Throckmorton Sign: THE PENIS POINTS TO THE PATHOLOGY

Example (courtesy http://www.radswiki.net):

“The penis points to an enchondroma in a patient with Maffucci syndrome”

Medicine: serious business.

* Pimping: (verb) The act whereby students are quizzed on minutiae and medical trivia during rounds or class (i.e. “Which 19th Century Prussian scientist discovered?”). This activity is usually reserved for the Attending or residents and fellows with attitude.

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7:00AM - Arrive at the hospital.

My work day begins bright and early at 0700. Typically, I arrive 5 minutes late because every day I tell myself that I can make up the time by driving fast. For some reason I think I’ll be more rested if I sleep five minutes later — it makes sense at 6:00am anyways. Once I get to the hospital I head into the back entrance and take the stairs to the second floor. Usually the other medical student on the service is already there and has a list of the day’s patients waiting for me. About this time the internal medicine resident on my team is overhead paging “Student Doctor John V, please call 7507″. The three of us then begin the process of dividing up the patients. We usually try to keep some semblance of continuity of care going, thus any patients I saw the day before I will see again. This works best for the patient and the students/residents. As a student, I typically have at least 2-3 GOMERS assigned to me on any given day. The other 2-3 patients assigned to me can vary from good cases to baker-acted nutjobs to patients who make you want to poke your eyeballs out and everyone in between. After I get my patient assignments, I check to see how many new patients I have. For each new patient I print out a handy worksheet from medfools.com that helps me keep track of the patient’s medical history, history of current hospitalization, medications, orders, complaints, etc.

7:15AM - Head up to rehab

I try to hit the rehab floor first. They physical therapists like to start pulling patients out of their rooms for physical / occupational therapy at about 8am. This means that if I get upstairs too late I have to interrupt what is usually a group physical therapy so I can interview and examine the patient in front of the group. The patients usually don’t mind but you can feel the hate radiating off the physical therapists whenever this happens.

The problem with the rehab floor is two-fold. First, the charts are usually no where to be found. There is a chart rack behind the main nurses station that the charts are supposed to be in when they’re not being used, but usually the charts are AWOL somewhere out on the floor (the floor is a term we use to refer to any part of that floor other than the nurses station — not the literal ground). The second problem with the rehab floor is that the vital signs are never, ever done and/or chartted by the nurses yet. This means I have to leave that part of my note blank and come back later in the morning to fill those in.

Rehab patients are usually quick and straightforward. Unfortunately they’re often in a lot of pain and many of them are very depressed (imagine being stuck on a hospital floor for 6 weeks while you relearn to feed yourself after a stroke). Medically, the patients are usually easy cases. To be cleared to go up to the rehab floor, you first have to be deemed medically stable. For the most part, on the rehab floor we just manage anticoagulent therapy, blood pressure, and sugars. Each case takes me about 10 minutes to see the patient and 10-15 minutes to write my note (unless something is out of the ordinary). My recommendations are almost identical from patient to patient, day to day:

“(1) Continue to monitor ________

(2) CPTx (continue present treatment)

(3) DWA (discuss with attending) - Dr. Smith”

Dr. Smith / John V., MS IV

7:55AM - Head downstairs to the medical floors

The medical floors are a whole different beast. For one, there are all sorts of techs, nurses, aids, students, interns, residents, fellows, and attendings hustling and bustling about in the morning. The first and most important thing you need to know as a medical student is the hierarchy of medicine. Obviously anybody above your rank has first rights to the chart, and anyone below your rank will usually give the chart up for you. The nice thing about being a medical student is that you’re acting as an extension of the resident, who is acting as an extension of the attending. So nurses, aids, techs, etc. usually will let you have the chart so you can go on about your work. However, if an intern, resident, fellow, or attending has the chart — tough luck. You just have to come back and hope some other physician doesn’t have it.

Once I get the chart, I dig into the orders, medications, and progress notes sections. My job as a student is to know absolutely every test, every specialist, every opinion, every medication, literally everything that is going on with a patient and that has changed with the patient overnight. Sounds easy, right? Unfortunately this often involves interpreting the hand-writing of the other physicians on the case, as well as spending an inordinate amount of time reading CT and x-ray reports and figuring out who ordered what test and what the result was exactly. I usually spend about 20 minutes with the chart and the lab results on the computer before I even think about seeing the patient. I usually try to assimilate this into some sort of loosely connected picture in my brain before I see the patient so I can efficiently talk to the patient, answer his/her questions, provide basic information, ask relevant questions, and do a focused physical exam.

Actually seeing and examining the patient is the quickest and easiest part of the whole process. I usually spend about 5-10 minutes talking to the patient. After I finish the interview I run through my standard schtick “Any chest pain, palpitations, diaphoresis, shortness of breath, nausea, vomitting, diarrhea, fevers, chills, abdominal pain, leg pain?” The physical exam is pretty standard for most patients, with attention to specific systems depending on why the patient is in the hospital. Every patient gets a basic cardiovascular, pulmonary, abdominal, and extremety physical exam. After the physical I wrap up the interview, answer any questions, and head out to find an open table to write up my note.

The day to day hospital notes by physicians (called progress notes) are usually written in a standard format — though some attendings ignore and/or modify this format to their pleasing. The standard format is called a “SOAP” note — s for subjective, o for objective, a for assessment, p for plan. These notes are hand-written in my hospital. In the subjective portion you write a basic subjective narrative of what’s going on with the patient. This portion is usually a bit flexible as sometimes objective data (such as # of stools passed yesterday, etc.) is included. The objective portion is where I write my physical exam results and any lab results. The assessment where you list any and all relevant diagnoses in order of relevance to your specialty. The plan section is self-explanatory.

Here’s a sample SOAP note:

S - Patient seen and examined. No new complaints / concerns. Continues to complain of pain in left shoulder and “tailbone”; describes pain as 5/10 nonradiating intermittent stabbing worse with movement. Also continues to complain of decreased appetite and fatigue. Participating in physical therapy. + BM last night. Denies CP/SOB, n/v/d, f/c. Asking when she can go home.

O - Vitals: P - 68; R - 18; BP - 112/65; T - 97.9

General: AAO x3 (alert and oriented to person, place, time), NAD (no apparent distress)

CV (cardiovascular) - RRR (regular rate and rhythm), S1S2 (specific heart sounds) noted without m/r/g (murmurs, rubs, gallops)

Pulm (pulmonary) - CTAB (clear to auscultation bilaterally), no r/r/w (rhonchi, rales, wheezes), no conversational dyspnea, adequate respiratory effort

Abd (abdomen) - soft, NT/ND (non-tender, non-distented), +BSx4 (positive bowel sounds in all four quadrants)

Ext (extremities) - no c/c/e (cyanosis, clubbing, edema), negative homan’s sign

Labs: Pending

A - (1) status post ground level fall and left shoulder fracture

(2) Hypertension - well controlled

(3) Paroxysmal atrial fibrillation

(4) Coronary artery disease - stable

(5) History of CVA (stroke)

P - (1) Continue blood pressure monitoring

(2) Fall precautions

(3) Continue rehab

(4) Discuss with attending - Dr. Smith

– Dr. Smith / John V., MS IV

After I’ve written my note I make a copy of it to carry with me so that I can answer any questions my attending has later in the day. I repeat this process about 3-4 times, depending on how many patients I need to see.

12:45PM - Scramble to lunch

….to be continued

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from xkcd.

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Johnny writes,

Conservatism is simply the preference for the hypothesis which requires less rejection of established knowledge. See the example in the post above. Modesty is simply the preference for the hypothesis which includes more familiar phenomenon. For example, that caller who hung up when you answered could be a burglar calling to see if you are home, but a more modest hypothesis is that someone dialed the wrong number. Simplicity is self-explanatory — similar to Occam’s razor.

Clete responds,

With respect to conservatism in particular, how do these not tend to maintain and propagate errors of the past? With these as your criterion, once you start down a wrong path, how would you ever do a course correction?

Johnny responds,

That’s a good question because conservatism can and does propagate errors and I’ll give you an example here in a minute. (I’m finding this hard to verbalize, so please ask for clarifications if I am not clear). In order to understand why conservatism is a “virtue” in science, we have to start way back at the purpose of science. The purpose of science is to approximate the truth, not to dictate the absolute Truth. The way we evaluate whether or not science is approximating the truth is by testing its predictions and descriptions of what we can measure and observe (because we assume that which we measure and observe is true). So assume for a moment we start out with a model that describes a particular phenomenon very well. However, one day some graduate student discovers a particular subset of events within the phenomenon that the model does not accurately describe. There are two choices. We can try to integrate a new model into our old model to form some sort of hybrid model that describes both phenomenon with accuracy, or we can scrap the old model all together because there is some error in it. Because science is trying to approximate the truth, it always choses the option which increases the accuracy. So no matter how many errors are integrated into a model, with each subsequent modification, the model gets closer and closer to perfectly describing reality.

For a good illustration, take a piece of paper on it’s side and draw a circle at one end. At the other end, make a starting point. Now draw a short line in a random direction from your starting point. That’s your first hypothesis. Now you measure the difference between observation / prediction (the end of the line) and truth (your circle). Now draw another line extending from your first line that more approximates the direction of the truth circle. And then another from that line. The idea is that by conserving that which is established and integrating new ideas, you maximize your descriptive powers and you move closer and closer to the truth even if there are some errors in your lines. This is considered superior to completely scrapping a line very close to the truth circle because it does not hit the circle directly (non-conservatism).

Now, some times bits and pieces of models have to be chopped out to help integrate new ideas. But so long as these modifications move a model towards better description, this is acceptable. Other times, two models are completely incompatible. In this case, it usually takes a few decades of research before one model emerges triumphant over another.

I hope I explained that well, I can’t remember for the life of me how it was explained to me, and the books I have dealing with this topic are back in Florida at my parents house.

Clete responds,

Based on Johnny’s answer to this question, it would seem to me the conservatism in science is only virtuous if one has it in mind not to rock the boat too much. Any theory which describes a fundamental paradigm shift would automatically be rejected regardless of its power to explain observed phenomena.

….

…I understand that extraordinary claims require extraordinary evidence, if for no other reason than that those who need to be convinced are entrenched up to their necks in the uniformitarian paradigm. Paradigm shifts always present a great deal of emotional and intellectual inertia and it seems clear to me that this conservatism criteria is designed to reinforce that inertia. Not very useful in a pursuit of the truth if you ask me. Our first duty should be to the truth, not to the scientific status quo.

Johnny responds,

I don’t think you fully understood my answer (likely the issue was with my explanation). It’s not the case at all that fundamental paradigm shifts will be automatically rejected based on conservatism. It just means that new paradigms must meet at least the standard of evidence the old paradigms meet. Any new hypothesis worth it’s weight will be evaluated against current knowledge. If it is possible to integrate a new hypothesis within the model of current knowledge to yield more accurate descriptions, then why would you not consider this superior to rejecting the former model outright? If we reject the former model outright we are left with no model, no description, whereas if we integrate two models, we are left with a closer approximation of the truth. If two models cannot be integrated, then one will eventually topple. Conservatism says that it is most probable hypothesis is the one with the most evidential support. However, it does not ensure this conclusion by any means. And so new hypothesis which contradict existing knowledge must have significant evidential support to be considered a serious contender against a better supported hypothesis.

In fact, the principle of conservatism is intuitive . You and I use it in every day life when making every day decisions. We use it when we read the Bible, and scientist use it when they do science.

Here’s an example:
We have been measuring the gravitational constant on Earth for several hundred years with dozens and dozens of different methods and by thousands and thousands of scientists with ever increasing accuracy. Today, I got on my scale and the scale told me I weighed 75 pounds. Yesterday, my scale told me I weighed 170 pounds. I now have two things to consider.

Hypothesis #1 The gravitational constant is wrong and has been measured wrong for 2 centuries.
Hypothesis #2 My scale is broken.

Established observation: The gravitational constant is 9.8m/s^2

Conservatism says that it is much more probable that my scale gave an inaccurate reading than it is that the gravitational constant has been measured wrong all those years. Thus, integrating the models: the gravitational constant was measured right AND my scale is broken. The integrated model produces a closer approximation to reality and explains both phenomenon while preserving the established observations.

——————–

Conservatism is a foundational principle of the philosophy of science, and it works the same in physics as it does in origins science. Conservatism does allow for the integration and assimilation of errors at times (see Newtonian physics), but here is the key: Any true error in a description of a phenomenon must manifest itself as observation given the right conditions (otherwise, by definition, it is not an error). For this reason, any true error will eventually manifest itself given that we , and when it manifests itself it will be corrected.

Conservatism is the very strength of the scientific method. It is in this principle that science moves continually towards closer and closer approximations of the truth. It demands the highest standards of evidence for competing hypothesis, and thus we can have confidence when established descriptions are eventually overturned in favor of newer descriptions.

Like I said, it’s very intuitive — I know at first the integration of errors seems like a drawback, but in fact it’s a strength. If we reset every time we found a mistake we’d still be at square one, because ultimately our best descriptions are going to fall short. We cannot observe all phenomenon and see all physical states, and thus our confidence in our science is as strong as what we can measure. Thus, conservatism gives us a backbone on which to move forward with descriptions, moving ever towards the goal of the “perfect description”.

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As you can see, the way to a man’s heart is actually through the bottom of his foot. This poster was supplemented by several other posters which included innumerable bullet points scattered about the various boards like spilled marbles. There was a bullet-point list of conditions that reflexology treats, a bullet-point list of toxins, a bullet-point list of reflexology products, a bullet-point list of the benefits of reflexology, and a bullet-point list of benefits of foot detoxification. Empirically measurable results was curiously absent.

Perhaps most intriguing — and by intriguing I mean annoying – was the fact that this booth was the most popular booth in the general area. There was actually a line of people waiting to get into what was apparently the detoxification zone. Eight or nine chairs were set up in the exhibit, all of them filled with bodies eager to rid themselves of the “some 500 toxins” they encounter daily. Rid the toxins through their feet, of course.

• Toxins are the cause of most diseases.

At the foot of each chair was a tub full of liquid and an IonInfra machine. This machine runs a low current through the water, which helps remove toxins from your body by introducing “millions of ions” into your bloodstream. These ions then neutralize toxins and remove waste from your bloodstream through your feet. The water changes color and consistency throughout this whole process..

• You’ll see the excreted toxins in the water. The water will change color and consistency—from orange, brown through to black.

The actual pamphlet explaining the mechanism of action of this machine had to be seen to be believed. At the time, I did not have the presence of mind to snag a pamphlet to scan — I was too busy deciding whether or not it was justified to be visibly angry that such idiocy was being shoved on an unsuspecting public for a profit. However, I found the manufacturers website which contained the same mind-boggling science included in the pamphlet. Here are some excerpts:

“It generates a frequency to create negative ions. It aims to improve, among other things, liver and kidney function through an electro-magnetic detoxification process carried out on the feet. The treatment is normally given by placing your feet in water in which an “array” will be activated. When the Ion Cleanse Detox is activated it produces ions (positive and negative) This causes movement and Any time you have electrical movement you will have a magnetic field. A magnetic field will vary in force. This variance is called a wave length or FREQUENCY will cause a VIBRATORY RATE OR TONE”

“A water molecule is composed of two hydrogen atoms and one oxygen atom. When the molecule loses a hydrogen atom, the remaining OH molecule takes on a negative charge. As you walk along the beach, your body absorbs millions of these negatively charged ions, which alkalize the blood and tissue. Because of poor diet and high stress, we tend to accumulate and store excessive quantities of waste products, such as diacetic, lactic, pyruvic, uric, carbonic, acetic, butyric, and hepatic acids.”

“The IonInfra (Ion Detox) creates precisely the same environment as the walk along the beach, only more powerfully because your feet are in direct contact with the ions being manufactured in the water. Place your feet in the water, turn on the unit and within seconds, millions of ions enter your body and begin to neutralize these tissue acid wastes.“

I found it absolutely dumbfounding that some people people were eating this up. It was clear from the various conversations taking place that several people were taking a serious interest in purchasing this $750 contraption.

As I watched this spectacle, my mind explored various explanations for the change in water color. I also thought of several very easy ways to test the InfraIon detox process. All I needed was a syringe, a helpful detox technician, a water sample, and a medical laboratory willing to do my bidding. For free. Unfortunately I was unable to secure the latter necessity. Dr. Mark Atkins and Ben Goldacre of The Guardian’s Bad Science, however, had both the equipment and a willing laboratory to carry out such an experiment.

To be continued…

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