Tuesday, February 23, 2010

Whistleblower Grand Rounds Vol. 6 No. 22: It’s ‘Alimentary’, Doctors!

Jacobs Ladder PHOTOCREDITi[1] It’s been a while since I’ve attended a conventional medical Grand Rounds. These were events where a medical luminary would fly in to give a medical audience a state-of-the-art presentation on a medical subject. Ideally, the speaker was a thought leader and a researcher on the issue.

These presentations were usually not a demonstration of the virtue of humility. We physicians, as a class, have generous egos. Academic physicians occupy a higher rung on the ego ladder. Medical Grand Rounders (MGRs), who are on the GR speaking circuit, often must bring their own ladders to assure they will be able to reach their desired atmospheric height.

Jacob’s Ladder Photo Credit

At least in the old days, before the GR speaker would assume his position behind the rostrum, a designated pre-speaker would offer an introduction. The audience would hear a list of awards, achievements, journal editorial positions, department chairmanships, honorary degrees, publications and book chapter authorships, military service, Boy Scout merit badges and various other hosannas. How do these introducers, who may have never met the main event personally, know their bios so well?   Do the MGRs provide their own intro speeches?

During the traditional GR presentation, seasoned MGRs periodically demonstrate a tincture of haughtiness with a rhetorical technique that has irked me since my medical training days. When the MGR refers to some world famous, pioneering medical researcher, a name known to every physician in the audience, the MGR casually refers to this near deity by his first name, as if they are drinking pals. Here’s a hypothetical example.
The Scene:        MGR giving Grand Rounds on polio.
Power Point:    Data from Jonah Salk’s vaccine research.
MGR:                 “Here’s what Jonah was getting at here…”
Sorry readers, but I’ve been waiting 20 years to ‘blow the whistle’ on this one.

To any academic physicians, or even MGR who is still reading, please forgive my light hearted poking. Every practicing physician, including me, is in your debt.

For me, as this week’s Grand Rounds host, I assure you that I approach the task with great humility, stretching to reach the first rung of the ego ladder. I am honored and delighted to offer a compendium (or should a gastroenterologist use the word smorgasbord ?) of the medical blogosphere. There is great talent in this community.

In visiting some prior Grand Rounds, I was awestruck by the technical wizardry wielded by many of the hosts. Either they have graduate degrees in information technology, or there was a 12-year-old kid nearby. I have neither of these advantages, so there may be a fewer bells & whistles, even for an avowed whistleblower.

I received 33 blog entries to review, or digest. While they were all meritorious, there must be some mechanism to separate the truly great from the merely awesome. But, how best to accomplish this? Should I adopt the ‘Rock, Paper, Scissors’ method used by Ivy League admissions’ offices?  Perhaps, a random lottery draw? Eeny, meeny, miney mo?  No, all blog entries will have to prove their resilience and worth.

All entries will travel a road mined with traps and hazards waiting to disable them. Which will be cut down and which will survive the journey?  This will be a blogger’s version of The Odyssey, where the winning post must overcome deadly obstacles as he strives to return home
Every entry forwarded to me appears on this post, even the procrastinators who offered various lame excuses .

250px-Tonsils_diagram[1] The 33 entries have all entered the oral cavity, the start of the alimentary canal.  It’s a long way to the rectum. Let the games begin!

The entries are now being masticated, or chewed, and bathed with saliva. Allergy Notes gets crunched by powerful rear molars.
Allergy Notes warns asthmatics not to take Long-Acting Beta-Agonists (LABAs) as sole treatment. The post doesn’t explain why, but it does suggest a doomsday scenario if LABAs are taken alone. Perhaps, this is common knowledge to all physician specialties except gastroenterology.
The remaining 32 posts are propelled into the esophagus, the muscular tube that quickly transmits food into the stomach, But, there is a stealth trap waiting to ensnare an unsuspecting blog post. This esophagus has a Zenker’s diverticulum, a sneaky pouch just beyond the throat.

zenkers-surgery[1] Teen Health 411 gets trapped in the Zenker’s.

Photo Credit

Nancy Brown at Teen Health 411 offers us a brief tutorial on transgender issues, admittedly a subject that hasn’t entered my universe.

esophagus The remaining 31 entries tumble down the esophagus.  Behaviorism and Mental Health and The Cockroach Catcher gets stuck at a tight sphincter, or valve, at the bottom of the esophagus. 

See endoscopist’s view of the esophagus at left. 

Patrick Hickey, a retired psychologist, writes in Behaviorism and Mental Health that schizophrenia is caused more by nurture than nature.  His post is entitled, Schizophrenia is Not an Illness.  While this is beyond my field, I had not heard this view previously.
Am Ang Zhang points out in The Cockroach Catcher that Harvard MBA graduates have not achieved a legacy of success.  Your humble GR host had some difficulty following this post, but perhaps some of you will nail it.
Twenty-nine entries have made safe passage into the stomach and are rafting in rough waters. They confront torrential waves of powerful digestive chemicals and stomach acid.  Ask An MD and Dispatch from Second Base cannot tolerate these harsh conditions and they are dissolved.
Jackie, a new blogger, writes in Dispatch from Second Base about how a second medical opinion gave her a new path to the same destination. She offers a personal voice to the emotions and trials of surviving cancer.
Dr. D, for our amusement, weaves La Cosa Nostra into the development of medical education casting Abraham Flexner in a nefarious light. For the Whistleblower, this post in Ask An MD  is slightly conspiratorial, but judge for yourself. We report – you decide.
stomach Twenty-seven drenched entries are still afloat and are being tossed about in a toxic soup as the stomach tries to neutralize them before they can exit. 

A scope’s eye view of the stomach!

250px-Stomach_endoscopy_1[1] The remainder manage to exit the stomach and enter the duodenum, the initial portion of the small intestine, 20 feet of tubing that culminates in the colon, or large bowel.

Dark spot in photo at left is called the pylorus. This opening separates the stomach from the first portion of the small intestine, called the duodenum.

In the first portion of the duodenum, called the bulb, a large ulcer traps Dr. J’s HouseCalls.  Since acid is a major force in ulcer formation, her post is likely to make the ulcer worse.
Mary Johnson’s post in Dr. J’s HouseCalls easily survived the stomach’s acidic waters as her post had more acid than the stomach. Mary expresses strong views about our government and I surmise that she will not be posting on 'Obama for President' yard sign in 2012.
Beyond the ulcer, but still within the duodenum, the pancreas and liver secrete digestive chemicals. Highlight Health and The Fitness Fixer, who were not donning recommended protective gear, fall victim to these caustic fluids. They will be missed.
Walter Jessen in Highlight Health informs how we should dispose of unwanted medicines so that our medications don’t enter the food chain. While this post is not quite a spellbinder, it does offer practical advice on a relevant subject.
Jolie Bookspan in The Fitness Fixer relates that elderly individuals who have been hospitalized have higher fracture rates after discharge. While I am not persuaded there is cause and effect here, she reminds us that we often overlook certain aspects of health in our hospitalized patients. In my experience, nutrition, is another frequently neglected issue.
In the duodenum, there is a very small opening that leads to tunnels that connect to the liver and gallbladder.  Suddenly, the gallbladder hurls a gallstone through this tunnel which is ejected into the duodenum like a projectile.  It smashes into Insureblog and Health Business Blog like an aerial drone attack.  Both entries are pulverized on contact.
Henry Stern of InsureBlog relates an anecdote of a physician who is billing a patient’s insurance company for a service that I suspect has no authorized ICD code. I cannot attest to the veracity of Henry’s vignette, but I appreciate his brevity.
David Williams, in Health Business Blog, discusses that screening mammograms in elderly women cause more harm than healing.  There’s been more press on mammography in the past 6 months than there has been in decades.
small_bowel_2 And then there were 22, who have now entered the endurance phase of the journey. With 20 feet of small intestine, this becomes a blog entry’s marathon run.  Obviously, only a trained entry can survive this Blogathlon event.

Photo of small intestine.

ACP Internist, Shoot Up or Put Up, Supporting Safer Healthcare and ACP Hospitalist thought they could coast to the finish line relying on prayer, instead of preparation. This was a miscalculation. All four were carried from the field in a state of exhaustion and dehydration. The rest sail onward along the tortuous 'Highway to Hemorrhoids'.
Ryan DuBosar of ACP Internist informs us about several states that are incentivizing primary care physicians to serve in rural and underserved urban regions. As in medicine, making the diagnosis is easier than finding an effective remedy.
You know the bloggers at Shoot Up or Put Up are from ‘across the pond’ because they spell the word favourable wrong. In this post, diabetes is viewed through a Disney prism. This niche blog has attracted 131 fans, perhaps including Mickey, Donald and Pluto.
Rita Schwab of Supporting Safer Healthcare must be important because she has lots of letters following her surname. Rita shares an overview of the the power and hazards of the social media world. This is a good intro review, but not quite a 140 character tweet. Word count: 750 words.
Kirk Mathews on ACP Hospitalist summarizes James Orlikoff’s address to hospital leaders advising them what they need to do to stay solvent. For example, he instructs that hospitals view patients as their customers, and not physicians.
As the Darwinian journey continues, more than half of the original blog entries are still viable.  But, unseen hazards remain.  As Diabetes Mine, Cases Blog and  Colorado Health Insurance Insider round a sharp bend of small intestine, they lose control and land on a patch of viscous mucous, which ends their alimentary sojourn.  No, they won’t starve.  They are amidst a nutritional stream that will maintain them until, hopefully, a miracle or a rush of fluid will set them free. 
Amy Tenderich in Diabetes Mine shares an interview with Olympic cross-country skier Kris Freeman, who is a Type I diabetic. I had to give Amy a point deduction for exceeding Grand Rounds submission length limit, but I enjoyed her post and her enthusiasm. I was most amazed to learn that Kris Freeman has 30 pairs of skis with him!
CasesBlog shows us a Venn diagram from 3 locales where folks live beyond a century. If you’re interested to equal their longevity, check out the post. I confess that I did not view the 22 minute and 12 second YouTube presentation, but those of you with idle time are welcome to do so.
Colorado Health Insurance Insider either knew, or guessed, that overutilization of imaging studies is a recurrent Whistleblower rant. This post discusses why MRIs are overused and how this abuse can be curtailed.
Oh my stars, look ahead!  What is that slimy monster slithering upstream?  It is a sea monster that is charging straight for the entries with hostile intentions.
230px-Ascaris_lumbricoides[1]It’s the dreaded intestinal parasite, Ascaris, a worm who lives inside guts.  InteractMD freezes from fright. How To Cope With Pain and Medical Justice are immobilized by the beast.  These three entries ‘take one for the team’ as they occupy and distract the enemy allowing the others to pass by.

Michael Benjamin of InteractMD is a full service medical blog.  He posts interesting stuff daily on various medical subjects.  It’s worth checking out.  Michael speculates whether denture cream users will be the next major class action lawsuit.  Find out why.
How To Cope With Pain is devoted to a critical issue, coping with chronic pain, This piece, a guest post on the blog, is a thoughtful piece on making peace with pain. The blog is a great resource for those who suffer from chronic pain and those who suffer with them.
Medical Justice is a blog devoted to pursuing meaningful tort reform and points out absurdities in the current medical liability system. In this post, MJ advises physicians who might be contemplating a romantic tryst with a patient’s spouse, how they can avoid legal jeopardy. For those who have suffered the anguish of wrongful litigation, this site can be your sanctuary.

Intestinal life is fickle.  Just as the surviving entries creep past the predatory roundworm Ascaris, the worm snaps his tail like a bullwhip, taking out Healthblawg and the Happy Hospitalist. (I guess the beast likes the letter ‘H’.) 
David Harlow, of Healthblawg, gives a wonk’s analysis of the state of health care in Massachusetts. In short, it ain't pretty. In summary, costs continue to rise; price variations are unrelated to outcomes and there is an excess of academic and specialty medicine. Find out what David’s views are on the governor’s plans to mandate medical price controls. More noteworthy, this is the only piece I’ve read recently on Massachusetts that doesn’t discuss the recent electoral victory of Scott Brown.
The ever Happy Hospitalist was slightly less happy than usual in his post that explained why chiropractors succeed in promoting their healing in the absence of medical evidence. HH expresses both frustration and admiration. If I can paraphrase Happy, ‘It’s the Wellness, Stupid!’
250px-Schongauer_Anthony[1] Novel Patient, Everything Health and Six Until Me are all moving downstream at a steady pace, unaware of an impending ambush. Suddenly, they are served with legal papers by plaintiff attorneys, who inhabit certain digestive organs, who allege they have committed medical malpractice on patients none of them can recall.  They are hauled off to depositions and can no longer compete.

Painting of St. Anthony plagued by demons.

Lauren, at Novel Patient, inspires us with her piece on the power of positive thinking and prayer. She is afflicted with autoimmune diseases with neurological involvement. Her post relates that she took a ten foot walk, her 2nd walk in a year. In her own words, she plans ‘to take in one step at a time’. To Lauren, Godspeed.
Toni Brayer, bloggerette extraordinaire, introduces us in Everything Health to an extraordinary physician, William Halsted, a nineteenth century surgical pioneer and innovator, who attended at Johns Hopkins Medical Center. Toni reviews the book, 'Genius on the Edge – the Bizarre Double Life of Dr. William Steward Halsted’, pointing out that Halsted, like most geniuses, are complex individuals. For those drawn to medical history, read Toni’s post and then read the book.
Kerri, at Six Until Me, shares a tale that all of us have experienced. She involuntarily enters the labyrinthine domain of insurance company billing. She manages to extricate herself without inflicting harm on anyone. She proposes a novel use for broccoli spears that might be of interest to ENT (ear, nose & throat) physicians.
Seven remaining sailors are meandering toward the end of the long and tortuous small intestine, headed for the primary domain of the gastroenterologist – the colon.  To gain entry into the promised land, the entries must pass through a valve, which serves as a gatekeeper between the small and large intestines.  In a modified game of Russian Roulette, 6 pass through, but then Evidence in Medicine is crushed when the valve clamps shut without warning.
David Rind, an academic physician, recently introduced Evidence in Medicine and is already gaining traction in the blogosphere. He laments the success of snake oil salesmen hawking unproven or disproven remedies. I agree that these hawkers need to be reined it, but snake oil, eyes of newts and cat’s claw can only be sold if there are buyers. We need to target both the supply and demand channels of quackery.  Nicely done, David.
colon Six surviving entries now enter the colon.  They are swimming in a sea of …, I guess you all know what they're swimming in, even if you are not trained gastroenterologists.  The photo at the left is their current home in the colon.  

They are survivors and, like other Survivors, they have colluded and voted Fibro World off the colon.  It’s become Lord of the Flies, GI style.
Dot, along with her Fibro Mom write Fibro World blog. In this post, Dot gives a preview of a new medicine that is under FDA review for fibromyalgia. Blog posts that discuss a single medicine can be hypnotic, but Dot has made her post lively and personal. It’s well done and worth the read.
230px-Polyp-2[1]WIKI PHOTO CREDIT What do I espy in  the distance?  It’s a polyp, similar to the thousands I’ve removed .  This is a pedunculated polyp, meaning it’s like mushroom with a stem attached to the colon’s wall.  It starts swinging wildly and, like a medieval knight’s mace, it strikes down MedLibLog and Dinosaur Musings.
Photo Credit

Laika, of MedLibLog, rants about complementary and alternative medicine, or CAM, which I suspect she would support renaming as, SCAM. She details an accusation that Wordpress kicked out a blogger who was critical of a naturopath. Don’t grab your pitchforks yet, as we don’t know the facts about why the blogger underwent debloggification. Perhaps, his post broke the decency barrier. Laika’s post is well done and worth reading. CAM has become controversial, but like Laika, I’m not sure why it should be.
Dinosaur Musings has an excellent post on medical futility. In a twist, she states that we physicians often peddle the snake oil with the same enthusiasm and results as ‘alternative’ medicine practitioners. Quacks are not the only ones quacking, according to DM. This is a worthwhile read.
There are 3 excellent posts remaining. As we are witnessing each night in Vancouver, only 1 contestant can get the gold. The 3 are have traversed most of the large intestine and are headed for the rectum. There is light at the end of the tunnel. In his zeal to prevail, as the name of his blog suggests, Life in the Fast Lane accelerates and is impaled on a chicken bone that was inadvertently swallowed by the individual who has graciously loaned his GI tract for this issue of GR.

Chris Nickson in, Life in the Fast Lane, shows us his great wit in a post arguing why ADHD emergency room physicians are uniquely qualified. Chris includes a flow chart which I rank between clever and hilarious. Great stuff from ‘Down Under’.
190px-Hemorrhoid[1] The final two posts are hurtling toward the outside world.  It looks like we may need an endoscopic photo finish.  Hippocratic Oaf lunges forward, risking it all, and smashes into an internal hemorrhoid. Dazed and reeling, he falls back, within reach of the finish line.

Hippocratic Oaf, the creation of a 3rd year medical student, is well done. With puckish British humor, or humour, he lets us watch him puncture some folks with needles and catheters. This post offers a realistic and behind the scenes view of medical training.  It made me recall the day I was ‘taught’ how to draw blood from a veteran.  For me, it was do one, see one, teach one.
We are left with the winner, a post by a blogger who is trained in orifice emergence. Academic OB/GYN has reached daylight.

Nicholas Fogelson of Academic OB/GYN writes an outstanding post that should be required reading for medical students who are contemplating a surgical career. Nick nicely separates the craft of surgery from the profession of surgery, and explains why the latter is more important than the former. Judging by his post, I suspect that he is an excellent teacher.

There were many great posts, and I hope you will sample them.  Enjoy and have a great week!
Next week’s Grand Rounds host will be Doctor Anonymous.


  1. Great digestion of the Grand Rounds posts. :)

  2. Boy, that's a LOT to digest, but VERY satisfying!

    Thanks for hosting, and for including our post.

  3. Thanks. I know it is difficult to follow, but in the UK the likes of them are taking over and messing up the banks and now the hospitals. There must be money in it somewhere as at least 4 major US insurance companies are poised to take over. Or could it be that they are hedging their bets?

  4. "A tour de force of Grand Rounds. I enjoyed the journey through the
    digestive system. Thank you, Dr. Kirsch for putting me in the intestine
    (where all good things happen). I will enjoy reading these excellent posts
    all week from midnight until 2AM."
    Toni Brayer, MD

  5. An educational, from many perspectives, and entertaining Grand Rounds!

  6. Great Grand Rounds! Thanks for including my post!

  7. Hysterical.

    Given the alternative, I think I'll keep working on that ulcer.

    Perhaps some (herbal) tea will settle it down?


  8. Fantastic
    Loved the journey!
    Good quality nutritious blogs, broken down for visual digestion - alimentary really

  9. Hey Dr. Kirsch,
    Thanks so much for including my blog! Love the clever way you presented them all, although I have mixed feelings about mine dissolving in stomach acid :)
    Thanks again and I can't wait to check out some of these other blogs--they look great!

  10. Thank you, Dr. Kirsch, for the terrific intestinal tour. I never thought I'd be so disappointed not to make it to the end of the colon!! Congrats to the victor, Nick - you're a real trouper.

  11. Great trip throught the tract.
    This on waste drugs may be more palatable to you



  12. That was ... that was something else. Very entertaining write-up, and I appreciate being included. :)

  13. Great job and thanks for the winning spot! I am humbled and appreciative to be among so many great blogging colleagues.

  14. Thanks for the link, and great work on a very comprehensive Grand Rounds. It's really amazing to see the variety of medical content out there--a lot of high quality blogs indeed.
    You also managed to entertain us with a pictorial tour of the GI tract--how charming!

    Keep the podcasts coming, and if any of your readers are interested in creating their own medical podcast, I would be happy to help them out.