Anti-Bloomberg Bill in the Soda Wars: Two Wrongs do not Make a Right!

Posted by Pranab on April 24, 2013 in Public Health

Since posting my rant on the now age old debate about paternalism (or as the people over in USA are calling it: Nanny State) versus public health, I have been reading a lot more about the Soda wars and it emerges that now it is way more hotly debated than ever before.

Following in the steps of Mayor Bloomberg, Mississippi Senator Tony Smith has authored a bill that mandates that the government cannot dictate what the people can or cannot eat. Besides doing away with any prohibitions on portion sizes, it is also against the mentioning of calories per served bit on the menu. The New York Daily News believes that the state Governor is about to sign off on the bill making it a law, well, that effectively bans bans.

The bill is receiving enthusiastic support from, erm, Big Food (not that I meant the pun), for obvious reasons. But, wait, there’s more. The author of the bill, Sen. Smith has a massive conflict of interest to report. He owns this thing called a Stonewall’s BBQ, which, I believe is a chain of food stores. So, if Bloomberg had his way, he might have been up against severe financial constraints. Prophylactic self-preservation, or advocacy for autonomy? You decide!

The problem with the legislation being authored by Senator Smith is that it is a dead end for any legislative advocacy against obesity. Now I have not read the exact bill being passed through the system, and most of my understanding of its contents are through second or third hand reports from news sites, but still, what I read did not sit well with me. This piece of law would effectively kill off any and every attempt at regulating obesity in the state.

And anyway, a person with such massive conflicts of interest should not have been even involved in the law-making process in the first place. It just goes to show that it is indeed money that makes the world go round!

What is interesting to note is that, with a self-reported prevalence of obesity in adults pegged at almost 35% (BRFSS, 2011), Mississippi is one of the most obese states in the States. And it may be possible that the actual numbers are a tad higher because self-reporting may give rise to a lower estimate. Senator Smith writing such a self-serving ban on bans makes me wonder whether there may be something in Dr. House saying “Patients are idiots” (and extrapolating it to “People are idiots”) and thus redeeming Mayor Bloomberg’s law in the eyes of autonomy advocates like myself!

Image and Stats sourced from the CDC.

The paternalism which dictated the passing of the Bloomberg-Soda-bill also rankled my conscience. However, Dr. Aaron Carroll presents a counterpoint on the JAMA Forums that is very interesting to note (please note that he, like me, is not all hung up on the idea that Bloomberg had it right by calling to cut the size of certain sugary drinks):

When I first expressed my belief that the soda ban would do little to reduce obesity as an actual policy, because there were still plenty of ways to consume calories in New York City, many expressed a belief that the law was more of a symbol than an intervention. By bringing to light and focusing on the unhealthy nature of sugared beverages, the ban might have encouraged many people to choose on their own to consume less of them.

if Mayor Bloomberg wanted to take a symbolic stand against obesity and make people aware, then the whole brouhaha over this issue has indeed been a giant success. Its ripples have reached as far as India, where me and my colleagues mill around and discuss paternalism and public health over healthy, calorie-limited, size-restricted beverages while we are doing our daily jog on the treadmill. Or not.

Image Credit: SodaHead

But, in all seriousness, I agree with Dr. Carroll, when he says:

Martyring the attempt to ban unhealthy beverages has brought even more attention. The repeal might do just as much good as the policy itself.

In my last post on this Soda Wars issue, I expressed the fact that I was confused whether curbing some certainly-alienable individual rights for the sake of the greater good was a completely ethical and desirable step. I was torn. Being an ardent advocate for patient autonomy, I had wanted the same freedom of choice to spill over in public health policy-making as well. However, in this matter, I am ready to take a stand. The Anti-Bloomberg Bill hides a sinister financial conflict behind the façade of individual autonomy. It puts a stalemate to all discussions and legislations to combat a complex socio-political issue. It stymies all the progress made by the martyring of Bloomberg’s Soda Bill. It effectively neuters the legislative route of public health policy-implementation. At the risk of sounding anti-civil-liberties, I must end by saying that this makes Bloomberg’s Bill look way more acceptable an alternative.

Image credit: SocioEcoHistory

PostScript:

Bloomberg Meme: He actually wanted to pass a bill that would limit the noise levels in earphone to avoid ear injury in adolescents. The adolescents, of course, were not too thrilled.

Anti-Bloomberg Bill: Most of my understanding of the contents of this bill is from secondary and tertiary sources as I have not read the original bill. If there are any inconsistencies in the interpretation, that may be due to the loss in transcription through several levels of blogging and analysis. Do let me know if I have got any aspect of this bill wrong.

Balance: Obesity is a public health menace and as a trainee in the field, I believe we must strike a balance between the extremes that the two sides have taken on this issue. Policy-making is sometimes the fine art of striking a compromise, a balance between the desired and the acceptable. Pushing legislation on people that they are not ready to accept is not going to make things better.

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Tags: anti-bloomberg bill, blooomberg, conflict of interest, diabetes, New York City, Obesity, portion size limitation, soda wars Permalink

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The Family Physician: A Dying Romantic Idea

Posted by Pranab on April 23, 2013 in Medical Humanities, Public Health

I have been known to lament the loss of the prestige of the basic medical degree (MBBS) in India. While you may or may not agree with it, the truth remains that nobody who is doing (or has recently done) an MBBS course wants to stay out at that level. Everyone wants to go and be a specialist or super-specialist. In the melee of confusion arising therefrom, we are slowly pushing the generalist, family physician to an early extinction.

Even William Osler, the Father of Modern Clinical Medicine, was enamored by the concept of the omnipresent (and often omniscient) general practitioner. Osler once said:

“It cannot be too often or too forcibly brought home to us that the hope of the profession is with the men who do its daily work in general practice.”

That is the reason, why, every time I come across a feel good story about a family physician working out from the rural hinterlands, helping people without regard for money or fame, I feel a small twinge at the depths of my heart. I am sure we all do feel that pull some time or the other. However, society and economics have warped us into calculative beings that always try to balance both sides of the ledger and then leave a lot on the savings column. There is no denying that life is like that and turning away from it is being in denial, but, sometimes, I wonder if it would do the skewed, curative-obsessed, over-medicalized culture today some good to have them re-oriented to the primary care model.

That is part of the reason why I read the news article about Dr. Russell Dohner from Rushville, Illinois with considerable interest. The other bit that really drew me to the piece was the fee he charged from his patients: 5$!

This is a bit of an old article from Yahoo! News, and I am linking to it so that you can check out the whole story for yourself, and without having me to spew the same stuff over again.

Image Credits: Associated Press/Jeff Roberson (from Yahoo! article)

I understand that having an alternate, steady income, (he admits that his livelihood is maintained by the money the farm brings in) and not embracing the expensive modern gadgetry (computers, fax, EMRs) has kept his practice alive. He also does not take any medical insurance and often waives the fees for patients when they are in a spot of bother. He is, in every manner, the quintessential country family doctor, who, the article reckons, has delivered the whole town. I also recognize the fact that his advanced age (he was 87 years old at the time of the publication of the Yahoo! article) would be a deterrent for practice in most institutions. Asking anyone to even emulate his actions would be an act of insanity in an age where medical care is rapidly becoming the most expensive commodity up for grabs.

However, these issues aside, he has chosen to forego the fees that his seven-decade spanning experience deserves. He charges a nominal fragment of what he could have easily asked for. The farm-is-there logic is strong, but it also shows that he did not run after the lucre. Despite everything, it even softens the cynic’s heart.

However, when you are 28 years old, sometimes with a family to take care of, and with an inhuman load of $300,000 or more in student debts on your shoulder, the last thing that you want to do is to repair to rural Illinois and serve as a Family Physician looking at patients for a farthing (and sometimes, not even that!). Dr. Dohner, I am afraid, may be the last one of a dying breed. With his demise, the chapter on the altruistic, ever-on-call-at-hand, ready to help Family Physician may go out of vogue. Now your FP may be a person in a conglomerated private practice who works on the same principle that any corporate body functions with – making profits. And you cannot blame him for that!

We may not have fields or farms to fiscally support our eccentric medical desires; we may not have our medical educations sponsored by the government, and hence, being debt-free, turn our lives in for society; we may have the very-understandable foibles of wanting to live a good life; but I am also very sure, there is that one neglected corner in our hearts that we are in denial about, where we want to be the Dr, Dohner, for whom people from four or five counties can vouch for.

Not unlike this old country doctor, who caught the poet’s fancy with his frugal life and limited desires:

Old Doc Brown

He was just an old country doctor
In a little Kentucky town
Fame and fortune had passed him by
But we never saw him frown

As day by day in his kindly way
He served us one and all
Many a patient forgot to pay
Altho’ Doc’s fees were small;

But Old Doc Brown didn’t seem to mind
He didn’t even send out bills
His only ambition was to find
Sure cures for aches and ills

Why nearly half the folks in my home town
Yes, I’m one of them too
Were ushered in by Old Doc Brown
When we made our first debut;

Tho’ he needed his dimes and there were times
That he’d receive a fee
He’d pass it on to some poor soul
That needed it worse than he

But when the depression hit our town
And drained each meager purse
The scanty income of Old Doc Brown
Just went from bad to worse;

He had to sell all of his furniture
Why, he couldn’t even pay his office rent
So to a dusty room over a livery stable
Doc Brown and his satchel went

On the hitching post at the curb below
To advertise his wares
He nailed a little sign that read
‘Doc Brown has moved upstairs’;

There he kept on helpin’ folks get well
And his heart was just pure gold
But anyone with eyes could see
That Doc was gettin’ old

And then one day he didn’t even answer
When they knocked upon his door
Old Doc Brown was a-lyin’ down
But his soul – was no more;

They found him there in an old black suit
And on his face was a smile of content
But all the money they could find on him
Was a quarter and a copper cent

So they opened up his ledger
And what they saw gave their hearts a pull
Beside each debtor’s name
Old Doc had writ these words, ‘Paid in full’;

It looked like the potter’s field for Doc
That caused us some alarm
Til someone ‘membered the family graveyard
Out on the Simmons farm

Old doc had brought six of their children
And Simmons was a grateful cuss
He said “Doc’s been like one of the family
So, you can let him sleep with us;”

Old Doc should have had a funeral
Fine enough for a king
It’s a ghastly joke that our town was broke
And no one could give a thing

‘Cept Jones, the undertaker
He did mighty well
Donatin’ an old iron casket
That he’d never been able to sell;

And the funeral procession, it wasn’t much
For grace and pomp and style
But those wagonloads of mourners
They stretched out for more than a mile

And we breathed a prayer as we layed him there
To rest beneath the sod
This man who’d earned the right
To be on speaking terms with God;

His grave was covered with flowers
But not from the floral shops
Just roses and things from folks’ garden
And one or two dandelion tops

For the depression had hit our little town hard
And each man carried a load
So some just picked the wildflowers
As they passed along the road;

We wanted to give him a monument
Kinda figured we owed him one
‘Cause he’d made our town a better place
For all the good he’d done

But monuments cost money
So, we did the best we could
And on his grave we gently placed
A monument – of wood;

We pulled up that old hitchin’ post
Where Doc had nailed his sign
And we painted it white and to all of us
It certainly did look fine

Now the rains and snow has washed away
Our white trimmings of paint
And there ain’t nothin’ left but Doc’s own sign
And that is gettin’ faint;

Still, when southern breezes and flickering stars
Carress our sleeping town
And the pale moon shines through Kentucky pines
On the grave of Old Doc Brown

You can still see that old hitchin’ post
As if an answer to our prayers
Mutely telling the whole wide world
‘Doc Brown has moved upstairs’.

Regular program of bitter, cynical writings shall commence soon. Don’t lose hope, ye ones of little faith.

Tags: Exams, family physician, general practice, MBBS, Medical Education, PG, PGMEE, russell dohner, USMLE Permalink

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USMLE 2013 and IMGs: All That Glitters is NOT Gold

Posted by Pranab on April 21, 2013 in #MedEd

I have pretty much been declared the official (Indian) USMLE rumor-monger by one of the most famous USMLE coaching institutes that held introductory classes to tell the masses what USMLE was all about. Thank you sir, you made my day.

Now, again, another disclaimer. The last time I wrote about the USMLE match (this one: The USA Dream for IMGs: Coming to an end? Analyzing the 2012 Match) I received a lot of hate mail and comments telling me, pretty much, to buzz off. Hence this time, before launching into my tirade, I shall dwell on this paragraph a while longer. I am NOT trying to dissuade anyone. I am NOT spreading rumors. I am simply trying to analyze the numbers being given out by the authorities in charge of the system and trying to interpret them within the limits of my intellectual and academic abilities. I may well be wrong, so please do not take my word to be sacred, and end up bashing me or praising me. I am just following the logical train of thought that I can construct. Where it leads me to is not in my control. Also, whatever I am writing is MY understanding of a very complicated system. And it maybe entirely WRONG. If it is, let me know, I shall make the required edits.

Ok. So then, down to the brass tacks.

The NRMP has not yet come up with the detailed analysis and numbers yet – another couple of months for that – but they have released an advanced report and press releases that have quite a lot about the IMGs, which specifically is my area of interest. You can read the whole thing over at the ECFMG Reporter.

Before I start with the number crunching, let me first make sure you all have heard of this new thing this year, called the “all-in system”. Till the last year’s match, programs were not compelled to fill all their seats through the Match. Now before you start shoving knives into my throat let me explain. This meant that the programs could fill in seats through systems beyond the match. Pre-match offers, for example. This year, to ensure that there was a more level playing field and more or less uniform judgment of all applicants, the NRMP declared that programs had to go all-in or all-out. That means, they had to declare that they were going to fill ALL their slots either through the Match or through other non-match routes. No more walking the dual path. And although it is not yet clear how many programs chose to be all-out (hopefully, the NRMP will come out with that data when the publish the detailed numbers for this year’s match), it is only reasonable to assume that most programs would have opted to go for filling residency slots through the match. So, do not let the higher numbers fool you into believing that the future is rosy. In fact, the ECFMG Reporter reports:

This policy is a factor in the higher numbers, compared to last year, of both positions offered through the 2013 Match (up 2,358 or 9.8%) and the number of IMGs participating in the 2013 Match (up 1,549 or 13.9%). It also, presumably, reduced the number of positions available outside of the 2013 Match.

Now, what that means is that there were more seats to deal with in the Match this time around than any of the previous years. So, whenever you see a spike in this year’s numbers, keep in mind that they might have been because of this newly placed policy rather than because of an increase in scope. I am not denying there is an increase in scope. There possibly is. But until and unless the end-of-the-year data for 2012 match is released, we cannot say that for sure. For the purposes of this post, I shall stick to the numbers from 2011 match for data whenever the ones from 2012 are not available or are incomplete.

	2013	2012	Change
Total Residency Slots available	26,392	24,034	+2,358 (9.8%)
IMGs Participating	12,683	11,107	+1,576 (14.2%)
IMGs Matched (US+Non-US)	6,311 (49.8%)	4,886 (43.9%)	+1425
Non-US IMG Applicants	7,568	6,835	+733 (10.7%)
Non-US IMGs Matched	3,601 (47.6%)	2,775 (40.6%)	+826
US IMG Applicants	5,095	4,281	814 (19%)
US IMGs Matched	2,706 (53.1%)	2102 (49.1%)	+604

These numbers are all very rosy, until you take a look at the situation that eventually transpires when the non-match candidates are chucked into the equation. For this purpose, we shall cast a glance on the 2011 numbers, In the 2011 match:

Positions filled by IMGS through Match = 4,626

Total IMGs entering PGY-1 for the year 2011-12= 6,754

Thus IMGs entering by non-Match routes= 2,128

So, in 2011, almost a third (31.5%) of the positions filled by IMGs were filled through non-Match routes.

Though I do not have the US/Non-US break up for this number, yet, this seems like a pretty serious bit of statistics to me. And, if you notice, the eventual number of IMGs matching into the system in 2011-12 was much more than those that matched in the match in 2012-13 and even the all-in system of 2013-14, So if you are an IMG who managed to snag a position this year, well, that’s a pretty darn good job. Give yourself a pat on the back.

Mean times, if you, fellow student, are traveling the arduous journey along the path of USMLE, well, if you want to attain nirvana, hurry up. Otherwise, the journey may end in a cul-de-sac!

Yes, the numbers this year may still be a bit higher than what has been reported, but since not many programs would have opted to go all-out, it is unlikely that the bump would be significantly large.

So, in conclusion,the following stand out:

1. There has been a large spike in the proportion of non-US IMGs matching into PGY1 positions this year, but how much of it is attributable to the all-in system needs to be factored in before jumping with joy.

2. The rate at which the IMGs are applying is fast outstripping the rate at which the positions are increasing. Even with the all-in system in place, the growth difference this year was about 4%, which is a pretty steep climb.

3. Another metric that is of utmost importance is the positions/applicant ratio. This metric was 0.77 overall last year and 0.91 for US Seniors. In comparison, this year, the positions/IMG applicant is 2 and for non-US IMGs, it is 2.1. Although this is much better than any odds you may face in India, this is not very hot as compared to the other years in the USMLE history!

4. The rates of US-IMGs matching into PGY1 positions is also increasing, as expected. And this year, there was a major spike in the number of US-IMGs applying for Residency. As US medical education remains unacceptably, and often, unaffordably expensive, more and more US students will see it fit to gather their undergraduate degree from one of the developing world countries, where they can get by wit a fraction of the 300,000$ they would otherwise may have been burdened with. As this trend continues, it shall spell more pain for the IMGs. The way I see it, and I may be wrong, is that, any program will be happy to accept an American applicant over an International Grad who may have slightly superior credentials than his US colleague. The fact that they would not present a diplomatic difficulty, what with Visa and other laws changing every year in different countries, is indeed a tempting proposition.

Bottomline, USMLE still seems like a better bet, at least numerically speaking than the Indian PG exams. However, you need to factor in the costs, the time and the rapidly shrinking opportunities (as compared to the previous years) before you make this apples-oranges comparison.

And if you are a USMLE aspirant, I wish you all the best, and hope you shall not be dissuaded by this post simply because the numbers-gradient is fast becoming steeper.

Post-Script:

Several friends of mine have matched into the PGY1 positions this year. And none of them will say that the process was without pain or heartache or headache. It just comes with the terrain. My intentions in writing these USMLE series of posts is NOT to discourage people, but to make them understand the risks, as I understand them, before they take this very expensive, very time-consuming leap. This also feeds my interest in Medical Education, because this is an extraordinarily transparent and open system which lends itself to analysis (and criticism), as far as the outcomes are concerned. We all know the great mystery of the USMLE scores and interviews process, so no comments on that!!!

I only wish that the Indian PG entrance system gets streamlined lends itself to a similar vein of accountability, and I believe that instituting the NEET-PG, a unified entrance exam for Post-Graduate Medical Education in India is the right formula to that end.

So, friends, whether or not you are a doctor/medical student/PG aspirant/USMLEan, follow nd support the #saveNEETPG movement on your social circles. Thanks.

Now you may post your blasting of my thoughts again. Or if you want to stay anonymous, use the contact form on my contact page.

Image Credits: First one, Fizzzy. Second one: Random Facebook share.

Tags: All-In Match, IMG, International medical graduate, Match, Match 2013, Medical School, NRMP, PG, PGMEE, Residency, Step 1, United States Medical Licensing Examination, USA, USMLE, USMLE Match, USMLE Step 1, USMLE Step 2 Permalink

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The USA Dream for IMGs: Coming to an end? Analysing the 2012 Match

Posted by Pranab on January 8, 2013 in #MedEd

My attention was drawn to an article in the JAMA today (1) by one of my friends who is actively pursuing the USMLE route. And after reading this, I guess I have to admit that one now has to make haste in order to prevent waste. Now I have long been wanting to write about this but somehow never came around to do it. Finally, having read this article today, I decided to give it a go. Now this is entirely my perspective on last year’s match and it may be entirely off-base. So do not put too much of thought into this. This year several of my friends are appearing for the match and I wish them the very best of luck. Also, this post is intended to be a wake up call for those who have been sitting on their dates, trying to do that extra bit to eke out an exceptional score. it is time to take the plunge!

Let us start with some number crunching first – get the boring stuff out of the way before the real horror movie starts. No, just kidding… The number of students applying for residency in the US programs has increased in leaps and bounds, as the NRMP report shows in this trend-chart dating back to 1952 (2):

Tags: AIIMS, Exams, IMG, Medical Policy, Medical School, PG, PGI, PGMEE, Step 1, USMLE, USMLE Step 1, USMLE Steps Permalink

A Lexicon for Public Health Students: The Design Effect

Posted by Pranab on December 17, 2012 in #MedEd, Public Health

Reblogged from my previous post on the Community Medicine Education Blog, as a part of the new series where I go about de-mystifying stuff that confuses… mainly me!

Of late, in all our Journal Clubs, design effect seems to get a lot of attention, so much so, that there has been talks of having a short session on design effect itself! Here goes my attempt to talk about this much discussed topic!

Definition:

Like the British politician (and two times Prime Minister) Benjamin Disraeli, I too hate definitions, so I shall try to make this as painless as possible!

In survey based studies, almost always, a complex sampling system, like a cluster sampling or a stratified sampling, is used. In comparison to a simple random sampling where all the members of the universal set to be studied have an equal probability of getting selected, in these complex sampling frames there are, almost always, unequal probability of selection or clustering of selected samples. Thus, based on the design adopted for a study, there is a deviation of the study sample from the sample selected by simple random sampling.

Thus, the design effect is a factor which measures the “distance” or “amount” of variation of a particular study sample (selected by a defined design) from the simple random sampling of the whole population the study aims to target.

Kish (1) and Moser (2) in their work, define design effect with much greater mathematical precision. They define it as the ratio of the variance of the estimated outcome under the cluster sampling method to the variance of the same outcome that would be expected if the same number of individuals were selected by a simple random sampling technique .

Simply put,

So basically, design effect is a measure of the impact caused by a deviation from the simple random sampling design

An Alternate Definition:

It can also be shown (and this definition is used more often in social studies) that:

Where n is the average cluster size and is the intra-class correlation coefficient of the outcome variable in question.

Intra-class Correlation Coefficient:

Now as the above equation clearly shows, the design effect depends on two factors:

- the average size of the cluster

- the intra-class correlation coefficient (ICC)

So what is this ICC?

Simply put, the members within the same cluster are more likely to be similar to each other (and hence have a high ICC) than members from different clusters.

However, not always shall a variable have similar trends within the cluster. Let us consider an example. In our journal club discussion on hypertension (3) a two stage cluster sampling was employed. In the whole island of Car Nicobar, there were 308 tuhets (aka extended joint families). In the first stage, 40 of these were selected randomly, and in the second stage, all the members aged >18 years in every tuhet were selected. By doing this, they recruited almost 1000 subjects. Now, it is clear, that in simple random sampling, these 1000 subjects would have been picked from all 308 tuhets, thereby giving more variability in the results, but in the first stage, selecting those 40 tuhets made life easier for the investigators, but eroded statistical power of the study due to the deviation, which we defined before, as the design effect.

Now the members within the same tuhets would have similar food habits, salt intake and certain other risk factors for which the ICC would have been high. If a dot plot was made, it would appear something like this, where the members of the same cluster show clustering of the variables (source: Wikipedia):

On the other hand, some other features, like physical activity or disability rates would not show such clustering. Plotting these factors on the dot plot charts would reveal something like this, with low ICC (source: Wikipedia):

Hence, the question that naturally arises next is: how to estimate the ICC?

Determining the Intraclass Correlation Coefficient:

Before we embark on the explanation of how to derive the ICC, I would like to point out that in a cluster sampling, there are two levels where variability is introduced, unlike in a simple random sampling, where there is only one level of variability.

In an SRS design, the only measure of variability of the subjects is at the individual level. However, in the cluster sampling design, the variability exists between the clusters (between every tuhet) and also within the clusters (the individual level).

Using this conceptual model, the mathematical formula used to define the ICC is:

Clearly, from this equation, we can see that the value of ICC ranges between 0 to 1. In the extreme case, where the ICC approaches 1, the variance within the cluster will have to approach 0, which means that almost all the members within the cluster shall provide a similar response. That means, the effective sample size (the significance of the effective sample size is discussed later) would be reduced to the number of clusters (and eventually result in a very high design effect).

Conversely, a very low value for the ICC would mean that the variance between the clusters is much lesser than the variance within the clusters.

And finally, the extreme case where the ICC is 0, implies that there is no correlation of responses within the members of the same cluster! This would effectively mean a design effect of 1.

In social studies the value of ICC ranges between 0.01 and 0.02 (4) but it is more advisable to actually calculate the ICC using a pilot study. More and more studies nowadays are reporting post-facto ICC (like the paper we discussed for road traffic accidents in last week’s journal club (5) which calculated the Deff for the various factors and showed that they ranged from 1.2 to 2.24 for various outcome factors, although they had taken 1.5 overall – hence, the study was underpowered for some variables, while for others it was adequately powered), but few studies publish the piloted values of ICC (6) (probably because they are not calculated).

Note: There are extensive equations to discuss the derivation of the variance between groups but I am not going into them mainly because I did not understand them. I am still a newbie at this stuff so I hope you shall forgive some of these omissions. If however, you are interested in them, do drop me a line and I shall mail the papers discussing the derivation. You will have to make me understand them thereafter!

The Effective Sample Size (ESS):

So, it follows from the above discussion, that cluster sampling is a weaker sampling method than the simple random sampling. So, although one may feel that they have recruited adequate number of subjects for the study (calculating sample size using standard formulae), the end result is that they have, effectively, recruited much lesser than the number they originally aimed for.

So, if there are m members in each cluster, and there are a total of k clusters, the actual study sample size is “mk”. However, taking into consideration the design effect thanks to cluster sampling (Deff), the effective sample size (ESS), is much lesser and it is given by the simple equation:

So, the smaller the design effect, the larger the effective sample size!

Design Factor:

Coming to the last and slightly confusing part of this discussion about design effect – the design factor. Unfortunately, in our undergrad days we do not really get a very good grounding in Biostatistics, so my concepts are a little flimsy. I shall try to explain this matter as best as I understand it. If you find any errors in this, please do not hesitate to point them out to me.

The design factor (Deft) is simply the square root of the design effect. So, if design effect is 4, the Deft is 2.

But what does that mean?

Now as we have discussed, design effect tells us how much larger a sample should be to nullify the effect of deviating from the simple random sampling. Design factor, on the other hand, tells us, how much larger the standard error (and hence the confidence intervals) should be in order to approximate the results that would have come from a simple random sampling.

Now a new question arises: how to interpret these results?

If Deff is 4, then the sample size that would be required for an adequately powerful study would be 4 times that calculated by the standard formulae. And since Deft would be 2, it would mean that the confidence intervals of the cluster sampled study should be twice as large in order to approach the results that would be obtained from simple random sampling.

So, in a way, Deft is also a measure of the variance of the clusters.

A design factor of 1 would mean that the effect of clustering of the study subjects on the precision of the results obtained is negligible and despite a cluster sample, the study approximates the results that would have been obtained from a simple random sampling. Design effect would also be 1 in this case, and hence, would mean an ICC of 0 (as discussed previously)!

A design factor greater than 1 would mean that the observed results from the cluster sampling have standard errors greater than what would have been obtained from a simple random sampling. Hence, if tests of significance are applied without adjusting for this, they would falsely report non-significant results to be significant, thus giving rise to Type I error or alpha error (null hypothesis is true, but erroneously rejected).

A design factor less than 1 would mean that the observed results from the cluster sampling have standard error lesser than what would have been obtained from a simple random sampling. Hence, if tests of significance are applied without adjusting for this, they would falsely indicate significant results to be non-significant, thus giving rise to Type II or beta error (null hypothesis is false, but erroneously accepted).

Once again, like ICC, there are only few variables that have a design factor that regularly exceeds 1 by a wide margin. This would indicate a large amount of homogeneity within the cluster, hence giving rise to a bigger design factor (and design effect). A classic example might be religion or ethnicity/race when households (like tuhets) are considered to be the clusters.

References:

1. Kish L. Survey sampling. London: Wiley,1965:148–81.

2. Moser CA, Kalton G. Survey methods in social investigation. Aldershot: Dartmouth Publishing, 1993:61–78.

3. Manimunda SP, Sugunan AP, Benegal V, Balakrishna N, Rao MV, Pesala KS. Association of hypertension with risk factors & hypertension related behaviour among the aboriginal Nicobarese tribe living in Car Nicobar Island, India. Indian J Med Res. 2011 Mar;133:287-93. PubMed PMID: 21441682; PubMed Central PMCID: PMC3103153.

4. Donner A, Klar N. Design and Analysis of Cluster Randomization Trials in Health Research. American ed. New York, NY: Oxford University Press; 2000:9,112-113.

5. Dandona R, Kumar GA, Ameer MA, Ahmed GM, Dandona L. Incidence and burden of road traffic injuries in urban India. Inj Prev. 2008 Dec;14(6):354-9. PubMed PMID: 19074239; PubMed Central PMCID: PMC2777413.

6. Killip S, Mahfoud Z, Pearce K. What is an intracluster correlation coefficient? Crucial concepts for primary care researchers. Ann Fam Med. 2004 May-Jun;2(3):204-8. PubMed PMID: 15209195; PubMed Central PMCID: PMC1466680.

Tags: Cluster Sampling, Design Effect, postaday, Research Methodology, Sampling Techniques Permalink

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Banning Gutkha: Paternalism in Public Health or Pro-Active Advocacy?

Posted by Pranab on November 11, 2012 in Public Health

I have been meaning to write about this matter for a few days now, just never managed to make time for it. There has been a huge hue and cry over the banning of gutkha in certain states of India. While the public health professionals have more or less welcomed the move, the smokeless tobacco industry has hit back. In a series of prominent advertisements put out in the leading dailies, they have tried to highlight the plight of their industry and garner public support and sympathy for their cause.

I am presenting some of these adverts that have caught my eyes:

The above advert, a quarter page plea, was published on 1st October, 2011. The following one came up on the 10th of the same month:

The third one followed a mere 5 days later, on the 15th of October:

Ranging from the emotional to the economic, they have run through the gamut of reasons and arguments to augment their case. A slight hint at the nexus between the policy makers and big tobacco, represented by the cigarette industry, has also been made. This harkens back to the early days of the war against smoked tobacco, when the causal relationship between cigarette smoking and lung cancer was not strongly established.

However, I shall stray from the ban-all policy. I mean increasing prices, implementing legislations against public smoking, levying taxes and spreading awareness about the ills of smoking has helped to curb the rampant smoking levels but still, smoking remains a social illness that refuses to go away. A blanket ban is now being tried with the smokeless cousin – the gutkha. It remains to be seen how this works out.

Now, there is always the debate whether one should assume a pro-active, sometimes paternalistic role, while implementing public health measures like banning of gutkha or restrictions on smoking or one should provide everyone with the required information and evidence and then let the people make the decision for themselves. Now I am a big supporter of individual freedom and shared decision making, no matter what the issue. In a paternalistic move to ban gutkha, a number of stakeholders (the producers and the consumers of the product, primarily) were left out of the decision making matrix. This is, in my opinion, not the way to go.

The truth remains that until and unless people are made aware of the extent of damage caused by a particular substance, simply banning it will not solve the problem. It might make it worse as unregulated, fly-by-night scamsters may come up with poorer quality and adulterated products that impose a greater risk on the individual. A similar problem was envisioned with the illegal status of commercial sex workers who were rendered vulnerable to sexually transmitted infections and homosexual people, especially men having sex with men (MSMs) who refused to come out of hiding for fear of legal persecution and hence were left in the shadows.

However, the ground reality remains that in a nation like India, sometimes, it is very difficult to establish such great shared decision making platforms. In a largely agricultural, rural-based population with poor levels of education, behavior change is a difficult task. The thing is, entrenched behaviors, like use of intoxicants is difficult to weed out merely by passive processes like behavior change communication, which, I believe, is, on the best of days, a weak and anemic tool to counter the menace of smoking or drinking or substance abuse in general. Hence, the easier and better (or so perceived) method is cracking the legislatory whip. Banning gutkha.

So while it does not gel with my ideals of perfect public health policy-making, it does seem to be the only one which has the highest probability of working out well. Some may say this was a choice where the least poor alternative got selected.

What is your opinion? Paternalism or power to the people?

Tags: Banning Gutkha, Gutkha, Legislations, postaday, Public Health, Smoking, Tobacco Permalink

8 Comments

William Gosset: A True Student

Posted by Pranab on September 21, 2012 in History of Medicine

Today I attended a Basic Epidemiology class meant for the undergraduate students as I thought it would be good to brush up on my basic knowledge. The topics for the day were Hypothesis Testing and An Introduction to Randomized Controlled Trials, both pretty important ones, no matter which level you are studying at. What struck me was the amount of details the students were taught. To be entirely honest, in my undergrad days we did not get such detailed statistical teaching, and I was borderline jealous of the lucky 7th semester students. However, this post is not about the class or its importance (or the lack thereof), but what stood out for me – a moment from the history of medicine. This post is a result of some online meandering following up on that momentary whim.

We have all used the Student’s t-test at one point of time or another during our lives but I wonder how many of us ever wondered who this “Student” fellow was. Well, to be entirely honest, till today, I had dismissed him as a brooding Statistician with a long white beard, heavy monocles and an intent look… you know, the ones you find on Wikipedia. While I was quite correct in stereotyping the look, digging beneath the surface revealed a much fancier and colorful story behind the apparently benign (and somewhat boring)name of Student.

Born to Agnes Sealy Vidal and Col. Frederic Gosset (June 13. 1876) at Oxfordshire, he went to New College, Oxford, where he studied Chemistry and Mathematics. He was awarded First Class degrees in both subjects, obtaining his Mathematics degree in 1897 and his Chemistry degree in 1899. The same year, he went to work with Arthur Guinness and Son as a Chemist. Yeah, you read it right, He went to work for THE Guinness company and was posted at Dublin.

Digressing for a while here, I must say that the history of the Guinness company is in itself an interesting study, especially since in its long 253 year history, it has withstood the ravages of two world wars and three major economic meltdowns – no mean feat that – but what probably makes the brand instantly recognizable for the aficionado of historical trivia is its association with the Battle of Waterloo. Apparently it was so famous in 1815 that the wounded soldiers at Waterloo were asking for Guinness by name, and were getting magically revived by partaking of the wonder-drink. The company cashed in on the legends by publishing a series of advertisements on this theme in the 1930s and 1940s when the print media was just taking off. They say it went viral…

Anyways, coming back to the story of Student. Guinness had a policy of employing the brightest minds coming out of Cambridge and Oxford in order to bolster the statistical and biochemical working of the company.(3) Being a brilliant student, Gosset naturally was picked up by the company. It was thus a stroke of great luck for future statisticians and researchers that he did not go on to become an Engineer like his father owing to his poor eyesight.(4) Now for those who are wondering why I am obsessing over the Guinness company (beside the obvious reason), well, just hold on to your hats, let me just say that this company also had a major role to play in Gossett getting his moniker of Student. While this is pure speculation, I must say if Gossett were alive today, and had seen the popularity that his discovery had found, he would rather had it called Gosset’s t-test than Student’s t-test! But then again, he was a very unassuming and humble person, so…

When Gosset joined Guinness, Dublin, his task was to perfect the process of brewing beer.(5) The principle was that one had to add an exact amount of yeast colonies to a certain amount of fermenting barley to turn it into beer. Too few colonies and the brew would be incompletely fermented and too much, it would become bitter. So the challenge was to count the colonies and add just the right number of them. Gosset innovated around this problem by using the newly developed Hemocytometer to count the yeast colonies. However, the challenge was to extrapolate the findings from a small sample of the yeast extract to entire jars of the sludge! This is akin to the problem medical or social scientists face when they draw a small sample from the huge universe to study some factors! It was in this setting that the mathematical and statistical training Gosset had acquired, came into the picture.

It was the use of the hemocytometer that resulted in Gosset’s first publication and the assumption of his pseudonym, Student. A researcher at Guinness had previously published his work, leading to loss of trade secrets of the Guinness brewery and hence the company had put a blanket ban on all publication efforts by their employees. While in today’s “publish or perish” world this would seem like a counterproductive policy that would drive away the best brains from the company, those were rosier and better times, where the weight of one’s achievements was not measured by the length of their publishography.

Gosset had to plead with the brewery that the paper which he proposed to publish was an absolutely philosophical and mathematical assertion and would have no dealings with the secret workings of the Guinness factories and hence, would be of no practical importance to the competition. The authorities gave in, but added the rather practical rider that he was better off publishing them under a pseudonym (he chose “Student”) in order to avoid conflicts with other staff member with publication ambitions.(6) At this juncture, Gosset’s friendship with Karl Pearson came in handy. Pearson agreed to hide Gosset’s personal information and allowed him to publish under a pseudonym in Biometrika, the statistics journal he had founded in October 1901. In this article (7) Gosset discussed “how the scatters of the yeast colony counts using the hemocytometer was similar to the exponential limits of the binomial distribution”.(5) Thus, with this publication, the transformation of Gosset into Student began!

Pearson was a giant in his field and he first met Gosset in 1905. He was one of the people who built up the fundamentals of modern statistics. Gosset worked under him for two terms in 1906-1907 and worked on Poisson’s distributions and helped Pearson with the statistical work for his papers. In 1908, when Gosset was working on the theory for the t-test, Pearson helped him, but apparently did not recognize the importance of his work.

Pearson also believed that the only method to assess population parameters was by using large samples. Gosset set about to try and formulate a formal method in which he could try using small samples in order to generate representative statistics. He conducted some empirical experiments, like the following:(5)

In 1 experiment, Gosset prepared 3000 pieces of cardboard, on each of which he wrote 2 sets of data on 3000 “criminals.” One set of values were heights, and the other values were the lengths of the left middle fingers. Gosset shuffled the cards, drew at random 750 samples of 4 cards each, and computed means and standard deviations of each. Then he obtained the difference between each sample mean and the population mean (n=3000) and divided the difference by the sample standard deviation to obtain 750 z scores. He plotted the scores as probability functions and discovered that even without any of 4 parameters of Pearson, one could estimate the population mean and the associated error with a degree of certainty.

The four parameters Pearson had suggested were:

1. Mean

2. Standard Deviation

3. Symmetry

4. Kurtosis

Pearson contended that if one knew the four parameters for a set of variables then once could locate the position of one observation in the entire spectrum of observations. In order to describe the scatter of the observations, he introduced a set of skewed curves as well.(5)

These empirical experiments led to the publication of the second paper.(8) This was a long algebraic discourse but later readers have described it to be surprisingly lucid and jargon-free.(5)

Image is from the authors of (5). If you are so inclined, you can check out the cleaned out version of the real paper as a PDF on the University of York, Department of Mathematics page here. If you can cross the paywall, then take a look at the real deal on the Biometrika page here. Although this is a debate for another time, but I find it very irksome to see that an article published over a century ago is still under copyright wraps. This just points to one of the so many things that ail the scientific publication world. I’ll save the rant about open access and copyrights for another day…

As is often the thing with concepts that are ahead of their time, Gosset’s (who was now known as Student to the publishing intelligentsia) work did not find much appreciation from the statistical world. It was not until Ronald Fisher had found a formal proof and enlisted practical applications of the t-test that people started to sit up and take notice. Apparently Gosset had written to Fisher informing him about his paper, saying that: “I am sending you a copy of Student’s Tables as you are the only man that’s ever likely to use them!”(9) Fisher modified the t-tests (don’t ask me how or why, I am statistically too impaired to go into the workings of that answer) to suit his theory of the degrees of freedom. Fisher was also responsible for the introduction of Gosset’s t-distribution in regression.

Gosset worked with a lot of the major statisticians of the day. Besides maintaining an active friendship with both Pearson and Fisher, two of the leading lights in the world of statistics at that time, he also maintained fruitful liaisons with others like Neymar. Karl Pearson’s son, Egon, himself a master number-wizard, pieced together a lot of information about the life and work of Gosset from the vast epistolary evidence he left behind, being the over-zealous letter writer that he was. Wikipedia claims that maintaining friendships with both Pearson and Fisher simultaneously was no mean feat because both had huge egos and a massive loathing for each other. It would take a man with a special amount of resilience and equanimity to be friends with both the vitriolic rivals. And Gosset was just that kind of a person. McMullen, a personal friend of Gosset’s, wrote: (10)

… he was very kindly and tolerant and absolutely devoid of malice. He rarely spoke about personal matters but when he did his opinion was well worth listening to and not in the least superficial.

A humble man despite the heights of his achievements, what struck me was the way he would interject his admirers. He would cut them short saying: “Fisher would have discovered it all anyway.”(9)

In 1934 he met with an accident and was confined to a sedentary life for a while. This time saw an explosion in the production of the statistical work by Gosset. He was bed-ridden for three months and took almost a year to recover. However, the accident left him with a limp that he carried for the rest of his life. Although he was transferred to London in 1835 to take charge of the new Guinness brewery opening there, it did not hamper his statistical work and he kept producing papers under his assumed identity of Student. He also branched out into working on theories of resistant strains of barley that would grow in adverse situations. Thus, his contributions cut across borders of different disciplines – statistics, botany, business – he was truly a man of multiple interests.

He succumbed to a heart attack in 1937 at the age of 61 years. There were multiple obituaries in Biometrika, which had been the major publisher of his life’s works. Even the usually secretive Guinness company relented and allowed his friends to posthumously publish a selection of his works in 1942.(11)

The appearance of articles written by Student was surrounded by an aura of mystery and romanticism as very few people outside of the closely knit statistical group knew the actual identity of Student. And although the obituary in Times finally removed the shroud on the question of who Student really was, it was still quite some time before he was accredited directly for his work:

All but one of Gosset’s papers were published under his assumed pseudonym. The t-test has now become a routine tool in the repertoire of pretty much anyone who has dabbled with research, irrespective of the field of research. I think there could have been but fewer apt eulogies for a person of such caliber than the one that was proposed by Ronald Fisher: Gosset was the “Faraday of statistics”.(12)

References:

1. Image of William Sealy Gosset from Wikipedia: Now in public domain in the EU and Australia and some other countries 70 years after the death of the individual.

2. 1941 Guinness Ad image from this link associated with the EBay UK listing here. It seems that the advert is no longer available for sale.

3. O’Connor, John J.; Robertson, Edmund F., “Student’s t-test”, MacTutor History of Mathematics archive, University of St Andrews.

4. Plackett RL. Student’: A Statistical Biography of William Sealy Gosset. Oxford, United Kingdom: Vlarendon Press; 1990

5. Raju TN (2005). William Sealy Gosset and William A. Silverman: two “students” of science Paediatrics, 116 (3), 732-735 DOI: 10.1542/peds.2005-1134

6. ^ Hotelling, H.. British Statistics and Statisticians Today. Journal of the American Statistical Association. 1930;25:186–190.

7. “On the error of counting with hæmacytometer”. Biometrika 5 (3): 351–360. February 1907.

8. Student. The probable error of a mean. Biometrika. 1908;6:1–25

9. Wikipedia: William Sealy Gossett Accessed on 22nd September, 2012

10. William Sealy Gosset, 1876-1937, in E S Pearson and M G Kendall, Studies in the History of Statistics and Probability(London, 1970), 355-404.

11. Gosset WS. “Student”’s Collected Papers. Pearson ES, Wishart J, eds. Cambridge, United Kingdom: Cambridge University Press; 1942

12. H. Kohler: Life of Gosset

Tags: Biographies, Biostatistics, History of Medicine, Research Blogging, Statistics, Student's T-test, T-test Permalink

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Remembering Tinsley Harrison, the Oslerphile Physician

Posted by Pranab on February 16, 2012 in #MedEd, History of Medicine

The past few weeks have been very demanding on me and I have not had the best of times, either on the personal or on the professional front. So, today, I took a break from the usual drudgery of life and decided to take a step back and remind myself of the bigger picture of things. While reading through Osler’s Aequanimitas (check it out here) I was reminded of how Osler had been a guiding spirit in the life of another great medical hero that we have idolized over the years: Tinsler Randolph Harrison.

Tinsley Harrison (TH) was the son of a sixth generation physician, William Groce Harrison, who worked in close proximity with Osler for a short period and was the conduit through which the Oslerian wisdom flowed down into TH. If I have my dates correct, the lives of TH and Sir William Osler did not overlap too much because Osler passed away when TH entered Johns Hopkins in 1919.

TH was a bit of a prodigy and was done with high school at the age of 15 years and entered the sophomore class of 1916 at the University of Michigan. He excelled there and was permitted to pursue graduate school while in the fourth year of college. TH was intensely interested in studying Law and probably would have done that has his father not intervened. Osler had advised Groce Harrison to make his son a “teacher of medicine” when TH was barely three years old. At this juncture it is worthwhile to mention that Groce Harrison virtually worshipped Osler. In fact, anecdotes go that young Tinsley could distinguish between God, Jesus Christ and Sir William Osler by the time he was four years old! So, at the behest of his father, Tinsley decided to take up Medicine. So, his final year at Michigan in college was also his first year in medical school. It was 1918 and he had started medical school at the unusually precocious age of 18 years only!

Now Groce Harrison, being the protégé of Osler that he was, insisted that Tinsley complete the rest of his medical training at Johns Hopkins, which was virtually synonymous with the work of Osler. As I said before, unfortunately, Osler passed away the same year as TH went to Johns, but that did not stop him from building Osler up as the model of the perfect physician. Osler was not just an inspiration for TH during his medical school, but throughout his career and life. Osler and his musings were a part of the very fabric of life and philosophy that TH believed in. In fact, it is famously said by his students that TH would ask all his students to keep a copy of Osler’s Aequanimitas by their bedside and read it as often as possible!

Image Credits: Wikimedia

It must be mentioned that TH was in great company while he was in medical school itself. His room mate and tennis partner at Johns was none other than Alfred Blalock, pioneer surgeon, who developed a greater understanding of the pathophysiology of hemorrhagic shock, the Blalock-Taussing Shunt and surgical treatment of Tetralogy of Fallot, the so-called series of Blue Baby surgeries (on account of the fact that the babies became blue during cyanotic spells). Blalock himself was no mean a mind and though he was dogged with ill health, suffering several bouts of tuberculosis that impeded his work to a large degree in the early years, he left an indelible mark in the world of Surgery. He shared a lifelong friendship with his med school friend Harrison and their careers would cross paths several times in the years to come. Interestingly, one should note that like TH, Blalock was also an early prodigy and entered med school at the unusual age of 19 years! It is said that the first paper that he published in 1927 regarding the pathophysiology of surgical shock was originally written by none other than TH himself, based on the data collected by Blalock because he was down with a severe bout of tuberculosis at that point of time.

Image Credits: Medical Archives of the Johns Hopkins Medical Institutions

Harrison’s protégés remember him as a fantastic teacher, a passionate clinician and in the true Oslerian philosophy, a believer in the ways of the clinical diagnoses rather than an over-reliance on instruments/investigations. It is said that he possessed a disdain for gadgetry and over reliance on testing in order to reach a diagnosis and believed in a thorough history taking and clinical examinations. One of the most famous stories about TH is about the time when he was the Distinguished Professor of Medicine of the Veterans’ Administration. There was a case at one of the VA hospitals that had left the Housestaff stumped for a diagnosis despite multiple tests. TH started on the patient with the history and followed it up with a three minute long palpation of the precordium which led him to a diagnosis of ventricular aneurysm. So remarkable was his method that it is said that the audience gave him a standing ovation for this. Of course, later cardiac catheterization was done and the diagnosis was confirmed. More recent studies have concluded that the precordial palpation has special importance in the diagnosis of cardiac diseases (1);

An apical impulse lateral to the mid-clavicular line or greater than 10 cm from the mid-sternal line was sensitive but not specific as an indicator of left ventricular enlargement. In patients without left ventricular hypertrophy, an apical diameter greater than 3 cm in the left lateral decubitus was sensitive (92%) and specific (91%) for an enlarged left ventricle. The positive and negative predictive values were 86% and 95% respectively.

That TH was a prodigy is also stated by some of his peers who talk about how an IQ test was administered to him when he was once hospitalized during the later years of his life. It is said that he came out with a score of 185! (2)

Harrison embodied the concept of the researching physician. His prolific clinical skills are legendary but his foray into the world of medical research, the numerous breakthroughs in the disciplines of cardiology and shock are somewhat dwarfed by the image of Harrison the clinician and Harrison the educator. He joined the newly reopened vanderbilt University school of medicine at Nashville as the Chief Resident in 1925 (incidentally, Blalock joined as the Chief Resident in Surgery at the same time). He stayed on the staff of Vanderbilt for 16 years, during which he published a mind boggling 107 original papers! He also brought out the first two editions of the authoritative tome, The Failure of Circulation while he was there in 1935 and 1938. There is an interesting tale about the 3rd edition of the book, which, incidentally never got published. In 1944, the Harrison family was moving from North Carolina to Texas in two vans when one of them caught fire. The fire was so devastating that nothing could be salvaged, including the completed manuscript of the 3rd edition of The Failure of Circulation, which, ultimately, never came out.

After a brief stint at Dallas, where he served as the Dean for a short period of time, he went back to his roots at Birmingham to Chair the Department of Medicine at the University of Alabama School of Medicine. He initiated here, like he did previously at Vanderbilt, a unique system of coordination between the different clinical and pre-clinical/diagnostic departments of both the medical and surgical specialties. He would use his personality and his stature to recruit physicians of national prominence from Harvard and Mayo. Under his leadership, the University of Alabama School of Medicine rose to be one of the most respected institutes nationally.

It was in 1950 itself, when he was moving back to Birmingham, that the thought of editing the first edition of what is today THE textbook for all medicine aspirants was conceived. (3) He led a team of the best professors – Adams, Beeson, Resnick, Thorn and Wintrobe – to bring out 5 editions of the tome in his lifetime. Now in its 18th edition, this book represents a unique movement in the world of medical texts seeing as how it is closest to being one of the most complete texts possible. Now while that makes the size of this book a little intimidating, yet, it remains a joy to read. I searched extensively online to see if I could dredge out an image of the very first edition, but it was in vain, so here, let me show off mine!

Tinsley Harrison was not just a clinician. He was a remarkably well rounded personality. Aside from his academic life, he is said to be the prototype of the forgetful professor that one would guess he was. His peers say that it was a largely his wife’s credit to have kept the absent minded professor free from dealing with the drudgeries of daily living by making his life as organized as possible. Following the completion of his medical school at Johns Hopkins, Harrison moved to Peter Bent Brigham hospital where he worked for two years. It was during his sojourn at the Brigham, that he married Betty Woodward, who remained a strong and calming influence in his life. Notably, while he was working at the Brigham, he was associated with the likes of Samuel Levine, William Dock, Chester Keefer and henry Christian. His lifelong love for the circulation system was also implanted during this phase when Samuel Grant introduced him to the clinical investigations of the cardiovascular system using the Fick principle.

CO = Cardiac Output, C_a = Oxygen concentration of arterial blood and C_v = Oxygen concentration of mixed venous blood. Image Credits: Wikipedia

Harrison was also a bit of a sportsman. He was the Southern Doubled Tennis Champion (his partner was none other than Blalock!), an avid golfer and even at the age of 70, he was adept at water skiing!

I have left one of the most interesting aspects of Harrison’s bedside teaching for the last because this is something I really enjoyed learning about. His bedside teaching skills are legendary but he would organize the bedside teaching in a unique way which would cater to all the echelons of medical professionals that flocked to his lectures. In every bedside excursion, he would take the history only and make his diagnosis or set of differentials based on the findings that he would elicit in the history. He would then ask the resident to do the physical examination in addition to the history of the case and based on those findings, the resident had to reach a set of differentials, if not a final diagnosis. The intern was allowed a little more leeway in that he would have access to the routine laboratory findings in addition to the history and physical examination in order to aid his diagnosis. And finally, the “lowly” medical student would be allowed to ask for additional investigations, imaging, etc. in order to get to the diagnosis. This is a unique format that would provide an intellectual stimulus to all the people present there and not just let the residents run away with the game. As an avid mediquizzer myself, I can only imagine the kind of excitement that this format of bedside teaching would generate!

Tinsley Randolph Harrison and Sir William Osler have been two of the biggest names in Medicine in the past century. They are legends in their own rights, but somehow, the more I read about Tinsley Harrison, the more I seem to think that he was somehow the carrier of the baton that Sir Osler left behind. It feels wonderful to be part of a profession that boasts of intellectual giants as these. It reminds me that I am part of a much larger game, extending much further beyond the limits of a few examinations and a few disappointments. I am part of a culture of medicine that has triumphed over mechanization of thoughts, actions and execution.

From time to time a personality scintillates across the medical firmament, who dazzles all beholders. Tinsley Harrison was such a person, a delightful, passionate, vivacious physician. He stimulated everyone with whom he came in contact and he placed an indelible stamp on the medical events of his day. (4)

Dedication page of the 9th edition of Harrison’s Internal Medicine which was published after the death of Tinsley R. Harrison in 1978.

The dedication above was wrong. Tinsley Harrison continues to stimulate and inspire people. People like me, who sometime lose sight of the real reasons they fell in love with Medicine in the first place while navigating through the bumpy terrain of life. People whose closest association with him is through a book… Thank you for reminding me of the real reason that inspired the passion in me to do medicine. Thank you for making me fee rejuvenated once again so that I can take the bull by the horns and live to fight another day. And above all, thank you, for reminding me of the “master word” that your idol asked us students of medicine to engrave in the tablets of our hearts:

“Though a little one, the master-word looms large in meaning. It is the ‘Open Sesame’ to every portal, the great equalizer in the world, the true philosopher’s stone which transmutes all the base metals of humanity into gold. The stupid man among you it will make bright, the bright man brilliant, and the brilliant student steady. With the magic word in your heart, all things are possible, and without it all study is vanity and vexation. The miracles of life are with it; the blind see by touch, the deaf hear with eyes, the dumb speak with fingers. To the youth it brings hope, to the middle-aged confidence, to the aged repose. True balm of hurt minds, in its presence the heart of the sorrowful is lightened and consoled. It is directly responsible for all advances in medicine during the past twenty-five centuries.And the master-word is Work, a little one, as I have said, but fraught with momentous sequences if you can but write it on the tablets of your hearts, and bind it upon your foreheads.” (5)

References:

1. Eilen SD, Crawford MH, O’Rourke RA. Accuracy of precordial palpation for detecting increased left ventricular volume. Ann Intern Med. 1983 Nov;99(5):628-30. PubMed PMID: 6227265.

2. Merrill AJ. Memorial. Tinsley Randolph Harrison. Trans Am Clin Climatol Assoc. 1979;90:xxxviii-xi. PubMed PMID: 390820; PubMed Central PMCID: PMC2279388.

3. Dalton ML (2001). William Osler’s influence on the career of Tinsley Randolph Harrison. Southern medical journal, 94 (7), 724-7 PMID: 11531181

4. Isselbacher KJ, Adams RD, Braunwald E, et al. Harrison’s Principles of Internal Medicine. New York. McGraw Hill Inc. 9th Ed. 1980, Dedication page.

5. Osler W. An Address ON THE MASTER-WORD IN MEDICINE: Delivered to Medical Students on the Occasion of the Opening of the New Laboratories of the Medical Faculty of the University of Toronto, October 1st, 1903. Br Med J. 1903 Nov 7;2(2236):1196-200. PubMed PMID: 20761153; PubMed Central PMCID: PMC2514735.

Tags: Harrison, MedBlogging, Medical School, Medical Student, Medicine, Osler, postaday Permalink

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The Map of the Cat Conundrum: Richard Feynman and AIIMS November 2011

Posted by Pranab on November 13, 2011 in #MedEd

Well, that sounds like an odd assortment of topics to group under the same heading, does it not? Well, today I had the misfortune of experiencing first hand what Feynman had described ages ago in Surely You’re Joking, Mr. Feynman?

As my blog readers might know, I had an examination today, and before you ask me, I will submit that it did not go all too well. In this post I would like to discuss an aspect of the question paper that I found particularly irksome. Now I am not, for one moment, saying that these particular problems caused me to take a really bad test, but what I am saying is that questions like these make studying for an exam a pain in the neck. I know I was not too well prepped for the exam as it was, and expecting a miracle would not be scientifically sound judgment, but anyways, my point is, an exam should be geared towards a constructive assessment of a student and NOT a “destructive” one.

Anyways. As any Feynman fan will remember, he decided to drop out of Physics for a while and check out Biology while he was in Princeton to just get a feel for what was going on in the world of science around him. Trust a scientific genius like him to do something weird like this. Anyways, so when he was doing Biology, he had a rather fun run in with a librarian when he demanded a “map of a cat” to study its anatomy.

Now, in order to preserve the joy of the original reading, let me quote to you:

The next paper selected for me was by Adrian and Bronk. They demonstrated that nerve impulses were sharp, single-pulse phenomena. They had done experiments with cats in which they had measured voltages on nerves.I began to read the paper. It kept talking about extensors and flexors, the gastrocnemius muscle, and so on. This and that muscle were named, but I hadn’t the foggiest idea of where they were located in relation to the nerves or to the cat. So I went to the librarian in the biology section and asked her if she could find me a map of the cat.

“A map of the cat, sir?” she asked, horrified. “You mean a zoological chart!” From then on there were rumors about some dumb biology graduate student who was looking for a “map of the cat.”

When it came time for me to give my talk on the subject, I started off by drawing an outline of the cat and began to name the various muscles.

The other students in the class interrupt me: “We know all that!”

[Now THIS is my favorite part!]

“Oh,” I say, “you do? Then no wonder I can catch up with you so fast after you’ve had four years of biology.” They had wasted all their time memorizing stuff like that, when it could be looked up in fifteen minutes.

So, it goes without saying, something similar happened in today’s exam. We had a series of questions on Indian Penal Code [I remember the questions all to well, and plan to recall them in a later post, like I had done before – major crowd pullers, these; sorry to game the Goog dear reader, but I love getting me some hits!].

Now I find questions that ask us for information about the principles of the law or for that matter, punishments and other stipulations a meaningful enquiry, but what I absolutely do not get is why they would ask us questions like:

A doctor can be punished for issuing a false certificate under which of the following section of the Indian Penal Code:
a. 197
b. 147
c. 157
d. 167

I understand, we need to know that there is a legal framework against issuing of a false medical document, and we are held primarily responsible for it. But how does it do me, a doctor, any good to know WHICH section I shall be tried under for this? My mother is a lawyer and even she has no idea what the answer should be. [But I do, and I think that is pathetic!]

I have seen the Indian Penal Code, and it is a book hardly any bigger than the OHCM. And the Penal Codes are VERY well arranged. it would hardly take anybody who knows how to read, not more than 5 minutes to locate the answer to this particular question. There were 3 other questions like this, specifically asking for the particular Penal Code section involved.

Another reason I find this line of questions very illogical and impractical is the fact that Indian legal system is a veritable mine of legal documents. One of the oft quoted legal booklets is the Criminal Procedure Code and we are routinely drilled on the contents of the same. So, how many of these legal books should I read? As a doctor, I can justify any number of crimes I could commit in course of my professional life [if I was a betting man, and I am not, my money would be on the fact that some of our professional brethren may already have done that sort of thing!] that could be covered by the obscurest of Indian legal paraphernalia. Does that mean I have to learn the specific portions? Heck, since when did we stop making the lawyers?

This time around there was a question which asked us what the maximum sentence for breaking the Organ Transplantation Act of 1994 was. It is still a more reasonable question, since knowing that I can be docked for more than 5 years might keep me from stealing a kidney or something [no, really, I mean it], but in the previous years, they have asked WHICH YEAR the law was implemented. Once again, what good does it do if I know that the law was implemented in 1994? Does it have any bearing on my clinical abilities or my medical acumen or whatever?

Another question which has an interesting bent ONLY if you are in jurisprudence or whatever was:

A chronic alcoholic, who was brought in for medical examination following a violent assault on his neighbor had not consumed alcohol in the past four days and was found to be suffering from delirium tremens. In this case, according to the Indian Penal Code:a. He has no criminal responsibilities for his actions
b. He has criminal responsibilities for his actions
c. He has partial responsibilities for his actions
d. He has diminished responsibilities for his actions

Now I bet if you asked a lawyer this question, he would ask you back: “What do you want it to be?” but the truth remains that the final decision on his criminal responsibility does not really lie with the doctor. It is good enough that he can diagnose the person to be suffering from delirium tremens, and the rest of the work should be done by the legal eagles.

Just in case you are wondering what this answer might be, I will invite you to read this excellent paper on: Intoxication as a defense in criminal law.

Now you know what a deviously complicated question that was! What good does it do to a doctor to know about this issue?

These questions are basically just sieves put in place to separate the “grain” from the “chaff”. They encourage rote based learning, something that is at the bottom of the problems plaguing the whole Indian educational system, not just the medical front. If we are to be tested as proper medics, do us the honor of asking us proper questions. I am not saying that these questions altered the outcome of the exam for me. My preparations, if not adequate, will not take me across any kind of an examination. But I would surely like to take an exam where I am not left looking at the paper and wondering why I had not spent more time mugging up “the map of the cat”.

Tags: AIIMS, AIPGMEE, Exams, MedBlogging, Medical Education, Medical School, Medical Student, Medicine, PGI, PGMEE, PostADay2011 Permalink

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Protected: Emerging and Reemerging Infectious Diseases: A Public Health Challenge

Posted by Pranab on June 15, 2013 in #MedEd

Tags: RATPISS, reemerging infectious diseases Permalink

1 Comment

Guest Post #1: India – One of the Fastest Growing Economies

Posted by Pranab on April 19, 2013 in Life Beyond Medicine

This is a guest post written by Ms. Deepali Kaul. I have made slight grammatical and syntactical edits and otherwise, left it untouched. This article and its opinions and contents are not due to me, but to Ms. Kaul. Any links are not endorsements and are meant for informational purposes only. If you want to submit a guest post for consideration (though I wonder why!), please contact me!

Independent of its growing population, the Indian economy has been seen to touch new heights of success. Despite the limiting factors like poverty and disparity in income, Indian economy is considered as one of the fastest growing economies in the world. Liberalization policies have its unique contribution in growth, in market exchanges rates, trade volume and to boost demand. Indian economy with its diverse features has allowed opportunities to work in India to grow in several sectors like agriculture, handicrafts, textiles and other fields.

Agriculture has given 66% of its shares in growth of Indian economy and along with it the service sector is also taking speed to hold an important position in growth, in Indian economy. The Indian economy holds 12th position in market exchange rate, it is the fourth largest in purchasing power. Even following the recession of 2007 – 2009, India managed to keep its growth rate up to 9.668% in 2010. One of the strengths of India is its English speaking economy that has given new horizons to grow. Technical support and customer care support have given employment to a large number of youth giving wide employment to millions of people.

India is also expanding in manufacturing, aviation, tourism, retailing, and pharmaceuticals. It is expected that there would be appreciable growth in these sectors. India has a strong IT workforce which is next to agriculture in providing huge work opportunities to educated Indians. The IT hub has reason to smile for Indians as it is increasing each day. Future forecasts tell IT would be one of the principal industries of the country in coming years. The IT sector contributes 58.4% to national GDP.

India has seen strong growth its economy thanks to the Government’s efforts in recent years. But still it has to go a long way as the population is one of the major issues that has to be dealt with. Though India is ranked as 12^th in the world in its market exchange rate, its unending population, poverty and illiteracy is neutralizing its power. Apart from this, India’s export capability has seen stiff competition from China’s remarkable export potential of manufactured goods.

Recently India’s emerging economic growth has slowed down to 4.50 percent, whereas China has been in first position in increasing economy with 7.80%. It is expected that ASEAN 5 (Vietnam, Malaysia, Indonesia, Thailand and Philippines) countries will soon hold a strong position in world economy, it was evident ASEAN 5 showed a growth rate of 5.7% in 2012 that clearly predicts their prosperous economies in the near future. Economists of the world predicted if the same situation exists, it would become hard for India to cope up with countries these countries growing economies.

India has struggled in last year because of its rigid and endless government policies imposing in restrictions on foreign investments. Too many regulations and red tape have avoided economic growth of the country.

But if the positive aspect is focused, India has great strength of education. Indian education system is in demand worldwide. It is one of the leading players in high-tech field contributed by highly qualified and educated workforce. But still, it is also limited as education expertise is not spread uniformly in the country; it remains restricted to some areas. Only a small number of people is able to get higher education, resulting in high rate of unemployment. Other bigger issues have also to be dealt by the country like electricity problem, water problem that dogs the energy sector. On the positive note controlling its population and speeding, economic growth will definitely make India one of the super powers of the world.

Tags: Economy, Guest Post, India, Indian Economy Permalink

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New York Soda Rule: Raising the Debate on Paternalism in Public Health

Posted by Pranab on April 18, 2013 in Public Health

Paternalistic attitude in unilateral implementation of public health policies, especially with respect to banning of (harmful) substances, has been one of the issues that I have been debating not only with my colleagues, but also with my own self, for a while now. Aside from the obvious stake in the matter as a student of Public Health and Community Medicine, this has been an issue that has left me in a bit of an ethical and moral quandary. This Perspectives article in the New England Journal of Medicine just irked the sense of confusion and vacillation in me again, inspiring this post in the middle of what has been a torrid season of writer’s block.

So, some background before the commencement of my rant. New York City’s charismatic Mayor, Michael Bloomberg, in a bid to tackle the obesity epidemic in USA, proclaimed a law, which forbade the sale of any “sugary drink” that was larger than 16 oz. Obviously, Big Fizz was not going to take this lying down and they took it to court where Manhattan state Supreme Court Justice Milton A. Tingling struck down the law, saying:

the rules are “arbitrary and capricious,” applying to only certain beverages and only certain stores.

“The loopholes in this rule effectively defeat the stated purpose of this rule,” he wrote, complaining of “uneven enforcement even within a particular City block, much less the City as a whole.”

Fox News

Bloomberg obviously thinks that the ruling is a grave error and vows to take the cudgels up until he wins.

Image credit

Now, to come to the dilemma that has been ailing me. And this isn’t just me. This issue has raised passions on our Facebook Healthcare discussion forum Tabula Rasa as well:

The question that has been plaguing me is:

Does the Government or any public health regulation body have the right to infringe on an individual’s right to make a choice in order to regulate their behavior for the sake of the greater good?

And in my opinion, there is no simple, straight forward answer to that question. Before you lash out at me for my stand, mind it this is a stand that is evolving and is open to debate and discussions, and very likely to change in the future. Like I once said on this blog, this is my way of thinking out loud and inviting discussion and discourse to help modify and train my way of thinking.

So, if the disease in question is an infectious one, where there is an immediate risk of danger to the people around you, it makes sense for the Government or the public health bodies to step in and modify behaviors. That is the basis of all our activities in the field of immunization and primary prevention of diseases. Without this intervention, we would still be suffering from small pox or polio. So, there is little debate about the regulating agencies stepping in to modify behavior associated with issues that are likely to affect the susceptible population from an index case.

The issue gets more complicated for conditions like obesity or diabetes, which are classic non-communicable diseases, yet, the burden of which, directly or indirectly, may affect people all around the afflicted one. Thus, in a country with a national, universal health insurance system, where the money to pay for the healthcare demands of an individual comes from the taxes of all, these NCDs may pose a major problem. Taking the example of a diabetic patient, one can argue, that since he is using up more resources and causing a higher burden on the monetary demands of the system (and hence, indirectly, on the individual via inflation and taxes), his non-communicable disease is spreading monetary misery all around.

In such a case, can we not extend the same logic we applied to infectious diseases, to curb behaviors or risk factors known to precipitate diabetes in a person who is predisposed to it?

On the flip side of the argument, we have the question of autonomy.

We debate issues of patient autonomy, the right to choose one’s own treatment (or sometimes, even the lack thereof: remember Kerry Wooltorton, anybody?), and the ability to make informed decisions. As physicians, we stand on the high pedestals of Patient Centered Care or User Driven Healthcare or Shared Decision Making and demand that the patient be informed about all the pros and cons about the decision they are making, be informed about what other alternatives they have… and then let them make their own decisions. So, why can we not do the same when it comes to public health issues?

In an ideal world, we would not need to ban any substance, no matter how deleterious they were. We would need to empower the population and then let them make the decisions. However, that calls for an inordinate amount of awareness and motivation on the part of the “public” to make such liberal public health systems work. To address the subsequent issue of greater demand on health systems by the individuals who ultimately “fall prey” to their “indiscipline”, one could argue the case for institution of penal measures, like higher premiums on health insurance or more restricted coverage. But, that in itself is another matter to debate about!

It is all nice and good to discuss these theoretical implications. But coming to the ground realities, especially in a nation like India, where the strain on the resources is severe and the supply, minimal, we need to take a long and hard look at issues like Behavior Change Communication, which has traditionally been long-time investments with unpredictable outcomes. Another major problem is adherence to instructions/treatment regimen. Although it shall be difficult to unearth national level statistics on this, I am sure all clinicians will agree when I say that owing to the lower socio-economic, educational and awareness levels, people do not tend to have good compliance with prescribed treatment. This is when they are suffering from a diseases and perceive the need to take medicines to alleviate their symptoms. I wonder how difficult it shall be to inspire the same person, who is loathe to take medicines for an ailment, to stick to a behavior pattern (that may be quite ascetic and unrewarding in the short run) to prevent a disease in some distant future! In this age of globalization and instant gratification, it seems to be a difficult practical point to implement the “ideal world” scenario.

So, I guess, threshing it out, for me, autonomy and the ability to be one’s own master ranks way higher than paternalism in public health for the greater good. It has its pitfalls and most definitely is not the ideal way to go about ensuring that everyone enjoys life with the best possible levels of health, both of mind and body; but at the same time, it leaves with the individual, that very important essence of freedom to decide. And that, for me, is paramount! So, despite all the negatives, I would rather that the individual is given the right to choose his way of life rather than impose on him a “healthy” lifestyle.

Tags: Bloomberg, Debates, House MD, NEJM, New York City, Obesity, Paternalism, Soda Rule, Substance Abuse, YC Permalink

2 Comments

Another Start-up Bites the Dust: Elsevier Buys Mendeley

Posted by Pranab on April 10, 2013 in Medcetera

When TechCrunch reported that there were talks going on between Elsevier and Mendeley this January, I did not want to believe it. Being an ardent user and advocate of the platform, I wanted it to stay out of the clutches of Big Pub. But it is now official, Mendeley has been acqui-hired by Elsevier for an unknown amount, which could be anything from65-100 million US $.

After Posterous being pwned by Twitter last year and then eventually getting shut down this year, my mind immediately bodes ill on hearing this bit of news. Mendeley was not doing too poorly after they had introduced “pro” features and monetized successfully. Their revenues had apparently tripled since they asked people to cough up money for extra storage space and bigger teams and all that.

There never is a good environment about the acqui-hires. When Twitter took over Tweetdeck, and the Posterous, their death knells were predicted months before they were rung. And Elsevier comes with not the best reputation in the business. From surreptitiously removing journals from the free/susbsidized HINARI, to hiking institutional subscription fees by astronomical amounts, to facing academic rage for being a successful money-minting business in an otherwise gloomy financial environment – it does not bode well for the nay-sayers, who believe that Mendeley will ultimately go to enhance Scopus, Elsevier’s own initiative.

However, talking purely from the financial and outcomes point of view, this was not a bad move. If Elsevier continues the free version and keeps Mendeley adequately de-centralized as to be able to make their own innovation without too much hierarchical foot stomping, then this is absolutely the best. The developers can concentrate on delivering the best possible product without having to worry about raising money to keep the business afloat.

The Mendeley Blog has put up a QnA style post which assuages my fear that the free version would be closed. And to keep skeptics like me happy, they have thrown in an additional sop – they are doubling everyone’s storage space, to begin with. So, y free account now has a massive 2 GB box. They also assure me that the take-over does not mean that Mendeley shall stoop to promote content from their parent company. But the veracity of that claim can only be established with time.

Anyways. I am a little bit unhappy that the start up has been phagocytosed (not that I complain; fiscal reasons can be more than compelling); but Richard Horton tells us, “Elsevier is changing”:

Mendeley joins Elsevier (our publishers). Surprised? Some are. But Elsevier is changing. The enthusiasm for open access is real: @lancetgh.

— richard horton (@richardhorton1) April 10, 2013

And more than a few have guffawed at this claim. I shall, for the time being, prefer to hold my horses.

But, as I said when Posterous was gobbled by Twitter, I congratulate CEO VIctor Henning and the others in the Mendeley team on the success. I just hope that they continue to run the program as they have done, but better, now that they are (probably) unencumbered with financial considerations.

Tags: Acquihire, Elsevier, Mendeley, Money, OA, Open Access, Posterous, Twitter Permalink

← Older posts

Scepticemia

Anti-Bloomberg Bill in the Soda Wars: Two Wrongs do not Make a Right!

PostScript:

The Family Physician: A Dying Romantic Idea

Old Doc Brown

USMLE 2013 and IMGs: All That Glitters is NOT Gold

Post-Script:

The USA Dream for IMGs: Coming to an end? Analysing the 2012 Match

A Lexicon for Public Health Students: The Design Effect

Banning Gutkha: Paternalism in Public Health or Pro-Active Advocacy?

William Gosset: A True Student

References:

Remembering Tinsley Harrison, the Oslerphile Physician

References:

The Map of the Cat Conundrum: Richard Feynman and AIIMS November 2011

Protected: Emerging and Reemerging Infectious Diseases: A Public Health Challenge

Guest Post #1: India – One of the Fastest Growing Economies

New York Soda Rule: Raising the Debate on Paternalism in Public Health

Another Start-up Bites the Dust: Elsevier Buys Mendeley

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