is there such a thing as spending too much time with a patient? The question seems preposterous, when recent time motion studies showed that physicians in general, and residents in particular, clock embarrassingly few face-to-face minutes. The quote above was said with a wink and a nudge, but there are situations when it can be true, particularly if you talk to a patient—or get talked to—instead of having a conversation.

Two groups are at highest risk of talking too much—trainees and consultants. Many an internist remembers having to pick up the pieces after a consulting physician flew by the bedside to throw an unasked for opinion bomb. Think hematologists talking about insulin regimens, cardiologists about causes and treatment of back pain, or orthopedic surgeons about code status. “But one doctor said…” and a perplexed look is the usual outcome, more so if the consultant debated him or herself out loud.

Fellows are even more efficient sowers of confusion. Unlike some of their superiors, they still remember other fields well enough to a) have a valid opinion, and b) keep it to themselves. Where they are at highest risk for foot-in-mouth is the area of their future expertise—picking up just enough from the attendings to sound knowledgeable, yet not knowing enough to tell the patient what they don’t know. Even at later stages of training, a fellow’s best plan shared with the patient may tumble down when the attending gives a diametrically opposed recommendation. The common scenario is one in which there is no evidence, and clinical judgment rules. You can either not share your own view, or punctuate every conversation with “But we’ll see what my attending says.” More time wasted, and for nothing.

Patients themselves can be talkative, sometimes to their detriment. The reasons are many, and understandable: they have much to say about themselves—relevant to why they are in the hospital and not so much, they might not have anyone at home listening, they may have some level of delirium, dementia, or other cognitive disorder. Being able to identify such a person, and then knowing how to direct the conversation, is an unknown skill for most trainees and goes against today’s dogma of giving patients time to talk. No harm done to the chatty ones, but there are only so many hours in the day, and some of them should be spent thinking.

To be clear, we don’t have an epidemic of young doctors staying in the hospital until 2am while demented World War II veterans regail them with half-made up stories from Normandy. If only. But more isn’t always better, and physicians need to know when to speak up (to get their patient back on the topic), and when to stay quiet (not to overwhelm them with half-baked ideas).

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Vanredno stanje

Moj frizer, Amerikanac grčkog porekla, je nakon očeve smrti proveo mesec dana u Atini da bi prodao stan—neplanirano, pošto nije znao da je Grčka zatvorena u avgustu. Para imao nije, pa je vreme provodio gledajući grčku televiziju (“6 glava preko celog ekrana, viču jedna na drugu”) i razgovarajući sa ujakom i njegovim prijateljima, uglavnom o prljavim, pokvarenim, lenjim Albancima.

Utisak: ljudi su svuda isti. Svako ima svoje crnce i Meksikance, i svoj FOX News.

Juče su grupe siromašne omladine sa viškom vremena i manjkom ciljeva—možda a možda i ne podstaknute vrhom baltimorske sive i crne ekonomije—lomile, palile, i krale po svom gradu. Policija je bacala suzavac, omladina je bacala cigle. Razlog za demonstracije brzo su zaboravili i demonstranti, i policija, a pre svih novinari.

Da nisam na odmoru, bio bih iznerviran jer je deo grada kojim svakog jutra idem na posao bio u haosu. Kao što je 23-ojka koja me je vozila od Karaburme do Instituta za histologiju stajala dok su palili ambasade u Kneza Miloša.

Ljudi su svuda isti, osim kad nisu.

Naša zalutala omladina voli da pali, lomi, i pljačka centar grada. Baltimorska uništava sopstveni, već propali komšiluk. Naša se nominalno bori za Kosovo (ili, izgleda, za istrebljenje suparničkog tima), baltimorska protiv policijske brutalnosti. Situacija u Baltimoru je jasna: narko preduzetnici sa jedne strane, policija sa druge, siromašni crnci kao pijuni u sredini. Ko se drži po strani popije zalutali metak, suzavac, lom vratnog pršljena. U Srbiji se teže razaznaje ko koga napada, podržava, podstiče, i brani. Ne znam šta je bolje, i ne znam za koga.

Pretpostaviću da ste kao svaki dobar akademski građanin odgledali The Wire. Dejvid Sajmon je na svom blogu već ranije pisao kako je čudo što do bacanja cigli nije došlo ranije, i u većoj meri. Neki su u komentarima to protumačili kao podrška jučerašnjim protestima. U svom poslednjem tekstu je zamolio ljude da prestanu sa paljenjem, i da se vrate kući. Neki drugi su u tome videli bogatog belca koji crncima naređuje da ćute.

Sviđa mi se kako Sajmon razmišlja, a i napravio je odličnu seriju, pa ću reći da je u pravu čim ga napadaju obe strane. To nije neki argument, ali i pored skoro pet godina provedenih u Baltimoru, bolji nemam—razmišljao sam o drugim stvarima. Ako vas interesuju rasne borbe i rat protiv droge u Americi, a imate par sati, pročitajte Sajmonove stare članke i odgledajte ovo. Ja vam neću uzimati više vremena.

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Kaposi’s: not your every day sarcoma

Kaposi’s sarcoma is an often misunderstood disease. You don’t need to have AIDS to get it; if it is AIDS-associated it doesn’t always disappear with antiretroviral therapy; and if it does it may come back years later. Even oncologists in the US don’t see it often, let alone podiatrists—hence some bizare treatment recommendations in the slides below.

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The pitfalls of ultrasubspecialization

If you haven’t yet seen the new PBS documentary on Cancer, do it as soon as possible. A free stream is available on the PBS website but it is well worth the $15 on iTunes.

It makes many good points, one of which is the siliness of viewing cancer in general, or of any particular organ, as being a single entity. Genitourinary and GYN malignancies are sill fresh in my mind after this last rotation, so an example that comes first is prostate cancer. Most have your standard testosterone-dependent, androgen deprivation therapy-sensitive cells. Once they stop responding to hormonal therapy, treatment is still targeted towards the (now mutated) androgen receptor. Small cell prostate cancer, however, looks and behaves differently—tending to be bulkier, more aggressive, and having earlier visceral organ metastases. Ultimately, we treat it more like its namesake in the lung, with cisplatin and etoposide.

That was an easy distinction to make, since small cell prostate cancer looks nothing like adenocarcinoma under a microscope. Not so for breast cancer. We now know that it is at least four diseases which are at first glance all the same: luminal A (hormone receptor-positive, Her2-negaitve); luminal B (HR-positive, Her2-positive); HR-negative, Her2-positive; and triple-negative (also called basal-like, though definitions of basal-like breast cancer vary). The first three, which we are now able to distinguish with immunohistochemistry and FISH, have different behaviour, treatment, and prognosis. The fourth is a catch-all category that probably contains many different diseases we don’t know about yet. Some of those triple-negatives may have more in common with colon or lung cancer than they do with other malignancies of the breast.

Which organ the cancer is in should be important to a surgeon or a radiation oncologist, who have to deal with the anatomy. But should medical oncologists subspecialize by organ, or by cell? Why is a neuro-oncologist better suited to treat primary CNS lymphoma than a hematologist whose main interest are aggresive lymphomas? Does a GI oncologist have a better skillset and knowledge base for dealing with neuroendocrine tumors of the pancreas than an oncologist who deals with endocrine gland malignancies? Are there other, not so obvious connections between different cancers that we are missing because of ultrasubspecialization?

I don’t know enough oncology to answer any of these questions, but they are interesting questions to make.

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Male breast cancer, a slide show

As the year winds down, these tumor board presentations will get less frequent. For now, though, it is still once a month. My latest, on breast cancer in men, seemed to be well-received. I suspect it was because, unlike most rare cancers, this one was easy to fit into a preexisting pattern: it is just like female breast cancer, except for… And voilà—you get quick and easily understood knowledge about a whole new disease entity.

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Apple’s App Store rules, Dosegate edition

First they came for the nerds.

Now they are coming for the doctors (see What’s New in Version 3.0.5). The makers of MedCalc, the best medical calculator app out there, explained what happend in detail1. This was the rule they were supposedly infringing:

22.9 Apps that calculate medicinal dosages must be submitted by the manufacturer of those medications or recognized institutions such as hospitals, insurance companies, and universities.

Nevermind that many doctors view themselves as institutions—this is an idiotic rule. Is University of Baltimore, which has no biomedical science courses or programs, allowed to publish a drug dose calculator? Is GEICO?

The FDA has issued guidance for mobile medical apps. It specificaly allows calculators that use generally available formulas, and forbids apps which calculate radiation dosage, but does not mention drugs. Where, then, did this rule come from?

It is, of course, the same App store rules that allowed these pearls of quackery.

It’s madness, and it’s maddening.


  1. Seeing that URL made me appreciate the developers even more. 

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