Denialism Blog

Month: November 2008

  • Choosing a medical specialty

    It’s that time of year, 4th year medical students (like me – kind of) are choosing their future careers and starting to interview all over the country in their residency programs of choice. I’ve been notably quiet – subsumed in work, study and applications – but I am catching up on writing about the clerkships I’ve done in the meantime (Pediatrics, Psych, OB/Gyn and Family Medicine). But since I’m applying for residency now (MD/PhDs have an abbreviated 4th year) I figured now would be a good time to tell people about what this is like, and in the coming months what cities I’m going to be in from time to time.

    Choosing a medical specialty is a big decision. I’ve necessarily made up my mind, am very confident I’ve made the right choice and encourage you to take bets on my choice – it will be fun to see what people think. But the decision making process is famously difficult and many different strategies have been devised to help the indecisive (not me). Perhaps most famous is this chart first published in the BMJ by then-resident Boris Veysman:
    i-edbcd560d6996b5e5b969f2deb9aeb99-Medicalspecialty.gif

    If you’re very patient you can answer 130 redundant questions at this site offered by UVA to help you make up your mind, or read one of the books on the subject.

    Then there is the famous Goo index, which I think may be quite useful. Basically, chose your specialty based on which types of bodily fluid you can stand being in contact with every day for the rest of your life. If you have a low tolerance for any goo, psychiatry or neurology might be up your alley. If you can take any fluid being sprayed at you at high velocity, surgery may be an excellent specialty for you.

    Then there is the general opinion among the goo-heavy specialties that you should avoid the goo you dislike the most. For instance, if snot is bothersome, avoid pulmonary specialties and pediatrics. If it’s urine, maybe you shouldn’t go into urology (or if you don’t want to stare at genitalia all day). If you don’t mind blood but don’t like any of the stinky stuff, maybe neurosurgery is the right match. It’s all about balancing your goo exposure.

    If you don’t want to get divorced during residency, maybe read this paper. The surprising result? Psychiatry is the worst at a 50% cumulative divorce rate followed by surgery at 33%, and most other medical specialties between 22-30%. I guess psychiatrists drive their spouses nuts when they bring their work home.

    There is the Myers-Briggs guide to specialties which is only useful if you’re the type of person that likes astrology or other advice based on vague, general descriptions of people coached in psuedoscientific drivel. There is a lot of study of personality traits specific to different specialties, a review of the subject concludes that for the most part medical students tend to be too homogeneous for the blunt-instrument personality tests to distinguish something so specific as an ideal career choice and there is more variation of personalities within a given field than between fields.

    So, using these highly-scientific and time-tested methodologies, which kind of medicine would you like to practice? Which do you think I chose?

  • "Kennedy" is a name, not a qualification

    I can’t cover this topic better than Orac; he’s the expert. I would like to suggest that you go read his post.

    This is important. I voted for Obama. I believe that he is one of the brightest people we’ve every had the chance to vote for, and I think that after 8 years of open hostility to science, we have a chance to remove some of the politics from the issues that affect all of us.

    But Obama has floated a lead balloon for the head of EPA. Robert Kennedy, Jr. is an anti-science wacko. He has drunk the Kool Aid (I know, Flav-R-Ade, stop correcting me!) of the anti-vaccine movement, and crankery is never isolated—it always carries over from one area to the next, as it indicates a flawed way of thinking. Read Orac’s post for specifics.

    Building an administration is probably hard. Please, Mr. Obama, don’t get off on the wrong foot with science. Please?

  • Double Plus Good: No George Bush Waste Station in SF

    A group in San Francisco managed to get a measure on the city ballot that would rename our Oceanside Water Pollution Control Plant to the “George W. Bush Sewage Plant.”

    I thought this a supremely bad idea. Such a move (like protesting the Marine Core in Berkeley) would invite a conservative reaction, possibly stripping the city of federal funds.

    And as a local public utilities supervisor pointed out, our waste station is progressive, like much of the city: “The potential irony here is that this is a modern facility that protects the ocean and the environment every day,” [Tony] Winnicker said, “and I’m not sure that’s the right legacy for President Bush.”

    Well, Measure R failed by 69-30 percent! There is some good sense in San Francisco, sometimes. We also rejected a measure that would have legalized prostitution. More on that later.

  • Pediatrics

    I’ve been busy, as you might imagine, with work, study, and applying for medical residency. However, I thought it was about time to get people up to date with some of the clerkships I’ve finished in the meantime before letting you guys in on some of the decision-making processes involved in choosing a residency.

    So, time to talk about pediatrics. Pediatrics, despite a reputation for warmth and fuzziness, is a challenging field. Kids aren’t just little adults, and the treatment and diseases of infants are different than those of toddlers, which are different from pre-adolescents, which are different from the problems of teenagers and young adults. It’s an intense mixture of preventative medicine, diagnostics, and a lot of the intangible skills involved in getting the necessary information out of uncooperative patients and distressed parents. One also has to remember that a pediatrician has to spot the rare very sick kid in a field of sniffles, coughs, and possibly malingering youngsters who just want out of school. It’s a helluva a field of medicine, and if anything it has made me more passionate about educating against anti-vaxxers and quacks. For one pediatrics is critically dependent on prevention – which the anti-vax movement seeks to undermine with potentially dangerous consequences. For another, many of the diseases of childhood when they do occur are serious – but imminently treatable if recognized. The idea of a quack tinkering in this field without proper respect for the enormous amount of medicine involved, and potential for harm, is terrifying.

    So let’s talk about a set of pediatric cases and just to piss off the gun nuts, why it’s a good thing that pediatricians screen for guns in homes.

    Let’s emphasize the differences between medicine in different age groups. Because it’s pediatrics the past medical history is easy – they have none. Here are two cases, details altered, but both real patients I saw almost at the exact same time.

    Patient #1: A 2.5-year-old male presents to the ED because her mom is concerned he is “puffy”. She sought care in a PCP’s office 6 days ago who initially treated him for a potential allergic reaction with Benadryl and advised her to return if he did not get better. The child has had no illnesses except for a cold 2 weeks ago, has met developmental milestones and is fully immunized. Mom has lost confidence in her PCP and now presents to UVA, very worried. On physical exam the child appears to be alert, awake, in no acute distress, with completely normal physical exam except for puffiness – non-pitting edema in the extremities and face.

    Should we be concerned? What tests would you order in this patient?

    Patient #2: A 14.5 year old male presents to the ED with a camp counselor with complaint of fainting during band practice (it’s summer and it’s hot). For the last week he has felt unwell, but has been continuing to go to practice and participating in activities. He has had no other illnesses, is fully vaccinated and has a normal physical exam. He has no other complaints except his eyes are “puffy”.

    Should we be concerned? What tests would you order in this patient?
    (more…)

  • How drunk is too drunk—another foray into medical ethics

    The best ethical questions are real ones. Sure, it’s fun to play the lifeboat game, but when you’re dealing with flesh and blood human beings on a daily basis, games aren’t all that helpful. So here’s a non-life-and-death question: if a patient comes to see you and smells of alcohol, can you add an alcohol level to their blood work without specifically informing them?

    Ethical discussions are best held as, well, discussions, so I’ll lay out some ethical principles and let you discuss before I weigh in further.

    First, any patient who comes to see a doctor signs a “general consent for treatment” which usually contains a phrase such as:

    I request and authorize Health Care Services by my physician, and his/her designees as may deem advisable. This may include routine diagnostic, radiology and laboratory procedures and medication administration.

    Second, for your reference, here is the summary of the AMA’s code of medical ethics.

    And finally, a brief list of the most agreed-upon basic principles of medical ethics:

      Beneficence – acting in the best interest of the patient.
      Non-maleficence – avoid harm to the patient
      Autonomy – the patient has the right to refuse or choose their treatment
      Justice—fair distribution or resources
      Dignity
      Truthfulness/informed consent

    Remember that ethics aren’t a checklist. Real life situations are just that—real, with real people.

    OK, the thread is now open.

  • Looks Like the Same-Sex Marriage Amendment Passed

    Here in California, the Mormons poured millions into an initiative constitutional amendment to ban same-sex marriage, after the California Supreme Court found a right to marry in the State’s Constitution.

    Proposition 8 looks like it has passed. Currently, it’s 52-48 in favor, with 95% of the vote counted.

    I’m really just posting this in order to share this anti-Proposition 8 commercial that was running in California. It might be the most offensive political ad ever. Check it out:

  • Watch the returns here!

    Watch it happen live! And if I can, I’ll though in some useless editorializing.

    Now fivethirtyeight and CNN have excellent widgets to watch as well. Fivethirtyeight.com is especially cool, as it has developed a nice reputation for actually being right. Currently, they are projecting a rather wide victory for Obama.

    Ohio an Penn!!!!!

  • The Adman Can Attack Afflictions!

    The Times’ Amanda Schaffer covers a retrospective of public health posters on display at the National Academies until December 19th, 2008. The catalog (pdf) is online.

    My favorite:

    It reads:

    “No home remedy or quack doctor ever cured syphilis or gonorrhea. See your doctor or local health officer.”

    You could replace “syphilis or gonorrhea” with just about anything! Perhaps we should reissue this poster to deal with the modern quacks!

  • Discourse give me hives

    But a fascinating lesson in scientific discourse is currently underway in the blogosphere. It all started with a harmless little analysis of a letter published in NEJM. The strange part (to those of us who live here) was that the authors responded. On the blog. For real. And they were kinda pissed (in the American sense of the word; I have no idea if they’d been drinking, but probably not. After all, they’re not bloggers).

    Communication in medical research is slow. In general, this can be a good thing. Before research is published in a respected journal, it should be thoroughly reviewed. Follow up letters to the editor are necessarily few and delayed, given the nature of the medium.

    Blogs are changing this. More and more scientists and physicians are blogging about peer-reviewed research, and how this will affect scientific discourse is anyone’s guess.

    (more…)

  • If You're Surpsied, You're Not Paying Attention

    The Journal reports the obvious under the headlines “Tainting of Milk Is Open Secret in China” and “Milk Routinely Spiked in China:”

    Before melamine-laced milk killed and sickened Chinese babies and led to recalls around the world, the routine spiking of milk with illicit substances was an open secret in China’s dairy regions, according to the accounts of farmers and others with knowledge of the industry.

    Farmers here in Hebei province say in interviews that “protein powder” of often-uncertain origin has been employed for years as a cheap way to help the milk of undernourished cows fool dairy companies’ quality checks. When the big companies caught on, some additive makers switched to toxic melamine — which mimics protein in lab tests and can cause severe kidney damage — to evade detection.

    […]

    China’s biggest local seller of liquid milk, Mengniu Dairy Co., and multinational food company Nestlé SA both say they were aware that Chinese farmers and traders added unauthorized substances to raw milk, but that they didn’t know melamine was among them. “We knew there was adulteration” going on for many years, says Zhao Yuanhua, Mengniu’s spokeswoman. Among other common milk additives: a viscous yellow liquid containing fat and a combination of preservatives and antibiotics, known as “fresh-keeping liquid.”

    If you’re buying pet food made in China or anything else for that matter, it’s time to pay more for a product manufactured in a country like America, where we have had oversight and controls on food production for over a century.