Sve se vraća

Brzo: koje su još uvek profitabilne izvozne industrije u Srbiji?

Poljoprivreda, OK.

Ljudi, naravno.

Još nešto?

Uopšte nije teško.

Ovakvi naslovi:

Vučić i Dinkić spremaju izvoz oružja Arapima!

se brzo zaborave. A onda vam ljudi sa progrešnog kraja nišana koji ste prodali u trideset i petom poslovnom poduhvatu stoleća zakucaju na vrata.

Zatim pročitate gde evropski teroristi nabavljaju oružje (za nestrpljive: u Briselu), i spisak najvećih uvoznika srpskih rukotvorina vam postane jasniji (Belgija je bila na četvrtom mestu).

Ovo nije problem samo sadašnje vlasti—i prethodnici su se ponosili dostignućima srpske metalurgije.

Zato mi je drago što se Srbija—i ljudi i državne strukture—prema izbeglicama ophodi bolje nego komšije. Ali, nemojmo se pretvarati da je država samo nedužni posmatrač onoga što se dešava na Bliskom Istoku.

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Can you post to a Pelican blog from iOS?

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.

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High-dose cyclophosphamide for GVHD prophylaxis

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).

Error: Embedded data could not be displayed.

You can view a full-screen version of the slideshow here.

As this may be incomprehensible without someone explaining the slides, I may one day upload a version with a voice-over.

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Programming, meet medicine

John Siracusa is a programmer. Merlin Man is a lifehack guru-cum-internet personality. If you are in a medical field, there is no particular reason you would know them.

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?

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Lečenje u NIH-u

Jedna od mnogih stvari po kojima se NIH razlikuje od ostalih zdravstvenih ustanova je da pacijenti ne plaćaju ništa. Zdravstveno osiguranje nije potrebno, lekovi—od kojih mnogi koštaju $1.000 po dozi—se samo pokupe u apoteci, a ako živite daleko od Betezde platiće vam (domaći) let, voz, gorivo. Do pre 10-15 godina plaćali su i hotele, sada je tu samo dnevnica od $50.

I meni najzanimljivije—ne leče samo državljane. Štaviše, na nekim protokolima ima više legalnih i ilegalnih imigranata iz Centralne i Južne Amerike nego Amerikanaca. Ko god se pojavi na pragu instituta i ispunjava uslove za upis na studiju može da računa na američke poreske obveznike. A niko neće oterati nekoga ko je veoma bolestan ali ne ispunjava uslove, naročito ako standardnu terapiju ne može primiti kod kuće.

Zato svaki put kada čujem da se u Srbiji skuplja desetine i stotine hiljada evra da bi se neko poslao na lečenje u Italiju, Rusiju, ili Nemačku, pomislim na stvari koje se rade ovde i da li bi one pomogle. Ima ih previše za nabrajanje, tako da je najbolje otići na clinicaltrials.gov—sajt koji ima podatke o svim aktivnim studijama koje finansira NIH—i pogledati da li postoji nešto što se izvodi (ne samo finansira) ovde. Ono što sam video u poslednjih godinu dana, bez nekog reda:

  • aplastična anemija
  • srpasta anemija
  • B-ćelijski limfom
  • primarni CNS limfom
  • transplantacija koštane srži/stem ćelija za mijelodisplastični sindrom, akutne leukemije, limfome
  • Kapoši sarkom
  • hairy cell leukemija
  • hronična limfocitna leukemija
  • primarni efuzioni limfom
  • limfogranulocitoza
  • LGL leukemija
  • metastatski ili neresektabilni rak pankreasa
  • hepatocelularni karcinom
  • holangiokarcinom
  • metastatski rak debelog creva
  • metastatski rak jajnika
  • trostruko-negativni metastatski rak dojke
  • metastatski rak grlića materice
  • rak bešike
  • rak prostate rezistentan na hormonsku terapiju
  • metastatski rak pluća
  • mezoteliom pleure i/ili peritoneuma
  • timom
  • adrenokortikalni karcinom
  • metastatski melanom

Ovo ne uključuje pedijatrijska oboljenja, kojih ima još toliko. I ne uključuje bolesti koje sam video van Instituta, pošto vam u drugim akademskim centrima u Americi računi stižu iako ste na studiji.

U većini slučajeva se nekome iz Srbije sa metastatskim rakom ne bi isplatilo da prelazi okean kako bi primio eksperimentalnu terapiju čija se efikasnost još istražuje. Ali, treba se raspitati—mogu da zamislim situaciju u kojoj bi itekako vredelo.

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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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