Month: June 2017

Exam week and most of us are feeling burned out. “I just want to get this over with,” lamented one classmate. “Studying another few hours won’t change anything.”

We had four exams, three hours each, one per day, from Monday through Thursday, starting at 8:00 am or 9:00 am. All were computer-based.

The main NBME exam was challenging and surprisingly clinically-focused. Example: “Where is the lesion for someone who has right-sided intention tremor?” (Answer: right cerebellum; not everything in the brain is cross-wired.) Type-A Anita complained, “I thought it would be much more detailed and less big picture. I studied all the wrong things.” There were numerous questions on peripheral nerve deficits as a result of disk herniation. Students complained that this subject was not covered in “significant detail” during lectures.

The anatomy exam, developed locally by Doctor J, was a blend of challenging second-order questions and basic identification questions, with both multiple-choice and short-answer styles. Students complained that the second-order questions as not testing only “anatomy material”. For example, three students complained about questions asking to locate the lesion site for various visual field deficients. Several memorable questions started with a group of stroke symptoms and asked the student to identify the blood vessel most likely affected. Students were outraged at these applied questions. “I cannot believe Doctor J put that question in. He put that in just to screw us over.”

Students were also frustrated by the locally-developed clinical exam covering the HEENT (head, ear, eye, nose, and throat) exam, the neurological exam, and child development. We looked at computer images of different retinas. Given a description of a patient’s reflexes, we had to name the peripheral nerve or spinal nerve roots that might be damaged. We looked at a computer screen image of an ear canal that we would have seen through an otoscope. We were asked to identify the age of kids based on certain observable skills and behaviors. Type-A Anita complained to several classmates, “I don’t need to know this for Step 1” (the board exam we will take at the end of our second year). The classmates echoed back, “I don’t need to know this because I don’t want to be a pediatrician.” Students complained about the image quality of the ear canal, even though a higher quality image would not have helped them answer the question. Students complained, “This material overlapped with our other exams.”

The patient case exam asked to propose hypotheses for various clinical scenarios. What tests would you order? What diseases should be on your differential for this given test result? What other information would you want to know? How would you manage this patient with Parkinson’s? What other symptoms and test results would you expect from this patient? Most students do not study for this exam. Students complained about the drugs that were covered.

After our last exam, Jane and I went to a brewery. Students trickled in as people finished. “Cheers to another step to becoming a doctor!” Dorothy Disinterested responded, “I have lost so much faith in our medical system. It scares me to think that we are one-quarter of the way to doing stuff to patients.”

Statistics for the week… Study: 15 hours. Sleep: 5 hours/night; Fun: 1 night. Example fun: We met at a classmate’s apartment for pool and darts around 8:00 pm before heading downtown for an “End of M1” celebration. My classmate and I went to a less crowded part of the bar to get another beer. We were listening to a bartender’s conversation with some of her friends. A friend asked the bartender, “What have you been up to since you graduated college?” She responded, “Working here pretty much.” My friend commented afterwards, “That’s too bad she went to college with all that debt. She could have been the manager by now if she started after high school.”

More: http://fifthchance.com/MedicalSchool2020

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A friend sent me “Who is Reality Winner? Accused leaker wanted to ‘resist’ Trump” (Fox News, so should I de-friend this guy for being Deplorable?). The substance of the case doesn’t interest me too much. I have to assume that “a [U.S. government] classified intelligence document” is mostly speculation and misunderstandings. What I am curious to know is whether the National Security Agency hired an employee (even through a contractor) named “Reality” and expected things to work out.

Readers: Was this spirited gal actually working in an NSA facility?

Related:

• Code Warriors (book about the NSA): “On an Army sergeant’s salary of $100 a week, [the NSA employee who turned out to be selling secrets to the Soviets] owned two Cadillacs, a baby-blue Jaguar sports car, a thirty-foot cabin cruiser, and a world-class racing hydroplane; he told coworkers a series of contradictory and patently fantastic stories to account for his sudden wealth, including that his father owned a large plantation in Louisiana, that he had made a successful investment in filling stations, that he owned land containing a valuable mineral used to make cosmetics, and that he had won the money as prizes in boat races.”
• article about tracing source of this document via laser printer dots

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Apple, Facebook, and Google have soaked up a huge percentage of humanity’s wealth. Why aren’t they enriching our lives more?

Since I’m a Gmail user, let’s take Google as an example. Google knew that I was going to Moscow (itinerary emailed to my Gmail address). Google knew my schedule (Calendar). Google should know my various interests by now, from reading my Gmail messages and Docs content. Due to me being of such an advanced age that I still use email rather than text, Google definitely knows my real social network (the people with whom I correspond via email).

Why didn’t Google suggest to me a whole bunch of cultural events? People to meet? Groups to join? The stuff that Google tries to help with is stuff that was already pretty easy to do in the pre-Internet days, e.g., book a hotel or airline ticket. Even in those areas, Google is simply following the mid-1990s leaders such as Expedia.

I don’t think that one can argue that enriching lives is unprofitable and therefore these profit-seeking companies aren’t interested. Selling tickets to events should lead to commissions. Connecting people to meet in public places, such as restaurants or bars, should also lead to commissions. These could be a lot more lucrative than what Google gets from selling mouse clicks.

Readers: if we assume that human boredom leads to a lot of purchases, e.g., of movies and games, why aren’t companies such as Apple, Facebook, and Google chasing this market through actual social connections?

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Three hour-long lectures on child development. A student commented, “Who knew that children are blind as a bat when they are born. 20/300 vision!” Afterwards, several instructors brought in children aged one month to five years for a workshop. Each pediatrician noted specific tasks, behaviors and skills. Dorothy Disinterested was reprimanded for “not being interested in the subject material and being on her cellphone”. Dorothy explained afterwards, “I am just not interested in children.”

Also three hour-long lectures on cerebrospinal fluid (CSF) circulation. The brain is surrounded by an outer connective tissue called the meninges (meningitis is the inflammation of this connective tissue) composed of three layers (outer to inner): dura, arachnoid, and pia. The dura, a fibrous white sheet, is strongly adhered to the inside of the skull and, via dura folds, divides the cranial cavity into quadrants. The falx cerebri divides the brain into left and right hemispheres. The tentorium cerebelli is a horizontal sheet that separates the cerebrum (above) from the cerebellum (below). These dural folds are tightly adhered to the arachnoid, named for its resemblance to a spider web, a clear membrane that wraps around the exterior surface of the brain. The innermost layer is the pia, another thin membrane, follows the contours of the brain into its crevices (sulci and fissures). The subarachnoid space, the space between the arachnoid covering and the tightly adhered pia, is filled with CSF.

CSF is produced in four connected brain cavities called ventricles. The left and right lateral ventricles connect to the third ventricle through a thin constriction called the interventricular foramen of Monro. The third ventricle drains through a narrow constriction called the Aqueduct of Sylvius into the fourth ventricle of the brainstem. CSF exits the fourth ventricle into the subarachnoid space through three foramina (the two lateral Foramina of Luschka and the medial foramen of Magendie). Students appreciated that the early 19th-century anatomists who discovered these respective structures have last names whose first letters correspond to the structures’ anatomical positions: Francois Magendie for medial; Hubert von Luschka for lateral.

The CSF suspends the brain in fluid, thereby protecting the delicate tissue structure from small shocks and providing a buoyancy effect, which turns a 1500-gram brain into 25 grams. Without the buoyancy effect, the weight of the brain would crush itself. Each ventricle contains a choroid plexus where 500mL CSF, enough for four complete daily changes, is produced by ependymal cells. CSF circulates through the ventricles, draining metabolic waste products of neurological activity, such as glutamate (excitatory neurotransmitter) and potassium, into the subarachnoid space.

My favorite trauma surgeon explained the different types of hemorrhages. Blunt trauma can fracture the skull causing an epidural hemorrhage, rupture of the meningeal arteries that travel along the inside surface skull. After a car crash, the patient will go unconscious. They will then wake up for a “lucid interval” of roughly 30 minutes, then suddenly go unconscious again as the ruptured meningeal artery leaks into the brain. A subdural hemorrhage typically occurs in old age. The brain shrinks, which stretches the small veins that drain blood from the brain to the large venous sinuses in the dura. Slight trauma can then cause the veins to rupture, starting a slow bleed that brings the patient into the ED days or weeks later with headache and confusion. Both types of hemorrhages can result in sufficient elevation of pressure to cause herniation of the brain, in which parts of the cortex protrude through holes in the skull.

Our patient case: Greg, a 23-year-old male with Mike, his cardiologist father and Jennifer, his nurse mother. Jennifer’s pregnancy was completely normal until a 30-week ultrasound. The obstetrician noted an enlarged skull with a protrusion on the right side. The mother explained, “My OB told me, ‘Something came up on the ultrasound that we need to take another look at.’ I knew something was wrong. Whenever a physician sees something bad that they have to refer you out to a specialist, they refuse to tell you a definitive answer..” Jennifer waited several hours in the waiting room until the specialist could see her. “I did not want to call Mike because he was dealing with a tough heart case.”

Further ultrasound examination confirmed that Greg’s Aqueduct of Sylvius had narrowed, causing hydrocephalus (abnormal accumulation of CSF). The choroid plexus continues to produce CSF despite the increasing ventricular pressure in his lateral and third ventricles. The increased ventricular pressure and size was damaging developing brain tissue and preventing the skull from closing. The physicians told Mike and Jennifer that Greg would unlikely be able to survive and that, if he did, he would have severe cognitive deficits.

“We knew this was bad,” continued Jennifer. “We both have medical backgrounds so we were imagining the worse. Mike immediately became an expert on this condition. Keep in mind in those days Google was not around. Mike went to medical libraries to scour the limited literature on this condition and its outcomes. Our doctors recommended we terminate the pregnancy. But when I saw the ultrasound, I could not terminate. He was my boy.” Jennifer was immediately scheduled for a cesarean section. Greg was whisked away to the NICU for intensive treatment. He had a ventriculoperitoneal shunt (tube inserted through brain tissue into a ventricle to drain CSF into the peritoneal cavity) and several cranial skull surgeries to release the increased intracranial pressure.

Greg is 5’5 with a cheerful smile. He speaks slowly but carefully. “More articulate than some of our classmates,” commented one student afterwards. He chuckles after his jokes. He has terrible vision as a consequence of visual cortex damage.

Most of Greg’s medical care occurred in his infancy. He had two additional surgeries to restructure his skull at age 8 and 14. He lives with his parents and works part-time as a clerk at a local grocery store. His mother said that Greg’s social life is more active than their own: “There are all these support groups for disabled people. I feel like every week I am ferrying him to an event downtown.” He is intellectually disabled but has an encyclopedic knowledge of the Harry Potter books. Several female classmates tested his knowledge after the session.

One week before exams and Pinterest Penelope, our class social chair, released the results of “class superlatives”, one per student. One student complained about the distraction from studying: “She is just trying to sabotage us.” I received, “Most likely to ask Low Yield Questions in Lecture”. Type-A Anita got, “Most Likely to Complain About Said Low Yield Question Asker”. Our lone Canadian (we have no other foreign students) got “Most likely to curse in front of a patient.” Our class president received, “Most likely to use ‘I’m a Doctor’ line at the bar”. The shy Asian received, “Most likely to ruin his/her white coat and need to order another”. Dorothy Disinterested apparently does have at least some interests. She received “Most likely to hook-up with a patient” (as the social chair is also female, this did not generate any complaints to the deans).

Statistics for the week… Study: 20 hours. Sleep: 7 hours/night; Fun: 1 day. Example fun: a “finisher prize” for the last day of class, beer and burgers with four classmates.

More: http://fifthchance.com/MedicalSchool2020

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One of my friends in Berkeley, California recently linked to “The Invisible Workload That Drags Women Down” (TIME, December 29, 2016). She has previously used Facebook to heap scorn on the stupid, racist, sexist, and anti-gay Americans who voted against Hillary. Also to throw rocks at skeptics of published climate change predictions. After the election of the Trumpenfuhrer, she condemned the “anti-intellectualism” to which America was now doomed (a country that produced Britney Spears can be considered somehow anti-intellectual?).

The research described (from 1996, so it is unclear why the editors of TIME thought it was news in 2016) is based on 23 data points, all from couples with infants:

She interviewed 23 husband-wife couples, finding them through the rather quaint method of reading birth announcements in a local newspaper. All had brought a baby home in the last year.

The author’s thesis is that women are wearing out their brains ensuring stocks of toothpaste and peanut butter in the house. In a private message, a male reprobate asked for his opinion wrote

“wrong toothpaste is the kind of thing that can seriously ruin a child’s morning—not to mention their parents.”

If my kids tried to whine about toothpaste, I would make them eat it. Wtf.

The poster’s female friends, however, were impressed with this article and the underlying research. The post was showered with “likes” and comments in agreement.

Of course, given the topic of my recent talk at the economics university, I felt that I should question this celebration of social science…

Even if you accept that 23 is a statistically significant sample and that the sample was appropriately random, this covers only those couples with an infant. The vast majority of couples do not have an infant at home (owing to the tendency of infants to age out of infancy). Would you expect the division of labor to be different among couples with an infant compared to couples with no children or couples with teenagers? Why would it be reasonable to apply these findings to all male-female partnerships?

Women in lesbian couples would be a lot more productive, then? Because there is no man to “drag them down”?

(And gay male couples wouldn’t have essential supplies in their house because there was no woman to notice that they were running out?)

In a society where there is little social pressure and no legal requirement to be part of a couple, any study that concludes that some class of people are exploited within couples leads to the questions “Why would they agree to join a couple?” and “If part of a couple, why wouldn’t they go back to being single?”

These questions generated a flurry of ad hominem attacks from the warm-hearted pussyhat-wearing Hillary supporters. Despite their professed reverence for the scientific method, and contempt for those Trump voters who purportedly reject it, none of them seriously addressed the substance of the above questions.

From the inability of these folks to entertain any questions regarding their beliefs, can we concluded that faith in American female victimhood is now a religion?

Getting back to the substance of the study, is it actually kind of insulting to women? The TIME author assumes that men can manage household inventories: “If she were gone, you bet her husband would start noticing when the fridge went empty and the diapers disappeared.” If that assumption is correct, then women just need to do is stop worrying/noticing because a male partner will pick up the slack. Why aren’t women intelligent enough to do this?

If the assumption is false and men are hopelessly inept and managing toothpaste and peanut butter is preventing women from being successful in their careers, working women could hire someone (another woman?) to handle this management task. If women adopted this strategy they would be as or more successful than men in the workplace, but have a slightly lower spending power (since some after-tax income would be going to the toothpaste/peanut butter manager). If women aren’t adopting this strategy, why aren’t they intelligent enough to adopt it?

I’m in agreement with part of the article (not the “women are too stupid to see how badly they are being exploited” part!). I think that Americans of both sexes have their brains filled up with clutter that is the result of owning and managing too much stuff. By owning a house instead of renting, for example, the typical American is forced to think about plumbing, electric, paint, appliance repair, etc. By owning a car, the American is forced to manage recall notices, re-registration, property tax payments, etc. Let’s not get started on what it is like to own an aircraft, be a pilot, or renew one’s airport security badges periodically!

Readers: What do you think? Are American brains filled with non-work task-related clutter? If so, is there is a substantial gender difference? [Is the 1996 research obsolete due to Amazon Prime (2-day) and Prime Now (2-hour) services?]

Related:

• How feminists explain the phenomenon of women voting for Donald Trump

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One of the first slides for the three hour-long lectures on higher cortical function involved an updated Gallz’s phrenology for 21st century tasks (https://blakerivers.files.wordpress.com/2010/06/male-female-brain.jpg). Tattooed Talia, sitting next to me, expressed outrage: “Shopping! Jealousy!” During a break, Pinterest Penelope, a female classmate and social chair whose laptop screen is often filled by Amazon or Pinterest during lecture, said to Talia, “I love your boots! Where did you get them?” Talia and Penelope spent the rest of the break discussing the challenges of ordering the right shoe size online.

A psychiatrist in his 50s came in to present research on schizophrenia. Schizophrenia runs in families. According to the NIMH, “The illness occurs in less than 1 percent of the general population, but it occurs in 10 percent of people who have a first-degree relative with the disorder, such as a parent, brother, or sister.” According to the latest research, a region of the prefrontal cortex (surface area of the brain) is less metabolically active in individuals with schizophrenia. Unfortunately, nobody knows whether this is a cause or effect of schizophrenia. Nonetheless, the psychiatrist suggested screening individuals at risk of schizophrenia with fMRI(functional Magnetic Resonance Imaging) to measure prefrontal cortex activity. If below normal, preventative interventions could be attempted.

After lecture, the psychiatrist talked about his interest in the mental health of incarcerated individuals. “Society is committing genocide against these prisoners, primarily blacks. They develop terrible mental illnesses in childhood. When they become incarcerated these illnesses spiral out of control. It is a sick cycle.” He was lobbying state legislature for more extensive mental health programs in state jails. He also talked why he loves psychiatry. “It is a surreal experience to witness some of these disorders. Bipolar disorder causes patients to swing between fits of mania and extreme depression. We can predict these cycles with almost pinpoint accuracy.”

We had two hour-long lectures on cerebral blood regulation. The brain always needs 750mL of oxygenated, glucose-rich blood per minute. That’s 15 percent of resting cardiac output, which totals roughly 5L per minute. When you begin to exercise, stroke volume and heart rate increase causing a surge in cardiac output to about 12L per minute. How does the brain maintain constant perfusion (blood supply to tissues) while cardiac output varies? The increased pressure is sensed by stretch receptors in arteriole walls of the brain. The increased wall tension causes the arteriole smooth muscle to constrict to relieve this increased wall tension. This myogenic (muscle) response increases the vascular resistance of the brain tissue, thus maintaining the 750mL-per-minute perfusion, and diverting flow to other areas of lower resistance, for example, muscle. The opposite occurs when there is a decreased cardiac output from, from example, hypovolemic shock or cardiac insufficiency.

The two lectures that followed detailed anatomy of cerebral blood supply. The blood supply to the brain originates from the carotid arteries and the vertebral arteries. These form a miraculous structure at the base of the brain called the Circle of Willis. If one contributory artery is blocked, the brain will still get plenty of flow from the others. Doc J commented, “Evolution clearly valued ensuring the brain gets its oxygen and glucose.” The Circle of Willis feeds the six bilateral (left/right) arteries of the brain: left/right anterior cerebral artery (ACA), left/right middle cerebral artery (MCA) and left/right posterior cerebral arteries (PCA). The MCAs supply most of the brain. Unlike other tissues such as muscles, the brain does not have any energy reserves. Without a continuous supply of glucose (or ketones in the fasting state) and oxygen, brain tissue begins to die within minutes. A classmate and his girlfriend are passionate about fitness and supplements. They fast for three days every two months to “reset the system”. He thinks a brain diet of ketones will help prevent Alzheimer’s Disease.

Anatomy lab investigated the contours of the cranial cavity and the main blood structures. Due to time constraints, the instructors decided to perform the time-consuming removal of the brains from our cadavers’ skulls. Next week we will explore “brains in buckets”. Some students were disappointed. “I’ve been looking forward all year to removing the brain.” One of our favorite labs was during the heart unit. We were simply asked to “remove the heart”. A student commented how he found removing the structures that anchors the organ of interest helps build understanding of the anatomic relationships.

With the brains removed, we saw the holes (termed foramina and fissures) in the cranial cavity through which structures such as nerves and blood vessels pass. There are 12 holes per side that we need to know, e.g., foramen magnum (for the spinal cord), superior orbital fissure (optic nerve and ophthalmic artery), foramen rotundum (sensation of the face), and the hypoglossal foramen (nerve to tongue muscles). About half the cadavers still had their Circle of Willis. It looks more like a pentagon. You quickly appreciate how anatomic variations can lead to immense clinical differences for the exact same stroke. Some cadavers have more developed connections within the Circle of Willis (posterior communicating arteries and anterior communicating artery). These individuals would have a less severe stroke with an occluded carotid artery.

My favorite trauma surgeon discussed the two different types of strokes. An embolic stroke is caused by a decrease in blood perfusion to a part of the brain. This is commonly caused by a blood clot traveling up to an artery of the brain or from the slow accumulation of plaque causing stenosis (narrowing) of an artery that supplies the brain. A hemorrhagic stroke is caused by blood leaking out from a vessel, typically from a ruptured aneurysm or prolonged hypertension causing small tears in a capillary bed. We viewed different MRI and CT scans of strokes. She described the “Death-Star” sign. A subarachnoid hemorrhage (“sudden worst headache of your life”) in the Circle of Willis leads to a five-pointed star on CT scan as the blood pools in the contours of the cranial cavity.

A first-year vascular surgeon fellow attended the dissection. He described the carotid endarterectomy, a procedure to treat Atherosclerosis (hardening and narrowing of arteries) and thereby reduce the risk of stroke. The common carotid artery bifurcates into an external and internal carotid artery typically a few centimeters above the thyroid cartilage at a bone called the hyoid bone. The turbulent flow at this bifurcation makes this a high risk site for plaque build-up and intimal (innermost layer of blood vessel) thickening causing stenosis (narrowing) of the internal carotid. The increased blood velocity and shear stress on the plaque wall increase the chance that a small calcium deposit will chip off. As this silent killer travels from the large diameter carotid to smaller arteries, the small deposit begins to enlarge as the body’s clotting system takes over. This blood clot can then get lodged in a small artery. If it gets lodged in the ophthalmic artery, for example, it would causing sudden “curtains to fall” as the retina becomes starved. If it occludes part of the middle cerebral artery, it might cause weakness of the upper extremity and face.

Carotid plaque can decrease overall perfusion pressure to the brain. The Circle of Willis can maintain normal cerebral perfusion pressure with 85 percent stenosis of single internal carotid artery. Above 85 percent, the brain tissue supplied by the end of the main arteries begin to get less flow, leading to a “watershed infarct” with slurred speech and poor comprehension of words.

The carotid endarterectomy is analogous to snaking out a slow bathtub drain. The vascular surgeon detailed the steps while making cuts into a cadaver. He made an incision along the neck exposing the sternocleidomastoid muscle (SCM). The SCM was retracted to reveal the carotid sheath. He opened the carotid sheath and retracted the internal jugular vein and vagus nerve before clamping the carotid arter. In a live patient, he would then have measured the back-flow pressure distal to the clamp. “I need to ensure there is enough perfusion from the Circle of Willis to maintain perfusion of the entire brain without one carotid artery. If the pressure is below about 40 mmHg, I need to create a shunt [install a bypass] of this clamped flow.” He then opened the carotid artery and scraped away some plaque. He gave us the opportunity to feel the vessel. The cadaver’s carotid artery had severe stenosis (greater than 85 percent). The plaque, hard due to the calcium deposits, comes off in sheets. Over half the thickness of the artery was plaque! He then sutured together the carotid vessel incision and closed the wound.

What’s the biggest risk of this stroke-prevention surgery? Postoperative stroke. “It’s impossible to get all the plaque because it goes all along the vessel. You have to decide where to stop.” The surgeon described how he has to ensure that the interior of the artery is smooth. Otherwise these plaque edges will stick out and become dislodged from the shear stress of the blood flow.

The vascular surgeon urged us to follow our interests: “I am still in disbelief I get up every morning and get to perform what I love. It’s just crazy to think about. There is nothing like surgery. Don’t let the amount of time for training turn you off of surgery or any other speciality. Follow your passion.” (Fortunately we’re all in medical school, so the economic consequences of this advice are not as potentially disastrous as following our passion for painting or poetry.)

Our patient case: Jerry, a fit 42-year-old male presenting to the ED for upper extremity weakness and slurred speech. Jerry noticed he had trouble holding his toothbrush before bed. “When I grabbed the cup of mouthwash, I dropped it. I thought to myself, ‘Huh? This is weird.'” I forgot about it and went to bed. When I woke up, my wife said that I was slurring my words. She rushed me to the hospital where everything went black.

Jerry was having a stroke in his MCA. His wife described how furious she was with the doctors. “It seemed like they were just sitting around twiddling their thumbs.” The neurologist added, “Because we did not know when the stroke really set in, we could not use TPA. [Tissue plasminogen activator is a potent clot buster.] Guidelines state that unless you can identify the occlusion occurred within an hour, TPA administration could cause hemorrhagic stroke causing more harm than good.” [A recent article in NEJM recently disputes this time restriction. (http://www.nejm.org/doi/full/10.1056/NEJM199512143332401#t=article).]

Jerry had a relatively minor stroke in a small branch of the left MCA. It still took months to recover from it. He had trouble with his right arms, swallowing and speaking. “I could barely speak for three weeks.” He went to occupational therapy for two months. Most people would now have a hard time realizing Jerry had a stroke. “The main issue I have is that I cannot feel my entire right chest, shoulder and upper back. Some words seem to have just left me. I cannot seem to recall a lot of complicated words.”

“What scares me the most is why this happened. I am a pretty fit person.” The neurologist explained that the Jerry does not have the main risk factors for a stroke. “He does not smoke, does not have afib [atrial fibrillation]. We could not even find an ASD [atrial-septal defect].” He brought up the ASCVD risk estimator to show he was doing pretty well (http://tools.acc.org/ascvd-risk-estimator/). This nagged at Jerry. “I did not know what to tell my two kids.” The neurologist recommended he join a clinical trial with a new drug to prevent strokes. “This clinical trial has given me confidence, even though I don’t know if I am on the drug or the placebo. I just believe it is doing something.” After one year, Jerry will know to which group he had been assigned and, regardless of his original group, will have the option to be

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My Facebook friends are excited about condemning anyone who questions the propriety of movie theaters holding “all-women” screenings of Wonder Woman. The main attack leveled at the Neanderthals (Deplorables?) who suggest that movies should be open to patrons of all genders is that they are “sexist” and that “sexism” continues to pervade our society.

Wikipedia:

Sexism or gender discrimination is prejudice or discrimination based on a person’s sex or gender.

It would seem that the theater owners are discriminating (sell/don’t sell) on the basis of sex or gender. But it is the people opposed to this who are guilty of “sexism” in actual English usage.

Does this mean that the dictionary definition of “sexism” is now obsolete? People seem to be using the word in a new way.

Separately, my friends are saying that the depiction of a female superhero is “game-changing” and “revolutionary”. Yet Wikipedia says that the character dates back to 1941 and that “The Wonder Woman title has been published by DC Comics almost continuously except for a brief hiatus in 1986.” What’s game-changing about this particular movie? (of course I cannot go myself because it is not targeted at 3-year-olds; maybe if there is a Masha and the Bear and Wonder Woman movie I will be able to watch it)

Finally, if a theater admits only people who identify as “women” at 7:30 pm, how do they know that at 8:30 pm the entire audience will continue to identify as “women”? So I don’t see how it would be possible to have an “all-women showing”. Maybe they could have an “all-women ticket sale” since they could ask people for their gender ID at the time of purchase.

One movie, many questions!

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“Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records” (WBUR) gives the practitioners’ perspective on our country’s trillion-dollar(?) investment in computerized medical records (how do we get to $1 trillion when a typical hospital seldom spends more than $100 million on the initial implementation of a system?; I’m factoring in years of typing by personnel as well as the ongoing support and service costs for these IT systems; we’ll get to $1 trillion soon enough!).

My perspective on this has always been that most of the value of a DBMS comes from situations where comparisons across records have a lot of value. So an electronic medical record (EMR) would be most valuable if a doctor treating Patient A wanted to see what happened with Patients B through Z or what happened with all patients having the same condition who were treated in that hospital. These turn out not to be common queries.

Are we budgeting to pull out of this financial dive when full artificial intelligence is developed? An AI assistant will listen to a doctor or nurse speaking and then fill out the screens of a $100 million electronic health record system that has its technological roots in the 1960s?

Related:

• Electronic medical records don’t save money (2013 study)
• Most efficient medical record system for dogs and cats: paper
• Brain surgeon tortured by software developers and hospital bureaucrats (they’re not doing any better over in England)
• How well will hospitals adapt to their new $100 million IT systems? (2009)
• Health care IT industry profits from crony capitalism (2013)

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Auditory week began at 8:00 am with some classmates upset because the room was different than stated on the shared Google Calendar that is our primary source of scheduling information: “Ugh, now I have to pack all my things up.” We moved across the hall and Doctor J tried to reassure the class by promising it wouldn’t happen again.

The ear is involved in hearing and balance. The pinna (outer ear flap, also called auricle) funnels sound into the ear canal to strike the tympanic membrane. On the other side of the tympanic membrane is the middle ear, an air-filled cavity that is connected to the oral cavity through the eustachian tube. We practiced using otoscopes on each other in a clinical workshop led by a female otolaryngologist in her 40s. It hurt! Every few minutes we would hear a shrieking “ouch”. The worst was when a student from one group hastily grabbed a new tip to practice the technique lurched over and hit another group’s otoscope wielder. The otoscope twisted in the student’s ear. Despite these mishaps, we learned a great deal. After you get past the ear wax and hair, the tympanic membrane comes into view. The malleus, one of the three ossicles (ear bones), is attached at the umbo, a small white spot near the center of the tympanic membrane. In a normal ear you can see the pale outline of the malleus through the transparent membrane.

The otolaryngologist went over some commonly diagnosed ailments using the otoscope. A more opaque tympanic membrane suggests fluid, instead of air, is behind the tympanic membrane in the middle-ear. The fluid is typically from a middle-ear infection, which can cause temporary hearing loss and pain. She explained that we can also diagnose pierced ear drums and grossly malformed ossicles. A student asked, “What are the common procedures you do?” The answer was removing the broken ends of Q-tips from the ear canal. He followed up with “Do ENTs promote the use of Q-tips for business reasons?” She laughed and responded, “Oh, God, no! Those visits are so boring.” Her passion is performing cochlear implants to restore hearing in children (see below).

When a sound wave hits the tympanic membrane, the membrane transmits the vibration to the the ossicles. The malleus (“hammer”) rotates the incus (“anvil”), which in turn displaces the stapes (“stirrup”). The stapes is the interface between the middle ear and the cochlea, a fluid-filled, snail-shaped bone of the inner ear. The stapes lies in the oval window, described as a “bony defect” of the inner ear, that interfaces the stapes with the encapsulated fluid (note that if you didn’t have this “defect” you wouldn’t be able to hear). The stapes transmits the mechanical energy to propagate a pressure wave through the tube to the exit at the round window (a “bony defect” of the inner ear interfacing with the air-filled middle ear). The cochlea is U-shaped, with the oval window opening into the scala vestibuli. The 360-degree turn is called the heliotrema, and the scala tympani ends at the round window.

The two divisions of the tube (scala tympani and scala vestibuli) are separated by a space, the scala media, another fluid-filled tube. This turns out to be the actual source of all hearing sensation. The scala media changes in thickness along the length of the tube, making it sensitive to different sound frequencies. For example, one frequency might lead to a high pressure in the scala vestibuli 1 mm from the oval window, and a low pressure in the scala tympani 1 mm from the round window. This signal would cause the scala media at this region to bend towards the scala tympani. Along the length of the scala media are hair cells, receptors that excite neurons when the scala media deforms as little as a few nanometers. The sensation of sound occurs when signals travel through the brain stem into the primary auditory cortex, part of the surface of the brain that happens to be near the ears. A cochlear implant works by turning the varying voltage from a microphone into nerve signals corresponding to what would have been the movements of the hair cells.

As will become important in the patient case below, the scala media is continuous with another fluid-filled bone, the vestibular apparatus, an accelerometer critical for balance. This tube is divided into three thin canals (sensing rotation) and two sacs (sensing linear acceleration). Due to inertia, the fluid inside the tube will tend to stay put as the head moves, enabling hair cells to sense a change in pressure within any of the five compartments.

I ate lunch outside with Straight-Shooter Sally. She is the first person in her family to go to college, let alone medical school. Her father is a mechanic. She worked for three years after college as a social worker with adolescent drug addicts in a poor urban neighborhood. “These kids quickly get involved with the drug scene,” explained Sally, “Drugs are the easiest avenue to create friend groups and to avoid attack by the gangs. When kids get arrested they are given the option of going to juvy or rehab. Everyone choses rehab.” Does rehab work? “Every summer I would come back and see the same kids. It was a revolving door and we did not have any tools to make a difference. The three-month rehab was nothing for them. Their father went to jail for three years—what’s rehab speaking to a counselor for a few months?” She continued, “These kids go to failing schools, come home to disorganized families, and the only thing they aspire to is what they see in the community. The drug dealers are the ones who have the snazzy cars, women, and money.” She concluded, “I don’t know the answer, but these kids need help—education, role-models, jobs, anything. Counseling was not going to solve it. I had to get out of there.” She switched jobs and became a health coordinator before starting medical school at age 28.

Our patient case: Giorgio, a 50-year-old salesman who developed right ear pressure and diminished hearing after an evening shower. When he woke up, his ear felt like it was about to “pop” and he had lost all hearing on that side. Two common tests with tuning forks, the Rhine and Weber tests, suggested that the hearing loss was due to a sensory-neuronal deficit rather than a conduction deficit. In other words, he had damage to the hair cells, cochlear nerve, or brain cortex, rather than a mechanical blocked ear or perforated tympanic membrane. An MRI revealed an acoustic schwannoma, a non-malignant tumor of the supporting Schwann cells of the vestibulocochlear nerve as it exits the internal acoustic meatus into the cranial cavity. The tumor had begun to squeeze the cochlear nerve. “Most acoustic schwannomas grow less than one millimeter per year,” said the neurologist. “Some years they just lay dormant. For whatever reason, they might spike for a few months then go back into a dormant state.” Georgio’s tumor was removed by a surgical resection through a retrosigmoid craniotomy approach (incision behind the ear).

The neurosurgeon (not Giorgio’s surgeon) explained the risks. “It all depends if the tumor has facial nerve involvement.” The facial nerve exits the cranial cavity in the same hole, the internal acoustic meatus, as the vestibulocochlear nerve. If you touch these fibers, it can lead to ipsilateral facial paralysis.” During the surgery they insert electrodes into the facial nerve to verify, after each layer of tumor is removed, normal conduction from the surgical site to the facial muscles. “There is not a consensus on whether the whole tumor should be removed if there is facial nerve involvement. If you can get, say, eighty percent of the tumor, you might be able to resolve the hearing deficients and decrease the risk of facial nerve damage. But, the tumor could slowly grow back.” My classmates and I watched a Youtube video on the surgery (https://www.youtube.com/watch?v=PBE5rQ7B0Ls). “This is wild,” exclaimed an aspiring female surgeon.

Giorgio underwent a full resection. He quickly regained most of his hearing. “I have worse hearing in my right ear, especially in the higher frequencies. For the most part, I hear fine.” He does have persistent tinnitus (ear ringing). “Right now, focusing on it, I hear it, but I get used to it.” He experienced terrible balance issues for months after the surgery. “I had to completely relearn how to walk. My whole balance seemed to have just reset to a new normal. I was completely dependent of my family for three months.” He also experienced a poorly healing wound on the skull behind the ear. “I was taking airline trips for my job with an open wound on my head. Not the most sanitary environment. One day in the car, my wife looked at my wound, and forced me to go see a plastic surgeon.” The plastic surgeon performed a skin graft to revascularize the infected wound. The wound healed shortly thereafter. The neurosurgeon added, “I see these occasionally. It’s not a petrid, ozzy infection. It’s a lingering infection.” Despite this complication, Giorgio was very satisfied with his care. He is slowly getting back into playing competitive tennis, although he still experiences balance issues.

We learned that Giorgio immigrated to the US as a student. He still maintains citizenship from his Scandinavian birthplace. A classmate asked what kind of treatment he would have received under the socialized medicine system of his birth country. “Completely differently,” explained Giorgio. “I would not have been allowed to get operated on. If it is not considered life-threatening or malignant they would not pay for it.” One classmate, a Canadian citizen and US green card holder joked, “I keep my Canadian citizenship for a Get Out of Jail Free card. If I get cancer, I’m packing my bags and heading to Canada.”

I shadowed my physician mentor for an afternoon. It was a busy day so he saw some patients without my assistance. In 4 hours, I saw 7 of the 14 patients. The first patient was a 45-year-old gentleman, overweight but certainly not obese, presenting for follow-up after hospitalization with a transmetatarsal amputation (TMA). He was in disbelief after losing half of his left foot (including the toes) due to a foot ulcer. The physician delved into how he was managing his diabetes. His last sugar readings were off the chart and from over a year ago. He had not been taking his medications for several months. “It was too expensive,” he explained. This was typical of our patients who make too much money to qualify for Medicaid, but not enough to afford Obamacare health insurance. Our patient’s motivation: “I will do anything you tell me. Just let me have two legs when I see my thirteen-year-old son graduate college.”

The next patient was a thirty-year-old mother presenting for follow-up for a prescription opioid refill indicated for joint pain. We informed her that the state has a new law requiring an annual recreational drug test for prescription opioid recipients. She responded, “Yeah, I smoke weed.” She will come back in six weeks for her drug screen. The physician told me that this doesn’t always work out: “One of my patients failed the drug test for marijuana. I gave him a second chance six weeks later. He remarkably tested clean for weed… but positive for cocaine.” He did not get the refill. My attending also mentioned that these new rules will be costly for patients. “Insurance companies generally do not pay for drug screening. Patients have to pay $200 out-of-pocket unless they’re on Medicaid.”

The next two patients, a 40-year-old man and a 70-year-old woman, both presented for follow-up due to chronic obstructive pulmonary disease (COPD). Both smoked a pack a day. The doctor told each, “If you keep this up, you will eventually be on oxygen.” Both had

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Barbara Whitehead’s The Divorce Culture (1996), quoted in “A Brief History of Divorce in America”:

Before the mid-1960s, divorce was viewed as a legal, family, and social event with multiple stakeholders; after that time, divorce became an individual event defined by and responsive to the interests of the individual. … divorce moves from the domain of the society and the family into the inner world of the self.

Let’s take a look at some articles readers have sent in this season and compare them against the above-noted trend.

“11 Questions to Ask Before Getting a Divorce” (nytimes). The word “children” appears twice in the article, published by a newspaper in a winner-take-all jurisdiction (see the New York chapter), and once it is in the sentence “If there are children, who will take the lead in keeping track of their activities calendar?” (not, “How will they go to college if 100 percent of the family’s savings are spent on divorce litigation?”). The paper tells adult readers that the important stuff is adult happiness and emotions: “Do you still love him or her?”; “Would you really be happier without your partner?”; “What is your biggest fear in ending the relationship?”; “Are you letting the prospect of divorce ruin your self-image?” There seems to be no question that if one adult can become happier or better off, a unilateral (initiated by one partner against the other partner’s wishes) divorce is a good idea. Part of the “better off” calculation is financial and the Times wisely advises people considering suing for divorce to meet with financial advisors and litigators, with the implication that it might make sense to stay married if divorce isn’t sufficiently lucrative.

The cash aspects of family law are buried pretty deep in the Times article. Perhaps New Yorkers aren’t mindful of the cash implications? “Hamptons bachelors are getting vasectomies so golddiggers can’t trap them” (New York Post) suggests that perhaps at least some are (maybe the Post and the Times are actually in two different cities that share a name?). Some excerpts:

“There’s a spike in single guys” who get the procedure in spring and early summer, said Dr. David Shusterman, a urologist in Midtown.

“They don’t want to be in the situation of being accused of fathering an unwanted baby,” said Dr. Joseph Alukal, a urologist at NYU. “That’s their fear — being told you’re paying for this kid until it’s [an adult].”

“This extortion happens all the time. Women come after them. [They get pregnant and] want a ransom payment,” said Shusterman. “Some guys do an analysis of the cost — for three days of discomfort [after a vasectomy], it’s worth millions of dollars to them.

“It’s not that they don’t want kids [someday],” he said. “They don’t want kids on other people’s terms.”

Manhattan matrimonial attorney Ira Garr said of such unplanned, paternity cases: “I deal with this every year. There’s potential to [have to] pay out a lot of money.”

Child support is 17 percent of the father’s salary up to $400,000, after which the amount is at a judge’s discretion, according to Garr. For someone who makes $1 million a year, Garr estimates annual payments of $100,000 — a total of $2.1 million until the child turns 21. Meanwhile, a vasectomy is typically covered by insurance or costs $1,000 out of pocket. [see also Burning Man: Attitudes toward marriage and children for a quote from a man who considers the internal rate of return on a vasectomy]

Here’s a detail I’m pretty sure that the New York Times won’t be covering…

She offered to dispose of the used condom, but when she was in the bathroom for a while, John got suspicious. He found the woman seated on the toilet and inserting his semen inside of her.

[One thing I learned on my most recent trip across the Atlantic: the above situation is covered in an annual lecture to schoolboys at an elite English “public school”, complete with references to caselaw in which an appeals court held that a plaintiff’s entitlement to child support was not impaired by her use of “a syringe”. (See also the Boris Becker case in our chapter on England, et al.)]

This obituary of a divorce lawsuit defendant (Pittsburgh Post-Gazette) is a dog-bites-man story (see the “Children, Mothers, and Fathers” chapter for some statistics on the correlation between being an American divorce lawsuit defendant and committing suicide). Nonetheless it is interesting that a mainstream U.S. newspaper would publish it. Excerpts (daughter’s name elided for privacy):

The cardiologist, researcher and educator at UPMC devoted his life to curing disease, doting on his children and making life better for those less fortunate. … After spending the first half of his life in a communist country, Dr. Nemec built what most would consider a successful life, admired by his colleagues and patients and an expert in complicated heart procedures.

But, even in the face of this happy and accomplished existence, Dr. Nemec refused to submit to what he saw as oppression and took his own life at his Swissvale home on May 8. He was 54.

Dr. Nemec’s daughter, …, 25, a psychologist from Sydney, Australia, said her father wasn’t depressed, but chose to end his life rather than pay nearly half of his annual income for spousal support as he was ordered to do in a recent divorce order.

What courts in Minnesota — where her mother filed for divorce four years ago — saw as fairness, he saw as injustice that he could not tolerate, said [the daughter], who received an email from her father on the day after he died, detailing his heartbreaking decision.

“He was always very, very anti-communist. This was definitely about his moral principles,” [the daughter] said. “He thought this was a poorly designed system and just didn’t want to be a part of it and would rather give the money to a worthy cause.”

[Illustrating the critical importance of venue, note that Dr. Nemec’s plaintiff wouldn’t have suffered any financial hardship from her defendant’s suicide had she lived in Massachusetts. The family courts there would have ordered the cardiologist to purchase life insurance with his plaintiff as the beneficiary. She actually would have been better off as a result of his death because she would have gotten all of her alimony entitlement in one lump sum. Note further that Dr. Nemec would have been better off (and perhaps still married) if he had stayed in almost any European country (not the U.K., though) due to the fact that the financial incentives for divorce plaintiffs are comparatively limited there. If he had been determined to emigrate to the U.S., he would probably still be alive if he’d read Real World Divorce and settled in a state that disfavors alimony (e.g., Alaska) or simply doesn’t offer it (Indiana).]

Meanwhile, in Italy the courts have essentially done away with alimony (Business Standard; see also The Local), bringing that country into line with where Germany went in 2009 (with child support limited to less than $6,000 per year, the only way to make a profit from marriage in Germany is to stay married).

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