Wednesday, July 30, 2008

Into The Night... Call




Since I have night call tonight, I found the following post (registration required) to be appropriate:
Below is a list of things that will help get you through the night:

1. Toothbrush: Nothing is worse than presenting a morning case with bad breath. Don't fret over toothpaste, as you can often find small tubes that are provided to patients. Be sure to make friends with your nurse, as he or she will gladly direct you to the stash of patient hygiene products (including toothbrushes if you forgot one).

2. Study guide: It never hurts to bring along a review or question book when you take overnight call. You may find yourself with hours and hours of spare time to study.

3. Medications: If you take scheduled medications, do not forget to bring an extra supply. You may have been told that you will be home post-call by noon, but anticipate delays and avoid feeling sick because you have skipped a dose.

4. Dollar bills: I cannot stress this enough. Most hospital cafeterias close by midnight. With an erratic schedule, you may not have time to grab dinner. Therefore, your only option may be vending machines which, as you know, only take change or dollar bills. There is nothing better than a Snickers bar and Mountain Dew at 3 am!

5. Phone charger: Hospitals get poor mobile phone reception. Bring your charger so that you can focus on dying patients, not your dying cell phone.

6. Snacks: If you are health-conscious or enjoy frequent small, healthy meals, then don't forget to pack something that you will enjoy during your shift.

7. Backpack: It goes without saying that you will need a bag of some kind. My advice is to choose a subdued, dark-colored, and easily hidden bag for your things. Ladies, avoid large, fancy purses; they are easily spotted and oftentimes go missing.

8. Lock: Some clerkships will provide you with lockers. Be sure to lock up (or hide) your valuables.

9. ID: Do not forget your medical school or hospital ID. Hospitals operate very differently at night, and without ID, you will find yourself locked out of many wards, offices, and surgical suites with no one around to help you. Scary!

10. Warm clothes: Hospitals get notoriously cold at night. Bring your favorite college alumni sweatshirt and show off your pedigree while keeping warm!

I am not sure how busy other people are during call, but I don't think I have ever stayed overnight at the hospital while on call, unless it was a night shift. Then again, I've never been on a call where I wasn't busy all the time. So yea, the list sounds good, but I have no need for a toothbrush or a study guide. An extra pair of scrubs? Now that's something I like having around.


Monday, July 28, 2008

Hanging Up Stethoscopes For Laptops

Arnold Kim's story is only indirectly tied to medicine, but I think it is striking nonetheless. As a recent article noted, Kim has made his "hobby" his full-time job and decided to stop practicing medicine:

Jay Paul for The New York Times

For eight years, Arnold Kim has been trading gossip, rumor and facts about Apple, the notoriously secretive computer company, on his Web site, MacRumors.com. It had been a hobby — albeit a time-consuming one — while Dr. Kim earned his medical degree. He kept at it as he completed his medical training and began diagnosing patients’ kidney problems. Dr. Kim’s Web site now attracts more than 4.4 million people and 40 million page views a month, according to Quantcast, making it one of the most popular technology Web sites.

It is enough to make Dr. Kim hang up his stethoscope. This month he stopped practicing medicine and started blogging full time.

While many people may say 'Oh cool' and move on, if you really think about it, this is quite unbelievable. Imagine if 50 years ago, a doctor had left medicine to write poetry. Some may have praised it, but no one would have seen it as a lucrative career move. This speaks volumes about both the rise of network economies as well as the fall in medicine's perceived value as a career. It no longer carries the prestige or the financial renumeration to even compete with a blog (albeit a pretty darn good one)!


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Friday, July 25, 2008

The Personal Statement

Writing the personal statement is for many students the most tedious part of the residency application. Having just recently completed mine, I can attest to that. The hardest part I think is getting an idea and then knowing how to format it appropriately. While there are many resources on the web, I found this article on the AMA site helpful:

Some helpful suggestions in getting started:

1.Go back to your medical school application essay. Some students find it useful to look at that as a basis for their residency statement. Specifically the introductory and final paragraphs.

2. Find out if your school has a writing office, which can help you with your statement.

3. Use a theme to structure your essay. This helps unite all aspects of your statement.

4. Provide concrete examples that pertain to your life, goals and experiences.

5. Be concise. Refrain from using a lot of unnecessary words.

6. Begin your essay with an attention grabber: a quote, a story, an anecdote, or a riddle.

7. Finish your essay with a conclusion that refers back to the beginning of your statement and restates the theme.

8. Have your departmental program director evaluate/critique your statement. Remember they have probably seen thousands of essays and is most likely the best authority at your institution to evaluate your work.

9. Don’t be afraid to start from scratch if your essay is not working.

10. Do write about what interests you, excites you. Your reader wants to hear a positive essay not a negative one about the profession.

Keep reading to learn more about the statement, as well as read a sample personal statement.


Thursday, July 24, 2008

Incompetence and Antipathy

I cannot claim to have had a particularly unique medical school experience. I'm sure like most other medical students, I have had my fair share of excellent residents as well as terrible ones. Luckily, the terrible ones have been a distinct minority. Yet, sometimes, as I come across these 'rough spots among diamonds,' I wonder how they came to be in their positions.

Not everyone who applies to medical school is accepted, and not everyone who applies to residency programs matches. Yet, these people have managed to jump both hurdles. If these people are allowed in, who exactly is being filtered out? What is it like in other professions? I thought medicine tried to hold its own to higher standards, yet sometimes I see some of the most callous behavior among physicians themselves.

To be clear, I should differentiate between the two types of behavior that pique my anger. The first is incompetence. A few physicians I have encountered are particularly lacking in skill, some to the degree that I fear they may actually one day do bodily harm to patients. I suppose I cannot make any specific claims to prove that feeling of mine, but I think the basic question to ask the colleagues of these individuals is, would you let them treat you or your family members? If the answer is no from an overwhelming majority of their peers, then one must seriously wonder why these doctors are allowed to treat patients from the general public.

The second type of behavior is antipathy. Doctors are sometimes harsh due to the serious nature of their work. However, the harshness should be focused on the process of taking care of patients. Yet, some residents and even attendings make it a habit of belittling people in a manner that is not productive and has nothing to do with practicing medicine. It saddens me that such rotten apples have the title that I aspire to. I do not believe they should be allowed to practice medicine.

This post was not triggered by any particular incident, but rather by my reminiscing about the past 1.5 years as I filled out my residency application. The process requires me to jump all these hurdles to demonstrate my true interest in the field, yet I wonder what value this all has when clearly the system is not good enough to keep the incompetent and/or rude physicians out of the field.


Wednesday, July 23, 2008

Medgadget


Not much to say today, other than check out Medgadget, a blog devoted to emerging medical technologies. I particularly like the post about C-arm / DynaCT, a relatively new technology to let interventional radiologists take CTs of their patients during procedures. Perhaps a bit dated, but it was interesting to read about the cutting edge technology and then see how far behind the stuff we learn in med school is.


Tuesday, July 22, 2008

The Heparin Mishaps: Would More Technology Help?


Dennis Quaid? Heparin? Confusing, perhaps, but there have been several recent cases of overdoses of the drug heparin. One case unfortunately involved the children of actor Dennis Quaid. Some have proposed that automated systems may have prevented these errors, but the Wall Street Journal's health blog argues otherwise:

There’s just one problem in this case: automation wouldn’t have done much for the tots in Texas. A pharmacist made an error mixing heparin solution, often used to flush IV lines — and IV flushes often aren’t part of physician orders anyway. You can read the statement from Christus Spohn, which also says there’s no indication as yet that heparin contributed to the deaths in the NICU.

Doctors typically prescribe a dose of a particular drug over a particular time, and whether it should be administered intravenously or by mouth, for example. But a pharmacist often decides just how the drug will be prepared, whether by syringe into an IV or pre-mixed with saline. The pharmacist may note that a heparin flush is indicated before and after administration, or the nurse may know that it’s just part of the standard procedure.

The article does go on to note that some advanced systems do exist, but even they have their drawbacks:

Another up-and-coming technology might have helped the Quaids, but not the Texas tykes: Bar Code Medication Administration, or BCMA. Those systems require medications to be labeled with bar codes in the pharmacy identifying drug, dose and patient, and then checked — via scanner and computer — against codes in the medical record and a patient armband. But if the wrong dose is mixed and mislabeled in the pharmacy, overdoses can still occur.

“There still is that interface of human to computer that is always going to be plagued with problems,” Zachary Stacy, an associate professor at the St. Louis College of Pharmacy, tells Health Blog.


Clearly, the human element means these systems will always have some level of error, but I think this should not be used as a strong argument against their use. Any reduction in the rate of errors is an improvement, even if not all errors can be eliminated. What these hospitals really need to do is examine the processes and safeguards they had in place and why they failed to prevent this error. If they have too few techs who are perhaps overworked, the solution may actually lie in hiring more staff rather than switching systems.


Monday, July 21, 2008

Medicare Update

Last week, I posted about the proposed 10.6% cut in Medicare payments and its impact on the healthcare system. Since then, President Bush vetoed a bill that would reverse this scheduled change, but Congress overruled his veto:

But the House voted, 383 to 41, on Tuesday afternoon to override the veto. Soon afterward, the Senate voted by 70 to 26 to do so. Although the Senate vote was close enough to provide some suspense, it was still over the two-thirds needed, as a number of conservative Republicans who typically side with the president broke with him on this issue.

The bill cancels a 10-percent cut in payments to doctors that would otherwise occur automatically because of a statutory formula that reduces payments when spending exceeds certain goals. The president said he supported the main objective of the bill, to forestall reduction in physicians’ payments, but that he had too many reservations about other aspects of the legislation.

Mr. Bush said he opposed the bill in part because it would reduce federal payments to private Medicare Advantage plans, offered by insurers like Humana, UnitedHealth and Blue Cross and Blue Shield. In his veto message to Congress, Mr. Bush also complained that the bill would “perpetuate wasteful overpayments to medical equipment suppliers.”

It will be interesting to see how this plays out the next time there is a scheduled change in Medicare payments. The current system seems untenable in the long run, but with all the vested interests, it seems like it will be hard to change the status quo anytime soon.


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Friday, July 18, 2008

Why Health Policy Matters: Medicare Payment Cuts


Medicare is a foreign concept to me as a medical student. I am inundated with tons of information about biological processes and disease, but I have received very little formal education about the business of medicine. Perhaps it seems too lowbrow for the higher purposes to which doctors should aspire. However, I think it is important to be aware of these things, and I find myself quite ignorant. My basic understanding of how doctors are compensated is that Medicare sets payment rates, and then insurance companies use these rates as a proxy for their own rates. Doctors then perform services, report them to Medicare or insurers, and the payers then pay the doctors accordingly. However, this system is facing a major threat. Medicare is about to cut payments by 10.6%:
Congress returns to work this week with Medicare high on the agenda and Senate Republicans under pressure after a barrage of radio and television advertisements blamed them for a 10.6 percent cut in payments to doctors who care for millions of older Americans.

The advertisements, by the American Medical Association, urge Senate Republicans to reverse themselves and help pass legislation to fend off the cut.

How to pay doctors through the federal health insurance program is an issue that lawmakers are forced to confront every year because of what is widely agreed to be an outdated reimbursement formula. But the dispute, which showcases the continued potency of health care issues, has reached a new level of urgency this year. Some doctors are reassessing their participation in the program and powerful interests on all sides are in a lobbying frenzy.

The real major problem here is that at the end of the day, patients suffer. Many doctors end up closing their practices to new Medicare patients because each patient would represent a "loss." The costs of the supplies needed to treat them would be greater than Medicare's reimbursement. As rational economic actors, one cannot blame the doctors for not accepting such a deal. The current government is a strong proponent of free market solutions, but here the free market is acting appropriately in response to external factors, but the result is clearly less than ideal. Our healthcare policy shows such cognitive dissonance, with the same factions railing about 'socialized healthcare' yet strongly lobbying to continue or increase the government-funded "socialist" Medicare program. A longterm solution is needed, but in the interim, Congress should maintain at least the current payment level if it has any interest in preserving Medicare.


Thursday, July 17, 2008

Avastin: Worth The Price?


Similar to my recent post on CT Angiograms, the cancer drug Avastin has come under new scrutiny about whether its benefits justify its costs:

Looked at one way, Avastin, made by Genentech, is a wonder drug. Approved for patients with advanced lung, colon or breast cancer, it cuts off tumors’ blood supply, an idea that has tantalized science for decades. And despite its price, which can reach $100,000 a year, Avastin has become one of the most popular cancer drugs in the world, with sales last year of about $3.5 billion, $2.3 billion of that in the United States.

But there is another side to Avastin. Studies show the drug prolongs life by only a few months, if that. And some newer studies suggest the drug might be less effective against cancer than the Food and Drug Administration had understood when the agency approved its uses.

Like the CT Angiograms, the difficulty here is what costs should be paid to improve the quality of life of a terminally ill patient. While compassionate people may think that almost any cost is justifiable, one must recognize that from society's point of view, those dollars could be used to pay for TB drugs or for preventative care or for vaccines for children. As a society, America has seemed to strongly preferred costly tertiary interventions that benefit few patients versus more bland primary interventions that prevent disease across many individuals. Is this right? I am not sure, as ideally both ends of the spectrum would be covered, but I feel that we do tend to lean too far towards costly interventions on patients who may be better off with simply receiving palliative care. What do you think? Feel free to comment.



Wednesday, July 16, 2008

No Rest For The Weary


I cannot fully judge the veracity of this blog post, but I must admit the 6 side effects they mention of poor asleep do seem to affect. The one that scares me the most? Temporary paralysis:
Imagine you are lulled from sleep and feel a heavy pressure on your chest. You can barely breathe, can’t speak or call for help, and you definitely can’t move. You have to really concentrate just to move a finger because, though your mind is awake, your body is still in sleep mode. Some have compared it to being possessed. This experience is called sleep paralysis, and it can be a very frightening, unnerving disorder. Even though sleep paralysis isn’t often discussed, it’s a common and perfectly normal (albeit disturbing) experience—most of the time. “It can be a symptom of narcolepsy, but … [it’s considered] a normal entity if it happens once in a while,” Julianne explains. Sleep paralysis is caused by a disruption in REM sleep, which can be brought on by stress or being extremely tired.
Scary, no? Why are you still reading this anyway? Get some sleep!


Tuesday, July 15, 2008

Are CT Angiograms Worth It?


As a medical student preparing to apply for radiology residency programs, I admit I have a bias towards viewing diagnostic tests as beneficial. However, there are many reasons to have some skepticism about this view. The recent passing of Tim Russert has led many to think about how we perform preventive screening for coronary disease. One suggestion is to use a new technology, CT Angiograms, to help screen patients:
A group of cardiologists recently had a proposition for Dr. Andrew Rosenblatt, who runs a busy heart clinic in San Francisco: Would he join them in buying a CT scanner, a $1 million machine that produces detailed images of the heart?

The scanner would give Dr. Rosenblatt a new way to look inside patients’ arteries, enable his clinic to market itself as having the latest medical technology and provide extra revenue.
However, there was a downside to having the technology available:

Although tempted, Dr. Rosenblatt was reluctant. CT scans, which are typically billed at $500 to $1,500, have never been proved in large medical studies to be better than older or cheaper tests. And they expose patients to large doses of radiation, equivalent to at least several hundred X-rays, creating a small but real cancer risk.

Dr. Rosenblatt worried that he and other doctors in his clinic would feel pressure to give scans to people who might not need them in order to pay for the equipment, which uses a series of X-rays to produce a composite picture of a beating heart.

“If you have ownership of the machine,” he later recalled, “you’re going to want to utilize the machine.” He said no to the offer.

Such concerns go beyond one doctor, with proponents of CT angiograms lining up against payers who question their value:

The Centers for Medicare and Medicaid Services had decided to push back.

The agency, which this year will spend more than $800 billion on health care, rarely questions the need to pay for new treatments. But last June, Medicare said it was considering paying for CT heart scans only on the condition that studies be done to show they had value for patients.

Concerned about the overall proliferation of imaging tests, Medicare said it might require a large-scale study to determine the scans’ value.

The plan met with fierce resistance, particularly from a relatively new organization of specialists, the Society of Cardiovascular Computed Tomography. The society has 4,700 physician members and one purpose — to promote CT angiograms.

Needless to say, the group put up intense lobbying pressure, and Medicare eventually gave way. Still, the case is an interesting mix of health economics, medicine, and society. The new technology raises the issue of not only how much benefit it provides, but also whether that benefit is worth the cost. I think there are worthwhile arguments on both sides. On the one hand, you have to have some people "go first" and use the technology in order to see if it is worthwhile, so some funding / market must be there. However, on the other hand, you do not want to blindly enable the technology in general only to later find out that it was of little use. Medicine, it seems, has chosen to err towards the side of trying everything now, and only checking later if it actually worked. Such is modern medicine in the U.S., I guess.


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Monday, July 14, 2008

Michael E. DeBakey, 1908 - 2008


As you probably already know, Michael E. DeBakey passed away over the weekend. Many know of him as a pioneering surgeon, educator, and medical statesman. His accomplishments are widely known, and I cannot add much to that.

However, for my little part, I remember seeing Dr. DeBakey a few times, but my favorite memory was one Sunday morning a few weeks ago. My mother had convinced my father and I to check out the local Farmer's Market. While randomly browsing different produce, I spied a scooter out of the corner of my eye. Who else was it but Dr. DeBakey? Haha, seeing him there was a bit bizarre, but at the same time, it was nice knowing that at 99, he was still out and about. My little anecdote is probably trivial, but it reminds me that no matter who we are, we share a common humanity, whether we are a world-renowned heart surgeon... or just a medical student. Rest in peace, Dr. DeBakey.


Friday, July 11, 2008

How Not To Fake A Heart Attack

Check out this defendant who is acting as his own lawyer. Note the timestamps at the bottom of the frame:

Haha, at least mention some numbness in your arm or try to sweat! C'mon now!

Thursday, July 10, 2008

The iScan?

A fun little party trick from Not Totally Rad:
At a recent folk dance, I was resting on the sidelines, and noticed that a friend had her foot propped up on a chair with an ice pack on it.
SR: "What's wrong?"

Friend: "Someone stepped on me during the last dance."

SR: "Want me to have a look at it?"
I had preloaded a picture of foot X-ray on my iPhone, and when I put it on her foot, the effect on her was all that I have could asked for.
Check out the sample image of the trick here. Hehe, even more reason to go get an iPhone now...



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Wednesday, July 09, 2008

Geriatrics and Antipsychotics


On the heels of my ground-scuffing post on adolescents and antidepressants, the NYTimes has published a piece on the overuse of antipsychotic medications in the elderly:

The use of antipsychotic drugs to tamp down the agitation, combative behavior and outbursts of dementia patients has soared, especially in the elderly. Sales of newer antipsychotics like Risperdal, Seroquel and Zyprexa totaled $13.1 billion in 2007, up from $4 billion in 2000, according to IMS Health, a health care information company.

Part of this increase can be traced to prescriptions in nursing homes. Researchers estimate that about a third of all nursing home patients have been given antipsychotic drugs.

The increases continue despite a drumbeat of bad publicity. A 2006 study of Alzheimer’s patients found that for most patients, antipsychotics provided no significant improvement over placebos in treating aggression and delusions.

Is there anything psychiatrists won't try to cure with a scrip? Heh, just kidding, but the off-label use of psychiatric medications is disturbing, as I saw on my own psychiatry rotation. Sometimes, I wondered whether we were truly living up to the maxim of "do no harm."


Tuesday, July 08, 2008

Why Primary Care Matters

Kind of an old post, but kevinmd discusses on his blog why the shortage of primary care docs matters:
Primary care should be the backbone of any health care system. Countries with appropriate primary care resources score highly when it comes to health outcomes and cost. The United States takes the opposite approach by emphasizing the specialist rather than the primary care physician.

A recent study from The New England Journal of Medicine analyzed the providers who treat Medicare beneficiaries. The startling finding was that the average Medicare patient saw a total of seven doctors — two primary care physicians and five specialists — in a given year. Contrary to popular belief, the more physicians taking care of you does not guarantee better care. In fact, studies show that increasing fragmentation of care results in a corresponding rise in cost and medical errors.
Keep reading on here. Still curious? I've discussed this shortage before on scrub notes as well: A Shortage of Primary Care Physicians?


Monday, July 07, 2008

Medical Marvel: Pruritus

Pruritus, you say? Plain ol' itching? How could that be a medical marvel? Yet, in his new piece for The New Yorker, Atul Gawande manages to do just that. Like most people, I have not given itching much thought (except when I have one), but "The Itch" shows what happens when pruritus is taken to the extreme:

“Scratching is one of the sweetest gratifications of nature, and as ready at hand as any,” Montaigne wrote. “But repentance follows too annoyingly close at its heels.” For M., certainly, it did: the itching was so torturous, and the area so numb, that her scratching began to go through the skin. At a later office visit, her doctor found a silver-dollar-size patch of scalp where skin had been replaced by scab. M. tried bandaging her head, wearing caps to bed. But her fingernails would always find a way to her flesh, especially while she slept.

One morning, after she was awakened by her bedside alarm, she sat up and, she recalled, “this fluid came down my face, this greenish liquid.” She pressed a square of gauze to her head and went to see her doctor again. M. showed the doctor the fluid on the dressing. The doctor looked closely at the wound. She shined a light on it and in M.’s eyes. Then she walked out of the room and called an ambulance. Only in the Emergency Department at Massachusetts General Hospital, after the doctors started swarming, and one told her she needed surgery now, did M. learn what had happened. She had scratched through her skull during the night—and all the way into her brain.

And if you think that is nuts, read the whole article. Done reading? Have a few questions about how real all that stuff is? Check out this Q&A with Gawande about some of the more incredulous points in the piece. And, if you're still curious, keep on reading at Gawande's personal website.


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Friday, July 04, 2008

Happy 4th of July!


In the spirit of Independence Day, and of being safe, here are some links on fireworks and firework safety. Mostly, this is an excuse for me to link to pictures of firework injuries, which are somewhat morbidly fascinating:
Have fun today! Stay safe!

Wednesday, July 02, 2008

Diabetes: The Sleeper Disease

A recently article noted the public's misperception of the dangers of diabetes:

In a set of recent focus groups, participants were asked to rank the severity of various health problems, including cancer, heart disease and diabetes.

On a scale of 1 to 10, cancer and heart disease consistently ranked as 9s and 10s. But diabetes scored only 4s and 5s.

“The general consensus seems to be, ‘There’s medication,’ ‘Look how good people look with diabetes’ or ‘I’ve never heard of anybody dying of diabetes,’ ” said Larry Hausner, chief executive of the American Diabetes Association, which held the focus groups. “There was so little understanding about everything that dealt with diabetes.”

It's sad. Even among people I know well who I know are intelligent just do not process the risks appropriately. They utilize the logic that, if I don't feel sick now, I must not be sick, and therefore avoid preventative care. Call it the paradox of prevention, I guess. Honestly, before med school, I was the same way. I thought diabetes just meant high blood sugar, but after seeing patients with ESRD due to diabetes, foot ulcers because of neuropathies, and vision loss, it is shocking how little people know about this disease relative to diseases like cancer. We have fancy "cancer centers," but where are the hospitals focused on diabetes? People talk about high blood pressure as a "silent killer," but perhaps the title best belongs to diabetes.


Tuesday, July 01, 2008

Your Brain Lies To You

Your brain lies to you? At first glance, a preposterous statement. Why would anyone lie to themselves? But upon further inspection, the statement reveals more layers. It is not stating that we lie to ourselves, which is fairly common, but rather our brains are lying to us. It turns out, the lie is an innocent one, but can have significant effects nonetheless. As authors Sam Wang and Sandra Aamodt describe:
FALSE beliefs are everywhere. Eighteen percent of Americans think the sun revolves around the earth, one poll has found. Thus it seems slightly less egregious that, according to another poll, 10 percent of us think that Senator Barack Obama, a Christian, is instead a Muslim. The Obama campaign has created a Web site to dispel misinformation. But this effort may be more difficult than it seems, thanks to the quirky way in which our brains store memories — and mislead us along the way.

The brain does not simply gather and stockpile information as a computer’s hard drive does. Facts are stored first in the hippocampus, a structure deep in the brain about the size and shape of a fat man’s curled pinkie finger. But the information does not rest there. Every time we recall it, our brain writes it down again, and during this re-storage, it is also reprocessed. In time, the fact is gradually transferred to the cerebral cortex and is separated from the context in which it was originally learned. For example, you know that the capital of California is Sacramento, but you probably don’t remember how you learned it.

This phenomenon, known as source amnesia, can also lead people to forget whether a statement is true. Even when a lie is presented with a disclaimer, people often later remember it as true.
The implications of this phenomenon are disturbing. It helps explain why people often make very definitive statements, yet when questioned for further information, have a difficult time supplying the source or other related information. It is especially troublesome when a person has a high degree of confidence with a high degree of source amnesia. This pairing leads them to make statements with high certainty with little regard to how they came to be so certain. A vicious cycle develops: if the statement is questioned and found to be true, this result just increases their confidence / cockiness. However, if false, the person discounts the result as something "misremembered." I used to think of this as a kind of mental laziness, but now, perhaps I should be more compassionate and realize that the person is not lying to me; perhaps, instead, their brains are lying to them.


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