Lab Soft News

A Clinician Laments the Decline of the Autopsy

It may be time for me to print another lament about the decline of the autopsy as a follow-up to my blog note from August of this year (see: The Declining Autopsy Rate and an "Unattainable" Solution for the Problem). This new essay was written by Dr. Sandra Gompf who is an infectious disease specialist (see: A eulogy for the autopsy, and a call for its return). Here is an excerpt from it:

Evidence-based medicine and health insurers generally focus on what’s medically necessary, not what’s epidemiologically relevant, not what soothes the mind of the bereaved or of the physician grieved and mystified by the loss of a patient. Once, the autopsy was a venerated tool for medical advancement and humility. An invaluable means of learning one’s own limitations and the extraordinary diversity in nature and human physiology, it has now become an unreimbursed after-thought. An irrelevant thing, especially since the patient is already dead, there are living patients to care for, and people just need to “move on.” And it just doesn’t pay to know that your diagnosis pre-mortem was wrong; it only adds fuel to the malpractice attorney’s fire, which further fuels already skyrocketing malpractice insurance premiums. In life, a diagnosis based on assumptions is unacceptable. There are tests that must be run, high tech imaging, much probing and invading. Yet in death, an assumed cause is what goes on the death certificate well over 90% of the time....We should be thirsting for this knowledge, yet we throw away the opportunities to improve every day. I propose that the autopsy is more relevant than ever. That the dead can indeed live and speak through a thoughtful pathologist’s hands and eyes. That more than ever, doctors need to know what they are missing with all the bells, whistles, drugs, and treatment guidelines at their disposal. I have never found an autopsy on one of my patients to be less than a profoundly humbling and highly educating experience.

She's right, of course. There is only one good, and perhaps even better, substitute for the classic autopsy. That is the virtopsy, sometime referred to as the catopsy. With this latter procedure, a high-intensity CT scan is first performed on the deceased patient in order to identify and locate known, and unknown, pathologies. This imaging procedure is then followed by an abbreviated autopsy to confirm the CT findings and discover other lesions. The virtopsy is the standard of practice in the U.S. military (see: NYT Highlights the "Virtopsy" Used for All Military Autopsies) and in countries like Switzerland. You can acquire more details about the procedure from the University of Zurich virtopsy web site.

As far as I can tell from a Google search, the virtopsy has achieved little traction in the U.S. since I first began to write about it in Lab Soft News about three years ago. I attribute this lack of progress to the following: (1) most pathologist groups and departments give little thought to improving their autopsy service, viewing is as an unreimbursed activity used primarily for resident training and for cases when the cause of death is not obvious; (2) deployment of a virtopsy service requires extensive capital investment to purchase the CT scanner and remodel the autopsy suite; (3) broad acceptance of virtopsy programs would immediate render all pathologists, and particularly forensic pathologists, inadequately training to perform a key component of the virtopsy, interpretation of a CT scan; (4) there is no hue-and-cry or pressure from any portion of the medical, patient, or healthcare consumer community to move in this direction.

Strategies Developed by States for Retaining and Attracting Physicians

As medical schools and teaching hospitals proliferate in the various states, state government officials, academics, and healthcare executives ponder how to retain this physician talent (see: How states are keeping doctors from moving out). A recent article provided details about some of the answers. Below is an excerpt from it:

Widespread concerns about physician shortages have many states working to keep doctors trained in medical schools and residency programs there from crossing state lines to practice medicine....On average, only 39% of U.S. physicians practice in the same state where they went to medical school. Forty-eight percent practice in the state where they completed graduate medical education, said [a] report...by the AAMC Center for Workforce Studies. As a result, medical schools, hospitals, medical societies and state legislatures increasingly are taking a practical approach to retain the physicians and doctors-in-training they already have........Many states have responded [to physician shortages] by opening new medical schools or expanding existing ones. Several offer incentives such as bonuses, scholarships or loan repayment programs to keep physicians from leaving. Communities also are developing new residency programs in hopes that physicians will develop long-term professional and personal relationships during GME training that will tie them to the area....Recruitment and retention often go hand in hand. For example, many medical schools recruit students from the states in which they are located, with the idea that students are more likely to practice in their home state. But such efforts can be thwarted if there aren't enough GME positions for those students after graduation....

Ever wonder why there is a continuing stream of new medical schools being opening up across the country as well as an an expansion of GME residency and fellow slots in the state teaching hospitals? It's all about ensuring an adequate number of physicians for the state in future years with particular emphasis on physicians in specialty practice. As noted above, "forty-eight percent [of speciality trainees] practice in the state where they completed graduate medical education."

There is one other facet of this issue of physician recruitment not alluded to in the article. The majority of newly minted speciality physicians take jobs as hospitalists. These are hospital-based, hospital physicians as opposed to those who select private practice in the community. This trend is expected to continue unabated. It was described in a previous note (see: Hospitals Use Their Medical Schools, Residencies for Later Physician Recruitment). Here is a quote from this previous note:

I asked the dean of a major medical school recently about how the school and its teaching hospital were accommodating to this trend. He said that they were well positioned to recruit the most talented hospitalists in the future because they could observe their medical students and house officers over time and select the best of them for subsequent job offers. He added that this explains, in part, the impetus for hospitals across the country to launch medical schools and increase their numbers of post-graduate trainees: they are seeking the means to ensure an adequate supply of well-trained physicians in the future.

The hospital executives will increasingly be in the driver's seat regarding the future direction of healthcare in concert with governmental officials and health insurance executives. As hospitals expand their services, they want a dependable supply of highly qualified physicians to hire as hospitalists. The best way to guarantee this supply is through tight links to local and regional medical schools and post-graduate speciality training programs.

Companion Diagnostics Gains Wider Acceptance in FDA Despite Challenges

The future of cancer therapy and molecular diagnostics lies with personalized medicine, with each new drug coming to market with a companion diagnostic. The FDA and its physician panels are getting much more serious about the need for the latter as evidenced by some recent news (see: A Push to Tie New Drugs to Testing). Below is an excerpt from the story:

The Food and Drug Administration last year rejected the company’s drug to treat a subset of leukemia patients whose tumors had a particular genetic mutation. The main problem was not the drug itself, the agency said. Rather, ChemGenex had not specified a companion test that could reliably detect the mutation so that the drug could be given to the patients it is intended to help. These days, it is often not enough for pharmaceutical companies simply to bring a drug to market. Regulators and insurers are also prodding the companies to develop tests to pinpoint which patients are most likely to benefit from a drug, thereby sparing other patients from needless side effects and expense. The pressure has thrust drug and diagnostics companies into sometimes awkward partnerships aimed at developing such tests, which are called companion diagnostics. There were at least 25 such deals in 2010 and 15 in the first half of 2011, up from only seven in 2008....But the simultaneous approval of new drugs and tests is still rare....There are numerous economic, scientific and regulatory obstacles to developing companion diagnostics, executives and analysts say. Often, scientists simply do not know what to test for to predict a drug’s effectiveness, or they don’t find out until near the end of the drug’s clinical trials. And coordinating development and approval of a drug and a test — by two separate companies reviewed by two F.D.A. divisions — can raise the cost of drug development if not done well....Moreover, it is often a dance between a giant and a pixie, locked in an embrace but with a tendency to move in opposite directions. Pharmaceutical companies can spend hundreds of millions of dollars to develop a drug, then can reap billions of dollars a year in sales with high profit margins. Diagnostic companies typically spend several million dollars to develop a test, with annual revenues also around that level, and low profit margins. For pharmaceutical companies, the risk is that a test can lower sales of their drugs by restricting use to a fraction of potential patients.

I am having some trouble believing the claim that pharmaceutical companies "scientists simply do not know what to test for to predict a drug’s effectiveness, or they don’t find out until near the end of the drug’s clinical trials." It's highly unlikely that a pharmaceutical company would invest millions, or even billions, of dollars in the development of a new drug and not have a deep understanding of its mode of action or gene target. If this is the case, then they surely would have some idea about how to develop a companion diagnostic. This latter knowledge is also increasingly important in the research subject selection during drug trials. The companion diagnostic can be used to choose the ideal research subjects for inclusion in the trials and, in so doing, increase the therapeutic effect of the drug.

No, I think that the root of the problem is embedded in the following two points: (1) drug companies want to try to avoid the availability of a companion diagnostic because its presence would reduce the number of potential drug recipients; and (2) they are uncomfortable partnering with diagnostic companies which would hold key scientific knowledge and whose performance could put the success of the new drug at risk.

What we now see with the ChemGenex case cited above is an FDA physician panel stressing the need for companion diagnostics for new anti-cancer agents that can cost thousands of dollars per month. Here's a relevant quote about this topic from another article emphasizing the criticality of a "single clean, validated [companion] diagnostic test "(see: ChemGenex shares battered after FDA panel setback):

Members of the [FDA oncology] panel [that reviewed the ChemGenex drug application] raised questions about the company's trial data and its testing strategy. The therapy is designed to treat leukemia in patients with a specific genetic mutation, and researchers used various tests to identify patients for the clinical trials. The experts want a single clean, validated diagnostic test to make sure the right patients are being given the drug. "...."I doubt it will be years, but I suspect it will be months" before a test can be validated, said ChemGenex CMO Adam Craig. ...."This is something that just represents fairly sloppy drug development," said Gail Eckhardt, the panel chairwoman.

IVF Clinics in the U.K. Accused by Pioneer in Field of "Ripping Off" Couples

It's rare that physician "insiders" complain about the price of healthcare services in their field. A recent article about the cost of IVF in the U.K. therefore caught my attention (see: IVF clinics 'are ripping off desperate couples). Below is an excerpt from it:

Fertility clinics are charging women who want to have children three times the actual cost of their treatment – with the NHS [National Health Service] as guilty as private practitioners in exploiting desperate couples. The accusation comes from the fertility pioneer Lord Robert Winston, who today launches a scathing attack on the high cost of fertility treatment in the UK and the unfettered use of expensive, unproven tests by private clinics. The Labour peer and former head of the NHS  IVF clinic at Hammersmith Hospital said there was a "huge amount of exploitation going on" and that some of the charges were a "scandal". "A combination of avarice on the part of the clinics and desperation on the part of the women is driving this market" ....Figures show over 45,000 women had IVF in 2010, with 60 per cent paying for themselves and 40 per cent treated on the NHS....For the majority of patients, who must pay privately, the average basic cost of treatment is £2,500 a cycle in clinics run by the NHS and £3,500 in private clinics. The price of drugs and tests is added to the bill which can double the cost. Lord Winston said: "My view is that both NHS and private clinics are charging much more than the cost of delivering the treatment." He calculated the costs, taking account of salaries and overheads, for a large unit treating 2,000 patients a year where economies of scale meant it could carry out treatment more efficiently....Lord Winston also attacked the growing use of experimental techniques for which there was little evidence by private clinics trying to enhance their success rates. "There are no randomised controlled trials and without trials we cannot know that they work. Can you imagine going into hospital with cancer and a doctor saying, 'I am going to give you this treatment because I think it might work?

Given that the cost of most IVF services were originally not covered by insurance and also viewed by participating couples as essential, I suspect that the price structure for this service was primarily demand driven. These high price-points have persisted to this day. As Winston says above, "a combination of avarice on the part of the clinics and desperation on the part of the women is driving this market." Note that the price of services which are evoking his criticism in the U.K. are only a portion of those in the U.S, which may be two or more times higher. For what it's worth, here's a link to a web site on IVF cost that shows the cost of services by country. Such high costs drive some couples abroad via the IVF medical tourism route (see: In Vitro Fertilization (IVF) Cost Abroad). I have blogged previously about reproductive tourism including surrogate pregnancy (see: An Introduction to Reproductive Tourism Including Surrogate Pregnancy).

Perhaps even more shocking than these price issues is Winston's claim that private IVF clinics in the U.K. are using unproved experimental techniques to improve their success rates. However, it's well known that, in the U.S., the FDA review of medical procedures and devices is often less rigorous than that required for new drugs. Witness the current controversy about the use of metal-on-metal hip prostheses (see: Metal-on-Metal Hip Implant Controversy Escalates).

Fragmentation of Healthcare Delivery as a Barrier to Participatory Medicine

Participatory medicine is the term used to describe the empowerment of patients to take a more active role in decisions relating to their healthcare, a variant of consumer empowerment (see: Interpreting the Tea Leaves: Ten Hot Trends in Healthcare, Lab Medicine, and Pathology Informatics; Participatory medicine). A recent blog note by Dr. Kevin Pho discussed the extent to which participatory medicine is influenced by the personality of the treating physician as well as that of the patient and barriers to patient involvement (see: How much guidance do patients want with their medical decisions?). Below is an excerpt from the article:

There is a spectrum of how much physician involvement patients want. Some may want physicians only to suggest and inform but leave the ultimate decision to them. Others prefer doctors to have the final say. The only way to know a patient’s preference is through a continuous relationship where that comfort level can be developed over time. After several encounters, a clinician should have a sense of how much, or how little, direction a patient needs. Sadly, two factors in healthcare today work against such a sustained doctor-patient relationship. One is the fragmentation of medical care. More patients are seeing not only a primary care physician (PCP) in a clinic, but also a hospitalist when admitted to a hospital, along with an array of specialists both in the hospital and the clinic. According to a [recent] study, Medicare beneficiaries saw an average of two primary care physicians and five specialists working in four different practices. Without knowing the patient well, each provider may differ with his or her input in the medical decision process, which can frustrate patients who may have their own ideas of how much their doctors should be involved. Next, consider the decay of primary care itself. There is a profound shortage of PCPs....Patients who cannot schedule timely primary care appointments go to the emergency department, where they encounter clinicians they’ve never met before. The shortage is compounded by what is shown in the results of [a recent survey] which revealed that 30% of PCPs were likely to leave the field, citing burnout from time pressures, a chaotic work pace, and little control over their work. Both the shortage and attrition of primary care providers worsen the odds of forming long-term relationships with patients.

One of the two major barriers to participatory medicine, cited by Pho, is the fragmentation of care. He raises a very significant point. Most of the the most significant medical decisions that  are made by a patient occur in an inpatient hospital setting. Even if a patient has a well established relationship with a PCP for ambulatory care, his or her inpatient care will frequently be turned over to critical-care hospitalists and other hospital-based specialists. These interactions may often be fleeting or disjointed and may not allow the treating physicians to develop an understanding of a patient's personality and interest in playing an active role in decision-making.

I was at a loss to come up with possible solutions to this problem, given the direction in which acute care delivery is headed. However, a critical care physician provided me with an idea. She said that palliative care specialists often provide essential continuity-of-care for critically ill patients and help avoid the mixed messages inherent in the fragmentation of physician care. This is a medical speciality that is now growing in popularity (see: Impressive Growth in Hospital-Based Palliative Care Teams). It may be that these palliative care teams may be helpful in promoting more autonomy for hospitalized patients.

Biotech Billionaire Invests in a "High Speed Rail System" for Genomic Data

In a recent blog note, I suggested healthcare IT and hospitals may want to hitch-a-ride on the research computing -omics cloud that is rapidly developing (see: The -Omics Cloud: A Healthcare IT Solution Already Developed for Genomics Research). More evidence for progress in the genomics research sector was provided by a recent article about investment in a "high-speed rail system" for transporting genomic data in support of cancer research (see: Biotech billionaire mounts digital attack on cancer). Here is an excerpt from the article:

Dr. Patrick Soon-Shiong has taken part of his fortune made in the biotech game...and spent it on a high-speed rail of sorts to transport genomic data among researchers and medical care facilities around the U.S. The initial focus of the previously announced Chan Soon-Shiong Institute for Advanced Health (CSS Institute) will be supporting cancer research....Soon-Shiong and his wife Michele Chan formed CSS Institute earlier this year. The billionaire's nonprofit has a supercomputer housed in Arizona for genomic data analysis and two data centers in the state. He's also taken financial responsibility of and the chairman role at the National LambdaRail (NLR), the 12,000-mile fiber-optic network that enables high-speed data transfers of 100 gigabits per second among hundreds of researchers, physicians and hospitals in the U.S....The CSS Institute's supercomputer and data centers have been linked to the NLR, with genomic sequencing hubs around the country expected to follow....[T]here are about 500GB of data in each genome...and now groups have begun projects that involve sequencing many genomes, and sharing the huge amounts of data generated from those projects among collaborators requires IT infrastructure that is equal to the task. Enter Soon-Shiong's nonprofit and the fiber-optic network he's bankrolling. Suddenly, sharing mountains of data, including those from sequencing and imaging tissue, start to sound manageable. An important aspect of the CSS Institute's work is to streamline the translation of scientific discoveries into new therapies....Cancer treatment has shown signs of speeding up due to genetic findings that help match patients with treatments, and the oncology field is expected to be the initial focus of the CSS Institute.

This article indicates that there is a new component in support of the genomic research supercomputers that are cropping up around the country -- fiberoptic networks that will connect them and allow them to share data. One of them is the National LambdaRail (NLR). Needless to say, cancer diagnosis and treatment is the epicenter of genomic research and entrepreneur/ philanthropists like Dr. Patrick Soon-Shiong are helping to make integrated and collaborative research computing a reality. It also make sense that individuals such as he are investing in information technology rather than making bricks-and-mortar donations to universities and hospitals. Such investments would seem to come naturally to individuals who have make their fortune in biotech.

Do Patients Need Protection from Hospital-based Medical Apology Programs?

Are hospital "medical apology programs" a problem for patients who choose to participate in them? They seem to be, at least according to a recent blog note by Gabriel Teninbaum of Suffolk University Law School (see: Protecting patients from medical apology programs). Below is an excerpt from his post:

To deal with the aftermath of medical errors, an increasing number of providers are encouraging injured patients to participate in “medical apology programs.” The idea, proponents say, is for patients to meet with facility representatives to learn what happened and why.  It gives the patient a chance to ask questions and it gives providers a chance to apologize, and as appropriate, offer compensation.  These programs are promoted as humanitarian, and, at least in terms of providing an emotional outlet for patients, they are. The evidence also suggests that they are about something else: money.....A 2010 study found that at one major facility, apology programs resulted in fewer injured patients making claims and, among those that did, they accepted a fraction of the amount in settlement compared to patients who made claims before the program was instituted.  For minor injuries, no real harm is done by this; but the outcome can be cataclysmic for seriously injured patients who accept an apology in lieu of compensation. One explanation for why apology programs are so effective at keeping patients from asking for money is the strategic and legal expertise of those that run them.  When a patient participates in an apology program with a provider, it is only after the provider’s attorneys and risk management experts have coordinated with the provider....Patients, by contrast, are less likely to have legal advice.  Some programs, like the one run by COPIC – the largest malpractice carrier in Colorado – outright forbid participating patients from having counsel.  One 2003 study found that 96% of apology programs do not advise patients to seek legal counsel before participating. 

It will come as no surprise that part of the justification for hospitals mounting medical apology programs is to reduce the number and size of malpractice suits against them. Presumably this saves money for the hospital and their medical malpractice carrier. This goal notwithstanding, I personally view such programs as having merit. It's certainly useful for a harmed, or potentially harmed, patient to hear the hospital's side of a problem and an apology for an incident. I also don't see the need for the hospital personnel participating in apology programs to advise patients to seek legal counsel before participating in such a program. I think that it would be a very rare patient who was harmed due to a hospital error who did not seek advice from legal counsel. There are an ample supply of attorneys in medical malpractice law who would be eager to take on such cases on a contingency basis.

Eight Reasons Why Nurses Get Fired; Drug Abuse among Nurses

A recent article that included a list of eight reasons why nurses get fired caught my attention (see: 8 Reasons Nurses Get Fired). Below is the list:

1. Giving into Temptation—Abuse of Prescription Drugs
2. Demand for Perfection—Making Too Many Mistakes
3. Cyberspace Collides With Reality — Facebook Usage & Information
4. Put On a Happy Face—Grumpy or Negative Attitude
5. Obtain Proper Licensing—Failure to Renew or Receive Nursing License
6. Patient Treatment—Abuse of Patients
7. The Disappearing Act—Too Many Absences
8. Inner Politics—Proper Handling of Management

True enough, but these are also the reasons why most people get fired. All you need to do to get such a universal list is to delete the word "prescription" from item #1 and substitute "customer" for "patient" in #6. Drug-abusing and drug-diverting physicians and nurses are the reason why there are special "medical-professional panels" offered by reference labs as part of their drug screening programs (see: "Point-of-Work" Drug Testing; A Growth Industry). Here's a quote from an article about drug abuse among nurses (see: Narcotic Use and Diversion in Nursing):

Substance abuse among nurses can range from 2% to 18%....The rate for prescription type drug misuse is 6.9%....The prevalence of chemical dependency is 6% to 8% (130 to 170,000) according to the ANA estimates....According to Burke, director of the Cincinnati Police Pharmaceutical Division, his squad arrested one health care professional every six days. 70% were nurses. He stresses that not all are caught (1998). In the state of North Carolina, there are 108,462 licensed nurses. In 2000, there were 90 nurses with drug related violations. Sixty-two nurses were enrolled in alternative treatment programs [in the state]. So the statistics show there are more nurses diverting and using than actually reported.

I suspect that nurse drug testing policies vary from hospital to hospital but usually include testing at the time of hire plus perhaps some variant of random testing (see: drug testing at hospitals).

 

 

Impressive Growth in Hospital-Based Palliative Care Teams

One of the most interesting and worthwhile recent trends in healthcare is the rise in palliative care. It can provide a set of important choices when patients and their families face life-threatening illnesses. A recent article discussed the its upward trend. Below is an excerpt from the article (see: Hospital-based palliative care rises 19%)

The nation has improved its overall grade on providing hospital-based palliative care to a B, up from a C in 2008. The higher grade is due to a 19% rise in the number of hospitals with palliative care teams since 2008, according to a report released in October. The number of 50-plus bed hospitals with palliative care teams has nearly tripled since 2000 to 63%, said the research conducted by the Center to Advance Palliative Care...Eighty-five percent of hospitals with 300 beds or more have such teams in place, the report said. Palliative care teams are composed of physicians, nurses, social workers and chaplains who help patients with serious or life-threatening illnesses by treating pain and other symptoms, finding the best setting for the patient after discharge, and alleviating psychosocial and family burdens...."This is starting to become the standard of care throughout the country," said [an expert in the field]. "There is an accumulating body of evidence that not only does palliative care improve quality of life and quality of care but also significantly reduces hospital spending." For example, patients with lung cancer who received palliative care along with conventional treatment survived 2.7 months longer than patients who received only standard oncologic care, according to a [recent report]....There is one oncologist for every 141 newly diagnosed cancer patients, compared with one palliative medicine doctor for every 1,200 patients with serious or life-threatening illnesses, the report said. There are 73 accredited palliative care fellowship programs in the U.S. producing about 90 new palliative medicine physicians annually. The report calls for lifting the cap on Medicare-funded residency positions and redistributing some unused slots to accredited palliative medicine fellowship training. Despite broader availability of palliative care teams in hospitals, too often the patients' primary physicians wait too long before involving palliative specialists....

Like geriatrics, there will probably never be a sufficient supply of palliative care physicians. I am sure that the day-to-day work of these specialists can be stressful and certainly not as remunerative as, say, the practice of oncology. Nevertheless, it's a critical component in hospital critical care. The key to providing adequate services around the country, as noted above, are the palliative care teams composed of physicians, nurses, social workers and chaplains who attend to patients with life-threatening illnesses. This is an example of hospital-based multidisciplinary teams that must include physicians but which can extend the reach of palliative care physicians in the face of their current inadequate numbers (see: Can the Cleveland Clinic Model Be Replicated in Other Hospitals?). This sounds like a reasonable objective: lift the cap on Medicare-funded residency positions and redistribute some unused slots to accredited palliative medicine fellowship training.

Web Sites Referring to Lab Soft News Ranked by Visits

On occasion, I review the web sites that refer to Lab Soft News ranked by visits to keep abreast of the most popular search engines and other sites directing traffic to the blog. Here is a list of the leading ones selected from a single day's traffic:

google.com; 30.8%
bing.com; 3.4%
google.co.uk; 2.2%
google.co.in; 1.9%
search.yahoo.com; 1.8%
google.ca; 1.7%
linkedin.com; 1.6%
theatlantic.com; 1.1%
google.com.au; 0.9%
t.co; 0.7%

There are a few interesting ideas and observations that emerge from this list.

• It will  come as no surprise to anyone that Google, as the dominant global search engine, is the major referring site to Lab Soft News. Adding the referrals of the U.S. arm of Google with those from in the United Kingdom, India,  Canada, and Australia, we see that the total number of referrals account for 37.5% of a day's visits.
• Note that Bing accounts for 3.4% of visits. The U.S. searches of Yahoo are being "powered" by Bing (see: Update on the Web Search Wars; Yahoo Influence Diminished).  Even adding the Bing and Yahoo referrals together, the combined percentage is only 5.2%. Bing's U.S. search market share in October was reported to be 14.8% so that the experience for this blog is far below this number (see: Bing U.S. market share flat at 14.8% during October).
• The 1.1% of referrals from The Atlantic is an interesting story. I posted a note in July, 2008, about Nick Carr's article in The Atlantic and the controversy it has created (see: Is Google Making Us Stupid?). Here is the link to the original article from the July/August 2008 issue of The Atlantic:  Is Google Making Us Stupid?. Nick was questioning whether web search is permanently affecting our brains. This topic is so controversial that it has stimulated a 5,000 word essay in the Wikipedia (see: Is Google Making Us Stupid?) He subsequently wrote a book, The Shallows, he which he continued to explore this controversy. I personally think that web search is changing the way that we skim/read for information on the web but is also making us more productive. Pew Research has published a superb collection of opinions about this controversy with most people saying that web search is not having a deleterious effect on our minds (see: Does Google Make Us Stupid?). At any rate, Nick and his controversial ideas have continued to draw readers to this blog and, for that, I am grateful.
• I had to perform a Google search to figure out what the URL "t.co" represented in the list above. It accounted for 0.7 of the referrals to this blog. Here's an excerpt from the Wikipedia entry: It's  a] URL shortening service created by Twitter. It is only available for links posted to Twitter and not available for general use. Eventually all links posted to Twitter will use a t.co wrapper. (see: T.co)