If you thought talking smack about CAC scans got people mad...

The man who discovered PSA writes an op-ed piece arguing for scrapping it as a screening tool.

On NPR.org: "Overshooting Obama's Health"

New writing of mine, posted elsewhere (and broadcast on All Things Considered on 3/4/10):
"It doesn't take a CT scan to know that President Obama should keep exercising, watch his diet, and quit smoking. So deciding not to do a test like a coronary artery calcium CT scan isn't just about avoiding the financial cost of the test. If the results of the test won’t change what we recommend, then the patient is taking risks for data that won’t make a difference."

Black tar heroin coming to white people near you

Graph: Black tar heroin vs powder heroin, and HIV among injection drug users vs HIV among men who have sex with men, in a map of the US and Canada from Ciccarone and Bourgois 2003--click on the graph for a full-size picture.

Black tar heroin is moving east, says the LA Times, in this first part of a three part article I'll be reading over the next days, being moved by folks from Xalisco, Mexico. The strategy described in the LA Times article involves low-profile low-weaponry low-volume operations targeting white people who've been using prescription opiates, and moving small cheap quantities of black tar heroin as an alternative to Oxycontin and Percocet.

What will this mean for clinicians on the East Coast if the Xalisco teams and their ilk manage to continue moving black tar heroin eastward? UCSF researchers have hypothesized that the properties of black tar heroin itself contributed to less spread of HIV among West Coast heroin users because black tar heroin has to be boiled more; and remaining bits of gooey leftovers in syringes caused users to rinse their works more thoroughly, and to switch out needles more frequently. But black tar heroin also most likely means more bacterial soft tissue infections.

When I started as a pre-med in San Francisco, I volunteered on a healthcare for the homeless medical van. The van would stop and I would circle the surrounding blocks, telling everyone who looked homeless, "Outreach van, down there" and sending them to the nurse and the medical resident who were in the van. In addition to handing out socks and vitamins, a lot of what we did was abscess care. It seems kind of crazy and unthinkable in Boston, but almost inevitable in San Francisco at the time, that medical residents would be lancing and draining small abscesses in the back of an Econoline van. Better that than let some not entirely well-organized heroin addict wait for the bacteria to build up to bigger balls of pus (and attendant complications) until finally winding up in the San Francisco General Hospital emergency department.

At one point, the San Francisco Department of Public Health startedwhat became known as "the abscess task force" to try to deal with the huge number of soft tissue infections, most dramatically abscesses, but also necrotizing fasciitis, botulism, and other soft tissue badness. These problems can be linked to black tar heroin through greater amounts of intramuscular and subcutaneous injection. Black tar heroin users seem to do more shooting into muscle and skin-popping because black tar heroin users sclerose their veins faster. And the boiling of the tar (which Ciccone and Bourgois posit helps kill HIV virions) does not kill the spores of Clostridium species. That seems to mean greater vulnerability to tetanus, botulism, and gangrenous skin infections when the spores of C. tetani, C. botulinum, or C. pefringens get embedded in the tar and then shot into soft tissue.

As far as I can find, there has not been a direct comparison of bacterial infection rates among injection drug users by geography--but it looks like there is a natural experiment in the making, if someone is ready to track it. And, an opportunity to set up systems for early detection and treatment of soft tissue infections, before they begin to swamp new cities' healthcare systems the way they did in San Francisco.


Ciccarone D and Bourgois P, Explaining the geographical variation of HIV among injection drug users in the United States. Subst Use and Misuse 2003 December; 38(14): 2049–2063.

There'll always be a Texas: nurses prosecuted for reporting improper behavior by a physician

It's certainly possible that nurses might report a doctor to bosses or regulators just to be spiteful. But the system has to make reporting easy, and safe, to make sure that quality issues don't get missed. That's what makes it such a travesty to criminally prosecute nurses for reporting concerns about a doctor's conduct. It would be a travesty even if the nurses' concerns ultimately weren't legitimate. But it's especially egregious when what's being reported is, in fact, bad behavior--stuff like emailing patients to promote his own herbal supplements that he was selling on the side.

New York Times covers the case.
Texas Nurses Association offers updates and legal defense fund information.

And as a bonus, because the Internet is full of glory, and for your edification, are Amazon reviews submitted by the doctor in question, which may singlehandedly convince you that these nurses were truly noble fighters for healthcare quality.

Google is specifically full of glory, and yea, noble also, for it teaches that this same doctor donated $968 to Ron Paul, and is a Facebook fan of "Ladies of Liberty" which is an organization for libertarian ladies to get other ladies involved in libertarianism, and also is a fan of Leviticus diet tips; and that he also appears in a program on "God's Learning Channel" as a doctor who treats patients with Morgellon's Disease...

The VA feels different this year...

iPhone photo in the lobby of the West Roxbury VA hospital. Maybe it shouldn't, because it's the same hospital and the same patients--with a few more younger guys back from Iraq and Afghanistan than the last time I was here--but the president and retired General Shinseki (now the chief of the VA) make it feel a little different to walk in the door.

The Veterans Administration: the Linux of medical records

I just spent three weeks in our local Veterans Administration system. Mention "VA" to any group of doctors and you are sure to hear funny stories; a great many doctors have at least some of their medical training within VA hospitals, and those hospitals are full of characters among both their staff and their patients.

VA hospitals have various frustrating aspects you'd expect from a large federal bureaucracy. But they also share a common sense of purpose and community unusual in other hospitals. Because of their commitment to a particular group, they feel almost like massive community health centers, in which there is a sense of shared purpose built not on organizational advancement but on the welfare of the community which the organization serves. It's this part of the VA which makes it a great system.

Along the way, the VA has accomplished various things that other healthcare systems haven't. One possibly more broadly transformative innovation is VistA--the Veteran's Administration electronic health record software, now available as open source software for any organization that wants to use it. Revisiting VistA this last three weeks, I can testify: VistA really is the bomb-diggity.

I say this as someone who works in a hospital that regularly wins prizes and high rankings for its own electronic medical records and ordering systems. Our electronic medical record is easy to use and intuitive, the design has an Edward Tufte-style simplicity (though sadly without sparklines), and is full of useful features. I regularly use it as a selling point for medical students considering our hospital for residency. Having used various electronic medical records during my time as a medical student and in external rotations as a resident, I'd put our system against anyone's.

The VA's system is uglier-looking and harder to learn how to use. But even in three short weeks as a novice user, I found it quite powerful, especially when it allowed me to access veterans' health records scattered across various VA hospitals around the country. At the end of the day, any data storage system can only be as useful as the data it stores; when so many VA hospitals are linked, the software is more powerful partly because of the information it provides. And when I got past some of the difficulty in getting used to the program, some of the way it integrates information is actually more useful than the record system I use.

Most importantly, it is available as open-source software, which any medical organization anywhere can use. Its ordering system, once learned, is easily integrated into the rest of the record. I also liked its graphing features which allowed visual displays of prescriptions and lab values charted over time; many electronic medical records have this kind of feature, but somehow the VA's system works better than most to provide sensible x- and y-axes for the data which is being presented. Uploading radiologic images takes longer than I would have liked but this is likely a fixable problem.

The stimulus package of last year included a big bunch of money to support dissemination of electronic medical records. Spreading open-source VistA will likely be one of the cheapest ways to accomplish this. If I were a large healthcare system, I'd take this system and maybe put some extra money into building a more intuitive and lovely-looking graphical interface on top of it (the one in use at the VA is from 1997)--but I'd keep VistA.

doctor with a bomb

Above: Radovan Karadzic, psychiatrist and perpetrator of the Srebrenica massacre and other atrocities in Bosnia. Below: Ikuo Hayashi, a neurosurgeon and one of the perpetrators of the Tokyo subway sarin gas attack.


Yet another doctor has apparently joined the ranks of violent absolutists, as a Jordanian doctor working as a CIA informant turned out to be a double agent, and blew up CIA agents and a Jordanian intelligence agent. This particular man, having blown up a bunch of people who can reasonably be described as combatants, can't be said to be a terrorist as much as a kamikaze, but apparently in the cause of advancing jihadist and terrorist ideology. (Or so says the CIA; take that for what it's worth.)

Still, as Simon Wessely explained in the New England Journal of Medicine in his 2007 essay, "When doctors become terrorists", written just after seven doctors and a medical technician tried to blow up a bunch of stuff in Britain, doctors have been high achievers in the world of terrorism. Ayman Al-Zawahiri, a surgeon, is Al Qaeda's number two. Wessely also reviews the innovator of airplane hijackings in the late 1960s and early 1970s, a Tokyo sarin gas attacker, and one of the main perpetrators of war crimes in Bosnia, as well as those master clinicians of medical mass murder, the many doctors involved in Nazi Germany's atrocities. More recently there was Major Hasan, the US Army psychiatrist who killed 13 in a shooting spree in November, perhaps acting as a terrorist, perhaps acting just as an ordinary American lone gunman looking to rack up posterity points, but definitely doing a lot of damage in the process.

Various right-wing blogs have been pointing out the number of well-educated people in the ranks of Islamic jihadist terrorists, as a way of trying to smash the argument that jihadism comes from grievances of the oppressed. And honest members of the left can remember that past terrorism in the name of socialist or communist revolution also often came from well-educated and relatively privileged people. We need not diminish the tragedies of the oppressed to understand the difference between oppressed people's grievances and terrorist tactics.

Terrorists from lives of privilege are people who are inclined to make the actual grievances of oppressed people into abstractions; to respond to those abstractions with absolutist solutions; to divide the world into good and bad; and to believe that having a comprehensive analysis of a situation allows the justification of the sacrifice of a few for the good of the many. The poor and oppressed people may still be looking for an extra cow for the herd, or an end to drug dealers hanging out on the corner; their putative allies among the privileged, meanwhile, abstract those concrete goals into global policy aims, to be advanced by terror when simple non-violent political organizing is not possible or not sufficient.

Terrorism is not a war technique. Terrorism works because it attacks anonymous non-combatants, whose deaths become terrifying to all others because there is no rationale or particularity to the target beyond some vaguely defined group or national membership. To target these people--ordinary people--doctors are perfect perpetrators. We know a range of ordinary people well, often better than most well-educated people do; yet internally, at our worst, we hold ourselves apart from them.

It's hard to know the percentage of well-off and well-educated people within organizations like Al Qaeda or its affiliates. A blog post in Small Wars Journal--don't ask me how the Internet led me to that blog, because I don't really remember--suggests that our preconceptions about social class may blind intelligence efforts to the violent possibilities of the privileged. However common or uncommon the trustfundamentalist terrorist might be, when looking for the perpetrator of the next terrorist plot, perhaps we shouldn't be looking for people with nothing to lose because they never had it in the first place, but people who have nothing to lose because they want something other than material goods, and have the money to get it.

Some of the terrorists of tomorrow, whether jihadists or other murder-happy extremists, will be doctors. It's hard to know exactly what drives these people, and in most cases we'll probably never really know. But it's tempting, at least, to think there is a particular medical personality disorder type at risk. These are the people who will see their patients as diagnoses; and their targets as symbols. They will look past the sweetness contained in the human qualities of frailty and contradiction, and look instead for complete solutions to the imperfection of the world. They will believe in small elites with special knowledge. And then, magic bullets of medicine having failed them, they will turn to holy bombs.

Wessely S. When doctors become terrorists. NEJM 357;7 August 16, 2007
Haddick R. Do assumptions about class create a vulnerability to terror? Posted to blog Small Wars Journal.