(Not really, although if I were a neuroscientist [which, I am sure, the professors who made a noble attempt to teach me that subject would agree it's a good thing for everyone that I am not] I think it would be a promising area of research. It’s known that increased use can make regions of the brain larger; for example, concert pianists tend to have particularly large portions of the motor region devoted to the fingers. I want to scan some used-car salesmen and politicians as well as certain “science” “journalists” and see if we can’t locate the areas involved in truth-stretching.)
Via @sbma44, this article has what might be the worst headline I’ve ever read.
The article itself, minus the headline and lede, is really interesting and, I think, accurately represents the research.
When a neurosurgeon electrically jolted this region in patients undergoing surgery, they felt a desire to, say, wiggle their finger, roll their tongue or move a limb. Stronger electrical pulses convinced patients they had actually performed these movements, although their bodies remained motionless.
That’s cool! As a quoted scientist points out, volition is presumably a sensation like anything else, and it’s interesting to find the brain region where that occurs.
What I want to know is whether the headline’s author seriously thought that free will might actually be something that scientists could invoke with electricity or just thought that would make the article sound more interesting. I mean, surely, whatever disagreements philosophers and theologians might have about the nature of free will, even the lowliest layperson can agree that it’s by definition something that somebody with a scalpel and a probe can’t do to you.
Exciting news in women’s health: a relatively cheap DNA test for HPV (the virus that causes cervical cancer) looks like it works better than Pap smears in preventing cervical cancer through early detection. (New York Times, New England Journal of Medicine).
This is huge for developing countries. The widespread use of Pap smears in the US and other developed countries has made cervical cancer largely a preventable disease. But in much of the world, repeated office visits for cytology that must be read by a pathologist are just not doable. In this study, a single HPV test made a significant impact.
The article has started an interesting debate about the role this will play in the US - it sounds likely that HPV testing will continue to prove better than Pap smears. That alone won’t change women’s experiences much (the DNA sample is still obtained from the cervix, so it requires a pelvic exam), but we may be able to stretch out the interval between screenings.
As both the NY Times article and the editorial accompanying the NEJM article point out, research has already shown that the interval between Pap smears can be extended after enough negative tests, and that screening very young women for cervical cancer leads primarily to excessive procedures. Neither of those has been fully accepted yet by either gynecologists or patients. Presumably any proposals to use relatively-infrequent HPV testing as the primary screening modality will be met with similar caution, so I expect we’ll be doing annual exams for the foreseeable future.
It’s interesting to think about how this will affect my practice, though - it is weird to imagine a clinic schedule where annual exams don’t predominate!
(I have to say, also, that the New York Times article gets a gold star for health reporting. Not only does it accurately report the results of the study, but the background information it provides is all correct. I’m particularly impressed that the article points out that the current recommendations for Pap smears are not for every year in most women, and that most women do contract HPV but the vast majority of these infections are benign and cleared up quickly by the body’s defenses.)
This is so true. I didn’t realize how important pens were going to be when I entered the medical field, and now I am sort of fixated on them.
Today, in fact, I was teaching a CPR class and needed to provide a pen for people to sign the attendance sheet. The only one I had in my purse was a high-quality one. I lent it out, but only after announcing to the whole class that it was mine and nobody better steal it.
Usually I do employ the Sacrificial Pen strategy Michelle describes - pharma pens are great for this but I actually bought a pack of Bic pens to “lend” as well. Hey, my pens cost a dollar apiece! (As I tell people whenever I’m forced to lend out a good one.)
My current favorite pen:
The only drawback is that I currently only have the 0.7mm size and I really like 0.5mm better.
My previous favorite was a very popular one, the Pilot G2:
On one rotation, it turned out my attending had the same preference - he saw my pen in my pocket and accused me of stealing his! Luckily mine were 0.5mm and his were 0.7mm so we could keep them straight.
One of the things you have to learn in order to sound smart while presenting a case (in other words, telling a patient’s story) is how to make generous use of signs. In general, signs are objective manifestations of illness, as opposed to symptoms, which are subjective: for example, in strep throat, severe pain is a symptom while white patches on the tonsils are a sign. Obviously, it is very important to make note of these.
Lots of them are eponyms: for example, Lhermitte’s sign is a sensation of electricity shooting down the spine while bending the neck forward; it’s considered classic for multiple sclerosis. (It’s also technically a symptom, not a sign, if we’re going to be pedantic about it, which of course we are.) Kernig’s sign and Brudzinski’s sign are pain when the leg is raised by an examiner, and pain causing involuntary hip flexion when the neck is flexed by an examiner, respectively; both are classic for meningitis, and I can never keep them straight. Grey Turner’s sign, bruising in the flank area, indicates internal bleeding and is frequently checked for in cases of pancreatitis. (Most of these signs have not been exhaustively investigated and it’s unclear how useful they actually are, but we love them anyway.)
When reporting these, we generally say something like “The patient has a positive Brudzinski sign.” This formulation is apparently so catchy that it has spawned a whole slew of other signs, most not particularly respectful.
Some are flippant terms for actual helpful diagnostic findings. For example, patients with pelvic inflammatory disease usually exhibit exquisite cervical motion tenderness. This is sometimes referred to as a “positive chandelier sign,” as in, the patient is jumping up to the chandelier during the pelvic exam. Of course, no one would write this in a medical record, but it’s not uncommonly heard in emergency rooms.
Then there are some terms that grow up in particular institutions. One that I’ve heard several times is the “10 allergies” sign. Patients who list more than a small handful of allergies are much more likely than others to have multiple vague complaints that are beyond the powers of modern medicine to solve, and I’ve heard more than one resident grumble “positive 10-allergy sign” before going in to see a patient.
I think the best (and also worst, in some sense) of the irreverent terms is the “fish sign.” You see, our hospital has a big fish tank stocked with many beautiful tropical fish. There’s a camera which broadcasts a view of the fish on the hospital’s closed-circuit TV system. Patients who are comatose, severely demented, or otherwise unable to express their viewing preferences often have their TVs set to the fish channel. That’s a positive fish sign. It’s considered a poor prognostic indicator.
This article bemoaning what young doctors and doctors-in-training wear seems to have kicked up some controversy. It mostly just made me roll my eyes.
First, it took me a bit to figure out what exactly was objectionable about all the pictures at the beginning of the article. Obviously it’s inappropriate to display your navel or your entire sternum down to the xiphoid process (particularly if your ribs are countable), but I’m still not sure what’s so bad about the second picture. Open-toed shoes? Painted toenails? The pigeontoed pose? The slight glimpse, thanks to camera angle, of thigh?
Nearly a decade later, my impression is that more young physicians and students are dressing like that resident. Every day, it seems, I see a bit of midriff here, a plunging neckline there. Open-toed sandals, displaying brightly manicured toes, seem ubiquitous.
It’s true that open-toed shoes are a poor choice for any place you might be exposed to a biohazard; I wouldn’t wear them to the hospital (or probably to work at all, as I don’t find sandals comfortable for extended walking), but I wouldn’t think it strange if an internal medicine physician wore them. (And the biohazard objection is a bit flimsy anyway; nobody objects to doctors showing their wrists or ankles.)
Another complained about a male student who came to class unshaven, even though he hadn’t been on call the night before.
He came to class unshaven? The horror! I hope this physician never visits my school, where male students regularly have beard-growing contests during finals and females often turn up with wet hair (at least you know it’s clean!).
In a study published last year in The American Journal of Medicine, patients surveyed in one outpatient clinic overwhelmingly preferred doctors photographed in formal attire with a white coat to photos of doctors in scrubs, business suits and informal clothes — jeans and a T-shirt for men, an above-the-knee skirt for women.
Above-the-knee skirts are considered informal on the level of jeans and a T-shirt? I guess someone should have told me and thousands of other women before our med school interviews… (Very few people wore what I would call “short” skirts, but many wore skirts an inch or two above the knee. Your average twentysomething woman looks frumptastic in a suit with a below-the-knee skirt.)
Seriously, I know that the way we present ourselves is important, and I take care with my dress. When I’m seeing patients, I usually wear dress trousers, a shell, sweater, or button-down blouse, and closed-toed shoes. I don’t display cleavage or wear casual khakis, very trendy clothes, or jewelry beyond a simple necklace. I take note of what female physicians wear, and I always ask myself, “would I wear this to visit my grandma?”
The problem is, while my grandma is certainly a proper older lady, she doesn’t see anything wrong with her granddaughters looking attractive. Evidently, some of the doctors who will be evaluating me do:
Her research has also found that physician clothing can influence scores on board certification oral exams, in which a senior doctor assesses a younger doctor’s medical knowledge.
“You don’t want to look too attractive to be serious,” she said, adding that “a certain amount of the nerd factor” can help a doctor’s performance.
I’m nerdy, for sure. But I don’t always look like it (though the white coat helps). After having observed the nastiness that resulted when Jill from Feministe dared to dress in such a way that onlookers could tell she has breasts, I’m a bit concerned that simply dressing tastefully and seriously isn’t good enough. Who knows when someone is going to decide that I look too attractive? Maybe I should start shopping at Coldwater Creek.
Every week my summer research program has a Friday lunch talk meant to enhance our career preparation. Today it was about “Balancing Work and Family.” I was interested to see how they’d address the subject - I often get frustrated with these talks because they’re generally put on by women’s associations and feature only female speakers, which perpetuates the idea that only women have to worry about balancing work and family (because they’re the ones deciding to add work to their traditional task of running the family, presumably).
This one was actually quite good. It addressed the issues faced by dual-career couples, which is really the way to look at it. The issue isn’t being a woman who works, it’s being a person who works while your spouse also works. Men who don’t have stay-at-home wives also have to deal with it. Accordingly, there were two speakers, a male surgeon and a female gastroenterologist, both married to fellow physicians.
Unfortunately there wasn’t a whole lot of advice given (somehow they had the impression that the audience was largely made up of undergraduates and that nobody was actually trying to plan out when to have children or how to manage staying in the same city yet). But there were interesting statistics: apparently 22% of male physicians are married to physicians, and 44% of female physicans are. (I’m not totally sure how that works, maybe the percentages of physicans who are married, and fewer female physicians are married at all?) Comparing physicians in dual-doctor marriages to physicans married to non-physicians, the dual-docs were more involved with their children, made a little less money individually but more as a family, and felt their careers didn’t take precedence as often. I think that makes sense - when the other person is just as career-oriented as you are, things have to be equal and you can’t push all the childrearing duties onto the other person.
Both of the speakers were very encouraging, and I thought it was great to hear from people who were happily and successfully living in dual-career families. The surgeon mentioned that he and his wife make sure to be home by 6, they leave work at work on the weekends, and so on. And it sounded like maternity leave and that sort of thing is becoming standard even during residency.
At one point an audience member asked whether it’s common for people to take some time off while their kids are young. Both speakers said that it can be done if that’s a priority. Then the female speaker talked about the fact that women tend to feel a lot of guilt about not being there as often as their friends or neighbors who stay at home are. She said you just have to work that out and realize that nobody spends 24 hours a day with their kid, and children never get confused about who’s their mom, dad, nanny, or other caregiver. They love them all, but parents are always special. I thought that was pretty reasonable.
Then the male speaker said his wife had found it really difficult to deal with the guilt feelings, and ended up cutting down to working three days a week so she could be home with the kids some days, rather than always feeling guilty that she wasn’t taking them to play dates or whatever like the stay-at-home mom next door. He said she was very happy with her decision, which is great (and heaven knows three days a week as an academic surgeon is still a far more high-powered career than most people will ever have), but I think it’s really unfortunate that women still so often feel such guilt about having a career. It’s not like she was neglecting her kids before, but there’s still such a big cultural push for women to be primary caregivers that it’s difficult to ignore that.
Anyway, it was a good presentation and I found it mostly very encouraging. Though this was the second time a speaker told us they had brought in a newborn to sleep under the desk while they finished a grant application! I guess that is definitely a way to combine work and family.
For quite some time, I’ve been encouraging female friends to ask their doctors for emergency contraception prescriptions at regular office visits. Most people don’t wait until they’ve cut themselves to go buy bandages; they keep them in the medicine cabinet just in case. Similarly, any woman who’s of reproductive age should probably have emergency contraception (EC, available under the brand name Plan B) on hand. Thanks to politically-motivated decisionmaking at the FDA, emergency contraception is still a whole lot harder to get than bandages. (Even women who choose not to be sexually active should consider getting EC; there are plenty of reports of women who are denied access to the medication after being raped.)
The American College of Obstetricians and Gynecologists has just launched a campaign called “Ask Me” to encourage women to ask for EC prescriptions before there’s an emergency. This is a great move by ACOG. Of course, it would be better if physicians would ask their female patients if they’d like EC, but until that happens, patients should take the responsibility for asking. That way, you can fill your prescription ahead of time (by mail or out of town, if you live in an area where it’s difficult to obtain) and have it on hand just in case you need it.
Also, while I would of course never suggest taking medicine for which one does not have a prescription, it’s worth noting that the only reason Plan B is not currently available over-the-counter is the aforementioned political struggle at the FDA, and so there’s no medical reason why you couldn’t share your prescribed EC with a friend in need. I am sure, however, that the ACOG would not approve of such an action.
As an endnote, a very useful website about EC is maintained at Princeton. It offers peer-reviewed explanations, phone numbers to get EC if you need it, and instructions for using standard birth-control pills as an emergency contraceptive regimen.
Listening to NPR today, I learned that leprosy, which is now curable with modern medications, is currently more prevalent than measles in the United States.
Also, the disfigurement is partly just due to skin infection, and partially because leprosy attacks the nerves, causing loss of pain sensation in the extremities, and patients inadvertently injure themselves over and over, eventually leading to disfigurement.
Finally, leprosy is now officially known as Hanson’s disease, after the scientist who discovered the bacterium that causes it.
You know how the typical example of old-fashioned medical quackery is the practice of bleeding?
I learned this week that bleeding is actually a recommended (and proven) treatment in some cases, though it’s called “phlebotomy” and done with sterile needles rather than dirty knives and a basin. Evidently there are certain conditions in which you have too much iron or too many red blood cells in your blood. (Red blood cells contain a protein called hemoglobin, which contains iron and serves to transport oxygen from your lungs to your tissues. That’s why iron deficiency is a problem - not enough oxygen transportation.) In this situation your blood essentially becomes sludgy. Even though there’s more than enough iron, the hemoglobin is too crowded to work properly, and the patient literally turns blue around the edges.
The treatment for this is phlebotomy. They’ll remove several units of blood over a period of time in order to get rid of the extra stuff, and make sure the patient is well-hydrated so the blood just thins out. It’s quite effective.
(This may contain errors in the details; I’m summarizing from what a physician with a thick accent told me during a brief conversation during clinic.)
I have a very low-key teaching style. Today I was teaching a chemistry class and I made some comment about gas molecules zooming around, which made one student laugh and ask me if that was a technical term. I probably could come up with fancy-sounding words (though maybe not while thinking on my feet), but I think it’s more effective to use simple words if the fancy ones don’t add anything different - the easier it is for people to understand the vast majority of what I’m saying, the more likely they’ll be able to focus on the parts that are actually new material, rather than spending time deciphering blather.
People say doctors are really bad with the jargon, and it’s totally true. Half my classmates have already started up with MI for heart attack, hyperlipidemia for high cholesterol, diapheresis for sweating, and “Please move medially” instead of “Move to the middle of the row” to accommodate latecomers.
I realize that some of these offer more precision than the lay terms, and so they’re certainly useful in technical situations, but I’m amazed at how quickly people forget what is actually going to make sense to a normal person who doesn’t spend six hours a day listening to medical lectures.
And some of the terms appear to be replacing other technical terms: evidently, saying “urination” for what the less couth might call peeing isn’t technical enough! We have to call it micturition.