Blood, Simpler | The New Yorker

Theranos and Elizabeth Holmes are utterly fascinating. To develop a diagnostic testing company in complete secrecy over 10 years that is now valued at $9 billion is unreal.

Speaking of Theranos’ valuation:

Investors have valued the company at more than nine billion dollars, comparable to the two major diagnostic labs.

Comparable valuations, but not comparable scale of business:

Quest runs about thirty full-service laboratories around the country; it performs six hundred million tests of all kinds annually—Theranos’s aim is to hit one million blood tests in 2015—and owns four thousand vehicles for picking up samples.

Valuations never make sense to me.

When I first read about Theranos earlier this year, the proposition—hundreds of laboratory tests from a few drops of blood obtained by finger-stick—seemed too good to be true. Conversely, why not? Why do we have to draw so much blood?

I am not a pathologist and definitely not qualified in any way to answer that question. I think the juxtaposition between Theranos’ promise and the eventual reality is what makes it such a fascinating company. As mentioned several times in the article, transparent peer review needs to be conducted before we can fully buy into Theranos’ promise. Comparison to 23 and Me is quite apt; Theranos will undoubtedly go through growing pains which will include government oversight.

I can’t wait to see what happens. I would prefer, both for my patients and myself, easier diagnostic testing, but it has to live up to current standards for accuracy.


Surgeons and GPs more likely to cause car accidents than other workers | The Guardian

Difficult to judge the validity of this study, but the results are chilling nonetheless:

For every 1,000 surgeons who drive a car, 361 made an at-fault claim in the past five years, compared with just 3.5 building society clerks, the research found.

I think about this whenever I drive home from the hospital late at night after a long day. Be safe on the road.


E is for...Enterovirus 68 | HAI Controversies

Eli Perencevich:

Never a dull moment. Just as facilities have begun wrapping up their Ebola preparation plans, there’s gathering evidence that several US states may be facing large clusters of acute respiratory illness associated with human enterovirus 68 (EV68).

Great post on the recent enterovirus outbreak (including a discussion of a Morbidity and Mortality Weekly Report from 2011 discussing an outbreak of EV68).

I have been working in the ED during this period and we have certainly been very busy.

What bothers me is the lack of information about the extent of this outbreak. Our current understanding is limited to what individual hospitals and health departments are investigating on their own. We have invested billions of dollars in health information infrastructure, yet there is no easy way for an entity like the CDC to quickly pull microbiology data from hospitals [1]. At a bare minimum, all decent sized academic medical centers run their own micro labs and organize patient data in databases—if not full EMRs—and we should be able to link those together and query them.

Unfortunately, we probably won’t know the full extent for quite some time as we use proven, but antiquated epidemiological tools.

Enterovirus–68-like Respiratory Virus Sickening Children Across the US | NEJM Journal Watch

  1. At least not that I’m aware of and nothing has been reported from such a system.  ↩


Doctors Raise Concerns Over Apple HealthKit | Forbes

An interesting and nuanced analysis of the possible impact of HealthKit for doctors.

I will propose a more mundane and broad analysis: HealthKit won’t matter.

Doctors won’t trust the data and won’t know what to do with most of it. Additionally, the data will remain siloed within patient’s phones despite high-profile partnerships with EMR companies because most physicians don’t use those EMRs and even those that do often run outdated versions.

The current pursuit is novel ways to collect data. Apple has taken the next step and is trying to collate and organize it. However, the crucial step—one that will require research [1]—is making sense of the data and providing actual guidance. So far, nobody seems to be taking this step (at least not at scale).

  1. Yes, research (!), that long and nasty process of trying to understand something.  ↩


Should Twitter be Regulated at Medical Meetings? | 33 charts

Bryan Vartabedian MD:

We don’t need our meeting dialog subjected to legislation.

Using terms like “regulation” and “legislation” creates a straw man. Of course we don’t want meeting organizers to formally control the use of social media at meetings. However, we should be careful in our use of social media at meetings.

The biggest danger I see is the public broadcasting of non-peer reviewed research that may be deeply flawed.

Scientific meetings are the beginning of the vetting process for research findings. Meeting organizers do a cursory review of research prior to accepting it for presentation at a conference. This review is based on submitted abstracts and mostly involves ensuring the research is relevant to the conference; it does not involve scientific review. Thus, when a researcher stands at the podium promulgating their conclusions, few people have had a chance to critically review their methods and findings.

In contrast, research published in scientific journals has been through a formal peer review process and found fit for public distribution.

We are also in danger of over-simplifying complex research findings in our dash to encapsulate a speaker’s words in pithy 140-character snipits. We tend to broadcast select conclusions that reflect our own biases and may misrepresent the researcher’s own thoughts. 140 characters does not allow for qualification or explanation of a result.

While I agree with Doctor V that “regulation” or “legislation” are wholly unnecessary, I would implore conference attendees to think twice about what they tweet at meetings.


Virtual surgery gets real | Rémi Rousseau

Researchers in Paris used two synchronized GoPro cameras to capture a total hip replacement from the surgeon’s perspective and then played it back in 3D on an Oculus Rift as a training tool.

When you’re a surgeon in training, you always have a task to do during the surgery; it becomes difficult to see what the main surgeon is doing. Being able to live a surgery in the surgeon’s shoes thanks to the Rift is very useful to replay the surgery in detail, pause, fast forward or backwards. It can also be an inspiring way to share and learn new techniques among surgeons.

Maybe a bit of an overstatement, but viewing complex surgeries from the lead surgeon’s point-of-view has undoubted value for both surgical residents and experienced surgeons learning new techniques.


✚ A tale of two nights—the problem with resident work hours

A few weeks ago, I worked Friday/Saturday overnight shifts on the general inpatient pediatrics team. The two nights were complete opposites.

On Friday night, when I arrived at the hospital my team was just finishing up 3 admissions. I immediately went to work helping out with those admissions. We admitted 4 more patients overnight. We were steadily busy throughout the night without much of a break.

On Saturday night, we had zero admissions [1]. I received a couple of pages regarding minor issues. I relaxed most of the night and got several hours of good sleep.

Due to the resident work hour restrictions, I had to be out of the hospital by noon following each of those nights, regardless of how hard I worked or how much sleep I got.

We restrict resident work hours because work hours are easy to count [2]. They are not indicative of what we are really trying to avoid—fatigue. Unfortunately, fatigue is very difficult to measure and even more difficult to predict. Until we make progress in this area, we will continue to see minimal impact of work hour restrictions on patient safety.

  1. According to the senior residents, busy Friday nights followed by slow Saturday nights are quite common. Their speculation—people take their children to the doctor’s office on Friday before the weekend, the doctor doesn’t feel comfortable with the patient and can’t see them in follow-up the next day, so they send them for admission. On Saturdays, parents tend to try to wait it out until Monday to see their regular doctor. I have no empiric or even much anecdotal evidence to support this theory.  ↩

  2. While easy to count, work hours are by no means an accurate measure. All residency programs I am aware of rely on self-report of work hours.  ↩


Progress notes are a poor tool for doctor-patient collaboration | KevinMD

Steven Reidbord MD:

[Physicians’ progress notes] assist in performing and archiving medical work, much as a scientist’s laboratory notebook records the design, data, and results of experiments. Progress notes were not designed to be a legal defense against malpractice suits, justification for third-party payment, quality-assurance tools for health institutions, or educational handouts for patients. Yet these notes now serve many masters…

But even in the best-case scenario, progress notes are a poor tool for doctor-patient collaboration. By nature they are shorthand, telegraphing complex medical reasoning in a few words…Written material designed specifically for patients is better suited for reminders about what was discussed and how to take medications as prescribed.

We need to fundamentally re-think clinical documentation.

The current structure serves no one well. Physicians don’t like their EMR generated progress notes because they are junked up with extras for billing purposes and become click-laden nightmares to create. Insurance companies don’t like them because of the amount of unstructured data. Patients don’t like them because they are polluted with medical jargon and difficult to navigate.

In the transition from paper to electronic records, nobody stopped to fundamentally examine the role of doctor’s notes and the myriad of purposes they now serve in modern medicine. EMR designers simply took the SOAP note format and made it electronic instead of trying to re-think how an electronic format could facilitate a new approach to documentation.

All parties are seeking more from our documentation. Without a re-design, all parties will continue to be frustrated.


How to tell someone that she is dying | The New Yorker

Peter Ubel writing about how doctors trained to treat disease can clash with patients who have different perspectives:

By the end of this particular appointment, the oncologist had done what modern physicians are supposed to do—he informed his patient of her treatment alternatives and he left the final choice up to her. But, in the process, he left the patient little choice but to accept one of these alternatives rather than to leave her cancer untreated.

During my oral exam for my surgery rotation in medical school, I was asked how I would describe the treatment options for breast cancer to a newly diagnosed patient. I started off by saying that the first option would be to do nothing. I was laughed at by the surgical oncologist administering the test.


✚ The First Week

I completed my first week of residency yesterday. 76 hours total.

Like much of my medical training thus far, there were some very tough low moments and some great high moments. I had some tough patients throughout the week and was beginning to become very frustrated. But, then I performed a lumbar puncture on an infant that came back with zero red blood cells [1] which instantly brought me back to center. I can do this.

Compared to such experiences in med school, they are similar but on steroids. I have gone home each day mentally exhausted.

Strangely, the medicine is one of the easiest parts [2]. You learn most of the medicine you need in the third year of med school and refine that in the fourth. What you don’t learn—and what residency is for—is how to be someone’s doctor.

It’s hard to walk into a patient’s room and say, “Good morning. I’m your doctor and I’m going to take care of you today.”

Luckily, I have had a great team to work with and great support from my residency program and hospital. I truly believe I am at one of the best programs in the country for training clinical pediatricians. It’s going to be a tough road but I am incredibly excited for the journey.

  1. Lumbar punctures (or ‘spinal taps’) are a requisite procedure for all pediatricians and performing them without having any red blood cells is a consummate skill.  ↩

  2. By no means do I mean to say I’m an expert clinician or know everything about pediatrics; far from it. The medicine aspect is still difficult, but compared to some other, less familiar skills (like speaking with families or navigating foreign hospital systems) it can seem easier.  ↩


Spit here: can Cue's $199 lab-in-a-box keep you healthy? | The Verge

Josh Lowensohn writing for The Verge:

“There are over 140 million doctor visits for cold and flu symptoms every year in the US. In more than 31 million of those visits, the patient has flu,” [Cue co-founder, Ayub Khattak] says. “We want to enable people to get this health information in minutes and, if flu is detected, communicate their result to their doctor who can order a prescription to the local pharmacy.”

This sentiment—order a lab test and, if positive, give Drug X—seems to be the prevailing belief in Silicon Valley about how medicine is practiced [1]. Unfortunately, it just isn’t that straightforward, even for something apparently simple like the flu.

The biggest concern with influenza is secondary bacterial infection causing pneumonia. These infections are what made the 1918 influenza pandemic so deadly. A rapid flu test tells you absolutely nothing about such secondary infection.

There is a reason why doctors ask a lot of questions and examine patients. Seemingly innocuous questions like, ‘Have you been feeling short of breath going up stairs,’ can yield lots of information. When it seems like your doctor is making pleasant small-talk, half the time they are gaining valuable information.

Don’t expect to plop down $199 for this box, test your family for flu, and have your doctor call in a prescription for Tamiflu. Coupling a lab-in-a-box system with an app to ask additional questions may prove to be useful for many conditions. However, the most likely scenario—you complete an in-home test, answer lots of question on the app, and still find yourself going to the doctor’s office for a more complete exam.

  1. To be fair, this seems to be a common belief among the general public as well.  ↩


In memory of Rebecca Meyer | Kottke

Jason Kottke:

...Author Elizabeth Stone once wrote that having kids was deciding to "have your heart go walking around outside your body". Steve Jobs put it similarly: your children are "your heart running around outside your body". That's the truest sentiment I've ever read about parenting; it feels exactly like that to me. Reading Eric's writing about Rebecca, a girl so close in age to both my kids, has affected me greatly. That could be me. My kids suffering. My heart, broken and dying. Imagining one of them...I can't even do it, the tears come hard and fast, washing away any such thoughts.


A 'connected' doctor balances his priorities | mHealthNews

Eric Wicklund:

… [Michael Jordan, MD] feels that mHealth and EHRs are uncomfortable dance partners at present, but will get into rhythm once providers (and EHR vendors) learn how to sort through the data to offer doctors what they need at the point of care.

A little difficult to decipher what exactly ‘providers’ means in that sentence, but the overall message is that people other than doctors need to figure digital workflows and relevant data for doctors.

This is one of my biggest concerns with digital medicine—people without any medical training or experience treating patients are creating the tools doctors rely on everyday. I firmly believe this is why the first few generations of EMRs have been poorly designed for clinical workflows.

We need doctors to lead the user experience design for the next generation of digital medical tools [1]. Doctors with experience and training in the myriad aspects of technology and data need to sit with designers and programmers and work cooperatively to create a great experience for using such tools in any clinical setting. It needs to be magical and delightful.

  1. I am talking specifically about the user experience not the actual user interface, data structures, networking, programming, etc. I’m also talking specifically about the digital medical tools doctors (and other providers) will use; not patient portals, mHealth tools, or the like.  ↩


Clinical Informatics: Prospects for a New Medical Subspecialty | JAMA

Don Detmer MD and Edward Shortliffe MD PhD:

Clinical informatics is not simply “computers in medicine” but rather is a body of knowledge, methods, and theories that focus on the effective use of information and knowledge to improve the quality, safety, and cost-effectiveness of patient care as well as the health of both individuals and populations.

This is an important paper for anyone interested in the nascent medical subspecialty of clinical informatics.