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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More germs Planes desks and even kisses

Airplanes are so permeated with bacteria that it is truly a wonder that anyone survives a flight. Ill bet you thought it was the air in the cabin, but a recent story in USA Today says otherwise. "The real problems lie on the chair upholstery, the tray table, the armrests and the toilet handle."

What should germophobic passengers do? "First, they should travel with and use an alcohol-based hand sanitizer. They should also travel with a small pack of disinfectant wipes," said the microbiologist who did the study. "The first thing I do when I sit down is to wipe down the armrest and tray table because thats where my arms will be. You need to decontaminate where youll be spending your time and eating."

From MailOnline: "Millions of us spend our days slaving over a keyboard. But lurking between the keys, hidden on the mouse and nestled in your phone lies [sic] more than 10 million bacteria—400 times more than on the average toilet seat." [Despite what I reported in my last post, the toilet seat will remain the gold standard for comparing contamination levels until it is unseated.]

At least that is way fewer bacteria than the next study found.

"Every Kiss Begins With 80 Million Germs" headlines WebMD about a paper published in the journal Microbiome. WebMD story says, "In one experiment, the researchers gave 21 couples a probiotic drink containing bacteria before they kissed. Swab samples afterwards showed the transfer of those 80 million germs."

From the methods section of the paper: "One of the partners was invited to consume 50 ml of a probiotic yogurt drink containing L. rhamnosus GG, L. acidophilus LA5, and B. lactis BB12 [all non-pathogens]. After 10 seconds, saliva and tongue swabs were collected from this partner (donator) and after a second intimate ["full tongue contact and saliva exchange"] kiss of 10 seconds, saliva and tongue swabs were directly collected from the other partner (receiver)."

Saliva has some antibacterial properties. Maybe the researchers didnt wait long enough to test for bacteria after one of the partners drank the yogurt? People who have 80 million pathogenic bacteria in their mouths probably have bad breath and poor oral hygiene. I doubt they are indulging in 10 second tongue kissing.

And heres an excerpt from the conclusion. "This study indicates that a shared salivary microbiota requires a frequent and recent bacterial exchange and is most pronounced in couples with relatively high intimate kiss frequencies of at least nine intimate kisses per day [my emphasis] or in couples sampled no longer than 1.5 hours after the latest kiss."

Ten second kisses? Nine intimate kisses per day? Other than perhaps high school kids, who is kissing 9 times a day for 10 seconds at a time?

Bottom line? After eating yogurt, wait at least 90 minutes before tongue kissing someone.

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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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Readmissions Sometimes its the patients

My Twitter friend Dan Diamond (@ddiamond) posted a picture of a slide that said a hospitalized patient was taught to inject insulin using an orange to practice on. When he was readmitted to the hospital with a very high blood sugar, it turned out that instead of injecting himself at home, the patient was injecting his insulin dose into an orange, and then eating it.

Weve all heard stories about patients who took suppositories by mouth instead of the way they were intended.

Since doctors get blamed for just about everything, some would say that patients who take suppositories by mouth or eat an orange filled with insulin do so because they were not properly taught by their doctors (or nurses).

I have blogged before about the problem of who is at fault if patients do not follow up. Although I feel that much of the time its the patient who decides not to return for follow-up, it seems prevailing sentiment and possibly even the courts say its the physician who should be held responsible.

But how do you explain this? A study in Heart, a BMJ journal, found that of 208 hypertensive patients referred to a clinic for suboptimal blood pressure control, 52 (25%) were either completely or partially non-adherent [aka non-compliant] with their antihypertensive medications as determined by urine mass spectrometry.

The authors concluded that urine testing for medications or their metabolites would help doctors avoid ordering unnecessary investigations for patients whose blood pressures were not well-controlled.

The reasons for patient non-adherence were not mentioned. Could all 52 patients not have been told about the importance of taking their medications? I doubt it.

You might think the 15% who were partially non-adherent may have forgotten to take the drugs occasionally, but it turns out that most of those in this group took adequate doses of most of other their prescribed medications. This suggests that they selectively omitted some doses of one or more drugs.

The only explanation I can fathom for the 10% who had no traces of any BP meds in their urine is that they just said "to hell with it" and didnt take their meds at all.

I know someone with type 2 diabetes who doesnt watch her weight or what she eats and doesnt check her blood sugars. She says, "Youve got to die of something. Id rather live my life the way I want to."

Is it that doctors and nurses arent educating the patients or are the patients at fault?

The answer to this question has important implications because of the newly established financial penalties for hospitals with high readmission rates.

Older methods that may improve adherence are tracking prescription refills and having pharmacists or nurses specifically assigned to explain medications to patients in detail.

Heres something that might help.

A recent meta-analysis showed that adherence to HIV/AIDS antiretroviral therapy was modestly improved when patients were sent reminders to take their medications by text message. Those who were more adherent had lower viral loads and better CD4 counts.

Of course, such an intervention assumes that patients have mobile phones or pagers capable of receiving texts, will check for messages, and will act upon the advice. Compared to patients with HIV/AIDS, those with hypertension might tend to be much older and possibly not as technologically savvy.

So what is the solution? I dont know, but sometimes the problem is the patients.

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More ratings—this time its residency programs

Can you really decide which surgical residency program is right for you using Doximitys Residency Navigator?

I dont think so, and heres why.

The rankings of residency programs were obtained by surveying surgeon members of Doximity. They were asked name the five top programs for clinical surgery training. When the survey was announced in June, I predicted that most respondents would probably overlook the word "clinical" and focus on the usual famous academic institutions.

I also pointed out that anyone not intimately familiar with a program would be unable to judge whether it is good or not and suggested that reputation would be the main driver of results.

In fact, that is exactly what happened. Of the top 40 programs listed, all are based at university hospitals, as are 66 of the top 70. Back in June, I speculated about the top five programs and got the first two correct but in the wrong order.

A 2012 survey of surgical residents with over 4200 responders (an 80% response rate) found that community hospital trainees were significantly more satisfied with their operative experience and less likely to worry about practicing independently after graduation. Wouldnt you then expect a few community hospital programs to be among the top 40 hospitals for clinical surgery training?

Proof that the surveys findings are not reliable is that every one of the 253 surgical residency programs in the country was mentioned by one or more of those who responded. This included one program that has been terminated by the Residency Review Committee for Surgery. At least it appears near the bottom of the list.

The number of voters who cited the lower ranking programs must have been very few, meaning the difference between the 200th and 240th program ranks is probably not statistically significant.

Some programs that were rated are so new that very few or no residents have graduated yet. How could anyone know if they are turning out competent clinical surgeons?

Board passage rates for programs, which are available online, were omitted for some and were not clearly identified as the percentage of residents who passed both parts of the boards on the first attempt only.

The percentile rankings of alumni peer-reviewed articles, grants, and clinical trials are displayed prominently. What do those data have to do with the research question—which residency programs "offer the best clinical training"?

So whats the bottom line?

You can put the Doximity Resident Navigator in with the other misleading ratings of hospitals and doctors. Applicants considering surgical residencies should not rely on it for guidance.

It has warmed the hearts of faculty and residents at highly rated programs, but I wonder how the OR lounge discussions are going at places where programs ranked lower than expected.

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How to rank surgical residency programs

In September, Doximity, a closed online community of over 300,000 physicians, released its ratings of residency programs in nearly every specialty. Many, including me, took issue with the methodology. Emergency medicine societies met with Doximitys co-founder over the issue and echoed some of the comments I had made about the lack of objectivity and emphasis on reputation.

I wonder if it is even possible to develop a set of valid criteria to rate residency programs. Every one I can think of is open to question. Lets take a look at some of them.

Reputation is an unavoidable component in any rating system. Unfortunately, it is rarely based on personal knowledge of any program because there is no way for anyone not directly involved with a program to assess its quality. Reputation is built on history, but all programs have turnover of chairs and faculty. Just as in sports, maintaining a dynasty over many years can sometimes be difficult. Deciding how much weight should be given to reputation is also problematic.

The schools that residents come from might be indicative of a programs quality, but university-based residencies tend to attract applicants from better medical schools. The other issue is who is to say which schools are the best?

Faculty and resident research is easy to measure but may be irrelevant when trying to answer the question of which programs produce the best clinical surgeons. Since professors tend to move from place to place, the current faculty may not be around for the entire 5 years of a surgery residents training.

The number of residents who obtain subspecialty fellowships and where those fellowships are might be worthwhile, but would penalize programs that attract candidates who may be exceptional but are happy to become mere general surgeons.

Resident case loads including volume and breadth of experience would be very useful. However, these numbers have to be self-reported by programs. Self-reported data are often unreliable. Here are some examples why.

For several years, M.D. Anderson has been number one on the list of cancer hospitals as compiled by US News. It turns out that for 7 of those years, the hospital was counting all patients who were admitted through its emergency department as transfers and therefore not included in mortality figures. This resulted in the exclusion of 40% of M.D. Andersons admissions, many of whom were likely the sickest patients.

The number and types of cases done by residents in a program have always been self-reported. The Residency Review Committee for Surgery and The American Board of Surgery have no way of independently verifying the number of cases done by residents, the level of resident participation in any specific case, or whether the minimum numbers for certain complex cases have truly been met.

So where does that leave us?

Im not sure. I am interested in hearing what you have to say about how residency programs can be ranked.

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