Medical School 2020, Year 2, Week 25

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From our anonymous insider…

Musculoskeletal week features 14 hours of lecture.

Monday morning, A nerdy early 40s orthopedic trauma surgeon discusses osteomyelitis (bone infections) and infectious arthritis (joint infections). An infected bone or joint requires surgical debridement to remove the infected tissue. “Antibiotics cannot penetrate this avascular infection. Ubi pus, ibi evacua. The age-old mantra. One of the most satisfying things is taking pus out. You go in and leave it better than they arrived, period.” Students’ favorite part of his lecture: “A classic case of chronic osteomyelitis is a WWII soldier who was shot. The bullet seeded bacteria that was walled off by his immune system from the healthy tissue. 45 years later in the soldier’s old age with a depressed  immune system, the infection activates.”

A lively 50-year-old pediatric orthopedist presents childhood muscle and bone disorders. Her practice involves improving gait and balance in movement disorders such as cerebral palsy. She does this by using braces, botox injection into certain muscle groups, and tendon release/transfer.

Cerebral palsy, present in about 2 per every 1000 live births, is a “non-progressive movement disorder caused by ischemia to the developing brain, typically in utero but also in early childhood. Example ischemic events include a cord wrapped around neck of baby in utero, stroke or a near drowning event. “When parents hear CP, they immediately picture a wheelchair bound, drooling, not functional child. If the anoxic event covers the entire motor cortex, then yes. But, more often CP deals with specific muscle groups. Some just have an issue with a few toes. CP is a spectrum.” She explained how cerebral palsy a common malpractice suit. “If your baby has cerebral palsy, call us to sue your Ob/Gyn. It is not always the obstetrician’s fault. 70 percent of events are thought to be prenatal.” 50 percent of CP cases have a history of prematurity. “Interesting the advances in prenatal care have not improved the incidence of CP.”

[John Edwards, the 2004 Democratic VP nominee, had a pre-Senate career as a plaintiffs’ lawyer suing physicians in cerebral palsy cases, At trial he would channel the words of the unborn child for the jury’s benefit. Expert witnesses hired by insurance companies defending these lawsuits would explain that there was no scientific basis for holding the obstetrician responsible, but the juries would often award millions in damages. Attempts to set up funds to compensate all cerebral palsy victims, not just the ones who sue, have been fought by trial lawyers. Edwards was a candidate for the 2008 Presidential election, but his campaign was impaired when a former campaign worker gave birth to his child and funds needed to be diverted to keep the new mother quiet. (She could have sued for child support in North Carolina, but the revenue obtainable through conventional family law is limited compared to in California or Massachusetts.) Edwards was criminally prosecuted by the U.S. Department of Justice for this diversion of funds to Rielle Hunter, but a month-long trial resulted in a mistrial on most counts.]

Our orthopedist lecturer showed a before-and-after video of her 10-year-old patient with cerebral palsy. The child initially had limited mobility, walking on his toes with a scissors gait. “Everything was tight. I was giving regular Botox injections, but those were having diminishing effects. I performed an adductor tendon release and transfer.” After the surgical intervention and physical therapy, the class could not discern any gait abnormality. “This child will not be able to compete in sports, but he’ll live a relatively normal life. Remember that cerebral palsy does not spread; we call it a static encephalopathy.” Several classmates were astonished about the tendon transfer surgery. Jane: “We can do that?”

She concluded with some career advice: “Do not assume children with physical impairments have mental impairments. Just because their body is failing them does not mean their mind is failing them too. And when you choose a specialty, think whether you are improving the quality of your patient’s life, or just prolonging their suffering.”

Our third lecturer: a surgeon specializing in nerve reconstruction presents on upper extremity nerve injuries. Type-A Anita, an aspiring Ob/Gyn, exclaimed in horror about nerve injuries during delivery: “That happens? We are barbaric!” Erb’s and Klumpke’s palsies occur if the infant’s head is placed in extension or if the infant’s arm is placed into abduction (away from body), respectively. “If the kid regains elbow flexion in three months, there is a good prognosis that he or she will fully recover.” The surgeon explained that it is possible to do nerve transfers. “We can get back elbow flexion and shoulder range of motion. Animation of the hand and wrist are still extremely difficult.”

Gigolo Giorgio ask about the potential role for nerve scaffolds in the future. “It is here! We use it today, keratin scaffolds, pig submucosal, cadaver scaffolds. And some people are starting to use nanotechnology to implant growth factors and such. That’s above me, I’m just the mechanic!”

Two sports medicine physicians held workshops on common musculoskeletal injuries using X-rays, CTs and MRIs. “Knee dislocations used to be caused only by severe trauma such as a football injury or car accident. We now are seeing low-velocity knee dislocations. An obese individual will step off a curb, and the momentum of the body on a fixed tibia will posteriorly dislocate the knee. Really no good surgical repairs for that so far.”

After lecture I attend the weekly “quarterback” meeting where rotating students air concerns and complaints about the curriculum to the block director. Students complain that lecturers get off-topic following questions from unprepared students. Mischievous Mary and Geezer George cited infractions from students who did not know the anatomy of the brachial plexus (nerves innervating the upper extremity). “I do not go to lecture because of it. It is more effective for me to use that time studying in the library.” George: “There is something wrong when some of the best-performing students do not go to lecture.” Several students tried to show their maturity relative to others in the class. A student recommended that two or three lectures be highlighted each week that require preparation. Mischievous Mary and Geezer George lept on it saying “we are not kids, if you did not prepare just shut-up during lecture.”

Wednesday morning, our sixth lecturer: a 50-year-old orthopedic surgeon lectures on bone diseases. Osteoporosis, and its precursor osteopenia, are diseases of disordered bone deposition resulting in decreased bone mass density [BMD]. “Your bone mass density peaks in your late 20s, and continues to decline thereafter. Moderate weight-bearing exercise is the most effective way of to raise your peak BMD, and to decrease the decline of BMD after your glory days. Moderately overweight individuals actually have stronger bones because they load their bones with more weight.” (He may be taking his own advice here; Pinterest Penelope described him as “tubby.”)

Why is osteoporosis bad? “The weak bone from osteoporosis is prone to fracture from normal weight-bearing activities and falls. People with osteoporosis can spontaneously fracture their vertebrae with no injury at all. Someone who falls on their butt or side should not get a fracture. One-year mortality after a hip fracture is 30 percent. This is not something you just put a screw in it and be done with. Yet, our medical system does not think about bone health. I see so many patients who have been on glucocorticoids on and off for asthma. [chronic steroid use causes osteoporosis.] They have terribly weak bones in their 50s. Frankly, there is nothing to do about it now.”

Thursday morning the whole class turned out to hear the last orthopedist lecturer, Hot Shot, a spine surgeon known for being one of the most highly compensated surgeons at the university.

“When the spine is injured, it shuts down. This is called spinal shock. Reflexes will be absent, even if the connections are not broken. You cannot assess the spinal cord injury level until spinal shock is over [2-3 days].”

Hot Shot explained why he choose Ortho: “I never wanted to do a rectal exam again. Boy, was I wrong. As a junior resident — that’s the guy in ER — my attending would tell me every single trauma case gets a rectal. If you do not do it on the patient, I will do a rectal exam on you.” He explained that every trauma patient should have a bulbocavernosus reflex test to assess the spinal cord integrity. This reflex is elicited by applying pressure to the glan penis or clitoris (or tugging on a Foley catheter), and feeling for increased anal sphincter tone.

Gigolo Giorgio asked whether spinal shock could be shortened by steroids. “We do not know what causes spinal shock. Like most things in medicine, our understanding is observational.”

After lunch, two state health department epidemiologists lead a workshop on an example hepatitis C outbreak. The senior epidemiologist begins describing the case: “I got involved after two or three calls from EM physicians diagnosing acute hepatitis from a new hepatitis C infection.” Hepatitis C is reportable disease in most state, meaning every physician must report the case to the health department. She scheduled a private meeting in a McDonald’s parking lot with one patient, a 25-year-old male college student. “Fast food parking lots are a good meet-up location. People want to remain anonymous.” (This is apparently an occupational hazard; the 55-year-old woman weighed at least 180 lbs.) The patient reluctantly explained that he visited a nearby college for an Ultimate Frisbee competition and “raging” party. Alcohol, cocaine, marijuana, IV drugs were all used. The patient explained, “There were a few tattoo artists hooking people up. I got a small one. I do not even remember it, I was so wasted.”

The junior epidemiologist, a 40-year-old with pink and purple hair, interviewed two other patients, including a married graduate student who had sex with several partners at the party. This patient provided contact information for one of the tattoo artists. The tattoo artist was an herbal medicine enthusiast in her 40s who claimed to use a homemade needle-cleaning machine. After interviewing 10 people (providers and patients), the epidemiologists completed their case report, estimating that, between tattoos, sex, and IV drug use, 200 people were exposed to hepatitis C.

[If the Editor were qualified to work in a state health department, the report would read “People spent 85 percent of their time at the party having sex with strangers, getting tattoos while too drunk to remember, and injecting recreational drugs. They wasted the rest of their evening.”]

We go to our small groups. Straight-Shooter Sally: “[The epidemiologists] seem so cynical.” My facilitator, a 45-year-old EM physician who stopped practicing seven years ago after she gave birth to children, but is trying to study for her boards now: “Everyone who works in the ED becomes cynical. Part of it is your job training, you are supposed to see the worst in everyone to not miss anything. Part of it is just who you are dealing with. Some people just think different. No shame in taking advantage of the system. For example, I had a patient with a connective tissue disorder who would keep coming to the ED every few days. He would purposely dislocate his shoulder to get Dilaudid (hydromorphone). In residency we had this homeless couple who would come in once a week, matter of factly state they were contemplating suicide knowing they would have to be admitted. They would get ‘two hots’ [warm bed, warm meal]. The male was a registered sex-offender so he was not allowed to go to homeless shelters. Instead he was surrounded by children in the ED.”

Straight-Shooter Sally gives a 20-minute presentation on tobacco cessation. She presents the findings of a “landmark study” (“A Randomized, Controlled Trial of Financial Incentives for Smoking Cessation”, NEJM, 2009) in which people who could receive $750 over a one-year period were three times more likely to quit. All of us have seen COPD [chronic obstructive pulmonary disease] patients during our shadowing. They can barely walk, but they still smoke. Might they be more likely to quit if Medicare or Medicaid didn’t pick up nearly all of the cost of their care? Type-A Anita shut the question down: “No, people would die.”

I shadowed my family medicine physician mentor that afternoon. Regarding the first patient, a 54-year-old male with chronic hepatitis C infection, my attending says, “Ask him about his alcohol intake.” I ask, “Sir, how much alcohol do you drink per week?” He responds, “A bit.” “What do you mean by a bit?” Patient X: “Well it depends on the day. I have a few beers most days. If there is a football game on, at least a six pack. If there is a NASCAR race, then at least 12 beers.” The attending came in, explaining”We cannot treat your Hep C until you quit drinking.” Patient responds: “Doc, I cannot. NASCAR is coming up. I… I… I just can’t. After NASCAR season we can talk.”

Our patient case: Elizabeth, a 22-year-old female diagnosed with spinal muscle atrophy (SMA) at the age of 2, presents for excruciating hip pain and lower back pain not managed by her pain medications. She has had two spine surgeries for scoliosis and three hip surgeries to prevent hip subluxation (partial dislocation) that are common in SMA due to muscle deterioration.

SMA is a genetic disorder where a defect in the survival motor neuron 1 (SMN1) gene results in progressive loss of the anterior motor horn neurons in the spinal cord that innervate muscles.  These muscles begin to atrophy causing joint weakness, joint instability, and pain. Elizabeth’s neurologist explained: “If you ever see these patients, your heart will break. They have full cognition, full sensation. Their minds are trapped in their bodies.” (Don’t go to North Dakota if your heart is easily broken; SMA prevalence there is 3-10X more common than in the rest of the U.S.)

Elizabeth: “I was quickly put in a wheelchair. I have a less severe form of SMA, but I still work hard on PT to maintain my function.” Her 55-year-old mother added: “Elizabeth of course needs help going to the bathroom, putting clothes on. She cannot rotate herself from one shoulder to the other while she sleeps. You cannot imagine how difficult it is to try to help your child in the middle of the night while she screams out of pain from you touching her.”

Elizabeth has minimal strength in her arms and legs. Her atrophied back muscles cause severe spine deformities. These have required three separate spine and hip surgeries within two years. She is unable to walk.

“I enjoy therapeutic horseback riding and training service dogs,” continued Elizabeth, who had brought her enormous shaggy service dog. “Service dogs are not pets. They are medical equipment.” The Bernese Mountain Dog helps pick up and carry items and also prevents depression. “Emotional support dogs are a fraud. I go shopping with my mother and one time a dog wearing a service vest started barking at my dog who was working on a task for me. The owner did not even apologize. It was fake. Emotional support dogs are ruining things for people who really need service dogs.” (Type-A Anita blushed. She has been obtaining emotional support dog documentation to facilitate flying her black Labrador puppy to fly home during upcoming vacations. Nearly all of the couples in our class have been adopting puppies lately and getting together at a local dog park.)

[Editor’s Christmas gift idea for Anita: “Black Labs Matter” poster, with optional yellow Lab holding an “All Labs Matter” sign.]

What did Elizabeth wish people knew about the disability community? “People with disabilities are not stupid. I still have a brain. When I am at the grocery store with my mom, people come up to us and ask: ‘What is her name?’ My mom just turns around and ignores it. I respond, ‘I am right here!'”

Mischievous Mary asked the mother how she learned about the diagnosis. The mother, today in her late 50s explained, “I have two older children. I knew something was wrong with Elizabeth quickly. I kept bringing her to the pediatrician because she was missing her milestones. The pediatrician brushed them aside and said she would be fine. ‘She’ll be sitting up in no time.’ I called a doctor who is a family-friend. He agreed that something was seriously wrong and scheduled an an appointment with a neurologist. The neurologist called with the rest results one evening while my husband was out with the kids. I was all alone as he said, matter of factly, ‘Your daughter has spinal muscle atrophy and will not live for more than five years.’ I do not remember what happened for three days after that. I had a nervous breakdown.” (Straight-Shooter Sally afterward noted that it was possible that the doctor had good intentions, citing an HIV patient’s doctor who called the patient at home so as to avoid a public scene in the medical office.)

“I hated people after that phone call,” the mother continued. “I hated anyone who had a healthy child. ‘Why me?’ I would ask. When I went to my oldest son’s basketball games, it would knock me down seeing these healthy kids and their happy parents in the stands. It sounds terrible to say, but when my sister had a healthy baby girl, I hated her too.” She continued: “I dropped everything and devoted my whole life to my baby. This destroyed my marriage. I regret this, but my marriage was destroyed by my daughter.”

There is some hope for SMA patients. Elizabeth’s muscle movements improved dramatically after starting nusinersen (Spinraza), an orphan drug approved by the FDA in December 2016. “The new drug is amazing. I did not notice anything until my fourth dose. I used to have to use two hands and struggle with all my might to lift an object like a cup. One day I noticed I could pick up a cup with one hand!”

There may be even more hope for Biogen, the marketing partner for Spinraza. The list price is $125,000 per injection ($750,000 in the first year and $375,000 annually after that). The geneticist explained: “No one pays the sticker price. Most people are in a clinical trial, or the insurance company is negotiating behind closed doors to bring the price down. The only challenge I have faced is with the hospital pharmacy carrying these expensive orphan drugs. We have learned to never bill the patient. It just creates mayhem. Before we purchase the drug we get pre-approval from insurance or deal directly with the drug company.”

Elizabeth concluded by saying, “Do not listen to what other people tell you. Everyone told me I would never be able to ride a horse. I can now trot a horse all by myself.” Elizabeth goes on dates with other women and advocates for the local LGBQT community.

Friday concludes with a suture workshop. A plastic surgeon lectures on the types of sutures and various suturing techniques. Each student is gifted a basic suturing kit with forceps (“pickups”), needle drivers, and scissors. We practice on chicken breasts and a suturing model that incorporates synthetic material to mimic the epidermis, dermis, and subcutaneous fat. Mischievous Mary, an aspiring cardiothoracic surgeon, schmoozed with the general surgery clerkship director who helped with the workshop. Pinterest Penelope: “God, she was sucking up so much.” Jane and I steal a few sutures to practice at home.

Statistics for the week… Study: 12 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: Jane’s father, an internist, rents a three bedroom ski condo for a nearby medical conference. Jane, her sisters, and I join for a weekend getaway. I am falling behind in my studying for the upcoming block exam.

More: http://fifthchance.com/MedicalSchool2020

Nominating Brett Kavanaugh was a clever ploy to get Amy Coney Barrett approved?

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In a comment to “Judge Kavanaugh dust-up shows that Republicans need to abandon white men?” I wrote

Imagine for a moment that Amy Coney Barrett had been appointed. A cisgender man sends a letter to a senator saying that she tried to force him to do something sexual 30 years ago. He has been in therapy ever since he was attacked by Ms. Coney, a high schooler with raging hormones. The therapist will corroborate that the victim shared his painful memories well before the nomination of Mrs. Barrett. Would anyone believe this or care?

Is it possible that the nomination of Kavanaugh was a clever door-in-the-face maneuver to get the Senate to breathe a big sigh of relief and approve Amy Coney Barrett?

[Separately, if Kavanaugh is rejected and goes back to his regular job, the necessary logical conclusion will be that Americans are content to have a rapist on the United States Court of Appeals for the District of Columbia Circuit, but they can’t tolerate a rapist on the Supreme Court?]

How to avoid opioid addiction

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Some things that I learned about opioids from working with billions of insurance claims (teaching SQL at Harvard Medical School) and reading papers by Denis Agniel…

Note: All of this information relates to legally prescribed opioids after surgery (folks who use opioids illegally aren’t likely to ask an insurer to reimburse them!).

Americans are getting more prone to abusing opioids, with rates of abuse rising since 2012.

Doctors are not gate-keepers. They write nearly twice as many opioid prescriptions as patients actually filled.

After reports of opioid addiction, docs started prescribing lower doses around 2014, but they extended the number of pills/days. This increased addiction (34 percent increase in misuse rate per week), as did every refill (71 percent increase per refill). What doctors should be doing is giving high doses for less than two weeks, then telling patients to go cold turkey.

Young men are more likely to abuse opioids after surgery than young women, but rates converge around age 30.

Combining benzodiazepines with opioids puts a person at high risk for addiction.

Main take-away: Try not to take opioids for even one day longer than you need to and definitely don’t go for more than two weeks.

I met Bill Burr’s source

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We attended a birthday party in our suburb recently for a 1st grader. I asked the hostess what she was up to lately. She said “Physical labor.” It turned out that what she meant by “physical labor” was caring for two healthy children, both of whom were the responsibility of the government/taxpayer from 7:15 am to 3:15 pm on weekdays (1st and 6th graders). She does no work for wages. Her house is not especially well decorated or organized. The four food groups that I’ve seen her serve: microwave, frozen, wine, and takeout. Perhaps she was the source for Bill Burr’s “The most difficult job on the planet” ?

[Separately, her personal situation provides a good micro example of the macro economic shrinkage to the U.S. from our family law system. She and her to-be-former husband are embroiled in divorce litigation. Massachusetts is a winner-take-all state and both she and her husband are seeking to become the winner. Both have decided not to work during the roughly three years that the case is expected to last. Each litigant hopes to be declared the “dependent spouse” and “primary parent,” which would entitle that person to live off the other for at least the next 17 years (until the youngest child turns 23). Although there are alimony guidelines intended to limit the duration of alimony as a function of the length of the marriage, if one litigant can convince the judge that he or she cannot work, alimony could be extended until the death of the payor. What’s the twist here? One litigant holds an MBA from an Ivy League business school. The other litigant is a fully trained attorney with experience in one of the hottest and best-paid areas of law. Both previously earned more than the salary of a judge in Massachusetts and both will be testifying that it is impossible for them to find work, even as they drive past 50 restaurants with “help wanted” signs on their way to the courthouse.]

Readers: What’s the most epic description of hardship you’ve heard from a suburban parent lately?

Medical School 2020, Year 2, Week 24

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From our anonymous insider…

Genetics week is taught by a 53-year-old pediatrician specializing in complex genetic diseases. Jane described her as “brilliant, but slightly awkward.” She began: “You all know when you walk by someone, say at the grocery store, who just doesn’t look normal. We are going to develop a systematic exam and language to explain these features.” We scrolled through slides of patients with various syndromes. “We’ll start with severe dysmorphic characteristics, and then use the same analysis on less severe phenotypes.” We look at kids with low set ears, flat nasal bridge, presence of epicanthal folds (skin flap covering lacrimal duct in lower nasal corner of the eye), smooth philtrum, and a high interpupillary distance. The geneticist: “You would be surprised how many terminologies in genetics have had to be changed over the years because they are no longer politically correct. We’ve changed simian crease to single palmar crease. We no longer use the term Mongoloid to describe upward-sloping eyes.” (Most people have two palmar creases.)

After the 12 PowerPoint images, we play “Is it Normal?” in groups of six. Each group rotates through 15 stations, where we analyze an image and decide if it is normal or abnormal. The geneticist explained this is the same game they play at conferences: “Whenever we go to the annual genetic disease conference, the main lecture is preceded by a game where each geneticist in the audience tries to beat the computer in identifying genetic diseases from pictures. The computer gets better and better each year. Humans still win though.” Straight-Shooter Sally: “I cannot wait until we have this technology in the office. I won’t have to memorize this stuff.”

[Editor: the Google AlphaGo team trained a computer to screen medical images. See “Development and Validation of a Deep Learning Algorithm for Detection of Diabetic Retinopathy in Retinal Fundus Photographs” (Gulshan, et al. 2016; JAMA). Maybe they will start selling ads for medical school loan refinancing next to the results?]

She concluded by explaining linkage analysis studies using VNTRs (variable number of tandem repeats). These regions exist on each chromosome and are passed through generations. “VNTRs provide a genetic fingerprint of each individual. I practiced in the age of patents on inheritance tests for specific genes. A family I worked with had autosomal dominant polycystic kidney disease (AD PCKD). The father needed a kidney, and his daughter wanted to donate. We needed to ensure the daughter did not have AD PCKD, but a patent troll had purchased the polycystin gene patent and raised the price to $10,000. Instead of paying the troll, we determined that she did not have the disease using an older technology linkage analysis of the family. We found a VNTR associated with the polycystin gene of the deceased father. We were able to clear the daughter based on her lack of this VNTR.”

Gigolo Giorgio: “How do people think of this stuff?! Not many people can do what she does. She has a special skill.” Lanky Luke: “I want each of my future children to go see her for a check-up. Make sure there is nothing wrong with them.”

After lecture, we debate ethics cases in groups of 10 while a licensed genetic counselor and pediatrician rotate. For each case, we divided into 2 subgroups of 5 to take each side of the debate. Frustratingly, we never learned an authoritative resolution of any of these issue. [Editor: perhaps it varies by state?]

Case 1: Huntington’s disease testing for a minor.  A mother wishes to test her 8-year-old child whose father died from Huntington’s disease. Anticipation is a phenomenon in certain genetic diseases where the onset and severity of the disease increases as the disease is passed down through generations. For example, a grandfather may get Huntington’s at age 45, the mother at age 40, and child at age 30. Straight-Shooter Sally: “The mother is violating the future autonomy of the child. We should wait until he is 18.” The pediatrician added: “We also need to consider if this test is indicated. Would the answer change treatment?” Jane: “Does the mother have a right to know if her child has the disease? Perhaps she could get the test, and withhold the results from her child until he is ready to make a decision.”

Case 2: Adoption of a child at risk for Fragile X syndrome, an inherited disease characterized by moderate mental retardation and dysmorphic features. Rebecca, a 14-year-old with Fragile X syndrome, is raped and becomes pregnant. The rapist is imprisoned. The family places the child on the adoption list, but declines amniocentesis testing for the child. The family requests you, the physician, withhold the 50 percent risk of the child having Fragile X syndrome from the adoption agency to improve chances the child gets placed into a “good” family.  Should the patient be required to get tested via an amniocentesis? Do you inform the adoption agency or withhold the information even if requested? Pinterest Penelope: “I don’t think you can force a mother to get a test she does not want. Amniocentesis is not without complications.” Straight-Shooter Sally: “I understand that, but an adoption agency should have the right to decline to list the child then.” Lanky Luke: “It would violate the trust in the adoption system. Fewer families would be willing to adopt a child if they risk not knowing the health of the baby.” Jane: “There are families that are actually seeking to adopt special needs children.” Lanky Luke: “These are interesting dilemmas, but I do not believe it is doctor’s role to decide what, from their perspective, is the right course of action. We should have started by studying the laws.”

[Editor: The same-sex couple that ministers to the spiritual needs of the Millionaires for Obama in our Boston suburb has two special needs children, neither of whom has any genetic connection to either father. A handful of deeply closeted Deplorables in our town occasionally grumble about the cost to the school system of providing for these voluntarily adopted children of the pastor and his husband.]

Case 3: A pregnant alcoholic heroin user refuses to enter rehab and stop abusing these teratogenic compounds (those that can disturb the development of the embryo or fetus). My EM facilitator commented, “This happens much more than you can imagine.” Can you force her to receive addiction treatment or counseling? Jane: “This is child abuse.” Lanky Luke: “Is this not a double standard? If you assume the fetus has a right to not be harmed by teratogens, would not this argue against abortion after some age?” We discussed Wisconsin’s 1997 Unborn Child Protection Act, whose constitutionality was still being argued 20 years later (see “Supreme Court allows Wisconsin to enforce ‘Unborn Child’ law” (Wisconsin Gazette, August 11, 2017). Type-A Anita became passionate on the subject of preserving abortion rights: “You need to educate the mother. I wouldn’t consider [daily heroin consumption] child abuse.” (The mom is unaware that heroin and alcohol are bad for kids?)

Breaking from the genetics theme, on Thursday we had three hours of lecture on back pain. A soft-spoken orthopedist with a Southern accent explained, “Doctors hate dealing with back pain. Ironically is is also the number one cause of office visits and 4 out of 5 malpractice lawsuits are related to back pain.” His example of a typical case: “I fell while working at Walmart, and I want to sue Walmart for hurting my back. I want to get opioids and a check every month.”

He continued: “Real back pain is debilitating though. Always ask the patient to show you where the pain is. A lot of people say back pain, but the issue is in the SI (sacroiliac) joint, the hip, or the kidney.” How to tell the difference between real and malingering? Start with Waddell’s sign: push on spine and ask to rotate hips. “My favorite is to ask patients who come in limping to limp backwards. No one ever practices limping backwards.” He added, “Be cautious though. They will immediately know that you know they are FOS [“full of sh*t”]. Makes rest of the visit a little awkward. My advice is to refer any back pain patient to orthopedics. We are trained to handle the real ones, and the FOS ones. I always ask how patients make the pain less. Most people with real back pain have found a way to lessen the symptoms. The exception is a herniated disk. Someone with a herniated disk has trouble finding comfort anywhere.”

“We’re the Microwave generation,” said our 45-year-old orthopedist. “Patients with a chronic condition expect immediate relief from one office visit. Our main cure is time, however. 8 out of 10 patients with back pain will be better in 3 months with none to limited therapy; 9 out of 10 people will be better in 6 months. It is tough to ask someone to be in this excruciating pain for three months though.”

That afternoon, a geriatrician gave a lecture on dementia and then we broke into small groups to practice mental status exams, including the MoCA (Montreal Cognitive Assessment), recently taken by President Trump. Anita projected a picture of Rear Adm. Ronny Jackson, the physician who “stamped” Trump’s exam. Anita: “There is no need to worry guys, our Commander in Chief is smart.” The Hillary-supporting students proceeded to trash Dr. Jackson’s credentials. Straight-Shooter Sally: “I am shocked that Trump scored 30/30.” A handful within our group matched the President’s score, but most of us lost 2-3 points on short term memory. Type-A Anita, looking at her near-the-bottom score, concluded: “Trump lied. Doesn’t it amaze you how he can lie so easily and so much?”

Our patient case: Connor, a 6’4″ 59-year-old CPA presents on his wife’s urging for forgetfulness. Family history reveals his grandfather and father had dementia in his 60s. (Lifetime risk of developing Alzheimer’s is 10 percent, but the risk is 25 percent when a first-degree relative has Alzheimer’s and the correlation is stronger for early-onset dementia.) Connor: “My wife and I grew up together as neighborhood friends from kindergarten and started dating in high school. She saw my family deal with my father’s dementia. He would walk out of our house and get lost for hours until the police picked him up. He got very aggressive in his 70s before he died.” (Connor was speaking to us three years after his diagnosis, but he remained intelligent and articulate.)

Martha, who had been a stay-at-home wife, took over: “I started noticing things years before he was diagnosed. He would come home later and later from work. Things would take him longer. He was having to stay much later every day to finish the same amount of work, until 8:00 or 9:00 pm in the office. He lost his sense of time.” Connor was diagnosed with early-onset Alzheimer’s in 2014 and retired from his accounting job.

Martha: “One conflict was about our taxes. I know nothing about finances. He was adamant about continuing to do them. This became a crisis in 2016. He kept saying he would be able to do the taxes. The deadline was approaching and he still had barely started it.” Connor was ashamed about having to file an extension and asking for help from a CPA friend: “I just couldn’t get all the papers together.”

Students asked Martha how her typical day had changed. “We talk about something, and ten minutes later he forgets. It can be infuriating. He’ll forget where we are driving to; he’ll forget to pick something at the store that I told him ten times. I try to be more patient. I pray every day for the strength to be patient.”

What other changes had she noticed? “He has some balance issues. He used to love playing basketball with our grandchildren. He fell one time and has had to stop. He has the same preferences. He likes the same food.” Ambitious Al asked about intimacy. Martha: “He looks the same, but I know he has become a different person. We do not sleep together. I have not slept with other people, but I have considered it.” Connor was visible uncomfortable.

Mischievous Mary asked the geriatrician: “What are the guidelines to getting genetic testing for Alzheimer’s?” “As of now, the guidelines do not support testing patients, early or late despite the genetic risks. This may change as the costs come down, but until there is some prevention therapy, the test will not change management of the disease.”

Mischievous Mary: “Martha made the disease all about her. I wish we heard a little more from Connor.” Pinterest Penelope: “That was 45 minutes of trashing poor Connor.”

[Editor: Anyone who stays with an Alzheimer’s-afflicted spouse in our age of no-fault, no-shame divorce, should be celebrated for heroism, not criticized for speaking frankly. Martha could walk down to the local family court at any time and get a warm reception by saying “Connor is annoying me with his illness so I’d like to take 50 percent of the cash and pension and move to a beach condo in Florida.”]

Straight-Shooter Sally: “This was the most powerful patient case.” Jane: “It gave me chills.”

Rather than drive one hour to her rural home, Jane’s sister used her key to move into our house for stomach flu recovery. We diagnosed her with norovirus based on profuse diarrhea, fever, and chills. The sister’s nursing colleague bought over IV kits and saline bags, and we used the skills we learned in Year 2, Week 13 to hook her up to a saline drip. Rather that welcoming this this opportunity to practice her skills at establishing IVs, Jane was concerned about catching the bug.

Jane and her Health Professions Scholarship Program (HPSP) military comrades did not get paychecks on time due to a one-day government shutdown. “I only learned because the HPSP Facebook group is blowing up. People are yelling at each other about whom to blame — Trump or the democrats.”

Statistics for the week… Study: 14 hours. Sleep: 6 hours/night; Fun: 2 nights. Example fun: MedProm. Nervous Nancy hosted a pregame before the short walk over to the conference center ballroom. The rumors of Persevering Pete dating an M1 are true and his M3 ex departed shortly after the new couple arrived. Faculty exited en masse as students stormed the dancefloor to Justin Timberlake’s Filthy.

More: http://fifthchance.com/MedicalSchool2020

Why won’t Claire McCaskill pick up Christine Blasey Ford in her Pilatus PC-12?

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Christine Blasey Ford is facing some challenges in making it to Washington, D.C. “Kavanaugh accuser says GOP trying to ‘bully’ her” (Politico):

The GOP has been told that Ford does not want to fly from her California home to Washington, according to the Republican senator, which means she may need to drive across the country to make the hearing. Ford has reportedly told friends she is uncomfortable in confined spaces, indicating a physical difficulty in making the trip by plane.

From “Claire McCaskill, Elizabeth Warren describe their #MeToo stories of sexual harassment” (Washington Examiner):

One of the stories — elicited in response to the social media #MeToo campaign — came from Sen. Claire McCaskill, D-Mo., who said a senior state lawmaker told her decades ago that she may need to trade sexual favors for passage of legislation.

“I cautiously approached the very powerful speaker of the Missouri House of Representatives” McCaskill said. “He looked and me and paused and said, ‘Well, did you bring your knee pads?'”

“I do think he was joking, but it was shocking that he would make that joke to a colleague,” said McCaskill, who has previously opened up on the incident.

McCaskill owns a Pilatus PC-12. Suppose that she were to demonstrate her passion for the #MeToo era by sending the crew and plane out to the Palo Alto airport. Rather than be confined in a five-seat automobile for five days, or endure the suffering of domestic First Class airline travel, Dr. Ford would be able to spread out in this massive executive 11-seater (2 pilot seats plus typically 8 seats and a restroom in the back) as she made her way to Washington, D.C. to testify.

[How do we know that McCaskill owns a PC-12? “McCaskill repays nearly $300,000 for unpaid taxes on plane” (CNN):

Sen. Claire McCaskill, D-Missouri, acknowledged Monday that she failed to pay nearly $300,000 in personal property taxes owed over the last four years for the partial ownership she and her husband have in a private plane.

McCaskill, a vocal supporter of reform and transparency in the Senate, described the failure to pay taxes as unintentional and said she will sell the plane.

McCaskill’s acknowledgement comes shortly after Politico reported that she used tens of thousand of dollars from her Senate office budget to cover the costs of chartering the plane for Senate business. After the story broke, McCaskill repaid the U.S. Treasury $88,000 for 89 flights.

McCaskill said the disclosure had created a “perception” problem and the “appearance of impropriety.” She sought a full accounting of her use of the plane which revealed the failure to pay taxes.

Did she sell the plane? Seven years later, “McCaskill admits to using private plane for part of RV tour”:

A campaign aide confirmed to CNN that the plane used during the tour is different from the one McCaskill had in 2011.

“Clearing The Air On Senator “Aire Claire” McCaskill’s Use Of An Airplane”:

In a political stunt, she demanded her husband “sell the damn plane.” But shortly after her reelection, the senator and her husband  bought a new, more expensive plane.

Technically, the plane is owned through TLG Aviation LLC, a McCaskill-owned business entity valued at over $1 million.  It’s all detailed on the senator’s personal financial disclosure form for the fiscal year 2016. Aero Charter, the company hired by Senator McCaskill to operate the 2009 Pilatus PC-12/47E [N5346M], wrote to the Federal Aviation Administration (FAA) earlier in April 2017 to ask for the tracking information on the plane to be blocked from the public.”

If you do try to track this plane on FlightAware, it says “This aircraft (N5346M) is not available for tracking per request from the owner/operator”.

How does a senator pay for an airplane that costs $5 million new? “Claire McCaskill’s wealth comes into focus” (St. Louis Post-Dispatch, 2011):

In 2005, months after McCaskill announced her candidacy for Senate, [ex-husband] Exposito was fatally shot in a hardscrabble neighborhood across the border in Kansas.

By then, McCaskill was married to developer Joseph Shepard, whom she met at the birthday party of a mutual friend. Their union meant that the details of Shepard’s vast business enterprise had to be revealed under disclosure rules for elected officials and their spouses.

Shepard has made a fortune investing in affordable housing, an industry that employs complex investment vehicles and intricate tax credit swaps. Shepard’s holdings, according to forms filed with the U.S. Senate, are divided among dozens of limited partnerships, from Abilene, Kan., to Zephyrhills, Fla.

So it turns out to be tax dollars that ultimately paid for the plane. “Businesses linked to McCaskill’s husband get $131 million in federal dollars” (Kansas City Star):

Businesses tied to U.S. Sen. Claire McCaskill’s husband have been awarded more than $131 million in federal subsidies since the Missouri Democrat took office in 2007, an analysis by The Kansas City Star found.

Joseph Shepard’s personal income from his investments in those businesses has grown exponentially during his wife’s two terms in the Senate.

The federal payments don’t go directly into Shepard’s pocket. Most of the money goes toward operating costs for government-subsidized housing projects Shepard is invested in. Those companies then distribute the profits to Shepard and other investors.

In 2006, the year before McCaskill entered the Senate, her husband’s personal income from those investments was between $1,608 and $16,731, according to the senator’s financial disclosure forms.

In 2017, five years into McCaskill’s second term, Shepard personally earned between $365,374 and $1,118,158 from investments in housing projects that received federal subsidies, the disclosure forms show. Disclosure forms only provide ranges of income.

Shepard (the rich guy) was previously married. That wife sued for divorce and, during the litigation, filed for a restraining order alleging domestic violence (police report and Petition for Order of Protection). Having married a man who was accused of assaulting a woman, McCaskill could offer to join for the trip and talk with Dr. Ford about the circumstances under which it should be #BelieveTheSurvivor.]

 

iOS 12 review

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I upgraded an iPhone X to iOS 12 earlier this week. The best feature is that Google Maps will work via Apple CarPlay.

The software is terrible at figuring out when to use WiFi calling. With full-strength 75 Mbits symmetric WiFi and 1/2 to 1 bar of service (the only thing that the Millionaires for Obama hate more than Trump is cell towers) the phone decides “well, let’s just keep using that quality Verizon mobile network”.

iMessage has been reconfigured for teenagers. If you want to send a photo you have to go through a screen in which you are prompted to take a new photo (selfie?) before you can tap on an obscure button to get to the taken-an-hour-earlier-or-whatever photo that you actually want to send. Worse, this “instant camera” app has the “old photos” icon in the top left corner, not to be confused with the “regular camera” app in which the “review old photos” is in the lower left corner.

Summary: a weak effort for suburbanites; due to the incompetently handled WiFi calling situation, the phone is barely usable as a phone.

Related:

Should Donald Trump be regarded as a hero of the environmentalist and anti-climate change movement?

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We were at a friend’s house for dinner the other night. The hosts are both medical doctors and were hugely enriched by the Federal government’s expansion of funding for the health care industry during the Obama Administration. Lately they’ve been hugely enriched by the booming economy (at least here in pharma- and health-care-heavy Massachusetts) and stock market.

As per usual for Massachusetts, however, they are forecasting imminent doom for both the country and the planet due to Donald Trump’s existence. When I asked “What have you personally suffered as a result of Donald Trump being in the White House?” the answer is that it is not legitimate to think of one’s own welfare. They are especially virtuous because they are thinking on a planetary scale and are virtuously concerned with all of humanity, not merely their thriving personal finances and situation. Two particular knocks against Trump is that he is relaxing environmental regulations so that our local atmosphere will be polluted and that he will be responsible for a planetary-scale meltdown of climate change, e.g., due to withdrawing from the Paris Agreement.

Yet Wikipedia says that the entire machinery of the Paris agreement was hoping to “mobilize $100 billion per year … by 2020” (and in terms of reality, about $10 billion total was actually contributed over a period of years). The economic boom from Donald Trump’s corporate tax rate cut has expanded the U.S. economy by more than $10 billion a week. Perhaps the hated Trump won’t work with the hated Republicans in Congress to spend this new wealth on combatting climate change, but the next President (a virtuous Democrat?) will have that opportunity.

If fighting the increase in atmospheric CO2 is a long-term problem, having been built up for the past few hundred years, what’s wrong with accumulating wealth now and spending it once Donald Trump has hopped on his personal Boeing 757 for the trip out of D.C. and back to private citizenship? Since Trump has been much more successful in generating economic growth than previous presidents (Obama did have a dead cat bounce off the Collapse of 2008), if we assume that a wealthier country has more flexibility in terms of what it can do to combat climate change, should Donald Trump actually considered be the hero of the environmentalist hour?

[Analogy: Lyndon Johnson was able to pursue both the Great Society and the Vietnam War only because of 200 years of accumulated wealth. Medicare and Medicaid were created by Johnson and have become the government’s largest spending area. The Great Society also made food stamps permanent and expanded taxpayer-funded housing for Americans on welfare. So the Trump economic boom could in theory pave the way for a future Great CO2 Vacuum. Congress is currently indulging in deficit spending, but the additions to the national debt seem likely to be smaller than the growth (i.e., we’re still paying off debt that Congress accumulated during the Reagan years (they said “yes” to his tax cut proposal, but “no” to his proposed spending cuts), but we’re doing it as a richer country).]

Related:

75 percent chance of career failure considered in a positive light

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I was chatting with a successful physicist the other day. I said that reading Losing the Nobel Prize made me realize what a risky career choice science was. He scoffed at my timidity. “If you get into a top graduate school, you’re practically guaranteed a post-doc.” (i.e., a $52,116 per year job after 5 years; roughly at age 35 if the PhD program is started at 24 and it takes 6 years to earn the doctorate) What about after that? “You’d have a 1 in 4 chance of getting an assistant professorship.” Once on the tenure track, he considered actually earning tenure to be straightforward.

If we define “success” in science as a long-term job as a scientist, he was saying that the chance of failure was a minimum of 75 percent (maybe closer to 90 percent if we consider the probabilities of not getting into a great graduate school, not getting a post-doc, and not getting tenure once on the “tenure track”). In his opinion this was only a minor detraction from the appeal of a career in science.

Related:

  • How Many PhD Graduates Become Professors? (from 2016: “life science PhD graduates in the US have only a 16% chance of finding a tenure track position”; but how many people on “tenure track” actually do get that lifetime guaranteed job?)
  • “Women in Science” (“This article explores this fourth possible explanation for the dearth of women in science: They found better jobs.”)

Medical School 2020, Year 2, Week 23

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From our anonymous insider…

Neurology week is shortened by two days of snow cancellations (the hospital and rotations for M3 and M4 students are on a normal schedule).

A 45-year-old neurologist with a British accent lectures on neuromuscular disorders such as Parkinson’s disease, Huntington’s disease, Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease), and Multiple Sclerosis. Gigolo Giorgio asked about why deep brain stimulation (DBS) works for certain conditions? Neurologist response: “All of DBS is voodoo. There is not real science behind it, but it works. We just do not know why.”

He teaches us about tardive dyskinesia, a permanent movement disorder after exposure to antipsychotics. In a healthy person, dopamine from the substantia nigra (black pigmented neurons in the midbrain) acts to facilitate muscle movement via stimulation of the basal ganglia, a network of neurons located deep in the brain (“deep nuclei”). Antipsychotics block dopamine signaling, an attempt at reducing the symptoms of bipolar disorder and schizophrenia. This can have the same effect as damaging the substantia nigra, as happens in Parkinson’s disease. “Tardive dyskinesia happens after long-term use of the drug. We believe it is the brain trying to rewire around the drug. There are lawyers filling courtrooms around the nation suing doctors and pharmaceutical companies for this. There are more lawyers focusing on it than neurologists!”

He concluded: “The history and physical exam are are a dying artform. Some conditions, such as Guillain-Barré, you see nothing on imaging. Surgical residents, if they even have a stethoscope, put the diaphragm on the “Surgeon’s triangle” — where they can hear the abdomen, heart and lungs in one place. I ask what they got out of it and they respond, ‘Umm, they are alive.’ The answer is in the patient. You should know what is wrong with 95 percent of patients after taking the history. If you leave the room without knowing, DO NOT order tests. Go back in and take a good history, then do a good physical, and then order those unnecessary $5,000 imaging studies.

A 55-year-old neurologist reads through slides on seizure disorders. Several students doze off or check social media. She went five minutes over the 10:50 am official end time. The next lecturer, a 75-year-old neurologist, had snuck into the room five minutes early for the 11:00 am block and blurted out, “Are you done? I’ll just do this another day.” She then storms out. We have found a reason to have a PhD block facilitator in our lectures. She ran out of the third floor classroom and managed to corral the senior citizen on the first floor.

Despite a late start time due to the chase scene, the older neurologist did not disappoint. She lectured on myelopathies (disorders of the spinal cord). She ignored her uploaded powerpoint and used the chalkboard. We started with basic anatomy of the spinal cord and its blood supply. She asked, “Does anyone surf?” Buff Brad raises his hand. “How do you surf?” He slowly responds, “I wade out on my stomach, then pop up.” She responds: “You are clearly a novice. First time surfers lay on their stomach and extend their back as they surf out to catch the next wave. This prolonged hyperextension of the spine causes compression of the anterior spinal artery in what is termed Surfer’s myelopathy, potentially causing permanent paralysis.” The class laughs. [Correct technique is a yoga-style pose on one’s knees.] She concludes: “My husband died, so I have no one to not listen to me except medical students. It is such a pleasant surprise you are all listening to me.” In the Age of Universal Offense, students were divided over her lecture. Everyone agreed they learned a great deal, but some were turned off by her sense of humor.

Wednesday morning, our chief of neurosurgery, a man in his 50s (see Year 1, Week 15), lectures for two hours on traumatic brain injury (TBI). The IT staff as usual comes in before the lecture to to ensure that the required-by-regulation PowerPoint slides were ready and that the video is recording. The Chief: “I don’t think I will be using it at all. PowerPoint is a way to present material you do not know.” He made chalk drawings on the blackboard.

Any patient presenting for TBI will be scored using the Glasgow Coma Scale (GCS), which evaluates the patient’s eye, verbal and motor responses to stimulus. “Glascow Coma Scale is like the SAT. You get a score for just showing up. Glascow Coma Scale starts at 3. Don’t say 2 to an attending. You’ll sound like an idiot.” Pinterest Penelope wrote this advice down. The Chief: “What are you doing? Pens down and listen.” [Editor: Research shows that students who take notes learn more, even if they later discard those notes. See “The Pen Is Mightier Than the Keyboard: Advantages of Longhand Over Laptop Note Taking” (Mueller and Oppenheimer 2014, Psychological Science) and its references.]

Gigolo Giorgio was startled by the Kernohan’s notch phenomenon. Kernohan’s notch phenomenon typically occurs due to a hematoma (extravascular blood in the brain) causing the uncus, an inferior lobe of the brain, to herniate through the connective tissue floor of the brain into the brainstem canal. Nerves exiting the brainstem, namely CN III that innervates muscles of the eye, are compressed and lose function. “If the pupil is dilated on the left side, I go in on the left side, right?” However, occasionally the uncus can push the midbrain to constrict the contralateral CN III instead of the ipsilateral CN III. “I can operate on the wrong side of the brain because of this false localizing sign,” he continued. “This was not unheard of before we had stat CTs commonplace in hospitals.”

The Chief: “Medicine is a language. Isn’t medical school so easy compared to crazy particle physics you did in undergrad. If you approach it just like a language it is not that difficult. Medicine is learning to convey complex data in succinct phrases. If a resident calls me and says there is 4mm midline shift after trauma I am going to run out of bed. If a resident says there is a 1mm midline shift with a small hematoma, I am going to say, ‘Yep that’s a old alcoholic brain that is compensating for a subdural swell. We can deal with it tomorrow.’ I just downloaded a lot of information quickly. Practice presenting patients, that is what we will be evaluating you on in rotations.”

Straight-Shooter Sally: “I don’t think I learned much for Step 1 [the exam we’re taking this summer]. He did not get past his 2nd PowerPoint slide, but who cares.”

[The neurosurgeon’s life was also educational for us. His wife loyally managed the home front, including two kids, through a 7-year residency. As soon as the surgeon began earning a surgeon’s wage, she went down to the courthouse and shed the husband while keeping the kids and his income.]

Our patient case: Jimmy, a 69-year-old recently retired internist, was celebrating his 50th wedding anniversary with a trip to Scotland. “We were traveling with a group tour. I started to feel terrible. I was vomiting and felt weak. I was getting on the next train when I fainted. I initially attributed it to dehydration.” He continued, “When we were walking on the cobblestone paths in one of the beautiful small towns, I started to see double. I did not know which of the two people in front of me was real. As physicians we know double vision under the context of systemic symptoms is a serious concern, but denial is powerful. Because I did not want to ruin our wedding anniversary, I tried to hide the symptoms from my wife. We had been waiting so long for this trip and my retirement.”

His wife interjected, “I made us fly home early. He just looked weak. He was barely eating.” Once back, their son, also an internist, realized something was amiss, and interrogated Jimmy. GI symptoms are rare for Lyme disease, but the presence of diplopia, malaise, and hiking in endemic areas prior to the overseas trip caused the son to immediately suspect disseminated Lyme disease. The family took him to the ED.

Lyme disease is a tick borne illness caused by the Borrelia burgdorferi that is easily treated with antibiotics. Lyme disease is divided into three phases: early localized, early disseminated, and late disseminated. Jimmy never had the classic early localized symptoms of the  “bull’s-eye” rash (erythema migrans), present in 80 percent of patients. Early disseminated Lyme disease occurs weeks to months after the initial tick bite. Jimmy’s double vision was caused by inflammation of peripheral nerves (peripheral neuropathy). He was also diagnosed with myocarditis (heart muscle inflammation) and atrioventricular (“AV”) heart block, under-diagnosed complications of early disseminated Lyme disease.

Jimmy arrived at the ED and was worked up for Lyme disease only due to the persistence of the internist son. “They were trying to work him up for a MI [myocardial infarction] and PE [pulmonary embolism]. I kept saying, ‘no, no get Lyme serology’.” Once the test came back positive, he was started on doxycycline (antibiotic). His EKG showed mild AV block, and he was placed on cardiac monitoring. Over the course of five days, his symptoms improved remarkably, and he was discharged on day seven.”

Gigolo Giorgio: “Why is there not a Lyme vaccine?” The internist son: “There was a Lyme vaccine. [FDA approved in 1998] GSK withdrew it after the early 2000s vogue for class action lawsuits against vaccine manufacturers. There is a new product in development using injected antibodies against burgdorferi bacterium that would protect for one season and then wear off. Has anyone gotten IVIGs [intravenous immunoglobulins] before traveling? They hurt! Great business model though. Europe is further in testing the vaccine now even though the US had it first.” Another physician in the audience jumped in: “All my horses and dogs have the vaccine!”

[Editor: Mindy the Crippler, our Golden Retriever, got Lyme vaccines in 2014, 2015, and 2016. In 2017, less than a year after the most recent shot, she got… Lyme disease. This is in the tick-plagued hell of the western Boston suburbs (“woodsy”).]

During lunch, we split into small groups in small groups to talk with M4s about Step 1 and the match process. My group was led by two women who are both applying to Ob/Gyn. Step 1 exam is an 8-hour exam with seven 1-hour, 40-question blocks and a 1 hour optional break split between each block. It costs $610 to register for the exam. “Do not study First Aid or any textbook,” said the Florida native “Just do questions on UWorld, and go over each answer.” She explained that she cried in the middle of Step I. “I had to call our school counselor for support.”  The Bostonian, engaged to a recent graduate of the school visiting for support, described her Step 1 experience: “I had to get my fiancé to hold me [fortunately, he’s one year ahead of her in his medical training]. I threw up the breakfast he made me. Fortunately, he packed me sandwiches and granola bars so I did not take the exam on an empty stomach.”

After the M4s left, we stayed to consume the catered sandwiches and chat. Anita led the discussion: “Now no one can deny that our president is a racist pig.” [Donald Trump had recently characterized Haiti as a “Shithole”] Anita explained that she preferred immigrants from unsuccessful countries: “We want immigrants who understand hardship. They will be grateful, educate us, and create jobs.” Why not a merit-based system? Anita did not want immigrants taking the high-paying jobs. [Editor: like hers!]

Jane and I attend a late afternoon reception for applicants to our medical school who have come for final interviews. Most were fresh out of college and wanted to know about research opportunities at our school as well as nightlife (they don’t seem to have an accurate estimate of how much time they’ll have for partying). Some of the male applicants asked about the dating scene. The female applicants gathered around Southern Steve. We’d spread the (completely false) word that he had invented a successful medical device in between college and medical school and the women wanted to know more about him.

Thursday night means Burgers and Beers. Tonight we celebrate Sarcastic Samantha graduating PA school and finishing her Board exam. She will not get her results for two weeks, but is already excited about starting work: “I am 27, and have never had a real job!” U.S. labor force participation will not be growing, however, because my college friend who works as a project manager at Amazon exiting to “travel and reflect,” as soon as his stock options vest in March. “I do not respect or want to become any of my bosses,” he explained, adding that eventually he wants to work in the nonprofit sphere.

[Editor: Nobody gave him the standard briefing “If you have a job without aggravations, you don’t have a job.” Even sadder, apparently nobody told him about SSDI!]

Samantha plans to search for puppies if she passes her exam. “It takes several months to get all the licences and paperwork processed to begin to practice.” Luke wants to stick with their beloved cat. “I do not want a dog. Samantha wants a dog. So… we compromised and we’re getting a dog.”

[Editor: They’re using the same “one-woman, one-vote” system that we have in our house!]

I ask Samantha and Luke, “When are you going to have kids?” My plan is to have kids after Luke gets into residency and I have a job there. I do not want to be moving and searching for a new job in a foreign city while pregnant.” Luke: “I don’t want kids soon. Samantha wants kids soon. So… we’ve compromised and will have kids soon.”

Friday’s 2.5-hour weekly ethics seminar is taught by the 55-year-old director of our Masters in Public Health program. The topic is “Social Determinants of Health.” We had been assigned the first 30 minutes of the seven-part PBS documentary series Unnatural Causes: Is Inequality Making Us Sick? (2003). “Power, typically framed in political terms, is the ability to control an individual’s destiny,” she opens. “Power is used in public health as a goal because this is destroyed in a lot of communities and groups.”

[Editor: The government spends $trillions on Medicaid and then spends $millions funding a documentary about how Medicaid doesn’t work?]

MPH director: What did you take away from the video?

Orthopod Oliver: More money, less problems.

Pinterest Penelope: I was shocked by the discrepancy. CEO has 10 years longer to live than workers.

Straight-Shooter Sally: I was surprised that the discrepancy is not just low versus high income. Middle class is also on the scale.

MPH lecturer: “The video cited the famous Whitehall study of british civil servants in 1967 and 1985. People theorized that the CEO would die prematurely due to a heart attack from stress. What we found was the idea of a social gradient of health.” The low-level workers were the ones to drop dead first. [Editor: Another great argument for collecting welfare rather than meekly taking one’s place at the bottom of the bureaucratic pyramid!]

She emphasized that the term health disparity is out of fashion. “Health disparities is about what communities do not have. There is a certain victim-blaming mentality in this terminology. We now use the term health equity because everyone deserves the right to health. Health inequalities must be addressed to achieve health equity.”

Donald Trump’s proposed border wall might be the biggest public health improvement since the USDA stopped promoting carbohydrates via its food pyramid, according to our lecturer: “In public health there is something called the Latino paradox. As people settle in LA from Mexico and South America, they acclimate to US culture. We know their health declines. They no longer have the support system of, say, their small Guatemalan town. We think our lifestyle and communities are great, but in a lot of ways it is not. Our kids eat fast food, don’t exercise, don’t have strong community and family ties. They come from a good diet, strong ties, little screen time, etc. Their health declines as they try to live the American dream.”

Empowered by Oprah’s speech at the Golden Globes, Anita changed her cover photo to a Lord of the Rings frame reading “The Age of Men is Over.” Her next post:

In response to the escalation of hateful incidents since the 2016 national election, the National Abortion and Reproductive Rights Action League is pleased to offer a Bystander Intervention Training. Join us to learn how to step up and be supportive when fellow community members are facing harassment and hate speech. This training will provide a grounding in the principles of nonviolence and de-escalation, followed by interactive scenarios where we practice our new skills. …

Statistics for the week… Study: 12 hours. Sleep: 8 hours/night; Fun: 1 night. Example fun: Winter formal begins at 8:00 pm, but our class, dressed in tuxedos and ballroom gowns, gets delayed at a pregame. While most play beer pong, Jane, Buff Brad, his girlfriend, and I play couples pool at the bachelor pad apartment. Faculty begin leaving when we arrive around when “Get Low” comes on. I never understand why they play hip hop music at this formal. Faculty might enjoy themselves more if they could partake in the dancing. No one threw up to my knowledge but several people fell down dancing and taking selfies in front of the photo backdrop.

More: http://fifthchance.com/MedicalSchool2020

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