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Medical School 2020, Year 2, Week 22


From our anonymous insider…

We return for the New Year after a one-month break to study oral health. Exquisite Emily, a 26-year-old Iranian-American traveled to Thailand with her boyfriend, a Deloitte consultant. Type-A Anita and her boyfriend, a work-from-home web developer, took a 1.5-week trip to Japan. She sent a snapchat of the opening “In a galaxy far away” with Japanese subtitles on opening night of Star Wars: The Last Jedi in Japan. Most students flew home to visit family for this extended break.

A recently retired 65-year-old hospital dentist (“former section chief turned professional grandpa”) leads a total of eight hours of lectures on head anatomy, the basic oral exam, and common oral pathologies. He described the various lesions of the oral cavity, such as leukoplakia (unscrapable white thickening of mucosa) and thrush (scrapable white plaque of fungus). “Whenever a patient comes in with an oral lesions that I am unsure about, I tell them, come back in two weeks. Most harmless things will go away on their own in two weeks as the mucosa is turned over. If I do nothing, it will disappear in two weeks. If I give you something, it will disappear in 14 days.”

“The dentist is the last bulwark of arrogance. Dentists do not like to refer anything out. We are notoriously bad collaborators. Compare that to you guys [doctors]. You are completely dependent on radiologists, hold extended cancer panels, reach out to specialists, etc. This collaboration ensures the very best care for the patient.” The dentists summarized why dentistry and medicine are separated. “There were two milestones in this divide. First, dentistry schools completely separated from medical schools. The second occured in 1965 when Medicare was begin created. The ADA [American Dentistry Association] lobbied to be excluded from Medicare. Dentists did not want to be involved with insurance.” Lanky Luke whispered, “Dentists are looking pretty smug now that they are still in private practice without having to negotiate with government insurance.” The internet at our school is quite slow as we attempt to play several linked videos in the slide. Gigolo Giorgio joked: “This must be the result of Net Neutrality being overturned. ISPs must be slowing our bandwidth because they think we are watching porn with all our anatomy searches.”

Wednesday was led by the “Dane”, a Danish-trained dentist and researcher. She was supposed to teach us oropharyngeal cancers but we never made it past the title slide as she answered questions. One student asked how is dental care different in Denmark than the United States. “Every child has free dental care. As an adult you pay for it, but it is much cheaper and we do not have such income inequality as you do. Only people with cavities are the immigrants. Our statistics are lower because of them.” She continued, “It is truly amazing the income disparity in the United States. And mark my words. This is only made worse by this horrible tax plan that will just make the wealthy wealthier. And this idiot president.”

[Editor: Denmark is not a paradise for everyone. An American child support plaintiff who collects $200,000 per year tax-free would be capped out at $8,000 per year per child in Denmark (see http://www.realworlddivorce.com/International ). The American who lives rent-free in means-tested public housing in an expensive neighborhood of Manhattan, San Francisco, or Cambridge would in Denmark wait many years for public housing in a dreary suburb.]

Lanky Luke: “If she thinks so little of our country, why doesn’t she go back to Denmark?” Gigolo Giorgio to the GroupMe: “Will they post the title slide?” Lanky Luke: “If not, I will report this infraction to the LCME.” Both got over 10 likes.

On Thursday we go over to the clinic to interview five patients with oral pathology. I started with a 70-year-old patient treated for squamous cell carcinoma of the oral cavity requiring surgical removal of most of his hard palate. He had a surgical obturator filling the space. He removed the obturator revealing a 3 cm diameter hole in the top of his mouth. Looking up into his mouth, we could see his maxillary sinus and nasal cavity, specifically the inferior turbinate! Gigolo Giorgio gasped. “What does it feel like to touch that with you finger?” “The gentleman responded, “Oh, nothing abnormal, it can be a little sensitive.” He described his routine for cleaning the obturator and cavity every evening: “Just like brushing your teeth!” A dentist explained the anatomy of the teeth. “If a dentist is asking you to replace amalgam filling with a fancy composite, they are just trying to steal your money. It frustrates me so much. Amalgam works just as well and lasts a lot longer. Composite will need to be replaced within 10 years. These dentists figure, they can get more money by fixing that in a decade. Amalgam will last a lifetime.” (This was in contrast to another patient we interviewed who had only a small indentation in his tongue remaining after recovering from a squamous cell carcinoma tumor that had spread all over his throat and oral cavity.)

At lunch, students debated if welfare benefits should include dental care when many Americans not on welfare cannot afford dental care. Students all agreed that dental health is an important part of people’s overall health. Nervous Nancy: “This is clearly a good investment. Inexpensive procedures like cleanings prevent the more costly deterioration of health.” We googled the dental care benefits for welfare and students were surprised to learn that states are required to provide dental care to children on Medicaid. Lanky Luke: “I do not see how our system is much different than Denmark’s. Children are guaranteed dental care if they cannot afford it, if they are on Medicaid.” Straight-Shooter Sally expressed concern for the working poor, potentially ineligible for Medicaid. Luke responded, “I wonder if the increased demand for dentistry from welfare participants might price out some of the working poor.”

Mischievous Mary changed the subject: “Guys, I need your help. I am applying for a grant tailored to women in science. The essay asks: How do I promote other women in science? Any ideas?” Lanky Luke: “Tell them you empower students and patients to feel comfortable in their chosen identify.” (Our Office of Student Affairs keeps us advised weekly regarding scholarships targeted to specific subgroups of Americans. This week’s email mentioned the BuckFire Law Firm’s Diversity & Disability Scholarships. A requirement is “a disability diagnosis from any person qualified to make a diagnosis,” so perhaps medical students could diagnose each other?)

Our patient case: Harold, a 35-year-old grocery clerk with a history of alcoholism and tobacco use presents for worsening ear pain over the past two months. He reports a decrease in appetite, and denies fever. On physical exam, the external ear canal is not inflamed and the tympanic membranes are transparent. He has hard lymph nodes palpated on both sides of his neck. Erythroplakia (a nonscrapable white plaque with blood vessels) is noted on the posterior lateral border of the tongue. Smoking and alcohol use account for 80 percent of oral cancers and therefore squamous cell carcinoma is high on the differential. A biopsy reveals an invasive squamous cell carcinoma. He is referred to a oncology who initiates radiation therapy.

Harold described how he had to quit radiation therapy after 12 rounds. His ENT explained that Harold’s gold fillings caused the radiation to unexpectedly scatter and deliver higher does to his oral mucosa and salivary glands.” Harold: “I could barely drink, let alone eat, because it hurt so much. My mouth was so dry my tongue would get stuck to the top mouth, and I would have to take several painful sips of water to pry it down.”

Two years after the radiation therapy, Harold presents for a sense of “fullness” in the back of his throat. Harold’s cancer had returned. His ENT explained recurrence is not uncommon for oral cancer. “Field Effect” is the theory that a carcinogen, for example, smoking can cause mutations in a large area of tissue, but on different time tables. This time the cancer was far more advanced, spreading to his mandible.

Harold underwent a partial mandibular resection (jaw removal) with a fibular transplant and chemotherapy. A section of his mandible, from midline to the temporomandibular joint is removed, and replaced by a section of his fibula (a small bone in the lower leg not needed to support the body). “We preserved his temporomandibular joint so he still has some range of motion.” Mischievous Mary: “Oh my god! I would never have known. We can do that?”

Harold has lost most of his teeth due to periodontal disease and removal of unhealthy teeth prior to radiation therapy. As he described: “More teeth, more problems.” He eats mostly soft foods such as yogurt, fish, and smoothies.

At lunch students complete the 30-minute Y2Q medical school questionnaire conducted by the AAMC. Examples:

  • “How frequently have you been publicly embarrassed?”
  • “How frequently have you been threatened with physical harm?”
  • “How frequently have you been physically harmed?”
  • “How frequently have you been asked to exchange sexual favors for grades or other rewards?” [Editor: question lifted from the Harvey Weinstein Memorial School of Medicine?]
  • My teachers and mentors have told me that they have high standards for my performance. (agree/disagree)
  • The medical school experience, to this point, contributes to students’ ability to work in disadvantaged communities. (agree/disagree)
  • I often feel as if my performance is being judged as a member of the identity group that I belong to more than as an individual. (agree/disagree)

After classes end at 4:00 pm on Friday, we drive 3.5 hours through a snowstorm to a ski resort for the second annual ski weekend (Jane and I did not go last year). 32 students, 28 classmates and 4 significant others, cram into a four-bedroom ski lodge located in a prime location that is walking (shuffling?) distance from entering a Black Diamond slope. Jane and I drive up with Nervous Nancy, soon to be celebrating her 29th birthday. “I feel like everyone from my former life is getting older and moving on with their lives. My best friend bought a house. My other friend is pregnant. When I went back to school, I got younger.” The car that booked the AirBNB had to drive down the other side of the mountain to pick up the rental keys. The rest of us sat in our heated cars for 1.5 hours drinking beer and wine until the keys arrived at 10:00 pm.

Once in the house, our class switched from drinking to drinking games, beginning with Kings. Tailgate Todd, a Clemson graduate with charming southern hospitality, suggests the game  Fishbowl. Every Fishbowl participant writes down two or three words on small pieces of paper. We then divided into two teams, male versus female. One participant from each team tries to act out the words while the remaining team attempts to guess correctly as many words in one minute. The women destroyed us. We settled the score by beating them at Flip Cup, four rounds to one.

Persevering Pete who has been a teetotaler, due to a history of alcoholism in his family, had his first alcoholic drink, a Tito’s vodka cranberry with seltzer water. Around 1:00 am, students began to slumber off to bed for skiing tomorrow. The limited beds and bedroom floor space was settled according to who signed up and paid first. Jane and I were subjugated to the living room with Anita, her web-developer boyfriend and Nervous Nancy. Anita had brought a Queen size, self-inflating air mattress that took up most of the space. Nervous Nancy was relegated to the couch, while Jane and I inflated our twin air mattresses squeezed between the frigid sliding door and Anita’s mattress. I did not sleep the entire night.

[Editor: I wonder if alcohol consumption and lack of sleep may explain why the U.S. healthcare system is in trouble.]

At 5:00 am, Stoner Suzy, a wealthy daughter from Southern California, and her (unbeknownst-to-me) boyfriend Gigolo Giorgio were moving around the house. Tonight she was experiencing chest pain, difficulty breathing, and peripheral angioedema (leaky blood vessels causing swelling). Her feet were swollen to the point that she couldn’t put on shoes and her fingers were swollen enough to cause pain around a ring. A few students performed rapid exams, and the general consensus was a combination of anxiety and dehydration. Suzy was concerned that it was a heart attack. Giorgio wanted to take her to the hospital, at least a 30-minute drive in terrible conditions.

After waking up the owners of three cars that were blocking Giorgio’s Subaru, he determined that it wasn’t safe to drive down the steep driveway, slick with new snow and ice accumulation. They called an ambulance, which arrived in 20 minutes. Five paramedics came into the trashed house with mattresses strewn across the living room. They drove off around 7:00 am, as the remaining students were waking up for a day on the slopes. Due to lack of coverage, we didn’t get any updates on Suzy’s condition until the much-improved couple returned at 4:00 pm. Suzy’s EKG was normal, which ruled out a myocardial infarction (heart attack). She was given IV fluids and worked up for a PE with a chest CT (negative as well). She had been upgraded from her usual dose of marijuana to fentanyl and discharged. (Tom Petty, Prince, Shiloh actor Blake Heron, and rapper Lil Peep all died from fentanyl overdoses.)

Jane and I return early from the bunny slopes and drink mimosas with the 10 non-skiers. Around 2:00 pm, a large group of students return from the slopes including Persevering Pete, Nervous Nancy, Tailgate Todd, and Steve. Following his pioneering sampling of alcohol the night before, this was Pete’s first time on skis. By choosing a classmate as an instructor, Pete found himself on a black diamond slope with the experts. Thirty seconds later he was in a ditch. “We couldn’t even see him there was so much snow thrown into the air,” recalled Nancy. “We thought he was going to have to be carried off.” After 60 seconds, Pete slowly rose, perhaps saved by the rented helmet, and walked the remaining half mile. “I lost vision for a few seconds, but I remember the whole experience.” Pete decided to forgo drinking that evening.

Statistics for the week… Study: 8 hours. Sleep: 4 hours/night; Fun: 2 nights. We are all zombies.

More: http://fifthchance.com/MedicalSchool2020

Stephen Hawking demonstrated that Facebook slows down progress in science?


Stephen Hawking died today. Among the eulogies is this one showing a 2017 Facebook posting by the physicist. I wonder if Facebook can be considered harmful to the progress of science. If a scientist is on Facebook then by definition he or she is not in the lab or at the blackboard, right?

Scientists also use Twitter, especially to let others know about an academic paper that they like. I wonder if this is harmful or helpful. If lots of people follow the most famous leaders then Twitter simply accelerates the trend toward groupthink? Or maybe this is helpful because there are no so many journals that nobody can cut through the clutter so one should just read what everyone else is reading?


Cora: is it time to shut down the flight schools?


“Cora is an electric ‘sky Uber drone’ from Google’s Larry Page and Sebastian Thrun, 2021 New Zealand launch plan” (electrek) shows a machine that can handle the roles of airplane or helicopter without depending on a human pilot or gasoline. Though it is still in development, I wonder if this means we should be thinking about shutting down flight schools. Despite the roughly $1 trillion spent by NASA plus a lot of R&D dollars spent by traditional certified aircraft manufacturers worldwide, we’re not that far from the 1930s when it comes to passenger-carrying airplanes and helicopters.

What do readers think? Will this kill interest in the Cessna 172, Robinson R44, and similar hands-directly-connected-to-flight-controls machines? Personally I would consider it a huge advance if the electric motors and relatively modest cruise speed means that Cora lacks the deafening interior noise and bone-shaking vibration of a piston-powered light aircraft.

The AStar fuel shutoff lever, and surviving a helicopter water landing


Friends have been asking me about the recent AS350B2 helicopter crash into the East River (nytimes). The pilot, who survived, mentioned the possibility of the fuel shutoff having been snagged by something in the cabin. At that point there was nothing to do but autorotate to the water. I asked a friend who is an experienced AStar pilot for an explanation. Here was his response:

The fuel shutoff on the B2 models and previous versions is on the floor just in front of the collective. They’ve had issues with passenger bag straps catching on the lever and pulling it back. Eurocopter now has a plastic guard to help protect this from happening but obviously still happens.

(It’s the partially hidden RED lever- yellow is the throttle and skinny red one is the rotor brake)

They could also catch and yank the throttle to the cutoff position as well.

He is currently flying a newer model of the same machine:

on the B3s and EC130s it’s now on the ceiling above your left shoulder. You wouldn’t think it be easy but passengers are always dropping their handbags and camera cases between the seats.

[Note that it was also an EC130, a related design, that crashed recently in the Grand Canyon (see NTSB report available on the Grand Canyon helicopter crash). Unfortunately, the pilot and a surviving passenger of that crash remain hospitalized due to their burns (update).]

Unlike airplanes, helicopters do not naturally float. Therefore if they are operated over water it is conventional to have pop-out floats that a pilot can activate via a button on the collective pitch control. This is supposed to be done right at the bottom of the autorotation as the helicopter rushes toward the water. The pilot, Richard Vance, should not be faulted for the helicopter flipping upside down. In theory it might be possible for a pilot to do a perfect autorotation and land with zero forward velocity and then float like a boat, but in practice getting the pop-outs popped and landing gently enough for the helicopter to remain intact is an achievement.

[The floats aren’t primarily designed to stop the helicopter from flipping over; they are to keep the helicopter from immediately sinking to the bottom of the river/lake/ocean. Flipping is usually a consequence of landing with at least some horizontal speed and catching the front of the skids in the water (the center of gravity of a helicopter is pretty high). If one were to land into a headwind and do a truly beautiful autorotation, like some of us occasionally do at the airport during practice, it is possible to land without any “ground run” (search YouTube for examples). But remember that even the heroic Captain Sully landed downwind on the Hudson instead of turning right and landing upwind, which would have resulted in about 20 knots less forward speed on impact. The cell phone video of this crash made the landing look almost perfect and the helicopter was upright for a brief time, so it is kind of mystery as to why it flipped.]

After that it is generally recognized that escaping from the flooded helicopter is not something that a typical person can do without training. People who fly regularly in helicopters (or even light airplanes) over water, e.g., offshore oil rig workers, may be required to take a water egress survival course (example). Escape was made more challenging in the case of this New York City crash because the passengers were in harnesses for doors-off photography rather than in conventional seat belts with a single-button release.

2018 has been off to a sad start for American helicopter enthusiasts (see also this Newport Beach R44 crash). However, at least one crash resulted in minimal injuries and a cautionary lesson for the rest of us. I have resisted adding an iPad or similar to our helicopter panel and workflow. It is painful to fly with certified in-panel avionics that were already obsolete when designed in the 1990s, but I fly VFR-only in the helicopter and want to be looking out the window. I’ve also avoided doing any kind of agricultural work due to a feeling that it is an accident waiting to happen. Maria Langer, a thoughtful and experienced pilot, combined iPad and ag flying and lived to write about the resulting crash.


  • pilot’s Mayday call (interesting partly because the LGA Tower controller, after learning that 350LH had an engine failure over the East River asks “Do you require any assistance?”)
  • FAA registration for N350LH, which confusingly shows that it was an AS350B2 helicopter, but made in 2013 (by which time the B2 model had been superseded by the B3; AINonline suggests that the B2 model was still in production as of early 2018 so perhaps it was possible to buy either a B2, with the vulnerable fuel shutoff, or a B3, with the relocated lever, in any given model year)

Medical School 2020, Year 2, Week 21


From our anonymous insider…

We return from Thanksgiving break for exam week: two standardized patient (SP) encounters, clinical multiple choice exam, NBME multiple choice exam, and case-based exam. Lanky Luke, Straight-Shooter Sally, and I were most concerned about failing the clinical exams.

My first “patient” is a 38-year-old female presenting for diffuse abdominal pain and a two-week history of bloody diarrhea (“tar colored”) with no recent travel or sick contacts. She takes Aleve (naproxen) four to six times per week due to headaches and joint stiffness. After the 25-minute encounter, I left the room with no idea what the correct diagnosis should be. Peptic ulcer disease from NSAID use? Inflammatory bowel disease? Irritable bowel syndrome from low fiber diet. I forgot to ask so many basic questions. Several students commented how they similarly stared blankly at the computer screen writing up the H&P (history and physical note).

My second “patient” is a 26-year-old female presenting for a two-day history of a burning sensation on urination. She denies abnormal discharge or change in menstruation. I complete a full “5 P’s” sexual history: partners, practices, protection against STDs, prior history of STDs, protection against pregnancy. She is in a two-year relationship with a female partner. One week ago, she had a few to many eggnogs at her store’s christmas party. She had unprotected anal and vaginal intercourse with a male partner. She is now concerned that her partner will contract whatever she has, and she does not want to tell her. I diagnose her with cervicitis (inflamed cervix) due to chlamydia or gonorrhea. I recommend dual treatment of ceftriaxone/azithromycin with Hep B/C vaccine and HIV screening for risky behaviors

[Editor: One of my Manhattan friends, whenever a Ph.D. introduces himself as “Dr. …” at a party, takes the new acquaintance aside and says “Doctor: I have this burning sensation whenever I go to the bathroom. What do you think it could be?”]

The challenging clinical 60-question multiple choice exam covered nasogastric (NG) tubes, Foley catheters, nutrition, and sexual history. Questions included:

  • Which of the following A-P chest xrays shows correct placement of the NG tube?
  • Which of the following patients is least likely to admit he/she engages in homosexual sexual practices? (answer: African-American male.).
  • What must be restricted on a renal diet? (answer: calcium, phosphorus, potassium, sodium… as a nephrologist explained, “nothing except for white bread”. )

Pinterest Penelope was frustrated at the clinical coordinator for including two questions on immunizations and screening tests based on sexual history, relationships that were not explicitly covered in lecture. The clinical coordinator responded, “Do not blame the messenger. We always tell you that information from prelecture readings and recordings can be tested.”

Pinterest Penelope after the NBME exam: “I knew everything, but a lot of the questions were poorly worded.” Gigolo Giorgio: “What did you put for the question asking about a vaginal ulcer. HSV [genital herpes] or syphilis [chancre]? It did not say if it was painful or not.” Penelope: “See poorly worded, there is a reason they are retired board question.” Students continue to complain about the black-and-white histology slides. One classmate who is color-blind apparently asked if there are any accommodations for the colorblind because the real NBME exam includes color pictures [Editor: “Pictures of Color”?]. “The answer is no.” One question asked about how to diagnose a penile ulcer due to syphilis. Straight-Shooter Sally: “I have no idea what is darkfield microscopy, but I think we’ve heard it before?” Jane: “Same! I just put it cause why not.” I also chose this answer, which is fortunate because darkfield microscopy is actually used to identify the culprit bacteria,Treponema pallidum.

Wednesday evening, with one exam remaining, Jane lost her studying motivation and indulged in a three-hour Buzzfeed binge. I was under strict instructions not to disturb her while she laughed hard enough to cry at cat videos and tweet compilations.

The case-based exam covered five patients: breast cancer, alcoholic liver cirrhosis, testicular cancer, acute kidney failure, and Crohn disease. Each case had eight short-answer questions.

Example questions:

Describe the treatment considerations in breast cancer. Answer: premenopausal women with ER positive breast cancer should begin tamoxifen; postmenopausal women with ER positive breast cancer should be aromatase inhibitor.

What are the histological characteristics of Crohn disease versus Ulcerative Colitis? Answer: Crohn disease is characterized by inflammation of the entire gut wall potentially causing strictures and fistulas (connection between two parts of the gut tube, e.g., small intestine and large intestine); ulcerative colitis is characterized by pseudopolyps, loss of haustra (gut lumen foldings) and enlarged crypts with neutrophilic infiltrate.

What kind of acute kidney injury is this given the CMP with BUN:Creatinine ratio and urinalysis. Answer: BUN:Cr > 20 suggests prerenal causes, e.g., dehydration or hemorrhage; BUN:Cr < 15 with high urinary sodium excretion suggests acute tubular necrosis.

A patient with G6P deficiency gets a URI and develops colicky abdominal pain. What is happening? Answer: Red blood hemolysis is causing pigment (bilirubin) gallstone (cholelithiasis) formation.

An overweight, 40 year old female on birth control develops colicky abdominal pain. What is happening? Answer: Cholesterol cholelithiasis (gallstones)

A 30 year old male develops hypertension, hematuria and flank pain. Ultrasound reveals several dilated cysts on both kidneys. What other tests should be ordered? Answer: a patient with adult onset polycystic kidney disease (PCKD) should get regular MRIs and echocardiograms to evaluate berry aneurysms in the circle of Willis (cerebral vasculature) and mitral valve prolapse, respectively. What is the probability his child will have the same disease? Answer: Adult onset PCKD is an autosomal dominant trait, therefore 50 percent.

(On the liver case:) Explain eight etiologies of the disease shown in the above histology slides.” Answer: Hep B, Hep C, Hep B/D coinfection, idiopathic/genetic, alcohol, obesity, biliary obstruction.

After exams, 15 students trickled into our favorite burgers-and-beers spot. Conversation shifted to the Republican tax proposal when Pinterest Penelope showed a BuzzFeed-produced video lobbying against the elimination of the student loan interest deduction. The video featured a Tufts University drama and communications graduate working as a “freelance production assistant” and receptionist struggling to pay over $118,000 in student loans ($118,000 is roughly 7 times the cost of in-state tuition and fees at Texas A&M medical school).

Lanky Luke: “Wouldn’t the increased standard deduction cover the entire taxable income of a struggling, underemployed drama graduate? I feel like so much of the ‘millennial’ frustration is directed at the wrong people. How much were her drama professors making while she was paying sky-high tuition?” Straight-Shooter Sally: “What has changed to propel tuition so high? That is what I cannot understand. There were drama professors 10-20 years ago.”

The topic turned to ongoing sexual harassment/assault charges and the #MeToo movement. Pinterest Penelope: “Can we just talk about sexual assault and how everyone is a terrible human being.” Mischievous Mary: “Someone who cannot figure out how NOT to sexual harrass someone is an idiot and should be fired.” Straight-Shooter Sally: “As a Democrat, I want Al Franken to resign. I know some of my friends who want him to stay to resist Trump, but that sets a terrible precedent.”

Lanky Luke: “Mike Pence is looking pretty smug with his no dining alone with other women outside his wife.”  Pinterest Penelope responded by referencing a Vox article, “Vice President Pence’s “never dine alone with a woman” rule isn’t honorable. It’s probably illegal” (sent in GroupMe chat). Luke: “So what are men supposed to do?” Three women all responded in unison: “Not sexually harass women.”

Type-A Anita: “When a male assaults a female, the male does not need to add that he is attracted to women. No, Kevin Spacey did not need to add that he is gay. Thank you for setting gay rights back a decade. You are trash.”

Friday evening, four female classmates independently shared Elizabeth Warren’s Facebook post. Pinterest Penelope added “Marry Me” on top of the link:

You might have heard that Donald Trump likes to call me “Pocahontas.” …  today, he stooped to a disgusting low. This afternoon, in the Oval Office, Donald Trump was supposed to be honoring Navajo code talkers – American heroes who helped save the world from fascism and hate during World War II. Instead, Trump stood right next to those Native American war heroes and came after me with another racist slur.

[Editor: This is definitely an unfair comparison. Pocahontas died at 20 years of age, an attractive young woman whose cross-cultural marriage prevented a war. Elizabeth Warren is a divorced 68-year-old.]

After Type-A Anita and Pinterest Penelope, Lanky Luke played a Tucker Carlson segment on the TV in the small group room for Persevering Pete, the class Orthopod, Jane and myself. The segment interviewed a transgender activist who argues race and sex can be chosen. Lanky Luke: “This is fantastic. I am going to apply to residency as part Native American, part Black. Derm residency, here I come.”

My small group went to our retired orthopedic surgeon facilitator’s house on Friday for a dinner party. After a few glasses of wine, we discussed the opioid epidemic. Surfer Saul: “When it was minorities addicted to drugs, the state began the war on drugs. The war on drugs was a method to suppress and incarcerate minorities, primarily African Americans and Hispanics. Look at how we judge crack-cocaine versus opioids. The moment it is white youth struggling, the drug abuse becomes a public health emergency.” [Editor: Actually if it is white youth who want heroin, the government will buy it for them! See “Who funded America’s opiate epidemic? You did.”]

Statistics for the week… Study: 15 hours. Sleep: 8 hours/night; Fun: Saturday night dinner with Jane’s sister (26 year old), newly back together with her boyfriend, a U.S. Navy retiree. The apparently healthy 37-year-old is applying for long-term disability, which will enable him to shift all of his daughter’s college expenses onto the taxpayer. He is concerned he will not be approved before school starts this August.

More: http://fifthchance.com/MedicalSchool2020

Stormy Daniels, prostitution, cell phone video, and the snowflake gynecologists


My Facebook friends have been posting daily about Stormy Daniels, an American porn actress. I’m not sure why living in the suburbs with kids has focused these middle-aged (and older!) folks’ attention on exotic sexual situations that they are unlikely to experience (though maybe not these days?), but now I am wondering too…

So that I don’t run afoul of Biblical prohibitions against gossip (useful, in my opinion, even for non-believers; I’m betting that professional atheist Lawrence Krauss now also shares my fondness for Leviticus!), I have not been tracking the question of whom the young thespian may have had sex with and how much cash she received in exchange for having that sex.

If a porn industry veteran can gather the attention of a nation, or at least its media (repeatedly on the front page of the New York Times, no longer content to leave this subject to the supermarket tabloids), let’s think for a minute about pornography. If professionals such as Ms. Daniels are involved, people are being paid to have sex. This is generally illegal (e.g., California Penal Code 647(b)). It is legal to have sex with, for example, an already-married dentist and either sell the abortion or profit from collecting child support (see “Child Support Litigation without a Marriage” and also “Litigious Minds Think Alike: Divorce litigators react to the Ellen Pao v. Kleiner Perkins lawsuit“, which includes a calculation of how lucrative it would be to have sex with a high-income partner in California), but the theory is it is the abortion being sold, not the sexual act. It seems to be legal to have sex in exchange for cash if a camera is rolling, according to the Supreme Court of California in People v. Freeman (late 1980s). How is it then possible to prosecute anyone, at least in California, for participating in prostitution? Everyone has a mobile phone capable of recording video, right? So if two adults are meeting in a hotel room and at least one of them has a smartphone, why isn’t it a defense to say that they were making a video or preparing to make a video (perhaps one of them also has a pocket tripod)? It is not illegal for people to gather near a Home Depot looking for construction work, right? So why would it then be illegal for people to gather at night holding up signs saying “Will act in your porn movie for $100 and I have a tripod”?

Separately, “Stormy Daniels on Being a Porn Star Mom” (8/23/2012) says

When the time is right, Daniels intends to be honest with her daughter about her career. She’s adamant about preparing her for the negative backlash she might experience from people opposed to the adult industry. “I’ll tell her Mommy has a job that some people don’t approve of, but Mommy’s proud of it and it’s for adults,” she says. Yet she also thinks it’s important to describe her career to her daughter in a filtered, age-appropriate way. Just like how police officers, bartenders, and emergency-room doctors wouldn’t share all the details of their job with their children, Daniels believes that discussing the adult industry should be no different.

Thus back in 2012, Ms. Daniels thought that doctors were tough individuals who dealt with situations that would make a child uncomfortable. In 2018, however, it the doctors who will need to be comforted by their children. From “How a crude photo from a Boston surgeon roiled the medical world” (Boston Globe, 1/12/2018):

During a speech to hundreds of doctors at a medical conference, a prominent Boston surgeon showed a slide that had nothing to do with medicine: Displayed on huge screens was a photo of a famous Italian statue of Shakespeare’s Juliet — with the surgeon and a colleague touching her breasts.

As chuckles and whispers rippled through the room at the November gathering, many female surgeons were incredulous — and then angry.

Dr. Jon Einarsson, then president of the large gynecological surgery organization holding the meeting outside Washington, D.C., at first seemed to defend this and another part of his presentation that drew objections. He pointed out that “all tourists’’ in Verona traditionally touch the statue’s breasts for good luck.

But when colleagues responded with a petition in protest, Einarsson, chief of minimally invasive gynecology at Brigham and Women’s Hospital, apologized. …

His speech, however, has had long-lasting repercussions, helping to prompt a reexamination of what many female gynecological surgeons say is a pervasive culture of sexism and sexual misconduct in a corner of medicine that is supposed to be all about caring for women.

Two weeks after Einarsson’s address, more than 100 surgeons sent the petition to the board of the AAGL, a leading organization of 7,000 gynecological surgeons who practice minimally invasive surgery.

The AAGL board later sent out a memo apologizing to members and saying it is “taking immediate action,’’ including organizing a task force to recommend stricter policies as well as consequences for violating them.

Board member Dr. Jubilee Brown, a gynecological cancer surgeon in North Carolina, is leading the new AAGL task force. … But “we need to make sure that moving forward [gynecological surgeons] have a way to feel safe with any concerns they might have,’’ she said. “We are all in a new age now.”

[Oddly enough, I inadvertently attended the 2015 meeting of AAGL! See Small-sample Behavioral Economics]

Note that, another thing that has changed between 2012 and 2018 is that the child of the porn star mom no longer enjoys a two-parent household. The Kansas City Star piece states “She has been married and divorced twice. Ex-husband Mike Moz is a publicist in the adult entertainment industry. According to Business Insider, she is currently married to fellow porn actor Brendon Miller. Before she married Miller she had a daughter in January 2011 with ex-boyfriend Glendon Crain.” The journalist, Lisa Gutierrez, deserves praise for working in the following phrase: “Porn fans know her body of work…”

Medical School 2020, Year 2, Week 20


From our anonymous insider…

The Saturday Friendsgiving has thinned the ranks of Monday and Tuesday lecture attendees. At least five of us, including me, are down with an upper respiratory infection.

Instead of watching the recorded lectures, I watch Pathoma and read Robbins & Cotran. Chronic kidney disease (CKD) is an irreversible loss of kidney function defined by a GFR of less than 60 milliliters per minute for more than three months. Pathoma explains the process of hyperfiltration, where loss of one group of nephron units, from e.g., infection, inflammation, hypoperfusion (low blood flow), causes the remaining functioning nephron units to increase GFR.

I return Wednesday for two hours of CKD treatment strategies by the nephrologist from last week: “What I love about nephrology is there are only four diseases that I have to know: diabetes, hypertension, pyelonephritis (kidney infection), and hereditary kidney disease. 95 percent of all CKD is caused by one of these and they are all covered in First Aid.”

He discussed some exceptions to this rule, starting with an unsolved mystery in Central America “Certain agricultural communities have up to 20 percent incidence of CKD. We do not know why.” (see “Chronic Kidney Disease Epidemic in Central America: Urgent Public Health Action Is Needed amid Causal Uncertainty”, Ordunez, et al., PLOS, 2014). He also described an outbreak of “Chinese herbal nephropathy” from a weight loss supplement that used aristolochia instead of stephania. This is the same compound that caused the 1965 Balkan Endemic Nephropathy in the Soviet Bloc. Aristolochia grows in wheat fields along Danube river Valley. This contaminated flour. “When I was in medical school, this was huge news. Now the region has 65 times the risk of getting uroepithelial cancer.”

We learned about the various types of dialysis for end-stage renal disease. “We tell our patients it is fine to travel. One of the beauties of effective government regulation is that all dialysis machines are standardized. We use the same settings for each machine. Our patients travel all over the country, and we are able to handle dialysis for visitors from anywhere in the world.”

The nephrologist concluded: “You will each briefly do a nephrology rotation. One of the things I wish you could see is the patients that are doing well. If patients do not take care of themselves there are serious consequences. You see these patients in the hospital. But if they do take care of themselves they can be healthy and productive members of society. You don’t see the patients who have jobs, families, and a good quality of life. I wish we could show you what it is like on the outpatient side. Come join us for a day!”

Our patient case: Jenny, a recently married 24-year-old manager at a fashion designer store. She was fresh out of college, had moved with her husband for new jobs, and purchased a house, all within one year. Jenny presents for one month of joint pain and an expanding rash over her face and torso. She was worked up for Lyme Disease. “I got a call a few days later by the nurse who referred me to a rheumatologist.” The earliest appointment was in two months.

“The next week I could not get out of bed because the pain was so bad.  I had to lie like a coffin. I thought I was dying. We had to cancel our honeymoon! That’s when my husband realized that the problem was more than natural laziness.” She chuckled, and continued: “I called my family friend who is a doctor. He gave me a list of tests to get. I called to get another appointment with my PCP, but I could only see a PA. I think she was insulted when I presented my long list of labs and tests.” Her labs showed abnormal urinalysis including albuminuria and red blood cells in the urine. “They now wanted me to see a nephrologist instead of the rheumatologist! I saw the nephrologist the same day.”

Her short, sarcastic 40-year-old nephrologist said that she had immediately suspected systemic lupus erythematosus (SLE or “lupus”) given Jenny’s age, sex, kidney function, and the expanding characteristic butterfly rash now covering her face. She started Jenny on several drugs, including an immunosuppressant, high dose NSAID, and steroids to bring her lupus into remission. Jenny has been in remission for almost three years since the initial flare up at age 24.

Jenny said, “My husband is a saint. Once I got the diagnosis, I immediately went to the Internet. WebMD is a dark hole of death. I thought every little ache or sniffle spelled death. After a week, My husband forbade me from looking up any information about lupus. If I was concerned about something, I told him, and he would search it.”

After roughly six months, Jenny began tapering down the powerful immunosuppressants. Her lupus is controlled now only with high dose NSAIDs. “The drugs I was on had terrible side effects, but I was just as scared about relapse. Weaning off the drugs takes months. My husband was the only reason I was able to follow the strategy. He reminded me every day, and kept track of the dosing schedules.” (Roughly half of individuals with chronic illnesses do not take their medications correctly.)

When would a nephrologist rather than a rheumatologist manage a patient with lupus? “It depends on what condition is the most urgent. If lupus is impacting the kidney, a nephrologist will manage the case until the kidneys are safe. The rheumatologist manages the day-to-day stuff, we get involved only to evaluate the kidney.”

Straight-Shooter Sally asked Jenny to summarize her care. “To be honest, I was not impressed with my PCPs. I felt like they failed me. But, I love my specialists. They know so much. Any question or concern, they have seen before and know exactly what to do.”

Surfer Saul asked Jenny if she is able to have children. Jenny’s rheumatologist does not want her to get pregnant due to the risk of a flare up from the hormone surge. Her nephrologist: “I think it is okay. I’ve had a few SLE patients get pregnant.” Mischievous Mary asked if pregnancy would stress Jenny’s kidneys because of the sudden increase in blood volume and hyperfiltration? “Oh no, pregnancy is good for your body, good for the kidney. Pregnancy is a protective risk factor for lots of cancers. I tell Jenny she can get pregnant.”

Gigolo Giorgio asked if Jenny, in light of her current knowledge of lupus, could remember pre-diagnosis flare-ups. “Yes, I got really sick in college once. Terrible. It had to be a flare up. I also remember being allergic to all these random things like yellow dye.”

A student asked the nephrologist what her patients can you eat on a renal-restricted diet? “Wonder bread and lettuce. There are no good options. Every food has things the kidney struggles to excrete. I have patients come in to me complaining of having Wonder Bread stuck to the top of their mouth.”

Our class discussed the proposed Republican tax plan at lunch. Students did not understand the changes to the mortgage interest deduction. One student believed that the new tax plan would increase the mortgage deduction limits “to benefit the wealthy in their McMansions.” Luke attempted to correct the group by stating the new tax bill would restrict and cap the mortgage interest deduction at $10,000. (This was also incorrect; it was state and local taxes that were limited to $10,000 while mortgage interest would remain deductible on loans of up to $750,000.) Socialist Sam, a 23-year-old self-described “Democratic Socialist,” responded: “Well, then, the deduction would distort the housing market. It would make it more expensive for people to move up in housing market, exacerbating racial housing discrimination.” (Decades of government subsidies to homeowners via the mortgage interest deductions apparently did not constitute a “distortion” to the housing market!)

Curiously for someone whose future paychecks will be coming from insurance companies, Gigolo Giorgio supported getting rid of the Obamacare “individual mandate” requiring citizens to purchase health insurance. “A bunch of my college friends took the $2,000 hit instead of purchasing health insurance.”

The argument continued on Facebook. Type-A Anita shared a Bustle article, “The GOP Senate Tax Bill Will Make It Much Harder To Be A Woman In America” underneath “hi warning friends only read this if ur ready to get good and depressed because IDK WHAT I EXPECTED FROM THE TITLE but wowie wow wow.” The main point of the article is that people who don’t currently pay taxes will be denied the opportunity to claim tax credits:

Millennial moms would also be impacted because the bill excludes 10 million low-income children from claiming tax credits. Because women still mainly shoulder the responsibility for child care, families in the lowest income bracket won’t receive tax benefits for their children when they’re the ones who need it the most.

[Editor: Let’s see if single moms are so discouraged by this new tax law that they turn over custody, and the child support cash that comes with custody, to the respective fathers!]

Some of our female classmates thank her for educating them (8 angry faces; 14 likes). Sample comments:

My brain cannot even comprehend the sheer cruelty of this bill


Facebook also brought news from my college classmate who decided to leave the United States for enlightened Brussels due to Trump’s election (see Year 2, Week 3). His coworker in Belgium has been “jokingly” calling him by a variety of anti-gay slurs:

I refuse. I will not be defined by your words and I will not be forced to accept them as “business as usual”.

His friends commented that Trump could be blamed for this outbreak of homophobia in Brussels.

Statistics for the week… Study: 25 hours. Sleep: 6 hours/night; Fun: none. We leave Wednesday after class for Thanksgiving break. Students complain that the administration scheduled exams for the week after Thanksgiving.

More: http://fifthchance.com/MedicalSchool2020

Tesla Powerwall versus generator


After two storms that knocked out power for hundreds of thousands of people in Massachusetts, where we agree to disagree with the Germans on the merits of underground power cables, folks are talking about their backup solutions. Here’s one message thread:

  • Exurbanite: We have no power. They are talking Tuesday or wed.
  • Me: How long can your gen run? [he is not on a gas line]
  • Exurbanite: About three weeks if I don’t get more fuel. But I can get fuel any day I want. My friend got a stupid Tesla power wall. I told him not to. I calculated that the Tesla battery is equal to one gallon of propane.
  • Exurbanite: I have 500 gallons.
  • Exurbanite: After the first night he woke up. Battery was at 18 percent. And that was with him conserving.
  • Our mutual friend: I am sure the UI is nice!

Readers: From the perspective of a single home, are power outages actually more common and/or longer than in the good old days? Or are we just more addicted to our electrically powered conveniences?

Personally I still like the idea of rooftop solar plus battery (though maybe not too useful after a big snow!). It is silent and does something useful when there is no outage. But my friend’s 500:1 comparison makes it seem ridiculous!


My Deplorable Uber Driver


On a recent Nor’easter-tinged odyssey from Boston to Seattle, Dallas, Washington, D.C., and back home to Boston, I took quite a few Uber rides. All of my drivers across three cities were immigrants from either Ethiopia or Somalia, with two exceptions: a Bangladeshi and a while male in his 30s.

In Dallas there is a lot of Presidential history, starting with the unfortunate memory of JFK being shot (by a guy who fired just three bullets; not like our modern AR-15 sprayers) and ending with the George W. Bush Presidential Library. I asked one of the Ethiopian drivers what he thought of President Trump: “Obama was in office for 8 years and didn’t change anything, so now I don’t pay attention to who is president or what he says.” What about on immigration? “Trump is not bothering me.”

In Seattle there is an infinite supply of virtue. People there say that they will do anything for homeless people… except provide homes for them. So the streets are packed with folks who are camping in the cold rain. (Contrast to Dallas, where nobody talks about their love for the vulnerable, yet the conservative Christians have set up “missions” that provide services, including beds, for the homeless. I didn’t see anyone sleeping in the street.) One of my Uber drivers, however, was that white male native-born American. He lived in Marysville, just north of the Boeing factory in Everett, Washington. He had voted for Trump because he thought that (a) welfare programs were enabling Americans to spend their lives as drug addicts, and (b) immigrants were reducing the wages of people such as himself (MIT has been looking into the net income of Uber/Lyft drivers and, if their initial number of $3.37 per hour is correct, the availability of Ethiopian and Somalian labor has indeed had a negative effect on this Deplorable!).

Separately, the Seattle airport requires drivers to show up in an electric or a hybrid car. In practice that means every Uber on an airport run is a Prius. I was shocked at how noisy the Prius is on the highway (my airport trips were at midnight and at 6:00 am and therefore we were able to exceed the usual 5 mph practical speed limit on I-5).


Medical School 2020, Year 2, Week 19


From our anonymous insider…

A reproductive endocrinologist begins Monday morning with a one-hour lecture on infertility. She explains that 15 percent of couples experience infertility, defined as more than one year of unprotected intercourse without conception. Fecundability, the probability of achieving pregnancy in a single menstrual cycle, should be about 25 percent. Infertility is on the rise in America: “More and more of my practice is managing PCOS [Polycystic Ovarian Syndrome, driven by obesity].”

An obstetrician finishes the day with three hours of lectures (four hours total for the day, so we were done at noon). “Spontaneous abortions occur in 20 percent of all pregnancies,” she notes. “Most people do not even realize fertilization has occurred because the abortion occurs in the first trimester. At eight weeks of age with heart sounds, there is less than 5 percent risk of spontaneous abortion.” The risk of miscarriage doubles every 5 years after the age of 35. (My female classmates, especially those who didn’t come straight from college, have been talking about this since M1. They may be residents well into their 30s so when do they have children?)

The OB lecture covers the placenta, the organ that exchanges oxygen, nutrients and waste between the maternal and fetal circulation. “The placenta regulates all the blood flow to the baby. If you lined 100 placentas up, I could tell you exactly which mother was smoking or using cocaine. Preeclampsia, eclampsia and HELPP [Hemolysis, elevated liver enzymes, low platelet count syndrome] syndrome all involve issues with the placenta.” We discussed placenta previa, where the placenta partially overlies the cervix. Cesarean section is performed at 39 weeks because of the increased risk of hemorrhage prior to delivery. “If a third trimester pregnant woman presents for painless vaginal bleeding, DO NOT perform a vaginal exam. During my residency, I saw another resident stick his finger right through the placenta causing hemorrhage.” [Editor: maybe don’t go to a teaching hospital?]

The rest of the week is devoted to three hours of daily lectures on nephrology. A 34-year-old soft-spoken nephrologist begins with a one-hour review of last year’s kidney physiology. The block director, a PhD in molecular biology, is charged with ensuring we get our LCME-mandated 10-minute break after 50 minutes of class. During the break female classmates discuss how good-looking the lecturer is, emphasizing his fitness and broad shoulders.

Pinterest Penelope (recently broken up from her M3 boyfriend): “I love younger physicians. They understand what we are going through. Our fondness of First-Aid, our cluelessness about residency, our anxiety about Step I. Older physicians live in a different world.”

Lecture continues with two hours on acute kidney injury (AKI). Every minute, 100 mL bleeds out of our capillaries through the glomerulus, a biological filter, into the kidney tubule system and finally the bladder. Over 99 percent of the filtered volume is reabsorbed through active transport of solutes creating an osmotic gradient for fluid reabsorption to maintain the body’s electrolyte and fluid balance. Kidney aging, drugs (e.g., antibiotics, and NSAIDs), and autoimmune diseases decrease the summed rate of filtration, glomerular filtration rate (GFR), and the proportion of electrolyte reabsorption. The nephrologist explains: “You lose about ten milliliters GFR every ten years after the age of 30. As long as you do not have a comorbidity, you will never lose enough to confer disease. The problem is most Americans will develop a comorbidity.”

Kidney injury is divided into several categories:

  1. Acute versus Chronic
  2. Location of insult: pre-renal (e.g., decreased blood flow), post-renal (e.g., ureter obstruction) or intra renal (e.g., inflammation of tubule system)
  3. Urine character: Nephrotic (protein wasting) versus Nephritic (red blood cell wasting)

Our patient case: 4-year old Baby Nora and her family hosted a family reunion cookout filled with beer, burgers and brats. Three days later, Nora develops a fever, abdominal pain, vomiting, and diarrhea. She is taken to the ED that evening, given IV fluids for dehydration and discharged home. The following day, Nora is brought back to the ED after her family notices bloody diarrhea.

On physical exam, Nora appears lethargic. She has tachycardia (high heart rate), tachypnea (fast breathing), a 101 degree fever, and hypotension (low blood pressure, 80/60). Given the bloody diarrhea and lack of symptom improvement, a “rainbow” is drawn. The tube for each test has a different color and when EM physicians are stumped, each tube is filled with blood. CMP (Complete Metabolic Panel) shows hyponatremia (decreased blood sodium) and uremia (elevated blood urea). ABG (arterial blood gas) reveals a primary anion-gap metabolic acidosis with respiratory compensation. CBC (complete blood count) shows leukocytosis (elevated white blood cells), thrombocytopenia (low platelets) and anemia (low red blood cells). Peripheral blood smear reveals the presence of schizoschites, suggestive of a vasculopathy. Urinalysis shows the abnormal presence of protein and red blood cells.

Her doctors are concerned about hemolytic uremic syndrome (HUS), the most common cause of acute kidney injury in children. The disease is caused by ingestion of Shiga toxin from E. coli O157H7, which typically accumulates in colonized food rather than being produced by bacteria that have colonized the gut. Also, if there is an infection, killing the bacteria all at once can release a flood of Shiga toxin. Thus antibiotics are not started and doctors will rely on the patient’s immune system to kill any remaining bacteria. Shiga toxin damages small blood vessels and causes formation of small blood clots (microthrombi). These blood clots shear red blood cells creating the characteristic schiztoschites seen on a peripheral blood smear.

Nora’s urine output continues to decline, and hemodialysis is started and continued for five days until her creatinine levels improve. Creatinine is a muscle protein product excreted by the kidneys at a constant rate used to measure kidney function. She requires one unit (300 mL) of packed red blood cells to maintain her hemoglobin above 7.5.

Nora gradually recovered during a 10-day hospital stay and, now age 9, does not remember the incident. Her parents reflected how scary the experience was. “I was furious at the doctor who sent us home when we brought her the first time. After the emotions simmered down, I have forgiven her. There wasn’t any sign that it was more serious than just a typical food poisoning.”

Nora’s kidney function, as measured by GFR, is back to normal, placing her among the lucky 70 percent who recovery fully.

Our two hour ethics workshop focuses on disability. We read Enforcing Normalcy: Disability, Deafness, and the Body by Lennard Davis, “a nationally and internationally known American specialist in disability studies [an academic discipline]” and English professor at University of Illinois at Chicago (Wikipedia). Our ethics professor: “He uses the Marxist perspective. The disabled population is oppressed, and thus must be be given justice. Davis argues as long as society uses an ableist mentality, we will be unable to correct the injustice. He exaggerates slightly, but within the pieces are an immense amount of insight into the human experience.” From the 1995 book:

When I talk about culturally engaged topics like the novel or the body I can count on a full house of spectators, but if I include the term disability in the title of my talk or a session the numbers drop radically. … our goal should be to help “normal” people to see the quotation marks around their assumed state. The fact is that disability as a topic is under-theorized — a remarkable fact for this day when smoking, eating a peach, or using a bodily orifice are hyper-theorized.  Because of this under-theorization, which is largely a consequence of the heavy control of the subject by medical and psychosocial experts, the general population does not understand the connection between disability and the status quo in the way many people now understand the connection between race and/or gender and contemporary structures of power.

… The category itself is an extraordinarily unstable one. There is a way in which its existence is a product of the very forces that people with disabilities may wish to undo. As coded terms to signify skin color — black, African-American, Negro, colorized — are largely produced by a society that fails to characterize ‘white” as a hue rather than an ideal, so too the categories “disabled”, “handicapped” “impaired” are products of a society invested in denying the variability of the body.

In the process of disabling people with disabilities, ableist society creates the absolute category of disability. ‘Normal’ people tend to think of ‘the disabled’ as the deaf, the blind, the orthopedically impaired, the mentally retarded. But the fact is that disability includes, according to the Rehabilitation Act of 1973, those who are regarded as having a limitation or interference with daily life activities such as hearing, speaking, seeing, walking, moving, thinking, breathing, and learning. Under this definition, one now has to include people with invisible impairments such as arthritis, diabetes, epilepsy, muscular dystrophy, cystic fibrosis, multiple sclerosis, heart and respiratory problems, cancer, developmental disabilities, dyslexia, AIDS, and so on.

…  In ‘talking’ with Deaf colleges on e-mail particularly those whom I have never ‘seen’, I often ‘forget’ that my interlocular is deaf. Recently, in planning to attend a session at the Modern Language Association on disability, I received and sent a welter of messages on email to a number of people involved. I had no way of knowing which of these people was disabled, or in which way. When speaking on the telephone with a person who uses a wheelchair, I have no way of knowing if that person is unable to walk.

When the ethics professor was busy with another small group, Geezer Greg said, “I could have learned more by watching Curb Your Enthusiasm. Larry David calls a mechanic to bring his car in. When he brings his car in and meets the mechanic in person, Larry is surprised to find that the mechanic is black: ‘You did not sound like it on the phone.’.”

Persevering Pete: “I am not sure what Davis is arguing. On one hand he does not want people to consider disabled individuals as a separate group, but he wants more financial assistance for the disabled.”

Luke: “Where does Davis draw the line on collecting disability checks? Am I on the spectrum?” Greg: “That’s a Curb Your Enthusiasm episode also! The girlfriend claims her son is on the Asperger’s spectrum, but Larry David thinks he is just a spoiled brat.” (The wife sues for divorce during Season 8, taking the house and putting Larry back on the dating market.)

The ethics professor did not mention the financial aspects of being classified as disabled, nor that medical doctors are now the gatekeepers for whether or not an American can get aspect to disability payments (see “How Americans Game the $200 Billion-a-Year ‘Disability-Industrial Complex'” (Forbes)), nor that some doctors earn 100 percent of their income as disability gatekeepers. This is something that Hippocrates probably could not have imagined.

Our week concludes with the Genital Teaching Assistants (GTA) teaching us how to perform the scrotal, penis, digital rectal exam, pelvic, and breast exams. The family medicine physician coordinating the workshop introduced this opportunity: “These are professionals that travel the country teaching these exam skills. Ask them any questions you have, this is their job. And let me tell you, they are good and they are very expensive — largest item in our budget, I am talking thousands of dollars — so we are partnering with internal medicine residents to bring them.” Gigolo Giorgio learned that the female GTAs make $90 per student ($70 for vaginal exams, $20 for breast exam) or over $1,000 (3 groups of 4) in the afternoon workshop. The national standard seems to be that male GTAs are paid less, but so far there have been no demands for equal pay. Luke: “How much would you have to get paid to do that?” A few of the guys responded: “No questions asked, sign me up.” No female classmates answered.

We are divided into teams of four and rotate through a male GTA for 1.5 hours and a female GTA for 2 hours. My group happens to be all male. The 35-year-old male GTA is a married family medicine resident with two sons who has been doing the GTA program as a side job for 3 years. Patricular Patrick leads the way beginning with the scrotal exam. We individually practice each step of the exam. The GTA is extremely helpful, drawing on his medical experience to emphasize certain pathologies to look out for at each step of the scrotal and penile exam. The digital rectal exam is last. As Particular Patrick is searching for the prostate, the GTA adds, “My right prostate lobe is slightly larger than the left.” There is a 15-minute break before the female GTA session. Pinterest Penelope was enthusiastic about having felt a direct hernia in a “65-year-old geezer,” but noted the “shriveled balls.”

Our female session is with a 25-year-old GTA with two years of experience. She uses a mirror to help guide each of us through the exam as we struggle to handle the speculum to locate the cervix and to palpate the ovaries using the bimanual technique. She emphasizes, in an Eastern European accent, never to close the speculum until partially retracted to prevent closure on the sensitive cervix. We took longer than expected, so only one of us is allowed to perform the uterorectal exam. Ambitious Al quickly volunteers with no shame. Gigolo Giorgio was disappointed he could not practice it. This snafu apparently happened in other groups as well, and a few students (not Giorgio to my knowledge) complained how this asymmetric experience was unfair to those who did not get to perform the rectouterine exam. The family medicine physician apologized.

Jane: “This experience hit a lot of us. It seemed like everyone respects what happened, it’s a kind of a milestone.” (Jane might not have heard a few wags joking about the scrotal, bimanual, and uterorectal “shocker” exam.) The Family Medicine instructor comments, “I am glad no one fainted. One gentleman last year fainted while examining the male GTA.”  Two (male) students became light-headed during both the rectal (male) and bimanual (female) exam, although no one fainted.

Jane and I ate dinner with her mother, learning that she loaned Jane’s sister just under $10,000 to pay off a Lowe’s loan for repairs on the ex-boyfriend’s house (see Week 14). Solvent thanks to this and Jane’s loan of $5,000 to pay off her credit card debt, the sister has recently gotten back together with the ex-boyfriend. “Well, I feel like an idiot!” said Jane’s mom, not a fan of this boyfriend. “I keep thinking if she still had the 10k ‘L’ [for Loser] hanging over his head, they would never have gotten back together.”

It is a week before Thanksgiving and Type-A Anita is hosting the class potluck Friendsgiving on Saturday afternoon.  Anita’s board game collection includes The Cat Game and Trump: The Game, a gift during the election night party. “Still too soon to play it,” said Anita. My favorite dishes: Straight-Shooter Sally’s sweet potato casserole, Gigolo Giorgio’s jalapeno guacamole, and Persevering Pete’s homemade rolls. Most of us elected to bring wine or beer rather than expose our weak skills in the kitchen, resulting in 10 bottles of wine and 6 six-packs arranged on the serving table. At 9:00 pm on the dot, 20 classmates whip out their phones to play HQ, a streaming, single-elimination trivia app with a live host. None of us get to share in the $5,000 that is divided among contestants who correctly answer all 12 questions. Classmate Butch Brock and his girlfriend Annabelle the Beauty made it to questions 6 and 7. Annabelle recently moved in with Brock, studied communications at a state university, works as a hostess at a local restaurant, and has decided to apply to PA school. Lanky Luke: “Isn’t there anything else people want to do besides medicine?” Jane and I left around 10:30 pm.

This Week in Facebook Activity: Type-A Anita shared Huffington Post’s “Trump Official Blocked Immigrant Teen Rape Victim’s Abortion Because He Personally Opposed It” and added “Tw: rape [Trigger Warning] Hot Take: if you’re a leaky pile of garbage concealed in human skin, you forfeit the ability to tell others what to do with their very real Human Bodies. no one can decide whether or not someone’s reason for an abortion is “good enough”. Anita shifted gears from attacking our weak commitment to advancing non-white causes to attack a non-white political candidate: “Anyone who invokes God as an unquestionable authority in a secular debate on REAL WORLD phenomena has no place in government. This woman, Angie Reed Phukan, is running for Comptroller of Maryland, and decided to let us all know what actual garbage she is ahead of time. (Anita has never lived in Maryland.) Later that evening, she shared an article on Viagra’s patent expiration: “by all means let’s help old dudes keep an erection but keep reducing people’s access to contraceptives #godwantsyoutohavelimpdick” Pinterest Penelope shared that one on Facebook and messaged the class GroupMe: “The hashtag!!”

Statistics for the week… Study: 18 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: Jane and I join her college girlfriend who works as an au pair and bartender in Dunedin, New Zealand. In order to stay in New Zealand, she is signing up for a master’s degree in international politics at a university there, using $17,000 in U.S. Federal student loans. (Editor: the U.S. welfare program for university bureaucrats now embraces the entire planet! Separately, if so many young people study international relations, why are there still wars?)

More: http://fifthchance.com/MedicalSchool2020

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