Thursday, March 13, 2014

‘It’s against all principles of scientific reporting’: Thousands of medical papers cite Wikipedia, study says - National Post

Universities ban students from citing Wikipedia in papers, and even the web site itself warns academics against referencing its articles, which any Internet user can alter at any time. But a new Canadian study has found that thousands of peer-reviewed papers in medical journals have cited Wikipedia in recent years — and the numbers of references are increasing fast.

The trend – apparent even in some of the world's most influential medical publications — raises the possibility of spreading misinformation and "could potentially affect care of patients," researchers from the University of Ottawa say in a paper just published by the British Medical Journal (BMJ). Articles in the BMJ itself have had 13 references to Wikipedia in the last decade, they note.

What struck the study authors most, though, is that the citations began to multiply in the last three years.

"The biggest surprise was the trend," said Dr. Sylvain Boet, an Ottawa Hospital anesthetist and health researcher who headed the study with Dr. Dylan Bould, another anesthetist. "It's exponential … It goes against all the principles of scientific reporting and referencing."

The problem is not only the accuracy of the information – which has actually been rated surprisingly high — but that Wikipedia articles are constantly changing, and tend to only summarize primary or secondary information sources, rather than containing original research themselves, the authors say.

Some of the "high-impact," or most influential, journals found to have had Wikipedia references could not be reached for reaction this week, or declined to comment on the findings.

Wikipedia has grown into the sixth most popular website in the world since its inception in 2001 – according to the Alexa Internet analysis service — with millions of articles that span the breadth of human knowledge.

Though each article can be edited by users, mistakes tend to be corrected by others relatively quickly, with one 2005 study rating a sample of Wikipedia entries similar in accuracy to Encyclopedia Britannica. What is more, health-related articles are overseen by an expert group, WikiProject Medicine.

Indeed, it is common for medical students and young doctors to turn to Wikipedia as an initial source, admitted Dr. Boet. The problem, though, is that there is no guarantee the information at any given time is, in fact, wholly accurate, and a Wikipedia entry cited by a journal paper one day may be quite different soon after, unlike a conventional article or book, he said.

That makes it harder for expert readers to assess research or, potentially, try to duplicate it themselves, said Dr. Boet.

Also, the International Committee of Medical Journal Editors urges that journal authors reference original, primary research — like the results of a clinical trial — not someone else's summary of it. In fact, Wikipedia articles often do provide those kind of primary references, yet some researchers ignore them and still cite the Wiki article instead, the study notes. Doing so is likely "quick and easy," especially if a scientist has limited access to the original source, speculated Dr. Boet.

"The possibility for the spread of misinformation from an unverified source is at odds with the principles of robust scientific methodology and could potentially affect care of patients," his paper concludes.

In fact, Wikipedia makes much the same point itself, noting that "for many purposes, but particularly in academia, Wikipedia may not be an acceptable source." It reminds readers that "anyone in the world can edit an article, deleting accurate information or adding false information."

Some universities frown on even students using it as a source for papers. Cornell University, for instance, warns undergraduates that Wikipedia provides a rudimentary overview of subjects and that it is likely that professors "won't let you cite it in a scholarly research paper."

Dr. Boet and colleagues discovered more than 1,400 journal articles from 2001 to the beginning of 2012 that referenced Wikipedia. The numbers started to soar in 2011, and 1,600 or more Wikipedia-citing papers were published in each of 2012 and 2013.

They appeared in some of the world's foremost journals, including NatureScienceThe Lancet Infectious Diseases and The Annals of Internal Medicine.

The majority of Wikipedia citations were for definitions or descriptions of medical or scientific terms or concepts, followed by historical and statistical references, the study indicated.

Slate: Should It Really Take 14 Years to Become a Doctor?

We need more doctors. On a global scale, the shortage is staggering: TheWorld Health Organization says we need 15 percent more doctors. In the United States, the American Association of Medical Colleges estimates the current deficit at almost 60,000 and forecasts a worrisome 130,600-doctor shortfall by 2025. There's one simple solution: We have to consider ways to manufacture doctors faster and cheaper.

An American physician spends an average of 14 years training for the job: four years of college, four years of medical school, and residencies and fellowships that last between three and eight years. This medical education system wasn't handed down to us by God or Galen—it was the result of a reform movement that began in the late 19th century and was largely finished more than 100 years ago. That was the last time we seriously considered the structure of medical education in the United States.

The circumstances were vastly different at that time. Until the Civil War, private, for-profit medical schools with virtually no admissions requirements subjected farm boys to two four-month sessions of lectures and sent them off to treat the sick. (The second session was an exact duplicate of the first.) The system produced too many doctors with not enough training. Abraham Flexner, the education reformer who wrote an influential report on medical education in 1910, put a fine point on the problem: "There has been an enormous over-production of uneducated and ill trained medical practitioners," he wrote. (Emphasis added.) "Taking the United States as a whole, physicians are four or five times as numerous in proportion to population as in older countries like Germany."

In other words, our current medical education system was originally designed to reduce the total number of people entering the profession. The academic medical schools that sprang up around the country—such as theJohns Hopkins Hospital in 1889—made college education a prerequisite. Medical school expanded from eight months to three years and solidified at four years in the 1890s. Postgraduate training programs were implemented, beginning with a one-year internship. These were brilliant reforms at the time.

Over the past century, there have been additions to, but few subtractions from, the training process. Residency and fellowship programs became longer and longer ... and longer. The path to some specialties is now almost comically arduous. Many hand surgeons, for example, complete five years in general surgery, followed by three years in plastic surgery, followed by another year of specialized hand surgery training. To be a competitive candidate for a hand surgery fellowship, it's also strongly recommended to spend two additional years on research at some point during the process.

The current system has costs beyond making doctors expensive and rare. The long process doesn't just weed out the incompetent and the lazy from the potential pool of physicians—it deters students who can't pay for so many years of education or who need to make money quickly to support their families. That introduces a significant class bias into the physician population, depriving a large proportion of the population of doctors who understand their background, values, and challenges.

One solution is to simply lop off a few years from the process. Writing in the Journal of the American Medical Association in 2012, bioethicist Ezekiel Emanuel (one of those Emanuels) and economist Victor Fuchsrecommended shortening each stage by about 30 percent. Four years of premedical training shouldn't be a requirement for those who don't want it or can't afford it, they argued. The fourth year of medical school is largely a breeze, and a few progressive medical schools are now offering three-year programs to reflect that reality.

As for postgraduate training, Emanuel and Fuchs attacked the increasingly common requirement that residents and fellows complete laboratory or clinical research projects. They don't buy the popular ideal that every doctor must be a "physician-scientist." Referring specifically to surgeons, they wrote, "The most important factor in becoming a competent surgeon is high volume—performing specific procedures many times over. A research year does not add to surgical volume and skills building."

Shortening the training process would entail costs. Kenneth Ludmerer, a professor of medical history and author of two books on this topic, argues that research isn't merely about scientific discovery, but learning to approach diagnosis and treatment like a scientist. He points out that even Abraham Flexner, writing more than 100 years ago, noted: "The practicing physician and the 'theoretical' scientist are thus engaged in doing the same sort of thing even while one is seeking to correct Mr. Smith's digestive aberration and the other to localize the cerebral functions of the frog."

"There is an inevitable tension in medical education between preparation and practice," Ludmerer says. "It is a perpetual dilemma that has become more severe, because there is now more to know."

Another solution, perhaps more elegant, is the outcomes movement. American medical schools and residency programs have traditionally relied on the "tea steeping" method: They expose students to information for a prescribed amount of time, and assume they're ready at the end of it. Years can be added if a student demonstrates gross incompetence in exams, but there's no opportunity for exceptional students to accelerate the process. Offering that chance makes educators uncomfortable—both because it relies heavily on imperfect examinations and because it partially undermines the traditional process—but it's time to experiment.

"Experiment" is the key word. The fundamental problem here is that the argument between traditionalists and reformers is essentially theoretical—we are in an evidence vacuum. It's ironic, because in virtually every other aspect of medicine, tradition and intuition were discarded decades ago. Researchers rigorously test what is the best moment to start someone infected with HIV on antiretrovirals or a patient with high cholesterol on statins. But doctors have very rarely examined their own training. When Emanuel and Fuchs published their proposal two years ago, they could find just a single study comparing the competence of physicians from the traditional four-plus-four medical education system with that of doctors from shortened programs.

There is no reason not to do this important research. More than a dozen medical schools now offer high school graduates the chance to earn a medical degree in six or seven years. Fellowship programs also vary in length. It's time to compare the medical boards scores, patient mortality rates, and other metrics for doctors with different lengths of training. The studies won't be easy—students entering shortened programs may be different in a number of ways, for example, biasing the outcome. But assiduous matching of the test and control groups, paired with honest statistical analysis, will partially address that problem.

The rank-and-file physician may herself be an impediment to reform. Every generation of doctors seems to be convinced that the next is inadequately trained, because the younger doctors didn't live in the hospital or spend enough sleepless nights there. Many warn that shortening premedical education will inevitably produce awkward automatons who can't relate to patients (as though the current system is flawless in that regard).

In recent years, however, studies have shown that reductions to working hours during residency have harmed neither patients nor doctors-in-training. We need to subject assumptions about duration of training to the most rigorous scientific assessment possible. It's time for doctors to turn the microscopes on themselves and their own training, and accept that the system that produced them may be imperfect. It's nothing against you, Doctor, it's just a scientific inquiry.

Wednesday, March 12, 2014

Patients who question their doctors are changing the face of medicine – and physicians are embracing the shift - National Post

Last week I was in California for the Future of Genomic Medicine conference, and I heard a presentation by "the patient of the future." Her name is Kim Goodsell, and she's a patient of the well-known cardiologist Dr. Eric Topol.

Before Goodsell started having medical problems she was one of the most active people imaginable — a formerly world-ranked Iron Man triathlete and enthusiastic kite surfer. But then she noticed episodes of irregular heartbeat. As years passed the arrhythmia became increasingly common. And her fine motor skills were disappearing.

Specialist after specialist failed to identify the source of the problems. Finally, Goodsell's own research led her to suspect a genetic malady — a mutation of a gene called LMNA. A genetic test confirmed her suspicions. Turns out Goodsell has a form of Charcot-Marie-Tooth disease, which causes her cells to make mistakes when they produce proteins.

Dr. Topol billed Goodsell as the patient of the future because she's an activist patient, someone who regards her health as a collaboration between herself and her doctor. More and more patients are regarding their health in a similar manner.

In fact, activist patients are changing the way doctors practice medicine. Take the public health campaign, Choosing Wisely, which Canadians will begin to notice across the country this April. Last month's Canadian Medical Association Journal ran a commentary about the campaign lead-authored by the University of Toronto's Dr. Wendy Levinson. According to Levinson, Choosing Wisely encourages both patients and physicians to examine whether certain medical tests are beneficial to the patients.

Before I get to what I think is so interesting about Choosing Wisely, I should mention that certain aspects of the campaign concern me. I worry that it's motivated by cost-containment strategies that could bias the public against preventive medicine. The campaign is a manifestation of an ongoing trend in the profession toward something called evidence-based medicine, which requires most every step in a patient's care to be supported by science and academic research. I like most aspects of evidence-based medicine, but it can be tricky when applied to preventive techniques.

Some things that doctors do aren't supported by science. At the Scripps conference, Nature editor Dr. Magdalena Skipper talked about the way negative findings — doing this prevents that — are really difficult to scientifically prove, but important for the future of medicine. To make the findings rigorous requires following thousands of patients for years at a time. That's very expensive — and unless it could lead to a blockbuster drug or medical device, few groups have the incentive to spend that kind. The DIY dementia test: sample questions from the quiz doctors claim will catch Alzheimer's early

Activist patients are changing the way we practice medicine — and we're likely to see more changes in future. Take Goodsell: Once she confirmed her mutation she became expert in the biological mechanisms of her disease. One form of treatment, she surmised, involved changing her diet to cut out sugars and to increase her consumption of omega-3 fatty acids, among other things. The changes seemed to help her symptoms, leading her to regain fine-motor control of her hands enough that she was able to use chopsticks and return to kitesurfing.

The ultimate indication of Goodsell's control over her medical destiny? When her doctor wrote up her case history for publication, he listed Goodsell as a co-author. The account is to be presented at a meeting of the Heart Rhythm Society of physicians. The ironic thing, though, is that Goodsell won't be able to see the presentation — because she isn't an accredited physician. Goodsell's story, and the Choosing Wisely campaign, both indicate that the medical profession has progressed a lot in terms of patient empowerment. But evidently, we still have some ways to go.

Dr. James Aw is the medical director of the Medcan Clinic.

Tuesday, March 11, 2014

Do Brain Workouts Work? Science Isn't Sure -

For a $14.95 monthly membership, the websiteLumosity promises to "train" your brain with games designed to stave off mental decline. Users view a quick succession of bird images and numbers to test attention span, for instance, or match increasingly complex tile patterns to challenge memory.

While Lumosity is perhaps the best known of the brain-game websites, with 50 million subscribers in 180 countries, the cognitive training business is booming. Happy Neuron of Mountain View, Calif., promises "brain fitness for life." Cogmed, owned by the British education company Pearson, says its training program will give students "improved attention and capacity for learning." The Israeli firmNeuronix is developing a brain stimulation and cognitive training program that the company calls a "new hope for Alzheimer's disease."

And last month, in a move that could significantly improve the financial prospects for brain-game developers, the Centers for Medicare and Medicaid Services began seeking comments on a proposal that would, in some cases, reimburse the cost of "memory fitness activities."

Much of the focus of the brain fitness business has been on helping children with attention-deficit problems, and on improving cognitive function and academic performance in healthy children and adults. An effective way to stave off memory loss or prevent Alzheimer's — particularly if it were a simple website or video game — is the "holy grail" of neuroscience, said Dr. Murali Doraiswamy, director of the neurocognitive disorders program at Duke Institute for Brain Sciences.

The problem, Dr. Doraiswamy added, is that the science of cognitive training has not kept up with the hype.

"Almost all the marketing claims made by all the companies go beyond the data," he said. "We need large national studies before you can conclude that it's ready for prime time."

For centuries, scientists believed that most brain development occurred in the first few years of life — that by adulthood the brain was largely immutable. But over the past two decades, studies on animals and humans have found that the brain continues to form new neural connections throughout life.

But questions remain whether an intervention that challenges the brain — a puzzle, studying a new language or improving skill on a video game — can really raise intelligence or stave off normal memory loss.

A series of studies in recent years has suggested that certain types of game training can improve a person's cognitive performance. In February 2013, however, an analysis of 23 of the best studies on brain training, led by the University of Oslo researcher Monica Melby-Lervag, concluded that while players do get better, the increase in skill hasn't been shown to transfer to other tasks. In other words, playing Sudoku or an online matching game makes you better at the game, but it doesn't make you better at math or help you remember names or where you left your car keys.

But other studies have been more encouraging. Last September, the journal Nature published a study by researchers at the University of California, San Francisco, that showed a driving game did improveshort-term memory and long-term focus in older adults. The findings are significant because the research found that improvements in performance weren't limited to the game, but also appeared to be linked to a strengthening of older brains over all, helping them to perform better at other memory and attention tasks.

In addition, brain monitoring during the study showed that in older participants, game training led to bursts in brain waves associated with attention; the patterns were similar to those seen in much younger brains.

In January, the largest randomized controlled trial of cognitive training in healthy older adults found that gains in reasoning and speed through brain training lasted as long as 10 years. Financed by the National Institutes of Health, the Active study (Advanced Cognitive Training for Independent and Vital Elderly) recruited 2,832 volunteers with an average age of 74.

The participants were divided into three training groups for memory, reasoning and speed of processing, as well as one control group. The groups took part in 10 sessions of 60 to 75 minutes over five to six weeks, and researchers measured the effect of training five times over the next 10 years. Five years after training, all three groups still demonstrated improvements in the skills in which they had trained. Notably, the gains did not carry over into other areas. After 10 years, only the reasoning and speed-of-processing groups continued to show improvement.

The researchers also found that people in the reasoning and speed-of-mental-processing groups had 50 percent fewer car accidents than those in the control group. The claims about commercial brain games are "a mixed bag," said Sherry L. Willis, a University of Washington research professor involved in the Active study. "There is a tendency for companies to say a certain measure represents X ability, but there may be insufficient, if any, research to support the asssertion," added Dr. Willis, who said a version of the training used in the Active study was available through Posit Science and AARP Brain Fitness.

Earlier this year, the National Institutes of Health invited applications to more rigorously test brain fitness training to stave off cognitive decline. Researchers say they hope the effort will help establish a consistent standard for determining whether a brain-training intervention works.

But while the science remains unclear, entrepreneurs have seized on what is likely to be a sizable marketing opportunity. In May, hundreds of researchers and businesses will gather in San Francisco for theNeuroGaming Conference and Expo to explore the latest research and the newest technology.

While there is no real risk to participating in the many unproven brain-training games available online and through smartphones, experts say, consumers should know that the scientific jury is still out on whether they are really boosting brain health or just paying hundreds of dollars to get better at a game.

"I'm not convinced there is a huge difference between buying a $300 subscription to a gaming company versus you yourself doing challenging things on your own, like attending a lecture or learning an instrument," Dr. Doraiswamy said. "Each person has to personalize for themselves what they find fun and challenging and what they can stick with."

Sunday, March 9, 2014

The Believer - The Empathy Exams by Leslie Jamison - @believermag

My job title is Medical Actor, which means I play sick. I get paid by the hour. Medical students guess my maladies. I'm called a Standardized Patient, which means I act toward the norms of my disorders. I'm standardized-lingo SP for short. I'm fluent in the symptoms of preeclampsia and asthma and appendicitis. I play a mom whose baby has blue lips.

Medical acting works like this: you get a script and a paper gown. You get $13.50 an hour. Our scripts are ten to twelve pages long. They outline what's wrong with us—not just what hurts but how to express it. They tell us how much to give away, and when. We are supposed to unfurl the answers according to specific protocols. The scripts dig deep into our fictive lives: the ages of our children and the diseases of our parents, the names of our husbands' real-estate and graphic-design firms, the amount of weight we've lost in the past year, the amount of alcohol we drink each week.

My specialty case is Stephanie Phillips, a twenty-three-year-old who suffers from something called conversion disorder. She is grieving the death of her brother, and her grief has sublimated into seizures. Her disorder is news to me. I didn't know you could have a seizure from sadness. She's not supposed to know either. She's not supposed to think the seizures have anything to do with what she's lost.

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