Stanford Medicine 25 Blog

Do You Know How to Measure an Ankle Brachial Index?

The ankle brachial index (ABI) is a common and useful exam in the outpatient setting to detect peripheral arterial disease. ABI’s should be measured in all people over the age of 50 if they are a diabetic or a smoker. It should also be checked in patients over the age of 60.

While many doctors simply order this test, we show you how to quickly measure the ABI yourself with a doppler and blood pressure cuff. Visit our page on ABI here and watch the video below to learn how to measure an ABI on your own!

IMG_3209

*|YOUTUBE:KnJDrmfIXGw|*

The History of Bedside Ultrasound: From Submarines to Sub-Interns

By Michael Vogel

Among the myriad of modern diagnostic tools, few can claim the certainty, consistency, and intimacy of ultrasound. In contrast to other dominant types of medical imaging characterized by large, foreign machines and uncomfortable noise and positioning, this sound-based imaging technique is one of the least intimidating and widely-used exam method, applied in fields ranging from Pulmonology and Gastroenterology to Obstetrics and Gynecology. However, conventional ultrasound can trace its roots to a form of militarized SONAR developed heavily in the period between World War I and II. Prototypes of “Ultrasonic Metal Flaw Detectors”, developed in tandem by Soviet scientist Sergei Y Sokolov and American engineer Floyd A Firestone in the early 1930s were used as an alternative to conventional RADAR methods for detecting submerged vehicles. These tools used short, high-frequency ultrasonic pulses to measure imperfections in the cast metal bodies of submarines, and their application in therapeutic medicine was simultaneously explored by American physicians. During a period stretching from the mid-1930s to the late- 1940s, ultrasound technology was used to perform a primitive form of craniotomy, by using high-frequency pulses to destroy parts of the brain. Additionally, this homeopathic application of ultrasound attempted to treat in patients with Parkinsonism, as well as other illnesses that include rheumatism, carcinomatosis, eczema, urinary incontinence, and elephantiasis. In fact, ultrasound wasn’t considered a diagnostic method until October of 1949 with the publishing of the “June ’49 Report” by George Ludwig. Since then, ultrasound has matured into “medical sonography”, and has expanded to become the primary diagnostic method for identifying the size, location, and pathology of muscles, tendons, and most internal organs.

IMG_20140717_105739

At Stanford Hospital, as well as many other prominent medical facilities worldwide, the use of bedside ultrasound is an essential tool in the repertoire of a hospitalist. Conventionally defined, Bedside Ultrasound refers to “a limited ultrasound examination performed at the bedside by the treating physician to answer specific clinical questions”. While bedside ultrasound originated in the quick decision-making of E.R. Physicians, it has now also found a home in internal medicine. Physicians use ultrasound to estimate central venous pressure through visualization of the inferior vena cava, estimate left ventricular function with limited echo, assess abnormalities in the lungs, evaluate the presence of ascites and pleural effusions, and to assist with procedures. As part of the physical exam, bedside ultrasound gives the opportunity to foster the physician-patient relationship. The Stanford Medicine 25 team provides informative resources that explore the depth of ultrasound technique, from the proper placement of the transducer to motions and technique that maximize diagnostic efficiency while minimizing patient discomfort. Ultrasound technology, with its rich history and varied application remains today as one of the most widely-utilized assisted-examination techniques, and is a fantastic way to integrate imaging technology into a comprehensive and patient-forward physical exam.

P.S: Some facilities warm their ultrasound gel before applying it on a patient’s body. This action serves no diagnostic purpose and is purely for the patient’s comfort, a philosophy we could extend to our physical exams as well!

IMG_20140717_104430

SOURCES

http://www.ob-ultrasound.net/history1.html

http://aquasonicultrasoundgel.com/blog/top-five-benefits-of-an-ultrasound-gel-warmer/

http://www.nlm.nih.gov/medlineplus/ency/article/003336.htm

http://www.slredultrasound.com/Filesandpictures/Guidelines2.pdf

The Babinski Sign

By Michael Vogel

Among the key players in the neurological revolution of the early 19th Century, few may claim as much lasting relevance as Jean-Martin Charcot. Lending his eponym to phenomena such as Charcot’s Joint (diabetic arthropathy), Charcot’s Triad (acute cholangitis) and most notably Charcot’s Disease (ALS), the French physician is widely considered to be a progenitor of modern neuroscience and psychology. However, one of Charcot’s most influential contributions to medicine is that of his protégé and contemporary, Joseph Babinski. Coming to professional fruition in 1893, Babinski is credited with the analysis and identification of several neuroses, including a peculiar diagnostic cue bearing his name today. First identified in a 26-line short form presentation at the 1896 Société de Biologie meeting, Babinski’s Sign became one of the neurologist’s most notable discoveries, and remains an invaluable resource for the modern practicing physician today.

Babinski

Babinski’s sign is a neuro-pathological cue embedded within the Plantar Reflex of the foot. Elicited by a blunt stimulus to the sole of the foot, the normal adult Plantar Reflex presents as a downward flexion of the toes toward the source of the stimulus. Babinski’s sign is observed when the Hallux (big toe) exhibits dorsal extension in response to the same plantar stimulation. While a response similar to the sign exists when the plantar reflex is elicited in infants, Presence of Babinski’s sign in adults can be indicative of a lesion or damage in the corticospinal tract, and identification of the sign remains one of the least-invasive methods for supporting an Upper Motor Neuron damage diagnosis. The sign became such an integral part of neurological doctrine that Babinski’s prototype reflex hammer, developed in 1912, became one of the essential tools of a modern neurologist. Even to this day, modern neurological examination textbooks refer to Babinski’s sign as “the most colorful exam finding in neurology”. All in all, Babinski’s sign and similar examinations of the plantar reflex (Chaddock sign, Cornell sign) are fond reminders of the utility of a comprehensive physical exam and that, with proper care and attention to detail, a physician can make confident diagnostic choices using simple, concise, and interactive methods.

*|YOUTUBE:K8qmSBbKV14|*

 

 

 

References:
Goetz CG (2009). “Chapter 15 Jean-Martin Charcot and the anatomo-clinical method of neurology”. Handb Clin Neurol. Handbook of Clinical Neurology 95: 203–12. doi:10.1016/S0072-9752(08)02115-5. ISBN 978-0-444-52009-8. PMID 19892118.

http://www.nndb.com/people/825/000207204/

Goetz CG (2002). “History of the extensor plantar response: Babinski and Chaddock signs”. Seminars in neurology 22 (4): 391–8. doi:10.1055/s-2002-36761. PMID 12539060.

http://stanford25blog.stanford.edu/2013/04/the-history-of-the-reflex-hammer/

Campbell, W. W., & DeJong, R. N. (2013). DeJong’s The neurologic examination (7th ed.). Philadelphia: Lippincott.

On Chekhov: The Marriage of Medicine and Literature

By Damiana Andonova

Anton_Chekhov_with_bow-tie_sepia_image

Anton Chekhov, Russian physician-playwright from Tagranog, must have written about more than a hundred physician characters in his literary career. They’ve appeared in plays from Platonov to The Three Sisters and many short stories. Each character is unique, variable in personality, in medical attitude, and method. What caricatures: the pompous speaker, the narcissist, the genius, the devout healer, the scatter-brained, boorish feldsher!

Students of literature are regularly reminded of Chekhov’s gun; his contributions to the literary world are many. By 1886, he had already found fame in St. Petersburg and beyond. But, what of him as a physician?

He practiced medicine during most of his literary career but officially retired from the medical profession in 1889. Despite this, he continued to provide free care in Melikhovo and often dabbled in public health initiatives. But what is perhaps most attractive about his medical career is how he bridged medicine and literature. He is quoted saying,

“Medicine is my lawful wife, and literature my mistress.”

His fascination with medicine, he unreservedly explored in his literature. To say that he created over a hundred fictitious physicians is perhaps only a small testament to his interest in unpacking the medical profession through literary means. He also used his medical competency to richly write about tuberculosis in “Late Blooming Flowers”, typhus in “Typhus”, and many other evocative scenes of medically urgent occasions. His dark descriptions, often besotted with reflection over medical attitudes explains why he wrote such aphorisms:

“People who have an official, professional relation to other men’s sufferings, for instance—judges, police officers, doctors—in course of time, grow so callous, that they cannot, even if they wish it, take any but a formal attitude to their clients, in this respect they are not different from the peasant who slaughters sheep and calves in the backyard, and does not notice the blood”
–Anton Chekhov in Ward No. # 6.

His storytelling, fabled to have been inherited from his storytelling mother, Yevgeniya, is powerful, evocative, and thought-provoking to say the least. His works merit a spot on a physician’s reading list, even if he did write of medicine practiced centuries ago.

Sources:
Chekhov, A. P. (2002). Ward No. 6 and other stories, 1892-1895. London ; New York: Penguin.
Coulehan, J. (2003). Chekhov’s doctors: a collection of Chekhov’s medical tales. Kent, Ohio: Kent State University Press.
Teuber, A. (n.d.). Anton Chekhov Biography. Retrieved June 24, 2014, from http://people.brandeis.edu/~teuber/chekhovbio.html#Biography%20Part%20I

Pathognomonic Signs and Metaphors of the Gynecologic Exam

By Damiana Andonova

Here we share memorable metaphors and pathognomonic signs, some of which are fruit and cheese metaphors in their own right. This is not mean to be an exhaustive list, but rather a reminder of the many interesting observations that can be made during a physical exam.

We begin with the peau d’orange appearance of breast cancer; the cervical petechiae that resemble the strawberry cervix of Trichomoniasis and the rather cottage cheese-like discharge of Candidiasis.

CDR415524-571
© 2007 Terese Winslow, U.S. Govt. has certain rights.

During a properly performed examination, a physician could further note cervical motion tenderness for pelvic peritonitis or perhaps pelvic inflammatory disease (PID). Of particular interest is the “Chandelier sign”, as the gynecologic patient would jump up and cling to the chandelier in utter pain.

Uterine size measured during a pelvic exam can also be likened to fruits: the non-pregnant or five weeks pregnant small pear, the three-month grapefruit (Margulies & Miller 2001).

Additionally, the physician could observe the esoteric grainy, sandy patches of schistosomiasis (of which S. haematobium is the etiological agent), the sulfur granules associated with pelvic actinomycosis, or utero-sacral nodularity, which is pathognomonic for endometriosis.

If a recto-vaginal exam is indicated and performed, a descending soft mass observed between the vaginal and rectal finger upon the Valsalva maneuver is pathognomonic for a rectocele. Similarly, the descent of a soft mass in the anterior vagina during the Valsalva maneuver noted in the bimanual portion of the pelvic exam can also be pathognomonic for a cystocele.

On the matter of observing discharge, some argue the color and consistency are pathognomonic for certain infections, including a frothy discharge for trichomoniasis and a thin fishy gray discharge associated with bacterial vaginosis.

Medical phraseology and the common every day language that can sometimes take over conversation can be fun to explore. And yet, while pathognomonic signs and metaphors can be fun to think about, they can also help us remember how useful the physical exam can be in the clinical encounter!

Can you think of more? Let us know!

Special thanks to Emmet Hirsch (Clinical Professor of Obstetrics and Gynecology at the Pritzker School of Medicine of the University of Chicago) and Paula Hillard (Professor of Obstetrics and Gynecology and Associate Char for Medical Student Education at Stanford University) for helping me in creating this article.

Cultural Competence at the Bedside

By Damiana Andonova

A clinician will encounter patients from all socio-economic strata, who speak foreign tongues and understand disease in ways that stand apart from the clinician’s own conceptions of disease etiology.

Perhaps they might encounter a Hmong elderly who complains of a heavy heart. What physical exam does one perform? Their spiritual understanding of disease etiology is linked to their soul, as Anne Fadiman eloquently explains in her text, “The Spirit Catches You and You Fall Down”. The proper course of action may not be just a diagnostic test but perhaps a concert of medicine and spiritual tradition.

Perhaps a 20-something Bulgarian mother demands she feeds you bread and honey before being discharged with her newborn after an emergency Cesarean.

Or consider the scenario that I experienced as a young medical observer:
A Chinese woman experiences post-partum depression after completing a traditional post-partum zuo yuezi, or period of confinement after her pregnancy; an Asian practice that is becoming popular in United States as well.

Abraham

For clinicians it may be difficult to negotiate the culture shock that can take place in the doctor’s office. Yet, the academic community’s response to teaching less technical competencies at the bedside usually results in the creation of many inaccessible, didactic texts that, while aimed at helping students learn, actually bring the student farther away from the bedside and leave the student confounded.

To shy away from academic reviews of the literature and copious reading lists that can be offered to shed light on this issue, we share a quick lesson of cultural competence at the bedside.

Harvey Cushing is perhaps, the greatest neurosurgeon of the 20th century. You may recall many eponyms including Cushing’s clip, law, and symphalangism; Cushing’s syndromes I, II, and III; Cushing’s triad, and some other hyphenated syndromes such as Bailey-Cushing syndrome. Of his many accomplishments, a singular quote on the obligations of physicians is memorable,

“A physician is obligated to consider more than a diseased organ, more even than the whole man — he must view the man in his world.”

This is an extremely fallible yet certainly achievable task. If you’ve listened to Dr. Abraham Verghese’s memorable anecdote about the linoleum factory worker (link), you’ll note Sir Joseph Bell performed his obligations to a sound degree.

Cultural competence is very useful tool to gauge how to approach a physical exam and what practical advice to offer to a patient.

Consider this case:
“The Hand Injury”
An uninsured, yet documented immigrant housekeeper visits Cook County Hospital after a serious injury to her hand while cutting an avocado. “The Hand Injury” received proper care and surgery, and is a single parent whose earnings rely on her ability to iron clothes, to wash the dishes by hand, and to vacuum.

Considering her job security is almost zero (private domestic workers can be fired at any time; they receive no mandatory paid or unpaid sick leave), how might treating and advising her as a hand surgery patient be different if she were a high school math teacher? Would it be any different if she were a freelance jewelry artist?

A long review of the literature will simply show that the discussion of cultural competency and sensitivity at the bedside includes awareness of socio-cultural diversity and the social production of disease as well as its implications at the bedside. An article might recommend a semester course in medical anthropology, too. Understanding her background can provide clues as to how to approach her care, and personalize it so that her care is effective, and as the industry prefers, efficient. Being culturally competent will also render “the hand injury” a useless synonym for her name.

The Stanford 25 bedside sessions as well as the Bedside 5 Minute Moment attempts to bring students closer to real patients and help them gauge differences between caring for the textbook patient and a real patient. Working at the bedside, then, brings students closer to the actual patient, and like Cushing says, gives residents a chance to “view the man in his world”.

Dr. Ahuja Leads a Stanford 25 Session on the Oral Exam

In our last Stanford 25 session, Dr. Neera Ahuja led a session on the oral exam. In this session, she talked about important findings of the oral exam for the internist that include abnormal findings of the tongue, buccal mucosa and salivary glands.

A few take-home points from Dr. Ahuja include:
· A comprehensive examination of the oral cavity can provide insight into a patient’s health and possible systemic disease processes (eg. Endocarditis, Sjogren’s, Amyloid, etc).
· Recognizing normal variants is key to being able to identify abnormal exam findings
· If you are going to take the time to examine the oral cavity, have a bright pen light (or the Stanford 25 key chain light) available for maximum visibility of the oropharynx

neeraMainPic

What Can Doctors Learn from Narrative Medicine?

By Damiana Andonova

Much like how the Stanford Medicine 25 is an initiative to revive the culture of bedside medicine, narrative medicine is a defense for the practice of medicine with narrative competence…

Patient-centered care is an important aspect of the National Strategy for Quality Improvement on Health Care. As such, healthcare institutions are strongly focusing on the patient-physician relationship and the patient experience.

In light of this focus and to better prepare medical students, educational bodies have begun to restructure their curricula to reflect the truly interdisciplinary work of clinicians—to not only diagnose and treat disease, but also care for the patient as a person rather than a body. This, many argue, requires narrative competence: to listen to the stories of patients and promote a healing partnership that is invested the patient’s experience of illness and recovery.

books

Despite the demanding academic trajectory of clinicians, many feel that gaps in narrative competence linger, as medical students are taught to be great diagnosticians and are fairly ill advised as to how to actually care for patients at the bedside. These gaps, educational initiatives and research studies have demonstrated, could be aptly addressed by the inclusion of medical humanities, and namely, narrative medicine to address the narrative aspects of medical practice.

Rita Charon, the pioneer of narrative medicine, claims that having such narrative competencies could facilitate patient engagement, as narrative medicine is a powerful and effective method for achieving empathic and effective patient-physician relationships. This is because literature not only provides provide a rich source of insight into the human condition and the role of those who provide treatment and care, but can also paint evocative images of illness and the path to recovery from a patient’s and physician’s perspective.

But what is narrative medicine exactly?
It is both a field of study and a literary genre. It is written text by clinicians, patients, and patients’ relatives that comments on some aspect of a medical journey. It includes patient narratives, physician narratives, and more recently, paintings and photographs; any text that can be used for analysis, interpretation, and observation—skills that are critical for a clinician.

What Narrative Medicine Can Offer to Clinicians:
• Empathic engagement
• Prevent burnout and natural jadedness
• Support and nurture compassionate instincts of clinicians
• Self-reflection
• Observation and interpretation skills
• Provide insight into the patient perspective

To further explore narrative medicine, you can read the many published short stories of William Carlos Williams, Richard Selzer, Rita Charon, and Chris Adrian. Of course, Dr. Verghese’s memoirs are also strong examples of the genre. For more recommendations, feel free to contact us.

For those who would be interested in exploring how narrative medicine can assist in self-reflection and prevent burnout, attempt to free-write some reflections of difficult experiences during a physical exam. Shy away from the “medicalized narrative”, which is often inaccessible, and rather ineffective for this purpose.

Sources:

2012 Annual Progress Report to Congress. National Strategy for Quality Improvement on Health Care. http://www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf
Charon, R. (2001). Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust. JAMA, 286(15), 1897. doi:10.1001/jama.286.15.1897
Chen, Pauline W. (October 23, 2008). Stories in the Service of Making a Better Doctor, New York Times. (about the importance of Narrative Medicine in medical education) http://www.nytimes.com/2008/10/24/health/chen10-23.html?pagewanted=1
Holloway, Marguerite. When Medicine Meets Literature. Scientific American, May 2005. http://www.scientificamerican.com/article.cfm?id=when-medicine-meets-liter
Last, J. (2008, April). Medicine and Literature: Passion, compassion, confusion and other emotions in stories of sickness and healers. Hektoen Internationa, A Journal of Medical Humanities. http://www.hektoeninternational.org/MedicineLiterature.htm

Dr. Barry Teaches the Exam of the Foot and Ankle

Thank you to Dr. Michele Barry for leading the Stanford 25 session last week on the foot and ankle exam. Residents were taught the basics of the exam and then practiced on each other. Dr. Barry trained in Rheumatology at Yale and now serves as the Director of the Johnson & Johnson Global Health Scholars Program at Stanford. Please read below for some take-home points of the foot and ankle exam from Dr. Barry.

Main1

Inspection: Look at the soles of the shoe and look for the pattern of wear. A person with normal gait and no foot deformity should have wear on the lateral aspect of the shoe. Deformities associated with foot and ankle will present as wear on soles at other areas of shoes. Look at lower extremities for hair pattern, purpura, LCV.

Palpation: Pain with movement, without movement, ROM (inversion=10 degrees, eversion=20 degrees). Evaluate the laxity of the joints in each foot and ankle. Strength and flexibility should be symmetrical, but if person has previous a fracture, injury, weakness one foot and/or ankle may have greater laxity on the affected side.

Eponyms of the Foot:
Lover’s Heel: Disease of Achilles tendon associated with gonococcal tenosynovitis, assess by performing squeeze test and ankle draw.
Policeman’s Heel: Pain from pressing over the heel of the foot that may be relieved by rolling the ball of the foot over a plastic coke bottle.

Main2

Write-up by Tanya Kailath, NP

Teaching Humility at the Bedside

By Damiana Andonova

In 1906, William Osler addressed the University of Minnesota medical students with some moving words.

“In these days of aggressive self-assertion, when the stress of competition is so keen and the desire to make the most of oneself so universal, it may seem a little old-fashioned to preach the necessity of humility, but I insist . . . that a due humility should take the place of honor on your list [of virtues]”

His words couldn’t be more relevant today.

Humility is an underappreciated skill in a time of global budgets, evidenced based approaches, and cost-containment. The bright, well-read, talented medical students who may lack humility are not uncommon. And while they strive to become the competent and confident physicians their future patients yearn for, they must also pay attention to learn their roles at the bedside, to be the sort of physicians their patients deserve.

Balancing the technical aspects of medicine with the more humanistic aspect of honoring and developing patient-physician relationships is of serious importance at the bedside; negotiating one with the other can be difficult.

Teaching this sort of confident humility, or humble confidence requires experience and practice. It is no understatement to say that teaching humility is hard. But, perhaps, teaching it at the bedside might have its advantages.

Jack Coulehan, MD, MPH, proposed four attributes for 21st century physicians should strive for:
1) Unpretentious openness
2) Avoidance of arrogance
3) Honest self-disclosure
4) Modulation of self-interest

How clinical professors can go about teaching them is not so clear.

There are several schools of thought. One school of thought suggests employing panel discussions with patients and physicians, home visits, book discussions, film screenings as well as the use of simulated, standardized, and real patients.

The other school of thought, and perhaps the most controversial, believes humility can be taught through acculturation. They find that perhaps medical school admissions look for signs of practiced humility in applicants, that clinicians in leadership positions select clinical professors based on the qualities of caring and humility, and that clinical professors model these virtues in all aspects of their teaching. It is very different from the current model in practice—find the best test-takers and find the most meritorious professors and hold lectures.

Still, other researchers suggest that medical students must deal themselves the task of “having heart” by taking time to self-evaluate, to think about shortcomings and areas to improve upon, and to remember there is always more to learn. An article that explores this is “The Importance of Stupidity in Scientific Research”. It is a highly recommended read.

Stephan Genuis similarly speaks of revisiting scientific impotence and integrity to recognize that science, like medicine, doesn’t always have the answers. In this century of rapid information turnaround, finding a way to underscore the importance of humility as part of the patient-physician relationship could decrease medical errors and ironically, iatrogenic and nosocomial disease, which Genuis argues, has accounted for “sobering rates of morbidity and mortality”.

The Stanford Medicine 25 approach to bedside manner deals, in part, with all of these ideas. The Stanford 25 session is taught by a seasoned clinician who welcomes questions, explains thoroughly. A resident then takes responsibility and volunteers to repeat the exam stepping out away from their desk and out of their comfort zone. They practice humility and compassion by teaching the exam to a fellow resident. This builds community, trust, and memory. It also has the potential to foster humility and compassion.

Teaching Humility at the Bedside

As clinical professors, one can do only so much. But perhaps Karin Hunt speaks of five good starting points.

1. Build confidence.
2. Master the art of great questions—“Who did you involve in the diagnosis? What do your fellows think of this diagnosis? Who was more comforted by the diagnosis you or the patient? ”
3. Get students out of their comfort zone—Allow them the opportunity to practice what you taught.
4. Help students improve.
5. Model humility.

Students, in return, can take responsibility to adopt this in their informal curriculum and spend a few minutes to self-evaluate, to think about the limitations and successes of medicine and their role at the patient’s bedside.

We leave you with this final thought:
“Oh that I had the heart to spare you grief! / The grace of humility is a precious gift,” writes Jack Coulehan, in his poem “Pantoun on Lines by William Osler”.

 

 

 

Sources:

Coulehan, J. (2009). Pantoun on Lines by William Osler. JAMA, 302(17), 1844. doi:10.1001/jama.2009.1505
Coulehan, J. (2010). On humility. Annals of Internal Medicine, 153(3), 200–201. doi:10.7326/0003-4819-153-3-201008030-00011
Coulehan, J. (2011). “A Gentle and Humane Temper”: Humility in Medicine. Perspectives in Biology and Medicine, 54(2), 206–216. doi:10.1353/pbm.2011.0017
Genuis, S. J. (2006). Diagnosis: contemporary medical hubris; Rx: a tincture of humility. Journal of Evaluation in Clinical Practice, 12(1), 24–30. doi:10.1111/j.1365-2753.2005.00599.x
Gunderman, R. B. (2014). A Call for Humility in the Regulation of Medical Education. Journal of the American College of Radiology. doi:10.1016/j.jacr.2014.03.025
Hurt, K. (2013, March 19). Can we teach leaders humility? Let’s Grow Leaders. Retrieved from http://letsgrowleaders.com/authenticity-transparency-trust/humility_and_leadership/
Li, J. T. C. (1999). Humility and the Practice of Medicine. Mayo Clinic Proceedings, 74(5), 529–530. doi:10.4065/74.5.529
Schwartz, M. A. (2008). The importance of stupidity in scientific research. Journal of Cell Science, 121(11), 1771–1771. doi:10.1242/jcs.033340