In science and particularly medicine, the public and patients can often be sold on statistics that are based on poor research methods and even poorer interpretation of those data by physicians. I am by no means the expert on science, although my PhD was in basic science and I tend to be a bit critical. However, I want to share with you how to not get bamboozled by statements like "it cut the number of heart attacks in half!" next time you are in a medical conversation.
In science we are concerned with showing that there is some difference when we compare two treatments. For example, if I increase blood flow (and oxygen) to a muscle, does it now use more oxygen than before? If so, does it now do more work than before? Often times we report this as "statistically significant" when we determine that "when there is no difference between treatments, the percentage of times we would accidentally say there is a difference is less than 5%". Read that sentence again - it is important.
This is often expressed in research as a "p value" of less than 0.05 or a "risk" of some sort that is above 1.0. When you see "relative risk" in a paper comparing two things, the risk is reported as 1.2-1.9 or some interval. A risk of 1.0 means there is no difference, so anything above that means there is an increased risk.
Example:
Two groups were examined, both with LDL cholesterol above 220. One group took a statin and the other did not. The no-statin group had an increased relative risk of death from cardiovascular disease over the next 10 years (RR 1.9-2.2). This means the no statin group had double the risk! Also, the statin group reduced LDL to 160, while the non statin group did not.
Seems impressive right? This means you should take the statin. Right? However, this is where the public and some physicians get tripped up. What if the risk of dying in that 10 years without the statin in the over 220 LDL group was 1 in 4 million? And by taking the statin your risk becomes 1 in 2 million, would you take it? Probably not. Even though you are accepting DOUBLE the risk! Now what if statins caused side effects in 1 in 10 or 1 in 20 patients? Now would you still take it? This is where our very important concept of "number needed to treat" and "number needed to harm" comes in.
Number needed to treat (NNT) is just what it sounds like - the number needed to treat to prevent 1 event (in this example it is death). If the NNT is 50, that means 50 people need to get the drug to prevent 1 death! NN to Harm (NNH) is the same concept - how many people do you need to treat to harm one patient?? In our example, if the NNT for 10 years was say 500 and the NNH was 10, would you take it?? Likely not - but this still gets reported in Time Magazine or in your local newspaper or even (gasp) by your local physician as "this drug cuts your risk of dying from a cardiovascular disease in half! you'd be stupid not to take it!"
Don't be fooled! Dig deeper! Next time you are speaking with your doc or reading a new report in Time, ask, "what was the NNT for this treatment?? And the NNH?" Then and only then can you accurately assess whether you are interested in the treatment or not. Be well!
Saturday, February 11, 2012
Orthopaedics
Well, I have decided to do Orthopaedic Surgery as a career. For many reasons that are of little interest to you, the reader. In brief, it combines my love for musculoskeletal medicine with Surgery with research. It is the perfect fit. I have also found that I am much more suited to the Ortho surgeries than I am the general surgery. That is, bending over for hours over someone's abdomen or throat as we cut and dissect was fun, but not nearly as fun as reducing bones back together, pining them with big screws, or screwing in plates to hold them together. Further, the concept of bone metabolism has taken ahold of me, specifically cancer in bone. I plan on doing Orthopaedic Oncology, which will also allow me to work with children with cancer (bone tumors) as well as do relief work in places like Haiti, when they need trauma/ortho surgeons to come in and help in the wake of disaster. General surgery, medicine, Rad onc, heme onc; none of these allow me to do all of these things - Ortho does. Now I have to figure out how to match at a hospital for residency! Orthopaedics is one of the most competitive specialties to get into!!
Thursday, January 26, 2012
New Postings
I am going to start doing a series of posts that will cover current medical issues that you may be curious about, starting with the concept of "number needed to treat" and what your doctor prescribes to you...
Monday, November 14, 2011
LGBT in America: What have we (not) done?
As I round on patients in the hospital each morning, I wear a small but conspicuous rainbow-colored pin on the lapel of my white coat. The pin is the Caduceus, the most well know symbol for medicine in society today (two serpents wrapped around a winged staff), while its colors represent the well recognized “gay pride flag.” Why do I wear this on my white coat, and is it really appropriate? After all, shouldn’t I keep any personal agenda of mine outside the clinic walls as I take care of patients? After all, who am I, a lowly scientist and junior clinician in the hospital, to mix politics or my feelings on human rights, with my work?
Nobel Laureate AV Hill, famous for his contributions to our current understanding of muscle metabolism, published a piece in the premier scientific journal Nature in 1933, speaking out against the persecution of the Jews just after the Nazis came to power, long before we knew what would come with the discrimination against the Jews: “Freedom itself is again at stake…100,000 in concentration camps, often for no cause beyond independence of thought or speech, something over 1,000 scholars and scientific workers have been dismissed…” He goes on to urge other scientists to speak out and be activists about this early discrimination against Jews in Germany. It will give you a cold chill to then read the reply from Prof J. Stark in an issue of Nature soon after that, where he replies that Germany is merely attempting to “curtail the unjustifiable great influence exercised by the Jews” and explains that such prominent scientists (e.g. Einstein) have “voluntarily given up their posts” while those in concentration camps are there “because they have been guilty of high treason…” Of course, we now know what would come from these early anti-Semitic movements, and history helps us easily side with the correct view on the issue. While current discriminations do not begin to approach the travesty of the holocaust, it helps to remember that the holocaust began as simple discrimination against a group of people.
One need not look far back in our own country’s history to see embarrassing examples of blatant abuse and bigotry toward other humans. It was once commonplace for Americans to own slaves; even after their emancipation, gaining equal rights with white citizens continues to be a long, hard fought battle. Likewise, women were not allowed to vote, much less contribute in most positions outside the home until relatively recently. Even today, they may struggle with being paid less for equal work in the workplace.
Luckily, these “norms” of society have been gradually changing as one, then two, then more people stand up and speak out against them. Today, with history on our side to offer important perspective, it is easy to criticize our ancestors and their seemingly tremendous ignorance. Yet what do we do today that future generations may judge us by? In one of our major historical guffaws, we now discriminate against people based on sexual preferences they have. Sadly, this is something we will all one day have to answer to our grandchildren: Imagine the questions: Grandpa, did homosexuals break the law? Were they hurting someone? What if someone decides that liking chocolate ice cream is bad – will I think be denied rights because of what I prefer in my personal life?
All questions of nature vs nurture aside, the simple fact remains that we have discriminated against a large population of people for a long time for no crime or disruption. Fortunately, this great country has a rich history of at the very least trying desperately to correct our grave discriminations of the past (e.g. affirmative action, title IX in sports). Sadly, these stopgap solutions are often delivered too little, too late, and with many problems. In the current situation, the solution could be simple – grant all people regardless of sexual preference equal rights. This includes the right to choose a partner one loves and marry that partner should one choose. Individual religions would still be free to define marriage as they see fit.
AV Hill used his prominent position in society to speak out against discrimination of a group of people; imagine if he had been better heard. In medicine, too often lesbian, gay, bisexual, and transgender (LGBT) individuals are given poor care by clinicians with little understanding or empathy for who they are. While my simple gesture of wearing this lapel pin might not change anything, my hope is that when my LGBT patients see this, they know they have a provider who respects and cares for them, and feels they deserve equal rights and standing in society. If respecting all people’s rights is ever considered inappropriate or unprofessional in the clinic, then I’d rather take off the white coat and walk away before I take off this pin. I hope you too will find your small way of supporting those we continue to discriminate against in society.
(Finally, while I welcome replies, I would caution that going on record as supporting discrimination of any people is often viewed unkindly by future, more informed generations. As you might have guessed, Prof Stark eventually was arrested and served time in prison after WWII.)
Nobel Laureate AV Hill, famous for his contributions to our current understanding of muscle metabolism, published a piece in the premier scientific journal Nature in 1933, speaking out against the persecution of the Jews just after the Nazis came to power, long before we knew what would come with the discrimination against the Jews: “Freedom itself is again at stake…100,000 in concentration camps, often for no cause beyond independence of thought or speech, something over 1,000 scholars and scientific workers have been dismissed…” He goes on to urge other scientists to speak out and be activists about this early discrimination against Jews in Germany. It will give you a cold chill to then read the reply from Prof J. Stark in an issue of Nature soon after that, where he replies that Germany is merely attempting to “curtail the unjustifiable great influence exercised by the Jews” and explains that such prominent scientists (e.g. Einstein) have “voluntarily given up their posts” while those in concentration camps are there “because they have been guilty of high treason…” Of course, we now know what would come from these early anti-Semitic movements, and history helps us easily side with the correct view on the issue. While current discriminations do not begin to approach the travesty of the holocaust, it helps to remember that the holocaust began as simple discrimination against a group of people.
One need not look far back in our own country’s history to see embarrassing examples of blatant abuse and bigotry toward other humans. It was once commonplace for Americans to own slaves; even after their emancipation, gaining equal rights with white citizens continues to be a long, hard fought battle. Likewise, women were not allowed to vote, much less contribute in most positions outside the home until relatively recently. Even today, they may struggle with being paid less for equal work in the workplace.
Luckily, these “norms” of society have been gradually changing as one, then two, then more people stand up and speak out against them. Today, with history on our side to offer important perspective, it is easy to criticize our ancestors and their seemingly tremendous ignorance. Yet what do we do today that future generations may judge us by? In one of our major historical guffaws, we now discriminate against people based on sexual preferences they have. Sadly, this is something we will all one day have to answer to our grandchildren: Imagine the questions: Grandpa, did homosexuals break the law? Were they hurting someone? What if someone decides that liking chocolate ice cream is bad – will I think be denied rights because of what I prefer in my personal life?
All questions of nature vs nurture aside, the simple fact remains that we have discriminated against a large population of people for a long time for no crime or disruption. Fortunately, this great country has a rich history of at the very least trying desperately to correct our grave discriminations of the past (e.g. affirmative action, title IX in sports). Sadly, these stopgap solutions are often delivered too little, too late, and with many problems. In the current situation, the solution could be simple – grant all people regardless of sexual preference equal rights. This includes the right to choose a partner one loves and marry that partner should one choose. Individual religions would still be free to define marriage as they see fit.
AV Hill used his prominent position in society to speak out against discrimination of a group of people; imagine if he had been better heard. In medicine, too often lesbian, gay, bisexual, and transgender (LGBT) individuals are given poor care by clinicians with little understanding or empathy for who they are. While my simple gesture of wearing this lapel pin might not change anything, my hope is that when my LGBT patients see this, they know they have a provider who respects and cares for them, and feels they deserve equal rights and standing in society. If respecting all people’s rights is ever considered inappropriate or unprofessional in the clinic, then I’d rather take off the white coat and walk away before I take off this pin. I hope you too will find your small way of supporting those we continue to discriminate against in society.
(Finally, while I welcome replies, I would caution that going on record as supporting discrimination of any people is often viewed unkindly by future, more informed generations. As you might have guessed, Prof Stark eventually was arrested and served time in prison after WWII.)
Sunday, November 13, 2011
Normal Burns - Ice??
I am not sure I am going to keep doing this, but I figure I might as well list a few posts of "common injuries" advice, since I get to learn this stuff, question it, and practice it everyday now...
When you burn yourself in the kitchen when touching a hot pot or pan, most people put ice on it - DO NOT DO THIS. Simply run cool water over it and then monitor it over the next day (severe blistering, turning black, etc may be concern for more severe injury and need for medical attention). Putting ice on a superficial burn only causes vasoconstriction to underlying dermis and causes the injury to worsen.
Please feel free to respond to this blog with questions for me to answer!
When you burn yourself in the kitchen when touching a hot pot or pan, most people put ice on it - DO NOT DO THIS. Simply run cool water over it and then monitor it over the next day (severe blistering, turning black, etc may be concern for more severe injury and need for medical attention). Putting ice on a superficial burn only causes vasoconstriction to underlying dermis and causes the injury to worsen.
Please feel free to respond to this blog with questions for me to answer!
Sunday, November 6, 2011
Recumbant Bikes in Hosp Rooms
Why is there no exercise equipment in the hospital?
Why aren't there trainers or assistants to get my patients moving? (PT evaluates and often cannot see them that much - they need trainer like people)
Why do we leave these people lying in bed all day? Who thinks this is at all a good idea, particularly after surgery, where you risk collapse of alveoli in lungs and clots in the legs from just sitting. Instead, why not have recumbent bikes next to each bed? They can strap in and just pedal. I am going to ask for a grant to do this study I think, but from who?
Why aren't there trainers or assistants to get my patients moving? (PT evaluates and often cannot see them that much - they need trainer like people)
Why do we leave these people lying in bed all day? Who thinks this is at all a good idea, particularly after surgery, where you risk collapse of alveoli in lungs and clots in the legs from just sitting. Instead, why not have recumbent bikes next to each bed? They can strap in and just pedal. I am going to ask for a grant to do this study I think, but from who?
Thursday, September 29, 2011
Surgery: In the OR
First of all, I LOVE surgery and will likely operate in some way for a career. They have a problem, then they work to solve it. And its fun.
Second, I am going to tell you a true story:
In my FIRST day in the OR, I am scrubbed in on a case (sterile) along with the resident doctor and the attending doctor (a BIG shot pediatric surgeon). Well, she is yelling at nurses about everything and just not happy about the scene in general (in really crazy ways, like expecting unreal things from them).
So, she is doing stitches and I am "following" her (holding suture and pulling as she goes). Suddenly, her hand is pulling a stitch through and she brings her hand UP BY HER HEAD to pull the string taut. I am standing there and get hit in the HEAD with her hand. I have not moved an inch. She flips on me - "get out of here! you just ruined the sterile feild - scrub out and dont even think about scrubbing back in!" I backed away, staying calm, then derobed and stood in the corner as she went on. It was awkward, but a great story (not doing it justice here I guess).
Funny thing is it never bothered me - it was kind of funny, kind of sad, etc. But none of it really bothered me other than it gave me a GREAT story to tell!
The next morning we had breakfast together and then did an operation together where she was really sweet to me. However, she tore a new nurse a new one over the culture tubes.
(full story is funny)
Long story short, I love surgery, even with these maniacs. We have a problem, we talk about, then we go fix it. And to boot the residents say hello to me and introduce themselves to me. Its actually a good atmosphere. No bullshit time wasting so far...
Anyways, to bed for me - we have 4 nonemergency cases tomorrow (which means with emergency it could be much more).
I am finally looking forward to getting up in the morning.
Second, I am going to tell you a true story:
In my FIRST day in the OR, I am scrubbed in on a case (sterile) along with the resident doctor and the attending doctor (a BIG shot pediatric surgeon). Well, she is yelling at nurses about everything and just not happy about the scene in general (in really crazy ways, like expecting unreal things from them).
So, she is doing stitches and I am "following" her (holding suture and pulling as she goes). Suddenly, her hand is pulling a stitch through and she brings her hand UP BY HER HEAD to pull the string taut. I am standing there and get hit in the HEAD with her hand. I have not moved an inch. She flips on me - "get out of here! you just ruined the sterile feild - scrub out and dont even think about scrubbing back in!" I backed away, staying calm, then derobed and stood in the corner as she went on. It was awkward, but a great story (not doing it justice here I guess).
Funny thing is it never bothered me - it was kind of funny, kind of sad, etc. But none of it really bothered me other than it gave me a GREAT story to tell!
The next morning we had breakfast together and then did an operation together where she was really sweet to me. However, she tore a new nurse a new one over the culture tubes.
(full story is funny)
Long story short, I love surgery, even with these maniacs. We have a problem, we talk about, then we go fix it. And to boot the residents say hello to me and introduce themselves to me. Its actually a good atmosphere. No bullshit time wasting so far...
Anyways, to bed for me - we have 4 nonemergency cases tomorrow (which means with emergency it could be much more).
I am finally looking forward to getting up in the morning.
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