From our anonymous insider…
We return for the New Year after a one-month break to study oral health. Exquisite Emily, a 26-year-old Iranian-American traveled to Thailand with her boyfriend, a Deloitte consultant. Type-A Anita and her boyfriend, a work-from-home web developer, took a 1.5-week trip to Japan. She sent a snapchat of the opening “In a galaxy far away” with Japanese subtitles on opening night of Star Wars: The Last Jedi in Japan. Most students flew home to visit family for this extended break.
A recently retired 65-year-old hospital dentist (“former section chief turned professional grandpa”) leads a total of eight hours of lectures on head anatomy, the basic oral exam, and common oral pathologies. He described the various lesions of the oral cavity, such as leukoplakia (unscrapable white thickening of mucosa) and thrush (scrapable white plaque of fungus). “Whenever a patient comes in with an oral lesions that I am unsure about, I tell them, come back in two weeks. Most harmless things will go away on their own in two weeks as the mucosa is turned over. If I do nothing, it will disappear in two weeks. If I give you something, it will disappear in 14 days.”
“The dentist is the last bulwark of arrogance. Dentists do not like to refer anything out. We are notoriously bad collaborators. Compare that to you guys [doctors]. You are completely dependent on radiologists, hold extended cancer panels, reach out to specialists, etc. This collaboration ensures the very best care for the patient.” The dentists summarized why dentistry and medicine are separated. “There were two milestones in this divide. First, dentistry schools completely separated from medical schools. The second occured in 1965 when Medicare was begin created. The ADA [American Dentistry Association] lobbied to be excluded from Medicare. Dentists did not want to be involved with insurance.” Lanky Luke whispered, “Dentists are looking pretty smug now that they are still in private practice without having to negotiate with government insurance.” The internet at our school is quite slow as we attempt to play several linked videos in the slide. Gigolo Giorgio joked: “This must be the result of Net Neutrality being overturned. ISPs must be slowing our bandwidth because they think we are watching porn with all our anatomy searches.”
Wednesday was led by the “Dane”, a Danish-trained dentist and researcher. She was supposed to teach us oropharyngeal cancers but we never made it past the title slide as she answered questions. One student asked how is dental care different in Denmark than the United States. “Every child has free dental care. As an adult you pay for it, but it is much cheaper and we do not have such income inequality as you do. Only people with cavities are the immigrants. Our statistics are lower because of them.” She continued, “It is truly amazing the income disparity in the United States. And mark my words. This is only made worse by this horrible tax plan that will just make the wealthy wealthier. And this idiot president.”
[Editor: Denmark is not a paradise for everyone. An American child support plaintiff who collects $200,000 per year tax-free would be capped out at $8,000 per year per child in Denmark (see http://www.realworlddivorce.com/International ). The American who lives rent-free in means-tested public housing in an expensive neighborhood of Manhattan, San Francisco, or Cambridge would in Denmark wait many years for public housing in a dreary suburb.]
Lanky Luke: “If she thinks so little of our country, why doesn’t she go back to Denmark?” Gigolo Giorgio to the GroupMe: “Will they post the title slide?” Lanky Luke: “If not, I will report this infraction to the LCME.” Both got over 10 likes.
On Thursday we go over to the clinic to interview five patients with oral pathology. I started with a 70-year-old patient treated for squamous cell carcinoma of the oral cavity requiring surgical removal of most of his hard palate. He had a surgical obturator filling the space. He removed the obturator revealing a 3 cm diameter hole in the top of his mouth. Looking up into his mouth, we could see his maxillary sinus and nasal cavity, specifically the inferior turbinate! Gigolo Giorgio gasped. “What does it feel like to touch that with you finger?” “The gentleman responded, “Oh, nothing abnormal, it can be a little sensitive.” He described his routine for cleaning the obturator and cavity every evening: “Just like brushing your teeth!” A dentist explained the anatomy of the teeth. “If a dentist is asking you to replace amalgam filling with a fancy composite, they are just trying to steal your money. It frustrates me so much. Amalgam works just as well and lasts a lot longer. Composite will need to be replaced within 10 years. These dentists figure, they can get more money by fixing that in a decade. Amalgam will last a lifetime.” (This was in contrast to another patient we interviewed who had only a small indentation in his tongue remaining after recovering from a squamous cell carcinoma tumor that had spread all over his throat and oral cavity.)
At lunch, students debated if welfare benefits should include dental care when many Americans not on welfare cannot afford dental care. Students all agreed that dental health is an important part of people’s overall health. Nervous Nancy: “This is clearly a good investment. Inexpensive procedures like cleanings prevent the more costly deterioration of health.” We googled the dental care benefits for welfare and students were surprised to learn that states are required to provide dental care to children on Medicaid. Lanky Luke: “I do not see how our system is much different than Denmark’s. Children are guaranteed dental care if they cannot afford it, if they are on Medicaid.” Straight-Shooter Sally expressed concern for the working poor, potentially ineligible for Medicaid. Luke responded, “I wonder if the increased demand for dentistry from welfare participants might price out some of the working poor.”
Mischievous Mary changed the subject: “Guys, I need your help. I am applying for a grant tailored to women in science. The essay asks: How do I promote other women in science? Any ideas?” Lanky Luke: “Tell them you empower students and patients to feel comfortable in their chosen identify.” (Our Office of Student Affairs keeps us advised weekly regarding scholarships targeted to specific subgroups of Americans. This week’s email mentioned the BuckFire Law Firm’s Diversity & Disability Scholarships. A requirement is “a disability diagnosis from any person qualified to make a diagnosis,” so perhaps medical students could diagnose each other?)
Our patient case: Harold, a 35-year-old grocery clerk with a history of alcoholism and tobacco use presents for worsening ear pain over the past two months. He reports a decrease in appetite, and denies fever. On physical exam, the external ear canal is not inflamed and the tympanic membranes are transparent. He has hard lymph nodes palpated on both sides of his neck. Erythroplakia (a nonscrapable white plaque with blood vessels) is noted on the posterior lateral border of the tongue. Smoking and alcohol use account for 80 percent of oral cancers and therefore squamous cell carcinoma is high on the differential. A biopsy reveals an invasive squamous cell carcinoma. He is referred to a oncology who initiates radiation therapy.
Harold described how he had to quit radiation therapy after 12 rounds. His ENT explained that Harold’s gold fillings caused the radiation to unexpectedly scatter and deliver higher does to his oral mucosa and salivary glands.” Harold: “I could barely drink, let alone eat, because it hurt so much. My mouth was so dry my tongue would get stuck to the top mouth, and I would have to take several painful sips of water to pry it down.”
Two years after the radiation therapy, Harold presents for a sense of “fullness” in the back of his throat. Harold’s cancer had returned. His ENT explained recurrence is not uncommon for oral cancer. “Field Effect” is the theory that a carcinogen, for example, smoking can cause mutations in a large area of tissue, but on different time tables. This time the cancer was far more advanced, spreading to his mandible.
Harold underwent a partial mandibular resection (jaw removal) with a fibular transplant and chemotherapy. A section of his mandible, from midline to the temporomandibular joint is removed, and replaced by a section of his fibula (a small bone in the lower leg not needed to support the body). “We preserved his temporomandibular joint so he still has some range of motion.” Mischievous Mary: “Oh my god! I would never have known. We can do that?”
Harold has lost most of his teeth due to periodontal disease and removal of unhealthy teeth prior to radiation therapy. As he described: “More teeth, more problems.” He eats mostly soft foods such as yogurt, fish, and smoothies.
At lunch students complete the 30-minute Y2Q medical school questionnaire conducted by the AAMC. Examples:
- “How frequently have you been publicly embarrassed?”
- “How frequently have you been threatened with physical harm?”
- “How frequently have you been physically harmed?”
- “How frequently have you been asked to exchange sexual favors for grades or other rewards?” [Editor: question lifted from the Harvey Weinstein Memorial School of Medicine?]
- My teachers and mentors have told me that they have high standards for my performance. (agree/disagree)
- The medical school experience, to this point, contributes to students’ ability to work in disadvantaged communities. (agree/disagree)
- I often feel as if my performance is being judged as a member of the identity group that I belong to more than as an individual. (agree/disagree)
After classes end at 4:00 pm on Friday, we drive 3.5 hours through a snowstorm to a ski resort for the second annual ski weekend (Jane and I did not go last year). 32 students, 28 classmates and 4 significant others, cram into a four-bedroom ski lodge located in a prime location that is walking (shuffling?) distance from entering a Black Diamond slope. Jane and I drive up with Nervous Nancy, soon to be celebrating her 29th birthday. “I feel like everyone from my former life is getting older and moving on with their lives. My best friend bought a house. My other friend is pregnant. When I went back to school, I got younger.” The car that booked the AirBNB had to drive down the other side of the mountain to pick up the rental keys. The rest of us sat in our heated cars for 1.5 hours drinking beer and wine until the keys arrived at 10:00 pm.
Once in the house, our class switched from drinking to drinking games, beginning with Kings. Tailgate Todd, a Clemson graduate with charming southern hospitality, suggests the game Fishbowl. Every Fishbowl participant writes down two or three words on small pieces of paper. We then divided into two teams, male versus female. One participant from each team tries to act out the words while the remaining team attempts to guess correctly as many words in one minute. The women destroyed us. We settled the score by beating them at Flip Cup, four rounds to one.
Persevering Pete who has been a teetotaler, due to a history of alcoholism in his family, had his first alcoholic drink, a Tito’s vodka cranberry with seltzer water. Around 1:00 am, students began to slumber off to bed for skiing tomorrow. The limited beds and bedroom floor space was settled according to who signed up and paid first. Jane and I were subjugated to the living room with Anita, her web-developer boyfriend and Nervous Nancy. Anita had brought a Queen size, self-inflating air mattress that took up most of the space. Nervous Nancy was relegated to the couch, while Jane and I inflated our twin air mattresses squeezed between the frigid sliding door and Anita’s mattress. I did not sleep the entire night.
[Editor: I wonder if alcohol consumption and lack of sleep may explain why the U.S. healthcare system is in trouble.]
At 5:00 am, Stoner Suzy, a wealthy daughter from Southern California, and her (unbeknownst-to-me) boyfriend Gigolo Giorgio were moving around the house. Tonight she was experiencing chest pain, difficulty breathing, and peripheral angioedema (leaky blood vessels causing swelling). Her feet were swollen to the point that she couldn’t put on shoes and her fingers were swollen enough to cause pain around a ring. A few students performed rapid exams, and the general consensus was a combination of anxiety and dehydration. Suzy was concerned that it was a heart attack. Giorgio wanted to take her to the hospital, at least a 30-minute drive in terrible conditions.
After waking up the owners of three cars that were blocking Giorgio’s Subaru, he determined that it wasn’t safe to drive down the steep driveway, slick with new snow and ice accumulation. They called an ambulance, which arrived in 20 minutes. Five paramedics came into the trashed house with mattresses strewn across the living room. They drove off around 7:00 am, as the remaining students were waking up for a day on the slopes. Due to lack of coverage, we didn’t get any updates on Suzy’s condition until the much-improved couple returned at 4:00 pm. Suzy’s EKG was normal, which ruled out a myocardial infarction (heart attack). She was given IV fluids and worked up for a PE with a chest CT (negative as well). She had been upgraded from her usual dose of marijuana to fentanyl and discharged. (Tom Petty, Prince, Shiloh actor Blake Heron, and rapper Lil Peep all died from fentanyl overdoses.)
Jane and I return early from the bunny slopes and drink mimosas with the 10 non-skiers. Around 2:00 pm, a large group of students return from the slopes including Persevering Pete, Nervous Nancy, Tailgate Todd, and Steve. Following his pioneering sampling of alcohol the night before, this was Pete’s first time on skis. By choosing a classmate as an instructor, Pete found himself on a black diamond slope with the experts. Thirty seconds later he was in a ditch. “We couldn’t even see him there was so much snow thrown into the air,” recalled Nancy. “We thought he was going to have to be carried off.” After 60 seconds, Pete slowly rose, perhaps saved by the rented helmet, and walked the remaining half mile. “I lost vision for a few seconds, but I remember the whole experience.” Pete decided to forgo drinking that evening.
Statistics for the week… Study: 8 hours. Sleep: 4 hours/night; Fun: 2 nights. We are all zombies.
[Editor: Denmark is not a paradise for everyone. An American child support plaintiff who collects $200,000 per year tax-free would be capped out at $8,000 per year per child in Denmark (see http://www.realworlddivorce.com/International ). The American who lives rent-free in means-tested public housing in an expensive neighborhood of Manhattan, San Francisco, or Cambridge would in Denmark wait many years for public housing in a dreary suburb.]
The number of poor Americans who live rent-free in expensive neighborhoods has to be such a tiny portion of all poor Americans that it’s really not worth mentioning. From what I hear, there is actually a long waiting list in the USA for Section 8 rental assistance. It’s also unlikely that all poor Danes are pushed out of the cities into the suburbs,
Phil was only referring to three neighborhoods so the entire US is irrelevant to his point. As for Manhattan my guess based on observation is that there is “a significant number.” As for the other two cities i would guess it is the same as Manhattan. It is a little bit odd for some of the most expensive real estate in the world to be given out for free by the politicians and bureaucrats – you would think that a better strategy would be to sell the expensive real estate to a developer and use the proceeds & property taxes to buy affordable housing in a more modest area — unless of course the real objective is to create jobs and payola for the politicians and bureaucrats and the housing for the poor is just, how do the economists but it, “an externality”? It is also a little bit odd that the right to free housing in expensive neighborhoods is a perpetual right — rather than one limited in time to help someone down on his luck get back on the straight and narrow.
I think the real question is why there is a waiting list. If public housing is a human right, why doesn’t everyone who wants one get a free house? (Everyone who refrains from work and wants food stamps, for example, gets food stamps; everyone who refrains from work in Massachusetts and wants Medicaid gets Medicaid.) If public housing is not a human right, why would a society spend $trillions on public housing?
See
https://philip.greenspun.com/blog/2015/09/16/cambridge-housing-authority-inequality-in-public-housing/
Jack: Look again at the text. Phil was comparing America to another country. The issue is anti-poverty programs in the USA. The statistics say that there are around 40 million poor Americans. The number who live rent-free in expensive neighborhoods in glamorous cities has be a tiny portion of the total.
If public housing is not a human right, why would a society spend $trillions on public housing?
The answer must be that existence of a human right is not a prerequisite to spending trillions on something. The invasions of Afghanistan and Iraq, for example, will add up to a trillions. Presumably those invasions were not justified by the right of anyone to invade and occupy those countries.
Having lived in Denmark for nearly 47 years I might be able to weigh in on a few things.
Dental care in Denmark really is world class. Free for everyone until age 18. My children have never had a single cavity and their teeth have been straightened out with braces (and, in one case, a minor operation).
When you turn 18 you have to pay yourself. An inexpensive private insurance will help you, should you get your teeth smashed in in an accident. But the “Cover everything, even cavities” private insurance is prohibitively expensive. Everyone I know just brush their teeth and have an annual checkup.
Most people pay their dentist with their own money and there’s a bit of competition among dentists. If a big operation is needed, danes might save some money by having the procedure in a top flight clinic in Poland or Hungary.
Nevertheless danish dentists are comparatively well off. They live in nice houses, drive germans cars and go on three holidays a year. They may have an au-pair. But help around the house is very expensive in Denmark and more or less the domain of the 1%ers.
Housing for danish wellfare receipients is dreary. You will indeed end up in a 1- or 2 room apartment in a dreary suburb.
It’ll be dry, the appliances will work – but it’ll still be a godforsaken place. LIke this
https://goo.gl/maps/NY9ddtGKwJz
With the unwelcome influx of immigrants there’s been a slight housing crisis.
This was partly solved by placing the immigrants in military style camps
These were so dreary
https://jyllands-posten.dk/indland/ECE9582955/nu-bliver-telte-fra-omstridt-asyllejr-endegyldigt-pillet-ned/
that even the immigrants left for greener pastures.
Anyway. The wellfare recepient will sit in a small apartment and have the time of his/her life: hot sex, cold beer and bad tv 24/7. Xbox and Netflix at 1 Gbps.
There’s a fine documentary about such specimen at
https://www.dr.dk/tv/se/prinsesser-fra-blokken/-/prinsesser-fra-blokken-1-4
(You will need a Chrome browser and http://tv4ever.dk to watch it and you won’t understand a word)
Yet, strangely, this life style is not very fullfilling and the system will be using both carrots and sticks to make them productive members of society.
They will have free education and free childcare (while studying).
To stay in their dreary apartment, they will have to get up in the mornng and do dreary work: street sweeping, paper clip sorting – doing stupid stuff with stupid people. Usually that’ll give them an appetite for a real education resulting in a real job some years down the line.
The system is designed to expose them to different kinds of occupations and have them choose the lesser evil.
Some people (surprisingly few) will never get a job and will rot in their apartments. But even there they may serve a function: they’ll show the beautiful young girls and boys starting on wellfare what’ll happen if you don’t get out in time.
Spending this much money and effort on lazy and immoral people rubs most americans the wrong way. But smart people have to adhere to science.
And science says that it’s less expensive to house people and educate them, than having them live in misery as a bigger burden on society
https://www.vox.com/2014/5/30/5764096/its-three-times-cheaper-to-give-housing-to-the-homeless-than-to-keep
https://www.theguardian.com/housing-network/2017/jul/12/housing-first-liverpool-homelessness-services-are-failing
This brings us to Lanky Luke and his “If she thinks so little of our country, why doesn’t she go back to Denmark.”
She probably will- especially if she’s having kids. But even americans like to go abroad, to, say, places like Argentina
https://philip.greenspun.com/blog/2013/02/14/why-is-argentina-so-poor/
or Miami
https://philip.greenspun.com/blog/2005/01/20/chilean-versus-american-airports/
and tell the locals that a lot of their their tasks/problems could be solved in a more efficient manner.
The “America. Love it or leave it, just don’t improve it” is the idiot stance and very unbecoming of a an academic. Somebody should tell Lanky Luke that.
The “America. Love it or leave it, just don’t improve it” is the idiot stance and very unbecoming of a an academic. Somebody should tell Lanky Luke that.
Tell Dumb Dane she would do well to keep her mouth shut as well. But then, who says academics have to be very smart? They are usually mere hothouse flowers with little secular experience but a lot of ego.
In Sweden, dental is free (that is, paid through taxes) until 18. Afterwards, judging from various receipts, the rule seems to be you pay a bit yourself and some sort of insurance covers the rest. I haven’t figured out the exact proportions.
There are both private practices and government run practices; I’m not sure there is a huge difference in quality. My own preferred dentist used to be at a government practice but had to switch to a private one after office drama about Incorrect Thought.
Regarding salaries, dentistry appears to be a good but not fantastic middle class job. You generally get paid enough to suffer the top income tax bracket it seems.
Steven: Suppose that a Danish citizen who has gotten hold of at least one child decides not to sign up for any of these school or work programs. So the citizen is able-bodied, but simply refuses to work for wages. Can he or she stay in that apartment and play Xbox at least for 18 years (until the child reaches adulthood)? What would the cash value of the welfare benefits be, do you think? How would the welfare package compare to the spending power of someone who worked at a McDonald’s?
Steven: Hey! The parking lot for that welfare housing project you linked to has a Mercedes in it! Is it possible that at least one of the tenants has a cash job? Will he or she be ratted out by Google Street View?
Thanks for the TV show link. I didn’t understand the dialog of “Princesses from the Block” (Google Translate), but it looks like one could make good money running a tattoo and piercing parlor near these housing projects.
The short answer:
Yes, some people can enjoy the McDonalds worker standard of living for decades on wellfare. The lucky/unlucky) few might even have a higher standard of living – for some time.
But they’re fed a diet of incentives to get their arses in motion.
The long answer:
You can’t compare cash/numbers
http://www.politifact.com/punditfact/statements/2014/sep/03/other-98/can-you-make-45000year-mcdonalds-denmark/
But let’s try with a scale.
1. You have a place to live and money for food (and tv, alcohol, games, other drugs). No holidays, no car and your bicycle is ugly.
2. You have a place to live, money for food and maybe a car. You may go on holiday once a year.
3. You have your own house or apartment. Maybe a car or two and the ability to go on holiday once a year.
4. You’re a dentist. More holidays and better cars and holidays for you.
Without a child the wellfare recipient will be stuck at 1.
Caseworkers, psycologists will ask “What’s your dream?” or “Where’s your protestant work ethic?”. Tell you about people in your situation that rotted away. Tell you about people in your situation that grew up and got a job.
Getting a child catapults the wellfare recipient to level 2, the level of the 37.5 hour/week McDonalds worker.
The idea is that children are innocent of their parents intellectual, psychological or moral failings. They should be able to show up in school looking nearly middle class.
The other – slightly counterintuitive – idea is that a high level of wellfare will keep up the wages.
https://www.economicshelp.org/blog/468/unemployment/the-rate-of-unemployment-benefits/
Which means that humans will do less stupid work and invest in automation.
You can game the system by churning out children in a steady flow. You may even achieve the better half of level 2 at child #3. Fortunately this practice isn’t that widespread among the indigenous population.
The system is not fond of kicking people out of their apartments, even if they misbehave and do not show up for “work”. Denmark has 6.6k homeless people out of 5.7M
https://en.sfi.dk/publications/homelessness-in-denmark-2017-13453/
Mostly old drunks, professional romanians and a few hard to treat mental patients. I got to know a hard drinking Afghanistan vet that had suffered homelessness for a short time.
Generally the system is not keen to have people operating at level 0.8 or below. That’s where they really start to cost money and become an even bigger blight on society. As we saw in the Florida example
https://www.vox.com/2014/5/30/5764096/its-three-times-cheaper-to-give-housing-to-the-homeless-than-to-keep
“You can pay at the smart counter or the dumb counter, your choice” as the saying goes.
The system can be gamed and surely it is gamed. But with the focus on education, it looks as if it works a bit better in northern Europe than in southern Europe where the youth is staying at home, playing Xbox, uneducated
https://www.statista.com/statistics/266228/youth-unemployment-rate-in-eu-countries/
The Mercedes in the parking lot must be the visiting drug dealer/sugardaddy/relative.
You can’t affford even and old Mercedes on benefits/wellfare.
Then again, it could be a tenant with 5 years of saving from his job at the nearby McDonalds. There’s a mix of blue collar working people and people on wellfare in the area. If it was just people on benefits, it could spiral into
Tom: I think Lanky Luke and his danish teacher should both continue talk to each other about solutions to problems. Way smarter than shutting up and suffering the status quo.