Can We Trust Information on YouTube?

Once upon a time, in my academic career, I worried that inaccurate mass media depictions of, say, diabetics would cause people to make bad care choices. If you’re thinking of Julia Roberts in Steel Magnolias right now, trust me: Julia Roberts in Dolly Parton’s hair salon is the tippy-tip of the iceberg. Now I worry more about YouTube, the modern-day Library of Alexandria of instructional videos.

In the past year or so I have watched YouTube videos, off the top of my head, to learn to: change a blinker bulb in my car, fix my thermostat, learn to run specific reports within Quickbooks, refresh my memory on how to do certain math problems for helping with my daughter’s homework, and shut off the “move to wake” feature in my iPhone. And dozens more.

But I’ve also used YouTube in the past to remind myself how to reduce my son’s dislocated elbow (my son’s orthopedic history gets more complex by the year). There’s an old saying in medicine: “see one, do one, teach one.” I needed to “see one” again before I subjected my son to it. The procedure was successful, for what it’s worth. (Being a doctor’s kid is weird. I digress.) Are you scheduled to have your thyroid gland removed? YouTube can show you the procedure. Are you a new type 1 diabetic who wants to practice carbohydrate counting for insulin dosing? Boom. Starting chemotherapy and interested in using cooling therapy to reduce hair loss? Look no further. Recently we talked about the reliability of physician rating sites (spoiler: potentially useful, but with major caveats). How do YouTube videos stack up for general medical information? For the purposes of this post, I’m mostly ignoring obvious conspiracy-mongering about COVID vaccinations, cholesterol medications, and whatnot. Like pornography, I trust that you’ll know those when you see them.

To get an answer on the accuracy and utility of YouTube videos for medical inquiry, I looked not to YouTube, but to PubMed, the search engine of the National Library of Medicine. Here’s what I found:

YouTube contains so much information that investigators tend to categorize it by learner, generally either medical trainees or the general public. Videos for medical trainees seem to be relatively generously reviewed by researchers. Using our example of thyroid surgery from above, one study found that most YouTube thyroid surgery videos were posted by surgeons operating in academic institutions, which they took to mean the intentions of the videos were purely educational and not promotional. But the researchers also noted that surgeons who had no history of traditional academic publications–i.e., not necessarily the most respected people in the field–posted the majority of surgeon-sourced videos. This led the authors to conclude that “Trainees and educators alike should critically analyze the quality of video content,” which is the academic equivalent of throwing shade. A systematic review of studies of YouTube videos aimed at medical learners backed this up, concluding that “While videos authored by academic physicians were of higher quality on average, their quality still varied significantly,” and “Video characteristics and engagement metrics were found to be unreliable surrogate measures of video quality.” That is, a video’s slick production and millions of views did not mean it was accurate.

Videos aimed at the general public tend to be more harshly judged. One study by two emergency room doctors investigating the quality of videos pertaining to the management of low blood sugars went so far as to say that “health videos should only be uploaded by physicians,” a statement hilarious in both its confidence and its wrongness. Surely someone without a medical degree somewhere, at some point, has been filmed saying something accurate and helpful. But, in general, the quality of public-facing YouTube videos does appear to suffer in comparison to professional learner-directed videos. A systematic review from 2015, admittedly ancient history in internet years, concluded that “YouTube contains misleading information, primarily anecdotal, that contradicts the reference standards and the probability of a lay user finding such content is relatively high.” But, on the bright side, they also found that “videos from government organizations and professional associations contained trustworthy and high-quality information.” We at KBGH, who have produced and posted videos of our own, hope that we fall into that category.

Let’s bottom-line what we can take from this research. First, beware of any video that makes claims that seem extraordinary. Someone who says that removing a food from your diet is as powerful as taking cholesterol medications for preventing heart attacks, for example, better have good evidence to back that statement up. Second, pay attention to the source. Videos from academic centers, government agencies, and professional associations appear to be the most reliable. But they’re also, I suspect, the most conservative. Few such organizations are willing to put themselves out on a limb compared to their peers. Finally, beware of using the number of views or shares as a marker of the reliability of a video’s contents. As we’ve discussed before in this very blog, the internet is set up to make sure the most radical statements get the most eyeballs.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

We Need to Support Black Doctors

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

The stark differences in health outcomes

We should never reduce any population of people to a set of statistics. Every one of those “statistics” has a story. But here are a few numbers that should get our attention:

African-Americans have a rate of COVID-19 that is three times higher than the infection rate of the population as a whole. Even worse, the risk of death of an African-American person with COVID-19 far exceeds that of other racial groups. While people of white, Latinx, and Asian descent have death rates that all fall between 20 and 23 deaths per 100,000 people, African-Americans have suffered a death rate more than twice as high: 50.3 deaths per 100,000 people. About one out of every 2,000 black people in America have already died of COVID-19. Let me repeat that: one two-thousandth of African Americans are already dead. From one disease. A similar death rate among white people would have resulted in almost 100,000 deaths just in that ethnic group so far. And sadly, Kansas has the highest racial disparity of any of the 41 states reporting such data.

But the damage is not limited to viral illnesses. Americans in general have lives about three years shorter than citizens of peer countries like those in Western Europe.

African-American men have a life expectancy that is, in turn, almost five years shorter than the American average. This means that an African-American man loses the better part of a decade in life expectancy compared to an average western European citizen.

And almost all of this difference is due to heart disease deaths, the risk of which is readily modifiable with solid, basic medical care.

What are the reasons for this disparity?

The basic medical care of black people is neglected for multiple reasons in our country, including a well-deserved historic lack of trust in the medical system by black people. Remember that in the Tuskegee Syphilis Experiment the U.S. Public Health Service intentionally and secretly withheld treatment from a group of black men with syphilis from 1932 to 1972 to study the “natural history” of the disease, jeopardizing the health of the men and any future partners. 1972!

A second problem is a dearth of black physicians, starting in training. African-Americans are tragically underrepresented in medical school. While African-Americans make up 13.4% of the American population, they make up only 7.3% of medical students. This disparity, while slowly shrinking over time, has real consequences. Patients may do better when cared for by someone who looks like they do. A 2018 randomized trial found that black men had far better outcomes when cared for by black doctors: rates of screening for hypertension, diabetes, high cholesterol, and obesity went up markedly in men with black doctors, by more than 25% in some cases. The difference appeared to be due to improved communication. Patients were simply more likely to bring up other health problems when assigned to a black doctor. Interestingly, uptake of “invasive” screenings—tests involving probing or a blood draw–increased only for the group assigned a black doctor. This would seem to reinforce the idea that trust, long missing with the medical establishment, is a vital part of the doctor-patient relationship. And the cultural knowledge imparted by someone from your own community can be priceless, something we have found in our CDC work on community health workers.

The increased rate of screening demonstrated in this study could have huge health implications. The investigators tried to estimate the effect of having more black doctors in the population as a whole and found that even a modest increase could reduce the black-white gap in heart disease mortality by 19%, and the and the overall black-white gap in male life expectancy by 8%.

Efforts are being made to attack this problem from the start. After all, the lack of black trainees isn’t simply the result of fewer black kids wanting to be doctors. Quite the contrary. Locally, the Medical Society of Sedgwick County sends member physicians every year to talk to high school students about the process of applying for and completing medical training. Nationally, the American Medical Association has a program called “Doctors Back to School” to facilitate physicians of color visiting grade schools to encourage minority students to consider careers in medicine. Kids cannot be what they cannot see, as the platitude goes.

But the real impediment to getting more black doctors probably lies in greater systemic reform of the type that is being aggressively advocated for nationwide. We need to see this as a failure of the system, not a failure of individual people. As you watch protests unfold nationally and locally, I hope your view of them changes when you see them through this lens.

Your Doctor Is Your Real Financial Planner

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

The last time you spoke to your financial planner, I suspect the first question she asked you was some version of “Where would you like to be in ten years?” Or twenty, or thirty. Maybe you told her that you wanted to have your house paid off, or to be out of debt, or to be retired, or to have enough savings to send your kids to college.

The last time you went to the doctor, though, I’m willing to bet your conversation was more…retrospective. Medical students are taught to use open-ended questions to initiate a visit, so he probably asked something like “What brings you in today?” And if you’re like most people your answer wasn’t “I want to make sure I’m happier and healthier ten years from now than I am today.” Instead you probably led with whatever complaint was bothering you that day: a rash, a sore joint, shortness of breath. This doesn’t mean you were doing it wrong. Doctors exist to relieve suffering, after all. The Hippocratic Oath states in part that “I will apply, for the benefit of the sick, all measures which are required.”

``Where would you like to be in ten years?`` isn't just a question that should come from your financial planner. It should come from your doctor, too.

But if you’ll allow the slight stretching of a metaphor, what if your interactions with your health care professional sounded more like your conversations with your financial professional? Because the person that is most in charge of your financial future may not be your financial advisor. It’s more likely your doctor. Here are some hard truths at the intersection of medicine and finance:

• Illness and injury are the number one cause of bankruptcy in the United States, contributing to almost two-thirds of cases.

• The risk of illness goes up as income falls, and more than two-thirds of Americans with incomes below $40,000 say they could not scrape together $400 in an emergency.

• Medical debt is the number one reason to get a call from a collection agency, and a sixth of Americans have an unpaid medical bill on a credit card.

• One-third of cancer patients have to ask friends or family for money to finance their treatments.

• Health insurance does not necessarily protect against catastrophic loss of savings if you get sick: the ACA, for all its good, did little to reduce medical bankruptcies.

• And the expense of medical treatment may actually make outcomes worse. Filing for bankruptcy is associated with a 79% increase in the risk of death in patients with cancer.

So “Where would you like to be in ten years?” isn’t just a question that should come from your financial planner. It should come from your doctor, too.

What if we applied a financial planning rubric to health and wellness? Once the shock wore off from your doctor asking you where you wanted to be in ten years, what would you say? If you were diabetic, you might first answer that you wanted to avoid the complications of diabetes: you wanted to keep your vision, you wanted to keep all your toes, and you wanted to avoid having to go on dialysis for kidney failure. These are all perfectly good answers, but they suffer from low expectations. They’re a little like telling your financial advisor that you want to avoid bankruptcy and avoid having the bank repossess your house.

What if you were more ambitious? What if you said that, in addition to all those, you wanted to run a 5k with your granddaughter, or dance at your son’s wedding without being out of breath? What if you said you wanted to be able to carry your infant grandson up and down stairs without fearing a fall? Fortunately, just as the best financial strategies tend to be simple, the best health strategies are simple, too. Just as the financial advisor would hopefully come up with a plan to start putting money away, your doctor would work with you to make a shared decision on how to get to the last dance at that wedding a few years from now. The financial advisor might tell you to maximize deposits into tax-deferred annuities, while the doc might work with you to start scheduling “deposits” of physical activity. Just as your financial advisor might tell you to knock off the daily trips to Starbucks, your doc might tell you to knock off the bright screens in your eyes for an hour or two before bed (and, hopefully, would tell you to take it easy on the #PSL).

The next time you have a meeting with employees about their health benefits, ask them what they think of this philosophy. After all, the Hippocratic Oath also says, “I will prevent disease whenever I can, for prevention is preferable to cure.” And more powerfully, “I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability.”  Also remember that as an employer, you have the opportunity to help your employees stay healthy by offering real food at work instead of processed foods, providing a wellness program in a box, or by helping to shape the environment in which your employees live.

How to get invited to speak at your old high school

Last night I was asked to give an address at the National Honor Society of from my old high school. These are my comments.

There’s a saying in medicine: “Every system is perfectly designed to achieve the results it achieves.” For example, if half the patients admitted to a certain hospital die, it’s because that hospital is set up perfectly to have a fifty percent mortality rate in the patient population it serves. Or there’s a murderer on the loose, if it’s an episode of Grey’s Anatomy. One of those. But where I’m going with this—the system stuff, not the serial killer side-track—is that what you’re about to hear applies to my history and mine alone. My interaction with the world so far has been perfectly designed to get me to this point. Your results may vary.

Step one: Live. I know that some of you are certain that your life will really start in May, after you graduate from Skyline. I know some student in college right now thinks her life will start as soon as she graduates from college. I know medical students who are positive that once they begin their orthopedic residencies, their lives will officially be underway. I know that somewhere there is an endocrinology fellow that thinks his life really starts when he opens his practice this coming July. And I definitely know people my age who are counting the days til their kids are off to college, planning on turning their oldest kid’s room into a gym or a movie theater. All of them are wrong.

You heard in my intro that I went to school for a very, very long time. Let me put it in perspective. When I graduated from Skyline after thirteen years in this building, I wasn’t quite halfway done with my education. I was eighteen when I got my diploma in May of 1994. When I walked out of the University of North Carolina for the last time in June of 2008 I was almost 33. I had never made more than minimum wage. But here’s the thing: I would have turned 33 whether I’d gone to medical school or not. Someday you will turn 40, if you’re lucky. You can spend the time between now and then talking about how great your life is going to be once it starts, or you can accept that you are living your life right now.

Out of my med school class of ~175 people, I know of two who died after completing their training: Shelley was an oncologist who died in 2015 at age 40 from a rare cancer. She was kind and patient. Weesam was my classmate at K-State and at KU Med. He was also the most encyclopedic source of knowledge about K-State football I’ve ever met. He was a vascular surgeon at Stanford when he died of leukemia at age 34, only a year after completing his training. Shelley and Weesam lived noble, meaningful lives that so happened to have been mostly taken up by their training. There is nothing wrong with that. They both lived. They didn’t wait to get a diploma or to walk across a stage or for the passing of some arbitrary date to declare their lives started. School, if that’s the direction you decide to continue, is life. An entry-level job is living. Some of my fondest memories--and it goes without saying, some of my saddest--are from high school, college, medical school, residency, and fellowship. The years since then are the whipped cream on top.

Step two: When someone offers to help you, accept. As a student at Skyline I was surrounded by people who showered me with kindness and expected nothing in return. I turned down so many offers from people who wanted to help me. I had no interest in Scholars Bowl. I turned my nose up at help with test prep. I thought I was the smartest person in the room most of the time, in spite of overwhelming evidence to the contrary. I wasn’t in National Honor Society because my grades weren’t good enough. I wasn’t much better in college. I don’t think many doctors advertise the fact, but many of us have to apply to medical school more than once to get in. I was one of those people. When I was a junior at K-State, I applied to a new program at KU called “Scholars in Primary Care.” It was an early-acceptance program for a limited number of students who agreed to practice primary care (think Family Medicine, Pediatrics, and whatnot) in an underserved area, like a small town or the inner city. My interview was in Garden City, and to say it was a disaster would be an understatement. I sat at the end of a long conference table with six or eight people seated around me. They peppered me with questions. They were local family docs, a professor from the junior college, an assistant dean of the medical school, and some others. I think one of them may have been a preacher. I’m not sure. At one point, they asked me about my future legacy, and I told a rambling story that not only missed the point of the question, but managed to make fun of golfers. To a room full of doctors! I did not get accepted to medical school that day. It could’ve been the unabomber haircut. I don’t know. The bowl cut in my senior picture out front was not the low point of my hairstyle story. At least I never had my brother’s perm. But I digress. It was not my proudest moment. I was not the smartest person in that room. But because this was an early-acceptance program I got a second shot later in the year. I was offered interview preparation help by the pre-med program at K-State, and I took it. In the fall I got another interview in Kansas City, and I managed, I think, not to offend any of my interviewers. One of them asked me what I would think if a student with grades and scores worse than mine, but who had a certain background that the school was looking for, got in ahead of me. This was a way harder question than anything about legacy or golf. I answered that if the school was looking for people to work in certain communities or do certain jobs, I knew that I wasn’t a good fit for all of them.

A couple weeks later I got a letter of acceptance. I was proud. My mom and dad were proud. Here’s what I didn’t know at the time: I was very likely the beneficiary of a kind of affirmative action for farm kids. My application was fine. I had a decent GPA, and I was on my way to graduating with honors, and I got a decent score on the MCAT, the medical school entrance exam. But now, after having served several years on the Admissions committee at KU and interviewing maybe a hundred applicants, I know that dozens of students with identical resumes and scores as mine get turned down every year. I sincerely believe that the reason I was admitted over kids like them was that I had an interesting background that was under-represented in the medical school. When I was in college in Manhattan, there were farm kids everywhere. Everywhere. Aggieville. “Ag.” You know what I’m saying? When I was at KU, there were maybe ten of us, including my wife and I. Does that matter? It depends on what perspective you take. If I look at the problem from the point of view of a wealthy doctor’s kid from Sedgwick or Johnson county who missed out on med school in spite of pretty good scores, it looks like a miscarriage of justice. My own kids are the wealthy children of doctors in Sedgwick county, and if they’re in that situation in the future, I suspect I’ll be annoyed. But from my point of view, I accepted the help I was given, and I’ve gone on to be a fairly competent physician who pays taxes and stays out of trouble. No tragedy was suffered by anyone. Side note: I still hate golf.

Step three: Know when you’re into something that doesn’t fit you before you get stuck. When I was a Senior at Skyline, once I knew where I’d be going to college, my dad asked me if I wanted to rush his old fraternity. I knew nothing about fraternities, but I was game. I went to Manhattan a couple times, and to Wichita once to a greyhound race, and it was okay. It felt weird, like I was trying to be somebody I wasn’t, but I met a couple nice guys. I figured that since I was a “legacy”--that’s what they call the descendants of fraternity or sorority members--I would get in and make friends, and my dad and I would have something to talk about. What I hadn’t counted on was this: They. Hated. Me. Well, “hate” is maybe too strong a word. I don’t think any of them wanted bad things to happen to me. They just didn’t want me in their fraternity house. They wanted to paddle someone else. So I had to make an embarrassing, last-ditch, emergency effort to move into the dorm. I was placed on an “Ag” floor (this was K-State, after all). I was a little bit bitter about that part; remember how I was the smartest guy in the room? I wanted nothing to do with farming, and I thought my experience might be narrower somehow that way. But I made friends on that ag floor that I keep today. One of them lives next door to me, on purpose.

When I went to college I was a journalism major. I liked writing, I love the sound of my own voice, as you’ve probably figured out, and I still consider journalism a very important pursuit, even if it is kind of a hard way to make a living. But toward the end of my freshman year, I was in a class where the professor was teaching techniques about sourcing and finding stories. He kept saying, over and over, how aggressive good journalists need to be. I couldn’t imagine myself being that person. I’ve been on the business end of a couple journalists in my career, and I wouldn’t switch places with them. I don’t like confrontation. I sweat when I’m nervous. I’m sweating right now. One day after that class I was walking through a random building looking at posters (we didn’t have smartphones then), and I saw an advertisement for the school of Human Nutrition. I knocked on the door of the department chair (like a good little aggressive journalist) and asked her about the degree options. That same day I went to the registrar’s office and changed my major. And that fraternity? My sophomore year my dorm hall put together a basketball team. Our starting five included a starting K-State running back at guard and a future second-round NFL draft pick at defensive end playing forward. We played that fraternity in the all-university playoffs and crushed them.

Step four: Try to take a generous interpretation of people. When I was an intern in Spokane, Washington I admitted a twenty-something guy to the hospital with a gruesome arm injury and a gunshot wound to the calf. He’d been running from the police. First they tased him. Then they shot him in the leg. When those things had failed to slow him down (meth is a very interesting drug), they sicced a dog on him that tore the skin from his upper arm.

That night, as I was busy with a thousand other things, as medical interns tend to be, I kept getting paged with requests for pain medication. This is a tough situation. The guy had plenty of reasons to be in pain, and I wanted to treat his pain, but he was also a methamphetamine addict in the midst of withdrawal, and I didn’t want to give him so much medication that he might be in danger. Or more importantly for my ego, I didn’t want to be his one-stop shop for narcotics in the hospital. So after the fourth or fifth call I went to see him.

Understand that sleep deprivation is a little like having kids. You might say you want five kids. But you don’t even have one yet. So don’t tell me you want five until you have four. And you might tell me you operate just fine on a couple hours of sleep a night (free medical advice: you don’t), but until you’ve experienced 36 hours in-house call, don’t pretend to know what kind of decision making you’ll be prepared to do once that happens. Anyway: I went to his room and asked what else I could do for him. I did not ask nicely. He proceeded to tell me what a substandard doctor I was, and how maybe I should have chosen a different career. What happened next is a little fuzzy, with the rage and the sleep deprivation and whatnot, but he and I ended up kind of wrestling around the room. Me in green scrubs, grappling with a recently tased patient with an open arm wound and a fresh gunshot wound who also happened to be in methamphetamine withdrawal and likely intoxicated on narcotics. You’ve never seen that on Gray’s Anatomy. Or maybe you have. Either way it was ridiculous. I knew it was ridiculous as it was happening, but I was reminded of that fact the next day in a tense meeting with the hospital administrator. Lesson learned. What should I have done differently? I should have taken a more generous interpretation of his actions. I should have recognized that however bad my night had been, his had been way, way worse.

Step five: say yes to things. Real, physical things. You’re going to hear a lot of people in the next few years tell you how important it is to “network.” As if you can go to a cocktail party and make magical connections with people that get you admitted to law school or employed somewhere. Well, maybe you can, but I’m the guy who couldn’t even get into his dad’s fraternity. So you can imagine how well I handle “networking” with a bunch of strangers. But when I was a freshman on the ag dorm floor in college, a guy I didn’t know that well asked me if I wanted to help decorate a homecoming float. Decorating a homecoming float was maybe in my bottom ten things I wanted to do that day, somewhere between becoming a Celine Dion completist and having a boil lanced. But I did it. And it was only a couple hours of work for a couple of days. Eventually I was a groomsman in that guy’s wedding, and now he owns a company with over two hundred employees.

Later in college, because I’d changed my major from journalism to Human Nutrition, I met a girl. She asked me if I wanted to join a band of students that went around teaching groups like fraternities and sororities how to keep from getting sexually transmitted diseases. Again: not the way I had envisioned spending most nights in college. But I did it. And you know what? Teaching a bunch of sorority girls how not to get an STD was about the most fun I’ve ever had. Then the girl told me she was going to med school. And because I’d changed my major to Human Nutrition (and thus met the girl) I’d already taken all the prerequisites for medical school. My point here is that if you do things with people you may make a friend. Or better, you may eventually meet a group of people trying to make the world better, who speak a common language, who have a set of shared rituals, and whose cause you want to join. Like I said, I took the MCAT and I eventually got in to med school. Then I married the girl. So maybe I’m giving you a best-case scenario. But the rule applies even to my current life. A few weeks ago, Melissa Jacobs asked me to come speak to Skyline’s National Honor Society. And here’s what I got out of it: instead of a night at home watching Office reruns, I got to spend the night with a group of really interesting people who share a love of baby blue, who have a set of shared rituals, and who want to make the world a better place. All because I said yes.

Links for Tuesday, October 9, 2018: Overtreatment of subclinical hypothyroidism, altruism and specialty choice, and Roman wiping technology

Treating your TSH level of 10 mIU/L with thyroid hormone probably won’t make you feel better

But your doctor will probably try to talk you into it, anyway (paywall):

“Although current guidelines are at first sight cautious with treatment recommendations, more than 90% of persons with subclinical hypothyroidism and a thyrotropin level of less than 10 mIU/L would actually qualify for treatment. However, results of this meta-analysis are not consistent with these guideline recommendations.”

Are altruistic students more likely to choose lower-paying specialties in medicine?

This paper is complex and paywalled, and I won’t pretend to understand it. But yes, it does seem that altruism is related to choosing lower-paying specialties and more underserved areas:

<$300,000 per year is defined as a lower-paying specialty, which calls my career choices into doubt.

How did ancient Romans wipe without toilet paper?

Let’s all share a collective shiver at the thought of a communal, stall-less bathroom with sponges on sticks, shall we?

Links are back! (for now, at least): Tuesday, August 15, 2018

The Gravel Boom Could Save Road Biking's Soul

This is true, and mostly for the reasons Aaron Gulley lays out: fewer cars and an attitude of adventure rather than competition. None of the assholery that turns up at road races is present at the majority of gravel races, unless you count a few people trying to change it for the worse.

Gravel Rides Are Saving Small-Town America

I guess gravel riding is "saving" a lot of things today. "Saving" is too strong a word for the effect of gravel races on small towns; a couple hundred riders one or two days a year is nice, but I doubt if it pays for that new school library. But no doubt I have traveled to and spent money in a dozen towns over the last few years I would have completely bypassed if not for gravel racing.

Med students don't go to class. This is not a new phenomenon

I don't mean to pull any kind of hard work card, because people work hard in every imaginable job. But it's hard to overstate how precious your time is in med school. The volume of information is overwhelming, and even a good lecturer can't typically deliver the material in a time-efficient way. It's much easier just to look at other people's notes (as in note service in my day) or to watch the lecture via podcast or webcast at double speed later. And most professors just aren't good lecturers. Not even Nobel laureates. Maybe particularly not Nobel laureates; the skill set that makes a good investigator is far removed from the skill set of a good teacher.

What's interesting here is that the move to pass-fail grading systems--which I completely agree with--has made performance on the national "step" exams that much more important. This, according to Orly Nadell Farber, is what is driving the further diminution of attendance at lectures. My response to this is for NBME to stop giving step scores to residency program directors.

Doctors are pulling their hair out trying to get parents to limit screentime

U.S. kids get an average of over 7 hours daily in front of screens, almost all of it because increased use of smartphones, tablets, and other devices. Not that anyone who has seen a kid in a grocery cart at the store lately needs to be told that. Why is this important? Because the more time you spend zonked out in front of a television, the more fat you tend to have (what we five-dollar-word types call "adiposity”). And adiposity means bad things later on, like heart disease and diabetes.

So the American Heart Association is recommending--again--that children and teens to get no more than 1–2 hours of recreational screen time a day. They also warmed my heart by continuing to recommend against having screens, including phones, in bedrooms and while eating.

Links for Sept 5, 2017: books by the foot, Chilis, McDonalds as community center, and radiology job security

Where do decorative books in restaurants and bars come from?

Answer: Books by the Foot, mostly.

Inside the Church of Chilis

I grew up about twenty miles outside of a small town. So small that the addition of something like a Chili's would really set the place on fire. I still remember when we got a Wal-Mart and when we got a McDonald's. I can't say that either of those were great for the town on balance. I suppose they offered some low- to mid-range jobs, salary-wise. My mom had one of them at Wal-Mart for years. But no one that I know of ever felt the kind of devotion to either place that's described in the hard-core Chili's trainers in this article:

For the right kind of new person, though, Chili's is the righest kind of place. Her story echoes Sara's, which echoes everyone else's at their level: She was pursuing a different path (grad school for criminal justice), but kept being drawn back to Chili's, where she realized she was happiest. She was searching for something and found it there. For Nikki, now, it has grown into pure purpose. "I live and breathe for this company," she says. "This is totally what I was supposed to do. This is what makes me tick everyday. Everything I do is with Chili's. This is not a job for me—this is my life."

McDonald's is a surprisingly important meeting place

Speaking of McDonalds, the burger place occupies a special place in the communities in which it's found (I'd say serves, but I'm not there yet): 

In Sulfur Springs, Texas, in the late morning, Lew Mannon, 76, and Gerald Pinkham, 78, were sitting alone at a table, the last of the morning regulars to leave. She was needling him about politics. (“I like to tease the men who come, get them all riled up, tell them they just don’t want a female as president.”) Both are retired, Gerald from working for an airfreight company, and Lew after 28 years as a bank teller.

When I asked Lew about her life, she started to tear up, stopped for a second, and composed herself. “Life is hard. Very hard. Seven years ago I lost my husband to leukemia. Then three years ago I lost one of my sons. Health complications from diabetes. When my son died, I had nobody to help me, emotionally, except this community here. Gerald lost his wife three years ago, and we have helped support each other through that.”

She stopped again, unable to speak from tears. After a moment of silence: “I look composed on the outside. Many of us do. But I struggle a lot on the inside. This community here gives me the support to get by.”

When I was in second grade, I got to have my birthday in McDonald's. It was noteworthy for a couple reasons: first, birthday parties were always a little touch-and-go with me, since my birthday so often fell dead-center in corn harvest; and second, because I was the first person in my class to have his party at the new McDonald's in town. I remember it all: the faux-wood bent booths, the paper hats, the Happy Meal toys.

None of these kids are me, but they might as well be. (http://bit.ly/2x7DyOo)

I was so excited to leave school to take my friends there that my mom tried to slow my down and I fell on the cement and tore my jeans. I didn't even care.

Radiologists are (rightly) concerned about how artificial intelligence may affect their careers

"Radiology has become commoditized over the years," Kelley says. "People don't want interaction with a radiologist, they just want a piece of paper that says what the CT shows."

See also: Let's kill radiology and pathology and combine them into "Information Specialists." (paywall)

Should a pharmacist be a bigger part of your practice?

Conflict of interest disclosure here: I receive some grant funding indirectly that works to get pharmacists and docs into collaborative practice agreements (CPAs).

But if the video above makes you think your practice ought to be using more pharmacy brainpower, take a look at the video below on how to establish a CPA:

Links for Wednesday, August 23, 2017: metformin reframed as wonder drug, cane vs beet sugar, and medicine as an inefficient time suck

Does metformin "promise" to extend life?

It may promise a lot of things, but until I see RCT data, I'm not convinced that we should put an old anti-malarial drug in the water. Metformin, I mean. And that RCT would be the TAME Study. Observational studies of metformin and cancer have been promising, but...

In two controlled trials involving patients with advanced pancreatic cancer, a notoriously difficult cancer to treat, metformin failed to provide any benefit.

So I'll hold out ultimate judgement until after the TAME Study. But this smells a little like 20 years ago when pharma invented osteopenia to sell bisphosphonates, and then tried to encourage "prophylactic" treatment of even osteopenia. (metformin link via marginalrevolution.com)

Are our cooking efforts sabotaged by the substitution of beet sugar for cane sugar? 

Brown cane sugar -- a combination of sugar and molasses, both inherent in the sugarcane plant -- is produced naturally as part of the process of refining white cane sugar by the traditional method, crystallization.

Brown sugar from C & H Sugar Co. and other cane refiners uses the process, but beet sugar is different. It's made by refining the sugar all the way to the final white granular stage, stripping off all the molasses because beet molasses is unfit for human consumption (it's recycled as cattle feed). Then cane molasses is added back into the sugar through a process called "painting."

Painting coats the granules but does not necessarily penetrate them -- the molasses can sometimes be rubbed right off.

As with white sugar, these different types of sugars act differently in the kitchen.

The best medical analogy for this seems to be the auto-substitution of in-class medications by insurance formularies. Detemir substituted for glargine, for example. 

Is medicine a "low-impact" profession?

The folks at 80,000 hours think so, noting that the number of people whose lives will be extended by a single doctor is low, or "pretty modest," as they say:

This analysis confirms the contentions above: physician density is negatively correlated with burden of disease16; the social determinants of health explain more of the variance in health outcomes than physician density17; there are steeply diminishing returns between increases in physician density and decreases in burden of disease16. Further, the ‘bottom line’ figures (which are likely optimistic) suggest an additional doctor adds four health years for every year they work. This is a lot less than can be accomplished through even modest donations to effective charities, and so suggests the ‘direct impact’ of medicine is pretty modest.18

(link from slatestarcodex.com)

Follow-up on medical school rank and narcotic prescriptions

I've had several conversations with fellow docs about the NBER paper from last week showing a relationship between medical school rank and narcotic prescriptions. Naturally, the responses I got were pretty skeptical. A recurrent theme I ran across was that the authors didn't pay enough attention to practice setting. 

1. Higher-ranked medical schools tend to produce more students who eventually land in academia, often at higher-ranked medical schools or residency programs.

2. Because of the culture of those high-performing places, characterized by greater access to subspecialists, a slower pace of practice, the presence of trainees to keep you honest and whatnot, you practice more conservatively and without fear of patients firing you for not giving them narcotic prescriptions.

 3. Perhaps people graduating from lesser-ranked schools end up in private practice, where there is more pressure to write a narcotic prescription to all those patients with back pain, just to keep them from 1) firing you, and 2) telling all their friends and family what a crappy, uncaring doctor you are.

4. So the speculated end result is that people graduating from higher-ranked medical schools end up writing fewer narcotic prescriptions than their peers from lower-ranked schools.

I pointed out to several people that the study took into account specialty and location; the relationship held for people in the same specialty and same county. The investigators pontificated on practice setting (noting that DO graduates often take care of a more rural, white population, for instance). But they didn't control for it. So I held my hands up ¯\_(ツ)_/¯ and moved on with my life.

But then I listened to a segment about it on the Weeds podcast today (start at 1:01:25):

UPDATE: I'm having some trouble embedding the audio, so if you can't get it to play, go here: http://bit.ly/2uLk2lY

Sarah, Ezra, and Matthew made note that the relationship held within the same clinic, so I re-visited the paper. I found this: 

Check the footnote. *slaps forehead*

So the investigators did account for practice setting, but since it was hidden in a footnote, I missed it. 

The take-home from this paper is still kind of hard to identify. I'm not in favor of necessarily checking the LinkedIn page of every doctor you see to check what med school she went to, but there is clearly some kind of relationship between the culture of medical schools and the prescribing behavior of graduates.

The lower-ranked your doctor's medical school, the more likely he'll write you a narcotic prescription

You read that headline right: investigators in an NBER paper found that docs who went to a lower US News-ranked school are more likely to write narcotic prescriptions, and the ones who write narcotic prescriptions are likely to write for more drugs, depending on the ranking of their school. And lordy, those osteopathic schools:

US News publishes several rankings, in topics from research to primary care to women's health. For this paper, the investigators used the "research" ranking, which is difficult to translate into medical student bedside education. After all, some of my best teachers in med school hadn't published a paper in a decade.

Several other take-home points from this. First, at first glance general practitioners write a ton of narcotic prescriptions; their rate on the y-axis is roughly double the overall physician population's. But when you consider that primary care docs perform well over half of all the visits delivered, that number of narc prescriptions looks less impressive.

Second, the effect size, if you're willing to take a leap and go straight to the idea that the quality of research at your medical school somehow has a causative effect on how many hydrocodone prescriptions you write, is huge. Using Harvard as the index school, the schools in the eighties and nineties have graduating docs writing three times as many prescriptions.

My first thought when I read this was that docs who went to lower-ranked schools may end up on places where they're more compelled to write narcotic prescriptions: places with high poverty, or a large blue-collar workforce, for instance. But the investigators accounted for that, and found that the relationship persisted even within the same county:

I can't help but try to apply this research to myself, even though I'm an endocrinologist and therefore mostly shielded from the narcotic game, and even though I see relatively few patients nowadays. But here we go. I attended the University of Kansas, which is comfortably ensconced in a tie at number 65 on the research list:

Oof. Medical school got a lot more expensive in the last couple decades.

So where would I live in the narc prescribing graph?

Riiiiiiiiight about there. It's a wonder I'm not a bonafide narcotic prescribing machine. 

What's unsaid in this list is that KU has three campuses (two at the time of my training). And it further goes without saying that the training in Wichita, Salina, or Kansas City may have subtle differences that would lead to slightly different physician performance or behavior. Furthermore, it would be interesting to see the research repeated with residency or fellowship training as the independent variable, since those are the years when trainees really fall into a groove of prescribing habits. If I were held to the standard of my internship with a University of Washington program, I'd be compared to the folks at the skinny end of the graph:

Go dawgs.

But if my fellowship training at UNC-Chapel Hill were the standard, I'd be in a nice, comfortable happy medium between the narc-crazed sixties and the narc-stingy pre-teens:

The take-home from this isn't that we should all check our doctors' CVs before we go see them, in fear of them hooking us on oxycodone. It's just that schools who inhabit the lower tiers of medical research need to do a better job of teaching narcotic prescribing. 

And obviously, the take-home for patients is to be very, very careful about requesting narcotics for pain. They don't work as well as we think they do, and the potential for harm is huge. 

I found this link, fwiw, via marginalrevolution.com

Links for Thursday, August 3, 2017: Robot Soccer, Weight Watchers can't pivot its message, Overuse of back surgery in professional athletes, and non-lecture based medical school

First things first: for any of you subscribing to the RSS feed of this blog, I've reduced the frequency of emails. Look for them on Thursdays at 10 am now. Moving on...

Humanoid robots are hilariously terrible at soccer (for now)

Weight Watchers is having a hard time adjusting its message to a more wellness-oriented and less weight-oriented world

The fact that we talk more about "wellness" and less about weight now isn't completely by accident:

In late 2015, Women’s Health, a holdout, announced in its own pages that it was doing away with the cover phrases ‘‘drop two sizes’’ and ‘‘bikini body.’’ The word ‘‘wellness’’ came to prominence. People were now fasting and eating clean and cleansing and making lifestyle changes, which, by all available evidence, is exactly like dieting.

I was the Medical Director of a large weight-loss clinic for several years earlier in my career. The quotes from people at Obesity Week in this article are heartbreaking:

I am 41, I would say. I am 41 and accomplished and a beloved wife and a good mother and a hard worker and a contributor to society and I am learning how to eat a goddamned raisin. How did this all go so wrong for me?

I'd much rather talk to people about being "well" and "happy" and "strong." Any day.

Are professional athletes the canary in the coal mine of excessive back surgery?

Should the experience of Tiger Woods and Steve Kerr help others make decisions about surgery? We imagine that they both received care from the most highly esteemed professionals, that cost was not an obstacle, and that their care was attentive. Presumably, their results did not meet expectations discussed with their providers. Steve Kerr has sought to share his experience with others and advised during an April 23 press conference, “I can tell you if you’re listening out there, if you have a back problem, stay away from surgery. I can say that from the bottom of my heart. Rehab, rehab, rehab. Don’t let anybody get in there.” Recent media reports indicate that Tiger Woods not only continues to experience back pain that is impeding his play, but additional consequences include side effects associated with opiate pain relievers.

Medical schools are moving away from the "Sage on the Stage" method of teaching

My medical school experience was very analog. We “learned” almost everything we learned via notes on those lectures. Most of the lectures were bad. Think “Bueller?” but with thyroid tumors. So, like this article notes, a small minority of students actually attended them. Maybe forty people (out of 175 in the class) sat and took in all they could in an hour of truly uninspired public speaking. So most of us acted on the judgement that our time was simply better spent elsewhere studying. We hired one another via a "note service" to take notes at lectures and distribute them by hand. Piles of photocopied notes filled the atrium outside the lecture hall daily. It was depressing.

I'm still volunteer faculty at the University of Kansas School of Medicine-Wichita. I teach a "problem-based learning" session about every other week. KUSM-W is in the process of moving to a curriculum that is almost completely problem-based. I enjoy the sessions as an instructor, but I wonder if they would have caused me some anxiety as a student; they're much more free-flowing than a set of notes to plow through. But the literature seems to indicate that they increase retention and more importantly, increase the likelihood of team-based practice in the future.