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.

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.

The field of breast cancer research is nothing if not full of highly-powered, multicenter, seemingly decades-long trials. Which is good, since there are many questions that need answering.

It was an honor to contribute to the NIH Clinical Center Grand Rounds this week—a straightforward presentation of a fascinating case, followed by the brilliant Drs. Kreitman and Pastan discussing the anti-CD22 immunotoxin Moxetumomab.

If the unstated goal of these rotation post-mortems was to summarize what I had learned, a single post may not be enough for breast cancer. Six weeks ago, I knew that it was common, maybe overdiagnosed, possibly overtreated, and beating all other cancers for research funding by a vast margin. All this was a vague sense of being informed—like a NYT reader may feel after reading the Sunday Magazine feature—rather than actual knowledge.

Having talked to a good number of women with breast cancer, and worked with a few attendings dedicated to the field, I know it enough to know that I need to know more; but also enough to keep me interested. What from the outside looks like cookbook this-marker-means-she’s-getting-that-treatment medicine is in fact an intricate work of knowing your patient, figuring out where she stands in the heaps of data generated by decades-long studies following thousands of women on different protocols, discussing the options, and coming to a mutualy agreed decision¹. Hard work, all of it.

Harder still is working on those data-generating trials. Anyone can think of a clinicaly relevant question, but can they make it into a feasable protocol? Can they gather a team to manage all the patients in the center, and all the different centers? Can they manage that team? Looking at a recent set of trials you will hear more about soon, the scale boggles the mind.

Side note: “We don’t have a crystal ball” is common oncspeak for “I don’t know what your prognosis is”², but if a person has breast cancer what are the Gail model or Oncotype DX if not (developing, imperfect) tellers of fortune? And wouldn’t it be great to have a similar set of tools and statistics for all cancers?

So, not going into the field, but thoroughly impressed.

Another month, another slide show. This one is about two things I had no experience with prior to fellowship—interleukin 15 and chondrosarcoma.

The rotation is called malignant hematology, but between Thanksgiving, Christmas, New Year’s, and everyone being away for ASH, it was a joke. The only memorable part were the first two weeks—the oncology consults at Georgetown—which reminded me that the NIH was indeed an ivory tower. This is compared to a well-known academic center. Compared to a community hospital—my last employer being a good example, though you may find much better—the Institutes in general and the Clinical Center in particular are a tower of crystalized angel tears sitting high on top of a mountain range on Mars. This is neither criticism nor praise, but a statement of fact².

Having only spent four days on Georgetown consult service, I would rather not comment¹. But here are ten things about the inpatient side of my home institution that might interest the outside world:

• There is only one EMR and no paper charts;
• Someone else, most commonly the research nurse, will obtain the outside records and have them scanned in—so the EMR is the only place you need to look for anything;
• There are usually no medical students, interns, or residents—it’s the NP/PA, fellow, and the attending running the show;
• Remember the 3am page from the nurse asking for a Tylenol order? If it is for someone on a phase 1 trial, you’d better check the protocol and call the attending before giving it;
• Patients can be “out on pass”—meaning they can leave the campus for up to 20-something days and still count as an inpatient, without needing to be discharged and readmitted;
• If a patient needs to stay an extra day or two because of transport issues, nobody blinks an eye;
• For three to to five days you will get weird looks if it is your patient, but there will be no passive-aggresive emails about the hospital not getting reimbursement;
• If it is six days or more it is likely they are homeless—social work will be on it;
• Ordering most imaging—ultrasounds, CTs, MRIs, etc—requires two steps: getting a time-slot from central scheduling, or the tech on call if it is a same-day scan, and putting in the order. Think about the implications and let it sink in;
• All discharge medications are dispensed from the outpatient pharmacy free of charge to the patient. Yes, all of them;

Most people treated at the Clinical Center are trial participants who are sick, rather than “just” patients. There are no administrative or financial pressures, no dealings with insurance companies, and not much concern with disposition. As you can imagine, this makes for a beautiful work environment.

Another week, another Quora question.

What is an online resource for learning statistics needed for clinicians explained in a language that could be understood by doctors?

There are many biostatistics courses available on Coursera. Living in Baltimore, I’m biased towards JHU’s offerings. “Case-Based Introduction to Biostatistics” by Dr. Scott Zeger is a good one. If you prefer text to video, here are three good resources:

• An article: “A Review of Basic Biostatistics” by Kimberly Dukes and Lisa Sullivan (free PDF)
• A short book: “The Science of the Art of Medicine” by Dr. John Brush (free, iBooks only)
• A textbook: “Statistical Inference for Everyone” by Brian Blais (also free)

If I had to pick one, it would be Dr. Brush’s book. He is a cardiologist writing for other physicians in a language they can understand. Also, Dr. Lehman recommended it, which is more than good enough for me.

This was the last tumor board of the year, and the first in which I did not discuss a hematological malignancy. Lung cancer is bad, doubly so when it’s metastatic, but looking at this patient’s history you can see it doesn’t necessarily mean months-not-years left. This particular patient is worthy of a case report, and one is indeed in progress.

For the first time since joining Quora, I found a question to which I can meaningfuly contribute. Thought you might like to see my answer.

Why would someone choose to be a chief resident (in internal medicine)?

Why indeed.

The cynical answers would be “out of a misguided sense of loyalty to your program”. The correct and not very useful answer is—it depends.

Most positions entail primarily administrative responsibilities, with some teaching and clinical duties, and a salary just slightly higher than that of a PGY-3. So, you can expect your patient care skills to languish unless you work on maintaining them, your teaching skills to be slightly improved—or at least no worse if you’ve had some prior experience—and your knowledge of hospital administration, people management, dealing with email, and making the most out of seemingly pointless meetings to go through the roof. If you have any interest in academic medicine, as a generalist and sub-specialist alike, this last skill set will be invaluable. It is also a stamp of approval of sorts for any fellowship program director looking at your CV if and when you apply.

You also have much more free time. Depending on how many chiefs your program has, it will be most or all weekends, and almost all federal holidays. This is a good time to study for the boards if you haven’t taken them already, write up the research you’ve been working on, or spend some time with your family (the chief’s maternity/paternity leave is usually more flexible, but that’s program-dependent).

The downsides: you will have one fewer year of attending-level salary, so if you have a large debt or other financial responsibilities think twice before saying yes; some friendships you made with the junior residents will be undone or temporarily put on hold, unless you are very careful about not playing favorites; you may lose some respect for your higher-ups, as it goes whenever you peek behind the curtain; you will need to develop a thick skin, if you don’t have one already. Some would say these last two are actually pluses. It depends.

Visa issues complicate the matter, but I won’t go into details—bureaucracy shouldn’t play a role in determining a career choice, and when there is will (your own as well as the program’s) there is a way to bypass any obstacles.

Hope this helps.