Another modest proposal

How not to answer clinical questions

No sooner had I put the final touches on my last post about physicians' overconfidence when trawling the web, than my colleague Michael Tennenhouse alerted me to an article in this month's Canadian family physician that should give patients pause (1). It's like what they say about ketchup: if you do not shake the bottle, none'll come and then a lot'll. Somebody please stop the flow.

Here is yet another example of what can go wrong when physicians set out to conquer the proverbial ocean of information without compass and sextant. Our Canadian crew, all family medicine residents at various Canadian universities, show more nautical expertise than the hapless landlubber in the Australian family physician (2). Unfortunately, they all could use some more lessons in navigation.

The Canadian article cites PICO also as the authors attempt to phrase an appropriate clinical question — although in my opinion their question leaves much to be desired. The Canadians then go on to complete a questionable search. On the surface things look reasonable. Yahoo! is not even on the map, and the authors are at least aware that "'Googling' your question does not necessarily lead to the best evidence-based answer" (p. 1535). PubMed is visited, "the obvious starting point." We then turn the rudder towards SUMsearch and TRIP.

A Quebec resource called InfoClinique is described as "excellent," but we are immediately told that it is available only to Laval University members. I tried it. It works slowly, searching a limited list of EBM sources (curiously, neither TRIP nor SUMsearch appears among its sources indéxées). When the results finally appear, the links are hidden behind lots of little x's. Recommending the unhelpful InfoClinique looks more like a well-meant attempt at Canadian two-solitudes inclusivism than a contribution to the authors' task.

Having steered around these shoals the authors glance briefly at textbooks, among which they include eMedicine, UpToDate, Dynamed and the resources to be found in MD Consult. They then sum things up by proudly describing how they answered their own question in under 10 minutes. Land ho!

While the general approach of the authors is acceptable, there are serious problems with their method. As my colleague pointed out to me, they choose mostly appropriate limits, but the actual search term selection, resulting from the poorly worked out question, is problematical. Their article nicely demonstrates some common mistakes made by many of our students and residents:

1. Poor question building, especially with respect to identifying the problem and the intervention.
2. The use of "red-herring" or unnecessary terms in the search strategy which artificially limit the results (in this case it's the term "expectant").
3. Uncritical review of the search strategy and results.
4. No use of MeSH in PubMed, or how to easily seek out the best MeSH from the most relevant retrieval, or how to use Related Article searching.
   

The authors argue in their second paragraph (p. 1535) that they have merely reproduced what most physicians would do given the case under consideration (premature rupture of membranes). They choose to use "the Internet alone" (i.e., free resources, except for InfoClinique). They choose to look at only "articles available without subscription, as we do not always have time to ask the library for an article when a patient is in front of us." Using a "variety of key words" their goal is "to mimic what is often done in practice." In other words, they are quite prepared to shortchange a patient, to flounder about on the web's treacherous expanse with poor preparation and ill-chosen search strategies, in order to save time and perhaps some expense. If this is truly mimicking what is done in practice, more's the pity.

In a recent post, T. Scott reiterates the point that physicians are drowning in information. Like most of us, he is "worrying about the health of the patients that are being served by physicians who have only the faintest notion of how to construct even the simplest search." As health sciences librarians it is "our responsibility to get [students] out of med school with a decent set of information management skills."

I couldn't agree more. So here is my other modest proposal. Let the aspiring family physician pass both these articles by. The Canadians and Australians have shown you how perilous the voyage can be in search of the best evidence. Seeing the library as little more than an obstacle in their way, they try to make the best of it on their own without capsizing. Sometimes they're lucky, in the same way that contestants in a bathtub race sometimes reach the finish line. But what furious paddling, what desperate flailing about all the while.

So pass these articles by. If you keep looking, however, surely something will, as they say, turn up.

"Precisely. It is evident to me that Australia is the legitimate sphere of action for Mr. Micawber! I entertain the conviction, my dear madam," said Mr. Micawber, "that it is, under existing circumstances, the land, the only land, for myself and family; and that something of an extraordinary nature will turn up on that shore."

References

1. Lacasse M, Lafortune V, Bartlett L, Guimond J. Answering clinical questions: What is the best way to search the Web? Can Fam.Physician 2007 Sep;53(9):1535-8. http://www.cfp.ca/cgi/content/full/53/9/1535

2. Qureshi F. How I use the internet. Aust.Fam.Physician 2007;36(7):538. http://www.racgp.org.au/afp/200707/17421

Expressive liberty

When freedom is outlawed only outlaws will be free.

Having just written a post on homelessness in Canada I was very interested to come across The expressive liberty of beggars, a new study released by the Canadian Centre for Policy Analysis, which claims that restrictions on peaceful panhandling, such as those found in the bylaws of many cities, constitute an illegitimate use of state power.

The 28-page paper, by Arthur Shafer, director of the Centre for Professional and Applied Ethics at the University of Manitoba, says there is no moral or legal justification for turning peaceful beggars into criminals. Shafer does not fail to connect the dots between poverty, homelessness and health. "Panhandlers communicate — whether through speech or via an outstretched hand and raggedy appearance — a message about dire poverty, unemployment, substance abuse, mental illness, and homelessness" (p. 9). More poignant than any manifesto, the visible presence of the poor and homeless defines the issues and demands that things must change. For more information, see the CCPA press release.

Here is the introduction:

It is morally perplexing that in 21st century Canada it could be a punishable offence for one person to say to another, peacefully, in a public place, “I’m in trouble and need help.” Yet that is the effect of City of Winnipeg Bylaw No. 128/2005. Other Canadian and American cities have enacted similar legislation, and a fast-growing body of jurisprudence in both Canada and America testifies to the fact that the criminalization of panhandling has become a kind of battleground. On this battleground, a clash occurs between competing values: social “hygiene” vs. freedom of expression; middle class discomfort vs. underclass economic need; commercial interest of downtown business owners vs. beggars’ right to plead for subsistence.

Of course, if a panhandler’s request for help were made in an aggressive or intimidating manner, then liberty-limiting legislation would be much less controversial. In Canada, the Criminal Code expressly prohibits demanding money with menaces. This prohibition, backed by sanctions, would be accepted by most people as a proper use of coercive state power.

The essence of the argument advanced in this report will be that restrictions of peaceful panhandling constitute an illegitimate use of state power.

Put simply, my contention is that peaceful beggars should not be turned into criminals. That’s because non-aggressive begging involves the kind of expressive communication between people that a free and democratic society should seek to protect rather than restrict. Freedom of expression is a fundamental human right — one that should be infringed only in exceptional circumstances. It follows that any law which restricts the expressive liberty of beggars should be viewed prima facie as a violation of human rights.

There is a substantial body of empirical evidence in support of the intuitively obvious hypothesis that beggars are a seriously marginalized group in our society: almost always poor and frequently homeless, often suffering from extremely poor health, mental illness, and alcohol or drug addictions, with few social supports and even fewer opportunities to make their plight known to their fellow citizens. For this reason, it is comparatively easy to adopt a “we/they” perspective on issues involving panhandlers — a perspective in which “we’ are the legitimate members of society while “they” are little better than social outcasts. Quite simply, this perspective is not ethically defensible. Panhandlers have as much right as middle-class citizens to dignified treatment. The very sub-title of this paper, with its sharp dichotomy between “them” and “us,” runs the risk of conveying, inadvertently, the message that beggars are mere specimens, pinned and wriggling on a hook, rather than participants in the project we call building Canadian society.

If members of the underclass are not recognized as having an important contribution to make to the formation of public opinion, then not only are they robbed of a basic right of citizenship, but everyone else in society is also robbed of potentially important information. Some would argue that the very poor have an especially important contribution to make to the so-called free marketplace of ideas. Critical scrutiny of ideas is an enterprise that requires the widest possible contribution from those with differing experiences and alternative perspectives. When the expressive liberty of the poor and homeless is censored, excluded, or otherwise marginalized, then the advancement of knowledge for everyone is prejudicially affected.
Autonomous citizens should not easily settle for such a limitation on their ability to formulate for themselves their view on such matters.

Indeed, the beggar’s generally downtrodden position in society makes a denial of his expressive liberty especially problematical. Since the free marketplace of ideas (like the free marketplace of commodities) tends to produce massive inequalities in access to expressive forums, special heed must be paid to the expressive needs of those who cannot easily make their voices heard. A liberal democratic society which values the rational autonomy of all its members must work diligently to protect norms of mutual recognition and respect in communication.

It is also worth noting that in Canada panhandlers tend to be recruited, disproportionately, from First Nations’ communities and from the ranks of other visible minorities. In consequence of the racial and other prejudice still widespread in Canadian society, it is common for members of these communities to have suffered serious discrimination in education, housing, employment, and other spheres of life. Drastic inequalities in life opportunities for First Nations people and visible minorities constitute an important part of the setting within which the great Canadian panhandling debate is currently being played out.

Thus, when issues of social policy are being discussed and debated by the community, it is of the highest importance that the privileged classes are not denied opportunities to hear and to take seriously the voice of the poorest and most oppressed members of society.

A modest proposal

Would this post sound more authoritative if I entitled it: "Predictive value of information literacy (IL) levels for recurrent mediocre search results (RMSR)?"

Last July I commented on a review article by Karen Davies on the information-seeking behaviour of physicians. The article appeared in the June 2007 issue of Health information and libraries journal. There were no real surprises in Davies' review. It's the old problem. Things are still in statu quo. Doctors have information needs and they have a wealth of resources to find the answers to their questions; but they do not have the time or the skills to get the best results from the tools at hand. Librarians have the time and training to provide the best resources and to meet physicians' information needs by using these resources in an expert manner; but we are often left waiting by the phone.

There are many physicians who are using the Internet intelligently to answer clinical questions and who have made the effort to get training in its proper use. And then there are the others who conform to all the bleak analyses of Karen Davies' article. What mystifies me is that not only are there physicians who don't get beyond "quick and dirty" searching or who simply don't know what they are doing, some even go so far as to hang that dirty laundry in public — even in the pages of prestigious medical journals. In an earlier post I discussed one such disaster, and now I must regretfully point out another.

When I came across the one-page "How I use the internet" in the Australian family physician, my first thought was, "Lucky patient you were. The first item that popped up in your doctor's web search was only a four-year-old article. Things could have been worse." The target of my scorn is a brief "practice tip" which, minus the illustrations, takes up half of page 538 in volume 36. Written by a general practitioner in Adelaide, it is an unintentionally humorous description of using the Internet to find information about discontinuing warfarin for a female patient who had suffered an episode of deep vein thrombosis. The author decides to conduct a "quick, computerised literature search using the Yahoo! search engine." He picks Yahoo! because the patient, a hockey player, is familiar with it, and he wants to allow her to be involved with her treatment.

In Yahoo! he enters the query, "Can d-dimer levels predict recurrent venous thromboembolism?" He justifies using this form of query by citing The well-built clinical question (an online tutorial developed by librarians Connie Schardt, Duke University Medical Center Library and Jill Mayer, University of North Carolina at Chapel Hill Health Science Library). "Entering key words would not help to construct a question and phrase it in such a way as to facilitate an answer," he writes. I had to read this sentence a few times, but its author seems to be claiming that entering a syntactically correct English-language question into a web search engine is preferable to a key word search. Cue Twilight Zone theme.

Our physician does not understand the difference between proper use of a web search engine and constructing a well built clinical question according to the principles of EBM. Like Captain Kirk consulting the ship's computer, he dutifully asks his question. And a fine one it is; but sticking to only this formulation of the question radically limits the possibilities for retrieval. It is an approach free of empirical duty. Had he consulted a librarian, our physician would have found that the skilled employment of key words in a Yahoo! search produces more recent articles on this topic, like one published just last year in the NEJM, which in turn cites a clinical trial that concludes: "The optimal duration of oral anticoagulant treatment in patients with idiopathic venous thromboembolism is still uncertain."

What our physician's quick and dirty method does produce as its first item is a JAMA article from 2003. Without further ado, he uses the information from this article to advise the patient, who — trusting soul — is "happy with the outcome of the search result." Aside from the problematic acceptance of Yahoo!'s ranking algorithm, why use only Yahoo! in the first place? Surely he must be aware of Google Scholar. A search that plugs the same question into that search engine turns up relevant articles from Circulation and Archives of internal medicine in the top ten. More importantly, why has he ignored PubMed, ClinicalTrials.gov, and other free EBM resources? And surely his young patient would have benefited more from being directed to something like the MedlinePlus article on thrombophlebitis or JAMA's own patient page on the same topic, which cites a 2006 JAMA article with new information on other measures for identifying patients at low risk for recurrent venous thromboembolism.

In his book The trouble with medical journals, Richard Smith quotes an aphorism that he valued highly as editor of BMJ: "Anybody is free to make a fool of himself in my journal" (p. 64). This was in the context of a discussion of BMJ's policy of allowing rapid, sometimes egregious, responses by email to published articles (a practice that was later tightened up by the editorial board). But in the case of the "practice tip" under review here, the editors must have read it and approved it. What were they thinking? This is a tip the way Swift's A modest proposal is social planning.

"The time constraints of a consultation" are cited as the excuse for this travesty of medical information retrieval. Our physician would have required less time to email the question to his local health sciences library and have them send the information. "How I use the internet" looks to me like a perfect demonstration of the dire need for improved information literacy for health care providers. Here is my modest proposal. If they truly wish patients to continue, as Mr. Micawber would say, in the enjoyment of salubrity, medical people and medical journal editors should view such amateurish squibs with greater suspicion. In short, they should not be published. Or next time, the patient may not be so lucky.

All thumbs

Housing and health in Canada

The French have a saying that their heart is on the left while their wallet is on the right (avoir le coeur à gauche et le portefeuille à droite). The Germans remind us that the left hand is the one with the thumb on the right (Links ist, wo der Daumen rechts ist). In Canada, it seems, we're all thumbs.

Thousands of people in this country are homeless on any given night. In 1998, the Toronto Disaster Relief Committee (TDRC), co-founded by Toronto "street nurse" Cathy Crowe, declared homelessness a national disaster. Over the last decade, spanning both Liberal and Conservative governments, the situation has become worse. The health implications of homelessness are obvious to everyone except those who pamper their compassion and need high stimulants to rouse it. An article by Dr. Stephen W. Hwang (St. Michael's Hospital, Toronto), which appeared in the CMAJ nearly seven years ago, warned of the problems caused by homelessness:

Homelessness affects a significant number of Canadians of all ages and is associated with a high burden of illness, yet the health care system may not adequately meet the needs of homeless people. More research is needed to identify better ways to deliver care to this population. Health interventions alone, however, are unlikely to overcome the adverse effects of homelessness and related social ills. The search for long-term solutions to the problem of homelessness itself must remain a key priority.

A report released last August by the Canadian Institute for Health Information (CIHI) sheds some new light on the complex relationship between mental health and homelessness in this country. People who are homeless are more likely to suffer from a mental illness or compromised mental health than the general population. On the other side of the coin, people with severe mental illness generally experience limited housing, employment and income options.

Improving the health of Canadians: mental health and homelessness provides an overview of the latest research, surveys and policy initiatives related to mental health and homelessness and, for the first time, presents data on hospital use by homeless Canadians. According to one startling statistic contained in this document, 52% of the visits to Canadian hospitals by homeless people are due to mental disorders, compared to only 5% among the general population.

People who are homeless tend to report higher stress, lower self-worth, less social support and different coping strategies — factors that are associated with depressive symptoms, substance abuse, suicidal behaviours and poor self-rated health. And the homeless mentally ill inevitably end up in hospital emergency departments.

The troubling relationship between mental illness and homelessness has been known for decades, and ample evidence was brought forth in the CMAJ article quoted above:

The prevalence of mental illness and substance abuse among homeless people is difficult to determine precisely, but consistent patterns have emerged from methodologically rigorous studies conducted in the United States and Canada. Contrary to popular misconceptions, only a small proportion of the homeless population has schizophrenia. The lifetime prevalence of schizophrenia is only 6% among Toronto's homeless population, and US studies have found prevalence rates of 10%–13%. Affective disorders are much more common, with lifetime prevalence rates in the range of 20%–40%.

The research called for in past years has been done. While there is always something else that can be learned through research, the general picture is quite clear. This country has a problem that is not going away. The studies have gone on long enough. To avoid "paralysis through analysis" society must act.

Bill Wilkerson, co-founder of the Global Business and Economic Roundtable on Addiction and Mental Health, expressed his impatience: "We have known for 25 years what this report is telling us yet again," he said. "So it's time for action, not time for more study." Wilkerson was involved in a task force that scrambled to find housing for mentally ill people who were deinstitutionalized in Ontario in the early 1980s. "The only difference, I think, is the problem then was new. Now it's old," he said. (Canadian Press report, 30 Aug 2007)

"The most obvious solution to homelessness is housing," says Tim Aubry of the Centre for Research on Educational and Community Services at the University of Ottawa (quoted in The Globe and Mail, 31 Aug 2007). There are two lengthy reports that confirm this common-sense remark. Housing is good social policy was published in 2004 by the Canadian Policy Research Networks. The authors elucidate further the link between homelessness and physical and mental health deficits. They argue that providing adequate housing is vitally important. "Spending money on housing does not take money out of health care – it reduces the cost of health care." Shelter: homelessness in a growth economy was released in July 2007 by the Calgary-based Sheldon Chumir Foundation for Ethics in Leadership. It claims that Canada's homeless population may be as high as 300,000. These staggering numbers are directly linked to increasing poverty levels. The government's response to homelessness has been "conflicted, sometimes bordering on outright neglect," and "has exacerbated efforts to reduce poverty in Canada." The report concludes:

If neglected, housing insecurity will continue to spread across Canada, fueling the relatively new phenomena of suburban homelessness, accelerating urban decay, and, in the face of record-setting housing prices, ensure the general economic erosion of millions of Canadians.

The Canadian government's new Homelessness Partnering Strategy began on April 1, 2007. It claims to be providing $269.6 million over two years to help communities across Canada combat homelessness. However, there is no housing in it, and it amounts to little more than a homelessness disaster relief program.

What of the response to the growing mental health crisis and its relationship to homelessness? On August 31 Prime Minister Stephen Harper announced the final selection of the Board of Directors for the newly created Mental Health Commission of Canada, which will receive funding of $55 million over five years. The Commission's goal is to help bring into being an integrated mental health system that places people living with mental illness at its centre. Sounds like more expense accounts and meetings, leading to more research.

Canadians are still waiting for an initiative that will include successful social housing as an integrated component of a broader social and economic policy to improve the health and welfare of the disadvantaged. Cathy Crowe of the Toronto Disaster Relief Committee wrote a powerful op ed piece last July about the Canadian housing crisis. She says: "Homelessness is our Katrina, but it wasn't caused by the weather." A public health nurse, Crowe is the author of Dying for a home: homeless activists speak out.


Meanwhile, our government does not see the irony in announcing last July that an American anti-virus software company is "donating security technology and expertise to 450 homeless shelters, which will help to ensure the protection of sensitive information on clients and operations." There are many excellent anti-virus and firewall programs available for free on the Internet. Here is the Canadian government crowing about supporting the work of shelters for the homeless, when all it is really doing is giving free feel-good publicity to a foreign corporation.

How does all this concern me as a librarian? The Diary of a Subversive Librarian highlights this quote from America Gone Wrong: A Slashed Safety Net Turns Libraries into Homeless Shelters:

In a democratic culture, even disturbing information is useful feedback. When the mentally ill whom we have thrown onto the streets haunt our public places, their presence tells us something important about the state of our union, our national character, our priorities, and our capacity to care for one another. That information is no less important than the information we provide through databases and books. The presence of the impoverished mentally ill among us is not an eloquent expression of civil discourse, like a lecture in the library’s auditorium, but it speaks volumes nonetheless.

Only a humanity to whom death has become as indifferent as its members, a humanity that has itself died, can inflict death administratively on innumerable people.

Theodor Adorno, Minima Moralia

Blogging med school

Health sciences students work on their own Gesamtkunstwerk

Long ago, when high tech was a gramophone with one of those little brushes attached to the needle cartridge, I went to a really tough school in my Ontario home town. The prom queen was selected by an arm wrestling contest; my physics teacher was an irresistible force while I was an immovable object; my French teacher, un type vicieux, threw chalk at me as if in retaliation for Wolfe's victory. When I chose to take typing instead of agriculture in Grade Nine, Buzz Bulgutch pulled me behind the machine shop, spat on his fist, and provided me with some striking gender-role instruction. I'm sure I'm not the only person who occasionally had his face rearranged and then washed with snow after the final bell. So I can identify with the way Emo Philips described his own experience at school:

I got into a fight one time with a big guy, and he said, "I'm going to wipe the floor with your face!"
I said, "You'll be sorry!"
He said, "Oh yeah? Why?"
I said, "Well, you won't be able to get into the corners very well."

I know how that felt. But seriously, after what I went through at Prince Edward Collegiate Institute (Pee See Eye, we called it), I'm very grateful that life at the University of Toronto was less eventful. What was the worst that happened, you ask? The Philosophy Department tried to expel me for cheating on my Ethics exam, when all I did was look into the rectitude of the guy next to me. I considered Mathematics, but I soon realized that, as the saying goes, there are three kinds of people: those who can count and those who can't. So I switched to English. I blindly groped through Milton, amassed a good many notes on Austen (then promptly lost them), and mushed diligently through the grim repressions of Victorian fiction. At the end of my undergraduate years I proposed a daring thesis: the influence of Chaucerian metre and early Tudor madrigals on Canadian poets of the sixteenth century. Sadly, I had to shelve the idea when I discovered that the only Canadian poetry of the sixteenth century that wasn't in Algonquian or Cree or Inuktitut turned out to be a salacious bit of French doggerel scratched onto a remote rock off the Newfoundland coast. I finally found modest success with my master's thesis: a sustained critical-theoretical analysis of The Cremation of Sam McGee. There are strange things done in the midnight sun, however, and subsequently I found myself squandering my intellect on postmodern discourse, hybridity, otherness, sexuality, subversion, deviance, heterogeneity, popular culture, the decentred self, the materiality of sign, historicism, and the aleatory, digitized topoi of the bifurcated aesthetic. I moiled for gold in measureless realms of non-Cartesian calculation, exploring decanted mind spaces and voided syllogisms, past etiolated expanses of nihilation, amongst the ossified remains of Enlightenment certainties and the empty sarcophagi of abendländisch-hierarchische Kreuzzugsidee.

In short, it's no wonder that my dissertation was rejected. Evolving slowly from my study of the epoch-making collision of Derridean deconstruction and romantic fiction, it was entitled: "I wake up screaming: reconsidering Barbara Cartland - the novelist in the light of recent rethinking of desire, deferral, the bodice, labyrinth, displacement, and the panoptic phallus." My professor called it a train wreck. I demurred. He spat on his fist and threatened to void my syllogism. I quickly shuttled over to library school and reclassified myself. Perhaps I should have stuck to my original dissertation idea: "What do we talk about when we talk about Gesamtkunstwerk?: negotiating Nietzsche in unmediated cyberspace." But this ground-breaking work would not have been shelved in the W's.

Being drawn more to dissecting concepts than cadavers, I had the good fortune to avoid the sublime tortures of that most menacing realm of postsecondary education: medical school. I truly sympathize with those who have to endure the rigours of years and years of answering pagers, running down endless hallways, tripping over gurneys, taking pulses, palpating distended abdomens, and memorizing reams of Greek participles — all while encumbered by an unruly stethoscope. Not to mention the daily indignities suffered by med rehab and dentistry students: poking at rotator cuffs or scraping plaque. I can see why they might be drawn to blogging, that or psychoanalysis.

There were no student bloggers in my day, no such satisfying means of publicly dealing with the daily horrors of academe. Writing papers on a typewriter leaves one too exhausted for much else. Besides, we were busy studying Madame Blavatsky or Lenin. But now students armed with the kind of computing power that will bring on the Butlerian Jihad are coming out of their corners in great numbers, enlivening the blogosphere with their angst and attitude. And medical schools are offering up their own unique crop of them. Take The Angry Medic, for example, who claims to be "an idiot who got into Cambridge University by virtue of his unusually attractive eyelashes." Then there's The Evil Resident: "it's psychosomatic. you need a lobotomy. i'll get a saw." Personally, I was drawn to the The Rejected: "Brush Your Teeth After You’ve Inhaled Cadaver Fumes for 2 Hours." (I knew there was something about those cadavers.) There are indeed strange things done here, only not in the midnight sun; instead they reveal themselves in the pale luminescence of the computer monitor. Not to be outdone by their medical colleagues, OT/PT and dentistry students are also flexing their blogging muscles. No doubt there are many nursing blogs too, but I ran out of steam before I could investigate to that extent. I'll devote some effort to the nurses' cyber-effusions at another time.

When I was trying to bring some student blogs together for an article in our Info-Rx Newsletter, I had trouble finding a decent list. I looked through some of the blog directories without a great deal of success. Of course, every blogger has his or her blogroll of favourites, so I ended up mainly working from these to create the following guide to what students are writing about right now. Of course, as always, once I had completed my labours, I found a fairly comprehensive listing from The Student Doctor Network, which conveniently tabulates an enormous number of student blogs, including other disciplines such as Pharmacy and Dentistry. There is a great deal of information on medical blogging at the Trusted.MD website. Even more blog lists (though not just by students) can be found at these sites: Healthcare Blogger Code of Ethics and Medical News Feeds.

No one source is complete, so I hope this list will be of help to the fevered mind that cannot rest until every blogging student in the health sciences has been tracked down. I see a permanent job for a few people who are willing to work for no salary while exposing themselves to resident evil, anger, fear, and cadaver fumes. As for me, if I don't wake up screaming I just may have to go back to renegotiating Nietzsche in the bifurcated aesthetic.

Blogs by Medical Students

There are dozens if not scores of blogs of interest to medical students, which cover the whole gamut from serious and furrow-browed to frivolous, very funny or decidedly disturbing. According to a November 2005 study by the Pew Internet & American Life Project, 19% of online teens keep a blog and 38% read them. This represents approximately four million students in the United States alone who blog, a significantly higher percentage than the adult population (7%). Now those hot-tempered teens are entering medical schools, inhaling strange fumes, and sitting up far too late at night in front of their laptops.

This is a selected list of English-language med student blogs (and by that I mean I couldn't possibly find all the blogs out there, with new ones coming online every day it seems). I also ruled out blogs that did not have very recent posts; so some infrequent posters, or bloggers who must have got lost on their summer camping trip, are not included.

6yearmed - "Danielle's journey through medical school. (I am a 23 year old medical student in my last year of medical school.)"

Adventures in medical school - A blog by Fiona, a 4th year medical student in Minnesota (?)

Agraphia - "Names are changed, stories are exaggerated, dates are made up, truths are bent. I’m a second year med student who has surprised himself with an ability to keep a blog running"

An American medic in Britain - "This blog does not actually exist. That guy you see in the picture? Not me. That Facebook badge? Totally fake. I do not attend medical school, nor have I ever thought about it."

Anatomy on the Beach - "A medical student studying in the Caribbean."

The Angry Medic - "The Angry Medic is an idiot who got into Cambridge University by virtue of his unusually attractive eyelashes."

The Anonymous Medical Student - a blog kept by an anonymous medical student "somewhere in the world."

Becoming a Doctor - "Musings of a non-traditional (read older, gay) medical student. Not always about the ins-and-outs of medical education, but often."

The Berry Patch - "Random thoughts and observations about life in Israel, life in medical school, life with an extremely spoiled pet, and life in general."

Blogborygmi - "A digest of developments in the life of an emergency medicine resident."

Blogs of Medical Students - "A webring of blogs by medical students & professionals from all over the world."

CCLCM Student Blog - "This blog describes my experience as a medical student at the Cleveland Clinic Lerner College of Medicine."

The Chronicles of A Medical Student In Melbourne - "The life and thoughts of an international student from Malaysia living in Melbourne, struggling with food, books, lectures and the currency exchange"

Constructive procrastination - "My name is Noel Hastings and I am currently a medical student at the University of Washington (E-2005) planning on specializing in Emergency Medicine. I am about to embark on my clerkships, wanna tag along?"

The daily life of a med school student - a.k.a "It's 2 AM and I'm looking at urine outputs."

A Day in the Life of an OptStudent - "The OptStudent Blog gives you an exclusive look at the life of an optometry student, from day one!"

The Differential: MedScape med students (various contributors)

Defying Gravity - "making my way through medical school one cup of coffee at a time"

Dose of Reality: the med students' blog - "This is where you’ll hear what it’s really like at the University of Michigan Medical School."

DundeeMedStudent - "I am a graduate entering medical school in Dundee. I enjoy ranting and moaning, so started a blog."

The Evil Resident - "it's psychosomatic. you need a lobotomy. i'll get a saw."

frylime: a quasi-medical autobiography - "the title was supposed to be 'turn your head and cough', but that could have been really weird..."

The Future Dr. House, D.O. - "Follow the life of an eager, wide-eyed, overly passionate premedical student as he slowly turns into the cynical, jaded and sarcastic, but brilliant, Dr. Gregory House, D.O."

The girl with the blue stethoscope - "I'm a medical student rapidly sliding towards the end of first year and I'm writing from the perspective of somebody who has had another career in health but wanted to be able to do so much more."

Half MD.com - "At the halfway point in medical education"

The Haversian Canal - "By Niels Olson, a Navy Lieutenant and third year medical student in New Orleans"

I Am Not A Drain On Society - "I'm destined to be a Drain on Society for at least another 5 years now - dodging tax and national insurance contributions while taking tax payers money to fund my education. Yeah right! By the time I finish (in 2011!) I will have been in full time education for 23 years (university for 9 alone). Depressing isn't it...."

I'm a medical student. Get me out of here! - "I'm a 5th year medical student at a Northern medical school in the UK. I like to moan and complain a lot and what better way to do so than with a blog. Follow my journey through medical school and life."

I'm not anti-social, I'm just pre-med - by Xavier Emmanuelle, Ontario

Intueri: to contemplate - "I am a female resident physician in psychiatry who lives in the shadow of the Space Needle."

Island Med Student - "My name is Kendra and I am a second-year medical student attending Ross University School of Medicine on the Nature Island of Dominica."

Medical Student Musings - A blogger from Sacramento "complains her way through one of the strangest and most dysfunctional educational experiences imaginable: medical school (and hopefully residency someday too)."

Med School Hell - "The medical school blog that helps students find their way through medical school and beyond with a no-bullshit approach to what medical training and the medical lifestyle is really about."

Medicine and Economics - "This blog was created to explore basic economic theory and how it applies to medicine in both the U.S. and abroad. I am currently a medical student in Miami, FL."

Med-Source - Emily Cooper, a med student at the University of Pennsylvania reviews a variety of online tools for medical students

Medstudentitis - "wishing life was this simple"

Mexico med student - "I'm an MS3 at Universidad Autónoma de Guadalajara School of Medicine in Guadalajara, Mexico."

Michelle vs. the Med Student - "Yes, I am a med student and my name is Michelle. I am interested in all things medical and I can be quite serious and professional in my foxy white coat."

Monash medical student - "deliberates abt medicine, Reformed Christianity, current affairs, & politics in Singapore; muses abt running, life in med sch & in general"

My life, my pace - "an MD/PhD student’s take on school, lab, LIFE"

Ms Ellisa - "I'm a 4th year medical student. I'm the only one posting and probably the only one reading, so who cares?! Still it's better than being in class... Oh- and it's Elli-S-A actually... :-)"

nosugrefneb.com/weblog - "I am a medical student at the University of Chicago pursuing an MD and a PhD in cancer biology."

Not My Second Opinion! - "A healthy discussion of philosophy, ethics and education by a medical student."

Of short white coats and stethoscopes - "I should start calling myself a 4th year now. Scary."

Orthopedic Residency: the attending perspective - "This blog is specifically for medical students interested in orthopaedics and orthopaedic residents. It is orthopaedic residency from the attending's perspective."

Over!My!Med!Body! - "I’m a med student on the west coast, currently in my third year."

Panda Bear, MD - "I am a former United States Marine Infantryman and currently an Emergency Medicine Resident Physician."

RambleStrip - "I'm a third-year medical student on my psychiatry rotation"

Reflections of a DC Medical Student - "A place to gather my thoughts about life during medical school and to share my experience with others."

The Rejected - "Brush Your Teeth After You’ve Inhaled Cadaver Fumes for 2 Hours"

The Rumors Were True - "I used to be a Midwesterner and am now a Caribbean medical student at St. George’s University."

Sarah goes to Deutschland - "I'm just blogging to blog. Hopefully someone will read it. :) Once I start medical school in August I hope to write about my experiences and hopefully assist a fellow future physician navigate the med school waters. If I can just help one person, it has been worth it!"

ScienceRoll - "A medical student's journey inside genetics and medicine through web 2.0"

The Scrivener - "The musings of a medical student."

Scrub Notes - "A med student's guide to making life in med school easy"

Streets broad and narrow - "my path through medical school"

Studying under a palm tree - "I'm an Australian medical student, almost 1/4 of the way through 4 years of the unknown- with many more years to come after that."

Toxic Megacolon - by John Dorian, Cleveland, Ohio

TruMed - "The true story of a medical student in the United States."

Two (presidential) terms later - and i'll still be a student - "Commentary on ethics, medicine, politics, and sports - plus assorted ramblings - from fourth-year MD/PhD student Aaron Kithcart at The Ohio State University."

Type B medicine - "Three type B med students who have decided to come out of hiding and give all of the rest of us a place to speak our minds. Know the rigors of being a type B in a type A world? Wishing everyone else would just chill out and take a deep breath? Check us out."

The underwear drawer - "The online journal of an Anesthesiology resident in New York City trying to get used to the idea of calling herself 'Doctor' without using those finger air quotes."

Unprotected text - "A scallywags [sic] journey through medical school." (Harry, London, United Kingdom. Biomed graduate student starting medical school Sept 2007)

Vitum medicinus.com - "I'm a 23-year-old going into his second year at a Canadian medical school, blogging about the funny, action-packed, and dramatic moments of my medical education."

With enough courage you don't need a reputation - "Have a dream, make a plan, go for it." These are my adventures about how I got into medical school and what happens next.

Yet Another Med School Blog - "Med School. Life. Other interesting tidbits."




Other Medical Blogs

The Dutch MedBlog.nl has a comprehensive list of English-language medical blogs of all kinds, not just by students. The blogs are ranked according to an algorithm that measures their relative popularity on the web. Very interesting.


Medical Blog Awards
For students new to the world of medical blogs, one place to start is with the winners of the Medical Blog Awards, given annually by the people who put together MedGadget.

Here are the prize winners for 2006:

Best Medical Blog is...
NHS Blog Doctor by Dr. John Crippen, a general practitioner from the UK. Described as an "extremely depressing" look at the state of the NHS, Dr. Crippen's blog also highlights the joys of being a doctor. That means simple and not so simple things such as patient contact, differential diagnosis, treatment and the follow up.

Best New Medical Blog is...
Flea, a weblog by an anonymous pediatrician "in solo practice in the Northeast U.S." Flea tackles many issues facing pediatricians today: from childhood obesity to anti-vaccination cranks and their websites that scare parents with pseudo-scientific proclamations.

Special mention goes to ScienceRoll, a weblog by Bertalan Meskó, a medical student at the University of Debrecen, Hungary, who has received the highest number of votes from readers.

Best Literary Medical Blog is...
NHS Blog Doctor by Dr. John Crippen. Special mention goes to Maria at Intueri (student blog).

Best Clinical Sciences Weblog is...

Anxiety, Addiction and Depression Treatments, a psychiatry website run by TreatmentOnline. Special mention goes to Clinical Cases and Images, a website felt by many judges to be an excellent resource on all things clinical.

Best Health Policies/Ethics Weblog is...

NHS Blog Doctor. Special mention from judges goes to Kevin, M.D. for his excellent daily blog that mixes politics, ethics, clinical issues and curiosities of medicine.

Best Medical Technologies/Informatics Weblog is... The Healthcare IT Guy by Shahid N. Shah, who is CEO of Netspective. His blog offers an insider's view on all the fast changes that happen in healthcare IT.

Special mention from the judges goes to Dr. Steven Palter's Docinthemachine, for his excellence in in-depth reporting on the latest medical technologies.

Best Patient's Blog is...

The Furry Monkey by Karen Theobald, a patient with Non-Hodgkin's Lymphoma. Special mention goes to Amy Tenderich for her Diabetes Mine, an excellent blog by a diabetes patient.

Check out the complete list of 2006 Medical Weblog Awards nominees.


Blogs by and for Med Rehab students

Have a look at Eugene Barsky's UBC Physio Info-blog. Eugene is a Physiotherapy Outreach Librarian at the Irving K. Barber Learning Centre, University of British Columbia. Rachael Lowe, a physio from UK is coordinating a number of physical therapy blogs that could be of interest:

* Physiospot Musculoskeletal

* Physiospot Sports

* Physiospot Womens Health

Says Rachael: "The aim of Physiospot is to provide a set of research article blogs that allow physiotherapists to easily stay up to date with current research in their area of interest."

OT/PT Blogs

These were rather hard to find. Here is a selected list of blogs by students and practitioners:

ABC Therapeutics Occupational Therapy Weblog - "reflections on a lifework of occupational therapy" (from a New York OT)

blogspotphysio

Housing OT - "James Lampert is an Independent / Private Occupational Therapist ( OT ) working in Kent, UK."

mamachill - by an OT student in Texas

The Life of a Future Occupational Therapist - "~Patti, OTS~ New Jersey, United States. I'm about to begin my first semester as a Graduate Student in Occupational Therapy."

Meta OT - from a British OT

Occupational Therapist in Equador - "I am currently living, volunteering and learning sSpanish in a town called Manta, in Ecuador."

Occupational Therapy: a blog about OT - an American OT student

Occupational Therapy Blog Experiment - "I'm an occupational therapist working in neuro rehab"

Occupational Therapy Dunedin - a neuro OT working in New Zealand

Occupational Therapy Educational Issues - Merrolee's bog - an OT educator from the School of OT, Otago Polytechnic, New Zealand

Occupational therapy for you - "learning more about how an occupational therapist learns"

Occupational Therapy in Egypt

Occupational Therapy Issues and Reflections

Occupational Therapy Otago - developed to explore using blogging as a professional development tool - New Zealand OT educator

Occupational Therapy Rehab Reflections - "I am an occupational therapist working in a community neurological rehabilitation centre."

Occupational Therapy Reflect

Occupational Therapy Students Belong - "I am a 24 year old first-year Master of Occupational Therapy (MOT) student. I enjoy reading OT blogs, and I love OT school!"

OT Exchange - (not exactly a blog) "This site provides a central place where therapists can exchange ideas, share experiences and brainstorm together."

Patti's blog - the life of a future occupational therapist

Physiotherapy Blog - "a physio's thoughts on physiotherapy, NHS, and the madness of modern healthcare"

reallycoolphysio

Reflections of an Occupational Therapist

Rehab Care Campus Relations

Rick Steinberg's Blog - an American OT working in the schools system

School OT thoughts

Set a man on fire - OT Student from Dunedin, NZ

Thriving in School - "We are the occupational therapists at Hosmer School, always searching for ways to improve school function and participation!"

Respiratory Therapy Blogs

Respiratory Therapy 101: Just Keep Breathing - "written by Anonymous Therapist, a respiratory therapist practicing somewhere East of the Mississippi and West of the Atlantic."

Respiratory Therapy Blog - "Respiratory Therapist in the Saskatoon Health Region since 1998."

Dentistry Blogs

I found these listings on the Student Doctor Network, but more work is required to get at the root of the dental blogging world:

• Dental 2.0
• D:Dental.exe
• Dental Harmony
• DMDstudent.com
• Rise beyond mediocrity
• Marcus Moss
• UT Memphis
• The Pre-Dental life
• ....0_0........Without thinking...^_^...
• Just Wiggle It

This just in! Have a look at these dental blogs:

Going Dental - "Providing information to dentists, students and patients since 2006."

OMFSource Blog - "The Students Guide to Oral & Maxillofacial Surgery Blog"

Predents.com

Student Dentist Social Network

Shelf life and life support

Problems with systematic reviews

Many systematic reviews in Cochrane and other resources are stale-dated. Even worse, they are not being used as frequently as you might think. A new kind of review is urgently needed. Recent research looks at the nature of the problem and what can be done about it.

An interesting post by Oliver Obst in the German-language blog MEDINFO comments on a couple of recently published articles by Canadian researchers that contain some, to me, fascinating revelations about systematic reviews (SRs) and meta-analyses. As someone who makes a living finding the good stuff for others, and aware as I am of the superabundance and pelting velocity of research in the health sciences, I have sometimes wondered about the reliability of systematic reviews, how and by whom they are being used, and whether they are making a difference in health care.

A study by Shojania, et al. in the Annals of internal medicine (1) informs us that, briefly put, systematic reviews have a short shelf-life. The authors demonstrate the speed at which the conclusions of 100 SRs published in ACP Journal Club were stale-dated with the appearance of substantive new evidence about the effectiveness or harms of therapies. Fifty percent of reviews were out of date within 5.5 years after publication, and 23% were out of date within 2 years. Significant new evidence was already available for 7% of the reviews at the time of publication. The results were most likely to change for cardiovascular interventions (presumably because of the large number of trials in cardiovascular medicine) or if the trials in the original review were heterogeneous.

Dr. Obst remarks that, even though the Cochrane Collaboration recommends updating SRs every two years, its own reviews succumb as quickly to the general scientific stale-dating as other peer review meta-analyses. Cochrane's survival rate is no surprise, continues Obst, since regular updates to its reviews, even the two-year recommended rhythm, are the exception rather than the rule. (See the 2007 Cochrane Colloquium abstract by Georg Koch (3), who reports that only 43% of reviews he analyzed were up to date.)

In the same issue of the Annals, Canadian physicians A. Laupacis and S. Straus (2), comment on the article by Shojania and colleagues, suggesting that SRs should be updated annually to keep them relevant. They go on to discuss the broader questions concerning the present state of systematic reviews. SRs, they agree, are universally acknowledged to be less susceptible to bias and the best source for making clinical, policy or personal decisions. The methodological quality of SRs has been improved. More SRs than ever are being published. So what is wrong with this picture?

Quite a bit, according to Laupacis and Straus. Before they get to the heart of the problem, they start with the assertion that SRs "are used less frequently by clinicians and policy-makers than one might think" (p. 273), and they cite a number of studies to support their position. Their main concern: If they are so important to best practice, why are SRs so seldom used? In trying to come up with an answer they look at problems with the clinical relevance of the questions addressed by SRs, the format of SRs, and their failure to place their findings in a clinical context. Here is an overview of their main points:

1. Why don't SRs answer the most important questions? SRs tend to address highly specific research questions of interest to the author but less likely to be relevant to the needs of health administrators, clinicians or patients. SRs do not usually address the broad, pertinent questions, such as, "What is the most effective treatment for X ?"
2. Why can't SRs be more readily used by the people who need the information the most? SRs are entirely dependent on randomized trials which, largely because of their specificity and lack of follow-up for adverse events, raise questions about their generalizability and therefore are insufficient to drive clinical practice on their own.
3. Why must SRs be so user-unfriendly? They are lengthy, complex and require an excessive amount of time and effort to digest. We can approach them only through the daunting chevaux-de-frise of stultifying prose, statistics, dense tables and charts, footnotes, and so on. It's so much easier to check UpToDate or a textbook, or to ask the person across the hall.
4. Why aren't SRs more useful for clinical practice and administrative decision making? They are not real-world practical. They focus on documenting methodological rigour, frequently do not provide sufficient information about basics like intervention or potential budget impact, and thus often fail to provide crucial contextual information for effective decision making by clinicians and policy makers.
   

How to encourage the more widespread use of SRs? To address the above issues some useful correctives are suggested:

• more exposure to SRs during clinical training;
• better liaison between researchers and the health care system, resulting in the commissioning and design of more pragmatic studies aimed at answering questions of greatest interest to clinicians and policy makers and most germane to patient care; and finally,
  
• more contextually relevant, user-friendly formats which present the information clearly for various purposes, e.g., they suggest three formats, from simple summary to full version.
  

The authors conclude: "We urgently need a new type of review. It would combine the scientific rigor of systematic reviews with the clinically nuanced contextualization and opinion of traditional review articles while clearly distinguishing between evidence and opinion" (p. 274).

A similar conclusion is reached in a recent article in the Zeitschrift für Gastroenterologie. The authors repeat the call for a friendly front end to the standard SR, the umbrella review. They also remind us of the ultimate purpose of all this effort:

The problematic nature of overly long texts with highly specific research questions should be addressed by the so-called umbrella reviews. This new form brings together the results of thematically applied Cochrane reviews in a way that is brief, standardized and systematic... It is to be hoped that these efforts will help to improve the user-friendliness of this database. For the Cochrane Library was not originally conceived primarily as a service for writers of textbooks, creators of guidelines and government committees, but above all as a quick, high-quality and reliable resource for bedside decision-making (p. 264) [my translation].

References

1. Shojania KG, Sampson M, Ansari MT, Ji J, Doucette S, Moher D. How quickly do systematic reviews go out of date? A survival analysis. Ann Intern Med. 2007 Aug 21;147(4):224-33.

2. Laupacis A, Straus S. Systematic reviews: time to address clinical and policy relevance as well as methodological rigor. Ann Intern Med. 2007 Aug 21;147(4):273-4.

3. Koch G. No improvement - still less than half of the Cochrane reviews are up to date. Cochrane Colloquium Proceedings [abstract online] 2007 [cited 1 Sep 2007] Feb 1;[P055] Available from: http://www.imbi.uni-freiburg.de/OJS/cca/index.php/cca/article/view/2008

4. Timmer A, Motschall E. Die Cochrane Library: eine Einführung für Gastroenterologen. The Cochrane Library: a short introduction for gastroenterologists. Z Gastroenterol 2007; 45: 259-264.