Rejected by JAMA in 2010.

To the Editor:

In his letter describing recently-introduced Congressional legislation to establish “healthcare innovation zones” (1), Dr. Kirch of the Association of American Medical Colleges (AAMC) listed his financial disclosures as “none.” I believe this is misleading.

Dr. Kirch did not disclose that the AAMC proposed such zones (2). As a federally registered lobbying organization that has spent $100,000-$400,000 annually on lobbying activities since 1999 (3), common sense dictates that one of the AAMC’s “products” is legislation.

Thus, Dr. Kirch should have disclosed his organization’s role in the product his letter described, just as he would have disclosed if his organization had invented a new drug or device expected to benefit the organization or its affiliates. At the very least, such disclosure would have helped the JAMA editors realize he was hyping something his organization helped create.

(1) Kirch DG. The Healthcare Innovation Zone: a platform for true reform. JAMA. 2010 Mar 3;303(9):874-875.   Pubmed 20197534

(2) "Rep. Schwartz introduces legislation to establish AAMC-proposed health care innovation zones." Press Release, Association of American Medical Colleges, July 10, 2009. Online at:   http://www.aamc.org/newsroom/pressrel/2009/090710.htm -- accessed April 4, 2010.

(3) Lobbying Disclosure Act Database:   http://soprweb.senate.gov/index.cfm?event=choosefields -- Searched on "registrant name" = "association of american medical colleges" on April 4, 2010.

Rejected by the New England Journal of Medicine in February 2010.

To the Editor:

Medical educators I’ve known have often cited the case histories in the Journal’s CPCs as model presentations of clinical information.

Unfortunately, case 2-2010 jeopardizes this reputation by saying the patient experienced “an episode of pain in his left arm … that radiated to his heart” (1).

Medical trainees should not emulate this statement, for three reasons:

First, it is not believable. The complex innervation of thoracic structures prevents localization of pain to any internal organ.

Second, it is ambiguous. Many patients believe pain near the left breast is “heart pain” (2), whereas physicians generally associate retrosternal discomfort with cardiac ischemia.

Third, even if this statement were a direct quote from the patient, it violates the precept to “question [the patient] until sufficient details are obtained to categorize the symptom in medical terms” (3).

No institution of medical education can rest on its laurels. I hope The Journal will re-dedicate itself to maintaining its pre-eminence in this vital field.

(1) Isselbacher EM, Kligerman SJ, Lam KM, Hurtado RM. Case records of the Massachusetts General Hospital. Case 2-2010. A 47-year-old man with abdominal and flank pain. N Engl J Med. 2010 Jan 21;362(3):254-62.   Pubmed 20089976

(2) Wood P. Diseases of the Heart and Circulation. 2nd ed. London: Eyre and Spottiswoode, 1956. Page 4.

(3) DeGowin RL. DeGowin & DeGowin's Bedside Diagnostic Examination. 5th ed. New York: Macmillan, 1987. Page 24.

Rejected by the New England Journal of Medicine in 2009. This topic is a bit of a bugaboo. See   Pubmed 3358592

To the Editor:

In case 32-2009 (1) I was surprised to see the patient’s height measured with impressive, millimeter precision: 165.1 cm. More likely, of course, this was simply a ludicrously precise conversion to SI units from an imprecise 5-foot 5-inch estimate.

Information, as defined by communications scientists, has been likened to the amount of surprise in a system (2). Thus, to feel surprise when reading about a patient’s unremarkable height indicates that a perturbation of informational content has occurred – surely undesirable in any scientific journal.

To maintain informational aequanimitas, I suggest the Journal report measurements in the units in which they were originally obtained. Converted values – in full misleading precision – could follow in parentheses.

(1) Tager AM, Sharma A, Mark EJ. Case records of the Massachusetts General Hospital. Case 32-2009. A 27-year-old man with progressive dyspnea. N Engl J Med. 2009 Oct 15;361(16):1585-1593.   Pubmed 19828536

(2) Applebaum D. Probability and Information: An Integrated Approach. 2nd ed. Cambridge, UK: Cambridge University Press, 2008. Pages 105-106.

Rejected by the New England Journal of Medicine in 2009. This case makes me angry.

To the Editor:

Desai et al (1) describe a tragic case of panhypopituitarism diagnosed only when the patient developed cardiogenic shock and required two weeks of mechanical and pharmacological inotropic support, plus an implanted defibrillator.

Because they focus chiefly on the final outcome, the authors consider the patient’s management as a success. Instead, they should have used techniques of aviation mishap investigation to question how this patient’s close, 21st-century medical care over the preceding year could have allowed an eminently treatable disease to reach Dickensian severity.

Why did the review of systems upon admission not disclose the patient’s symptoms of hypothyroidism? Why did the admission physical miss the obvious hair and skin signs? Why was the neurological examination deemed “unremarkable” when this patient very likely had markedly delayed relaxation of tendon reflexes (2,3,4)? Evaluating such suspicious findings could have advanced hormone replacement and averted complications.

Aviators live and die by their checklists – literally. Thorough patient histories and physical exams are medicine’s ultimate checklist. We shortcut them at our peril, and at the peril of our patients.

(1) Desai NR, Ceng S, Nohria A, Halperin F, Giugliano RP. When past is prologue. N Engl J Med. 2009; 360: 1016-1022.   Pubmed 19264691

(2) Jonckheer M, Blockx P, Molter F. Use of the Achilles-tendon reflex in thyroid clinical investigation. Acta Endocrinol (Copenh). 1970; 63: 175-184.   Pubmed 5467016

(3) [No authors listed] The Achilles heel of the ankle jerk. Journal of the American Medical Association. 1967; 199: 39.   Pubmed 6071124

(4) Chaney WE. Tendon reflexes in myxoedema: valuable aid in diagnosis. Journal of the American Medical Association. 1924; 82: 2013-20166.

Rejected by the US Naval Institute Proceedings in 2008.

To the Editor:

How ironic that Naval Academy plebes once had to memorize Matthew Maury’s high-minded statement “When principle is involved, be deaf to expediency” (1).

Although I agree with my fellow Virginian’s sentiment, it should be remembered that Maury’s personal principles – or lack thereof – resulted in him leaving the US Navy at the Civil War’s outbreak, joining the rebel cause, and taking up arms against what remained of the United States. Wikipedia reports that, among his wartime services, Maury perfected an “electric torpedo” that cost more Union vessels than all other causes combined.

Maury accomplished much that is worthy of respect, but his disregard for his Constitutional oath makes him a perilous exemplar of principled behavior.

(1) "When Principle Is Involved" by Harlan Ullman, US Naval Institute Proceedings. Feb. 2008, page 8.