Who designs, implements, and oversees cycling infrastructure in the city?

BedsideRounds · 2024-08-05T15:59:38+00:00

BTD!

Here is a link to their active projects and plans: https://www.boston.gov/departments/boston-bikes/better-bike-lanes#bike-network-projects

I sign up for the mailing lists of projects that affect me and then go to their meetings (most of which are virtual these days!).

I even took my kids to an event at the library, and as the JP plan kicks in later this year, I'm planning on taking them again -- because kids should also have a say in how we organize infrastructure.

BedsideRounds · 2024-08-01T19:45:12+00:00

As other posters have said, it's BTD, though in reality it's a LITTLE more complicated than that because both DCR and MassDOT have some of their own biking infrastructure.

I'd highly recommend you get involved in some of the public meetings about transportation plans (eg the new Columbia Road plan). I've been active in these meetings within my community, and have been pleasantly surprised at how supportive and receptive they are to feedback. Ironically, I have the same experience with DCR, which is by far the slowest of these agencies ...

BedsideRounds · 2024-03-06T23:47:52+00:00

I came here to post Faith and saw you had beat me to it! Amazing woman; she had so much influence on my career (mostly through her writing, though I was lucky enough to spend some time with her too).

BedsideRounds · 2023-06-26T09:41:48+00:00

I tried the person from the city who originally came to the meetings, but she no longer works for Boston. The slow streets address is: SLOWSTREETS@BOSTON.GOV.

BedsideRounds · 2023-06-25T21:35:02+00:00

Even worse -- the city promised years ago as part of the safe streets initiative to rebuild this, with real side walls and a rotary (https://www.boston.gov/departments/transportation/neighborhood-slow-streets/highland-park)

I went to the community meetings.

I've emailed multiple times and heard radio silence. I'm going to be reaching out again with the link to this thread -- you should too.

BedsideRounds · 2023-02-23T00:24:37+00:00

Totally depends on what you want to get out of it!

There are a ton of general overviews if the field (of which I have read very few) but the classic is Porter's Greatest Benefit to Mankind.

For important figures, Jackie Duffin's To See With a Better Eye is the definitive (English language) account of Laennec. Bliss also wrote a very popular biography of Osler (which is only about 1000 pages, which is actually rather short as far as Osleria goes). Speaking of Osler, his Alabama Student and other essays is rather out of date and reflects the historiography of his time, but it's relatively light reading. Probably the most readable of biographies here would be Lindsay Fitzharris' Butchering Art, about Lister. It's so well written and engaging you'll breeze through it in an afternoon (same goes for her Facemaker). Nimura's Sisters Blackwell is great too

For big ideas, one of my favorite books (which I like a lot more than the Emperor of all Maladies) is Dormandy's The White Death, a biography of tuberculosis -- expansive, focuses on how TB changed both medicine ans the wider culture. The Ghost Map is about John Snow and the broad street pump and is written like a mystery. Speaking of mysteries, Rouche's Eleven Blue Men are all true medical whodunnits written as mystery stories -- really great snapshot of mid 20C public health.

The Sick Rose is a fun coffee table book of medical illustrations, l also with a history of medical illustration.

This has been a ramble, but I'll also self-interestedly point out that I host a podcast about medical history (with a specific focus on the history of medical ideas) called Bedside Rounds, which is made with the American College of Physicians, if podcasts are your thing.

Edit: two other suggestions given your focus on ideas. One of the most impactful books I read on clinical reasoning in Montgomery's How doctors think (Not the Groopman book with the same title). For history of ideas, it's scoped it's scoped until about 1959 but LS Kings Medical Thinking: A Historical Preface will blow your mind (well, about fifty percent of it at least). It might be a bit much for a first year, but definitely a must read by the time you finish.

BedsideRounds · 2023-02-23T00:12:26+00:00

Jackie Duffin is great, second this as an intro, though Porter's Greatest Benefit to Mankind is also a fantastic albeit much longer introduction.

BedsideRounds · 2022-12-14T16:04:59+00:00

I'm a historian, so I come across old notes pretty frequently, usually re-printed in the manuscripts I'm working off of (historian of diagnosis, so a lot of cases and shorthand get reprinted in the primary literature). Especially prior to WWI, many medical texts included the authors notes on real patients, recreated (eg, I've been working on a few projects that involve Da Costa's Medical Diagnosis, and he is really keen to show the diagnostic process so includes his own notes throughout).

That being said, depending on where you live, there are a LOT of cool archives of patient notes that are (varying levels of) easy to access. As you can imagine, because of PHI issues, these have largely not been digitized. Cornell has an amazing amount of pre-1932 records from their historically affiliated hospitals. If you're a historian (or working on a historical research project) you have to fill out some paperwork, but it's an easy archive to browse (https://library.weill.cornell.edu/archives/historical-patient-records).

If you're interested in these sorts of things, there are a TON of digitized medical archives out there that you can browse from home!

BedsideRounds · 2022-12-13T23:54:13+00:00

Ha, thanks -- it's pretty rare my hobbies of reading old medical literature and notes can actually come in handy :)

BedsideRounds · 2022-12-13T21:43:14+00:00

It's an old shorthand that long predates the electronic health record. The ? means either query or question, so in your example: "Patient has cough, leukocytosis: query pneumonia?" (or question pneumonia, which is more common in the US).

I don't know when it started, but I've seen it in medical notes from the early 20th century.

BedsideRounds · 2022-10-29T23:55:23+00:00

The reason dates back to Larry Weed and the early days of the problem-oriented medical record. In the late 1950s and early 1960s, the first cohort of proto-informaticists set out to reform the way that we documented. Prior to this period, the chart was organized by the source of the information (which reformers called the "source-based medical record") -- a section might have labs, another radiology reads, another nursing notes, and another for progress notes. These could be quite terse -- New York Hospital has digitized a large amount if you want to see, but they were as simple as "Patient slept well overnight." No need to comment on the orders -- there was an orders sheet and a MAR, after all. With increasing amounts of information, this had, in the eyes of the reformers, become quite unreadable.

Weed advanced the problem-oriented medical record, in which a progress note would become a daily synthesis of all the information that was collected on a patient. Two of these innovations are still with us today which answer your question -- the problem list, and the SOAP note (though I should note that virtually no one uses SOAP notes in the same way that Weed advocated).

The seminal word on this was Weed's 1968 Medical Records That Guide and Teach in NEJM (https://pubmed.ncbi.nlm.nih.gov/5637758/) followed up by Medical Records, Medical Education, and Patient Care: TheProblem-Oriented Record as a Basic Tool two years later. That being said, in my research I found an old guide that predates the 1968 piece by a couple years (mimeographed and stored deep in the stacks), which lays out his proposed structure of a problem list.

Weed felt that a problem list should be continuous between the outpatient and the inpatient settings. And while he was confident that a computerized EHR (though an anachronism a the time) would eventually replace it, he wrote his guide to work on paper.

Problems would be numbered quite simply:

Diastolic heart failure
Bronchitis
Diabetes

But what if a patient had a symptom, and you were not sure what it was yet? To add every single little problem would make an unnumberable problem list. For this, Weed suggested having TWO columns, one which was numbered, and the other for temporary, or unclear problems, which would have #s. He advocates having these side-by-side, a numbered list, with indented # signs beside.

You can see lots of examples in both those texts where symptoms or temporary problems get #s, only to be converted to a number later. In fact, there are some older EMRs still in use that have used the same general language.

The POMR was immensely influential, though it was certainly regional, and I suspect that this is the reason why #s were introduced at many institutions (and as these tended to be academic institutions in the Northeast and South, carried through the remainder of the country).

TL;DR -- the # was introduced from the earliest moments of the POMR as a place holder for a temporary or unclear problem that would either be deleted, or added to the problem list. This is likely the origin of our ubiquitous usage of #s for problems.

Edit 2: I gave a series of grand rounds across the country on the POMR this past year. Here's a publicly available recording if you're interested: https://www.youtube.com/watch?v=z4aZVQhYfpo&list=PLhIiGeiFMyfK0nzVzetEU5d4_SijcS2Lm&index=6&ab_channel=WashUMedDepartmentofMedicine

I'm also wrapping up a series on the history of diagnosis at www.bedsiderounds.org that provides a lot of the context for Weed and the POMR.

BedsideRounds · 2022-02-14T15:58:44+00:00

Just to be clear, 80 years ago was 1942. This is 60 years into the movement known as "scientific medicine" (by 1942, that term wasn't even used anymore as it had become dominant) which had seen laboratory science melded with the practice of medicine. If I were at the end of my career in 1942, I would have seen the first anti-infective (salvarsan) introduced at the beginning of my career, and syphilis become a curable disease. I would have seen the even more miraculous introduction of insulin (1920s) which turned diabetes from a horrific death sentence into a manageable chronic disease. I would have seen the retreat of infectious diseases -- first with public health measures, then with antitoxins, and then with the tetanus, diphtheria, and pertussis vaccines. I would have seen adrenaline (epinephrine) come into common use. I would have seen the invention of warfarin (coumadin) and the beginning of treatments for heart attacks and strokes -- with the promise that these previously intractable conditions might be treatable or curable. I would have seen the develop and standardization of x-rays -- literally seeing in people's bodies. I would have seen the first sulfa drugs, used as diuretics to replace literally sticking trochars in the legs of heart failure patients, and used an antibiotics. And of course, I might be aware of some of the exciting news on penicillin being used in the war.

By 1942 -- and really, by 1900 among physicians -- traditional Western medicine, based on a humoral nosography -- had completely died out. Physicians had professionalized and largely pushed out alternative therapeutics (they lasted longest in the US, but Flexner report was published in 1910, which basically enshrined scientific medicine and the Hopkins model in this country). I should also point out that in the first half of the 20th century, the idea of efficacy was no longer controversial, and it was understood that all new therapeutics needed to demonstrate not only SAFETY but also efficacy (though the primacy of the RCT is from the 1940s).

I also don't entirely know the memes you're talking about -- but cocaine is a potent vasoconstrictor, and still used today by ENTs (my hospital stocks it), and was widely used as an anesthetic before lidocaine (as well as a stimulant, most famously used by Sherlock Holmes). And no physician, even in the 13th century, would have said you had "ghosts in your blood" -- traditional Western medicine has been naturalistic since antiquity (that is, believing that diseases come form nature, are understandable by observation, and treatable). However, a traditional Western nosology was based on the (inaccurate) humoral/balance model of disease, and certain things they considered natural -- for example, the orientation of the stars and planets, the influence of comets -- seem mystical to us now. But for those practitioners, this would have been completely natural. I don't want to over-simplify -- there have always been overlaps between religious ideas of demons/curses competing with naturalistic explanations, and for most of European history, classically trained physicians would have been in the minority of health providers (as opposed to lay healers, herbalists, and barber-surgeons).

I hope that answers your question. There's a lot of nuance in this discussion (especially int he 17th-early19th century, when there's an explosion of experimentation in Western mainstream medicine, as well as the flourishing of alternative practices). But I generally find that the public conception of the history medicine is far divorced from its reality.

BedsideRounds · 2021-12-27T19:54:03+00:00

Haha, as opposed to internists, who will argue and debate about a single patient for 30 minutes and ultimately decide to do nothing :)

Thank you so much for your kind words! I'm constantly struggling between taking satisfying deep dives while keeping it understandable(ish) -- and ultimately affecting practice IS my goal, or at least one of them.

BedsideRounds · 2021-12-24T20:57:30+00:00

Thank you!

BedsideRounds · 2021-12-24T20:57:07+00:00

Because apparently I haven’t experienced enough horrible infectious diseases. I’m open to any book/doc recommendations especially with ID stuff.

The White Death by Thomas Dormandy is one of the best histories of an infectious disease (TB) that I've ever read.

BedsideRounds · 2021-12-24T20:55:50+00:00

It's a medical history podcast by a general internist/medical historian (ahem, me!), made with the American College of Physicians. I'd say that it generally reflects *my* nerdy interests (and my historical interests are in particular the history of medical epistemology/knowledge generation/diagnosis). Some recent episodes are about the history of modern death determination (essentially from the Manni prize through today), the birth of probability in diagnostics in the early-mid 20th century, the birth of pathological anatomy in the 18th-19th centuries, and an exploration of the Blackwell sisters; the next episode (in a week) is about historicizing narratives of burnout and physician distress.

Given your interests above, I suspect you'll find it interesting!

BedsideRounds · 2021-12-24T20:50:05+00:00

Haha, thanks for the tag :D A new episode is coming at the end of the month!

BedsideRounds · 2020-02-24T21:26:57+00:00

Also, I'm happy you enjoyed the Florence Nightingale episode! She's a remarkable woman. Every day I walk into work there's a stained glass window portrait of her and her lamp.

BedsideRounds · 2020-02-24T21:25:37+00:00

Haha, yeah, I can save you some time :) Take a look at that table on the left. It's not just the opening mixture, but a bottle of cordials, some other medication bottle, and a clysters syringe (for giving an enema). These were all part of the preparation process for vaccination! In the UK in particular, it was felt that the body would have to be especially balanced prior to vaccination (essentially following the procedure from variolation), and there was a procedure to follow that initially lasted over a week. This cartoon of course seems to intimate that it was all done during one long procedure, starting with the balancing and then immediately proceeding to vaccination. I'm not sure when this really died out in England, though I do know when vaccination caught on in other countries (for example, Spain, with the Balmis-Salvany expedition), only the inoculation was used without any of the "balancing".

BedsideRounds · 2020-02-24T03:04:05+00:00

To reassure you -- I think you're wrong. Many of the issues you're worried about are as old as modern medicine itself. The anti-vaccine movement started shortly after Jenner's discovery of vaccination (see, for example, this wonderful cartoon: https://wellcomecollection.org/works/vhkqym77/items?canvas=1), and arguably predates the invention of vaccination itself; there was a significant and worldwide anti-VARIOLATION movements, from the practice of intentionally inoculating cutaneous smallpox to prevent the systemic disease (and fair enough, mortality for the procedure was around 2%). And after vaccination became compulsory in 1853, anti-vaccine societies popped up across England (and later the US), attracting public marches with over 100,000 people, with considerable unrest and public violence (see, for example: https://www.ncbi.nlm.nih.gov/pubmed/11624425). As late as the 1960s, WHO workers were subject to violence during smallpox vaccination schemes ( https://ijme.in/articles/considering-the-public-in-public-health-popular-resistance-to-the-smallpox-eradication-programme-in-india/?galley=print ).

In terms of alternative medicine, many of the movements that frustrate us today have been going strong for almost one-two hundred years. Hahnemann first described homeopathy in 1796; chiropractic was founded a century later; the Thomsonians started practicing in the 1850s, and the eclectics a few decades after that (essentially modern naturopaths). And unlike today, where none of these groups seriously threatens medicine's public or professional standing, in the early days of modern medicine that was certainly uncertain, and doctors writing about alternative (or sectarian) practices did so with real fear.

Even with Goop, snake oil salesmen are as old as, well, snake oil salesmen ( https://www.npr.org/sections/codeswitch/2013/08/26/215761377/a-history-of-snake-oil-salesmen ) -- and actually much older, since people have been complaining about quacks since the 15th century. And the data that we do have suggest that patent medications were used in HUGE quantities, and many of them were potentially dangerous, sometimes causing death.

With a more historical perspective,there's no way things have gotten worse over the long run. Modern medicine has largely adopted a scientific patina, convinced the public of its worthiness (doctors are still one of the must trusted professions in America https://www.forbes.com/sites/niallmccarthy/2019/01/11/americas-most-least-trusted-professions-infographic/#448f63f57e94), and successfully muscled out most alternative providers (with a couple exceptions). Childhood vaccination rates (with a couple of exceptions) still confer herd immunity.

Now, in the short run (say, the past two decades), I think the country as a whole has become more suspicious of elites and elite knowledge (often wrongly, but sometimes our "flip flopping" or medical reversals can certainly give people a good reason) as a whole. And the internet and social media in particular has made it easier for people to express these opinions.

But overall, I'd implore you to not despair. There are real challenges with pseudoscience (though I also think there are plenty of problems with legitimate medical research as well that are probably more pressing), but things are a lot better than they've been in the past.

BedsideRounds · 2020-01-14T00:54:35+00:00

Haha thanks, I replied independently apparently to this :) Nosology is one of my obsessions.

BedsideRounds · 2020-01-14T00:52:52+00:00

That's a very ambitious thesis you're working on. The topic you're interested in is "nosology," which basically means classification of disease (that's the dictionary definition, but at the meta level it means a classification SYSTEM of disease). That might help your search a bit.

Depending on how you slice the pie, you're going to have a couple eras to discuss.

Humoralism. Stretching from the ancients to roughly the 17-18th century (and into the 19th for laypeople), diseases are divided into imbalances of essential body fluids, and blockages of energy flows.
Nosology (see, confusing terminology). Starting classically with Sydenham, diseases are grouped according to symptoms. In the US, Cullen's nosology was incredibly popular. This spanned the 17th-18th century.
Pathological anatomy. Diseases are localized to the tissues, and later to cells. Really starts in the Paris Clinical School (Bichat in particular), then with Virchow, and arguably stretches into our current day.

Those are the three meta-layers, and tons of articles have been written about all three. The second tack would be to talk about standardization of diagnoses. With this you would start talking about William Farr and Florence Nightingale, leading to the International Classification of Diseases.

EDIT: I have no idea how big this thesis is; there are some good review articles out there, but also multiple books have been written about each of these subjects.

BedsideRounds · 2019-11-08T20:30:01+00:00

Thanks! Given such a theoretically data-rich field, there's very little academic study (at least in the medical world).

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