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New Blog

June 29, 2011

Thank you for visiting Number Needed to Treat. I have permanently moved my blog to a new website called ‘mediio‘. You can visit mediio to find out more and check out the connect page to see how you can follow along.

You may also follow me and my writing on Twitter.

If you would like to contact me directly, my contact information is available on my personal site.

Thanks again for visiting!

Big Data in Medicine

June 1, 2011

“Big data: the next frontier for innovation, competition and productivity” from The Economist

Properly used, big data could save the American health-care system $300 billion a year and the European public sector €250 billion.

Of all the industries mentioned in this piece, health care has by far the most to gain from collecting, aggregating, and analyzing data. In fact, health care providers already collect a huge amount of data each and every day–it’s called “patient records.” Unfortunately, this data exists in unusable formats isolated within silos in the hands of people who have no idea what to do with it (namely physicians; sorry, but I’ve seen the extent of epidemiological and biostatistical education in medical schools and it’s pathetic). Forcing electronic medical record (EMR) systems upon private practices will not solve this problem because most of the EMRs are incompatible and no mechanism exists to aggregate data on a large scale, which is necessary to leverage such data for quality improvement and new scientific inquiry. If we were able to aggregate large amounts of patient data (and some health systems are doing so), then we would be able to exploit variations in care processes to determine what works and what is useless. Many European countries, due to their single-payer system, already do this and continually contribute valuable research from this population-based data. The Dartmouth Atlas of Health Care is the most notable example of such data aggregation and analysis in the US. However, this project (and many others like it) largely relies on billing data which is inaccurate and limited. We need comprehensive aggregation of patient data (demographics, diagnoses, laboratory and radiological data, and discharge information/follow-up) and advanced analytical methods (such as natural language processing) to develop a more robust understanding of patient care and potential areas for improvement.

Board Prep

May 14, 2011

Over the next several weeks, I will be neck deep in preparing for the USMLE Step 1 exam (ie–the first round of boards for future physicians). This is a very important test for medical students (think of it like the SAT for getting a residency spot). As such, posting will be light. I hope to carve out a little time here and there to share some of my insights into board prep (ie–what works and what doesn’t, at least for me) and the whole ordeal of taking this “monumental” test, as well as some study aids. Unfortunately, I will be unable to post much original content or comment on other “hot” med blogosphere topics–there just ain’t enough time.

More importantly, if this blog goes dead for a little while, don’t fear–I haven’t died and I haven’t killed the blog. What will have happened is that I will have finally realized that I know nothing about medicine, gone through a complete freak out, and buried myself in a mountain of review books, question banks, and Goljan lectures.

This blog should return to its normal posting (and hopefully even improve) later this summer. Good luck to all the other med students preparing for Step 1, show the NBME who is boss!

Begin with the framework

April 29, 2011

The best med school lectures (or any lecture for that matter) all begin along the same lines:

When I was first learning this material, I found it really confusing and unintuitive but I found this framework/system useful when I was first putting the pieces together. This is still the basic framework/system I use to organize this material, but I’ve added in all the nuances over time. Here is the framework…

Lecturers, you job is NOT to stand in front of a group and spew forth volumes of information in a public demonstration of your mastery of the material. That is what PhD competency exams are for. Your job is to provide a simplified framework for your students to think about a certain problem/issue/subject. This is what is typically known as “the basics” but all too often skipped over in advanced coursework. Ingrain in your students the basic framework, then move on to adding nuances and exceptions once that basic framework is firmly established. Without a framework to initially work from, nothing is retained and, even worse, nothing is there for students to fall back on when they need to re-learn the material down the road.

Patients are not consumers

April 23, 2011

The idea that all this can be reduced to money — that doctors are just people selling services to consumers of health care — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values.

Paul Krugman on his blog arguing that patients are not consumers and health policy discussions employing such language are disingenuous.

Do we have too many clinical practice guidelines?

April 20, 2011

Dr Wes equating clinical practice guidelines (CPGs) with the ever-growing tax code

The short answer is: probably. A more complete answer, however, is that we have too many low quality CPGs that are published in unusably long diatribes in all corners of the medical literature. We don’t need fewer CPGs per se, but better guidelines published in a central location in an easy-to-use format.

It has become fashionable to use CPGs as a punching bag. Commenters like to point out that many of the recommendations contained in CPGs are based on lower grade evidence. They are not erroneous in this assertion. But they always fail to ask the next question: why?

The “highest quality” research is derived from multiple randomized, controlled trials answering a narrowly defined question. This is an expensive enterprise, especially if we expect researchers to conduct several trials for each step of the guidelines they develop.

The value of CPGs does not hinge solely on every step within the guideline being proven by multiple randomized trials. This would be ideal, but impractical. The real value of CPGs is in providing clinicians a common and systematic approach to a given disease. It allows a family physician in a rural practice to think like an experienced cardiologist when managing a patient post-MI. Fundamentally, CPGs put everyone on the same page and ensure, to a degree, patients receive the best level of care based on the available evidence.

Instead of spreading the irrational fear that “doctors will soon be behaving less like doctors and more like tax accountants,” we need to be pushing for better evidence–possibly engage ourselves and generate some of the evidence–and demand well organized, easily accessible guidelines.

Open access publication leads to more citations

April 14, 2011

Open access legal scholarship is 50% more likely to be cited than material published in proprietary journals

This paper provides empiric evidence suggesting open access publication of research leads to wider dissemination of information. I would very much like to see this study conducted using medical research.

An interesting aspect of medical research is the existence of evidence within specialty-specific silos. Each specialty tends to publish research in its own leading journal (unless their research happens to have such broad implications that JAMA or NEJM would publish it, but that is by far the minority). This system, although efficient at disseminating information to the most relevant audience, precludes cross-discipline integration of data.

I have personally come up against this in my own work. In writing about antibiotic usage, I came across papers in subspecialty journals (after all, almost all types of doctors prescribe antibiotics) that I couldn’t use because I couldn’t access the actual text.

This system especially hurts niche areas of research and prevents greater collaboration among researchers from different disciplines, ultimately producing inefficiencies in underfunded areas where efficiency is most needed. No scenario exists where open access publication of medical research would hurt the research enterprise. Medical societies need to demand greater access to their publications and force their publishers to develop more efficient delivery systems to reduce the costs involved in making greater access a reality (or cut out the publishers all together).


Med school v being a dog

April 13, 2011

[via A Cartoon Guide to Becoming a Doctor]

For all those contemplating their caffeine strategy for board prep

April 8, 2011

Link: How not to kill yourself with caffeine

Review of CAP Guideline iPhone app at iMedicalApps

April 6, 2011

Head over to for a review of Children’s Mercy Hospital’s recently released iPhone app for the management of community acquired pneumonia in children.