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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My top seven posts of 2015

I’ve been blogging since July of 2010. Here is a list of my most viewed posts of 2015. Thank you for reading and commenting.

“How much money do journal publishers make? A lot,” a look at the highly profitable world of journal publication, was number 1. Profit margins of the top for medical publishers range from 32% to nearly 42%. It’s a good business to be in.

Next was “A shallow water blackout is a silent killer.” What can happen if you hyperventilate before swimming underwater? You might die.

“How to pick the leading physicians of the world” was a humorous take on an “honor” bestowed upon me by a company that is a little careless about choosing its candidates.

In “Narcotics addicts can sue doctors and pharmacies for ‘enabling’ them,” we learned of a ruling by West Virginia’s highest court that spells trouble for both patients and physicians.

“Antibiotics for appendicitis? No thanks” was a critique of a Finnish randomized prospective trial of antibiotics vs. surgery in uncomplicated appendicitis. I had some serious concerns about the way the study was done and interpreted.

“Do surgeons still do postop care?” was a guest post by a medical hospitalist who felt that surgeons were no longer interested in taking care of their patients after operating. It drew a number of comments.

The seventh most-read post was “So you want to be a radiologist,” written by a radiologist who I asked to respond to an email I received from a pre-med student. It was a nice discussion of the pros and cons of the specialty.

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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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A Neat Way for Producing Cash by Marc Charles

Hi Gang:

This was published on LOP -- a proven method for producing cash....in this economy.....seriously:


League of Power -- Weekend Business Blueprint


Have fun and play nice!

Your humble host.........


Marc Charles

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Surgical training is different in Japan

Quite different than what we are used to in the United States as a paper published online in the American Journal of Surgery explains.

In the US, all residency programs are vetted by the Accreditation Council for Graduate Medical Education (ACGME). Japan has no central accrediting organization. Each hospital establishes its own training program without any national standardization.

Medical school graduates in Japan take a national practitioner examination and then complete a two-year rotating internship. Specialization in general surgery residency takes three more years after which the residents may obtain board certification.

The authors surveyed 76 teaching hospitals in Hokkaido, a prefecture in the north of Japan, and 49 (64.5%) responded.

Program directors were in place in 81% of the residency programs. Of that number, 79.3% devoted less than 5 hours per week to education [compared to an ACGME mandate that 30% of a program director’s time must be devoted to education], and 72.4% had dialogues with residents only when necessary.

Of those responding to the question, 31/36 (86%) "had teaching activities outside of clinical settings," but no program had protected time dedicated to teaching.

Fewer than half of the programs had skills or simulation laboratories, with 12.5% having formal simulation training as part of their educational agenda.

Only 55.6% of the programs evaluated the competency of their trainees in knowledge, skills, or scholarly activities.

Not surprisingly, only 8.6% of program directors were satisfied with the way their programs functioned.

To become board-certified in Japan, residency graduates must take a written exam for which the pass rate is 82.1% and an oral examination which has a pass rate of 100%. The pass rate for the oral exam has been an issue. A medical specialty board was established in 2014 and is preparing to oversee the quality of resident education and certification.

Lead author Dr. Yo Kurashima, Director of Surgical Education Research at Hokkaido University Graduate School of Medicine, answered a few questions via email. He said some of the hospitals limit resident work hours and allow residents to go home after call. However, "most do not define work hour limitations, so residents usually work from early in the morning to midnight every day."

No universal surgical residency curriculum exists in Japan, but a national surgical society recently listed criteria that must be achieved prior to board certification.

Dr. Kurashima did some training in Canada where he became familiar with North American residency methods.

For his next project, he said, "We are just starting a national survey which will investigate resident satisfaction regarding their residency.”

I suspect the residents might raise some concerns. I wonder if they will have time to respond.

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Unproven athlete training and recovery devices

A recent Wall Street Journal article reported that #1 ranked Novak Djokovic and several other tennis players frequently spend time in hyperbaric chambers after matches. This supposedly helps athletes recover and prevents injury.

A hyperbaric pod

Malcolm Hooper, the owner of the Melbourne "clinic" where the hyperbaric pods are located and a former chiropractor, said he has "seen gains in his patients, and the research suggests hyperbaric treatment can help many ailments." The article also quoted several athletes who favored the treatment but cited none of the research.

Also mentioned in the Wall Street Journal article was the Vacusport,, "a long tube with a skirt that seals the players legs in a vacuum and flushes lactic acid." Again, no evidence that it works was provided.

The Vacusport

I found a paper presented at a 2013 conference in Egypt called "Sport Science in the Arab Spring" that looked at 10 basketball players with an average age of 17 who exercised on a treadmill at increasing inclines for about 20 minutes. Lactate levels were drawn at several intervals during the period of exercise and after the subjects spent 30 minutes in the Vacusport. The average lactate concentration fell from 8.8 mmol/L after exercise to 1.1 mmol/L which the authors said was a significant difference [statistics not provided].

Before you jump on the Vacusport bandwagon, I must point out that we dont know how fast these athletes would have cleared their lactates without the device. Thats what is known in research parlance as a "control group."

A study of 33 swimmers found that after intense racing they reduced their lactates of  >10.5 mmol/L to normal levels by simply swimming a modified workout for 20 minutes.

The Vacusport paper looks a like Nobel Prize candidate compared to a study of the Elevation Training Mask, a device which supposedly reduces the level of inspired oxygen without the expense of training at altitude where the percentage of oxygen in the air is lower due to the decreased atmospheric pressure.

Elevation Training Mask

Through a series of valves which can be opened or closed, the mask increases resistance to breathing. How this translates into lowering the partial pressure of oxygen in the air I do not know.

A case report published on the Elevation Training Mask website [but not in a scientific journal] must be read to be appreciated fully. An intrepid chiropractor wore the mask himself during 6 weeks of exercising.

Over the course of the experiment his peak expiratory flow rose 4%, his 1 second forced expiratory volume rose 1.3%, and his oxygen saturation rose from 96% to 99%,. No statistical analysis was performed, but the author said, "I do feel that this change was significant that oxygenation reached the 99%." I disagree. Even it was significant, an oxygen saturation rise of 3% is not clinically significant. [See my post on why oxygen is not a performance enhancing drug.]

A website called Bodybuilding.com explains in more detail why the mask could not possibly simulate altitude training.

Rather than rack my brain trying to come up with a pithy comment about the mask, Ill use one I found on Bodybuilding.com. "According to Alex Viada, a successful hybrid-training coach and founder of Complete Human Performance, such high-altitude devices simulate altitude in the same way sticking your head in a toilet simulates swimming."

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