It looks like you can, provided you have a server running somewhere. Mine is a 2013 MacBook Pro with a dying battery.
This one I’m writing in Drafts, which will then copy the post to a Dropbox folder monitored by Hazel. This should trigger a simple bash script that processes the markdown file and pushes the newly created html files to github.
Very Rube Goldberg-y, I know. I’ll try doing it from Editorial next.more ...
That high-dose cyclophosphamide is being used for haploidentical donor transplants is well-known in circles that know what haploidentical transplants are. When I saw that Hopkins transplanters used it as single-agent prophylaxis in HLA-matched related donor transplants, I was intrigued enough to do a full literature review. This is the result, presented as a slightly-too-long fellow lecture, all 100+ slides of it.
Since I have a hard time remembering facts unless I know the history behind them, the section about the works of Dr. George Santos is rather long. It was also important to show that crude animal models can be both helpful (in telling you that higher doses of cyclophosphamide work better for GVHD prophylaxis that lower) and misleading (in making you think high-dose Cy is toxic to hematopoietic stem cells, thus changing your clinical trial design).
As this may be incomprehensible without someone explaining the slides, I may one day upload a version with a voice-over.more ...
They co-host a podcast that modestly has themselves as the subject matter. It is one of the best new podcasts this year, second only to CGP Grey’s (though with Road Work coming out this week, it may be a three-way tie). In this week’s episode, Siracusa had this to say about programmers (link to the audio here—it sounds better than it reads):
Plenty of people can espouse information telling some younger programmer “make sure you always call ‘srand’ before you call ‘rand’”, and they can easily tell you “don’t listen to that guy, you should not call ‘srand’ before you call ‘rand’”.
Neither one of them really understands it, because they can’t explain it. If that young programmer is saying “But why? But why? Why? How do these things work together? Explain it to me.” and they realize “Oh, I can’t explain it. All I have is this…”—it’s not a cargo cult, but it’s more like—”I have this practice that I’ve learned through supposed bitter experience that if I didn’t do this one time and something didn’t work, then I did do it, then it did work.” Very often in programming you can sort of learn that way where basically “I tried this one thing and it didn’t work, or this bug happened, then (I did) this other thing, and the bug was fixed”, and come away from that with a rule, or a heuristic, or something you think is an unwritten law without actually understanding the underlying…
Remind you of anything? In medicine, “cargo cult” is exactly
the term I would use. Programming’s saving grace is that it is a finite system created by humans, and—at least in theory—knowable. The human body is as black a box as it ever was—the only difference between now and the 1800s being a stronger flashlight.
So, programming clearly shares this with medicine: most of its practitioners don’t have a firm grasp of what they are doing, and don’t understand the underlying principles of their craft. Why, then, do we fool ourselves that adding programmers’ idiosyncracies to physicians’ by the way of electronic medical records, clinical decision support systems, and ultimately AI-run e-doctors, will somehow “fix” medicine instead of making it bad in a different way?more ...
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.
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.more ...
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.
Some speculation on my end there. They might have been on LSD. ↩
“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).more ...
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.more ...
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.more ...
Shortly after [posting my latest tumor board presentation][cmc8], I discovered that someone is making a documentary about men with breast cancer. The preview looked interesting.more ...