Breasts, Genitals and Profanity in the Service of Skepticism

It's time for another report from TAM6, coming to you from sunny downtown Las Vegas, where it got up to 107° F (41.7 ° C) today.

Highlights from today:

Ben Goldacre, M.D. is a British physician and journalist, and author of The Guardian's weekly Bad Science column. He spoke today about homeopathy in the U.K. He pointed out that in 1846, John Forbes, the Queen's own physician, was a strong opponent of homeopathy. He contrasted that to today, where the Queen's personal physician is a homeopath. Only partially tongue-in-cheek, Dr. Goldacre wondered if this movement toward wacky medicine correlated with the loss of the British Empire.

Richard Saunders gave a short summary of skeptical matters in Australia. The best part of his session was an audience-participation experiment of dousing. This elegant experiment was designed to help teach critical thinking to school children. With 5 plastic buckets, a bottle of water, a simple dousing rod, and about 15 minutes, he showed how elementary school kids can grasp and even derive for themselves the principles of randomization, and single and double blinding of an experiment. The next time one of my residents seems a bit hazy on these concepts, I'll bring out the dousing gear.

Penn and Teller hosted a short but zesty Q & A session about their Bullshit! TV series, politics and skepticism. As a longtime fan of their stage act, it was a great treat for me to hear Teller actually speak, which he does quite eloquently, by the way. My favorite Teller quote today:

Q. What skeptical accomplishment are you most proud of?
A. Bringing bare breasts, genitals and profanity to the service of skepticism.

My favorite Penn Jillette quote today:

Q. On your Bullshit! show, are you trying to be fair and unbiased?
A. No. We are trying to be fair and extremely biased.

Alexander Jason told us about some of his exploits as a crime scene analyst, and pointed out how helpful a critical mind was in his line of work. He also described his work with James Randi in the 1980's to help debunk fake faith healer Peter Popoff. The video clip below summarizes some of the events of this scandal.



George Hrab, singer, songwriter, and author extraordinaire entertained us with a number of his creations. My favorite Hrab line, when he had some early sound problems with his guitar: "It's a PC guitar." To a Mac user, 'nuff said.

Dr. PZ Myers, biologist and author of the excellent Pharyngula blog, did not actually disembowel a Christian on stage, as was earlier predicted by some. Instead he gave a nice discussion of the evolution of bat wings. He wrapped up his presentation with a slide of "gratuitous squid porn". It is noteworthy that his presentation is the only one so far in which video clips have worked flawlessly. As you might expect, he uses a Mac.

Dr. Neil deGrasse Tyson, astrophysicist, chairman of the Planetary Society and PBS Nova scienceNow host, gave a truly spectacular keynote address, which he called "Brain Droppings".


These "droppings" covered a wide variety of topics, all built around the central theme of the close relationship between the scientific literacy of a population and the intellectual and creative health of their nation. Tyson gave a vivid account of the role of rising religious fundamentalism in the fall of the Islamic intellectual empire around 1100 CE -- a disaster from which the Islamic scientific community has never recovered. Parallels drawn by Dr. Tyson between this disaster and the current U.S. decline in scientific literacy were quite chilling. One hopes that the next administration can begin to repair some of the great damage done in the last 8 years to U.S. scientific research by the current administration.

A brief list of some of the questions considered in this 90-minute talk:

• would an iPhone user have been burned at the stake 10 years ago (maybe so)
  
• is there life on other planets (almost certainly)
  
• does swami levitation work (yes, but only with sufficient flatus)
  
• should we put pictures of scientists on our money (yes, and equations too!)
  
• can lunar tidal forces affect your brain (yes, but they are a trillion times less than those exerted by your pillow)
  
• is breathing, eating and drinking through the same orifice evidence of intelligent design (duh, no -- this is a stupid design that actually kills people)
  

Note to self: Never, ever, ever speak after this man. I'm pretty sure that everyone on the program following Dr. Tyson was thinking the same thing. Neil deGrasse Tyson combines a keen intellect and a strong background in science and history with the passionate lecture style of an evangelical preacher. He makes a powerful advocate for science and its essential role in society. One can only hope that we begin to elect politicians worthy of such an advocate.

My Next Number is...

The title of this post is appropriate for two reasons:

1. this post is my 100th post on this blog
2. this was a phrase used today at TAM6 by Dr. Art Benjamin, the Mathemagician.

The Art of Memory

My favorite afternoon workshop was The Art of Memory by Banachek. Banachek is billed as the world's leading Mentalist, and he kicked off his session by memorizing an entire deck of cards in about 47 seconds. Over the next 2 hours, he showed us several ways to do this. This has got to win the prize for the most practical first day talk ever at a Las Vegas convention!

By the end of this two hour session, he had given us mnemonic tools for memorizing a grocery list, a speech and a 74 digit number. Knowing these techniques back in my pre-med and med school days would have been worth the price of admission, all by themselves.

Besides his prodigious feats of memory, Banachek performs some pretty swell illusions, as shown in the video clip below.



The fascinating story of Banachek's work with James Randi in Project Alpha is well worth the read. If you'd prefer to hear this tale in Randi's own words, The Amazing Show podcast on that subject makes for fine listening.

The Mathemagician

If Art Benjamin were John Henry, the steam drill would have had its ass handed to it in a handbasket. Art demonstrated this right off the bat, by outperforming 5 people with calculators in several numerical feats.

It's hard to wow a room full of practicing skeptics, but Art accomplished this pretty quickly, spouting out the squares of 4 digit numbers about as fast as the audience could call them out. Before the calculator dudes on stage could even enter the digits for most of the problems, he was writing the answer down on a flip chart.

It's usually a let-down when a magician tells us the secret behind a trick. Benjamin, however, is a great exception to this rule. Even after he explained to us the details of how he did all of these mental calculations, it remained jaw-dropping to watch him blasting through these techniques at warp 4.

I could hoard all of these secrets to myself, but that would be pointless, since his excellent book (Secrets of Mental Math: The Mathemagician's Guide to Lightning Calculation and Amazing Math Tricks) reveals them all within its pages.

In the following video clip from the TED Talks, you'll see why we also gave him a standing ovation:



Besides being a great stage performer, Art Benjamin is a professor of mathematics at Harvey Mudd College, with a special interest in combinatorics and Fibonacci numbers. In the Q & A session, someone asked him for the URL of his website. He joked that despite these credentials and being able to recite the first 100 digits of pi, he was unable to remember his own web address. How does he find his site online? He googles himself.

The Amazing Meeting

I'm spending four days at the Flamingo Hotel in Las Vegas, Nevada, attending the 6th annual edition of The Amaz!ng Meeting, aka TAM6. The following blurb is direct from the TAM website:

The Amaz!ng Meeting is a celebration of critical thinking and skepticism sponsored by the James Randi Educational Foundation. Thinking people travel the world to share learning, laughs and life with fellow skeptics and distinguished guest speakers.

The Amazing Randi tells an anecdote about Art Benjamin

With a name like that, one would expect the talks to be a lot more, well, amazing than the fare at the usual radiology meeting. The program includes some stellar talent, including James Randi, Dr. Neil DeGrasse Tyson (astrophysicist and PBS Nova host), Adam Savage (Mythbusters co-host), Matthew Chapman (author and great-great grandson of Charles Darwin), Dr. PZ Myers (biology professor and Pharyngula blogger) and Penn and Teller.

Critical thinking is one of the many things I try to teach my students and residents, and I'm always up for new ways of teaching this material. From the partial TAM6 faculty list above, one can see an unusually large fraction of the Jedi Council of critical thinkers. If one can learn by osmosis alone, I should get a lot out of this meeting.

June in Las Vegas is pretty much what you would imagine - 103° F (39.4 ° C) today, with 107 ° F (41.7 ° C) predicted for tomorrow. However, the air-conditioning at the Flamingo is so relentless that I shivered my way through the afternoon sessions. That pile vest I felt silly packing at home will stay on me for the rest of the meeting.

I'll post some meeting highlights as time permits.

Grand Rounds - Vol 4, No. 39

This week's edition of Grand Rounds is hosted by David Khorram of the Marianas Eye Blog.

Grand Rounds is a weekly anthology of the best medical blogging on the web.

Radiology of Competitive Speed Eating is my donation to this potluck of medical meditations. 

The "raison d'eater" for my post is to help explain some of the physiologic adaptions necessary to excel in the world of dog-eat-dog dog-eating.

I'm Not a Real Patient, But I Play One on TV

What do you call a patient who fakes their history, symptoms and physical exam to gain medical care? For many of us, this sounds like a classic case of Munchausen syndrome.

So what would you call it when a hospital administration hires such people to covertly evaluate the quality of care in their facility? Users and purveyors of this service use a variety of terms, including "mystery shoppers", "secret shoppers", "ghost shoppers", "undercover patients" and "sham patients".

This concept of Munchausen management is currently being pushed, ironically enough, by the ethics council of the American Medical Association. During their current 5 day meeting (which began on June 14) the AMA ethics council is pressing the rest of the AMA to endorse the use of undercover patients to evaluate the quality of care at medical facilities and physician offices.

The AMA's Virtual Mentor site has a point-counterpoint style discussion of this topic, with commentaries on both sides of the issue. Of the opinions posted there, I think that University of Illinois professor Richard C. Frederick, M.D. gets it right:

This practice highlights the crisis of medical professionalism—failure to view the physician as a professional. Finally there is the huge question about the consequences of using deceit in a field where truthfulness is a core virtue.

A Priori Assumption of Guilt

When police set up a sting operation in a pawn shop, a downtown hooker hangout, or a congressional office, they are not out to improve quality control. They are not doing it to prove that someone is innocent. They do it because they are pretty darned sure that something is wrong and they want out to nail someone for it. When there is sufficient evidence of malfeasance, I'll grant that a sting is a fine technique.

However, foisting the same tactic on physicians for "routine quality control" is a completely different kettle of fish. The message it sends is not: "We want to help you improve your care." To a health care practitioner, it clearly says: "We don't trust you." To patients, it is equally clear: "We don't trust your doctors."

Surrogate Endpoints

I am all for improving patient care. I want all of the patients in our medical center to feel welcome and well-taken care of. However, let me emphasize the word "patient" here. I want to get as much feedback as possible from actual patients on how we are doing and how we can do it better. Contrast this with data collected from a sham patient -- no matter how well these folks are trained, their data is going to be, at best, a surrogate of what an actual patient feels, needs and experiences. Since these medical mystery shoppers don't have actual medical needs of their own, they will pretty much be checking off items on someone else's arbitrary feature checklist. As Dr. Frederick puts it:

One wonders how effective the secret shopper can be in assessing physicians' most important roles. If these people are not sick, frightened, tired, and vulnerable like real patients, how helpful is their appraisal to the physician whose patients are frightened and vulnerable?

Doré's caricature of Baron Münchhausen

Is Anyone Actually Harmed by Sham Patients?

How ethical is it to put a sham patient through medical tests and procedures for which there is no medical necessity? If the only people concerned were the sham patients themselves, this might not be an issue -- after all, they volunteered for it, and are often paid to do this sort of thing.

However, sham patients are not the only ones put at risk by this practice. Consider the patient with real chest pain who has to wait in the ER a little longer while a sham patient with no disease at all is seen first. But wait, there's more. Dr. Frederick again nails it:

Consider the scenario where a nurse or lab tech gets a needle stick while treating this "planted" patient and develops hepatitis or HIV.

It's only too easy to extend this concept to the radiology department. Any time I perform a shoulder arthrogram on a patient, I and my radiology technologist are exposed not only to needle sticks, but also to a certain extra dose of ionizing radiation. I am quite willing to take a few extra rays if it will help an actual patient. However, the thought of doing so on a sham patient for no medically indicated reason makes me a bit livid.

The Problem of False Positives

Some apologists for medical mystery shopping rationalize the practice by pointing out the rare cases where unexpected findings turn up in these sham patients. A big problem with this is that the predictive value of a positive test is tightly coupled to the underlying disease prevalence. In a sham patient, that prevalence is usually going to approach zero. This means that a false positive result is far more likely than a true positive result.

What if a false positive result leads to a more invasive procedures, such as a biopsy or surgery? The results of this, alas, can occasionally be dire, and I'll offer one extreme example from a good friend. Two of his medical school classmates, upon reaching a certain age, gifted each other with a full-body CT exam. One of them underwent a needle biopsy after the CT showed a questionable lung lesion. This biopsy was complicated by a tension pneumothorax and death. This is about as dire as it gets.

Reaping What One Has Sown

If this management fad becomes commonplace in medicine, I can only hope that its proponents are quickly hoist on their own petard. For example, why should a hospital be the only one who can set medical spies on their staff? There's really nothing to stop a competing practice or hospital from doing the same thing. A disgruntled patient or former staff member could do the same thing, and spray the results all over the media and the web.

On a personal note, I would find it extremely hard to ever trust a hospital or departmental administration who inflicted a program like this on me. I'll let Dr. Frederick have the last word on this:

Finally, we teach our residents and medical students that when we are not truthful with our patients, we violate their trust. We also put into question the next physician's truthfulness. We have all heard a patient say, "Those doctors at that institution lied to me, so I trust none of them." In reality maybe only one physician lied, but all are tarred with the same brush. Trust is fragile, and, once violated, it is hard to restore. But trust goes both ways. Are we physicians not human too? Once we are fooled by these "good actors," will there be an element of doubt about the legitimacy of the next patient with a similar complaint? I work in an emergency room and have been lied to frequently, but not by my administration or the executive director of my group. Cynicism, already a problem in medicine, will only be made worse by the use of official deceit. As physicians in a profession where high ethical standards are essential, deceit, however well meaning, is not a tool we should use.

Friday the 13th

Friday the 13th was a fairly routine day in our radiology store today. Except for 4 of our patients who underwent shoulder arthrograms today, I don't think anyone here regarded it as a particularly unlucky day.

Just for the heck of it, I idly googled "13 radiology" just to see what popped up. Here are some of my hits:

The European Society of Musculoskeletal Radiology had its 10th Annual Meeting on Friday, June 13, 2003 in Aarhus, Denmark. A quick follow-up google search of "ESMR", "disaster" and "2003" didn't turn up any obvious catastrophes, so I'm assuming they survived somehow.

Vijay of Scan Man's Notes posted the following on Friday, April 13, 2008:

Happy Baisakhi to Punjabi friends
It is, I think, a rare coincidence that a major festival falls on what is traditionally thought to be an unlucky day.

Would this make the whole New Punjabi Year an unlucky one?

Hopefully, Vijay will post an update next April so that we can see how the Punjab fared following this inauspicious juxtaposition of dates.

Chapter 13 of Emergency Radiology, edited by Reisdorff, Schwartz & Williamson turns out to be "Radiology of the Cervical Spine", surely one of the more terrifying body parts to image.

Most frightening of all, the chapter for "Radiology Services" in the U.S. Medicare Claims Processing Manual turns out to be Chapter 13.  Coincidence or Satanic confluence? You be the judge...

El Camino del Rey Walkway

This has nothing to do with radiology, but I feel compelled to share it here anyway. This has got to be one of the most excruciating 6 minute video clips I have ever seen. I enjoy mountain hikes, but I'm not too wild about sheer drop-offs.

On second thought, this post does have some specious anatomic relevance. Let's just say that this clip would make a great workout video for one's cremaster muscles.

This video is best viewed full screen (click the little icon at the bottom of the video screen that looks like a square with brackets).



Originally built in 1901, this walkway now serves as an approach to El Makinodromo and El Chorro, famous climbs in Andalusia, Spain.

(via BizarroBlog)