I am sorry to go on like this Winston, but let’s face it; we are all concerned with our image. It is a basic human trait. Doctors are not immune. When I last wrote, my feelings were running high regarding the reports all doctors are responsible for completing. I stressed the importance of topic or idea segmentation to improve communication, but good communication requires much more.
All reports need more than just the appropriate formatting. What do we include? Of course the type of report dictates its contents. Test interpretation results, by their nature, report the data generated. Hopefully, these are skillfully separated into pertinent presentations or discussions of individual parameters. For the tests performed, a summation of the results should follow with any appropriate, suggested next steps.
Most medical reports are the results of our direct interaction with patients. Histories, physicals, consultations, progress notes, surgical reports and summaries of clinical notes are examples. While these reports are segmented in a long defined manner, they are often subject to abuses of several easily identifiable types.
The segmentation of doctors’ reports summarizing patient interactions is over 50 years old. New physicians are trained to segment their reports. Traditionally, such reports are divided into the chief complaint, history of the present illness, past medical history, medications, allergies, system review, physical examination, available test data, analysis, impression of the potential diagnosis and the plan for the patient’s future. It seems a lot, and it is, but it is what we do. A great deal must be accomplished in the time we allocate to meet with the patient.
Changes in the notes documenting patient interactions have been suggested in the past few decades; most notably the problem oriented segmentation of such reports. Segmenting reports to specific problems has been suggested to improve the identification and analysis of each problem. These approaches have has varying degrees of acceptance and have definitely improved communications of information. But abuses creating reports continue.
In reports, the all-encompassing segment on analysis is too frequently a single paragraph where the facts of the case are reviewed, an appropriate diagnosis assessed and recommendations presented. When prepared by a thorough physician, this portion of the report will be subdivided as appropriate for the facts of the case to discuss each individual item. The specific recommendations will be provided separately.
There are common techniques used in creating these reports that stand out as inappropriate when overused. I refer to the users of these techniques as the ‘filler’, the ‘ black and white,’ and the ‘obfuscator.’
A ‘filler’ delights in computer generated reports. At the appropriate place in his report, the ‘filler’ will copy and paste entire test results, consults, radiology or laboratory reports into their own. Another common filler technique is to insert a computer generated medical list completed by a nurse or assistant that is so easy to do and so official looking. All the while, to the educated eye, the presentation is screaming that they couldn’t identify what was important from the inserted report so they just included it all in their own. You can almost hear them say, “Look at my impressive comprehensive report.” Certainly the lengths of the reports are impressive. I recently received a consultation on one of my patients where the doctor used the filler technique to the maximum. The dictated computer report was 16 pages long.
The person using the ‘black and white’ approach is the binary report creator: lots of data and no nuances. The ‘black and white’s’ history will include yes and no answers for symptoms, give number results for standard questionnaires and closely follow current medical guidelines. This is particularly true for any therapeutic recommendations on the reports.
The ‘obfuscator’ will fill their assessments with facts and lengthy discussions of potential diseases and conditions, while not providing a consensus on issues of concern to the patient. Could it be they do not have an opinion, do not have a clue or just do not want to express an assessment of the patient’s issues? Maybe it is a “look how smart I am” assessment.
All of us use these techniques to some degree in our reports. Most medical reports tend to be repetitious and dull, but like a story, they can benefit from a logical progression in the presentation and understandable writing. Brevity, to a point, leads to clarity of communication.
I am sorry to go on like this Winston, but let’s face it; we are all concerned with our image. It is a basic human trait. Doctors are not immune. When I last wrote, my feelings were running high regarding the reports all doctors are responsible for completing. I stressed the importance of topic or idea segmentation to improve communication, but good communication requires much more.
All reports need more than just the appropriate formatting. What do we include? Of course the type of report dictates its contents. Test interpretation results, by their nature, report the data generated. Hopefully, these are skillfully separated into pertinent presentations or discussions of individual parameters. For the tests performed, a summation of the results should follow with any appropriate, suggested next steps.
Most medical reports are the results of our direct interaction with patients. Histories, physicals, consultations, progress notes, surgical reports and summaries of clinical notes are examples. While these reports are segmented in a long defined manner, they are often subject to abuses of several easily identifiable types.
The segmentation of doctors’ reports summarizing patient interactions is over 50 years old. New physicians are trained to segment their reports. Traditionally, such reports are divided into the chief complaint, history of the present illness, past medical history, medications, allergies, system review, physical examination, available test data, analysis, impression of the potential diagnosis and the plan for the patient’s future. It seems a lot, and it is, but it is what we do. A great deal must be accomplished in the time we allocate to meet with the patient.
Changes in the notes documenting patient interactions have been suggested in the past few decades; most notably the problem oriented segmentation of such reports. Segmenting reports to specific problems has been suggested to improve the identification and analysis of each problem. These approaches have has varying degrees of acceptance and have definitely improved communications of information. But abuses creating reports continue.
In reports, the all-encompassing segment on analysis is too frequently a single paragraph where the facts of the case are reviewed, an appropriate diagnosis assessed and recommendations presented. When prepared by a thorough physician, this portion of the report will be subdivided as appropriate for the facts of the case to discuss each individual item. The specific recommendations will be provided separately.
There are common techniques used in creating these reports that stand out as inappropriate when overused. I refer to the users of these techniques as the ‘filler’, the ‘ black and white,’ and the ‘obfuscator.’
A ‘filler’ delights in computer generated reports. At the appropriate place in his report, the ‘filler’ will copy and paste entire test results, consults, radiology or laboratory reports into their own. Another common filler technique is to insert a computer generated medical list completed by a nurse or assistant that is so easy to do and so official looking. All the while, to the educated eye, the presentation is screaming that they couldn’t identify what was important from the inserted report so they just included it all in their own. You can almost hear them say, “Look at my impressive comprehensive report.” Certainly the lengths of the reports are impressive. I recently received a consultation on one of my patients where the doctor used the filler technique to the maximum. The dictated computer report was 16 pages long.
The person using the ‘black and white’ approach is the binary report creator: lots of data and no nuances. The ‘black and white’s’ history will include yes and no answers for symptoms, give number results for standard questionnaires and closely follow current medical guidelines. This is particularly true for any therapeutic recommendations on the reports.
The ‘obfuscator’ will fill their assessments with facts and lengthy discussions of potential diseases and conditions, while not providing a consensus on issues of concern to the patient. Could it be they do not have an opinion, do not have a clue or just do not want to express an assessment of the patient’s issues? Maybe it is a “look how smart I am” assessment.
All of us use these techniques to some degree in our reports. Most medical reports tend to be repetitious and dull, but like a story, they can benefit from a logical progression in the presentation and understandable writing. Brevity, to a point, leads to clarity of communication.
Yes Winston, I am very opinionated about writing medical reports. Any document in medicine has a purpose for being created. Those purposes have evolved as well as the manner in which the information is generated. The types of reports have multiplied. My obsession with the creation of reports occurred as a result of a coping mechanism during my career’s evolution.
Once trained as a medical doctor, I was slow to make a decision on what to do with my career. My basic introduction to medicine had, by my own choice, been one of exposing myself to multiple fields. Once I selected internal medicine, it was shortly thereafter that I decided to concentrate my work in the field of lung diseases. With good fortune, ambition and fate, a short five years later I found myself in charge of the Pulmonary Function Laboratory at Walter Reed Army Medical Center.
My post graduate medical training at county, university, veteran and military institutions was designed to train me to be a medical doctor in the specialty of lung diseases. My knowledge of physiology was good for a pulmonologist, but almost superficial for my added job responsibilities. I set a goal to learn the field at a deeper level and was able to progress greatly over the years while I held that position.
On the practical side, tests were being done daily. Doctors from numerous specialties and clinics were ordering tests of lung functions and a report had to be generated for each. It was my responsibility to oversee the creation and quality of a large number of those reports. After leaving the military, I had similar responsibilities at a cardio-pulmonary specialty hospital for an additional 16 years. During the following 20 years, my reports were limited to interpreting sleep tests. Throughout my career, I have been responsible for an extremely large number of medical test reports.
In those early years I was progressively learning more about the details of my work. In my training and previous experience, I was exposed to reports which consisted of consolidated paragraphs with a signature at the end. As I learned more about the physiological aspects of our studies, I would segment portions of my reports to review each one in more detail. Over time, my reports became multiple, small descriptive paragraphs with many sections. At the end, I would summarize the results briefly.
As my knowledge increased, the report format evolved. I was separately analyzing and reporting each group of measured parameters. By doing so, their relationships were clearer and abnormal parameters were more readily identified. Constructing the report by simply separating each parameter analyzed, insured that the interpreting physician reviewed all the parameters and improved the communication of important results to the requesting physician.
Now, after 50 years working in this field, I am struck by how many respected doctors and physicians do not use such a format. Their single paragraph reports appear congested and chaotic when read, making it difficult to identify important numbers and features.
And yes Winston, our clinical reports, consults, progress notes and similar communications benefit from clear thinking and organization. It does not matter if the report is for other physicians, for your future reference, for insurance review or for the patients; a compartmental organized report demonstrates a thorough analytical analysis.
A medical report is a window on the organization and thinking of the professional who prepares it. A segmented, organized report communicates better and ensures attention is paid to each aspect of the subject. Continuous paragraphs of summarized facts suggest a chaotic, unorganized mind.
Yes, I am aware of the national TV ads for the hypoglossal nerve stimulator for Obstructive Sleep Apnea. Earlier this year I prepared an information sheet on the subject. I will add it to this letter.
It is a second line therapy and works for a limited sub group of patients with Obstructive Sleep Apnea. CPAP is far more successful in controlling sleep apnea.
It primarily indicated for those who have failed CPAP. Unfortunately, there is no accepted definition what constitutes failing CPAP therapy. Reasons for stopping CPAP are many and sometimes complex. I have been intrigued by the issues that cause a patient to discontinue or be unable to use it and will add more on the subject on another occasion.
RGH 29.112 Sept 2023
Hypoglossal Nerve Stimulator (Inspire) May 2023
Device
“Inspire” is a device that senses an obstructive apneas and then sends a signal to the hypoglossal nerve through a wire. It activates the nerve, which causes the base of the tongue to move forward. The device, wires that sense the apnea and the wire from the device to the nerve are implanted under the skin. It is remotely controlled.
Candidates / Indications (Varies from FDA, Insurance and Medical societies)
Its primary indication for use is failure to be able to use CPAP. Problems with insomnia, restless legs or other sleep disorders must be controlled before being considered for Inspire. The obstructive apnea rating (apnea hypopnea index or AHI) on diagnostic testing should be between 15 and 65. Weight should be a BMI of under 32. BMI varies by height. For a 5’11” person a BMI of 32 is 225 lbs. Some insurances will allow a slightly higher BMIs. You must be older than 18 years of age. It is indicated when apnea obstruction occurs at the base of the tongue.
Cost
A rough estimate of the cost of the device, its implantation, testing and physician visits will be between forty and fifty thousand dollars.
Insurance Coverage
“Inspire” is a second line therapy and insurance companies only approve those who have failed other forms of treatment.
Process
If you meet the criteria for the device, you will be evaluated to see if the device will correct your apnea. The evaluation steps include a facility based sleep study, a sedated endoscopy of your upper airway and provider visits. Many will not fit the type of obstruction that the device will correct and will not be candidates.
If you are a candidate, then implantation, physician review and repeat testing to insure appropriate function will be required. These steps include surgery, a post activation facility based sleep study and provider visits.
The overall time from initial consideration to successful activation is about 5 to 6 months. Medical follow up currently is recommended every 6 to 12 months.
Results After Implantation
The goals of treating obstructive apnea are to reduce the AHI to less than 5 and to improve the quality of sleep. CPAP will achieve AHIs < 5 a very high percentage of the time. The Inspire device will reduce the AHI to less than 5 in approximately 50% of recipients. The rest will have a reduction in their AHIs but not to normal levels. Standard therapies such as CPAP may still be needed.
Other Considerations
“Inspire” is a man-made product with batteries. Wires can break. Wires cannot easily be removed. Batteries or new wires may be required in the future. There are a limited number of experienced physicians available to deal with the device. Other devices may still be needed and recommended to control your apnea condition.
It is inspiring to learn of your interest in sleep apnea. I will be happy to do my best to simplify, clarify and muddy your understanding of the AHI. AHI stands for Apnea Hypopnea Index. It is the standard for defining the presence of significant sleep disordered breathing and the condition of Obstructive Sleep Apnea.
It started long ago in the history of sleep medicine. In actual time, it was just 40-50 years ago. Physicians noted breathing problems during sleep. Over a decade or so it was clear from investigations that the problem was one of blockage of the airway in the throat during sleep. The blockage resulted in less air getting in and out of the lungs. The blood oxygen levels would drop, while the carbon dioxide level would increase. The sleeper responded with increased breathing efforts, which opened the airway. By the 1980’s, testing for these variables had evolved from investigative to the clinical practice level.
The AHI is the fundamental measurement for obstructive and central types of sleep disordered breathing. The A stands for apnea, or absence of breath. The H stands for hypopnea, or a critical reduction of airflow causing the same physiologic changes that the apnea produces. The I stands for index but actually represents a measurement of rate, the number of apneas and hypopneas per hour of sleep. The apnea as used in AHI represents the absences of air movement at the nose and mouth. Respiratory efforts by the diaphragm and chest may or may not be present. These are the simple definitions.
Clinicians and physiologists have much more specific definitions. Our definitions include the magnitude and duration of physiologic changes, as well as the types of equipment used for the measurements and the frequency of the changes. It should not surprise you that significant debate continues about the details of those changes. Opinions differ. Unfortunately, the efficient computerized testing systems we utilize, ease the burden of testing large numbers of people, but limit the ability to look at multiple variations of potential changes in definitions.
In this country, current technical definitions and the threshold for diagnosing the medical condition of apnea are cemented in place by the regulatory bodies; Medicare and commercial insurance companies set the standards. While the definitions set are supported by reported evidence, the standards are far from perfect and will not change soon.
The AHI is the gold standard for the definition of obstructive and central sleep apnea. Five events, apneas and or hypopneas, per hour of sleep meet diagnostic level for apnea. The level of 5 events was arrived at arbitrarily, based on early work in the field. Although accepted by those regulating groups, the actual minimal AHI needed to establish the diagnosis is not really known.
It is known that the higher the AHI the greater the risk for long-term medical problems. When a sleep study is complete and the AHI criteria for apnea is met, it is described as mild (5-15 events}, moderate (15-30 events) or severe (>30 events) apnea. The adjectives (mild, moderate and severe) represent the long-term risk for medical complications, not how a person feels. These separations into different severities of apnea, represent more tradition than science. In fact, the AHI is only a good predictor of severity for long-term complications at high levels (more complications) and very low levels (less complications). In the decades since these definitions for the onset and the severity of the disease were adopted, much research has been done. It appears that further definitions of these obstructive events would improve the accuracy of our diagnoses and the predictability of the future for the patient.
The current definitions have served time well. As a clinical tool, the AHI has proven to be extremely useful. It is accepted worldwide. Tremendous improvement in diagnosis and therapy for sleep apnea has occurred utilizing these measurements. There are limitations, however. This is specifically true when scientific studies of the condition are performed.
The role of low oxygen levels has been investigated more than any other factor. You will recall oxygen is measured on testing by the noninvasive transcutaneous method that reports oxygen saturations. Our technical definitions include a certain drop in oxygen saturation that is caused by the interruption to the airflow during the breathing events. The roles of the duration, severity and timing of the drop of oxygen in the sleep pattern as well as the total time spent at certain levels of oxygen desaturation are not known. Studies reviewing low oxygen levels during apnea suggest that the time spent with saturations of less than 90% together with the AHI is more accurate in predicting long-term medical complications than the AHI alone.
Another major factor not addressed with current testing is the use of a rate measurement for diagnostic purposes. A rate does not measure total exposure to apnea events. That is dependent on actual sleep time. An easy example is the difference of someone sleeping six hours versus another person who sleeps nine hours. They both can have the same AHI, but the person sleeping nine hours will be exposed to 50% more apnea events than the person who only sleeps six. The importance of exposure has not been studied at all.
The events we measure, apneas and hypopneas, do not occur uniformly throughout a night of sleep. The event frequency can change based upon body position. They can occur more while sleeping on the back verses the stomach. The events can occur more in REM sleep than in slow wave or Non-REM sleep. Research into the effects of these variables as predictors of long-term outcomes is limited.
Well, I believe it is time to close. The AHI is an immensely useful tool in the diagnosis and treatment of sleep apnea. It is the gold standard measurement for the diagnosis of sleep apnea. It needs to be improved upon and will be. As you will learn throughout your career, medicine changes slowly. Opinions are more rigid in medicine and in science than most believe. So, keep an open mind. This, like all things medical, will change with time.
Thank you for sharing your friend’s newspaper opinion piece on the current epidemic with me. Congratulations to her on her writing success.
She is very emotional in her response, which is not unexpected for a non-medical person. Unfortunately she mixes politics with the natural history of infectious disease.
Her thinking is complicated by not having the training to have a full grasp of the numbers being reported about the epidemic. The numbers of epidemiology are complicated, confusing and often incomplete or not timely. As a professional, I have been having a difficulty sorting through what information is being reported. All of which is complicated by the frequent news headlines and incomplete data being presented on television, radio, newspapers and Internet.
Most people are emotional about the subject and that certainly includes those in the news business, government officials and surprisingly, some medical professionals. Many are not objective. Many have secondary interest. All know what is wrong, but they are short on fixes.
This infection will go on just like the flu does. The infection, despite all measures will spread though the population. It will not be stopped by social distancing, mask, hand sanitizers, or other non-treatment or non-immunization techniques. Those things may help you to avoid being one of the infected ones, but people will be people and the virus will spread. It will be stopped when enough people have been infected so that it becomes difficult for it to be spread, since most have developed immunity from prior infection (herd immunity). Or, it will be stopped when a good treatment is identified or an immunization developed.
Us old timers are at higher risk, as are those who have underlying conditions, most likely including untreated Obstructive Sleep Apnea. So Winston, use your CPAP!!! Your youth is a good, but not perfect, fortress and defense against this bug. It is best not to get it. Do what you can to protect yourself.
As the number of test performed increases, the number of cases of infection will increase. What you should watch is the number of patients with the virus hospitalized, the number of cases per capita, and the percent of tested patients who are positive for the virus. I would not follow the percentage of hospital beds used or beds available since hospital administrators, public health administrators, press and politicians can manipulate the percentages for secondary gain.
I differ in my opinion from your friend. This country’s response to the virus has been the best in the world with a few notable exceptions mostly in New York. A few of the major reasons would include:
More testing
Less dying
More secondary support – supplies, test, ventilators, vaccine work, emergency hospital beds, etc
More openness in data reporting
As a physician, there is no country in the world that I would rather be in during this, or for that matter, any pandemic. Mistakes have been made and more will be made, but those mistakes do not change my opinion of the country’s response.
The Wuhan virus is a mean respiratory bug that has the potential for serious illness and death. It is meaner than the flu, but only a little more so. Most people infected with the virus do not need hospitalization and many, if not the majority, do not even know that they were infected.
So Master Winston, keep a safe distance, wear you mask around others, and wash those hand. As they might say in the military, keep you head down and move fast. And of course, use your CPAP. This will pass.
Yes, I will try to answer your question. I understand your training has led you to believe that healthcare is a right. Why, you ask, did I pause before saying, “It’s not that simple. But if it were, the answer would have to be no.”
Consider first what is meant by the term, healthcare. Like most words, it is likely interpreted differently by almost everyone. The views will run from having clean water, a family doctor available for medical problems to those that would include anything to do with a person’s health. These are widely divergent categories of products and services based on different delivery systems and business models. It is almost impossible to discuss a ‘right to healthcare’ without understanding everything that is included in the discussion – the components of healthcare.
It is not the only term that needs to be defined. What do the promoters mean by the word, right? Maybe it is best to consider its meaning first.
When right is used as a noun, as it is in a ‘right to healthcare,’ common definitions according to Merriam-Webster include: qualities of moral correctness or moral propriety; something to which someone has a just claim; something to which someone may claim as their due; and, a cause of truth or justness. The proponents of a ‘right to healthcare’ usually mean the second or third of these definitions, a just claim or their due.
Healthcare has only one definition listed. Merriam-Webster defines it as ‘efforts to maintain or restore physical, mental or emotional well-being especially by trained or licensed professionals.’ Practically speaking, this definition would essentially cover all aspects of personal and public health. It would include the fields of preventive medicine, public health and personal medical care along with institutional medical care. Each of these fields is unique in how it is currently organized and delivered while sharing some common features. The shared features include the need for physical plants of operation, equipment to provide the services, support staff to carry out the services and a professional staff. These factors are needed in varying quantities and of different types for each of these fields of endeavors.
For clearer understanding we need to look more specifically at the services included in healthcare. These would include public health services, preventive medicine services (public or individual), individual’s urgent and chronic medical care, and institutional care (hospitalization and similar). We need to consider all the services that might be determined to be healthcare.
Public health is widely practiced throughout most local communities in our country. Public health services maintain and ensure clean water and adequate sewers, track communicable diseases and advise the population about those diseases. Their services, physical plant, equipment, staff and professionals are paid for and employed by government units. They are paid for by taxes and by fees for water and sewer services. For the majority of urban areas in this country, these health services are for all practical purposes already a right provided by the government. Certainly, there are exceptions for rural and smaller communities, but most citizens already enjoy public health as a government service. Paid for by their taxes.
Preventive medical services are currently provided by both government operations and individual medical providers. Examples of government services include monitoring of new and current medications for problems, providing recommendations for vaccinations, and monitoring of medical devices. Again, the facilities, staff, equipment and professionals are supplied and paid for by the government taxes and fees usually paid by the businesses for the service.
At a more personal level, physicians, providers, healthcare businesses and employers (insurance companies, medical practices, clinics, hospitals and businesses) may provide guidance and assistance on preventive medical measures that an individual needs. These businesses provide the physical plant, staff, equipment and professional organization needed. The expense for these services is recouped through fees, insurance payment, employers and other methods. The healthcare provided at this level is the first at which an individual may be responsible for all or part of the cost of the services.
The next component leads further into individual responsibility, providing an individual’s urgent and ongoing medical care. This is the form of healthcare we are familiar with and what is most often thought of when discussing ‘a right to healthcare’. In our country’s history, these services have been provided by individual professionals who own and operate their own businesses. Recent change in economics, economic policy and legal structures of medical businesses has led to more large organizations (hospitals and insurance companies) owning more of these types of businesses. In these operations in any form, the expenses – from cotton swabs to physician income – are paid for by individuals, either directly or through surrogates (employers, insurances or others).
An individual’s surrogates are the primary payees for the institutional care portion of our healthcare delivery system. This portion of healthcare, hospitalization primarily, is where the largest cost (facilities, equipment, staff and professionals) occurs. Again, most of the cost is paid for by individuals or their surrogates.
In these areas of healthcare where the individual is mostly responsible for the cost of the service, there is one major group of individuals that is not responsible directly. Those are individuals on government insurance such as Medicare. In Medicare and other government plans, a person may have a markedly reduced or no exposure to the direct cost of the services. Those who argue for a ‘right to healthcare” would like all services for all citizens to be paid for by the government.
My comments have gone on long enough so I will save my additional thoughts for a future letter. I would add in closing what I think summarizes the whole question.
A ‘right to healthcare’ should mean everyone has access to and freedom to decide how to obtain their healthcare. At present, I would argue that it is already the case, but it is disappearing rapidly. In reality, the discussion is not about freedom to get healthcare, but getting healthcare for free.
Yes, I received your note. I apologize for my delay in setting this up. Your idea to post these so you can keep track of them was a good one. I will select a few of my past notes and post them here for you.
I found the first of my letters. We will start with it.
RGH August 1, 2022
Winston
It will seem strange to receive this from me, as we have not talk seriously except on rare occasions. I have been a family friend beginning decades before your birth. Now, you are away from home with a new wife, pursuing a medical education. A calling I have followed for more decades than I have known your family. It is a difficult master with challenging hurtles and responsibilities that each of us experience differently.
Our interactions are few and infrequent, intermingled with talk from family and friends on special occasions and holidays. Meaningful thoughts don’t seem to reach across the table or room. Medical or should I say professional conversations often by there nature are inappropriate in those situations. So, I have returned to the written word to communicate my beliefs, attitudes and some would say prejudices developed over my 50 years in medicine as first a doctor and now as a physician.
Do not be surprised by the letters or the subjects. You may respond with your questions and thoughts, but do not feel obliged. They represent an attempt to pass to you some little perspective on your chosen profession.
Ref: Rat Journals, Sturgeon’s Law and the Hawkins’ Corollary
Yes, I know I have mentioned Hawkins’ Law to you many times. And yes, you need to know what I mean. I will answer that for you with a little background. Have you heard of Sturgeon’s Law?
Sturgeon’s Law “Ninety percent of everything is crap”
Corollary 1: “The existence of immense quantities of trash in science fiction is admitted and it is regrettable: but it is no more unnatural than the existence of trash anywhere.”
Corollary 2: “The best science fiction is as good as the best fiction in any field.”
Sturgeon was, early in his career, a science fiction writer and an editor of a science fiction magazine. He received intense criticism for the quality of writing in science fiction and his response was what was to become known as Sturgeon’s Law. References point out that others have had similar insights.
Voltaire in a short story, “… but in all times, in all countries, and in all genres, the bad abounds, and the good is rare.”
Rudyard Kipling in the ‘The Light that Failed’, “Four-fifths of everybody’s work must be bad. But the remnant is worth the trouble for its own sake.”
George Orwell in ‘Confessions of a book reviewer’, ‘In much more than nine cases out of ten, the only objectively truthful criticism would be “ This book is worthless”.’
I initially encountered Joseph Hawkins, M.D, when I was first year resident in internal medicine at the University of Oklahoma. At that time, Joe was the Consultant to the Army Surgeon General who oversaw assignments of duty stations for doctors going on active duty. I was a recent draftee about to enter the US Army.
Someone I knew in the Army had given me his name and the number of his office in Washington. I called him about my potential assignment on entering the Army, hoping not to go to Vietnam. When I advised him that I would be a partially trained internal medicine specialist when I went on active duty and suggested I might be valuable at a major hospital, he laughed. Joe gave me some sage advice. He said I should consider entering an Army medical residency program to complete my training. Probably the best advice I have ever been offered in my entire medical career.
Over a decade later, Joe and I found ourselves in Phoenix, in adjacent hospitals, in the same specialty – Pulmonary and Critical Care Medicine. He was the director of fellowship training for our specialty at a regional teaching hospital and I was the director of the Pulmonary, Sleep and Critical Care services, at a hospital that helped with their training programs. We shared training fellows and clinical experiences till his retirement.
At our monthly journal club meetings, Joe would frequently ask. “What does the Rat journal have in it this month?” One of our leading specialty journals had become focused on basic science research, departing from its decades long tradition of clinical based reporting. For a time it frequently involved rats. The journal became known to our group as the Rat Journal. Practically all of its publications had little to do with the practice of medicine and most had little to do with significant advancements in sciences.
I believe the growing volume of medical literature is, and possible always has been, of little practical or insight value. I would call it Hawkins’ Law or the Hawkins’ corollary to Sturgeon’s Law: Ninety percent of medical research is crap.
As physicians, it is our burden and task to sort the information overload and find the 10%. A firm foundation is needed in what is generally accepted knowledge, (knowing the current basic understanding of the medical disease, issue or problem) to judge how a new piece of information alters, changes or discounts our basic understanding. Remember that the understanding of all human diseases will be further defined, changed, or altered during your medical career.
