The Haversian Canal

Our patio was a petri dish when we bought it and neither Katrina nor a year of non-occupancy helped. Litchens, molds, at least four different species of funk that I could count. I called Brad Cazenave, who has a sign up on a post on South Carollton in front of the seminary. He did a great job powercleaning the patio, and for a reasonable price. He drove all the way from Kenner, too. So if you need a patio, driveway, sidewalk, whatever cleaned, in the New Orleans area, give him a call: (504)952-0289, or fax (504)464-0726. Address is 2841 Sharon St, Kenner LA 70062. Apparently, he knows how to play soccer too.

The NBME advises their question writers to write mainly what they call hinge questions, that is, the you are given some information, and you have to know the diagnosis in order to then answer the question. The anatomy of questions is generally something like this:

Misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection. Misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection, misdirection. _____question, _______, question, ________ which _______________ is most likely ___________ question, question ____________?

A. Distractor

B. Distractor

C. Answer

D. Distractor

E. Distractor

F. Distractor

G. Distractor

H. Distractor

I finished the Biochem shelf with about 10 minutes to go but they'd already frozen us in our seats (before the 10 minute warning anyone who finished could leave), so I thumbed back through looking for trends. That's the trend. I'd say 85 to 90% of questions is used the phrase which is most likely in a compound, complex, or compound-complex question.

Unlike the MCAT, which is easily parsed using Bloom's taxonomy, I'm not sure Bloom will be of much use on the USMLE. Perhaps, but I need to review it some more. Virtually all questions require the test-taker to walk one step beyond the information in the question, the answer hinges on you knowing something that's not in the question. For example:

A thirty-year old man presents with dyspnea on exertion. Chest radiogram reveals an enlarged cardiac silouhette. If a viral cardiomyopathy is diagnosed, which hormone is most likely increased the least in the circulation of peripheral muscles on ELISA?

A. Renin

B. Angiotensinogen

C. Angiotensin II

D. Angiotensin I

E. Aldosterone

See, you really don't need to know, for the purpose of this question, what the symptoms of a viral cardiomyopathy are. That's misdirection. It might be helpful to appreciate that the heart is weaker, but, what you really need to understand is how the above hormones interact. Renin is likely to go up. Angiotensinogen production may go up, but there may not be an observable increase in concentration because the extra renin is converting it to Angiotensin II. I don't even know what Angiotensin I is off the top of my head. Aldosterone will go up if renin and ang II go up. Peripheral muscle, eh, not really useful. ELISA, eh, not really useful. But, also, do you see how this might really be the question you'd face in the clinic (okay, maybe not in the clinic, but maybe in a clinical trial)? Which enzymes might you test for to diagnose this patient? What results do you predict?

Also notice how a rather awkward reversal was introduced, which hormone is most likely increased the least, to preserve the is most likely to structure. It could have easily been rewritten as is least likely to, but that would mess with the QA people reviewing the questions.

Finally, don't bother copying somone else's answers. During my ten minutes of intel collection, I couldn't match any patterns from one answersheet to another. I mean, I was in the back of the room (Kaplan tactic) and stared quite conspicuously. I wasn't trying to change my answers, I was doing intel.

Also, why do you suppose the proctors give the tests to the students at their seats, rather than having the students come get the tests? Wouldn't that be more efficient? Well, think of all the times the proctors walked those aisles and rows, and looked at things. Casually. While all the students stayed still. Gives a good opportunity to catch conspicuous cheating, doesn't it?

Covenant House's New Orleans site has opened a free health clinic, thanks in no small part to the vigorous efforts of Dr Karen DeSalvo. A group of Tulane med students got together and decided to pitch in with the hopes of keeping the clinic open on Saturdays. Led by Dr DeSalvo (woman front and center in red t-shirt) and Ben Rieff (upper right, beard and ball cap), a number of us painted the clinic from Friday, June 2nd, through Sunday. And late Sunday, let me tell you. Waiting to get in on Sunday morning, Dr DeSalvo told us that she'd been to a funder's conference the night before, and reported that the charities are experiencing Katrina fatigue. This, however, is not a Katrina issue. Covenant House's mission is long-term. They focus on taking in homeless children.

Officials restate the obvious when they say the levees aren't 'magic' and nothing is 'invulnerable' but, really, Denmark's levees are 'invulnerable'. There is a higher standard here people. Come on. The question should be when we will get to that standard.

We went to the the Algiers Commissary (map) yesterday and the produce, particularly the leafy greens, like lettuce and cilantro, were horrid. Ho-rrid. Turns out the man in plain clothes next to us was the produce manager, Bruce. Apparently they'll be closed today and Tuesday while tthey tear down all the shelves and put up new ones, but he also said, if we ever need anything that we don't see out, tto just ask. He brought out fresh lettuce for us and some of the most beautiful cilantro I've ever seen. Bruce, Mr Produce. Good person to know, particularly if you're on a Health Professions Scholarship in New Orleans.

Encounters

Insanity, however, is inherited.... Hannah Railing of Milliner's Dream on club feet.

Heroines, by Dr Charles.

Vent Wars, Part 3; or the Decannulization of Fred by PixelRN.

The Death Hour and a Translation, by Dr Hebert.

Sister's Bladder by Fat Doctor.

Part IV—The Conclusion, by Dream Mom.

Pruning, by Moreena T. of The Wait and the Wonder.

Seeing Patients, by the Tundra PA.

People like you, by Ian Miller of ImpactEDnurse.

Interviews

Dr David Moskowitz, President of Genomed, by Hsien-Hsien Lei of Genetics & Health.

Rhythm & Rhyme

If it Makes You Happy, then Why the Hell am I so Sad? A poem, with introduction, by Kim at Emergiblog.

Death Wish, by Dr Emer. About a relative—patient.

Ward Around, by Alex J Hamilton.

Complimentary and Alternative Medicine

Mercury and autism: Well look what the Griers are up to now, by Orac at Respectful Insolence.

Alternative. In the war of words, Neonatal Doc offers an alternative to "alternative" medicine.

Articles in Brief

New Study Reveals More Self-Injury on Campus. Jon Schnaars of Anxiety, Addiction and Depression Treatments discusses a study in last week's Pediatrics.

Boost Your Lungs's Health With Flaxseed Oil, by Gloria Gamat of Straight From the Doc, summarizes a study from the Journal of Nutrition.

Correspondence

Too much and too little. David Williams relates a personal encounter with conflicting opinions about the utility of chemotherapy.

Paint the Walls or Bulldoze the Building, Rita Schwab of MSSPNexus on leading committees.

How docs can be our own worst enemies, by GruntDoc.

Look Back in Anger, by Dr Hildreth, the Cheerful Oncologist, on a woman who raged against the dying of the light.

New Labor Induction Test, by Nurse Practitioner News

Knockin' Boots and Breakin' Hips, by Aetiology.

VA Data Stolen - What impact on public perception of privacy of health information?, by Bob Coffield of the Health Care Law Blog.

The Many Faces of Sexual Abuse, by Moof of All Blogged Up.

Her First Baby, by the Storkdoc.

Merry Olde England, by InsureBlog.

A Tree Grows in Oregon...Maybe, by the California Medicine Man.

Announcements

Unintelligent Design will host Pediatric Grand Rounds this Sunday.

Dr Deborah Serani wil host Grand Rounds next week.

Radiology Grand Rounds. Sumer Sethi of Sumer's Radiology is soliciting contributions.

Kim, at Emergiblog, is soliciting contributions for a new nursing Grand Rounds, Change of Shift.

Enoch Choi will be hosting a 1.5 hour medblogger meetup at Bloggercon 4 in SF on June 23-34, a tradition from the previous three conventions.

Among others, it's National Safety Month and Workplace Safety Week.

Late addition: Amy Tenderich of DiabetesMine is liveblogging from the American Diabetes Association annual Scientific Sessions conference.

End Matter

Keagirlisms, by Keagirl of Urostream.

This is a documentation post:

New Orleans is in USDA Hardiness Zone 9, which means its mean annual low temperature was between -1 and -7 °C between July 1986 and March 2002.

In the front yard we planted three Centennial Spirit crape myrtles (Lagerstroemia indica). According to the tag on the tree, they require full sun, and should be spaced 10 feet apart. They bloom from summer to fall, prefer semi-moist soil and have a medium growth rate. Their average size is 15 feet tall by 12 feet wide. They can tolerate cold down to -23 °C. Damaged limbs should be pruned and fertilizer is best applied, if at all, in the spring and summer. Each of the three 5 gallon plants cost $10. According to the grower's tag (different from the retailer's tag), indicates these plants have a low pollen count. How something that is literally covered in flowers can have a low pollen count, I don't know. The grower was apparently associated with the Texas Department of Agriculture's Go Texan program

In the back we planted two species, a Little Gem magnolia and a Crimson Queen Japanese Maple. The magnolia (magnolia grandiflora) is best in semi-shade, which I guess means shade from a semi? Spacing is 10 feet, it blooms in spring and summer, and prefers semi-moist soil. It has a medium growth rate and it's average size is 20 feet high by 10 feet wide. It can tolerate temperatures down to -18 °C. Little pruning is required and, if fertilizer is used, it is best applied in the spring and summer.

And here's where we come to the one I was concerned about, the Crimson Queen Japanese Maple. My wife and I both like Japanese maples. They're beautiful trees. However, prior to this I've only seen them in Kansas, Maryland, and San Diego. All were mature trees under a canopy of much taller trees. According to Dave's Garden, they are only rated to go down to Hardiness Zone 8b (low temperature: -9 °C) . They also prefer acidic soil and sun to light shade. So, the big question is, do the hardiness zones provide any useful information about planting in the tropics? Surely we don't need to worry about the plant freezing, but could it get to hot? I still don't have the answer to that, but Dave's Garden contributors to provide one point for me: I've probably been overwatering the thing.

We've been touring schools lately (our daughter will start in August 2007 and registration starts this October) and, on average, it appears children are now expected to produce PowerPoint presentations in, about, the fourth grade. Can we opt out of that?

1) Show comparisons
2) Show causality
3) Show more than 1 or 2 variables
4) Integrate word and image
5) Document everything and tell people about it
6) Presentation stands or falls on its quality, integrity and relevance

Well? What do you get out of class?

I got of some interesting feedback from people on this last semester because I recorded audio of the lectures for my medical school class last semester. The feedback mainly came in the form of "Thanks Niels, I that was so helpful when I . . ." or ". . . because I . . .". Anyway, what I gathered was that there are six basic reasons to go to class:

1) Any handouts that the professor chooses to deliver in class and only in class.
2) Announcements that may not be recorded. Professors ought record these before-class and after-class announcements as part of their audio, but they often don't.
3) A sort of stamp—a certification—that you couldn't possibly have gotten more out of the course.
4) Reading the nuances of the professor's performance for clues on emphasis and organization. This is exactly the same content that that the intelligence community seeks through HUMINT—human intelligence. About 80% of this can be gotten through audio, but the 20% you miss, really sucks. The organizational framework for knowledge is most firm after going to class.
5) Socializing with your peers. This is an investment in the future, but there are other ways to socialize with peers, if you're the sort of person who doesn't mind losing their hearing to overamped static, I mean, music, or inhaling a pack's worth of second-hand smoke in a crowded bar. In fact, I think what you'll find is that the people who go to class end up consorting more with each other, and those who don't go to class end up consorting a lot with a few poeple and individually less with more people, but that's pure speculation.
6) Until the advent of slides posted on the Internet and podcasting, the final reason to go to class was the organizational framework, the schema, the professor provides, and this is, even with podcasting, still somewhat true, and it remains the fundamental thing the student needs from the professor. More about that in a previous post.

I've also heard that people who don't go to class spend more time studying directly.

We got three Encore azalea shrubs, one gallon pots, in March. One died. Haven't seen blooms yet on the other two. The ones we still have are an Autumn Princess (Azalea x "Roblea') and an Autumn Angel (Azalea x 'Robleg'). The Autumn Princess averages 3.5'x3' and has salmon pink double blooms. It should be in light shade to full sun and well-drained. According to the tag it attracts butterflies. I wonder if that means caterpillers eat it. The Autumn Angel averages 4.5' in height by 4' wide, and has single, white blooms. The Azalea Society of America has more on these southern flowers.

Today we planted a pineapple, and, in pots, we planted
- an ice plant (Lampranthus) in a sort of large terra cotta ginger jar with pockets, with purslane in the pockets
- a desert rose (Adenium obesum) in a large, maybe 15 gallon pot
- two Miltonidium Pacific Sunrise orchids. Interestingly, we thought we were buying one and it turned out to be one that was force bloomed and the other had no blooms, and is probably much more likely to thrive. We'll see. Apparently this registered hybrid's name was changed to Oncidium Pacific Sunrise by the registrar. According to beautifulorchids.com they should be allowed to become moderately dry between waterings and prefer a relatively cool climate, 85° being the highest temperature. Guess we'll be keeping these in the shade. They prefer medium to fine fir bark for potting.

The first Radiology Grand Rounds will be hosted on Sumer's Radiology Site on 25 June, and it will be hosted every last Sunday of the month thereafter. Archives of Radiology Grand Rounds will be available at Sumer's site.

Dr Sethi will accept anything that is relevant to Radiology or medical imaging but you don't have to be a radiologist to contribute. I'd love to hear from physicians, patients, nurses, medical students, radiographers, imaging technicians etc, etc. Send submissions to sumerdoc@yahoo.com and if you're interested in Hosting Radiology Grand Rounds in future.

Went in to the French Quarter last night after dinner. I started in the Marginy and drove in across Esplanande on Royal, one down from Bourbon, and parked there, just past St Anne's Street. About two pedestrians on each block of Royal's sidewalks. What first struck me was the quiet. No music, at least none of that loud recorded audio that's often being pumped out the doors of every club on Bourbon. There was the rising and falling burble of conversation as fifty-something couples walked the almost empty streets, and the rolling-r r-r-r-r-r of a McQuay portable air conditioner parked outside the back of a club on St Anna's. Perfect light, though: overcast, the sun on the horizon. Crossing to Bourbon there was the usual harsh neon, but little of the usual filth, though I think I saw this woman again. Still no recorded audio. I'm going to start differentiating, I think, between live music and recorded sound. There's more to music than sound. The atmosphere, the artists, the company, the time, the place. Context.

One of the nice things about living in New Orleans these days is you get to enjoy a lot of national-quality press about your city. The cultural reporters especially have found themselves, perhaps for the first time, with a real mission: to preserve this period of New Orleans cultural revival. We were listening to NPR on the radio on Saturday evening, driving around looking for a park Dr Kahn had recommended to us, when we heard a segment about Elizabeth's Resaurant and their praline bacon. So we went there for a Father's Day breakfast. Expecting it to be packed, it was just right - almost full, but no line. Jim Hart is the new owner, having bought it from the previous owners, staff and all. Everyone is on good terms, and the old owner, Stewart, still drops in. Jim Hart, the new owner, got his law degree from the University of Arkansas and has travelled quite a bit since then as an insurance adjuster. A big man wearing a black golf shirt, black hair, and black resin glasses, he looked like a seasoned restauranteur. I congratulated one of the more senior waiters, Karen, who I'd mistaken to be manager, on the NPR segment. She was delighted to hear we'd come based on the segment brought Jim over, recommending perhaps they should ask everyone that came in if they'd heard the segment. Our waitress, Emily, was nice. She's a student at UNO; she wants to go into genetics.

The food? Excellent.

I strongly recommend students who are considering entering a historical essay contest consider starting by taking a oral history of a notable person at the school or in the community. Everyone has a story and many of them go unappreciated. For medical students, in particular, it is an excellent opportunity to explore interviewing from a different perspective. Here are some resources I wish I'd found and explored before I started:

Oral History Tips from geneaology.com.
Oral History Resources from PBS, compiled for their series The Rise and Fall of Jim Crow.
Institute for Oral History at Baylor University
Oral History Association
Regional Oral History Office at Berkeley
The Art of Interviewing, a collection of short articles at journalism.org.

There are, of course other types of interviewing, job interviewing, medical interviewing, criminal interviewing, accident interviewing, and I haven't collected resources on all of the here. If you have excellent resources for these, please let others and I both know by posting them in the comments section.

Now go talk with, learn about, and share with us, the great people you see every day.

Think before you let your friend or child buy those firecrackers.

Image courtesy of A Medical Student in Clinical Rotations

The first installment of Radiology Grand Rounds, volume 1, issue 1, is up at Dr Sumer Sethi's site.