Links for Monday, October 15, 2018: Uber quantifies the curb, non-yelling coaches, criminal malpractice, and handlebar shapes

Uber—not a bus company—has proposed a formula for optimization of curb space that makes buses look pretty good:

(quoting directly from the article)

Activity/(Time x Space)

“Activity” is the number of passengers using the curb space by a specific mode, “time” is the duration of their usage, and “space” is the total amount of curb footage dedicated to that use.

Here’s the example that the consultants use in their report, where a 20-foot length of curb is used for four hours as a parking spot by a single car carrying two people:

2 passengers/(4 hours x 20 feet) = .025 passengers/hour-feet, or 0.5 passengers per hour per 20 feet of curb

But if that space is instead used as part of an 80-foot bus stop serving 100 people in that four-hour block, the equation looks like this:

100 passengers/(4 hours x 80 feet) = .3125 passengers/hour-feet, or 6.25 passengers served per hour per 20 feet of curb

Clearly, the bus stop is a better use of public space. And naturally, those Uber cars that don’t take up curb parking look good, too. No surprise there, considering the source.

John Gagliardi is dead, which means that the Nick Saban school of coaching just got a little stronger. That’s a tragedy

My antipathy toward football is cresting (just search for “football” in this site and you’ll see why). But who can argue with a philosophy like this one?

“Gagliardi essentially preached a philosophy of anti-coaching, one that prized self-reliance and self-motivation and abhorred cruelty and authoritarianism. These were not bullshit, repackaged, supposedly out-of-the-box ideas like you find coming out of Silicon Valley. Gagliardi’s philosophy was deeply HUMAN, and deeply trusting. It also happened to be highly effective, so much so that similar techniques are now widely used in parenting books, academic teaching, and other fields.”

One thing the best coaches I’ve had did well—in sports, medicine, music, or other—was to make me feel good about what I was doing. They made me feel good about the process of improvement, no matter my starting point in terms of skill. They essentially told me, “I know you’re a person who tries hard. Let me help you direct that effort in the way that will get the most out of your foundational ability.”

A Texas neurosurgeon was so bad at his job that he got life in prison

When I was a resident, a local doc prescribed so many narcotics to so many patients at such outrageous doses that admitting one of his patients was a near certainty on any overnight call shift. But what did the guy in wasn’t that he was committing malpractice on a daily basis; it was that he improperly supervised his wife as a mid-level provider, leading to money laundering and conspiracy convictions.

We in medicine do a bad job of policing our own. The surgeon who body-checked Dr. Death away from the operating table in Texas deserves major credit.

On a lighter note, What Bars? lets you compare the shape, drop/rise, and weight of a few dozen different handlebars

Follow-up on medical school rank and narcotic prescriptions

I've had several conversations with fellow docs about the NBER paper from last week showing a relationship between medical school rank and narcotic prescriptions. Naturally, the responses I got were pretty skeptical. A recurrent theme I ran across was that the authors didn't pay enough attention to practice setting. 

1. Higher-ranked medical schools tend to produce more students who eventually land in academia, often at higher-ranked medical schools or residency programs.

2. Because of the culture of those high-performing places, characterized by greater access to subspecialists, a slower pace of practice, the presence of trainees to keep you honest and whatnot, you practice more conservatively and without fear of patients firing you for not giving them narcotic prescriptions.

 3. Perhaps people graduating from lesser-ranked schools end up in private practice, where there is more pressure to write a narcotic prescription to all those patients with back pain, just to keep them from 1) firing you, and 2) telling all their friends and family what a crappy, uncaring doctor you are.

4. So the speculated end result is that people graduating from higher-ranked medical schools end up writing fewer narcotic prescriptions than their peers from lower-ranked schools.

I pointed out to several people that the study took into account specialty and location; the relationship held for people in the same specialty and same county. The investigators pontificated on practice setting (noting that DO graduates often take care of a more rural, white population, for instance). But they didn't control for it. So I held my hands up ¯\_(ツ)_/¯ and moved on with my life.

But then I listened to a segment about it on the Weeds podcast today (start at 1:01:25):

UPDATE: I'm having some trouble embedding the audio, so if you can't get it to play, go here:

Sarah, Ezra, and Matthew made note that the relationship held within the same clinic, so I re-visited the paper. I found this: 

Check the footnote. *slaps forehead*

Check the footnote. *slaps forehead*

So the investigators did account for practice setting, but since it was hidden in a footnote, I missed it. 

The take-home from this paper is still kind of hard to identify. I'm not in favor of necessarily checking the LinkedIn page of every doctor you see to check what med school she went to, but there is clearly some kind of relationship between the culture of medical schools and the prescribing behavior of graduates.

The lower-ranked your doctor's medical school, the more likely he'll write you a narcotic prescription

You read that headline right: investigators in an NBER paper found that docs who went to a lower US News-ranked school are more likely to write narcotic prescriptions, and the ones who write narcotic prescriptions are likely to write for more drugs, depending on the ranking of their school. And lordy, those osteopathic schools:

US News publishes several rankings, in topics from research to primary care to women's health. For this paper, the investigators used the "research" ranking, which is difficult to translate into medical student bedside education. After all, some of my best teachers in med school hadn't published a paper in a decade.

Several other take-home points from this. First, at first glance general practitioners write a ton of narcotic prescriptions; their rate on the y-axis is roughly double the overall physician population's. But when you consider that primary care docs perform well over half of all the visits delivered, that number of narc prescriptions looks less impressive.

Second, the effect size, if you're willing to take a leap and go straight to the idea that the quality of research at your medical school somehow has a causative effect on how many hydrocodone prescriptions you write, is huge. Using Harvard as the index school, the schools in the eighties and nineties have graduating docs writing three times as many prescriptions.

My first thought when I read this was that docs who went to lower-ranked schools may end up on places where they're more compelled to write narcotic prescriptions: places with high poverty, or a large blue-collar workforce, for instance. But the investigators accounted for that, and found that the relationship persisted even within the same county:

I can't help but try to apply this research to myself, even though I'm an endocrinologist and therefore mostly shielded from the narcotic game, and even though I see relatively few patients nowadays. But here we go. I attended the University of Kansas, which is comfortably ensconced in a tie at number 65 on the research list:

Oof. Medical school got a lot more expensive in the last couple decades.

Oof. Medical school got a lot more expensive in the last couple decades.

So where would I live in the narc prescribing graph?

Riiiiiiiiight about there. It's a wonder I'm not a bonafide narcotic prescribing machine. 

Riiiiiiiiight about there. It's a wonder I'm not a bonafide narcotic prescribing machine. 

What's unsaid in this list is that KU has three campuses (two at the time of my training). And it further goes without saying that the training in Wichita, Salina, or Kansas City may have subtle differences that would lead to slightly different physician performance or behavior. Furthermore, it would be interesting to see the research repeated with residency or fellowship training as the independent variable, since those are the years when trainees really fall into a groove of prescribing habits. If I were held to the standard of my internship with a University of Washington program, I'd be compared to the folks at the skinny end of the graph:

Go dawgs.

Go dawgs.

But if my fellowship training at UNC-Chapel Hill were the standard, I'd be in a nice, comfortable happy medium between the narc-crazed sixties and the narc-stingy pre-teens:

The take-home from this isn't that we should all check our doctors' CVs before we go see them, in fear of them hooking us on oxycodone. It's just that schools who inhabit the lower tiers of medical research need to do a better job of teaching narcotic prescribing. 

And obviously, the take-home for patients is to be very, very careful about requesting narcotics for pain. They don't work as well as we think they do, and the potential for harm is huge. 

I found this link, fwiw, via