Monthly Archives: March 2013

You can call me The Doctor

tl;dr – I’ve killed the 0.1-0.25% occurrence rate line in UpToDate. Your doctor can verify the change in the section “Vasectomy and other vasal occlusion techniques for male contraception”. The newly revised number is simply : 2% for severe life quality affecting pain. Your doctor may not be aware of this as the change is not listed yet in the changelog that UpToDate provides users.

Edit: UpToDate has no intention of making this more visible.

No, it is not an oversight that the change is not in What’s new. Only selected topic updates will appear there, and generally those that represent significant alterations in treatment-related decisions.

So I had my surgery on of all day’s – Valentine’s day.

As they wheeled me into the operating room, I told one of the nurses that I was hoping an entirely different kind of valentine’s day. In a southern drawl, she said:

You just tell the boys back home that you were naked with three cute brunettes.

So, it’s been 3 weeks post-op and I’m happy to say that it looks like surgery was successful.   There’s still another 3 or 4 more months to go to be completely sure, but right now – things look really really awesome.

That would be enough for me to do the happy dance, but the thing that’s had me grinning from ear to ear since Friday?

I got my edit to UpToDate accepted.  It’s a small tiny edit, but it’s one that fixes an error that’s been perpetuated for about 30 years near as I can tell.

For those that are unaware, UpToDate is a massively deployed clinician’s database used by doctors around the world as a decision support resource. It’s used by 700,000 doctors globally. That’s a lot.  When I first started posting up on Reddit a couple months back, a redditor pointed me at the numbers in UpToDate as a reference that all doctors are going to use as a point of reference.

Before March 1, 2013, you would have found this in UpToDate:

The post-vasectomy pain syndrome is distinct from post-procedure pain, however, there is some controversy regarding its definition, and therefore prevalence. Rates for the post-vasectomy pain syndrome have been reported as 0.1 to 0.25 percent [41,42]. However, surveys have found that “troublesome” post-vasectomy pain is reported by as many as 15 percent of men, with pain severe enough to impact quality of life in 2 percent; survey respondents, however, may not have been representative of all post-vasectomy men [43,44].

That bold section is gone now.  Without it, it reads quite differently.  It looks like this now:

Historically, rates for the post-vasectomy pain syndrome have been reported as very low (<1 percent). However, surveys have found that the incidence of “troublesome” post-vasectomy pain is reported by about 15 percent of men, with pain severe enough to impact quality of life in 2 percent; survey respondents, however, may not have been representative of all post-vasectomy men [40,41].

I’m annoyed still that the <1% number shows up at all.  The two works cited by UpToDate in the newly revised text only show data that support the 15% occurrence rate.  You can read it yourself in Manikandan 2004 and McMahon 1992.

UpToDate has this to say on the matter:

Incidence reporting in the literature varies widely, The lower incidence figures reflect older literature, with the more contemporary data suggesting that the incidence of this problem is probably higher.

(emphasis is mine)

This weirdly reminds me of watching traders dissect the wording of the Fed every time a rate announcement is made in an attempt to find the ‘true’ meaning of the wording. I think my chinese ancestors called this “reading tea leaves”.  But I digress.

The snarky part of me wishes they’d reword the first sentence to “Historically – we couldn’t bother to do division properly, or read anything.”.  Just before I left for Winter Haven, I ended up pulling the articles cited in UpToDate.  What I found was pretty bad. You can see the full details here.

It turns out – the M in MD is not for math.  Of the two citations, one was a completely different topic, and the JAMA study from 1984 never made any claim that supported the 0.1 to 0.25% occurrence rate.  In fact, the study in 1984 explicitly shows 187 patients out of 10,590 had chronic pain.

I guess calculating 187/10,590 is a really hard thing to do.

The literature does vary widely, but as far as I can tell – there’s still no evidence to support the historical figures.   We can argue about the strength and validity of particular studies, but you don’t get to argue about numbers that just aren’t there.

As they say:  Every man is entitled to his own opinion, but not his own facts.

This kind of mistake happens all the time.  If you haven’t been following the mess going on in cancer research or the debacle that’s going on in academia with respect to peer review – it’s a disaster.   Statistical errors happen all the time now – it’s estimated that it’s happening ~15% of the time.

That though is a rant for another day.  Today – I’m celebrating my small victory.

On a side note – every email I ever got from UpToDate was addressed to “Dr. Ng”.  If anyone else wants to call me “The Doctor” – I’m totally cool with that.

Next post – something entirely nerdy.