…people are mastering more kinds of writing. Other technologies that grew more popular this decade required a different mode of expression: Instant messaging invited a breezy, fast-thinking tone; blog comments (again, the thoughtful ones) sharpened our debate skills; Twitter enforced even more economy onto our words.

In all of these, we were nudged toward something all writers aspire to: a strong, distinct voice.

Kevin Kelleher on how the internet has changed writing (via Om Malik’s reflections on 10 years of blogging) 
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Land of a Thousand Words

I’ve spent some time recently working with our new ED information system vendors on verbiage.

That’s what the industry calls the result of all the boxes we check when filling out an electronic chart. Those checked boxes develop into a narrative, with the help of software:

The patient’s chief complaint is abdominal pain. The onset was described as gradual. This episode began 6 hours ago. The problem is localized to the RLQ. The complaint is associated with fever and nausea and vomit. This is no association with diarrhea or constipation. The problem is persistent. 
Chekhov, it ain’t. But there’s a lot of pertinent positives and negatives that need to make it into the record, from a galaxy of possible complaints, modifying factors, and associated symptoms. I’m not aiming for art; just trying to maintain subject-verb agreement (though some phrases have had a certain poetry — my favorite so far is, “The presence of foreign bodies is uncertain.”)

Some thoughts on this process:

  • I will generate more chart verbiage than I could ever match with research publications, columns, blog posts and tweets. By this metric, I am finally a prolific writer (though my compensation per word is probably below industry standards). 
  • The (considerable) amount of time we’re spending on the verbiage is still not nearly commensurate with the amount of times we’ll see it (even understanding that any single chart is unlikely to ever be read again once the encounter is over, the phrases will come up over and over, in multiple encounters).
  • While it’s regrettable that circumstances force me to decrease the signal-to-noise ratio in our charts, I consider it worthwhile to try to make the noise a little less jarring.
  • While there are a lot of ED metrics worth streaming to the web or twitter (wait time, chief complaints for biosurveillance stats) I would really enjoy seeing (deidentified) brief excerpts — sort of like @GiggleMed but artful.  
Does your EMR have any noteworthy stock phrases? Good or bad? I think we’d be happy to cite your system as an influence.

There must be some kind of bad connection

A reader of my EMPractice LLSA review on paracentesis (still available, buy yours today!) wrote my editor with a question. Not, thankfully, on anything factual in my writeup, but rather on an issue of word usage.

This is picayune but a start. 2010 LLSA 4 paracentesis refers to a "Z tract" as a technique to avoid leakage. When I learned this years ago I thought it was Z track-as the pathway (track) left when the needle was removed. I thought using tract was just sloppy language. Checking Roberts for procedures I read Z tract-OK-solved. BUT then Roberts’ Illustrative Guide calls it Z track. So, evidenced-based mavens which is it?!!!
Our editor referenced the original NEJM article on which my review was based. The NEJM uses the term “Z-tract.” But further Googling turned up varied usage, and “Z-track” was far more popular.

Is there a definitive answer?

Of course not. This is medicine, after all.

I favor “tract” because it feels more consistent with other biological tracts — a 3D tunnel system like the GI tract.

I’ve always felt “track” was reserved for more linear or 2D systems, like a race track or tenure track.

This isn’t the first time this question has come up.  But what I find puzzling is so many online dictionaries and language sites all state that “tract” can refer to organ systems — but I’ve never heard the phrase “cardiovascular tract” or “musculoskeletal tract” — it’s always GI or reproductive tracts. Mostly, I suspect, because these are organ systems based around a single tubular structure.

Thus, it’s my assertion that the Z shape we’re making in paracentesis has more in common with a tracT than a tracK, and is more in keeping with the original definition of tract:
Tract: 1350–1400; (in senses referring to extent of space) < L tractus stretch (of space or time), a drawing out, equiv. to trac-, var. s.of trahere to draw + -tus suffix of v. action; Track: 1425–75; late ME trak (n.) < MF trac, perh. < ON trathk trodden spot; cf. Norw trakke to trample; akin to tread
Still, despite favoring the tracT side of this debate, I can’t say it’s completely unreasonable to call it a tracK and so I’m not planning on annoyingly correcting my colleagues who refer to it as such. The other big K-for-T switch in medicine, however — vomicking for vomiting —  must be corrected at every opportunity.

When all is well and well is all

Slate’s Juliet Lapidos recently reviewed a new book by Allan Metcalf on the story of OK (“America’s Greatest Word”).  Key graf:

The only etymology with hard evidence behind it, he says, is that OK began as a joke—a joke so bad, so boring, that I won’t cover it in detail. Briefly: In the spring of 1839, the Boston Post ran an article tweaking the Providence Daily Journal, which included the phrase “OK—all correct.” Get it? OK started as an intentionally misspelled abbreviation of all correct (oll korrect). It sprang, more generally, from an 1830s fad for abbreviations, like NG for no good and OW for oll wright or all right.
I’ve heard about this silliness before, and in fact referred to it whenever someone around me bemoaned the spelling of, say, “Gorillaz” or  ”Flickr.” The current trend in spelling hijinx doesn’t portend the end of civilization or reflect a decline in education, but rather, continues a longstanding English tradition. 
But the part about the review that I really liked focused on the inscrutability of “OK” (more below):

Metcalf gives less weight to the relativist OK, or the “noncommittal”OK, as he calls it, which “affirms without evaluating.” The word’s passivity, to Metcalf, is merely one of its many aspects, rather than an encapsulation of a third, less glamorous American philosophy: the shrug….
…Throughout, Metcalf stresses OK’s clarity over its opacity. He does not linger on its potential for unintentionally confusing exchanges…
He may be missing the usage of the future, it seems to me, in downplaying the baffling OK, deliberate or otherwise. When used in speech, the word benefits from facial and tonal and social contexts. As our conversations move increasingly into a textual arena, OK gets stripped of these supports. The lone OK in an otherwise blank e-mail tells us only one thing for certain: Our initial message did, in fact, fly successfully through the ether and land in the intended inbox. Whether the OK surrounded by white space is also meant to convey emotion—positive, negative, or something in between—we just can’t tell. Whether that uncertainty is positive, negative, or something in between is purely a matter of opinion. On the giving end, I rather like it—in fact, I couldn’t do without it.
I only wish Lapidos or Metcalf knew the many ways I get to hear (and use) “OK”, in the emergency department.

Because, sure, there’s an element of that affirmation-without-evaluation, like when a patient is explaining why she thinks she’s coughing (“It’s not my smoking — it’s that my grandson was sick last week” — “Okay”.)

There’s plenty of similar OK deployment when attendings are listening to residents’s case presentations unfold. The attending’s OK in this situation is used to further the narrative without biasing it; I try to hear the resident’s plan emerge without injecting too much approval or disapproval (that comes later).

There’s OKs with extra meaning, like the reassuring, professorial kind of OK, when frightened patients can take comfort that their symptoms are familiar to their doctor (it’s also heard when interns are being coached through their first central line).

But there’s another OK — one that I didn’t see Lapidos or Metcalf mention — a slightly aggressive, belittling OK. I still hear it occasionally, when explaining a case to a consultant or (thankfully rarely) hearing a resident take a patient history.

The aggressive OK is a perversion of the reassuring OK, really distinguished by just a matter of timing and tone. The aggressive OK means to imply, “Nothing you’ve said so far has justified why we’re having this conversation, so what else have you got to say?”

Call it the professional cousin of the teenager’s sarcastic OK. The aggressive OK comes as close to signalling disinterest, boredom, or hostility as convention allows.  Its use is, simply, not OK — but survives, I think, because this versatile word can disarm us with its commonness. 

1010 Wins

Calendar trivia has always interested me. And we’ve lived though some special dates, from the turn of the millennium to 9-02-10 day last month.

Today is no exception. And like 1/2/03 at 4:56, today we could experience a couple of memorable minutes.

But a few moments’ thought on the matter leads me to believe that the high frequency of notable dates we’ve been enjoying is going to come to an end soon.

Another endangered calendric item: those plastic eyeglass-like frames that attain ubiquity every New Year’s Eve, since the 1990 (or even earlier). In fact, for most of my life, each year has featured at least two bulbous numbers, ideal for making zany celebratory glasses (if I’m not explaining this well, see here).

I think this comes to an end for 2011. The impact on the economy is difficult to estimate.

Get it together

Bill Simmons sometimes pokes fun at the journalism cliche of collocated words that rarely appear apart from each other — you don’t often see the word ‘ruffled’, and when you do, you  know the word ‘feathers’ is likely to be close by.

There’s a similar phenomenon in medicine, though I stubbornly have refused to acknowledge it.

Consider the followed dialog that transpired during a recent overnight ED shift:

Resident: “I have a 32 year old woman with hyperemesis. I’d like to start antiemetics and IV fluids.”
Me: “Is she pregnant?”
Resident, befuddled: “Um, yeah? I said she has hyperemesis.”

Of course, the resident was using hyperemesis to denote hyperemesis gravidarum. But really, hyperemesis just means lots of vomiting. Just because it’s rarely used outside the context of pregnancy, it doesn’t mean it’s not a useful term (indeed, cannabinoid hyperemesis is another entity we sometimes see in the ED.)

What other terms get truncated like this? Anorexia nervosa comes to mind — saying “the patient has anorexia” literally just means there’s a lack of appetite, not a lethal eating disorder.

I’m sure there are countless others, but I’m wondering: could any of these medical terminology shortcuts lead to particularly dangerous misunderstandings?

I don’t think anyone would mistake a triad for a joint if a colleague said, “they’ve got Charcot…” On the other hand, abbreviating the confusing term “superficial venous thrombosis” could lead to a mixup in therapies…

How’d you get to be happiness

Somebody at Apple likes Goldfrapp.

They’ve used her latest album for this tutorial (scroll down) and the sublime Seventh Tree was pictured on the first Apple descriptions of the Remote app.

It’s nice when a monolithic institution shows a little personality.

Of course, my interest in Goldfrapp is mostly professional — who else has sung as well about ending up in an emergency department?

Can’t buy a thrill

Many of the peculiar terms and phrases we learned in medicine have found a new use in cyberspace, as titles of websites (consider 10 out of 10, The Central Line, or this blog — and that’s just emergency medicine sites).

But that’s the virtual world — what about the real world? This past week I saw a couple of products that make me think medical parlance could sell physical products. Consider:


OK, fine, it won’t really be a trend until Wendy’s is selling STEMI-burgers or we see Throckmorton-branded condoms. But I wonder if this could someday happen, given the improving economics of niche marketing. Or maybe the general public, through realistic TV shows and, yes, blogs, has picked up on enough of our lingo to make this work?

I can’t say. But I’d like to remind  readers that you can enjoy your Drug of Choice in a lovely, professionally-designed mug, on sale now in storeborygmi. 

A new kind of tension

There’s an adage I often think about: “A physician’s job requires the expression of  confidence. The researcher’s role is to express doubt.”

This was never more apparent than when I transitioned from the research environment into the clerkships of medical school. The language of decision-making had abruptly changed — in the lab, a year’s worth of experiments is summarized with “seems” and “suggests,” and every assertion is carefully calibrated to acknowledge uncertainty and a high standard for proof.

As a student on clerkships, I couldn’t quite wrap my head around the residents’ ambitious plans for patients:

  • “Check CBC, electrolytes, chest X-ray, EKG, oh, and, he needs a head CT.”  

This use of “need” too often seemed careless to me, as if any patient could need a test that was almost certainly going to be normal, that in most parts of the world would never even be considered.

But in the residents’ perspective, I came to understand the head CT was just an expected component of the patient’s management — it had nothing to do with likelihood ratios or pertinent life-threatening conditions that must be explored — it was simply part of the story for certain patient scenarios, and couldn’t be omitted without raising a lot of questions.

  • “We should also check a TSH level.”
Few patients ever needed a TSH level, as far as I recall — this wasn’t something that would hold up discharge, for instance. But checking thyroid function was often something that should also be done. Again, not because the residents had a firm grasp of the prevalence of thyroid disease in certain populations, but rather, because it demonstrated a thorough workup and, while not an essential or expected part of management, was nice for the attendings to see.

Over time, I gradually adjusted to this very nosocomial interpretation of “need” and “should.” Now that I’m an attending, and the students’ and residents’ plans are a lot more hypothetical (until they get my approval), I’m hearing a little more “want” and “think” and “maybe.” For me, it’s a welcome return — a language more in line with my background, and one that acknowledges the uncertainties of medicine. 

Some inner truth of vast reflection

I’ve seen a couple of examples of this now, so I’ve decided it’s a trend. Naturally I’m going to excerpt something from which to base this post:

This sentence claims to follow logically from the first sentence, though the connection is actually rather tenuous. This sentence claims that very few people are willing to admit the obvious inference of the last two sentences, with an implication that the reader is not one of those very few people. This sentence expresses the unwillingness of the writer to be silenced despite going against the popular wisdom. 
I’ve got further evidence to back this up from this humerous video (though I won’t embed it for stylistic reasons).

A pithy observation is shared, and of course, a link to a prior discussion on Metafilter.

After all this deliberation, I’ve got to conclude this trend has pros and cons, and a lot of unappreciated nuance. I just hope it turns out alright. 

Protect your language

The Efficient MD’s eyes are opened by the nasty thoughts Google Suggest offers up when someone starts typing “Doctors are…” Since Google Suggest lists only common results with which to complete your queries, it seems that the most common thing people think about doctors online is that we’re “overpaid” or “jerks” or “dangerous” or, most commonly, “sadists who like to play god.”

Surveys show people consider doctors to be among the most respected professions. So what gives?
 
Well, I’ve been paying attention to what Google can tell us about ourselves (the first Google Talk was a lot less useful, but arguably more interesting) for some time. But even before I knew Google Suggest was a weird and limited tool, I knew this:

Declarative sentences are the only kind of sentence that can be proven or disproven. Yet the people who use them most — and favor the short, simple variety of declarations —are often those least interested in arriving at truth.
That’s my guess why those “Doctors are…” statements seem so unfriendly to doctors.

You can find more head-scratching or downright funny Google Suggest screenshots here… It seems that questions from school assignments often find their way into Google Suggest. Finally, here’s an analysis suggesting the way the start of a question is phrased implies a certain sophistication of query.

The Stroke’s The Word

In May, when the new ASA stroke guidelines came out, this table’s title caught my eye. Now I’m copyediting a piece on stroke management in the ED, and this phrasing is probably the clumsiest part of the manuscript:

Suggested Recommended Guidelines For Treating Elevated Blood Pressure In Spontaneous Intracerebral Hemorrhage


My issue is with the unecessary hedging built into the title — “Suggested Recommended Guidelines.”

Why not just call it, “Some Ideas You Might Want to Consider, if That’s OK — I Know You’ve Got Strong Opinions About This” ?

Selection Bias

The bulletin boards of every major hospital I’ve worked in are bombarded by signs of variable quality, soliciting research subjects or volunteers. Passers-by are asked to call a phone number if they fit within a certain demographic, take a certain drug, or engage in a certain behavior.

Where I went to medical school, the research solicitations were amateurish and fun. For whatever reason, investigators at that hospital were performing a lot of research with alcohol (on, with, and for)… Signs were frequently up, in bright neon colors, asking for young men and women to drink alcohol and give blood (for an immunoassay), drink alcohol and enter a driving simulator, drink alcohol and take a quiz. I have many fond memories of being paid to drink — doing my part for science.

Now, I notice in some hospitals where I work, the ads are a little more slickly produced, but the ‘image’ conveyed to me is not exactly upbeat. Investigators are looking for patients with refractory depression, or active genital herpes, or WTC responders with respiratory problems.

When I see that many of the contact-stubs have been torn off of these solicitations, it prompts a different reaction than when the “drinking quiz” was recruiting.

Of course, I’m glad research on these diseases is being conducted. It gives hope, for both the volunteers and all patients.

Maybe the ED is warping my perspective on illness. Since I don’t spend much time in clinics anymore, it’s hard to remember what patients look like when they’re not having an acute infection, or flareup of some chronic condition.

When all the tabs are ripped off the posters, it hits home that there are sick people everywhere, making their way, just walking around me in the lobby, by the bulletin boards.

And that’s when I really wish for another alcohol study…

My patient, the car

I misinterpreted the title of a Polite Dissent post — Doctor or Auto Mechanic? — which immediately conjured a version of this classic game in my mind.

And since, well, some doctors are called “auto mechanics of the body,” I started making a list of tools and terms that sound like they could go in either profession — medicine or car repair.

So far my list includes the peak flow meter, front fascia, nebulizer, curing lamp, 4x4, clean-catch, head gasket, pacer leads, valve grinder, hepatic duct, surgi-lube, colposcope, universal joint, and of course, a Hemi.

I’m sure there are many more such terms, especially within the realms of orthopedics and … emissions.