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

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

Medical School 2020, Year 2, Week 5

From our anonymous insider…

Hematology and immunology. Immunology is one of the class’s least favorite topics. Gigolo Giorgio:  “I accept just taking a hit on the exam. It makes no sense to me.”

An enthusiastic 39-year-old immunologist kicked off the lectures. She explained, “We need about 100 million unique antibodies to be immune competent. We have about 30 billion B cells in the blood.  That means we only have 300 potential B cells that need to become activated if we are to mount an antibody attack against a given antigen. This is the key dilemma in adaptive immunity: How do you find them!”

Our first-year perspective on the immune system was cell-centric. This week we learn that the story is more complex and includes smaller-scale proteins from the complement system and larger-scale tissues such as the spleen filtering blood-borne pathogens.

Our current understanding of a typical bacterial infection:

  1. The innate immune system recognizes common pathogens. Complement proteins (smaller than cells and made by the liver) mark bacteria for opsonization (trigger for phagocytosis or cellular ingestion).
  2. Resident macrophages (cells) phagocytose (ingest) marked intruders resulting in an inflammatory “cytokine storm”. This causes systemic changes such as fever and increased production of immune cells in the bone marrow (lymphocytosis) and local changes such as blood vessel dilation to increase tissue perfusion and neutrophil infiltration into the tissue.
  3. Neutrophil infiltrate the inflamed tissue. Neutrophils, the most abundant leukocyte (white blood cell), are the immune system’s pawns that kill bacteria by eating them and producing high concentrations of hydrogen peroxide in the phagosome (walled off vesicle containing the bacterial cell inside the neutrophil). After the neutrophil has worn itself out, it will explode in a process called netosis. The neutrophil’s DNA acts like a spider web (called neutrophil extracellular traps) to prevent the bacteria from escaping the site of inflammation. Pus is dead bacteria and dead neutrophils.
  4. Adaptive immunity activated (if needed).
  5. If necessary, the spleen will filter bacteria in the blood (bacteremia) through small capillary beds called sinusoids.

The C3 protein is fundamental to the complement system and will bind to almost any biological molecule. How does the body avoid its own proteins being marked for phagocytosis? The liver releases anti-complement factors that bind to sialic acid, a component on human cell membranes. Streptococcus pyogenes, the bacterial strain causing strep throat and necrotizing fasciitis, expresses M protein to mimic sialic acid. The immunologist explained, “Although this molecular mimicry decreases the efficacy of the innate immune system, it is also Strep’s greatest weakness.” Our adaptive immune system readily produces antibodies that target M protein. The problem is that this antibody can cross-react with our own tissue causing a rare complication of sore throat: rheumatic fever (inflammatory disease that leads to skin rash, joint pain, and destruction of heart tissue).

If the innate immune system mechanisms are insufficient for clearance, the adaptive immune system will be activated. Resident macrophages will migrate to lymph nodes and present phagocytosed segments of foreign material on major histocompatibility complex (MHC) proteins to lymphocytes (T cells and B cells) that circulate among lymph nodes. Because the body can’t anticipate all of the epitopes (protein shapes) we might encounter, we use a game of probability. The immunologist explained, “We are finally unlocking the adaptive immune system. When I was doing my PhD in the 80s, how our adaptive immune system generates this antibody diversity was still not accepted let alone in textbooks. MIT Professor Susumu Tonegawa won the Nobel Prize for discovering VDJ [variable, diversity, and joining] recombination. He showed that each B and T cell mutates its own DNA to rearrange the genes encoding the B cell’s antibody or T-cell receptor. Each B and T cell clone has different DNA than your typical cell in your body! If this B cell antibody or T cell receptor recognizes a sequence presented on MHC, it will become activated. The activated cell will undergo clonal expansion [reproduction by division], and, in the case of B cells, will differentiate into a plasma cell secreting gobs of antibody against this specific antigen into the bloodstream.”

Our patient case:  Georgia, a 46-year-old female presenting to her internist for a routine physical. Medical history is unremarkable except for well-controlled hypothyroidism. She has swollen lymph nodes (lymphadenopathy) in her neck. Routine blood tests reveal elevated protein. Serum protein electrophoresis, a technique that separates proteins based upon electric charge, reveals an “M-spike” in the immunoglobulin (antibody) zone, suggesting an increase in concentration of a single clonal variant of immunoglobulin. “Georgia had a rogue plasma cell producing gobs of a single type of antibody. It is essential you understand the significance of clonal expansion to her condition versus the antibody response to an infection. During an infection, several B clonal species will get activated, each with a different antibody that binds to different sites of a pathogen. Infection causes a general increase in globulin concentration but not a spike.” The risk is as this single clonal variant continues to expand, it could push out the normal functioning bone marrow cells.

Georgia was referred to heme/onc (hematology/oncology) for further evaluation for this monogammopathy of unknown significance. One of my favorite lecturers, the young redheaded hematologist, followed Georgia for one year during which she began to have anemia, proteinuria (protein in urine), and bone lesions on routine tests. George was diagnosed with multiple myeloma (MM) at the age of 47 and, based upon her genetics and stage, given eight years to live. (Type-A Anita uses the helpful mnemonic “CRAB” to remember the classical signs of MM: hyperCalcemia, Renal impairment, Anemia, Bone lesions.) After her diagnosis, she quit her job as a secretary for a law firm and went on disability.

Georgia underwent several weeks of intense chemotherapy and a successful autologous hematopoietic stem cell transplant (HCT) over the course of a month-long hospital stay. She explained, “I never considered that I would die during the treatment.” She is now two years into remission and maintains an active life.

The HCT given to Georgia is the gold standard for MM treatment. “Why do we even give bone marrow transplants to MM patients?” asked the hematologist. She answered her own question: “The purpose of a bone marrow transplant is to be able to give higher doses of chemotherapy that would otherwise be lethal. We nuke the patient.” The hematologist recounted how bone marrow transplants were first investigated after the observation that individuals exposed to radiation from Hiroshima and Nagasaki developed pancytopenia (low blood cell counts). Bone marrow transplants were thought up as a way to reverse this aplastic crisis. “Leave it to the DoD to advance science. Pretty quickly oncologists applied the research to cancer treatment.”  

“The scariest part of multiple myeloma is that you are never cured,” explained Georgia, as she broke into tears. “It will come back every time. This tragic fact makes MM different from other cancers. I go to an MM support group every two months as opposed to a more general cancer group. It is such a different beast.” Georgia grew up in a large mid-West family with five siblings. “My closest sister withdrew from me after the treatment. I think it is just hard for her to accept.”

The hematologist added, “Plasma cells are the cockroaches of the immune system. They survive everything. The unfortunate truth is that the question is not if MM will relapse, but when. Further, the  traditional chemotherapy we use causes the plasma cells that do survive to have more mutations. Drug resistance develops after successive relapses.” She gave an impassioned speech on the importance of research. “The life expectancy for MM has increased dramatically. Maybe ten years ago, Georgia would have had to be maintained on melphalan [nasty chemo agent that acts via a similar mechanism to mustard gas] to contain her MM.” She turned to Georgia: “Could you imagine being on melphalan, the drug used during your bone marrow transplant experience, routinely?” “Oh, God, no. My hair, the diarrhea, the sheer pain. Mostly my hair though.” The class chuckled, and the hematologist continued, “This is changing because of the extraordinary advancements in targeted therapeutics. I love this field because it changes so quickly. Cancer years are dog years. A five-year-old article or clinical trial is thirty-five years old by my standards. Even the current issues of journals are a year late; you have to go to conferences to learn about the latest breakthroughs. It is frankly hard to stay up to date on every neoplasm [cancer]. The result is that oncologists convey out of date survival expectancy to patients.”

Jane had a slight hiccup with her mentee: the day after their first meeting, rumors surfaced that her mentee had disenrolled for personal reasons. The whole class joked that Jane made the helpless M1 quit. “What did you do to her!?!” We never learned the truth, but this classmate was quickly replaced by someone from the waitlist who became Jane’s new mentee: “Rebecca,” who had majored in electrical engineering at a large public university. Rebecca had spent a week at a DO (Doctor of Osteopathic Medicine) school: “I got a call from an unknown number. When I heard I got into this school, I almost fainted. My legs went weak. I packed everything back up and drove the next day eight hours. I really want to call my undergraduate prehealth advisor who told me I would never get into medical school because of my grades. Suck it!” An M1 told Jane, “I like your new mentee better than your last. Thanks!”

Statistics for the week… Study: 15 hours. Sleep: 8 hours/night; Fun: 1 day. Example fun: Dinner party with classmate and his wife, a marriage counselor. “My favorite patients at my old job were the couples with a schizophrenic.” A classmate who worked on a psych ward before matriculating at medical schools said, “Wow! I was scared out of my mind. I had this one patient who would say, ‘There is a woman standing behind you.’ I believed her! I could never do psychiatry.”

More: http://fifthchance.com/MedicalSchool2020

Philip Greenspun’s Weblog

Do they still line up kids at school and give them shots?

I have forgotten the state capitals, but one intact memory of elementary school in Bethesda, Maryland is lining up to get shots (vaccines?) from some sort of “gun”. These were administered roughly every 15 seconds either by the school nurse or a county health worker. It went so fast that I wonder if we were all effectively sharing one needle (HIV and hepatitis were not concerns for schoolchildren circa 1970).

The other day I was waiting for a friend at CVS so decided to use the time to get my “free” (i.e., included in my $ 10,000/year Obamacare policy) flu shot. Ten minutes later my friend showed up. It took roughly another ten minutes before the shot was “ready.” It turned out that three health care professionals had to process various forms on a computer screen, get a one-page questionnaire from me, and finally deliver the shot with a simple needle (less than one minute). A licensed pharmacist was required as part of the paperwork pipeline.

Here’s what I got in hardcopy:

  1. Two-page document regarding the vaccine (Flucelvax Quad). It says “This is an OFF-WHITE SYRINGE.”
  2. CVS Health Notice of Privacy Practices, a two-page document in 6 pt type. It is a paper copy that, among other things, says “You have the right to obtain a paper copy of our current Notice at any time.” It also says what will happen if I am or become “an inmate of a correctional institution.”
  3. A five-page “Vaccine Information Statement” that discusses the side effects (overlaps to some extent with Document #1)
  4. A Vaccine Consent and Administration Record
  5. A three-foot-long receipt for $ 0.00 (coupons following)
  6. A $ 5 off any $ 25 purchase special coupon specific to having gotten a “free” flu shot (i.e., for giving CVS the opportunity to bill the health insurer)

Is there now this much paperwork and process attached to what was, in my youth, a 15-second paperwork-free experience?

[I posted a shorter version of the above on Facebook and it generated the predictable encomiums about the wisdom of Obamacare requiring insurance companies to pay for flu shots:

I think the insurance companies cover shots as a preventative measure, hoping we won’t incur more healthcare expenses related to the flu we’d contract if we didn’t take the shot.

It should be free and universal. That will save the most money, and the evidence for that is stone-cold solid.

In other words, the central planners working for the government are smarter than the actuaries who work at insurers, which didn’t previously pay for flu shots. I decided to poke at this assumption a bit with “If it made actuarial sense to do this, why wouldn’t the UK bureaucrats be smart enough to figure it out? They don’t offer free flu shots to everyone. (source) Are the U.S. central planners smarter than the UK ones who’ve been doing it for decades?” That proved to be an impossible conundrum!]

Philip Greenspun’s Weblog

#metoo means it is a good time to go to law school?

More Americans are applying to law school this year (see “Law School Is Hot Again as Politics Piques Interest” from the WSJ, for example).

I wonder if all of the publicity around litigation following work-related sex is playing a role. After all, every plaintiff needs a lawyer and every defendant also needs a lawyer.

One new wrinkle that could make a career in law more lucrative is that folks have established a fund to pay plaintiffs’ legal expenses (described by the New York Times as a “legal defense fund, backed by $ 13 million in donations, to help less privileged women”; the word “defense” is curious since the cash will be used to paid to lawyers who are on the offense by representing plaintiffs).

This has the potential to transform workplace sex litigation into the same kind of opportunity as divorce litigation. From “Divorce Ligation”:

From a more practical standpoint, divorce litigation is more intense than other kinds of civil litigation because, depending on the state, one person can be designated by the judge to pay the legal fees for both sides. “Once my plaintiff gets a hint from the judge that she’ll be getting a fee award,” said one attorney, “she no longer has any motivation to settle. The lawsuit and trial are going to be free for her and anything she gets in the final judgment is gravy.” Another lawyer said “Most civil lawsuits end when each party has spent about as much on legal fees as the amount in dispute. By that point they’ve both learned their lesson that litigation generally makes sense for lawyers, not for litigants. In divorces, however, since all of the fees are being paid by the defendant there is no reason for the case to end until he runs through his savings, what he can borrow from friends and family, and what he can borrow from the bank.”

A competent family law practitioner in the Boston area, where this kind of system prevails, can easily earn $ 1 million per year.

[Note that this is very different from a contingent fee system in which a plaintiff’s lawyer gets paid if he or she wins. The risk of losing and not getting paid anything (and, in fact, typically being on the hook for some expenses) limits the number of cases that are filed. With a “legal defense fund” paying the lawyer who sues an employer on behalf of, e.g., someone who had sex with the boss but didn’t get a hoped-for promotion, neither the lawyer nor the victim/survivor has anything to lose.]

Readers: What do you think? No society in the history of humanity has ever devoted as much of its resources to litigation as the U.S. does, but we cranked out so many lawyers that, after the collapse of 2008, there was a surplus. Will the #metoo movement help turn this around to the point where going to law school becomes rational?

Philip Greenspun’s Weblog

Flight school wisdom: Don’t fly below 10 degrees Fahrenheit

Thanks to Trump and climate change it has been below freezing for the whole week here in Boston and sometimes below 0F. January 8, 2018 is supposed to be our next day with an above-freezing high temp (39) and February 3, 2018 our first day when it might get warm enough (46F) to melt some of the snow. Accuweather’s forecast of the next day when the low temp will also be above freezing? March 24, 2018!

Our flight school has blocked off aircraft on the coldest mornings. If the plane is on a Tanis or Reiff heater, why is this necessary? “We have found that we do more damage than we collect in revenue below 10F. It is not just the engine. Instruments, gyros, and anything else that has to move gets unhappy. Autopilot servos, trim servos, glass screens, electric fuel pump motors: all of it is unhappy.”

Philip Greenspun’s Weblog

American adults are the new high school kids?

American newspaper front pages are substantially devoted to stories about sexual interactions among various people whom we might have heard of (or at least one of any given pair). If we assume that what’s in the news is what Americans are interested in then we must conclude that American adults are tremendously interested not only in who is interacting sexually with whom, but also in the precise details of those interactions.

Previously, stories about celebrity sex would be relegated to interior sections of the newspaper. Adult residents of the U.S. talking about other adult residents would give only brief summaries of the sex acts, e.g., “X slept with Y.”

Was there ever a group of Americans who had the time and interest to follow others’ sexual interactions in detail? A group whose life was so intellectually unchallenging and devoid of serious responsibility that they had time to contemplate these tales, evaluate them for truth, and discuss the details of who did what to whom and which exact body parts were involved?

High school students!

Ergo, American adults are the new high school kids.

Readers: Agree or disagree?

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Philip Greenspun’s Weblog

Try not to work for a high school…

“Phillips Exeter Deans Failed to Report Sex Assault Case, Police Said” (nytimes)

The case began more than two years ago, when two female seniors, aged 17 and 18, told the deans that a male classmate had groped them against their will, in separate incidents in the basement of the church on the campus in Exeter, N.H.

In a detailed report by the state police that was obtained by The New York Times, an investigator with the major crime unit wrote, “I determined that there was probable cause to believe that” the two deans committed a misdemeanor by not reporting the accusation by the 17-year-old, who was covered by the state’s mandatory reporting law.

What actually happened to the 17- and 18-year-old victims?

The younger accuser said that days before she went to the deans, a popular male senior texted her that it was his 18th birthday, and asked her to meet him in the church basement, a quiet place where students sometimes studied, and which he was assigned to monitor. There, she said, he touched her buttocks and breasts and kissed her, even as she repeatedly told him not to, until she left.

The other accuser recounted a similar incident in the same place with the same male student, who she said put his hands under her shirt and touched her breasts, prompting her to leave.

Several months later, the girl felt unsafe with the male student still on campus, and showed signs of post-traumatic stress disorder, her faculty adviser told investigators.

[The journalists at the New York Times express no skepticism that teenagers are studying in a church basement rather than in their dorms. They don’t say “What a shame that a wealthy school like Exeter can’t build a library where students can study in a well-lit above-ground environment.”]

Why are the two adult deans busted?

A state law mandates that anyone in a long list of positions, including school officials, “having reason to suspect” sexual abuse of a person under age 18, which it defines very broadly, must report it to the state Department of Health and Human Services.

[i.e., the standard is the same whether it is a 4-year-old child or a 17.9-year-old “child”; note that the age of consent in New Hampshire is 16]

Who won’t ever be able to get a job unless he changes his name?

After the second meeting, the girl went to the police, and prosecutors soon charged the male student, Chukwudi Ikpeazu, with misdemeanor sexual assault. But a year later, in July 2017, as his trial was about to begin, they set aside the charge, and if he meets certain conditions — which have not been made public — prosecutors will drop the case.

$ 500,000 of private school tuition that can be flushed down the toilet. What university would admit him? If an admissions officer types his name into Google the first page will show “Sex assault charge against ex-Philips Exeter student dropped in last-minute deal”. This article is interesting because the initial idea for settling this without criminal prosecution was that the perpetrator and survivor would meet back at the church where the assault had occurred; the survivor agreed to accept daily fresh-baked bread “for the remainder of the school year,” but reneged on the deal and “eventually reported the incident to Exeter police. So the fact-pattern matches a lot of what went on in Hollywood. Survivors took the cash in exchange for keeping quiet, but ratted out their abusers and didn’t refund the cash.

Of course as someone who has worked as a teacher it is difficult to have sympathy for the deans (our natural enemies). But on the other hand I think this should be a cautionary tale for anyone who had planned to work in a high school. Failure to achieve full regulatory compliance can result in being arrested, something that is unlikely to happen to an employee at a tire shop.

Philip Greenspun’s Weblog

Why wouldn’t a Massachusetts town set up a school for gifted and talented students?

In a lot of states it is conventional to have special classes and/or schools for the highest academic achievers (the “gifted and talented” (a.k.a., those who read books instead of play video games and watch TV)). Massachusetts, however, isn’t one of them. It doesn’t seem to be illegal to do this. This letter on massgifted.org (“MAGE”!) says that “We have 407 school districts in MA but only about a dozen of them have programs for the gifted…”

Our Boston suburb of Happy Valley wants to spend $ 50 million on a same-size replacement for the K-8 school building. If the experience of other towns is anything to go by, it will cost $ 100 million. There are roughly 600 students who use this building, which means that the $ 100 million cost amounts to $ 166,667 per student.

This is roughly comparable to the endowment-per-student at some of our nation’s most prestigious and richest colleges and universities, e.g., Johns Hopkins, Boston College, Tufts, Wake Forest, Brandeis, Bates, et al. It is substantially more than some great colleges and universities, such as Hanover, Barnard, Georgetown University, Carnegie Mellon, et al.

[It may actually be more than the real endowment per student. A money-expert friend who has served as a college trustee says “The dirty secret is that these endowment numbers are not net of debt. A college can boost its ranking simply by borrowing money and putting it in the endowment. Also, when the college invests in a leveraged private equity or hedge fund, the entire nominal amount of the investment is recorded as part of the endowment. The real numbers are typically at least 30 percent lower.” He cited RPI as one of the worst examples of a school using leverage (not a bad example from the point of view of the president, who gets paid more than $ 7 million per year).]

If we wanted to boost our property values, why not keep the old building (add a few Japanese split-system HVAC units) and use the $ 100 million to set up something in the academic realm? Property values in Lexington, Brookline, and Newton have been off the charts because of their schools’ reputations. Houses in those towns sell within days, oftentimes to Asian-American cash buyers.

Since, by comparison to Maryland, Florida, or Texas even those suburbs don’t have much to offer gifted and talented students, why not make the “something in the academic realm” a gifted and talented program? Childless homeowners in our town can pocket a $ 2 million wire transfer from Hong Kong each time the parent of an academically advanced child is drawn in by the offering.

Maybe our town is too passionate about mediocrity to do this, but if you consider that suburbs ringing a city compete with each other, isn’t it strange that none of the towns would try it? Massachusetts towns have a lot of independence in terms of how they fund and run schools. Why wouldn’t town property owners get together and vote to make their property a lot more valuable? Are they more passionate about mediocrity than about getting rich? Or is there a flaw in the above analysis such that this wouldn’t be a likely way to raise real estate values?

Related:

Philip Greenspun’s Weblog

School = daycare attitude revealed by Houston parent

A Houston-based friend’s Facebook post:

I’m happy for the Astros winning the World Series. Really I am. But HISD’s decision to cancel school so the kiddos can take part in the festivities? Umm, hello, parents have jobs and stuff! Couldn’t the Astros be festive on Saturday?

He’s referring to “HISD schools, offices closed Friday for Astros World Series victory celebration”.

This is interesting to me because he is not upset that children will be denied the opportunity to learn. He is upset because taxpayer-funded daycare won’t be provided.

[In case you’re thinking that he might be anti-education or anti-intellectual… he is employed as a professor by Rice University.]

Related:

  • Smartest Kids in the World: American Schools

Philip Greenspun’s Weblog

What if your school could tap into the minds of 25 Harvard PhDs?

A letter, slightly tweaked, from our local public school district, which runs a small K-8 school:

Happy Valley Public Schools become a WorkPlace Lab for Harvard Graduate School of Education’s Doctor of Education Leadership (Ed.L.D.) Program.

… Happy Valley Schools will be the site for fieldwork by 25 graduate students in Harvard’s Doctorate program in Education Leadership (Ed.LD.). This program, at the Harvard Graduate School of Education, is a three-year, full-time multidisciplinary doctorate that prepares graduates to be transformative, system-level leaders in preK-12 education. Each cohort in the program comprises 25 experienced educators, selected from a large number of applicants, and the intensive training includes hands-on experience in local school districts, translating visionary ideas into real-world success. This fall, those 25 students will be doing their fieldwork in Happy Valley.

This massive infusion of brainpower should be awesome, right? Kids in Singapore had better watch out after these 25 high-achievers pump up our academics!

Or can those Asian kids sleep late? It seems that we were able to tell the Harvard geniuses which problems concerned us the most…

The Happy Valley Public Schools leadership had the rewarding challenge of thinking about how best to use the expertise and energy of the 25 experienced educators who are dedicating several weeks of effort to thinking about how to improve our schools. The leadership identified ‘problems of practice’ to serve as focus for the Ed.L.D. initiative:

Social Emotional Learning

What process could we carry out this year as part of our needs-assessment in order to feel prepared to craft a multi-year plan to support the social emotional development and learning for our students across the district? What social emotional content elements should we be attending to?

Public Relations

How could we better communicate with the larger community so that they know of the good work within our schools? What effective ways of communication and promoting the district would be within our resources (given our small size and capacity of administrators)?

Race and Identity

Help us tell the stories of our students’ experiences within our schools as it pertains to race and identity. What does it feel like to be a student of color or a white student?

Collaborative Practice

How can we support teams across the district as a vehicle for driving continued teacher/staff development? What factors, strategies, or approaches have other districts or organizations taken that have led to successful professional learning communities?

So… it turns out that we didn’t ask the young Harvardites for help with improving academic achievement.

Philip Greenspun’s Weblog

Medical School 2020, Year 2, Week 4

From our anonymous insider…

This week will cover mycology (study of fungi) and parasitology.

Our professor, a 60-year-old ID doctor with thick grey hair, used to go overseas six months of every year to treat rare disease outbreaks, including the 2014’s Ebola outbreak in Sierra Leone. He is celebrating his forty-fifth year of teaching medical students! When he went to medical school, Latin was an admission requirement. This would have been quite helpful in memorizing the 70+ pathogens covered during the previous three weeks as well as in pronouncing medical terminology. Instead of using textbook images for these diseases, he uses pictures of his own patients. During an investigation, he goes to the patient’s house and workplace to investigate potential exposures. One student’s summary: “He’s basically Dr. House!”

Dr. House likes to look at the big picture. “We think history is all about human actions. False. Two-thirds of the cells in our body are bacteria. We are the Uber for bacteria. Genghis Khan was about to conquer all of Europe. His army caught Yersinia pestis in Turkey. The Russians did not stop Napoleon’s army. Napoleon caught dysentery from Shigella outbreaks.” Several students are planning to read Guns, Germs and Steel on his recommendation.

Fungi are dimorphic organisms. At colder temperatures, fungi grow as the familiar mold, creating small inhalable spores. At body temperature, these spores convert into a circular yeast structure. Lectures detailed the three categories of fungi: dermatophytes (fungi that love keratinized tissue such as skin, nails and hair), systemic (fungi that can result in body-wide infections), and opportunistic (fungi that do not cause infections unless the patient is immunocompromised). Only dermatophytes are transmitted from person to person.

This block tends to evoke exotic diagnoses from students. “I’m going to get histoplasmosis [systemic fungal infection]!” exclaimed Straight-Shooter Sally after she removed an unwanted bird’s nest from her potted plants. “As I was throwing it in the trash, the nest broke in half. I inhaled all the bird poop and dust!” After class it is not uncommon to hear, “Do I have a rash on my hand? Do I have syphilis?”  One student after class asked Dr. House to inspect his foot. Dr. House had commented, “People who get athlete’s foot just on the nail, not the foot, are more likely to have diabetes.” The student asked, “Do I have diabetes?” Dr. House replied, “You’ll be fine. Remember to never treat your own children. I was convinced  my kids had meningitis when their first 103 degree fever occurred.” He ended with a joke: “If athletes get athlete’s foot, what do astronauts get…? Missile toe!”

Parasites are divided into protozoa (microscopic eukaryotic single-celled organisms) and helminths (macroscopic eukaryotic multicellular organisms). With only two days of lecture, we focused on the most common parasites, especially malaria. A common theme of this block is that many symptoms of disease are not caused by the pathogen-killing cells. For example, the watery diarrhea of Clostridium Difficile and Cholera are caused through a toxin-mediated mechanism releasing water into the lumen of the gut. The nonspecific flu-like symptoms of most viruses are not caused by cells dying but the systemic host immune interferon response. Malaria, caused by the protozoa Plasmodium, is an exception to this rule. Plasmodium infects and lyses (ruptures) red blood cells after replicating inside them. Different plasmodium species have different lysing rates giving a classical cyclical fever/anemia pattern ranging from 48 hours to months. Dr. House recounted how as late as the 1920s, syphilis was treated by giving the patient malaria (P. vivax)! The malaria would cause such a high fever it would kill Treponema pallidum. After the syphilis was cured, they would give chloroquinolone to cure the malaria.

We also learned about how the Rockefeller Foundation was founded to address the epidemic of Necator americanus (Hookworm) in the South (see http://www.pbs.org/wgbh/nova/next/nature/how-a-worm-gave-the-south-a-bad-name/).  Hookworm is a helminth that latches onto the gut lumen where it produces eggs that pass out in the feces. When a human walks barefoot through a field of fecal-contaminated soil, larvae penetrate into the foot. “Farmers would use human feces to fertilize the field where children would play barefoot.” Once inside, the worm travels through the blood to the lungs, travels up the trachea to the pharynx, and finally is swallowed into the gut. Each hookworm drinks 0.3 mL of blood per day. “The problem is you are not infected with just one hookworm, but thousands. Losing 30 mL of blood per day will cause severe iron-deficiency microcytic anemia.” Over time, this produces lethargy and mental retardation. It is estimated that 40 percent of school-aged children were infected with hookworm in the early 1900s. The Rockefeller Foundation led a massive public campaign that focused on schools to eradicate hookworm from the South.

Dr. House described the waterborne parasite called Cryptosporidium . “Crypto is all through the DC water system. It is resistant to chlorine treatment.” The immune system is normally able to contain the infection. However, some of my AIDS patients before HIV antivirals would have 60 bowel movements a day due to cryptosporidium. These people would live on the toilet, and die from dehydration and malnutrition.” Dr. House couldn’t end lecture without showing us live video, captured during a colonoscopy, of Ascaris (“Giant Roundworm”), which can grow up to a length of more than a foot in the human gut (https://youtu.be/HOaZCkA8Zvk).

Classmates were particularly interested in another waterborne parasite Naegleria fowleri, the “brain-eating amoeba.” Naegleria is found in warm lakes, including in the U.S. It is thought to gain access to the brain through the cribriform plate (thin bone separating the brain from nasal cavities) under barotrauma or a pressurized injection of infected water, e.g., falling during water skiing. I was conversing with a female hematologist in the hallway later than afternoon. She commented, “I will never swim in a lake out of fear of getting Naegleria.”

Our patient case: Grandma Martha, a 68-year-old female accountant with degenerative disk disease in her lower back. Her daughter brought her to the ED for worsening back pain, neck stiffness, and headache over the course of weeks. On physical exam, she showed diminished lower extremity reflexes. Dr. House explained, “Before you can order a lumbar puncture (“LP” or “spinal tap”), you have to rule out increased intracranial pressure which could cause herniation of the brain.” An MRI revealed several inflamed lesions of the meninges without evidence of increased intracranial pressure. LP results showed decreased protein, decreased glucose, and the presence of neutrophils in the CSF. Gram stain on the cerebrospinal fluid was negative (no bacteria observed). “The LP results were suggestive of a bacterial meningitis. However, her presentation did not fit. Bacterial meningitis is typically a very rapid onset of symptoms.” She was started on empiric antibiotics until culture results could be obtained. “I was driving home that evening listening to the news on the radio. They were reporting about an outbreak of contaminated steroids. I turned the car around. Not everything on the news is Fake News.” Several chuckles were heard in the audience.

Back in 2012, Martha had been getting regular epidural steroid injections for back pain. At least one was supplied by the New England Compounding Center (NECC) and, due to a profit-motivated sloppy approach to sterility, had been infected with the fungus Exserohilum rostratum. “We didn’t know how to treat it. No one had ever seen this before.” Dr. House added, “It is extraordinary how quickly the local health departments and the CDC responded. Within 48 hours of the first diagnosis, the CDC was calling patients.” (753 patients were injected with contaminated steroid; 234 developed fungal meningitis and 64 died. See https://www.cdc.gov/hai/outbreaks/meningitis.html.)

Martha was started on an aggressive antifungal regimen including amphotericin (known as “amphoterrible” due to its severe side effects including kidney failure) and voriconazole. “The challenge with fungi and parasites is that our immune system does not do a good job of killing it. Instead, they typically wall off the lesion to contain it. We did not know if our drugs could reach these lesions. We also did not know about the risk of recurrence. How long should we treat the patient?” Martha was in the hospital for 70 days, and continued treatment for another two months. She has fully recovered from the ordeal.

“I was fortunate compared to several other people who live with long term complications from the meningitis. Or who died. I know several people who have dealt with recurrent meningitis episodes,” explained Martha. A student asked about the recent 9-year prison sentence for the NECC co-owner and pharmacist Barry Cadden. “What would you say to him?” “Well, I wouldn’t say anything to him. I would punch him the face,” chuckled Martha. Her daughter jumped in, “I would punch him too.”

I had lunch outside with six classmates. One commented that “Medicine was really the Wild West a few decades ago. Could you imagine discovering these unknown disorders like hookworm?” Straight-Shooter Sally added, “The best part would be getting to name all these symptoms! How badass would it be to name Toxic Megacolon [severe, potentially lethal, distension of the colon that can occur when an antidiarrheal agent is administered during an active C diff infection.]”

Luke got in a heated discussion with Type-A Anita about her two years as an intern at the American Federation of Teachers. She was describing her work “empowering teachers in local communities across the globe.” Luke asked if these teachers were American. Anita responded that they were foreign teachers. Luke asked, “Why should American teachers be forced to pay dues to a union spending money on issues that are not relevant to them?”

Our group then walked over to the hospital’s SimLab, which is led by a retired nurse and EM (emergency medicine) resident. We practiced running a Code Blue where a patient was in cardiac arrest. The main purpose of the simulation was to introduce us to standard communication skills such as “call-backs” (acknowledging an order with a clear read-back) and SBAR (situation, background, assessment, recommendation) hands off.  Lanky Luke had run EMS for all of his undergraduate career. The rest of us had no idea what we were doing. The first simulation round we were sent without any guidance to resuscitate a dummy. Over time we got the rhythm of running a code. Two people focus on chest compressions, one person performs breaths, one person runs the monitor and defibrillator, and one person records events. I learned that if you are performing chest compressions correctly you can actually feel a pulse from the compression in the femoral (leg) artery.

What do people who don’t go to medical school do with $ 300,000 of college education and $ 300,000 of taxpayer-funded K-12? One of my undergraduate classmates on Facebook this week:

if you’ve been paying attention, you probably know I haven’t been the same since November 9, 2016. things changed not only in this country but also in how I view myself within that context. i joked that if Trump won I would leave the country…

well, now it’s time to follow-through on my promise. after weeks and weeks of trying to figure out what was next, I finally realized that I had no idea and couldn’t figure it out while remaining in my last job and in my last city. so as many of you know, I left DC and my job [social media analyst for advertising agency] …

but now the time has come for me to say goodbye to what used to be my home and is now just the place I try to avoid claiming. i hope to find myself in the coming weeks and months and find what makes me truly happy, in both work and in my personal life.

to that end, I am saying goodbye to the US of A and hello to everywhere else! i do not know where I will end up and although it’s a bit scary, I know I’ll find my way by the grace of a god (and maybe just a little luck)! if you have an iPhone, nothing will change between us. if you don’t, then you’ll have to settle for Facebook Messenger if you’d like to keep in touch (starting tomorrow).

au revoir america, it was fun until it wasn’t. for all those I’m leaving behind…fight the good fight, win back Congress and the WH, and maybe then I’ll pay you all a visit in the future (!?)

until then, peace&love…

We had a 2.5-hour lecture from two physicians: “Motivational Interviewing: Eliciting Patients’ Own Arguments for Change”. A 2014 landmark study found that “Behavioral patterns contribute more to premature death than genetic predisposition, environmental exposures and health care errors” (Annals of Internal Medicine, March 18, 2014). The main message is that patients need to feel like they have autonomy. “Don’t give them orders, give them options.” One internist described his patient who had been trying to quit cigarettes for a decade. “He told me, ‘Hey Doc, I am down to five cigarettes a day from a pack-a-day.’ I asked him, ‘What’s stopping you now?’ He responded, ‘If I give up now, my nagging wife will get all the credit.’.”

On Friday, we were assigned our M1 mentees. A social committee of M2s, four women and one man, stalked the M1s for this entire week (online and offline) and concluded by matching the new M1s with M2s. The matches were announced using a “Tinder match” at the annual M1 welcome party, featuring a full keg and a SnapChat Geofilter. The M1s received folders with their mentors” pictures and had to search for them in the house. Only one match was done with romantic hopes: Gigolo Giorgio and a cute sorority girl. Ten percent of the M1 class threw up during the party.

Statistics for the week… Study: 15 hours. Sleep: 6 hours/night; Fun: 1 night. Example fun:

Jane and I unfortunately missed the M1 keg/Tinder party to attend a surprise party for her sister, an advertising executive. Thirty family members crowded into a bar to watch the boyfriend, a pharmaceutical rep, propose marriage. Jane’s sister said yes.

More: http://fifthchance.com/MedicalSchool2020

Philip Greenspun’s Weblog

Medical School 2020, Year 2, Week 3

From our anonymous insider…

Virus week. Long days of lectures followed by three hours of studying old material on infectious bacteria in the evenings.

“The more I study, the less I know,” reflects Gigolo Giorgio, the class alcoholic frequently found on the dance floors of downtown clubs. One classmate asked Giorgio, “Is Campylobacter jejuni gram-positive or negative?” We were all impressed when Giorgio responded, “Gram-negative.” We were stunned: “How did you know that!” He answered, “Well I haven’t heard of it, and I’ve only studied gram-positives.”

This block is particularly challenging because the material doesn’t build on previous lessons. I feel more behind each day. “I’m still on gram-positive bacteria! I have not even started gram-negatives!” wails a classmate as we begin virology.

If you model a physician as an information processor, the result of this block is a database that is indexed in only one direction. For example, we study by investigating the properties of each pathogen one at a time. We can reliably regurgitate information from yesterday about a single bacterial species. However, when we attempt to develop a differential based upon symptoms, we have difficulty identifying potential culprits. For example, both S. pyogenes and an acute HIV infection can lead to sore throat. There were many blank faces when we were asked, “What are the common causes of sore throat?” Fortunately electronically implemented databases can be indexed in multiple ways. This is what gives clinical-assistance programs, e.g., UpToDate.com, their power to boost physician efficiency, especially in regions where ID doctors are scarce.

A 60-year-old internist who specializes in herpes and whose two children are also practicing physicians at the hospital introduces virology to us with four hour-long lectures. The Internist introduced infectious disease: “ID is not rocket science. It’s an approachable field if you have the interest and dedication to learn a lot of diseases.” Jane actually shadows the son and mistakenly thought he would be teaching us.

There are three types of viruses: RNA, DNA, and retrovirus. RNA and DNA viruses hijack host cell machinery to produce proteins of their own design. Retroviruses actually insert their own DNA into host cells.

A basic virus is a small particle containing genetic information (DNA or RNA) that encodes for its infective vector (the proteins that enable the virus to get into cells and reproduce). These proteins include the structural capsid protein(s), the polymerase(s) used to replicate the genome, and critical docking proteins to allow access into the host cell. The mode of transmission is restricted if the virus is enveloped in a lipid bilayer. “Enveloped viruses have an easier way to get into cells, but are much more susceptible to drying out on a surface. Non-enveloped viruses can last for days on a surface.”

The internist asked the class, “What is the difference between herpes and love…? Herpes is forever.” Herpesviridae is a large class of enveloped DNA viruses that include herpes simplex (genital warts and labial cold sores), varicella zoster (chickenpox and shingles), and the college-drag epstein-barr (“mono”).  “Sixty to seventy percent of the population is infected with HSV1 [herpes simplex 1, mouth cold sores],” said our lecturer. “Most people do not have reactions, but some people have outbreaks, particularly under stressful conditions. Does anyone want to tell their story about cold sores?” Two students volunteered that they have outbreaks, particularly around exam week. They both have a prescription for the antiviral drug acyclovir, which can reduce symptoms if administered during the beginning of the outbreak (typically a tingling or burning sensation). Herpes viruses remain latent in sensory nerves until the immune system is weakened. Reactivated virus will travel to the skin to cause an outbreak.

Shingles, caused by the latent varicella, will typically infect only a single dermatome (region of skin innervated by a single spinal nerve). We also learned about flaviviridae, which causes several nasty tropical diseases, including Dengue, Zika, and Chikungunya. “Each of these is transmitted through the same Aedes mosquito, so it is possible to get multiple outbreaks simultaneously. I’ve had patients with two at once.”

A number of students thought the viral lectures would have been more effective after a dermatology block (scheduled in two weeks). The early symptoms of viruses are typically nonspecific, with the exception of some characteristic rashes. For example, we looked at pictures for the common rash-causing diseases of childhood (measles, scarlet fever, rubella, slapped cheek and roseola) without having an understanding of what pathophysiological mechanism is causing these lesions.

The ID physician spent about 30 minutes on the hepatitis viruses. “There is now a ninety-five percent cure rate for all genotypes of Hep C. It’s truly unbelievable the surge in drug innovation. Five years ago we had almost nothing. Now there are over 12 drugs.” He commented how the first Hep C drug recently dropped in price to remain competitive as it only covers a few genotypes compared to the newer drugs.

Why are there are so many genotypes and viruses? Some viruses purposefully use an error-prone polymerase (enzyme used to replicate DNA/RNA) to accelerate their mutation rate. For example, influenza pandemics occur when a “genetic shift” arises that is sufficiently different from previous strains so that past exposure provides no immunity. This also means the influenza viruses make up to 10 percent null copies, incapable of infecting, but that is okay for an organism that is expending someone else’s energy.

We also learned that many cancers are thought to be a result of past viral infections. For example, cervical and anorectal cancer are almost entirely attributed to sexually-transmitted human papillomavirus (HPV) infection. This is a DNA virus and the cancer-causing strains are primarily HPV 16,18,31, and 33, which are covered by the Gardasil 9 vaccine (ideally administered to both males and females at age 11-12). Viruses typically induce a cell growth state to increase DNA and RNA replication. Some viruses even encode proteins that suppress growth inhibitors such as tumor-suppressor gene p53.

Wednesday and Thursday featured lectures on HIV led by a quirky, cynical ID physician specializing in HIV patients and speaking in a voice that was a bit like Brian Boitano’s. “Do you think he is gay?” a student asked after lecture. Type-A Anita quickly responded, “Of course he is gay. He treats HIV patients.”

HIV is a retrovirus with machinery to integrate its viral genome into the host genome. HIV’s genome encodes for (can produce) only nine proteins. Gp120 is a glycoprotein inserted into the cell membrane envelope that allows the virus to bind to CD4, a protein found on specific white blood cells. When bound, the hidden Gp41 aggregate to bring the viral envelope closer to the host membrane and eventually fuse allowing access to the host T cell. Other host proteins are necessary for viral fusion, including CCR5. One student sent a case report to the class GroupMe about an HIV-positive individual inadvertently cured of HIV when he received a transplant of bone marrow that lacked this protein. (http://www.nejm.org/doi/full/10.1056/NEJMoa0802905).

Two lectures were dedicated to managing HIV. The ID physician began: “My patient was diagnosed with HIV around age 40. She was confused until her husband admitted that for decades he would go on business trips and have unprotected sex with men. She got a divorce.” A student whispered, “I wonder if health insurance survives after divorce?” (Answer: depends on the state; see Real World Divorce)

The ID physician continued, “You are now supposed to prescribe antiviral drugs to anyone with HIV as opposed to those below a CD4 count threshold. Europeans still wait for a low CD4 count to develop, probably because of the cost of these drugs.” HIV antivirals, if taken regularly, are able to wipe out detectable virus particles in the blood and return CD4 count to normal. “There was a study conducted in West Africa where married individuals with one HIV-positive partner was treated. They evaluated how many HIV-negative partners contracted HIV over several years. Almost no one who adhered to the medication regiment passed the HIV to their partner. Some partners tested positive for HIV, but it turned out to be a different genetic strain. The partner had to have caught it from someone other than the spouse.”

We also learned about HIV prophylaxis treatment. At-risk individuals, such as healthcare workers in a high-risk region, or high-risk sexually-active individual, are prescribed HIV antivirals to prevent transmission. “If you are stuck with a needle from an HIV-infected patient, TELL SOMEONE. If you get started on prophylaxis drugs within 48 hours, we can basically guarantee a zero percent transmission rate. You have to hit the virus before its genome is integrated into CD4 T-cells.” One classmate asked, “Are there certain regions of the country where all gay people should be on prophylaxis?” The lecturer was slightly confused, but responded, “No. Assess the risk. If someone is having unprotected sex with two-three different partners a week, yes. If they are in a monogamous relationship, no. Also it depends on what insurance they have.”

A few classmates discussed afterwards if medical education weights HIV too much compared to more common viral infections. Less than 1 percent of the world is infected with HIV. In the US, 1.1 million individuals are HIV-positive, about 0.3 percent of our 325 million population.

Our patient case: Taylor, a 41-year-old black female, presents to the ED in respiratory distress. She reports worsening shortness of breath and persistent cough over the past 4 weeks. Chest x-ray shows glassy white highlights on the normally black air-filled lungs. This suggests diffuse intralobular infiltrates (infection in numerous spots within the lungs; a typical pneumonia is just one big spot). She is admitted and placed on antibiotics. However, her pulmonary function continued to deteriorate and she is transferred to the ICU. Her CBC revealed elevated lymphocytes with a CD4 T cell count less than 100. She is immediately started on antifungal medication to address a suspected Pneumocystis jiroveci infection. HIV test is positive.

Her two-week hospital course is challenging. Because of her low immune function from the HIV, she arrived at the hospital coinfected with several viruses. Then once in the hospital she acquired a conventional pneumonia from intubation and urinary tract infection (UTI) from the foley catheter. She makes a full recovery and is discharged for outpatient follow-up.

Taylor, now 55, is energetic and recently became a grandmother. “At the time of the diagnosis, my three children were 14, 16, and 21. I was in complete denial. I went to four doctors in town to get another HIV test. I finally accepted it while talking on the phone with my internist. I dropped the phone and wept. My children came into the kitchen and asked what was wrong. It felt impossible bringing this up with them.” Once Taylor acknowledged her HIV, she quickly began antiviral treatment without serious side effects. Her CD4 count has improved to normal, and she has not been hospitalized since the above episode.

How did your friends and family react? “I was severely depressed for several years. I’ve been on every single antidepressive that you can think of. You never know who will be there when you are most vulnerable. My best friends were the first to flee. Three of my siblings still do not speak with me. My sister will occasionally visit me, but she refuses to hug me, or let me see her children. People, especially in my community, remember the 1980s epidemic. They think if they touch, or even come near someone with HIV they will get infected.”

“I told my oldest son a few months after my diagnosis. He asked, ‘Do you know who did this to you?’ I told him the truth. ‘Yes. The man knew he had HIV, but still slept with me. When I found out and confronted him, he moved far away.’ I was scared my son would search him out and attack him. I fortunately calmed him down.”

How about coworkers? “I do not tell my coworkers about my health. I get my work done and get home for my kids. No socializing for me.”

The last question asked by a student was, “If you could go back, would you not sleep with that man?” The whole class put their heads down in shame. Taylor seemed a little taken aback, but responded, “Yes, I regret getting HIV.” Several students went up afterwards and gave her a group hug.

Back in lecture we were treated to three 2.5-hour sessions led by an experimental psychologist who studies human engineering in medicine: cognitive-biases, leadership and systems engineering in healthcare. She explained that she had worked at another institution on applying human engineering principles to the cardiac OR and had been recently hired into a newly created position at our hospital and school. “I am by no means an engineer. In fact, my former boss who was an engineer would always get frustrated when we had a meeting. We just think different.” She now conducts studies evaluating the use of checklists, standardized communication protocols, team meetings before and after surgery, and sleep schedules.

“Healthcare systems are not engaging in improvement by pinpointing individuals anymore. Instead, they are trying to improve the system in which actors engage,” she noted. “There were three occasions at the hospital where different nurses administered a full vial of insulin [about 300 cc; triple the correct dose]. The problem was that the nurses were used to getting insulin shots in a pre-formulated syringe with the dosage measured out instead of a whole vial. We implemented a standard insulin dispensary protocol.”

Lanky Luke, a conservative-leaning 25-year-old, vented his spleen after the third session: “What a complete waste of our tuition dollars. We have already had that lecture about respecting other professions [working in the hospital, such as nurses and technicians]. I am all for sitting down and figuring out ways to minimize errors but you have to maintain individual responsibility or the whole system shuts down. I don’t need an overpaid psychologist who knows nothing about medicine to teach me that. Why don’t you just bring in an experienced PA or nurse who can tell what it is like getting talked down to by a PGY1 [intern year].” Another student added, “Why are we discussing how to improve team communication when we don’t even know how to diagnose strep throat?”

Statistics for the week… Study: 10 hours. Sleep: 8 hours/night; Fun: 1 days. Example fun: Jane and I joined Luke and his wife Samantha for beers downtown followed by a space-themed Escape Room. Luke and Samantha had successfully completed one before. Three medical students and one PA student were not able to escape in the one-hour time slot. Let’s hope that we do better when solving medical mysteries.

More: http://fifthchance.com/MedicalSchool2020

Philip Greenspun’s Weblog

Medical School 2020, Year 2, Week 2

From our anonymous insider…

Three marathon 4-hour lecture sessions with infectious disease (ID) specialists. Some would cover over 10 different diseases caused by a specific bacterial strain in a mere hour time. Most of the information went in one ear and out the other, especially with the PhD microbiologists. About two-thirds of students stopped attending lecture after the first session. “I have to study this material on my own over several days to not suffer from information overload. I do not find getting bombarded at lecture is efficient use of my time.” They missed a few clinical pearls from the more lively ID clinicians.

One ID doctor delved into the disease-filled, gram-positive, spore-forming, anaerobic genus Clostridium. Spores enable a bacterium to lay dormant, surviving external pressures such as extreme temperatures, pH, and sanitation chemicals. C. difficile is able to survive hand sanitizer and many hospital disinfectants. “Only thorough hand washing will get C diff off your hands. Hand sanitizer does nothing to it.” C diff jumps from bed to bed in hospitals, causing terrible gastroenteritis. Although C. diff is not able to thrive against normal gut flora, after a broad-spectrum antibiotic that decimates the normal flora, C diff will overtake the gut leading to pseudomembranous colitis and the release of toxins that cause life-threatening rice-water diarrhea similar to cholera. The genus Clostridium also contains C. tetani and C. botulinum two related species that cause tetanus and botulism, respectively. C. tetani produces a neurotoxin that destroys inhibitory neuron activity producing a spastic paralysis, typified by lock-jaw. Why are rusty nails and dog bites associated with tetanus? The skin typically seals over a deep penetrating wound before it is fully repaired. Sealed off from the destructive power of oxygen, anaerobic bacteria such as Clostridium tetani thrive.  C. botulinum produces a similar neurotoxin, classified as a Tier I bioterrorism agent, that destroys neuromuscular junction activity, producing a flaccid paralysis. Otto Warmbier, the University of Virginia student imprisoned by North Korea, contracted botulism, which lead to respiratory arrest and coma. (The same Botulinum Toxin, “Botox,” can be harnessed to extend the expiration date of the Hollywood elite.)

A 35-year-old overweight unkempt ID pharmacist and an internal medicine resident led a highly effective two-hour lecture and workshop. Unlike the pharmacist at your local Walgreens, pharmacists who work in hospitals must complete a residency. Our lecturer said that his job was to eliminate any bug that comes into his hospital. He went over the clinical impact of antibiotic resistance: “the never-ending arms race.” “My job is to make you good stewards of antibiotics. Now, this can seem like a daunting task, especially when Cipro [broad-spectrum antibiotic] is OTC in Mexico, but let’s give it a shot.” The ID pharmacist added his opinion that there are few new antibiotic classes in the pharmaceutical pipeline because it is difficult to make a profit: “In addition to costing millions to bring a new drug to market, once it is in market, bacteria develop resistance so fast that it doesn’t have a long shelf-life. Further, the medical system reserves new antibiotics as a last line defense.” A student shared a Harvard-Technion experiment on the class GroupMe illustrating the rapid generation of antibacterial resistant genes. Escherichia coli with a fluorescence probe was plated on one end of a giant agar plate with steps of increasing concentrations of the antibiotics trimethoprim (Bactrim) or ciprofloxacin A time-lapse video depicts bacterial colonies traversing onto each step and completely covering the sheet by 12 days.

The 27-year-old internal medicine resident, reminded us that Group A Strep (strepococcal pyogenes) is one-hundred percent sensitive to penicillin. “Don’t be a jerk and give your poor patient a Z-pack,” she cautioned. [Azithromycin is a broader-spectrum antibiotic.] We were also informed that hospitals in different regions have different antibiotic schedules: “MRSA is much more rare in rural Idaho than in NYC. I would be terrified to get hospitalized in NYC.”

The workshop culminated in using iPads to play “Heads Up”. One student would put the iPad on his or her head and, based on hints from other group members, try to guess the bacterium or antibiotic displayed on the screen, e.g., 1st-generation cephalosporin or Clostridium tetani.

My favorite lecture was by a 35-year-old emergency medicine physician on the management of sepsis, a systemic immune response to infection. The immune response causes blood vessels to dilate, thus reducing blood pressure (hypotension), leading to multiple organ failures (“septic shock”). Patients who show up in the ED with septic shock have a mortality rate of twenty-five percent. “I like how he made you feel like you were in the ED. He gave so many different clinical cases,” commented a student after class.

The physician explained, “If a patient is in shock, I immediately conduct a RUSH (Rapid Ultrasound for Shock and Hypotension) exam. I am looking for what is causing the shock. Is it an internal bleed causing blood to pool in Morison’s Pouch [between kidney and liver] or around the rectum?  Is it cardiac tamponade [fluid in the sac of the heart restricting its motion]?” Once he has determined septic shock, he starts the patient on antibiotics even without any confirmation of bacterial infection. He then determines if the patient is fluid-sensitive, i.e., if cardiac output would improve with IV saline. The Starling Curve describes cardiac output as a function of End Diastolic Volume (blood volume) for a given heart contractility and vascular tone. The physician continued, “We used to just give the standard 30mL/kg. [2 L for a 70 kg person.] Now electrical engineers have given us the NICOM [Non-invasive cardiac output monitoring] device to determine if someone is fluid-sensitive or insensitive.” NICOM device uses two pairs of electrodes to measure the change in impedance across the chest to the abdomen as a bolus of fluid is injected into the patient. He concluded, “No idea how it works, but we use it everyday. It is pretty neat to see the Frank Starling Curve appear on the NICOM screen and watch the physiology we learn in medical school actually be applied.”

Our patient case: A young ED physician describes his treatment of Abigail, a 26-year-old waitress attending community college for interior design. She presents to the ED for a worsening blood-tinged productive cough, fever, syncope (fainting episodes), and back pain. Over two months she has been to the ED twice and been prescribed different antibiotics for a productive cough and myalgia. With blood pressure of 80 over 55 and heart rate of 110, she is immediately recognized to be in shock and is transferred to the ICU. The RUSH exam reveals left ventricular dysfunction suggestive of distributive shock (leaky blood vessels from suspected sepsis infection decreasing blood volume). Even after a total of two liters of IV saline, she requires pressors (norepinephrine) to maintain a MAP (mean arterial pressure) above 65 mmHg.

“Her entire course changed from a simple question: ‘Do you use drugs?’,” explained the ED physician. Abigail confirmed she regularly injects oxycodone into her veins. “We immediately suspected septic shock with endocarditis [infection of heart tissue] likely from Staph aureus, which has a proclivity to infect the tricuspid valve after getting injected into the blood.” Blood and sputum cultures grew methicillin-resistant Staphylococcus aureus (MRSA). She is immediately started on IV vancomycin (a non-penicillin-based antibiotic reserved for serious gram-positive hospital infections). Echocardiography reveals substantial vegetation on the tricuspid valve. The colonies were releasing small particles into her pulmonary circulation causing septic pulmonary emboli. In addition to heart and lung colonization, she developed osteomyelitis (bone infection) in her vertebrae. The immense immune response due to the bacteremia (infection in blood) and Staph aureus toxins caused glomerulonephritis (kidney inflammation) and hematuria (blood in urine).

“Although the bacteria is the cause of her sepsis, the infection was not the immediate concern,” explained the EM physician. Intensive support therapy including blood/plasma transfusions, fluids, mechanical ventilation, and vasopressors were given throughout her two-week ICU stay. “I’ve rarely seen someone recover completely in medicine after septic shock with tricuspid valve endocarditis. It truly amazes me. Heart, lung, kidneyall fully recovered except for lower back pain.” Abigail was transferred to a “step down” unit [in between the ICU and the general ward] and discharged to rehab.

When we returned to lecture, an ID physician introduced diseases of the spirochetes such as Syphilis and Lyme Disease. “Always note the presence of rash on the palms or soles.” This can help narrow down a broad differential as not many diseases cause a rash there. Syphilis, caused by Treponema pallidum, begins with formation of a chancre, a characteristic painless ulcer, on the penis or in the vagina that lasts for four-six weeks. “I can never understand how some males do nothing about this quite obvious lesion.” Patients then develop a generalized lymphadenopathy (enlarged or sensitive lymph nodes) with a  diffuse rash on the palms and soles that resolves. After a multi-year latency period (typically within 5 years of primary infection or 15-20 years after primary infection), some patients enter a serious tertiary phase that involve syphilitic aortitis (inflammation of the aorta potentially causing an aortic aneurysm ), neurosyphilis and gummas (red protrusions of the skin with a necrotic core).

Lyme disease, caused by Borrelia burgdorferi, requires an infected tick to be feeding on the human for at least 48 hours for the bacteria to change membrane proteins in preparation for human cell infection. The feeding ticks are typically less than two millimeters in size, so they are easier to miss than a syphilis chancre. Lyme-infected ticks and diseased humans are most common in the Northeast and upper Midwest, coinciding with large deer populations.

Statistics for the week… Study: 12 hours. Sleep: 8 hours/night; Fun: 2 days. Example fun: Our class held a Game-of-Thrones watch party. Straight-Shooter Sally: “Game of Thrones unites multiple generations under one roof. My parents love this show just as much as I do!”

More: http://fifthchance.com/MedicalSchool2020

Philip Greenspun’s Weblog

Medical School 2020, Year 2 begins

Before starting the publication of Medical School 2020, Year 2 entries, here are some Year 1 wrap-up thoughts from our anonymous insider:

Nearly every answer in medical school spurred another question until finally the answer wasn’t known or wasn’t answerable in the limited time for each subject. I eventually got used to the frustration that the system at-hand was too complex for a simple generalization. The every-two-month exam cycle gives students a sprint mentality, but I came to realize that it was okay to not know everything. Medical school is a marathon, not a sprint.

One year done and I’m more excited about working in healthcare, but disillusioned about the trajectory of American health. Diabetes, drug abuse, premature heart disease, psychosis. These are not typically driven by genetics, but rather symptoms of the society that we’ve built. Americans expect the healthcare system to clean up the mess, but seldom are doctors able to provide a complete cure for these ills of modern society.

I have also become disillusioned about our ability to formulate health care policy. We learned about ongoing clinical trials that pay diabetics to exercise and eat better, similar to the classic “A behavioral approach to achieving initial cocaine abstinence” (Higgins, et al. Am J Psychiatry, 1991), in which patients were given $ 1,000 to stay clean for 12 weeks rather than being put into rehab ($ 1,000 per day?). This could be much cheaper than Medicaid and Medicare paying to treat the inevitable complications. Politicians make beautiful speeches taking credit for providing insurance to millions of Americans, but where are these people who have purportedly been helped? Some of the hardest working people I met in the clinic made too much to qualify for Medicaid, but not enough to afford an Obamacare policy. They eventually have to stop work and show up in clinic with a far worse prognosis, e.g., half a foot that needs to be amputated, and the bill is paid by Medicaid or absorbed by the hospital’s charity care fund.

At least in our university-run, mostly Medicaid/Medicare-funded, health care system, I didn’t see obvious examples of what Jack Wennberg, the founder of clinical evaluative sciences, called “supplier-induced demand.” However, my attendings would nearly always refer patients to specialists out of fear of “missing something,” and every stubbed toe got an X-ray. Perhaps Wennberg’s estimate that 30 percent of healthcare expenditures are unnecessary or harmful is correct, but it wasn’t obvious which 30 percent we should have cut.

As a child I associated healthcare with doctors and nurses. One trip to the most popular restaurant across from the hospital campus and Jane and I realized that it was really more about administrators, lawyers, IT, and Human Resources staffers. I’m no longer surprised to see a hospital employee badge reading “business development officer” pinned to a business suit.

Classmates often wonder “Why does medical school cost so much?” Our conclusion is that the enemy may be us. Administrators and deans have proliferated along with LCME requirements in the name of creating an fair and equitable learning environment. Is it helpful to have lectures recorded? Yes, but it requires a huge IT department and expensive software. Our gym was just upgraded, which seems to have been a marketing decision because most classmates didn’t know that we had an in-school gym within the school in addition to the membership at a comprehensive fitness center (with pool!) that is covered by our tuition. The Wellness Committee and the Office of Inclusion and Diversity, led by a Ph.D. psychologist, seem to have unlimited funding to hold seminars on self-defense and microaggressions (I try never to miss one due to the great catering from local restaurants); funding for student-organized events on medical topics, such as a suture workshop, is limited to $ 2.50 per attendee and can be challenging to obtain. Waste is noted, but seldom criticized, due to the free-flowing Federal spigot of student loan funds.

I conducted an informal survey of classmates towards the end of the year. Some of their responses are below.

What has surprised you?

“The amount of independence. You hear about all these learning environment resources, different subjects, supplemental materials for purchase like Anki and Firecracker. It is pretty overwhelming at first. I eventually realized that if I just study the exact the same way [as in undergraduate courses] then I do well. It is just school.” [Jane]

“That I could actually be interested in surgery.” [Disinterested Dorothy, originally planning to follow her father into internal medicine]

“People like talking about their health problems.” [He obviously hadn’t met my grandfather!]

Is it more or less studying than you expected?  

“Less overall but exam week is brutal. It’s the way it is, not the way it should be.  I regret not being as organized and dedicated as some students. I would study more spread out instead of cramming before.” [Jane]

What did you wish you knew about healthcare that you know now?  

“I always thought doctors were unquestionable. Doctors are human. Ask them questions. If they are not explaining the reason, they are not doing their job right. I now know there are good doctors and bad doctors.” [let’s hope that she doesn’t practice these sorting skills at home; she’s the daughter of a physician]

“Healthcare is challenging but it is more accessible than people would think. I approach healthcare as a field in which if you work hard enough or study long enough you can succeed. Compare this to, for example, computer programming or engineering. No matter how hard I worked at that, I just could not do it.” [she majored in biology as an undergrad]

What do you like about the class and what do you not like about the class?  

“I like how our class is fun and likes to hang out with each other. We have a good sense of humor. What do I not like? Our class will complain about anything. They can also be quite disrespectful.” [Jane]

Do you wish you took time off before medical school.  Gap year or no?  

“No stigma either way.  Straight in or five years out doesn’t matter. Once you are here, you are here.” [Youngest classmate]

“It took me three application cycles to get into a school.” [Straight-Shooter Sally]

“I am glad I took a gap year. I don’t think I was intellectually mature enough to go straight through. I think I would have fooled around with all the free time in medical school if I didn’t learn some discipline working in the real world.” [Male classmate who worked for pharmaceutical company]

“I am glad I am here, but certain specialities are off the table for me. I’m too old!” [Upperclassman who started medical school at 35]

What do you think about our teachers?  

Passion is infectious.  When someone is passionate you can’t help but listen to them. M.D.s are more fun than Ph.D.s. Teachers talk about what they know. They know their patients. That’s why we are here.” [undergraduate physicist major known as the class gunner]

“About a third of the instructors are great. I give an instructor one chance. If I don’t like them, I no longer show up for lecture.” [Classmate notoriously late for the few lectures he does attend. If the class gives him the heads up it was worthwhile, he might watch the recorded lecture online.]

What do you think about anatomy?

“I liked MSK (musculocutaneous) dissections. It was satisfying using your hands to isolate muscle and fascia layers. Reproductive was pretty cool too. I literally cut a penis in half and took the fascia layers apart. Not many people can say that! Oh, and that bone saw was sick!” [Disinterested Dorothy]

“I hate anatomy. You cannot see anything in a cadaver. So excited to be done with it.” [Pinterest Penelope apparently has better things to do]

“Anatomy is the best part of medical school. It is the unique topic for medical school. All the other material a lot of us have have been to exposed to in various undergraduate majors. No one gets exposed to anatomy, at least at this level.”

Anatomy Advice for M1?

“Get in there to get over. Thinking about it is bigger issue. I never had issue. Doesn’t feel real because the cadavers are cold.”

“It is pretty rare to have surgeons take time out of their day to spend two hours helping you dissect. Take advantage of it.  You get out what you put in. Be interested in what you are doing. It looks bad when half the class leaves early from lab.” [Jane]

“Buy a pair of scrubs. You look badass and that way you won’t get your normal clothes smelling like the lab.” [Class Orthopod]

What are you excited about?

“Being a doctor allows you to make a decent living wherever you want to live. You don’t have to live in a big city where all the jobs are for young people.” [Classmate from Kansas]

“All my friends and family ask me about their health problems. It is fun to play doctor. We can now understand what is wrong with them. Ask us what to do about it? We are no better than the internet. Patient care comes from experience, not from education. I’m excited to eventually be able to answer their questions with action.”

What is something you would change?

“Administration treats us as kids, not adults. There is a resource for everything.” [Classmate who juggles a newborn and toddler with medical school studies]

“The cost of tuition. The founding of for-profit medical schools tells you all you need to know.” [Classmate with PA-student wife]

“Just tell me what is going to be on Step I. I do not have time nor the brain space for anything else.” [Type-A Anita…]

“Residency match. If you want to do a speciality, it has become so competitive. The Match is in a death spiral.” [Class Orthopod]


Following the curriculum isn’t enough if you want to be a good doctor. Friends at other schools, a few classmates, and a physician mentor agree that the focus of medical school is ensuring that the lowest denominator passes, not challenging each student to reach his or her highest potential. The resources are there for anyone who wants to take the initiative, but peer pressure works in the opposite direction. The most vocal students echo each other’s complaints that the curriculum isn’t sufficiently test-focused.

First year for most students serves a reminder that not all of us are special. Most medical students were near the top of their undergraduate class, but that was partly because their fear of failure (failure = less than an A) was so great they didn’t take challenging courses. Classmates’ first reaction to getting a question wrong may be to assert that the question was unfair, poorly worded, or that the answer was not worth cramming into our already crammed brains. We expect to be the discoverer of a new drug or the manager of a big project. One of my bosses during my gap year said, “What we really need are great employees. Leadership comes afterwards.” The more that I shed the entitlement mentality, the more I was able to focus on my strengths.

One thing that I learned is that medical students don’t relax until a few months prior to graduation. Classmates traded their fear of not getting into their first-choice medical school for three years of anxiety of not doing well enough on Step I (end of second year) and in rotations (third year) to get into their first-choice residency. One of our clerkship directors sent us an article about the surgery residency match process: “This leaves the 163 orthopedic residencies that participate in the Match in the unenviable position of having to sort through 88,169 applications for 717 total positions from just over 1,000 total applicants.” (Scott E. Porter, JAAOS, 2017)  I.e., a typical applicant applied to 88 programs, more than half of the total programs nationwide. Maybe the Web-based Match software will need to be updated with a Select All option…

Philip Greenspun’s Weblog