Effects of acupuncture on pain and inflammation in pediatric appendicitis

A paper [full text here] from The Journal of Alternative and Complementary Medicine says that "acupuncture may be a feasible and effective treatment modality for decreasing subjective pain and inflammation" in pediatric patients with appendicitis.

They studied six adolescents with appendicitis and administered acupuncture for pain control prior to surgery. Pain was assessed using three analog scales, and inflammation was measured using serial white blood cell (WBC) counts and C-reactive protein levels (CRP). CRP is a nonspecific indicator of inflammation in the body.

Figure 2 from the paper summarizes the results.

You can see that after 20 minutes of acupuncture, all three pain scores and WBCs declined. However, CRP continued to rise. Conspicuously absent from the figure and the text of the paper are any statistical analyses. This is due to the lack of a significant difference in any of these values because of the limited number of subjects studied.

The authors were undeterred and concluded "Although CRP as a general marker of inflammation stayed roughly the same on sequential blood draws, the median WBC showed a modest and noticeable drop. The implication of this finding is that the effectiveness of acupuncture may have a biophysiological basis." Look at the figure and decide for yourself if the WBC drop is really more noticeable than the CRP rise.

While the authors did mention some limitations of the study including the lack of statistics, they didnt discuss impediments to using acupuncture in patients who present to an emergency department. Whether patients were given antibiotics before or during the acupuncture session was not stated.

Even if the technique actually works [which is certainly not proven by this paper], how practical would it be to have an acupuncturist on call? Would she take in-house call? If not, how long would it take for her to get to the hospital? Would insurance pay for acupuncture? Would the acupuncturist be subject to work hours limitations?

The authors are not proposing acupuncture as a definitive treatment for appendicitis. So what is the clinical value of reducing inflammation? An even better way to reduce inflammation [and pain] is to remove the diseased appendix.

I know how difficult it is to publish papers and continue to do all the clinical and administrative work of an academic physician. As I have said on several occasions, many of my published papers were simply not very good.

But acupuncture to decrease inflammation in appendicitis patients? I doubt youll be seeing an on-call acupuncturist any time soon.

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Another reason not to rely on medical advice from the Internet

On New Years Eve, The Daily Beast published an article with suggestions about how to avoid a hangover.

Some of the tips were reasonable such as limiting yourself to one alcoholic drink per hour and maybe avoiding certain beverages like wine, bourbon, and Scotch, which contain congeners and have been associated with worse hangovers.

However, some of the advice is wrong.

The article recommends this on the day you plan to party:

6 a.m.: Rise and hydrate! Drink early and drink often. One of the main causes of a hangover is dehydration. Women should be drinking 2.7 liters per day, and men should get 3.7 liters. Thats 0.7 gallon and 0.97 gallon, respectively.

After you party, at 12 a.m.: Drink some water and get to bed. It’s your last chance of the day to hydrate, so seize it! Sip some water before your head hits the pillow, but avoid popping any anti-hangover pills.

The 6 a.m. recommendation has two important bits of misinformation. One, dehydration is probably not a major factor causing a hangover. A 2010 literature review explains that hangovers are much more complicated than most people think. From the abstract:

Markers of dehydration were not significantly related to hangover severity. Some studies report a significant correlation between blood acetaldehyde concentration and hangover severity, but most convincing is the significant relationship between immune factors and hangover severity. The latter is supported by studies showing that hangover severity may be reduced by inhibitors of prostaglandin synthesis. Several factors do not cause alcohol hangover but can aggravate its severity. These include sleep deprivation, smoking, congeners, health status, genetics and individual differences.

Two, the idea that you need to drink 8 glasses of water per day is a myth. The best plain English explanation of this appeared in the New York Times last summer.

The 12 a.m. suggestion may also be incorrect. Do you really need more water right before you try to sleep?

As the 2010 review pointed out, blocking prostaglandins by taking an anti-inflammatory drug like ibuprofen might be useful. However, a small risk of bleeding from gastric mucosal damage with the combination of alcohol and anti-inflammatory drugs is a concern.

Abstaining from alcohol or drinking it in moderation is the best way to avoid a hangover. Once you have a hangover, the best remedy is time.

A Washington Post article on the dangers of overhydration in marathon runners quotes an expert as follows: “Drink when you’re thirsty. It’s not something you have to tell your body to do.”

If you have normal kidneys and drink as much water as The Daily Beast recommends, you may avoid hangover because instead of getting drunk, you will be spending a lot of time in the bathroom peeing.

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A high school student has questions about a medical career and pathology vs surgery

A female high school student asks about pathology, surgery, and medicine in general. [Email edited for length.] See if you agree with my answers.

The field I am most interested in is pathology. I have a very logical mind and would enjoy being able to solve the complex puzzle of disease. I would also like the somewhat flexible hours compared to other more intensive specialties. However, I do have some qualms.

Im also interested in general surgery. I would love to learn how to perform all the different types of surgeries that surgeons perform. If I were to be a pathologist, would it be "knife-free"? Pathology really intrigues me, but participating in the occasional surgery sounds like it would be extremely interesting and full of learning opportunities.

There is some knife wielding in pathology. Specimens must be properly cut, and there is the occasional autopsy. However, its definitely not surgery.

What does a pathologist really do? Ive looked at various descriptions online, and none of them seem to be very specific. What would a typical day look like for a pathology resident? I was also wondering what types of skills pathologists are taught?

Pathologists spend most of their days looking at specimens, mostly microscopic slides. Here is what pathology residents at Johns Hopkins learn.

I know that medicine is constantly evolving. With new medical technology, certain fields will soon become obsolete. Do you think this will happen to pathology?

I suppose there will be some technical advances that might involve automated digital reading of pathology slides, but I believe there always will be a need for pathologists. A residency position in pathology is much easier to obtain than one in general surgery.

Since Im interested in both pathology and general surgery, I was wondering if there was a way I could do them both (in a combined program or something like that). I know this is highly unlikely.

It cant be done.

I am a very anxious person. Specifically, I have health anxiety. (Im all too aware of the irony). Do you think that the amount and intensity of the material covered during med school and residency could take a severe toll on a persons mental health?

I think every medical student at some point worries she might have a disease she just read about. Im not sure what to tell you because I am not a psychiatrist, but studying diseases for four years and having a health anxiety might be a problem.

I would also like to know whether being involved in medicine could dramatically alter a persons personality by magnifying their negative characteristics. I am very driven, hard-working, ambitious, logical, easily annoyed/frustrated, and sometimes easily distracted. Im quite anal-retentive and OCD. Some of my friends and family have described me as an emotional robot. How do you think these characteristics would be affected by a journey through medicine?

Many medical students and residents become less empathetic and more jaded as they go through medical school and residency. Except for being easily distracted, many of your traits are common in med students. Heres more about empathy and medical students.

Do you know how difficult it is for Canadian students to get into American med schools? Or do you know any medical schools abroad in English speaking countries (e.g. Scotland, England) that would be willing to admit international students? Also, would it be more difficult for a woman?

Its not easy. Here is a link to a website that has some data on Canadian applicants to US schools. I dont know much about UK schools. Ive written about Caribbean schools. Type "Caribbean" in the search field of my blog. Being a woman wont matter.

How would medicine affect interpersonal relationships? Im really close with my immediate family, and it would be difficult not being able to see them all the time, let alone during holidays or breaks. How can a person manage a serious relationship and medicine at the same time?

It can be done, but it takes some effort. I have written a few posts about so-called work-life balance.

Choosing a specialty is difficult
More about choosing a specialty
Anguish about choosing a specialty
Surgery and work/home conflict

I hope this helps. Good luck.

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More evidence that the manuscript peer review process is broken

To the surprise of almost no one, asking authors of research papers to submit names of potential peer reviewers for their manuscripts turns out to be a bad idea.

According to a recent New England Journal of Medicine article by Dr. Charlotte J. Haug, a number of research papers have been retracted because reviews were fabricated. Email addresses of suggested peer reviewers were not legitimate. The bogus email addresses were almost all created by authors of papers who then reviewed their own work favorably using fake identities. 

More about the problem can be found on the blog Retraction Watch.

This type of fraud is simple to do because anyone can set up an email address on Gmail or Yahoo mail using any name. Unless a reviewer has an academic email address, proving legitimacy is impossible.

However even if a reviewer has an “edu” address, how would an editor know that a suggested reviewer is not the author’s sister-in-law or a former mentor?

Every medical student who applies for residency knows that you don’t ask someone for a letter of recommendation unless you are sure that it will be favorable. Why would an author take a chance on recommending someone to review a paper without knowing that the review would be a good one?

I agree with the Dr. Haug that soliciting the names of possible reviewers from authors can save editors time and bother. Having spent three years as an associate journal editor, I have experienced the frustration of trying to find high quality reviewers or even a warm body of any quality to do the job.

I also agree with her that a root cause of this problem is the pressure on faculty to publish.

Another problem is that there are too many journals. In 2014, well over 5000 journals and 760,000 papers were included in Medline. The combination of “publish or perish” and superfluous journals leads to the proliferation of marginal papers.

The problem is not simply fake reviews. Since journal reviewers are not paid and have many other responsibilities, they may not thoroughly read papers or provide useful comments about manuscripts.

Some have suggested paying peer reviewers, but who would pay them? Certainly not publishers, even though they make tons of money. And paying might attract unqualified people looking to make a little extra cash.

What about post-publication peer review? It is already happening on blogs, on sites like PubPeer, and even on PubMed. However, the volume of papers published in medicine alone certainly precludes post-publication review of all of them.

Maybe it doesn’t matter. New journals are appearing every day. Most are “open access” and the charge authors “processing fees.” For many of these publications, processing fees do not include even a cursory manuscripts peer review.

With so many journals publishing just about anything for the right price, readers will have to do their own peer reviewing. Be skeptical my friends. 

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A medical riddle Where do incident reports go

Incident reports are frequently submitted by hospital personnel. Did you ever wonder what happens to them? I have.

Over the years, I estimate that I’ve heard of hundreds of such reports being filed, but rarely have I heard of a problem being solved or for that matter, any action being taken at all.

In fact, I don’t even know where they went or who dealt with them. When I was a department chairman, I sat on quality assurance and risk management committees. Yet we never discussed individual incident reports.

The original intent of incident reports was to identify patient harms and increase patient safety.

According to a 2009 post by patient safety expert Dr. Bob Wachter, hospital incident reports are a spinoff from the Aviation Safety Reporting System which had successfully used them for identifying potential safety issues such as near misses.

At Dr. Wachters hospital, San Francisco General, about 20,000 incident reports were filed every year. That is about half of what the Aviation Safety Reporting System receives per year, and San Francisco General Is only one of about 6000 hospitals in the United States.

Dr. Wachter feels that analyzing incident reports is not worth it. He estimates that each incident report creates about 80 minutes of work times 20,000 reports, which equals about 26,600 hours of wasted time. He also estimated that about one fourth of US hospitals do nothing with incident reports. That saves time but renders the reports useless.

He says an even bigger problem is that incident reports in his hospital fail to capture most events that harm patients.

That has also been my experience. I think most incident reports were filed by people wanting to "cover their asses" and most of the reported incidents were minor. A reference in Wachters article states that most incident reports are submitted by nurses with only about 2% by doctors.

Incident reports can backfire too. From a 2002 Medscape article: "In some states, under certain conditions, the incident report is considered confidential and cannot be used against the nurse practitioner in a lawsuit. However, if copies are made or the chart reflects that an incident report was completed, the incident report can then be subpoenaed by the patient and used against the defendants in court."

And from the Louisiana State University School of Law: "The nonjudgmental nature of an incident report is very important because in most cases the incident report will be discoverable in litigation. An accusatory remark in an incident report may gain unintended weight in a legal proceeding."

Since incident reports generate a massive amount of wasted time, fail to identify most events that harm patients, are frequently ignored, and can possibly have a negative effect on lawsuits, why are they still being filled out by the thousands?

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Warning Beware of misleading medical information on the Internet

While doing some research for another blog post, I came across a website for a company that makes private-label bottled water. One section of the site described the different kinds of bacteria such as aerobes which need oxygen to survive, strict anaerobes which are killed in the presence of oxygen, and facultative anaerobes which usually prefer oxygen but can survive without it if necessary.

So far so good. However, the next paragraph reads as follows:

The most virulent and destructive pathogens that affect mankind generally fall into the “strict anaerobe” category. They include bacteria like Staphylococcus aureus, Streptococcus pneumoniae, Clostridium botulinum and Escherichia coli.

This is wrong. Except for Clostridium botulinum, the organism that causes botulism, the other bacteria are aerobic. Staphylococcus aureus can be nasty, particularly if its methicillin-resistant (MRSA), but Streptococcus pneumoniae is not particularly virulent, and Escherichia coli, while a common cause of wound infections after bowel surgery, is part of the normal flora of the large intestine.

As wrong as that bacteriology lesson was, it pales in comparison to a more than 700 word essayon why you should drink warm water instead of cold.

If you have a few minutes, you should read it because nearly every sentence contains misinformation. Let me share a few of the highlights with you.

The consumption of warm water increases the tightening of the intestines, which optimizes elimination. Utter nonsense. By the time the warm water reaches the intestine, especially the colon, it would be at body temperature.

A very warm cup of water in the morning can help cleanse your body by flushing out toxins. The toxins — it’s always the toxins.

Adding ice to processed cold water will strip it of natural-containing minerals … as these minerals are essential to keeping the digestive tract healthy. If ice strips the water of “natural-containing minerals,” wouldn’t those minerals still be dispersed in the water?

Warm water, considered [by whom?] to be nature’s most powerful home remedy, can help alleviate pain from menstruation to headaches. What would be the mechanism for relieving pain in those two rather divergent areas?

Warm water increases body temperature, which therefore increases the metabolic rate. An increase in metabolic rate allows the body to burn more calories. A single glass of warm water is unlikely to have any effect on the bodys temperature or metabolic rate. If you drank enough cold water to make you shiver, that would have a more profound effect on the metabolic rate. Want proof? Read this.

Drinking a glass of warm water and a lemon will help break down the adipose tissue, or body fat, in your body. Ich don’t think so.

Premature aging is a woman’s worst nightmare, but luckily, this can be prevented by drinking warm water. No evidence is provided.

A clinical nutritionist and media health expert says have warm water, as drinking straight hot water can potentially be damaging to tissue in the mouth and esophagus. This is about the only piece of sound advice in the entire article.

If you want to drink warm water, I suppose it will not hurt you, but dont be disappointed if your intestines don’t tighten and you dont lose weight.

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A medical student in Cuba is looking for advice

Someone writes: I am trying to help a friends brother who is not a US citizen and currently a medical student in Cuba, and I came across your very informative web site. The brother most likely is going to be able to come to the United States in the fall.

My friend is wondering if he should complete the last year of medical school there in Cuba or come here and continue on. It seems like there is no benefit from completing med school in Cuba, given the difficulty to be licensed in the U.S. And the difficulty in getting a residency position.

Does any of the course work from his studies in Cuba transfer over to U.S? Is it likely that hed have to get a bachelors degree here before ever going to a U.S. Med school? My friend says that he has an outstanding record in the Cuban medical school, speaks excellent English, does well on tests, etc. Any advice you could give?

As far as I know, no medical students from Cuba have transferred to a med school in the United States recently or possibly ever. Regarding your questions, I can only give you my best guesses.

I doubt very much that a course from the Cuban medical school would be accepted here in the US. US med schools that accept a few transfers from Caribbean schools like Ross or St. Georges usually take those students at the beginning of the third year of medical school.

A few schools are doing combined BS/MD degrees in five or six years, but I dont know of a single US school that would take a student directly out of high school into a 4-year program.

A possibly more reliable way to become a physician in the United States would be to graduate from an American university, take the Medical College Admission Test, and apply to med school.

Last month, the ECFMG posted this on its website: "The ECFMG is pleased to announce that it will resume processing of service requests in relation to applicants from and institutions in Cuba. As previously announced, ECFMG was not processing such requests, pending approval of its license application for Cuba by the Office of Foreign Assets Control (OFAC) of the U.S. Department of the Treasury. Today, ECFMG was advised that OFAC has approved the license application."

There are 14 medical schools in Cuba. I do not know if any or all of them will be acceptable to the ECFMG or what position residency program directors will take on applications received from students in those schools. Many current offshore graduates are having problems obtaining residencies in US programs. What will happen with the addition of 14 more schools with an unknown number of graduates is anyone’s guess.The fact that he is a non-US citizen is not helpful.

One of the 14 is the ELAM medical school which has 19,550 students. Wikipedia says it is accredited by the ECFMG and the Medical Board of California.

It is not clear how that many students can be clinically trained in a country with only about 11 million citizens and 13 other med schools. For comparison, the US, which has 30 times the population of Cuba, has 140 allopathic medical schools with about 80,000 total students.

I dont know if Ive clarified things for you or made them more confusing. Your friends brother is going to have to decide for himself what he wants to do, but if he is a truly outstanding student, maybe he should stay in Cuba and finish his education. However, he must understand that there is no guarantee he will be able to obtain a residency in the US, and no residency means no ability to be licensed and no way to practice medicine here.

If any of my readers have other thoughts, I hope they will comment.

Addendum on 8/20/15 at 11:25 a.m. The medical student is not a US citizen.

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That time Skeptical Scalpel wasn’t skeptical enough

Yesterday I retweeted a link to “Live Action News,” a website with a video claiming that Planned Parenthood was selling fetal organs.

I had watched the video and read the accompanying article but failed to engage my skeptical radar. It turns out that the video was maliciously edited to portray Dr. Deborah Nucatola, Senior Director of Medical Services for Planned Parenthood, in the worst possible way. The video showed her “having lunch with actors posing as buyers who are interested in purchasing the body parts of babies who have been aborted” and discussing prices.

The website Media Matters describes some of the edits and explains why they are deceptive. It turns out that of the 150 minutes of the original footage, only 8 minutes were used in the "Live Action News" clip.

If I had watched the video more closely, I wouldn’t have needed Media Matters or the 150 minutes of original footage to see the flaws.

First of all, it begins with an introduction by a former ABC News anchor Connie Chung promising something shocking. But as you can see in the screen shot below in the lower left corner, it clearly says “ABC News 20/20 March 8, 2000.”

Another obvious clue is that the date and time stamp in the lower left-hand corner of the edited video itself is “2014 07 25.” In retrospect, it does not seem plausible that an anti-abortion organization would have sat on this inflammatory story for almost a year before releasing it.

In addition, the times differ greatly as the video progresses which obviously should have told me that major editing had taken place.





The "Live Action News website looks pretty bogus too.


I am very disappointed in myself for having fallen for this dishonest garbage.

It won’t happen again.

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OR tech How do I deal with an abusive surgeon

Have you ever come across problems with rage and temperament issues in the OR. I have been an operating room tech for many years and have been in a variety of surgical settings.

A certain surgeon brings in a lot of money to the hospital, but he is terrible. I have been called things no one has ever called me. He throws instruments on my table and mayo stand, screams, and implies that I and my colleagues have no idea what we are doing. I have reported him to my manager and the OR director, but nothing ever comes of it.

Other surgeons have witnessed his behavior and have said something, but nothing was ever done. I understand the OR is a beast of its own, but the culture has to change with these newer guys coming out of residency. The mindset of the surgeon being our customer, which is being rolled out to us now, is not reason for us to put up with abuse. What have you encountered on a peer-to-peer level on how to handle such demeaning behavior? I trained and worked at a level 1 trauma center with emotions that constantly ran high, and still it was less stressful than this particular surgeon. Thank you for your advice. 

A recent paper in the American Journal of Surgery addressed this topic. The authors interviewed 19 OR personnel including nurses, medical students, surgical residents, anesthesiologists, and 2 scrub technicians. Dr. Amalia Cochran, the papers lead author, told me the reason there werent more scrub techs was that they were reluctant to participate.

This figure, modified slightly from the paper, describes the harm that disruptive surgeons can do and suggests some coping strategies.

Italicized items are discussed in the paper

I suggest you read the entire paper. Your hospitals medical librarian should be able to obtain a copy for you without difficulty.

Its a tough situation. When I was a surgical chairman, I had some experience with surgeons behaving badly. I always had trouble getting the nurses and techs to go on the record with their complaints.

If your immediate boss cant help, maybe you could try your hospitals risk management department. A surgeon who bullies the staff is a patient safety risk. Some hospitals have anonymous hotlines where complaints can be lodged.

The only other thing I can suggest is to get several other staff to join in the complaints. Administration can ignore one or two people but not eight or ten.

Can anyone else comment?

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The Sticky Business Principle by Marc Charles

5:29 AM

Hello:

My column this week is about "sticky business".....I hope you enjoy it.

Marc Charles

The “Sticky Business” Factor

By Marc Charles

A business partner said my idea was too “sticky”.

He meant it in a bad way. But at least he said it with a smile on his face.

My partner was referring to a business with endless tentacles, paperwork, overhead costs, government red tape and a potential lawsuit magnet.

I’m sure you’ve heard about or been involved with a “sticky” business on some level.  I tend avoid them like the plague.

That’s why I was surprised when my partner suggested my idea was too “sticky”…..the nerve.

In my launching, reviewing and advising hundreds of business ideas and products over the last 29 years or so, only a fraction of them could be considered “non-stick”.

However, that doesn’t mean sticky businesses aren’t profitable.

The “stickiest” business I ever saw was also one of the most profitable….transporting hazardous (and nuclear) waste. 

The entrepreneurs who worked this venture could make $20,000 to $70,000 per load. The cost (and headaches) of running this business included retrofitted tractor trailers, maintenance (cleaning), drivers, government inspections, insurance, fuel, special licenses and certifications.

I wouldn’t recommend transporting hazardous waste for anyone without political connections, world class insurance, smart people and very deep pockets. 

On top of that, you’ll need nerves of steel. My friends were threatened, shot at and their transport vehicles were sabotaged. 

There is a boatload of businesses in the “non-stick” category. When I dissected the business idea I mentioned earlier for my partner he reluctantly agreed it wasn’t as “sticky” as he thought….the nerve.

Granted, nothing is “non-stick” or problem free all the time.

The bestselling “non-stick” frying pans rarely offer a money back guarantee should something stick.

A great “non-stick” business I found focuses on a hot rising trend called China. 

Actually, the business focuses on Chinese products, commerce and worldwide demand. I’ll tell you about it in a second. 

But first, I’d like to show you some new things developing in China right now. These things leverage the opportunity in a big way.

According the Financial Times China has opened the floodgate of cash reserves to get their “export machine” cranked up again. Apparently some Chinese (in powerful places) believe the financial crisis the last two years is receding. 

Money is flowing to entrepreneurs and businesses again like it did pre-2007.

Granted, Brazil is getting the lion’s share of attention (and money) lately because they’re surpassing the US as China’s largest trading partner.

But entrepreneurs in any country can leverage the China trend and a “non-stick” business I discovered by becoming a “finder”…..more on this in a second.

Another issue is China’s currency.

Import and export entrepreneurs are wondering if they’ll suffer a backlash over China’s currency policy. It’s a no-brainer Chinese wants to control the value of their currency (Yuan) against all other currencies.

But China’s currency has a couple of things going for it. First, China’s economy is relatively stable compared to the US and other countries, and second they have low government debt.

I’m not an economist…but a sound economy and limited government typically increases the relative value of a currency.

In real world currency trading China won’t be able to “control” much of anything, if they plan to do business with other countries.

But overall the Chinese currency should play a major role in international commerce in a good way.

China needs trading partners to survive. The country does not have the resources to be self sufficient. That’s a good thing for the “non-stick” business I found.

China needs to make and export products to the world, as well as import and consume them.

China is a living, breathing money monster which needs to be fed.

Lastly….China’s population is still growing like wildfire despite all the restrictions on having kids.

According to the World Bank China’s population was 1.3 billion in 2009 (1,356,359,928 as of January 2011).

And get this….

Chinese planners want to merge nine cities around the Pearl River Delta in the southern part of the country. This would create the largest “mega city” in the world with a population of 42 million people. This is greater than the entire population of California (39 million)!

China has unlocked the cash vault, the population is skyrocketing and they need trading partners to survive.

A “non-stick” business opportunity…..

The opportunity is about bringing buyers and sellers together and earning a percentage of each deal. This is also referred to as an import export “finder”.

I saw this opportunity in action the first time in Wausau Wisconsin.

The entrepreneur was making money as a “finder” connecting buyers in China with sellers in the US. His product was the herb ginseng. The buyers were Chinese distributors and retail stores.  

The herb ginseng is still wildly popular in China.

The import export “finder” opportunity is one of the hottest “non-stick” opportunities around.

By “non-stick” I ‘m referring to a business minus the tentacles, paperwork, inventory, buildings, employees (unless you want them), red tape, and massive overhead costs.

When you’re a “finder” you match buyers with sellers or visa versa and make money if and when a transaction is completed.

In most cases a “finder” simply facilitate deals or makes introductions to prospective partners.

And the best part is the lawsuit magnet aspect is almost eliminated.

Granted, one downside to this business is the learning curve…..and don’t kid yourself, it takes time. There are no exceptions if you want to learn this business.

But in my research I stumbled on a website which can accelerate the learning curve a hundred fold.

On top of that, I was so impressed with the impact the site, market and trend was having on entrepreneurs I developed what became known as the China Wholesale Trader.

The China Wholesale Trader is the most comprehensive resource library, how to course and interactive community in the world. See what entrepreneurs are saying about it here.

China is on the move again and there’s money to be made.

China was crippled by the financial turmoil over the past two years just like every else. But they’ve opened the cash spigot enabling companies to import and export products again!

In addition, there are more than 70,000 importers and exporters registered on AliExpress.com right now.

There are more than a million companies and entrepreneurs registered on Alibaba.com. Most of these companies and entrepreneurs are aggressively seeking business partners and deals as we speak.

People have compared AliExpress and Alibaba.com to eBay.

But the comparison is weak.

eBay focuses on the consuming masses. And eBay is a great place to sell imported products!

AliExpress and Alibaba.com focus on businesses and entrepreneurs.

This is one of the great “non-stick” business opportunities of the 21^st century.

Is the opportunity a good fit for you? I’m not sure. But it’s worth a “peak”.

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In what specialties can a surgeon be autonomous

I am a medical student who is trying to decide on a field. I am not chasing money but rather autonomy; thus I would prefer to work for myself rather than a hospital. So my question is, which fields of surgery are more amenable to private practice, and which fields tend to require the resources of a hospital or dont work as well without a hospital?

The way things are going; future use of the words “autonomous” and “physician” in the same sentence will be rare, if not unheard of.

Here are some figures from a July 2015 American Medical Association report.

• Younger physicians were more likely than older physicians to be employed. About 59% of physicians under the age of 40 were employed, versus 46.0% of physicians aged 40-54 and 33.3% of physicians 55 and above.
• Nearly one-third of physicians are in practices with more than 10 physicians, including 13.5 percent in practices with 50 or more physicians.
• Multi-specialty practice physicians were more likely than single-specialty practice physicians to report that their practices were hospital owned—44.6% compared to 23.0%.

Who knows what the percentage of employed physicians will be by 2020, but it surely will be higher.

I can think of only two surgical specialties that can be mostly independent of hospitals, otolaryngology and plastic surgery. I am not including ophthalmology because it isn’t really a classic surgical specialty.

The only way otolaryngologists and plastic surgeons can be autonomous is by concentrating solely on cosmetic surgery or working only in an ambulatory surgery center.

Otherwise, you would need a complete operating room—staffed by a nurse, an operating room technician and for some cases, an anesthesiologist—in your office.

Very few surgeons are able to limit their practices to cosmetic surgery directly out of residency or fellowship. Unless you join an established cosmetic surgeon in practice, which would of course limit your autonomy, you will need to be on call for trauma and be available for consults involving problems like pressure sores in hospitals to pay the bills.

My observation as a surgical chairman in community hospitals was that it takes years before the average plastic surgeon is able to develop a reputation and focus solely on cosmetic surgery.

You should also be aware that both of those specialties are highly competitive. In this years match, only 1 of 299 ENT positions went unfilled, and 364 US seniors had ranked ENT as their preferred choice. For plastics, there are two ways to obtain a position. The NRMP handles an integrated match which filled 144 of 148 positions. There were 162 US seniors who listed Integrated plastics as their preferred choice. The other match is independent of the NRMP and takes residents who have done varying years of general surgery. For that 2015 match, which placed applicants in positions starting in July 2016, 85 applicants submitted rank lists, and 68 of 70 positions were filled. That left 17 candidates unmatched.

Additional reading: A post on KevinMD entitled “So doctor, who’s your boss?”

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