The Only Bearish Blog Left

Slope, as you might suppose, is my favorite blog on the web. My second favorite, however, is ZeroHedge, and I’ve been an avid and daily reader for its entire existence. Because ZH has been steadfastly bearish since its creation in January 2009 (which, interestingly, was pretty much the exact almost-to-the-day bottom of equities in general), […]
Slope of Hope

Is there a bureaucratic definition of “romance”?

One of my moles inside the undergraduate mill at MIT got a mass email recently from three bureaucrats: the Provost, the Chancellor, and the VP of Human Resources:

As President Reif recently wrote in a letter to the MIT community, MIT is taking a number of actions to prevent and respond to sexual misconduct. We write today to update you on an expanded conflict of interest policy on consensual relationships among community members.

The new policy was initiated and championed by the Institute’s Committee on Sexual Misconduct Prevention and Response (CSMPR), led by Professor David Singer, Political Science, and has been adopted by MIT’s senior administration. We appreciate the many faculty, students, and staff who provided valuable input during the development of the policy. The final policy is stronger thanks to your engagement, and your commitment to advancing a culture of respect, fairness, and equality.

The last part is an interesting example of groupthink. How do these three bureaucrats know that all 4,500+ undergraduates have a “commitment to advancing a culture of respect, fairness, and equality”? Maybe some of them are committed only getting a degree and starting to repay their loans? Or maybe some of them think that a “culture of respect” prevents frank discussion of scientific errors and engineering shortcomings? Or maybe some of them support equal opportunity, but not “equality” (equal outcomes)?

The policy itself raises an interesting question. For example:

No MIT faculty or staff member may have a sexual or romantic relationship with any undergraduate student. [emphasis added]

In the age of Tinder, who decides what constitutes a “romantic relationship”?

Philip Greenspun’s Weblog

Medical School 2020, Year 2, Week 7

From our anonymous insider…

Exam week with three exams.

The main three-hour multiple-choice NBME exam consisted of 100 microbiology questions and 50 immunology and dermatology questions. Lanky Luke: “This was the hardest block since the beginning of medical school.” Several students complained about the emphasis on tropical diseases. “There must have been 10 questions on leishmaniasis. Every time I saw that as an answer, I would choose it.” Another student added, “I just felt it was not representative of what we will see on Step I. There were so few on hepatitis.” Several students reflected that they will never understand immunology. Type-A Anita: “I knew going in that I would take a hit on immunology. Oh well.”

The case-based exam asked about five hypothetical patients. It tested appropriate use of antibiotics, and classical “alarm” signs of serious imminent danger, for example, patient with sore throat who has difficulty swallowing and drooling may have epiglottitis with the potential to close off the airway. The clinical exam tested adult immunization schedules, screening guidelines, and dermatology pictures. Type-A Anita: “I know we need to know these, but I crammed the day before for immunizations and screening. I’ve already forgotten them!”

The clinical exam consisted of interviewing standardized patients (paid humans recruited from the community as actors) presenting for pneumonia. We used simulated stethoscopes to hear abnormal breath sounds. The clinical exam tested the same immunization schedules and screening guidelines as the case-based exam.

Recall that we meet three times per week for two-hour “case sessions.” Our facilitator is the redheaded hematologist/oncologist. This is the first time that our six-student group met off campus, sharing margaritas as a Mexican restaurant with our facilitator. We were joined by another case session group and their young emergency medicine facilitator.

Our heme/onc attending described the abrupt shift between fellowship and attending. “Even as a fellow, you have someone to bounce ideas off of, to confirm a diagnosis or treatment plan. It takes a little while to get confidence in yourself as an attending.” She had just returned from her first vacation since becoming an attending. “My husband forced me to go on the trip to the Dominican Republic. It was scary leaving my patients. I remember sitting on the beach with a mamajuana [local drink] and feeling completely relaxed. I realized that I had not felt relaxed since beginning my residency six years ago. And probably not since beginning medical school too!” [Hurricanes Irma and Maria passed through the D.R. a few weeks later.]

The other facilitator brought his wife, an Ob/Gyn, and their three children, the oldest aged eight. When should physicians have children? “We made an active decision not to have children during residency. My wife knows all too well that it is best to begin having children by age 35. This can be a serious constraint for women if they start medical school late. Residency is your training and you need to dedicate yourself to it.” The EM physician said he enjoys shift work. He can dedicate everything when he is there, and upon leaving the ER, “I am clear-headed and can focus on my children and wife.”

“A lot of my residents struggle if they have children,” continued the EM attending. “You will have to sacrifice something. Most of the time it means you will miss soccer games and friends’ birthdays. I find it is especially hard if their significant other is not in the medical world. Nonmedical spouses do not understand that once residents are off their 12-hour shifts, they are not done. After your shift, you hit the books. You study. The one exception is a resident I have now. He will not sacrifice his time with his children so after work he plays with his kids. When they go to bed, he hits the books. He just does not sleep and seems to functions fine thus far… I am not like that.”

After the facilitators left, Jane, Mischievous Mary, Deeva Debbie and I walked over to our favorite burgers and beer spot to work on our 100-beer card. After drinking 100 different beers at this restaurant, you are awarded with an embroidered mechanic shirt. Debbie is a a young Indian-American who dominates the class SnapChat story and Instagram. She journeyed to Portugal over the most recent break for a trip with two high school friends.

The women continued the conversation of children over beers. Debbie lamented, “I have no idea when I will be able to have children.” Mary reflected, “I now understand why my parents got divorced. My father was a internal medicine resident when they had two children. He was always gone. My mom had to everything: feed us, drive us, discipline us. She always felt like the bad guy. When my father was home, he would just want to play with us. There was just no time for my parents.” It always surprises me how many male physician lecturers in their 40s are not wearing a wedding ring. [Editor’s note: Our young medical student might want to read Real World Divorce and learn about the world of sexual and financial freedom opened up by no-fault divorce to any plaintiff suing a physician.]

After a well-deserved nap, Jane and I attended our classmate’s housewarming party. He and his wife, a marriage counselor, recently moved into a spacious new downtown loft. While people danced in the center, I talked on the sidelines with a 25-year-old classmate whose parents are Iraqi Kurds. His last trip to Iraq was in 2010, his freshman year of college.

I asked for his perspective on Iraq and the Kurdish people. “It’s hard for me to say. Everything I know is from my dad. My family was comfortably settled in the US when it happened. I just remember my father being glued to the TV during the Iraq invasion. He would cheer the U.S. army every step of the way. Saddam gassed my people.” Why has it gone so wrong for both the U.S. and Iraq? “I don’t know. It comes down to the Iraqi people as a whole were not ready for democracy.”

He is eligible to vote in the upcoming referendum on independence (held September 25, 2017; result: 93 percent in favor). “I think now is the best time for independence. We are ready. The state institutions are there and the Peshmerga will defend us against any invader — Turkey, Iran’s militias. It doesn’t matter that we are dispersed in Iraq, Syria, Turkey, and Iran. Everyone might invade us. I am concerned about the state of elections in Kurdistan. Unfortunately the only politicians come from just two families, but it is now or never. I’m voting yes for independence.”

Philip Greenspun’s Weblog

The Perfect Ten

If I were to make a list of the things I want to write about, at the BOTTOM would be this stupid market, and at the TOP would be SlopeCharts. So – – get used to it – – you’re going to be hearing about my new favorite product a lot. At least until common […]
Slope of Hope

Owards and Upwards

I tend to look at any bear setups lately with a very sceptical eye, and the nice looking nested double top setups on ES and NQ that last week closed with didn’t long survive the start of trading this morning. I posted on my twitter before the open that there was a high quality support […]
Slope of Hope

Netflix Channel Touch

Netflix, for all its wild movements over its existence, has followed a surprisingly steady ascending channel. The SlopeChart above contains the after-hours post-earnings surge (shown below). It’ll be interesting to see during tomorrow’s regular session if NFLX remains “contained” (to borrow a term from Mr. Bernanke years ago) or is so strong it breaks resistance.
Slope of Hope

Medical School 2020, Year 2, Week 6

From our anonymous insider…

One week before exams.

“We are going back to preschool,” said the young female dermatologist. “Dermatology is another language. We start with vocabulary.” She spoke in a monotone voice and enjoyed sadistic humor. “It helps if you know Latin. How many of you took Latin?” Two students raised their hands. She chuckled, “Well… that is too bad.” We went through several images, and described the lesion with the help of a handout with common terms: umbilicated nodule, erythematous maculopapular, scaly serpiginous plaque. The class was surprised to hear that erythroderma (diffuse erythema covering the body) is a “dermatological emergency”. This massive inflammatory response can cause a drop in blood volume and hypotension.

A dermatologic pathologist gave two hour-long lectures on skin histology (study of the microscopic structure of tissues) with slides of normal and diseased skin. I enjoyed seeing how certain skin issues manifested themselves so clearly on histology compared to other organ systems where the pathological manifestation is more subtle. He ended: “Gastroenterologists and dermatologists always argue with each other about what is the largest organ. There is a huge amount of blood flow to the skin. Inflammation frequently leads to skin changes. Think of the skin as a window into the body.”

“Dr. Joel”, a brilliant pedantic rheumatologist in his late 30s with a heavy Jamaican accent, discussed infectious diseases of the skin and immune disorders that manifest with skin symptoms. Roseola (“Sixth Disease” or “three-day fever”) is caused by human herpes virus 6 (HHV6). It is characterized by high fever, which can cause seizures in children, followed by a maculopapular (flat and raised erythematous dots) rash. Several of these childhood illnesses cause serious damage to a fetus if the mother becomes infected during pregnancy. A congenital rubella infection (German measles infection while pregnant) leads to the fetus having microcephaly and a patent ductus arteriosus (PDA). A male student commented, “Could you imagine living two hundred years ago before we understood the role of congenital infections? Your baby comes out as a dwarf or with microcephaly. Must be God’s will.”

These lectures should help us to answer multiple choice Board questions, but we are doubtful about being able to diagnose patients. Lanky Luke: “I feel much of medicine is getting the approval by society to witness disease. This ordained selection process entails paying it to the Man.” Luke thinks that more of our medical training should be an apprenticeship rather than lecture-based.

He got his wish when we went in for an afternoon to the dermatology clinic. Four-person groups crowded into each small examination room to spend 15 minutes with a patient volunteer and a dermatology attending or resident. My group first saw a 30-year-old female who has suffered from neurofibromatosis since she was a teenager. Only when the patient took her gown off did we see the copious neurofibromas (benign tumor of nerve sheaths) covering her body with the peculiar exception of her head and distal extremities (arms and legs). She could walk around in a long-sleeve shirts and slacks without anyone noticing. The patient allowed each of us to palpate her skin. Neurofibromas are thimble-sized fleshy cylindrical nodules with a dark brown color that sag from the skin. They feel mushy, almost like a fluid-filled vesicle. The attending noted, “A lot of patients first try to scratch them off. They return much worse.”

We rotated to the next room and a normal-appearing 50-year-old female. As we examined her more closely, we saw signs of scleroderma. She had sclerodactylyl (localized thickening of skin on fingers and toes) preventing full extension of her fingers. Her lips were permanently pursed with six or seven valley and ridges on the skin adjacent to her lips. “Before treatment with steroids, I could barely move any of my joints because the skin was so tight. I now live a normal life with my family.” Our patient did not have any of the life-threatening manifestations of scleroderma, which can include pulmonary hypertension and pulmonary fibrosis.

We then rotated through a case of eczema and psoriasis. Eczema, also known as dermatitis,  is characterized by pruritic (itchy), erythematous (redness that blanches with touch), oozing vesicles (fluid-filled sac) with edema (swelling) typically occurring on flexor surfaces. It is commonly caused by an over-reaction to an exposure such as poison ivy or the metal nickel (e.g., touching dime). Interestingly, eczema is more common in asthmatics. Psoriasis is an inflammatory condition without a known trigger characterized by acanthosis (keratinocyte hyperplasia; thickening of the skin) leading to scaly plaques on the extensor surfaces (e.g., the outside of the elbow). The attending confirmed the psoriasis diagnosis by eliciting the Auspitz sign, bleeding after a pinprick.

Our patient case: Fiona, a 42-year-old female elementary school teacher, presenting for bilateral stiffness and pain in her wrists, fingers, and knees that is worse in the morning. She had her thyroid gland removed (thyroidectomy) in her 20s after diagnosis of Graves’ disease: antibodies that bind to thyroid stimulation hormone receptor causing excessive thyroid hormone release. Her condition is now well-managed with synthroid.

She has been to her doctor several times over the past few years for joint pain in her hands. “I was originally diagnosed with arthritis. I got frustrated with my doctor. He would take an x-ray, prescribe physical therapy, and never follow up.” Over the last two months she has been unable to do several daily activities at work and the pain has begun to interfere with her sex life with her husband. Her proximal interphalangeal joints (proximal knuckle) and wrists are swollen and warm to the touch.

Fiona has rheumatoid arthritis (RA) defined by synovitis (inflammation of the synovium or fluid within joint capsule). The pathogenesis of rheumatoid arthritis is unknown, but some people are predisposed genetically and there are environmental risk factors, e.g., smoking, which increases the risk of RA up to 40 times in individuals with Shared Epitopes (SE) gene variants of MHC proteins.

Fiona never smoked, although she had the positive ACP titer (measure of antibody concentration in serum) that is typical of smoking-induced RA. She also had other hallmarks of chronic inflammation such as elevated C-reactive peptide (protein produced by liver suggestive of systemic inflammation). The Rheumatologist explained, “The ACP is helpful to know what kind of rheumatoid arthritis I am dealing with. However, once it is present I no longer care about it — think of ACP as a pregnancy test. You can’t get more pregnant once you test positive. Instead, I listen to Fiona’s symptoms and follow her C-reactive peptide levels.”

She was initially prescribed naproxen (nonsteroidal anti-inflammatory marketed as “Aleve”; similar to Advil) without any symptom relief. She currently takes methotrexate, a folate synthesis inhibitor used to treat several cancers and inflammatory conditions. “I will still get flare-ups if I over-exert myself, but I am able to be active. I even exercise three times a week on the elliptical.”

Describe the pain before your treatment? “My joint pain was unbearable before I was referred to Dr. Joel. Our family goes to the beach once a year… my one break from teaching. We always have a crab leg feast. I had to stop eating the crabs because my pain would be terrible for several days afterwards. I was bedridden. Perhaps it is punishment for the gluttony.”

Does anyone else in your family have immune disorders? “I know my mother had joint problems. She was never diagnosed with rheumatoid arthritis though.”

How does RA affect your family? “I’ve learned my limits now and my husband and kids are truly great about understanding. In the beginning they were a little confused. I still sometimes hear my kids half joke, ‘Oh, Mom isn’t cooking dinner? She is so lazy.’ Even with treatment I still have to be careful how much strain I put on my joints. Scrubbing or cutting too much will cause a bad flare-up that lasts for a few days.”

Dr. Stein, an internist who has been in practice for over 40 years, followed up on the “Motivational Interviewing: Eliciting Patients’ Own Arguments for Change” lecture from two weeks ago. “There are 5 stages of change: precontemplation, contemplation, preparation, action, and maintenance. We also no longer use the word compliance to describe the degree of a patient following prescriptions and medical advice. We now use the term adherence because it suggests an active role and collaboration of the patient with the doctor and treatment process.” 

After one hour and fifteen minutes of theory, Dr. Stein brought in one of his longstanding patients, an overweight female in her late 40s who quit smoking six months ago. She began smoking a pack a day when she was 14. “Smoking was a part of my life. I felt that I would not know what to do if I did not smoke. It helped keep peace in the house. It kept me calm during work.” She described how Dr. Stein would bring up smoking “every single time” she went in. “He said all the right things, but I was just not ready up in the head. The key was I felt comfortable with Dr. Stein. He was not judging me, pointing a finger. When I finally was ready, Dr. Stein leveraged this motivation to help me.” What made you quit smoking? “If you have a big enough why, you will figure out how to quit. I hated seeing my children grow up with me smoking. My father recently had a heart attack — I am sure smoking all his life did not help. I had these two drivers in my mind and I just went cold turkey.” We congratulated her for her smoke-free six months.

Afterwards we divided into four-person groups to present a patient from our clinical shadowing experience. We were fortunate to be presenting to Dr. Stein. Our goal was to practice how to present patients to attendings for Rounds next year and how to write a medical note. The general format of a note: chief complaint in the patient’s own words, History of Present Illness (HPI), Past Medical History (PMH), Medications, Family History, Social History, Review of Systems (RoS), Physical Exam (PE), Assessment, and Plan. The transgender wave has reached daily Rounds: “Don’t use male or female in HPI anymore,” said Dr. Stein. “It’s frowned upon.” After Dr. Stein revealed his fondness for “complementary medicine” (accupuncture, yoga, etc.), Gigolo Giorgio said that Dr. Stein reminded him of someone who had a “midlife crisis and suddenly turned Zen.”

We wrapped up the week by reflecting on a three-week prescription simulation. Students were divided into two groups: diabetics and HIV patients. The faculty gave us pill bottles filled with M&Ms. Our class president sent periodic GroupMe messages about various simulated issues. Example: “Update: your throat is burning and your chest is on fire! wait an additional 35 minutes after taking your pills before eating.” Some students ate all the M&Ms the first day. Some abandoned the simulation. Everyone forgot to take at least one pill.

Straight-Shooter Sally recounted the awkward conversation after her new roommates, a nursing student and college-educated bartender, accidentally read a message: “You forgot to take your HIV antiretrovirals for today. Double up.”

Mischievous Mary, a smart, petite jewish girl who dyed her hair pink last year because “it was the last time I could do something stupid before we start clerkships — unlike a tattoo, this is reversible.” She began school aspiring to follow in her father’s footsteps as an internist, but is now determined to become a heart surgeon. Mary responded to Sally’s story: “I realized this weekend that I have lost all sense of decency. I was in this quaint coffeeshop by my apartment studying STDs looking at pictures of penises on my computer, easily seen by the other patrons.” Jane added, “I was walking with Giorgio on the Greenway. We somehow got on the topic of syphilis. It took us several minutes to understand why people were looking at us strangely.”

Statistics for the week… Study: 20 hours. Sleep: 8 hours/night; Fun: none (one week before exams).

More: http://fifthchance.com/MedicalSchool2020

Philip Greenspun’s Weblog

What could President Trump name after Apple Computer?

Now that Apple is going to pay some Federal income tax (previous post), what would cost $ 38 billion that President Trump could name in honor of the company? Here are some ideas:

  • The Apple Computer Border Wall (estimated cost $ 21.6 billion, so it wouldn’t consume this one-time payment)
  • The Tim Cook nuclear-powered aircraft carrier (complete with fighter jets and rescue helicopters)
  • rename Interstate 280 to the “Android is No Good at All National Highway” (what has Junipero Serra done for anyone lately?)

Readers: any good ideas? Why not show some love to what I assume will be the nation’s biggest taxpayer in 2018?

Philip Greenspun’s Weblog