Medical Black Humor, that is Neither Funny nor Appropriate.

19 09 2011

Last week, I happened to see this Facebook post of the The Medical Registrar where she offends a GP, Anne Marie Cunningham*, who wrote a critical post about black medical humor at her blog “Wishful Thinking in Medical Education”. I couldn’t resist placing a likewise “funny” comment in this hostile environment where everyone seemed to agree (till then) and try to beat each other in levels of wittiness (“most naive child like GP ever” – “literally the most boring blog I have ever read”,  “someone hasn’t met many midwives in that ivory tower there.”, ~ insulting for a trout etc.):

“Makes no comment, other than anyone who uses terms like “humourless old trout” for a GP who raises a relevant point at her blog is an arrogant jerk and an unempathetic bastard, until proven otherwise…  No, seriously, from a patient’s viewpoint terms like “labia ward” are indeed derogatory and should be avoided on open social media platforms.”

I was angered, because it is so easy to attack someone personally instead of discussing the issues raised.

Perhaps you first want to read the post of Anne Marie yourself (and please pay attention to the comments too).

Social media, black humour and professionals…

Anne Marie mainly discusses her feelings after she came across a discussion between several male doctors on Twitter using slang like ‘labia ward’ and ‘birthing sheds’ for birth wards, “cabbage patch” to refer to the intensive care and madwives for midwives (midwitches is another one). She discussed it with the doctors in question, but only one of them admitted he had perhaps misjudged sending the tweet. After consulting other professionals privately, she writes a post on her blog without revealing the identity of the doctors involved. She also puts it in a wider context by referring to  the medical literature on professionalism and black humour quoting Berk (and others):

“Simply put, derogatory and cynical humour as displayed by medical personnel are forms of verbal abuse, disrespect and the dehumanisation of their patients and themselves. Those individuals who are the most vulnerable and powerless in the clinical environment – students, patients and patients’ families – have become the targets of the abuse. Such humour is indefensible, whether the target is within hearing range or not; it cannot be justified as a socially acceptable release valve or as a coping mechanism for stress and exhaustion.”

The doctors involved do not make any effort to explain what motivated them. But two female anesthetic registrars frankly comment to the post of Anne Marie (one of them having created the term “labia ward”, thereby disproving that this term is misogynic per se). Both explain that using such slang terms isn’t about insulting anyone and that they are still professionals caring for patients:

 It is about coping, and still caring, without either going insane or crying at work (try to avoid that – wait until I’m at home). Because we can’t fall apart. We have to be able to come out of resus, where we’ve just been unable to save a baby from cotdeath, and cope with being shouted and sworn at be someone cross at being kept waiting to be seen about a cut finger. To our patients we must be cool, calm professionals. But to our friends, and colleagues, we will joke about things that others would recoil from in horror. Because it beats rocking backwards and forwards in the country.

[Just a detail, but “Labia ward” is a simple play on words to portray that not all women in the “Labor Ward” are involved in labor. However, this too is misnomer.  Labia have little to do with severe pre-eclampsia, intra-uterine death or a late termination of pregnancy]

To a certain extent medical slang is understandable, but it should stay behind the doors of the ward or at least not be said in a context that could offend colleagues and patients or their carers. And that is the entire issue. The discussion here was on Twitter, which is an open platform. Tweets are not private and can be read by other doctors, midwives, the NHS and patients. Or as e-Patient Dave expresses so eloquently:

I say, one is responsible for one’s public statements. Cussing to one’s buddies on a tram is not the same as cussing in a corner booth at the pub. If you want to use venting vocabulary in a circle, use email with CC’s, or a Google+ Circle.
One may claim – ONCE – ignorance, as in, “Oh, others could see that??” It must, I say, then be accompanied by an earnest “Oh crap!!” Beyond that, it’s as rude as cussing in a streetcorner crowd.

Furthermore, it seemed the tweet served no other goal as to be satirical, sardonic, sarcastic and subversive (words in the bio of the anesthetist concerned). And sarcasm isn’t limited to this one or two tweets. Just the other day he was insulting to a medical student saying among other things:“I haven’t got anything against you. I don’t even know you. I can’t decide whether it’s paranoia, or narcissism, you have”. 

We are not talking about restriction of “free speech” here. Doctors just have to think twice before they say something, anything on Twitter and Facebook, especially when they are presenting themselves as MD.  Not only because it can be offensive to colleagues and patients, but also because they have a role model function for younger doctors and medical students.

Isolated tweets of one or two doctors using slang is not the biggest problem, in my opinion. What I found far more worrying, was the arrogant and insulting comment at Facebook and the massive support it got from other doctors and medical students. Apparently there are many “I-like-to-exhibit-my-dark-humor-skills-and-don’t-give-a-shit-what-you think-doctors” at Facebook (and Twitter) and they have a large like-minded medical audience: the “medical registrar page alone has 19,000 (!) “fans”.

Sadly there is a total lack of reflection and reason in many of the comments. What to think of:

“wow, really. The quasi-academic language and touchy-feely social social science bullshit aside, this woman makes very few points, valid or otherwise. Much like these pages, if you’re offended, fuck off and don’t follow them on Twitter, and cabbage patch to refer to ITU is probably one of the kinder phrases I’ve heard…”

and

“Oh my god. Didnt realise there were so many easily offended, left winging, fun sponging, life sucking, anti- fun, humourless people out there. Get a grip people. Are you telling me you never laughed at the revue’s at your medical schools?”

and

“It may be my view and my view alone but the people who complain about such exchanges, on the whole, tend to be the most insincere, narcissistic and odious little fuckers around with almost NO genuine empathy for the patient and the sole desire to make themselves look like the good guy rather than to serve anyone else.”

It seems these doctors and their fans don’t seem to possess the communicative and emphatic skills one would hope them to have.

One might object that it is *just* Facebook or that “#twitter is supposed to be fun, people!” (dr Fiona) 

I wouldn’t agree for 3 reasons:

  • Doctors are not teenagers anymore and need to act as grown-ups (or better: as professionals)
  • There is no reason to believe that people who make it their habit to offend others online behave very differently IRL
  • Seeing Twitter as “just for fun” is an underestimation of the real power of Twitter

Note: *It is purely coincidental that the previous post also involved Anne Marie.

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Internet Sources & Blog Posts in a Reference List? Yes or No?

13 02 2011

A Dutch librarian asked me to join a blog carnival of Dutch Librarians. This carnival differs from medical blog carnivals (like the Grand Rounds and “Medical Information Matters“) in its approach. There is one specific topic which is discussed at individual blogs and summarized by the host in his carnival post.

The current topic is “Can you use an internet source”?

The motive of the archivist Christian van der Ven for starting this discussion was the response to a post at his blog De Digitale Archivaris. In this post he wondered whether blog posts could be used by students writing a paper. It struck him that students rarely use internet sources and that most teachers didn’t encourage or allow to use these.

Since I work as a medical information specialist I will adapt the question as follows:

“Can you refer to an internet source in a biomedical scientific article, paper, thesis or survey”?

I explicitly use “refer to” instead of “use”. Because I would prefer to avoid discussing “plagiarism” and “copyright”. Obviously I would object to any form of uncritical copying of a large piece of text without checking it’s reliability and copyright-issues (see below).

”]

Previously, I have blogged about the trouble with Wikipedia as a source for information. In short, as Wikipedians say, Wikipedia is the best source to start with in your research, but should never be the last one (quote from @berci in a twitterinterview). In reality, most students and doctors do consult Wikipedia and dr. Google (see here and here). However, they may not (and mostly should not) use it as such in their writings. As I have indicated in the earlier post it is not (yet) a trustworthy source for scientific purposes.

But Internet is more than Wikipedia and random Googling. As a matter of fact most biomedical information is now in digital form. The speed at which biomedical knowledge is advancing is tremendous. Books are soon out of date. Thus most library users confine themselves to articles in peer-reviewed scientific papers or to datasets (geneticists). Generally my patrons search the largest freely available database PubMed to access citations in mostly peer-reviewed -and digital- journals. These are generally considered as (reliable)  internet sources. But they do not essentially differ from printed equivalents.

However there are other internet sources that provide reliable or useful information. What about publications by the National Health Council, an evidence based guideline by NICE and/or published evidence tables? What about synopses (critical appraisals) such as published by DARE, like this one? What about evidence summaries by Clinical Evidence like, this one? All excellent, evidence based, commendable online resources. Without doubt these can be used as a reference in a paper. Thus there is no clearcut answer to the abovementioned question. Whether an internet source should be used as a reference in a paper is dependent on the following:

  1. Is the source relevant?
  2. Is the source reliable?
  3. What is the purpose of the paper and the topic?

Furthermore it depends on the function of the reference (not mutually exclusive):

  1. To give credit
  2. To add credibility
  3. For transparency and reproducibility
  4. To help readers find further information
  5. For illustration (as an example)

Lets illustrate this with a few examples.

  • Students who write an overview on a medical topic can use any relevant reference, including narrative reviews, UpToDate and other internet sites if appropriate .
  • Interns who have to prepare a CAT (critically appraised topic) should refer to 2-3 papers, providing the highest evidence (i.e. a systematic review and/or randomized controlled trial).
  • Authors writing systematic reviews only include high quality primary studies (except for the introduction perhaps). In addition they should (ideally) check congress abstracts, clinical trial registers (like clinicaltrials.gov), or actual raw data (i.e. produced by a pharmaceutical company).
  • Authors of narrative reviews may include all kinds of sources. That is also true for editorials, primary studies or theses. Reference lists should be as accurate and complete as possible (within the limits posed by for instance the journal).

Blog, wikis, podcasts and tweets.
Papers can also refer to blog posts, wikis or even tweets (there is APA guidance how to cite these). Such sources can merely be referred to because they serve as an example (articles about social media in Medicine for instance, like this recent paper in Am Pharm Assoc that analyzes pharmacy-centric blogs.

Blog posts are usually seen as lacking in factual reliability. However, there are many blogs, run by scientists, that are (or can be) a trustworthy source. As a matter of fact it would be inappropriate not to cite these sources, if  the information was valuable, useful and actually used in the paper.
Some examples of excellent biomedical web 2.0 sources.

  • The Clinical Cases and Images Blog of Ves Dimov, MD (drVes at Twitter), a rich source of clinical cases. My colleague once found the only valuable information (a rare patient case) at Dr Ves’ blog, not in PubMed or other regular sources. Why not cite this blog post, if this patient case was to be published?
  • Researchblogging.org is an aggregator of expert blogposts about peer-reviewed research. There are many other high quality scientific blogging platforms like Scientopia, the PLOSblogs etc. These kind of blogs critically analyse peer reviewed papers. For instance this blog post by Marya Zilberberg reveals how a RCT stopped early due to efficacy can still be severely flawed, but lead to a level one recommendation. Very useful information that you cannot find in the actual published study nor in the evidence based guideline
  • An example of an excellent and up-to-date wiki is the open HLWIKI (maintained by Dean Giustini, @giustini at Twitter) with entries about health librarianship, social media and current information technology topics, having over 565+ pages of content since 2006! It has a very rich content with extensive reference lists and could thus be easily used in papers on library topics.
  • Another concept is usefulchem.wikispaces.com (an initiative of Jean Claude Bradley, discussed in a previous post. This is not only a wiki but also an open notebook, where actual primary scientific data can be found. Very impressive.
  • There is also WikiProteins (part of a conceptwiki), an open, collaborative wiki  focusing on proteins and their role in biology and medicine.

I would like to end my post with two thoughts.

First the world is not static. In the future scientific claims could be represented as formal RDF statements/triplets  instead of or next to the journal publications as we know them (see post on nanopublications). Such “statements” (already realized with regard to proteins and genes) are more easily linked and retrieved. In effect, peer review doesn’t prevent fraud, misrepresentation or overstatements.

Another side of the coin in this “blogs as an internet source”-dicussion is whether the citation is always appropriate and/or accurate?

Today a web page (cardio.nl/ACS/StudiesRichtlijnenProtocollen.html), evidently meant for education of residents, linked to one of my posts. Almost the entire post was copied including a figure, but the only link used was one of my tags EBM (hidden in the text).  Even worse, blog posts are sometimes mentioned to give credit to disputable context. I’ve mentioned the tactics of Organized Wisdom before. More recently a site called deathbyvaccination.com links out of context to one of my blog post. Given the recent revelation of fraudulent anti-vaccine papers, I’m not very happy with that kind of “attribution”.

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Much Ado About ADHD-Research: Is there a Misrepresentation of ADHD in Scientific Journals?

9 02 2011

ResearchBlogging.org
The reliability of science is increasingly under fire. We all know that media often gives a distorted picture of scientific findings (i.e. Hot news: Curry, Curcumin, Cancer & cure). But there is also an ever growing number of scientific misreports or even fraud (see bmj editorial announcing retraction of the Wakefield paper about causal relation beteen MMR vaccination and autism). Apart from real scientific misconduct there are Ghost Marketing and “Publication Bias”, that makes (large) positive studies easier to find than those with negative or non-significant result.
Then there are also the ever growing contradictions, that makes the public sigh: what IS true in science?

Indeed according to doctor John Ioannidis “Much of what medical researchers conclude in their studies is misleading, exaggerated, or flat-out wrong. (see “Lies, Damned Lies, and Medical Science” in the Atlantic (2010). In 2005 he wrote the famous PLOS-article “Why most published research findings are false” [2] .

With Iaonnides as an editor, a new PLOS-one paper has recently been published on the topic [1]. The authors Gonon, Bezard and Boraud state that there is often a huge gap between neurobiological facts and firm conclusions stated by the media. They suggest that the misrepresentation often starts in the scientific papers, and is echoed by the media.

Although this article has already been reviewed by another researchblogger (Hadas Shema), I would like to give my own views on this paper

Gonon et al found 3 types of misrepresentation.*

1. Internal inconsistencies (between results and claimed conclusions).

In a (non-systematic) review of 360 ADHD articles  Gonon et al. [1] found  two studies with “obvious” discrepancies between results and claimed conclusions.  One paper claimed that dopamine is depressed in the brain of ADHD patient. Mitigations were only mentioned in the results section and of course only the positive message was resonated by the media without further questioning any alternative explanation (in this case a high baseline dopamine tone). The other paper [3] claimed that treatment with stimulant medications was associated with more favorite long-term school outcomes. However the average reading score and the school drop-outs did not differ significantly between treatment and control group. The newspapers also trumpeted that  “ADHD drugs help boost children’s grades” .

2. Fact Omission

To quantify fact omission in the scientific literature, Gonon et al systematically searched for ADHD articles mentioning the the D4 dopamine receptor (DRD4) gene. Among the 117 primary human studies with actual data (like odds ratios), 74 articles state in their summary that alleles of the DRD4 genes are significantly associated with ADHD but only 19 summaries mentioned that the risk was small. Fact omission was even more preponderant in articles, that only cite studies about DRD4.  Not surprisingly, 82% of the media articles didn’t report that the DRD4 only confers a small risk either.
In accordance with Ioannidis findings [2] Gonon et al found that the most robust effects were reported in initial studies: odds-ratios decreased from 2.4 in the oldest study in 1996 to 1.27 in the most recent meta-analysis.

3. Extrapolating basic and pre-clinical findings to new therapeutic prospects

Animal ADHD models have their limitations because investigations based on mouse behavior cannot capture the ADHD complexity. Analysis of all ADHD-related studies in mice showed that 23% of the conclusions were overstated. The frequency of this overstatement was positively related with the impact factor of the journal.

Again, the positive message was copied by the press. (see Figure below)

”]Discussion

 

The article by Gonon et al is another example that “published research findings are false” [ 2], or at least not completely true. The authors show that the press isn’t culprit number one, but that it “just” copies the overstatements in the scientific abstracts.

The merit of Gonon et al is that they have extensively looked at a great number of articles and at press articles citing those articles.

The first type of misrepresentation wasn’t systematically studied, but types 2 and 3 misrepresentations were studied by analyzing papers on a specific ADHD topic obtained by a systematic search.

One of the solutions the authors propose is that “journal editors collectively reject sensationalism and clearly condemn data misrepresentation”. I agree and would like to add that the reviewers should check that the summary actual reflects the data. Some journals already have strict criteria in this respect. It striked me that the few summaries I checked were very unstructured and short, unlike most summaries I see. Possibly, unstructured abstracts are more typically for journals about neuroscience and animal research.

The choice of the ADHD-topics investigated doesn’t seem random. A previous review[4], written by Francois Gonon deals entirely with “the need to reexamine the dopaminergic hypothesis of ADHD” . The type 1 misrepresentation data stem from this opinion piece.

The putative ADHD-DRD4 gene association and the animal studies, taken as examples for type 2 and type 3 misrepresentations respectively, can also be seen as topics of the “ADHD is a genetic disease” -kind.

Gonon et al clearly favor the hypothesis that ADHD is primarily caused by environmental factors . In his opinion piece he starts with saying:

This dopamine-deficit theory of ADHD is often based upon an overly simplistic dopaminergic theory of reward. Here, I question the relevance of this theory regarding ADHD. I underline the weaknesses of the neurochemical, genetic, neuropharmacological and imaging data put forward to support the dopamine-deficit hypothesis of ADHD. Therefore, this hypothesis should not be put forward to bias ADHD management towards psychostimulants.

I wonder whether it is  fair of the authors to limit the study to ADHD topics they oppose to in order to (indirectly) confirm their “ADHD has a social origin” hypothesis. Indeed in the paragraph “social and public health consequences” Gonon et al state:

Unfortunately, data misrepresentation biases the scientific evidence in favor of the first position stating that ADHD is primarily caused by biological factors.

I do not think that this conclusion is justified by their findings, since similar data misrepresentation might also occur in papers investigating social causes or treatments, but this was not investigated. (mmm, a misrepresentation of the third kind??)

I also wonder why impact factor data were only given for the animal studies.

Gonon et al interpret a lot, also in their results section. For instance, they mention that 2 out of 60 articles show obvious discrepancies between results and claimed conclusions. This is not much. Then they reason:

Our observation that only two articles among 360 show obvious internal inconsistencies must be considered with caution however. First, our review of the ADHD literature was not a systematic one and was not aimed at pointing out internal inconsistencies. Second, generalization to other fields of the neuroscience literature would be unjustified

But this is what they do. See title:

” Misrepresentation of Neuroscience Data Might Give Rise to Misleading Conclusions in the Media.”

Furthermore they selectively report themselves. The Barbaresi paper [3], a large retrospective cohort,  did not find an effect on average reading score and school drop-outs, but it did find a significantly lowered grade retention, which is -after all- an important long-term school outcome.

Misrepresentation type 2 (“omission”)  I would say.*

References

  1. Gonon, F., Bezard, E., & Boraud, T. (2011). Misrepresentation of Neuroscience Data Might Give Rise to Misleading Conclusions in the Media: The Case of Attention Deficit Hyperactivity Disorder PLoS ONE, 6 (1) DOI: 10.1371/journal.pone.0014618
  2. Ioannidis, J. (2005). Why Most Published Research Findings Are False PLoS Medicine, 2 (8) DOI: 10.1371/journal.pmed.0020124
  3. Barbaresi, W., Katusic, S., Colligan, R., Weaver, A., & Jacobsen, S. (2007). Modifiers of Long-Term School Outcomes for Children with Attention-Deficit/Hyperactivity Disorder: Does Treatment with Stimulant Medication Make a Difference? Results from a Population-Based Study Journal of Developmental & Behavioral Pediatrics, 28 (4), 274-287 DOI: 10.1097/DBP.0b013e3180cabc28
  4. GONON, F. (2009). The dopaminergic hypothesis of attention-deficit/hyperactivity disorder needs re-examining Trends in Neurosciences, 32 (1), 2-8 DOI: 10.1016/j.tins.2008.09.010

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[*A short comment in the NRC Handelsblad (Febr 5th) comes to a similar conclusion]





An Educator by Chance

13 10 2010

The topic of the oncoming edition of the blog carnivalMedical Information Matters“, hosted by Daniel Hooker, is close to my heart.

Daniel at his call for submissions post:

I’d love to see posts on new things you’re trying out this year: new projects, teaching sessions, innovative services. Maybe it’s something tried and true that you’d like to reflect on. And this goes for anyone starting out fresh this term, not just librarians!

When I started as a clinical librarian 5 years ago, I mainly did search requests. Soon I also gave workshops as part of evidence based practice courses.

Our library gave the normal library courses PubMed, Reference Manager etc. We did little extra for medical students. There was a library introduction at the beginning and a PubMed training at the end of the curriculum.

Thus, when the interns had to do a CAT (Critically Appraised Topic), they had to start from SCRATCH 😉 : learn the PICO, domains, study types, searching the various databases.  After I gave  a dozen or so 1-hour long introductions to consecutive interns, repeating the same things over and over, I realized this was an ineffective use of time. So I organized a monthly CAT-introduction with a computer workshop. After this introduction I helped interns with their specific CAT, if necessary.

This course is appreciated very much and  interns usually sigh: “why didn’t we learn this before?! If we had known this…”, etcetera.

Thus we, librarians, were very enthusiastic when we got more time in the newly organized curriculum.

We made e-learning modules for the first year, two for the second year, a Pubmed-tutorial, and a computer workshop (150 min!). In the 4th year we grade the CATs.

The e-learning modules costed me tons of time. If you read the post “How to become a big e-learning nerd by mistake” at Finite Attention Span you understand why.

We used a system that was designed for exams. On my request the educational department embed the system in a website, so students could go back and forth. Lacking any good books on the topic, students should also be able to reread the text and print whatever they liked.

I was told that variation was important. Thus I used each and every of the 10 available question types. Drop down menus, clickable menus, making right pairs of terms etc. Ooh and I loved the one I used for PICO’s, where you could drag words in a sentence to the P, I, C or O. Wonderful.

Another e-learning module consisted largely of Adobe Captivate movies. As  described in the above mentioned post:

Recognise that you are on a learning curve. First of all, it is vital that your software does not always remind you to save individual files before closing the program. It is especially helpful if you can demonstrate this three times inside a week, so that you end up losing the equivalent of about two days’ work: this will provide you with a learning experience that is pretty much optimised.

Swear. Vigorously.

Become a virtuoso of the panic-save, performing Ctrl+S reflexively in your sleep, every three minutes (…)

Correcting the callouts and highlight boxes and animation timings so they don’t look like they were put together by committee is complicated. Also, writing really clear, unambiguous copy takes time.

It sounds familiar. It also regularly happened to me that I started with the wrong resolution. Then I heard afterwards: “Sorry, we can only use 800×600.”

But workshops are also time-consuming. Largely because the entire librarian staff is needed to run 30 workshops within a month (we have 350 students per year). Of course it didn’t end with those workshops. I had to make the lesson plan materials, had to instruct the tutors, make the time tables, the attendance lists and then put the data into an excel sheet again. I love it!

The knowledge is tested by exams. This year I had to make the questions myself -and score them too (luckily with help of one or two colleagues). Another time buster. The CATs had to be scored as well.

But it is worth all the pain and effort, isn’t it?

Students are sooo glad they learned all about EBM, CATS, scientific literature and searching…

Well, duh, not really.

Some things I learned in the meantime

  1. Medical students don’t give a da do not care much about searching and information literacy.
  2. Medical students don’t choose that study for nothing. They want to become doctors, not librarians.
  3. At the time we give the courses, the students not really need it. Unlike the interns, they do not need to present a CAT, shortly.
  4. Most of our work is undone by the influence of peers or tutors that learn the students all kind of “tricks” that aren’t.
  5. It is hard to make good exams. If the reasoning isn’t watertight, students will find it. And protest against it.
  6. …. Because even more important than becoming a doctor is their desire to pass the exams
  7. If the e-learning isn’t compulsory, it won’t be done.
  8. You can’t  test information literacy by multiple choice questions. It is “soft” knowledge, more a kind of approach or reasoning. Similarly PICO’s are seldom 100% wrong or right. The value of PICO-workshops lies in the discussions.
  9. The students just started their study. They’re mostly teens. These kids will have a completely other attitude after 4 years (no longer yelling, joking, mailing, Facebook-ing, or at least they are likely to stop after you ask).
  10. Education is something I did by chance. I just do it “in addition to my normal work”, i.e. in the same time.
  11. Even more important, I’m a beginner and have had no specific training. So I have to learn it the hard way.

Let me give some examples.

This year I wanted to update one of my modules. I had to, because practically all interfaces have changed the last two years (Think about PubMed for instance).

I made an appointment with the education department, because they had helped me enormously before.

Firstly I noticed that my name had been replaced by those of 3 people who hadn’t done anything (at least with regard to this particular e-learning course). Perhaps not so relevant here. But the first red flag…

The module was moved to another system. It looked much nicer, but apparently only allowed a few of those 10 types of questions. The drag and drop questions, I was so fond of, were replaced by irritating drop down menus. With the questions I made, it didn’t make sense.

The movies couldn’t be plaid fast forward, back or be stopped.

And the girl who I spoke to, a medical student herself, couldn’t disguise her dislike of the movies. First she didn’t like the call-outs and highlight boxes, she rather liked a voice (me speaking, deleting the laborious call-outs ?!). Then she said the videos were endless and it was nicer when the students could try it themselves (which was in fact the assignment). She ignored my suggestion that Adobe is suitable for virtual online training.

Then someone next to her said: Do you know “Snag-it”, you can make movies with that too!?

Do I know Snag-it? Yes I do. I even bought it for my home computer. But Snag-it is nowhere near Adobe Captivate, at least regarding call-outs and assembly. I almost mentioned Camtasia, which is from the same company as Snag-it, but more suitable for this job.

Then the girl said the movies were only meant to show “where to press the buttons”, which I repeatedly denied: those movies were meant to highlight the value of the various sources. She also suggested that I should do some usability testing, not on my colleagues, but on the students.

Funny how insights can change over times. The one who helped me considered it one of the best tutorials.

While talking to her, it stroke me that the movies were taking very long and I wondered whether each single call-out saying “press this” was functional. Perhaps she was right in a way. Perhaps some movies should be changed into plain screenshots (which I had tried to avoid, because they were so annoying Powerpoint like). If my aim wasn’t that students learned which button to press, why show it all the time?? (perhaps because Adobe shows every mouse click, it is so easy to keep it in..)

It is a long way to develop something that is educative, effective and not boring….

But little by little we can make things better.

Last year one of the coordinators proposed not to take an exam the first year but give an assignment. The students had to search for an original study on a topic in PubMed (2nd semester) and write a summary about it (3rd semester). The PubMed tutorial became compulsory, but the two Q & A sessions (with computers) were voluntary. Half of the students came to those sessions. And the atmosphere was very good. Most students really wanted to find a good study (you could only claim an article once). Some fished whether the answers were worth the full 4 points and what they had to do to get it. The quality of the searches and the general approach were quite good.

In good spirits I will start with updating the other modules. The first should be finished in a few days. That is… if they didn’t move this module to the next semester, as the catalog indicates.

That would be a shame, because then I have to change all the cardiology examples into pulmonology examples.

Gosh!…. No!!

Credits

The title is inspired by the  post “How to become a big e-learning nerd by mistake”.
Thanks to Annemarie Cunningham (@amcunningham on Twitter) for alerting me to it.

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Kaleidoscope 2009 wk 47

19 11 2009

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Kaleidoscope is a new series, with a “kaleidoscope” of facts, findings, views and news gathered over the last 1-2 weeks.

Most items originate from Twitter, my Google Reader (RSS) and sometimes real articles (yeah!).

I read a lot, I bookmark a lot, but only some of those things end op in a post. Since tweets have a half-life of less than a week, I thought it would be nice to safeguard some of the tweets in a post. For me to keep, for you to read.

I don’t have the time and the discipline to post daily about health news and social media as Ves Dimov does. It looks more like the compilation at blogs of dr Shock’s (see example),  dr Bates shout-outs, Health Highlights of Highlight HEALTH and Rachel Walden’s Womens health News Round-ups, but less on one subject and less structured. It will just be a mix of old and new, Social Media and science, just a kaleidoscope. Or a potpourri  if you like.

I don’t know if this kaleidoscope will live a long live. I already wrote 2 3 4 5 6 editions, but didn’t have the time to finish them. Well, we will see, just enjoy this one.

Ooh and the beautiful kaleidoscope is made by RevBean and is called: Eyeballs divide like cells. Looks very much like the eyeball-bubblewrap of a previous post but that is thus coincidence. Here is the link (Flickr, CC)

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Medical Grand Rounds

Louise Norris at Colorado Health Insurance Insider is this week’s host of Grand Rounds.(see here). There are many interesting posts again. As a mother of two teens I especially liked the insight Nancy Brown of Teen Health 411 brings us into what teens want when it comes to their relationships with their parents and the “would you rather…?” story that Amy Tenderich of Diabetes Mine shares with us. The punch line is great. Her 9 year old melts my heart.

At InsureBlog’s Hank Stern brings us an article about a British hospital that will no longer admit expectant mothers with a BMI of more than 34, because the hospital’s labor and delivery unit is not equipped to handle complicated births. Hank concludes: “Fear not, though, portly preggies have to travel but 20 miles to the next closest facility. Assuming, of course, that they can make it that far when contractions are minutes apart.”

Dr Charles of the The Examining Room wrote an in depth article about a cheerleader who was supposedly stricken with dystonia following a seasonal flu vaccine in August. Dr Charles not only highlights why (specialists) think it is not dystonia, but gives also background information about the efficacy of vaccins.

Recent editions of the Grand Rounds were at CREGRL, flight nurse (link), NonClinicalJobs (link) and Codeblog, tales of a nurse (link). You can always find previous and upcoming hosts at the Grand Rounds Archive at Blogborygmi.

3621322354_4bc3bb115e Breast cancer screening

The update of the 2002 USPSTF recommendation statement on screening for breast cancer in the general population, published in the November issue of The Annals of Internal Medicine has led to heated discussions in the mainstream media (i.e. New York Times and MedPage Today). Based on current evidence, partly based on 2 other articles in the same journal (comparison screening schedules and an systematic review) the guidelines advise scaling back of the screening. The USPSTF recommends:

  • against routine screening mammography in women aged 40 to 49 years
  • against routine screening mammography of women 75 years or older.
  • biennial (instead of annual) screening mammography for women between the ages of 50 and 74 years.
  • against teaching breast self-examination (BSE).
  • against either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities.

The two articles published in Ann Intern Med add to the evidence that the propagation of breast cancer self exam doesn’t save lives (see Cochrane review discussed in a previous post) and that the benefits of routine mammography in the young (<50) or old (>75) do not outweigh the harm (also covered by a  Cochrane review before). Indeed, as put forward by Gary Schwitzer at Schwitzer health news blog this is NOT a new debate. He refers to Slate who republishes a five-year old piece of Amanda Schaffer that does a good job of explaining the potential harms of screening. However it is difficult for women (and some doctors) to understand that “When it comes to cancer screening, more isn’t always better.” Indeed -as Kevin Pho at Kevin MD states, the question is whether “patients will accept the new, evidence-based, breast cancer screening guidelines”.

In the Netherlands it is already practice to start biannual routine mammography at the age of 50. The official breast cancer screening site of the RIVM even states that the US is now going to follow the Dutch guidelines 😉 (one of assessed guidelines in one the Ann Intern Med papers is Dutch). But people still find the  long established guidelines difficult to accept: coincidentally I saw tweets today asking to sign a petition to advance the age of screening ‘because breast cancer is more and more frequently observed at young age…(??)’ Young, well educated, women are very willing to sign…

No time to read the full articles, but interested to know more, then listen to the podcast of this Ann Intern Med edition:

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Systematic Reviews, pharma sponsored trials and other publishing news

Cochrane reviews are regarded as scientifically rigorous, yet a review’s time to publication can be affected by factors such as the statistical significance of the findings. A study published in Open Medicine examined the factors associated with the time to publication of Cochrane reviews. A change in authors and updated reviews were predictive factors, but the favorability of the results was not.

Roy Poses of the Health Care Renewal Blog starts this blogpost as follows: “Woe to those of us who have been advocates for evidence-based medicine”. He mainly refers to a study published in the NEJM, that identified selective outcome reporting for trials of off-label use of gabapentin: for 8 of the 12 published trials, there was a disagreement between the definition of the primary outcome in the protocol and that in the published report. This seriously threatens the validity of evidence for the effectiveness of off-label interventions. Roy was surprised that the article didn’t generate much media attention. The reason may be that we have been overwhelmed by manipulation of data, ghostwriting and by the fact that pharma-sponsored trials rarely produce results that are unfavorable to the companies’ product (see previous posts about Ghostwriting (Merck/Elsevier, Conflict of Interest in Cancer Studies and David Tovey about Cochrane Reviews). At least two authors of the NEJM review (Bero and Dickersin) have repeatedly this to be the case [e.g. see here for an overview, and papers of Lisa Bero]. It is some relief that at least 3 of the 4 NEJM authors are also members of the Cochrane Collaboration. Indirectly better control of reporting, i.e. by clinical trials registries, can improve the reliability of pharma sponsored trials and thus systematic reviews summarizing them. As a matter of fact Cochrane authors always have to check these registries.

At Highlight Health Walter Jessen writes about Medical Journal Conflict of Interest Disclosure and Other Issues, which also discusses how money can taint objectivity in scientific publishing. Half of the post discusses the book The Trouble with Medical Journals, written in 2007 by Richard Smith, the former editor of the BMJ.
By the way, Walter just hosted MedLibs Round with the theme “Finding Credible Health Information Online”.

Good news in the Netherlands: right after international Open Access week and the launching of the Dutch Open Access website (www.openaccess.nl), the Netherlands Organization for Scientific Research (NWO) has announced that it is in favor of Open Access. (via PLOS-facebook).

The open access nature of PLOS itself gets out of hand: they even peer-review T-shirts (according to Bora Zivkovic of a Blog around the Clock, see here)

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Other Health & Science News:

Medline Plus summarizes an article in the Journal of Nutrition, that states that Selenium supplements, may pose a heart risk.

Even Folic Acid and vitamin B12, when taken in large doses, have been reported to Increase Cancer Risk (WebMD)

Luckily WebMD also reports that dark chocolate seems to help against stress, that is it reduced stress hormones in the blood. However @evidencematters and @NHSChoices cast doubt on that“Chocolate cuts stress, says newspaper. Does the study really say that? And who paid for the study?…”

Scientists made the unexpected discovery (published in Molecular Cell) that BRAF, which is linked to around 70 per cent of melanomas and seven per cent of all cancers, is in fact controlled by a gene from the same RAF family called CRAF – which has also been linked to the disease. For the first time it is shown “how two genes from the same ‘family’ can interact with each other to stop cancer in its tracks” (Source: Info Cancer Research UK)

For the first time, scientists have successfully used exome sequencing to quickly discover a previously unknown gene responsible for Miller syndrome, a rare disorder. The finding demonstrates the usefulness of exome sequencing in studying rare genetic disorders. The exome is enriched for coding (thus functional) DNA, it is only 1% of the total DNA, but contains 85% of the mutations (Published in , source: PhysOrg.com)

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Web 2.0
For information regarding the FDA hearings on internet and social media see #FDASM: http://www.fdasm.com.

Read Write Web summarizes the new numbers released by analytics firm Postrank that indicate that reader engagement with blogs has changed dramatically over the last three years, primarily because of the rise of online social networks.

Twitter has began to relaunch the new retweet feature, although not without controversy. What do you think about the newest feature?

The Next Web gives an overview of which Twitter application is hot and which is not.

And Finally: Top 100 tools for learning, compiled by Jane Hart from the contributions of 278 learning professionals worldwide. You can see the lists here (HT: http://blogs.netedu.info/?p=1005)

The web 2.0 part is relatively short, but it is time to conclude this edition. Till next time!

  • MEDLIB’s ROUND 1.6 (laikaspoetnik.wordpress.com)
  • Tool Talk: quick links re Facebook, GReader and GWave (socialfish.org)
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    Presentation at the #NVB09: “Help, the doctor is drowning”

    16 11 2009

    15-11-2009 23-24-33 nvb congressenLast week I was invited to speak at the NVB-congress, the Dutch society for librarians and information specialists. I replaced Josje Calff in the session “the professional”, chaired by Bram Donkers of the magazine InformatieProfessional. Other sessions were: “the client”, “the technique” and “the connection”. (see program)

    It was a very successful meeting, with Andrew Keen and Bas Haring in the plenary session. I understand from tweets and blogposts that @eppovannispen en @lykle who were in parallel sessions were especially interesting.
    Some of the (Dutch) blogposts (Not about my presentation….pfew) are:

    I promised to upload my presentation to Slideshare. And here it is.

    Some slides are different from the original. First, Slideshare doesn’t allow animation, (so slides have to be added to get a similar effect), second I realized later that the article and search I showed in Ede were not yet published, so I put “top secret” in front of it.

    The title refers to a Dutch book and film: “Help de dokter verzuipt” (“Help the doctor is drowning”).

    Slides 2-4: NVB-tracks; why I couldn’t discuss “the professional” without explaining the changes with which the medical profession is confronted.

    Slides 5-8: Clients of a medical librarian (dependent on where he/she works).

    Slides 9-38: Changes to the medical profession (less time, opinion-based medicine gradually replaced by evidence based medicine, information overload, many sources, information literacy)

    Slides 39-66: How medical librarians can help (‘electronic’ collection accessible from home, study landscape for medical students, less emphasis on books, up to date with alerts (email, RSS, netvibes), portals (i.e. for evidence based searching), education (i.e. courses, computer workshops, e-learning), active participation in curriculum, helping with searches or performing them).

    Slides 67-68: Summary (Potential)

    Slide 69: Barriers/Risks: Money, support (management, contact persons at the departments/in the curriculum), doctors like to do it theirselves (it looks easy), you have to find a way to reach them, training medical information specialists.

    Slides 70-73 Summary & Credits

    Here are some tweets related to this presentation.

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    Grand Rounds Vol. 6 No. 2

    29 09 2009

    grandroundsblank

    Welcome to the latest edition of Grand Rounds, the weekly compilation of the best of the medical blogosphere! I presume you would rather take a tour through the Netherlands, visiting windmills and tulips, but we will save this for another time. Right now, let’s take a trip around the library.

    Library_book_shelvesBecause you know what William Osler, the Father of Modern Medicine said:
    “For the teacher and the worker a great library… is indispensable.
    They must know the world’s best work and know it at once. They mint and make current coin the ore so widely scattered in journals, transactions and monographs.”
    – William Osler, in Books and Men, in Aequanimitas, 210.

    ( Thanks to Chris alias @precordialthump for this quote, as a response to a Medical Librarian Round I just finished).

    Although books are the library brand, libraries -including medical libraries- have been changing dramatically from book shelves to learning centers, print storage to digital storage, from loaning at the desk to loading from the web, from catalog-centered to database searching and education.PAR-TIC-I-PA-TION, or 37 pieces of library fla...

    Well librarians adapt as well. We are also Internet-dependent.
    Now let me take you by the hand and lets go through the first steps of searching.
    Of course, if you have no time for this guided tour, feel free to skip the introductory sentences and read the posts that have been submitted to this round…

    Readers of this blog know that I mostly search for Systematic Reviews and Evidence Based Guidelines. Although not really applicable to the submitted posts, I will briefly mention the way such subjects could have been structured for a search.

    We don’t search for this…

    73655708_366cd3c35b horses made of stoneOn most occasions there is no need to look up literature. A patient needs empathy of the ones he/she loves, wants to be well informed by ready-to-use and understandable information, needs to be in the hands of a skillful doctor and is happy with some useful tips. For a doctor experience and (social and technical) skills are a prerequisite.

    The National Invisible Chronic Illness Awareness Week is held annually in September. The “How to cope with pain blog” gives  10 tips to make your invisible illness visible. This post proposes ways to educate others, decrease isolation and stigma, and allow others to help, when you have an invisible illness such as pain.

    Jolie Bookspan of the “The Fitness Fixer” shows a simple mechanical stretching technique that can be applied by a partner to ease symptoms of menstrual cramps.

    Moving books or whole labs requires some effort. But how much more effort does it take to move to a new children’s hospital, and at Christmas-time? Beth (Elizabeth Nelsen) of  “Not Terribly Ordinary” wrote down her thoughts on the night before the move.

    Ramona Bates at “Suture for a Living” writes down her thoughts on the increase of suicides in ‘our soldiers’ and the way to prevent this. Thoughts that were generated by events close to her heart. A sad subject, but beautifully written.

    Background  questions.

    Foreground BackgroundThere’s a distinction between background and foreground questions. A background question asks for general knowledge or “facts” (questions often starting with who, what, when, why, which). “What is type 2 diabetes?” “How can one  diagnose appendicitis?” “Which treatments are available for advanced prostate cancer?”  These questions can be best answered by books, databases like UpToDate and good quality websites. The novice in a field usually has more background questions than the expert.

    More and more doctors use the Internet to quickly access or to keep abreast of new information. “Clinical Cases and Images Blog” describes how doctors can add expert insights and comments about websites in the recently launched Google Sidewiki.

    Books are good for background questions, and are especially useful if they debunk long existing myths. Amy Tenderich at “Diabetes Mine” describes one such book, “Diabetes Rising”. She received this book (coming out in 2010) as an advance review copy and simply could not put it down. Read her review of the book and an overview of some of the diabetes-causes-and-cure-myths here.

    An excellent review allowing the readers to get good background knowledge about antiplatelet agents is offered by Flavio Guzman at “Pharmamotion”. His post gives an overview on the currently used agents in clinical practice, their classification, mechanisms of action and therapeutic use. It includes charts, figures and a video that reviews the most relevant aspects of antiplatelet therapy.

    Foreground  questions: Domain Therapy2463850234_6a9851b622

    Foreground questions ask specific clinical questions that try to find relationships between a patient and their condition, an exposure (therapeutic, diagnostic), and an outcome. They are generally very detailed questions that can best be answered with the information contained in published research studies (website UMDJ) or syntheses therof.
    Foreground Questions are usually structured in 5 parts: P I C O and domain (or study type) and are answered by searching for the best available evidence.

    The most common domain is Therapy/Prevention. The PICO stands here for Patient/Population/Problem, Intervention, Comparison/Control and Outcome

    When looking for the best evidence one searches for a few (not all) components and for the best study design, in the case of therapy: controlled clinical trials in the first place and -if not found- for cohort and case control studies.

    104311636_d8f2be6a7e P wit zwart“P” is definitively the most important letter in the PICO. It is the person suffering from a disease, the patient one desires to cure, the problem a doctor wants to solve. All health care should be ‘about them’: Patients.

    The patient-centered and sympathetic Rob Lamberts (alias Dr. Rob) of “Musings of a Distractible Mind” muses about The Medically Homeless. He summarizes his post as follows: There’s much ado about the quality of medical care and the plight of the patient in all of this (it’s about them, remember?), but what’s the central problem? In this post I put forth the concept of “Medical Homelessness,” which is a description of the patient who doesn’t have any one place where things are in order. Data is scattered all over the place and confusion comes at a high cost. Why does this happen? What can be done about it?

    The number of people affected by Alzheimer’s is growing at a rapid rate, and the increasing personal costs will have significant impact on the world’s economies and health care systems, according a new report on Alzheimer’s predicted rates. Alvaro Fernandez at “Sharp Brains” thinks that this report should act as wake-up calls for healthcare systems to focus on education & risk reduction initiatives and shares the main recommendations from an upcoming report prepared for the City of San Francisco. Recommendations include risk reduction (promote cognitive health and create a culture of “brain fitness” through mental stimulation, social engagement, physical exercise, and diet, early identification of dementia and ensuring that caregivers are aware of and have access to community resources, training and support.

    247846944_a24020fa54 LETTER I “I” is also an important component of the PICO. In case of a therapeutic or preventive question the I stands for Intervention.

    Dr Shock, a psychiatrist from the Netherlands has an outstanding blog with the electrifying name “Dr Shock MD”. With respect to interventions, the emphasis is not only on electroconvulsive therapy, but also on sex, drugs and….. chocolate! Which may or may not be typically Dutch. It should be noted, however, that the large number of posts mentioning a positive effect of chocolate, may imply a positive publication bias towards chocolate in favor of “good” results.  Last week he claimed that  Chocolate Saves Your Teeth, but his current submission is about the strong reverse association between (one year) chocolate consumption and cardiac mortality after a first acute myocardial infarction. It should be noted that this was a retrospective study, thus the evidence is much less convincing than would be obtained by  long-term, randomized controlled trials.

    Another post about nutrition, but more about the direct “Special Nutrition Needs for the Rescued (and the Rescuer!)” can be found at the “Medicine for the Outdoors blog”. Here, Paul Auerbach summarizes the key points from a presentation given at the Wilderness Medical Society Annual Meeting. The medical and psychological importance of providing proper nourishment to rescued individuals is of utmost importance.

    I don’t know whether it is our (Dutch) reputation, but there were (relatively speaking) an awful lot of sex-related submissions: almost 15%…
    First Daryl Rosenbaum at “Listed as Probable” looks at the pros and cons of “sex before the match”, as has been advocated by the coach of India’s cricket team; the coach tells his players to have more sex in order to improve performance on the field. But is this really the case? Well everything preceded by “too” is “too much”, my mother used to say…

    Dr. Val at “Better Health” is wondering whether Francis Collins, former director of the Human Genome Project and new director of the NIH is “bringing sexy back to science” In an age where celebrities are treated as credible sources of health information, scientists need to find a way to communicate with the public in a new and more engaging way. Collins, has started a new initiative called “Rock Stars of Science” to promote the field, protect people from misinformation, and get the public excited about science again.  “Whatever works”, dr Val concludes.

    The “UN Guidelines for Sex Education” are stirring opposition (before they are even published) from conservative and religious groups who are attacking the guidelines because of their portrayal of issues like sex education, abortion and homosexuality. Nancy Brown of “Teen Health 411” mentions 9 convincing reasons why these guidelines should not be blocked. Nancy concludes with: “Need I see more?” No, you don’t Nancy.

    477120721_db7f83921f CMost intervention studies compare an “I” with a “C”, Comparison or Control. Preferably efficacy should be tested in a randomized controlled trial (RCT), which has the least form of bias if well performed.

    Only one submitted post presents evidence that has been gathered through an RCT. Faith Martin of “Highlight Health” highlights a recent RCT published in the journal Health Technology Assessment (HTA). Results of this non-inferiority trial showed that home-based care in the United Kingdom is no worse than attendance at a day hospital for older adults. Surprisingly, the cost of the home-based rehabilitation provision was not significantly different to that of day hospital rehabilitation, Indeed, given there is no difference found in outcomes or costs, patients could potentially be given the choice.249722873_1b417cdb3a blauwe O

    The “O” in interventions is the outcome. It is important to look for outcomes that matter most to the patients and not for surrogate markers.

    Once it has been established that a treatment is effective it is important that there is compliance and the patients know “what to do”. With two videos “Allergynotes” shows how MDIs, Spacers, and Dry Powder Inhalers should and should not be used. Patients often use them wrong.

    It is in itself not enough to show the effectiveness of an interventions Costs aspects also come into play, politics, insurances, and decision support systems. The following 3 posts kinda fit in this subject. Since my knowledge of these US-specific subjects is poor I will stick to the descriptions given.

    Elyse Nielsen at “Anticlue” wrote “Using Rules to support clinical decisions. “It is all about using the CDS 5 rights model to plan to have the right rule based support in the right place in the systems.”

    “InsureBlog”‘s Henry Stern makes the case that CMS (The Centers for Medicare & Medicaid Services) overstepped its bounds by slapping down Humana’s efforts to educate its policyholders.

    Jeffrey Seguritan at “Nuts for Healthcare” writes about the Baucus bill. The Baucus bill being considered in the Senate Finance Committee is depending on an excise tax on high-end (“Cadillac”) plans as the biggest revenue driver for reform. While President Obama and health economists agree that this tax discourages wasteful health spending, many Democrats are pointing out how the tax would easily hit the middle-class. According to Jeffrey, this issue touches on the greater problem of our highly regressive and unfair tax subsidy on health benefits.

    Domain Diagnosis

    733162553_d694bb56d0 diagnosisIn EBM, diagnosis studies are mostly diagnostic accuracy study: one wants to know how good a test can predict or exclude a suspected disease. No examples of diagnostic accuracy studies here, but two examples of when diagnostic tests should be applied or not.

    At “Life in the Fast Lane” Toxicology Conundrum 018 (written by Chris Nickson) deals with the myth that “necrotizing arachnidism” can be caused by a spider bite of white-tailed spiders. A wrong diagnosis (i.e. a patient thinking a nasty sore is due to a spider bite) may lead to other disorders, often infections or cancers, being mistreated.  One of the embedded videos is typical of the misinformation about white-tailed spiders in Australia (presented by an exported Dutchman no less!).

    Bongi feels bad about the time when a registar “forced” him and another fourth year medical student to perform a useless “diagnostic test” on a stillborn baby just as a precautionary measure against the anticipated rage of her professor at handover: “you!” she indicated my friend and i, “you are going to go down to the morgue and get that baby’s blood. and you’d better move it. the sun will be up soon.”
    Soon the juniors found out that sampling of blood from a dead baby is not that easy. A very morbid story indeed.
    The best description is given by Bongi in South-African – a language I can understand (thanks Bongi):
    “dis ‘n storie van die ou dae tydens my mediese opleiding to iets gebeur het met ‘n oorlede baba wat nooit moes gebeur nie.
    ek is ‘n chirurg in nelspruit in suid afrika. die spesifieke ervarings van hierdie deel van die wereld voorsien baie interessante stories.”
    (inderdaad)
    Please read the entire story (in English) at “Other Things Amanzi”.

    Domain: Etiology/Harm

    3880192862_6d0f931e64 HARMOtherwise than regularly suggested the best evidence of harm or causality is often not provided by RCT’s, but by observational studies (preferably prospective cohort studies).  RCT’s are either not ethical, or are not suited to detect rare or late harmful effects. The same is true for the domain prognosis, which studies the influence of prognostic factors in the natural course of disease

    Other than with interventions the Outcome in this domain is the disease and the P is the population. The I is the causative factor.

    Although  “causation” can seldom be demonstrated by controlled clinical trials, care must be taken that any conclusions are based on sound observational studies. Anne Marie Cunningham, a doctor from the UK with interest in the use of social media and technology in education wondered whether a news article on the BBC with the Headline “Tech addiction ‘harms learning'” was based on good evidence. Downloading (at $24.99) and reading the report confirmed her suspicions that the BBC-conclusion about the relationship between Internet and mobile phone addiction and poor learning was based on poor science. Read the details on her blog “Wishful Thinking in Medical Education”.

    Sometimes new studies reveal that causes are different than thought. The failure of the U.S. to match longevity statistics of other developed countries is well-known, but Stacey Butterfield of the “ACP Internist blog” points at a study of the demographer Dr. Preston (reviewed in a column in the New York Times) that offers a different explanation for the gap. Stacey explains: “To put it simply, the study shows that it is lifestyle (particularly smoking) that sets Americans apart from other countries, not the quality of the health care. Other researchers have calculated that if deaths due to smoking were excluded, the United States would rise to the top half of the longevity rankings for developed countries. However, the good news is that many Americans have quit smoking in the past decade, so we should be seeing continuing gains in health. The bad news is that we’re working hard to make up the difference by getting fatter.”

    Indeed obesity is becoming a pandemic. Astoundingly, WHO figures from 2005 suggested that there are more people suffering from overweight-related problems than malnutrition. David Bradley Science Writer based in Cambridge, UK, reviews  a recent study on his blog  “ScienceBase” showing evidence from the UK with respect to the effects of current dietary trends and consumption patterns on health. Although the rewards of developing a safe and effective anti-obesity medication will be in the tens of billions of dollars, David regards it “highly unlikely that the growing epidemics of overweight and obesity are to be solved by popping a pill”.

    Sometimes harm is caused by mistakes.  In Fertility Clinic Mistake Ends Up Good Toni Brayer of “EverythingHealth” tells about the accidental implantation of an in-vitro embryo into another woman at the clinic. But some lemons can be made into lemonade: the woman with the wrong embryo kept the baby (without demanding custody) and recently gave birth to a healthy baby boy.

    Adverse conditions in a patient can result from the activity of physicians. Mostly this will be unintentional, but sometimes “doctors” deem other  factors more important than what is best for the patient. Technology consultant and blogger, Sarah Cortes, went by ambulance to a rural Hospital after she suffered a serious spinal fracture after diving. The hospital staff  intimidated and coerced her into accepting unnecessary reconstructive spinal surgery. Unnecessary, because she was able to swim and thus mobile, after the diving accident.  Sarah thinks that boosting of accreditation was the main motive for the hospital. This story, too, has a happy ending: with the help of Twitter, Sarah was able to leave for Boston, where she was successfully treated without the need for surgery. Without Twitter it might have had a less happy ending. Read her story here at her blog “Security Watch”.

    Thoughts about social media and patient safety can also be found on “Florence dot com”, the blog of  Barbara Olson. She wrote the post to suggest that social networking sites can help reveal beliefs, practices, and norms in healthcare systems that undermine patient safety. She noted that these might not be readily visible using more traditional means.

    An article in last month’s New England Journal of Medicine documented some disturbingly high exposures of Low-Dose Ionizing Radiation from Medical Imaging Procedures among patients. David Williams has been writing about patients getting too much radiation from diagnostic imaging for years.  At least in the US, patients and physicians have no way of tracking their lifetime dose. At the “Health Business Blog” David applauds a local initiative of a Boston hospital to track radiation exposure. He reasons that Personal Health Records could help keep track and also reduce the need for excessive scans.

    Well this concludes the official part of the Grand Rounds. I hope you enjoyed it. Thanks for your submissions.
    It was a pleasure reading them, although -I must admit- quite an effort writing them down….

    741879088_29d01c359b_m-another-dead-librarian

    Acknowledgements

    Thanks to Nick Genes for starting the Grand Round and Dr. Val Jones at Better Health and Colin Son at Residency Notes for keeping the carnival up and running.
    The Next Round will be hosted by Christian Sinclair, see here for the announcement

    Bonus

    I asked the contributors to spend one line telling me their thoughts on medical information (MI) and/or medical librarians (ML). Here is a selection of answers (I will leave out too obvious examples of self-promotion). I especially liked that doctors mentioned their own librarian or somebody they knew (i.e. from Twitter). In order of appearance:

    Beth (Elizabeth Nelsen) of  “Not Terribly Ordinary”  (ML): They help to bridge the gap between what We (the medical establishment know) and what They (patients and families) should know. Our new hospital will have a family resource center staffed by a medical librarian!

    Ramona Bates of “Suture for a Living” (ML): Invaluable

    Rob Lamberts at Musings of a Distractible Mind” (MI): chose this post because it focuses on medical information – both that of the patient and the information that informs decisions. The crux of our problem is not a lack of information, it is a lack of organization of the information we have.

    Alvaro Fernandez at “Sharp Brains” (ML, MI): libraries overall, and medical libraries in particular, can play a crucial role in educating professionals and lay audiences on the cognitive health implications from growing research on cognitive neuroscience and neuropsychology. In fact, I just gave a talk yesterday at New York Public Library precisely on this topic!

    Daryl Rosenbaum at “Listed as Probable” (ML): Don’t have any creative thoughts about medical librarians, just that our department has one that works with us and she is a very valuable resource.

    Dr Val at “Better Health” (ML):  they are the unsung guardians of truth in medicine. We need their help to combat the tidal wave of Internet misinformation that is confusing and harming patients everywhere.

    Nancy Brown at “Teen Health 411” (MI): “Teens need adults they can talk with and medically accurate information to facilitate healthy decisions. The habits they start as teens and the choices they make will influence their adult health.”

    Jeffrey Seguritan at “Nuts for Healthcare” (ML): With the rise of the Internet as the premier information portal, medical librarians are essential in helping providers navigate through sources of information that are accurate and credible. An alarming poll this year suggested that 50% doctors use Wikipedia, not the authority patients are looking for.

    Chris Nickson at “Life in the Fast Lane” (ML): Well, as you well know, we love medical librarians – especially the helpful tech-savvy ones that populate the Web!

    AnneMarie Cunningham at “Wishful Thinking in Medical Education” (MI): We have more publications (journals, guidelines and user-generated content) than ever but still many of those searching (clinicians and patients) can not find what they want or need. That is the challenge. Hopefully as time passes it will feel as if we are getting closer to the solution

    David Bradley at “ScienceBase” (ML): Medical, and subject specialist, librarians in general now play an even more critical role in helping their “customers” keep on top of the vast quantities of information available to them. Thankfully, there are some around who are quite expert and can pin down even the rarest of information beasts.

    Barbara L. Olson at “Florence dot com” (ML): I recently compiled a list of tweeps people interested in patient safety should watch on Twitter I’ve been following Sarah Vogel @sevinfo (Pharma/Biotech information researcher, librarian) for awhile and included her.

    David E. Williams at the “Health Business Blog” (MI, ML): Providing information at the point of care is critical to improving quality and reducing costs. Medical librarians can help clinicians learn to access and apply these tools

    Several contributors spontaneously said that they were going to, loved or had happily lived in The Netherlands. Amy even had a baby while over here!

    Interview will appear at http://www.medscape.com/index/section_2624_0

    Image Credits (CC-licence)

    1. Library Book Shelves, Wikimedia
    2. PAR-TIC-I-PA-TION, or 37 pieces of library flair Flickr.com: trucolorsfly-611479605
    3. Stone Horses: Flickr.com: automania-73655708
    4. The Background/Foreground picture is used everywhere, I’ve adapted it from the excellent book: Guyatt G, Rennie D, Meade M, Cook D. JAMA Evidence Users’ Guides to the Medical Literature. A Manual for Evidence-Based Clinical Practice. 2nd ed. Chicago, IL: McGraw Hill Co; 2008.
    5. Dolk-Banana Therapy Flickr.com: imagesniper- 2463850234
    6. P Flickr.com:duncan-104311636
    7. I [Aye-Aye] Flickr.com: urbanmkr-247846944
    8. C Flickr: urbanmkr-477120721
    9. O Flickr: urbanmkr-249722873
    10. Stethoscope Flickr: ponyapprehension-733162553
    11. An Honest Question Flickr: photos/hryckowian/3880192862/
    12. Another Dead Librarian by Doug! Flickr.com: librarygeek- 741879088

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    Dear Laika,This is my suggestion for Grand Rounds:Doctors add expert insights and comments about websites in Google Sidewiki
    http://casesblog.blogspot.com/2009/09/doctors-add-expert-insights-and.htmlAlternative:Myths About Health Care Around the World
    http://casesblog.blogspot.com/2009/09/myths-about-health-care-around-world.htmlLooking forward to Grand Rounds on Tuesday,
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