Citations from Edelman's New Media Academic Summit

I spoke today at the panel on transparency at Edelman's New Media Academic Summit. Ben Boyd was the moderator and Ellen Miller from the Sunlight Foundation was my fellow panelist.

Reviewing some of the #nmas10 tweets from the audience, I figured I should provide some links for the anecdotes I mentioned:

• BID CEO Paul Levy's blog is still the starting point when talking about transparency in medicine today. I had the chance to speak with him, a few years ago.
• Ed Bennett has done an extraordinary job following hospital social media adoption and highlights effective new media policies, as well.
• Hospitals are using twitter and billboards to broadcast ED waiting room times. This is not without risk, as billboards may not clarify the triage process, where seriously ill patients will be seen right away 
• ACEP president Angela Gardner's Twitter feed and ACEP's blog. 
• A recap of Better Health bloggers' meeting with Rep. Jack Ryan last summer during the healthcare reform debate. 
• Recent articles from NEJM and JAMA articles on med students and social media.   
• A lot of the developments in openness in peer review, and the world of grant funding, are chronicled at Nature's Peer-to-Peer blog. Bora Zivkovic has been and active and articulate  defender open publications, as well.

Special thanks to Dr. Val Jones of Better Health for getting me involved with this group.

Warm impermanence

I'm back from SAEM's Annual Meeting, and catching up on a boatload of emails and unread items in my RSS feed. Something's gotta give when social media use goes into high gear, but one of the things I missed was my own article in EPMonthly on using technology to keep current. Kind of embarrassing.

Anyway, some of the resources I highlighted were the same that Graham Walker mentioned in his comprehensive review of E-learning for EM. We're definitely entering a golden age for electronic resources in our specialty, and the tools to archive this material and make it quickly accessible are also coming along nicely. It's also reassuring, when others point out the mental risks from internet info consumption, that I've met so many accomplished and sharp people taking the plunge into this new media. What is it with early adopters, anyway? This quote comes closest to explaining the phenomenon, among any I've read:

I find that the early adopter mentality is widely misunderstood: Journalists going for a sociological angle on the people in line for iPads, for example, focus on a desire for status or attention, or to be first on the block. They completely miss the point. They don't understand that the desire is for the thing itself and for what it can do; that we imagined this device before it was announced; that we're constantly bumping up against the limitations of what's available today; and that when these things finally appear in stores, we say "At last!" And then we buy them, and use them, and immediately get frustrated with its shortcomings and start waiting for the day when the next model comes out.

This text was waiting for my in my RSS reader, and when I came across it I naturally tweeted the link, as well as added it to Evernote, before reprinting it here.

Can't buy a thrill

Many of the peculiar terms and phrases we learned in medicine have found a new use in cyberspace, as titles of websites (consider 10 out of 10, The Central Line, or this blog -- and that's just emergency medicine sites).

But that's the virtual world -- what about the real world? This past week I saw a couple of products that make me think medical parlance could sell physical products. Consider:

• This is Spinal Tape (via Joshua Schwimmer) 
• Drug of Choice coffee (via Rob Lamberts) 

OK, fine, it won't really be a trend until Wendy's is selling STEMI-burgers or we see Throckmorton-branded condoms. But I wonder if this could someday happen, given the improving economics of niche marketing. Or maybe the general public, through realistic TV shows and, yes, blogs, has picked up on enough of our lingo to make this work?

I can't say. But I'd like to remind  readers that you can enjoy your Drug of Choice in a lovely, professionally-designed mug, on sale now in storeborygmi. 

Pad & Pen

My piece on the iPad's potential in emergency departments is now up at EP Monthly. Check it out -- especially the ambitious developers who've left comments.

The speculation about this device in healthcare has gotten a little more detailed -- and optimistic -- as people have had the chance to use it this week. Other insightful comments are available from Larry Nathanson, Chilmark Research, and John Lynn.

A new kind of tension

There's an adage I often think about: "A physician's job requires the expression of  confidence. The researcher's role is to express doubt."

This was never more apparent than when I transitioned from the research environment into the clerkships of medical school. The language of decision-making had abruptly changed -- in the lab, a year's worth of experiments is summarized with "seems" and "suggests," and every assertion is carefully calibrated to acknowledge uncertainty and a high standard for proof.

As a student on clerkships, I couldn't quite wrap my head around the residents' ambitious plans for patients:

• "Check CBC, electrolytes, chest X-ray, EKG, oh, and, he needs a head CT."  

This use of "need" too often seemed careless to me, as if any patient could need a test that was almost certainly going to be normal, that in most parts of the world would never even be considered.

But in the residents' perspective, I came to understand the head CT was just an expected component of the patient's management -- it had nothing to do with likelihood ratios or pertinent life-threatening conditions that must be explored -- it was simply part of the story for certain patient scenarios, and couldn't be omitted without raising a lot of questions.

• "We should also check a TSH level."

Few patients ever needed a TSH level, as far as I recall -- this wasn't something that would hold up discharge, for instance. But checking thyroid function was often something that should also be done. Again, not because the residents had a firm grasp of the prevalence of thyroid disease in certain populations, but rather, because it demonstrated a thorough workup and, while not an essential or expected part of management, was nice for the attendings to see.

Over time, I gradually adjusted to this very nosocomial interpretation of "need" and "should." Now that I'm an attending, and the students' and residents' plans are a lot more hypothetical (until they get my approval), I'm hearing a little more "want" and "think" and "maybe." For me, it's a welcome return -- a language more in line with my background, and one that acknowledges the uncertainties of medicine. 

Some inner truth of vast reflection

I've seen a couple of examples of this now, so I've decided it's a trend. Naturally I'm going to excerpt something from which to base this post:

This sentence claims to follow logically from the first sentence, though the connection is actually rather tenuous. This sentence claims that very few people are willing to admit the obvious inference of the last two sentences, with an implication that the reader is not one of those very few people. This sentence expresses the unwillingness of the writer to be silenced despite going against the popular wisdom. 

I've got further evidence to back this up from this humerous video (though I won't embed it for stylistic reasons).

A pithy observation is shared, and of course, a link to a prior discussion on Metafilter.

After all this deliberation, I've got to conclude this trend has pros and cons, and a lot of unappreciated nuance. I just hope it turns out alright. 

Into a void we filled

I had a bunch of difficult shifts midweek last week and a lot of charts to complete, afterward. That, plus some other obligations, and I had fallen behind on emails -- to say nothing of the news. So while I had heard a little bit about the earthquake in Haiti, I hadn't really reflected on it.

Gmail had grouped the following messages last week from CNN -- all sent within a few hours of each other -- into a thread:

• CNN Breaking News: Hundreds of thousands of people have died in Haiti's earthquake, the prime minister told CNN today. 
• CNN Breaking News: President Rene Preval tells CNN that Haiti lacks capacity to hospitalize quake victims, asks for medical aid. 
• CNN Breaking News: R+B singer Teddy Pendergrass has died at age 59, CNN has confirmed. 

So forgive me, I knew something terrible had happened but I was having difficulty putting it into context.


This isn't necessarily new territory. But, much like with Katrina, the enormity really only sinks in, for me, when I read physician's accounts from the front lines. Something about comparing the challenges of working in my electronic ED with the endless supplies, state-of-the-art equipment, and an army of readily available specialists, to what these doctors are going through, conveys the horror more than a thousand breaking news updates or footage of crumpled buildings. 


Some informative, and responsible, medical accounts are available online (1,2). 


Here's a dispatch from a former colleague with ties to the area: 

My husband and I hitchhiked it to port au prince from the domincan republic; the devastation is of incredible magnitude; [X] and I both have family here; his father was pulled from the rubble alive after having been trapped for 16 hours; fractured ribs hand and leg ; his brother and stepmother killed;  we are still looking for 2 nephews; [X] and I stay on opposite sides of town since food and water are scarce; we are helping our families to ration; at night we sleep on the roads the only safe place since after shocks are still being felt daily; hospitals have turned away thousands so I care for whomever I can in the meantime; I delivered a baby on the sidewalk this morning; please send this email out to our colleagues and ask them to send whatever resources they can; the various teams deployed have still not covered a large portion of the city that is in need of assistance; I have still not been able to get in contact with my medical mission group for lack of communication.

People have been bellyaching about disaster journalism cliches for close to 40 years, but the physician-as-reporter is a new wrinkle that's coming under some scrutiny. From my perspective, I find the physician dispatches very helpful for contextualizing the disaster -- at least, until these doctors' heroics start to become the focus of the story, instead of the lens from which to view it.

Comment te dire adieu

A longtime reader wrote to ask if I had removed comments because they were a relic in this age of facey-spaces and tweety-pages.

That's when I realized my comments had disappeared. 

Haloscan, which had faithfully been providing free commenting to this site long before Blogger.com could,  is now under the control of another company. There was a warning sent to my email before the holidays that I promptly forgot about. And then sometime after Grand Rounds last week my comments were gone; not with a bang but a whimper.

There was a brief period of panic but fortunately, my login still worked on Haloscan.com and they let me download the 1279 comments blogborygmi has accumulated over the past six years. Folks are working on ways to import these old comments to Blogger. In the meantime, I've enabled Blogger's new (to me, at least) comment features.

Of course I understand after a growth phase, there's a need to convert resource-intensive services into sources of profit, even if it means charging for something that used to be free. I just wonder if the new owners of Haloscan (JS-Kit? Echo?) carefully thought this through:

1. They had a small group of early adopters who wanted comments on our blogs, long before a major platform offered them. 
2. We were happy enough with their service to stick with it, for the better part of a decade, even after more robust (and free) versions were offered by competitors. 
3. For various reasons, they needed to move us to a flashy new system. 

Were they really counting on us to start paying for this unnecessary new service? Or, put it this way: was there no other way to offset the cost of making a few blog veterans happy? It seems like they could upgrade us to the new platform for free and maybe get some positive, genuine word-of-mouth publicity, which I'm told is something bloggers have a knack for. Or, I don't know, maybe they could offset the cost by including advertising -- I've read there's some money in that.

Oh well. An opportunity for them has been lost, and for me, some old lessons have been reinforced. What about you? Feel free to leave a comment below.

My one lucky prize

GruntDoc's got a neat little post up how he infers his hospital's census:

My way to work goes through one of our myriad basement areas, the one where empty beds are stored.  I’ve seen literally none, and a lot.

The other night there were so many I couldn’t believe it. Our count is down. This, too, shall pass.

Follow the link for dramatic photo evidence.

These sorts of indicators are fun -- almost as elegant as the Ambient Orb sitting on the desk of Beth Israel Deaconess CEO Paul Levy, gently alerting him to the status of the emergency department waiting room.

Though I can access my emergency department's information system from home, and thus check ED crowding before my shift (if I see lots of admitted patients waiting for upstairs beds, the hospital's pretty full), I rarely do so. I'd much prefer the Orb's distilled, wordless updates to the information overload from our EDIS.

The other day, I got a new kind of indicator about the hospital's census. I had admitted a patient with a history of MRSA to an isolation bed, only to learn a short while later he was ready to go upstairs. This was surprising, as isolation beds are in short supply and patients frequently wait many hours in the ED for one (if not a day or more). In fact, the floor nurse was suspicious I had listed him incorrectly to a regular room, with a vulnerable roommate.

I called our bedboard to make sure they got the right listing. They told me the census was low enough to permit them to turn double-bed rooms into single isolation rooms (in college we called these "dingles"). I don't think I'd ever heard of that happening in our hospital, before -- though like GruntDoc I realized this, too, would pass.

Grand Rounds Volume 6, Number 15

Welcome to Grand Rounds, the weekly collection of the best in medical blogging, featuring works from physicians, nurses, researchers, students, patients and healthcare professionals.

It's a new year and I'm very happy to be involved again in organizing this "carnival of the caregivers." Many thanks to Dr. Colin Son for his role in scheduling hosts, and for writing the Pre-Rounds column for Medscape.com over these past 18 months. Special thanks to Dr. Val Jones of Better Health who will continue to promote and plan GR.

This is the 327th edition of Grand Rounds, and navigating web is pretty different compared to when I first hosted. I've been stubbornly resisting social media to help spread the word about each week's location for Grand Rounds, figuring quality writing will find a way to reach interested readers. But when you consider that the Grand Rounds community of patients, providers and pundits is its own kind of social network, it only makes sense to adopt these new tools.

And so, this week, in addition to the RSS feed and Google Calendar, we're rolling out the @grandrounds twitter account, and a Grand Rounds fan page on Facebook.

These (still comically underdeveloped) resources are hardly groundbreaking innovations in 2010, but then again, the blog carnival concept wasn't new when Grand Rounds started in 2004. Your suggestions to keep Grand Rounds accessible and relevant are always welcome, and your continued participation -- as readers, contributors, and hosts -- is essential. Thank you for your involvement over the years, and be assured, even with this expanded social presence, the purpose of Grand Rounds will always be to showcase excellent writing from independent voices in the medical field. 

I've loosely organized bloggers' contributions in the categories below, but first wanted to take a moment to highlight my favorite post of the week:

Editor's Choice

• Evan Falchuk of See First blog brilliantly deconstructs the popular new National Geographic chart on health care spending and life expectancies across the world, bringing clarity and nuance to a gross oversimplification. 

Medical News and Reviews

• In a timely post for air travelers, Dr. Ves Dimov of the amazing CasesBlog website examines the radiation exposure from full-body scans used for advanced airport security screening.

• The Blog That Ate Manhattan has the definitive take on the new mammography guidelines.

• What killed Franklin Delano Roosevelt? Dr. Ramona Bates sifts through the photos and reviews the evidence behind "FDR's Deadly Secret" over at Suture for a Living.

• Healthline's Teen Health 411 blogger (and recent GR host) Nancy Brown, PhD, reviews new data and concludes parents shouldn't panic about "sexting."

• Smile! Inside Surgery looks at tetanus, part of the continuing series of concise summaries of commonly occurring medical conditions.

• What just happened? Doc Gurley condenses all the medical news of the past year into a hilarious recap: Top 10 Health Lessons of 2009. Read it, lest you be doomed to repeat that bizarre year. 

Healthcare Policy Views

• If you're concerned about a nursing shortage, David Williams of Health Business Blog wants to reassure you, by welcoming robots and immigrants to fill the nursing shortage.

• In the latest from his Careful What You Wish For series at InsureBlog, Henry Stern contrasts his wife's recent mammography scare in the US to shortcomings in the UK's NHS system.

• In the US, electronic health record adoption is getting a boost from the government -- providers will receive incentives for "meaningful use" of EHRs. David Harlow of HealthBlawg thoughtfully reviews of the new definitions for meaningful use – a must read for those of us in health care informatics. 

• You've heard about patients in Canada or the UK who endure long waits to see specialists -- but did you know that less-educated patients wait longer? Over at Colorado Health Insurance Insider, Louise looks at why socioeconomic status influences wait times. 

• Dr. Val has a call to action for preventive health, asking readers to channel their frustrations over healthcare reform into staying fit and trim for the new year. That'll show 'em!

Case Reports / Notes from the Front Lines

• What happens when a son tries to 'drop off' his father, and treats a hospital like the adult Humane Society? The Happy Hospitalist becomes unhappy, and is forced to explain hospital admissions.

• Emergency Medicine blogger Chris Nickson at the Life in the Fast Lane blog writes about an unexpected ending to a family meeting about a dying patient, in his post: Bad News Broken.

• In a very personal post, Todd C. Williams reflects on his wife’s medical care and draws comparisons to his own work in project management. 

• Dr. Charles has examined his recommendations for exfoliating soap -- we can scrub off dead skin, but those little plastic microbeads from the soap will come back to haunt us, in surprising and sad ways. 

• At a blog called Own Your Health, medical journalist Roanne Weisman reflects on lifestyle choices and a family member's death, and concludes: she didn't have to die.

Good Medicine for the New Year 

• Sad that the holidays are over? You can still give the gift of information (and peace of mind).  Paramedic, author and businessman Greg Friese describes four methods people can use to compile medical history and emergency contact info.

• A blogging therapist named Will Meek (prediction: large inheritance) reflects on some common blurred thinking from a psychotherapeutic perspective, and offers some simple checks to keep folks grounded.

• Julie from The Doctor’s Rheum brainstorms some creative and inexpensive ways to address excuses for lack of exercise in the new year. 

• Dr. Jolie Bookspan recaps readers' success stories from the past year in her Fitness Fixer Reader Hall of Fame. 

Thank you for checking out this first Grand Rounds of 2010. Please visit DrRich at the Covert Rationing Blog for next Tuesday's edition!

Call for submissions -- Grand Rounds @blogborygmi on Tuesday January 5

The first Grand Rounds of the year will appear here, at blogborygmi.com, on Tuesday morning. 

The deadline for submissions will be Monday 1/4/0910 at 11:59 PM EST.

Please review the ancient but still relevant submission guidelines and email a link to your best recent writing to nick -at- blogborygmi.com, with a short description.

Also, please -- if you'd like to try your hand at hosting, or know of a blogger who'd make a great Grand Rounds host, please let me know. It's a wide-open year ahead of us.

Finally, if you've got suggestions for improving Grand Rounds -- social media integration, organization, anything -- I'm happy to listen.

Sleepwalking

Today the NY Times printed a piece pokes fun at, and highlights the dangers of, the new habit of texting-while-walking:

This summer, the American College of Emergency Room Physicians released a statement expressing concern about the issue, citing a Chicago doctor who was seeing a lot of face, chin, eye and mouth injuries among young people who reported texting and tumbling.

Hmm... I'm a member of ACEP, but I've never heard of ACERP. Is it some rival organization of emergency physicians whose practice is confined to four walls? Or, in its rush to condemn new technologies that enable communication on-the-go, has the New York Times abandoned the traditional practices of editing and fact-checking? 

More play time than money

Much has been written about health care reform, but there's something that's gone unremarked upon, as far as I know:

I don't think I've ever seen this much attention to legislative procedure.

And it's kind of remarkable, really -- just look at some of these mainstream news stories from Slate or the New York Times. And it's been like this for months now.

I remember briefly some discussion of the constitutionality of filibustering in relation to Bush judicial nominees a few years back -- the trivia around the nuclear option and all. But in all the big legislative debates I can recall, from the Brady Bill to NAFTA, DMCA, McCain-Feingold, the PATRIOT Act, Medicare part D and TARP, I don't think there's been such coverage of rival committees, proposed amendments and procedural maneuvers. I can't recall a time when so many different senators and representatives were regularly featured in the news.

There's probably some way to measure this -- counting mentions of the term "cloture" in the news over the years, perhaps, or determining the frequency of senators' names appearing in print.

Who knows? Maybe I'm just paying more attention this time around. But I'd bet the proliferation of punditry, speculative markets and blogs has spawned more detailed reporting.

It's not at all clear whether this increased reporting on legislative procedure translates to a populace more informed on policy options, although I'd wager that's the case. And while I'm sure there are still plenty of back-room deals and shady lobbyist rewrites, this increased public engagement and scrutiny of the legislative process has got to be a good thing, overall.

What I'm wondering is: What would have happened to all the vitriol over healthcare reform, if we didn't have all these frequent, detailed updates? Would we have seen less heated rhetoric, or could more have been possible?

Protect your language

The Efficient MD's eyes are opened by the nasty thoughts Google Suggest offers up when someone starts typing "Doctors are..." Since Google Suggest lists only common results with which to complete your queries, it seems that the most common thing people think about doctors online is that we're "overpaid" or "jerks" or "dangerous" or, most commonly, "sadists who like to play god."

Surveys show people consider doctors to be among the most respected professions. So what gives?
 
Well, I've been paying attention to what Google can tell us about ourselves (the first Google Talk was a lot less useful, but arguably more interesting) for some time. But even before I knew Google Suggest was a weird and limited tool, I knew this:

Declarative sentences are the only kind of sentence that can be proven or disproven. Yet the people who use them most -- and favor the short, simple variety of declarations --are often those least interested in arriving at truth.

That's my guess why those "Doctors are..." statements seem so unfriendly to doctors.

You can find more head-scratching or downright funny Google Suggest screenshots here... It seems that questions from school assignments often find their way into Google Suggest. Finally, here's an analysis suggesting the way the start of a question is phrased implies a certain sophistication of query.

While you're deciding

I took my board exam this week, and I think I liked it.

Which is not to say it was easy, or even altogether fair. And though I felt a little bit better upon finishing than these folks, I could be grossly deluded in my estimation of the number and trickiness of truly tough questions.

But there was a point in the exam, three or four hours into it, when I was overcome by the sheer variety of extraordinary patient presentations -- the environmental catastrophes, bizarre overdoses and bites from creatures great and small. Overcome, not because I've never seen patients like this (for the most part, I haven't) or because I didn't know how to diagnose and manage them (I think I did), but really because these questions underscored what an amazing specialty I've chosen.

I like that my specialty board expects a mastery of emergency topics on which there's no consultant to turn to, and that they expect me to be able to work in any part of the US -- places where snake bites or diving complications or altitude sickness is more common than my neck of the woods. Too often in emergency departments, we get caught up in managing patients with existing, complex diagnoses -- transplants, hereditary disorders, and the like -- who present with a list of specialists to notify. It's nice that our board has crafted a curriculum and though their exam, reminds us that at least occasionally, our medical input is indispensable. 

Favorite parts of the exam (that I can mention in an open forum):

• Taking the exam at 500 Fifth Avenue, an overlooked gem of a New York City skyscraper. In any other city, this 60-story art deco tower would be celebrated, iconic. In midtown, however, people's attention is drawn to the nearby New York Public Library and Grand Central Terminal, just a block or two away, as well as the other towers along 42nd Street -- Chrysler, Grace, and the new Bank of America building. But 500 Fifth is worth a closer look, if only to draw a comparison to the tower its developers built immediately after, a little farther down the street.

• I recently co-authored a short "chapter" in a review book about a rarely-encountered (by me, at least) ophthalmological emergency. It was on the board exam!

• When you walk into this Pearson testing center, you take a number -- and that's the testing station you're to which you're assigned. I took Number 14. The lady behind the desk called Number 12 to snap his picture and get him registered. Then, she called on me. When I jokingly asked what happened to Number 13, she replied something to the effect of: "You doctors may not be superstitious but we know better than give someone that number."

Of course, I do have a few gripes:

• For an electronic exam that's criterion-referenced (not curved), it seems odd that it'll take so long (usually 40-50 days, I think they reserve the right to take 90 days) to score it. 

• A huge fraction of the exam -- by some estimates, a third of all questions -- are experimental. I recognize the examiners' need to know how challenging or fair new questions are before making them "count" -- but when so much of a test is, well, untested, the examination process becomes an exercise in confusion and frustration, and it becomes impossible to gauge one's performance. By the time the scores come, months later, an opportunity for constructive feedback has been lost. Maybe this is ABEM's way of simulating the actual practice of emergency medicine? As a recent grad, let me suggest: why not experiment more on the residents? There's a lot of them, and their inservice exam is free (yes, I spent nearly $1000 for the privilege of taking a largely experimental test -- shouldn't it be the other way around? Maybe ABEM could offset some of the cost by letting us choose how much of the exam day will be spent giving them data on future questions).

• For a specialty that prides itself on recognizing zebras and considering the life-threats for even the most benign presentations, the exam has an unseemly predilection for "most common" questions -- the most common bug responsible for a given infection, the most common age group affected by a given disorder, etc. I know some demographic information and context is important, but these questions arise so often, it's almost as though the board doesn't want us to use broad-spectrum antibiotics, for instance, or work up younger adults with chest pain.

All in all, though, the exam experience was ok -- and not as bad as I was dreading. I just hope I don't have to repeat it.

Look at my circumstance

Here I am at the medblog track at Blog World Expo '09. I'm finally meeting some of the authors I've been reading for years. Then GruntDoc, one of my 'blogfathers', gives me grief for not posting more.

Well, to sate his appetite for new junior faculty sticking their necks out, here's some thoughts on the mandatory H1N1 vaccine that I put together for EPMonthly.

More to come, after the panels, dinners, and afterparties...

Can Web 2.0 improve this post?

If you were curious about some of the Web 2.0 sites or services I mentioned today in my talk, links are available below:

• My NCBI
• Google Alerts
• Google Reader
• #sa09 on Twitter
• WikEM

Here are the EM ultrasound resources I mentioned:

• ACES
• RUSH
• Ultrasound Guide for Emegency Physicians
• HQMedEd
• HQMedEd's YouTube Channel