Tuesday, March 31, 2015

Incidental Findings

Medicine is oftentimes filled with surprises. Consider the issue of incidental findings. Suppose a patient had has bad back pain. They had lifted something and as their physician you just want a simple plain X-ray to see if it is really L4-L5 as you suspect. You get a call from the Radiologist, not the usual response, in fact you hardly know them. But they tell you that there are multiple thoracic lesions, possibly a lymphoma. Now what?

That is an incidental finding. Yow were not looking for zebras but you found a herd.

Now consider dermatological mobile apps. I saw one today that may or may not apply, but it was a mobile dermatological app. Looking at acne, a common ailment especially with younger people.

The article notes:

Users who want to consult with a dermatologist can select a condition they want to get treated for in the app, which is currently only available for the iPhone. After they choose their condition, the app will provide users with an explanation of what to expect from the service. From there, they can choose a doctor. If users want to get the opinion of the first available doctor, they are guaranteed a 24 hour response, but they also have the option to choose a specific doctor. All doctors have a full profile that shows users where the doctor practices medicine, where they went to school...Then, they can upload pictures of their condition and after 24 hours, they will receive a response from the doctor with a treatment plan and a prescription, if needed.

Now assume a patient uploads a picture of their acne. Next to an acne lesion is a suspicious pigmented lesion. The patient did not ask about it, this after all is an iPhone picture, but you are concerned. The patient may have a melanoma. Incidental finding, lots of zebras.

Now what do you do? Contact the patient immediately? Who does the biopsy, where, how fast? You are now faced with a plethora of issues and possibly legal issues as well. What is your responsibility?

The problems may be significant. The problem with many mobile apps is that there may always be incidental findings. If one were in a physicians office perhaps a dermoscope would be available, a biopsy made, a record of the visit detailed, a discussion had. But arms length apps may present significant problems and massive legal issues.

New Dimensions in Peer Review

I noticed that Peer Review is now a paid process if you want it expedited. The Scientist reports:

Private peer review is now a multimillion dollar industry, with many journals now offering a service through which authors can fast-track their manuscripts through the process—for a price. Last week (March 24), Scientific Reports announced that, for a cost of $750, it had begun offering such expedited service, through the peer-review service Rubriq, which pays its editors $100 each per review. (Rubriq also offers pre-review services for researchers looking for feedback before submitting to a journal.)

It is not clear that such a process is good or bad. The purpose of Peer Review was to filter out bad papers, bad because they may have been incorrect, duplicated, unreadable, or just outright wrong. However as one having done it for years, Peer Review was a process of sending out proposed publications to individuals who would without prejudice examine and critique a work so that it became better if published.

Over the years the Editorship became more club like and if the right senior author appeared on a paper then it was published. This often led to publications not properly reviewed by the senior author and then retractions having been made. Internal reviews were often left to the external reviewer and then external reviewer assumed the internal reviewer did the work. The result is an explosion of retractions.

How will paying someone help. Not at all clear. It appears that the readers have become the reviewers, namely the marketplace.

Monday, March 30, 2015

Quality and Value

Words sometimes mean something. But at other times the mean a lot of different things and oftentimes they mean nothing at all. Take Quality and Value. I am always drawn back to the Quality idea that drove the prime character in Zen and the Art of Motorcycle Maintenance to insanity. He spent a lifetime trying to define it. Perhaps like pornography it is in the eyes of the beholder. But what is quality to me may not be quality to you.

The value in Health Care is all too often measured in QALYs, the subjective measure of the use of some treatment or lack thereof. In fact the ACA was written to prohibit its use. Alas, with the current administration even their own laws don't count!

Now in Healio we have an interesting piece worth tracking. They state:

In esponse to concerns over Medicare’s current fee-for-service payment system, the Obama administration announced in January that by 2018 Medicare instead will aim to associate half of all payments to the quality and value of health care provided...Some of the changes that private insurers and the government are hoping to advance are the use of bundle payments, population-based payments and Accountable Care Organizations....under the Affordable Care Act, Medicare will be cut significantly....“Relative to the rates that private insurers pay, the rates for Medicare and Medicaid are going to trend down over time. In fact, by the middle of the century, they are going to be about half of what private insurance pays hospitals,” he said. “We should be concerned that quality may suffer unless we do something about this.”...Research has shown that when Medicare payments to hospitals are cut, it leads to higher patient mortality and other negative outcomes,...

Yes, cut Medicare and people die. But ironically the Democrats blame the Republicans for that yet it is the ACA which mandates it.

Friday, March 27, 2015

Numbers Do Not Add Up

Sometimes people should read what they write. I do, at times, and that is why I am wont to change what I said...it may not add up. But if you are in the NY Times it seems to me that you get away with almost anything. Just look at the number of corrections to the on line stories.

Today in the Times I read a piece which I think spoke of scientists, and most likely engineers too, as well as physicians and surgeons, can get insight by looking at something differently. Wow, that is big news! As if what we have been done for two and a half millennium has been something different. But this statement really rang a bell:


In a recent experiment at the University of Virginia, researchers used a perceptual-learning module to train medical students about gallbladder removal. In the past, doctors removed gallbladders by making a long cut in the abdomen and performing open surgery. But since the 1980s many doctors have been doing the surgery by making tiny incisions and threading a slender tube called a laparoscope into the abdominal cavity. The scope is equipped with a tiny camera, and the surgeon must navigate through the cavity based on the images the scope transmits. All sorts of injuries can occur if the doctor misreads those images, and it usually takes hundreds of observed surgeries to master the skill. Half the students practiced on a computer module that showed short videos from real surgeries and had to decide quickly which stage of the surgery was pictured. The other half — the control group — studied the same videos as they pleased, rewinding if they wanted. The practice session lasted about 30 minutes. On a final exam testing their knowledge of the procedure, the perceptual-learning group trounced their equally experienced peers, scoring four times higher. Their instincts were much sharper.

Now slowly reread the last sentence. These are erstwhile surgeons removing a simple gallbladder via a scope procedure. Those that had this so-called perceptual technique score 4 time higher than the others. Now assume they all scored 100%. That means the regular docs got 25%! You want a surgeon who scored 25%, are you kidding me. Worse, there is zero chance the top group got all 100% most likely 80% average. That means the characters in the regular learning mode got 20%. But wait! We have no idea how badly the top group did, only that the others got only 25% of what they got!

Can we really believe this, does it make logical sense, does the "pattern" make sense? Not really. Perhaps they should go back and check the numbers, or make certain than none of them ever practice surgery...at least on my gallbladder!

Fiber Telecommunications and The Mid East

Telegeography has an interesting map on the many fibers going down the Red Sea through the Gulf of Aden and then to Asia. We all too often fail to recognize that this now Hot Spot is also a key strategic point for global telecommunications. A couple of years ago I was working on a proposed fiber across the Arctic above Russia and had indicated to various US Government types its strategic importance, the Russians not withstanding. The current situation in the Gulf region further intensifies this issue. In a brief moment these lines could be severed and global finance and commerce could suffer. It will be interesting to watch this effort. The irony is that Russia could have established itself as a Global conduit for such efforts but alas it has soured the well over the last year.

Thursday, March 26, 2015

Climate Change and the Academy

There are small groups forming on many campus locations whose goal is to eliminate any investments in what they see as "dirty energy" companies, and to support a program of "sustainability". At one extreme it is the banning of bottled water, never really drink the stuff, to reverting to a zero carbon footprint existence. Now I can appreciate that as I sit amongst my 4,000+ seedlings sprouting up around my office ready for their outside potting once the winter ends, it is the longest in 30 years here in New Jersey.

Now Harvard has had a bit of a time on this issue and their President has decided to answer the call to have a Campus wide discussion. As the Crimson announces:

University President Drew G. Faust will convene a panel about climate change on April 13, following several requests on behalf of a faculty group calling for an open forum about Harvard’s investment in fossil fuel companies.The panel will be moderated by talk show host and journalist Charlie Rose, who has interviewed Faust on television in the past. The roster of panelists is scheduled to include Harvard science and public policy professors as well as experts from outside the University.

The Harvard President has done a superb job on all she has handled and this is one way to address the campus debate. On additional consideration the choice of Rose is frankly quite wise. He has an amazing manner to evoke what a guest, presenter, position taker, really has to say, more so than any others in today's market. Unlike many other PBS types who spend time telling listeners what they think, Rose get to people and get them to tell what they think, which is useful.

This is an interesting approach and worth following.

In contrast MIT has a Sustainability Program. It allegedly purports to:

The Sustainability Initiative at MIT Sloan is built on the promise of a new future. We believe that environmental, societal, economic, business, and personal wellbeing are parts of an interconnected whole. The strains we face in each of these domains demand that we think differently and invent new ways of living and working. We are committed to creating a new vision for progress and prosperity and a world that will flourish and thrive for generations.  We empower students, faculty, researchers, and business leaders to join together in this endeavor.

 Somehow the above is reminiscent of my old days at MIT in the 60s with one small protest group after another. Now however they seem to set up Centers, appoint faculty, provide space and resources and put it on the students tab. Again, we see an ever growing cost of getting an education.