A paper of mine was published Did anyone read it

An orthopedist asked me if I could explain why a couple of papers of his did not generate any feedback. He wasnt even sure that anyone had read them. He enclosed PDFs for me.

Not being an orthopedist, I cannot comment on their validity.

But I think I can explain why the papers have not created much interest.

Are you familiar with the term "impact factor"? If not, here is a link explaining what it is:

A journals impact factor is an indication of how widely cited its articles are. One can also assume that it is a good indication of how popular the journal is and by inference, how many people read its papers. The impact factor has been criticized, but it is one of the few measures of a journals influence.

The two papers in question were published in Orthopaedics & Traumatology: Surgery & Research. A list of the top 40 orthopedic journals ranked by impact factor in 2013 showed that it ranked 37th with an impact factor of 1.061. That means the average number of citations for any paper published in OTSR was about 1, and 36 orthopedic journals were more widely cited than OTSR.

A paper in Physics World claims that that 90% of published papers are never cited and 50% are never read by anyone but the authors and the journals peer reviewers. I believe this is true of papers in medical journals too.

I was unable to obtain any figures regarding the number of subscribers to OTSR, but I suspect it is not large. This may also account for the lack of responses to the papers. My own experience is similar. It was very rare to receive any feedback about any of the over 90 peer-reviewed papers, editorials, or reviews that I had written.

Consider this. A blog post of mine "Appendicitis: Diagnosis, CT Scans and Reality" which I wrote 4 years ago has received over 19,600 page views and more than 100 comments. I am certain that post has been read far more than all of my published research papers combined. In fact, my 550 blog posts have recorded over 1 million page views.

What does it all mean?

Journals may have to adapt and become more like blogs. In the future, medical information may be disseminated by blogs and comments rather than journal articles and letters to the editor.

Will scientists CVs be valued more for the number of page views their papers receive than the number of peer-reviewed papers they publish?

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How to get the answers you want from a survey

This isnt about religion or politics, two subjects I tend to avoid. This is about surveys and how they can mislead.

I received this survey in the mail last week. It is from CatholicVote.org and is touted as the "largest survey of Catholics ever conducted on the issue of ObamaCare."

CatholicVote.org promises that the results will "send a strong and clear message to every politician running for election or reelection in the 2014 midterm congressional elections, that the overwhelming majority of Catholic voters demand ObamaCare be repealed."

Judging from the way the questions are framed, I think the message will be clear.

Here are a few examples:

From Section B "ObamaCares War on Christianity and Morality"

Question #2: Do you think ObamaCare is violating the Constitutions First Amendment protections for freedom of religion and freedom of conscience by forcing pro-life Americans to purchase health coverage that includes abortion inducing drugs?

A) Yes, this is certainly a violation of the Constitutions First Amendment protections.
B) No, this is not a violation of the Constitution
C) Not Sure
D) Other

Question #4: As a state lawmaker in Illinois, Barack Obama voted twice to deny lifesaving medical care to babies born in botched abortions. What is your reaction to this fact?

A) I support President Obama on this.
B) I am horrified and angered by this.
C) Not Sure
D) Other

From Section C "ObamaCares War on Freedom"

Question #5: Do you think President Obama knew about the crushing cost of ObamaCare for families across America, and was just lying about the cost to get ObamaCare passed into law? Or do you think he shares our shock and dismay at the staggering cost of ObamaCare?

A) I believe President Obama knew about the crushing cost of ObamaCare for families across America, and was just lying about the cost to get ObamaCare passed into law.
B) I think he shares our shock at the staggering cost of ObamaCare and was just unaware of it.
C) Not Sure
D) Other

Question #6: How do you think the mass exodus of doctors from medicine will impact your ability to see a doctor and get the medical treatments you need?

A) A doctor shortage on this scale will certainly drive healthcare costs up dramatically and make it far more difficult for me to see a doctor and get the medical care I need.
B) I dont think well see much impact from this doctor shortage.
C) Not Sure
D) Other

Had enough?

I look forward to seeing the results.

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The best general surgery residency programs for clinical training

Ive received a couple of emails from Doximity [A closed medical "community" of > 280,000 doctors] reminding me to complete a survey which they are sponsoring jointly with U.S. News & World Report. They are asking members, possibly only surgeons, to name the best general surgery training programs in the country.

Not mentioned in the email but stated at the beginning of the survey is that they want respondents to name the 5 best programs for clinical training.

I have a feeling that not everyone will notice the part about clinical training, and we will get a list of the usual suspects just as we do every year with the U.S. News best hospitals survey.

For several reasons, the survey is fundamentally flawed.

There are 240 general surgery residency programs in the country. Unless one is personally involved with a program, it is impossible to judge the competency of its graduates. How would I or anyone else who does not work there know whether residents training at UCLA or Baylor or Lehigh Valley are clinically competent?

There are no accepted ways to judge the clinical skills of any surgeon. Video recording of procedures with judging by peers can assess technical ability, and as shown in the recent New England Journal paper from Michigan, there is some correlation with outcomes.

The American Board of Surgery publishes first attempt board passage rates for all programs, but passing the boards does not necessarily equate to clinical skill.

Most surgeons have probably encountered only one or two graduates of any of surgical residency. Even if the ones we have seen were great, they may not represent the majority of graduates.

Ill bet I can name most of the top 5 programs right now. These are not necessarily the programs that produce the best clinically trained residents.

Here are my guesses: Massachusetts General, Johns Hopkins, Mayo Clinic-Rochester MN, New York Presbyterian-Columbia, Cleveland Clinic.

In the past, some institutions on my list were rumored to be terrible places to learn to perform surgery because the residents did a lot of watching and retracting but not much operating. Whether that is true today or was so in the past, I could not tell you.

I guarantee you that no community hospital will rank in the top 20 [maybe top 50] despite the fact that such hospitals produce many fine clinical surgeons.

I have no idea which programs produce the best clinically trained surgeons. After the Doximity-U.S. News survey results are published, you wont know either.

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Those who can publish Those who can’t blog

What’s your view on social media and science? For example, the role of science blogs in critiquing published papers? "Those who can, publish. Those who can’t, blog," says Jingmai OConnor.

According to Cell.com, Dr. O’Connor is a professor at the Institute of Vertebrate Paleontology and Paleoanthropology of the Chinese Academy of Sciences, and her comment was part of an interview published last month.

Dr. OConnor says, "It often seems those who criticize or spend large amounts of time blogging are also those who don’t generate much [sic] publications themselves." She thinks comments should be peer-reviewed and published only in journals. She worries about the public who may not realize "a published paper passed rigorous review by experts, which carries more validity than the opinion of some disgruntled scientist or amateur on the internet." She adds, "criticism in social media is damaging to science, as it is to most aspects of our culture."

Apparently she isnt aware that peer review is under fire from a number of respectable sources.

"If peer review was a drug it would never be allowed onto the market," said Drummond Rennie, a contributing deputy editor of JAMA. Richard Smith, former editor of the BMJ agrees "because we have no convincing evidence of its benefits but a lot of evidence of its flaws."

In 2015, 107 scientific papers were retracted by several journals because their authors, nearly all of whom were Chinese academics, had performed fraudulent peer review by creating fictitious names and email addresses of suggested reviewers so they could write glowing reviews of their own work. Some of these charlatans are from Beijing, where Dr. OConnor is based.

Australian bloggers found an error that had somehow been missed during "rigorous review by experts" regarding the number needed to treat in a New England Journal of Medicine paper on targeted vs. universal decolonization to prevent ICU infection. They contacted the papers corresponding author who acknowledged the mistake within 11 days. It took five months for a correction to appear online in the journal.

Whether Dr. OConnor likes it or not, the future will involve more immediate feedback about research papers. For example, PubMed and PubPeer already allow comments, and the BMJ also has a section for online rapid responses.

Blogger Marc Bellemare, an associate professor of economics at the University of Minnesota, cites David McKenzie, an economist/blogger at the World Bank who thinks that blogs play an important role in disseminating information to the public and "raise the profile of bloggers and their institution."

But Bellemare feels blogging might not be for every academic He quotes Tyler Cowen of George Mason University, who when asked why dont more economists blog replied, "I believe it is because they can’t, at least not without embarrassing themselves rather quickly, even if they are smart and very good economists. It’s simply a different set of skills."

Maybe Dr. OConnor doesnt have the skill set to blog. I say, "Those who can, blog. Those who cant, insult those who can."

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The solo general surgeon is a dying breed What is next

This is a guest post by Dr. Paul A. Ruggieri, a general surgeon in Fall River, MA and author of a new book “The Cost of Cutting: A Surgeon Reveals the Truth Behind a Multibillion-Dollar Industry.”

A potential casualty of employment in a hospital system may be the ability to openly disagree with the organization. Will surgeons, as highly paid employees, be confident enough to speak up against hospital policies affecting patient care without worrying about corporate retaliation? Will employed surgeons be able to speak out against hospital cost-cutting measures that infringe on patient care without being labeled whistleblowers or troublemakers? Can they voice their displeasure without worrying about the security of their job? If you are branded “not a team player,” referrals may dry up. Or, you may suddenly be “asked” to take more emergency room call. You may also be asked to travel farther to see patients and generate surgical business in another town. You may be replaced. You could end up as a surgeon without a practice. If let go, you may discover that the clause in your contract prohibiting you from practicing within the area drives you out of town.

Will employed surgeons be able to openly highlight waste and fraud without fear of losing their jobs? As highly paid employees, surgeons risk much if they criticize the organization that employs them, even when the intent is improved patient care. Knowing the economic stakes of speaking against the corporate team, I suspect many may choose to be silent.

Now that more surgeons are giving up their independence and joining the ranks of the employed, will they have the ability to unionize? Historically, surgeons have been an extremely independent breed of physician, perhaps too independent for their own good. For whatever reasons—ego, stubbornness, a view of themselves as well above the average working stiff, money, competitive juices—surgeons have never been able to use their local muscle to influence hospital behavior. Instead of being able to unionize freely decades ago, surgeons may now be forced to in order to survive.

Will unionized surgeons be given collective bargaining rights when negotiating with their employers? Will surgeons be able to strike if they feel the hospital systems they work for are not negotiating salaries or working conditions in good faith? Can you see it now, a Teamster walking the picket line in solidarity with a white-coated surgeon over improving health benefits? Will there be appeal boards to contest unfair firings? As employees, will surgeons be able to negotiate for vacations, sick time, or family leave?

The writing is on the wall for all surgeons, including me. The era of the independent surgeon is drawing to a close. More and more patients will be cared for by surgeons whose economic and surgical lives are directly influenced by the corporate entities that employ them. What, if any, impact will this dramatic shift in the surgeon’s professional world have on the access and quality of surgery practiced in the future? It remains to be seen, but there is a reason the American Medical Association (AMA) specifically addressed this shift in 2012 with new guidelines for physicians selling their practices. Tellingly, the AMA stated that “patients should be told whenever a hospital provides financial incentives that encourage, discourage, or restrict referrals or treatment options.” The AMA statement continued: “Physicians should always make treatment and referral decisions based on the interests of their patients.” Isn’t this how physicians and surgeons already practice, and have for hundreds of years? Or is it?

As a patient, should you know who your surgeon works for before agreeing to an operation? If you’re interested in a dinosaur’s perspective, the answer is “Yes!”

What do you think about Dr. Ruggieris view of the future?

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Should I become a general surgeon

One of the rewarding things about blogging is receiving many emails from high school, college, and medical students asking about general surgery as a career.

I try to answer every one of their specific questions and direct them to posts that Ive written on the subject.

A recent inquiry stimulated me to review all of my posts and put most of the questions about becoming a general surgeon in one place. They are about 500 words each. I hope you enjoy them. Here they are.

Is the solo general surgeon a dying breed?

What is the future of open surgery?

In what specialties can a surgeon be autonomous?

An applicant worries about the future of general surgery

Will automation affect surgeons skills?

Going to medical school and becoming a surgeon when you are older

A medical student from the UK discovers surgery and has questions

Is it possible to live a full life as a surgeon?

Choosing a medical specialty is difficult

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