Month: September 2018

From our anonymous insider…

Psych week. Based upon my M3 mentor, I am using the DSM-5, also known as the “Holy Bible for Psych” and the First-Aid psychiatry chapter to study. Straight-Shooter Sally: “I’m surprised we have only one week of psychiatry. Mental health has become a prominent national issue.” Lanky Luke: “Doesn’t surprise me. Step 1 doesn’t give much weight to psych.”

A quirky spaced-out 60-year-old psychiatrist introduces basic psych terminology and substance abuse disorders. He joked about the number of psych drugs. “There is a website that tests you on if a name is a drug or a Pokémon. Our former residency director is proud of getting 60 percent. Get ready ladies and gentleman for psych week!” The psychiatrist emphasized the diagnostic criteria for psychosis: presence of a delusion, hallucination, or disorganized thought. A delusion is a fixed, false belief. He gave several examples: “I’ve had patients who think they have Michael Jackson’s baby or are the president. Somewhat more common is a referential delusion. While they drive, they believe a billboard is speaking about them, or a TV is speaking to them directly.” Lanky Luke: “Is #NotMyPresident considered a psychosis?”

He began the substance-use disorder lecture by playing a BBC video of vervet monkeys getting drunk off stolen liquor from unsuspecting tourists on the beach in St. Kitts. “Among adults, 8.5 percent qualify as alcohol dependent or abusers. Think about that when you drive home tonight.” He continued: “Why do we have 10 percent of our human population with [genetic] phenotypes that make them susceptible for this dependence?” Students responded: “Alcohol is important in certain cultures to build social interactions”. Another student added, “Mating ritual.” The psychiatrist added, “I do not think I would have met my wife without alcohol. I have terrible social anxiety meeting new people. Alcohol certainly helps!”

“What about heroin? Did the poppy seed hijack the reward pathway to disseminate its euphoric seeds around the world or was it coincidental? Cocaine, amphetamines, heroin, fentanyl, and coca leaves all activate the dopamine reward system. The Incas built an empire on drugs. Mail carriers chewed on coca leaves for more energy while traveling across the 1000-mile empire. Why did they not knock down and steal coca from ancient 7-11s?” Students responded: “They did not make coca illegal”; “It was not purified”; “It was chewed through saliva.” He continued, “Right. Cocaine was purified in the 1880s. Sigmund Freud still has the best pharmacodynamics measurements for cocaine. When I was in medical school, they tried to replicate his experiments. They asked four volunteers to do cocaine and monitor blood levels for $500. Ninety-six people volunteered, but unfortunately I was not selected.”

He digressed on the history of drug use in America. “In 1970s cocaine was $100 for a gram… so about $50 to get high. Then we developed crack in the early 1980s and a rock was about $5. This spread like wildfire among the urban poor. With good intentions we tried to stamp down on it, but the result was mass incarceration. It’s tough to get a job after incarceration, so these former inmates are on disability with psych issues now.”

[Editor: Who has better mental health, the person who goes to school for 28 years and takes on $500,000 in debt in hopes of getting a job as a doctor, or the person who gets monthly SSDI checks without working?]

He continued, “We are seeing a similar transformation in opioids. You need poppies to make heroin so it gets expensive when the supply is reduced at the poppy farms. Fentanyl is completely synthetic; you can make it in your basement if you have basic understanding of chemistry for a lot cheaper. People are dying now from fentanyl, not heroin.”

He continued: “When you come to my floor your job is to understand the mindset of an addict. Most of you guys plan about five years in advance. You imagine a family, a house with a picket fence. A heroin addict can plan only a week in advance. Someone on methamphetamine plans nine hours ahead. Good luck getting a meth addict to come for a follow-up appointment in two days.”

He concluded, “We see that addiction spreads in culturally demoralized communities. I worked for two years on an Indian reservation, part of my penance for being an aging white male and therefore partly responsible for the introduction of alcohol in North America. What you quickly realize is the Navajo community has relatively low alcoholism compared to the Sioux because of their economic and cultural cohesion. With the decline of the coal industry, you see the same pattern in Appalachia versus the rest of the U.S.”

[Editor: Appalachian coal shipments to China are up in 2017 and 2018, but Americans still love their opioids just as much!]

Straight-Shooter Sally: “I wish we had a Drug Use 101 lecture. Terminology, ways to use it, cost, demographics, etc.. This was close, but no cigar.”

A tall 45-year-old child psychiatrist with a slight Eastern European accent briefly introduced Conduct Disorder. This is essentially the same as “sociopath” (also known as antisocial personality disorder), but the profession refuses to apply that label to anyone under 18. She spent the rest of the 100-minute lecture on attention-deficit hyperactivity disorder: “ADHD is a developmental disorder of inattention and impulsivity. They have task-irrelevant motor/verbal behaviors and delays in motor inhibition. A common observation from teachers is that the child will get derailed by any disturbance outside of the classroom, such as a squirrel climbing a tree or a cell phone ringing. Most kids will notice and get distracted, but they refocus on the task at hand.” If teachers can pick the ADHD kids out of the class, what is the role of the psychiatrist? “My job is to look beyond the obvious. There are a lot of disorders that have attention deficits. Individuals with ADHD frequently have other development delays such as language and social interactions. Classic case is a patient with ADHD and oppositional defiant disorder [ODD, cognitively inflexible child that deliberately annoys others and cannot think of compromise out of dilemma].” Persevering Pete whispered, “ODD sounds like a fancy way to call a kid a brat.”

She showed a slide with CDC data: 11 percent of school-age children and 20 percent of high school age boys have been diagnosed with ADHD. This is a 16-percent increase since 2007, and a 41-percent rise in the past decade.

She briefly described an emerging theory about ADHD. “ADHD patients whose mother smoked have a tuned-down dopamine reward system. They are hardwired to search for new things because the world around them is not interesting to them. These were the explorers of new worlds in the era of cavemen. When we force the child with ADHD to listen to boring lectures all day, they find it impossible to focus. However, when they find a passion, they can focus without difficulty. Stimulants such as Adderall [amphetamines] and Ritalin increase dopamine signaling causing them to be more interested in the dull activities.”

[Editor: Are there vats of Adderall and Ritalin sufficiently large to get Americans interested in computer programming? And maybe we all need Adderall and Ritalin during tax filing season.]

Once a patient has begun stimulant treatment for ADHD, they have regular check ups to assess attention, sleep, appetite, headaches, and mood changes. “We do drug holidays every two years. This usually happens when the child is learning to drive. When you ask children how they are doing, they will always say okay. Ask their parents how they are driving. People with ADHD [off the meds] have a much higher rate of car accidents.”

Pinterest Penelope asked why the United States treats way more ADHD than any other country. “I’ll try not to be too blunt. It’s several reasons. First, I think we have a greater demand for attention than we used to. I have parents and young adults come to me saying they need to pay attention for 16 hours per day [e.g., school plus music lessons then homework or a college student with an evening job]. It’s just not going to happen. Attention is a finite resource. Second, we do not train our children to delay any sort of gratification. The French use very strict schedules. Eat at this time with no snacks between. Third, other cultures are less willing to call this a disorder. The willingness of parents to give medications to young children astounds me.”

( “The worldwide prevalence of ADHD: is it an American condition?” (Faraone, et al. 2003; World Psychiatry) concluded that ADHD symptoms are actually just as common among children in other countries, though diagnoses may differ.)

My small group waited 10 minutes for IT to come deal with our projection difficulties. Type-A Anita used the downtime to ask if we watched the State of the Union speech, which she characterized as “disgusting.” Adrenaline Andrew, an aspiring EM physician whose family immigrated from Kurdistan: “I thought Trump was hypocritical. He was touting all these immigrants that he brought in, but he wants to keep them all out.” Straight-Shooter Sally commented on the Arizona policeman and wife who adopted a child from a heroin-addicted mother. “Oh my God! You do not know if that baby will be f***ked up. I could never do that.” Jane had watched some highlights on Facebook: “It was mostly a celebration of America, just a lot of patting ourselves on the back. I am not quite sure why we are celebrating so much.”

We changed the subject when Fashionable Fiona walked in late, waving a beautiful diamond ring, to announce her engagement to an MBA two years her senior. We all congratulated her. Type-A Anita announced, “I have to be the primary breadwinner before I get married.”

[Editor: Congratulating Fiona would have been considered a terrible faux pas in the 1950s; one congratulates the groom, not the bride, so as to avoid the implication that the woman was desperate to find a man. Separately, given that physicians have much longer careers than MBAs, let’s hope that she reads Real World Divorce and settles in a state that won’t offer her spouse the opportunity to tap her for a lifetime of alimony!]

Our small group facilitator is a brilliant personable EM physician married to a head and neck surgeon. She has been out of clinical practice for three years while taking care of two young children. “Don’t do the double doctor thing. It ends with one supporting the other.” She has to recertify her boards two years from now, and enjoys facilitating to prepare for her studying. “It is amazing how much more you guys have to know. All these genes, drugs.”

She recounted her medical school quest to get right-to-privacy rules altered in the state of New York. “When I was in residency in New York, we were not allowed to get a HIV or hepatitis test on a patient to see if we were exposed by a needle stick. We would have to weigh the risk of the patient to decide if we should go on these serious antiviral drugs. Imagine being on those drugs while doing residency. Fatigue. It was crazy. California and New York had these crazy antiquated laws. We lobbied [successfully] to get that changed. If you were exposed you could require a patient to get blood drawn to test for virus.”

Thursday morning, our last lecturer for the week is a 65-year-old psychiatrist who became blind after medical school. “Most specialites have diagnostic imaging and tests. Psychiatry doesn’t, with the exception of some new expensive functional imaging. Think of psych disorders like trying to treat heart or kidney disorders 100 years ago. We barely understand them. We are in the Caveman age of psych drugs. We are just beginning to tap into the mechanisms of the brain disorders.”

He described anxiety disorders: “The frontal cortex and amygdala are at war with each other. The amygdala is the old part of

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From our anonymous insider…

Musculoskeletal week features 14 hours of lecture.

Monday morning, A nerdy early 40s orthopedic trauma surgeon discusses osteomyelitis (bone infections) and infectious arthritis (joint infections). An infected bone or joint requires surgical debridement to remove the infected tissue. “Antibiotics cannot penetrate this avascular infection. Ubi pus, ibi evacua. The age-old mantra. One of the most satisfying things is taking pus out. You go in and leave it better than they arrived, period.” Students’ favorite part of his lecture: “A classic case of chronic osteomyelitis is a WWII soldier who was shot. The bullet seeded bacteria that was walled off by his immune system from the healthy tissue. 45 years later in the soldier’s old age with a depressed immune system, the infection activates.”

A lively 50-year-old pediatric orthopedist presents childhood muscle and bone disorders. Her practice involves improving gait and balance in movement disorders such as cerebral palsy. She does this by using braces, botox injection into certain muscle groups, and tendon release/transfer.

Cerebral palsy, present in about 2 per every 1000 live births, is a “non-progressive movement disorder caused by ischemia to the developing brain, typically in utero but also in early childhood. Example ischemic events include a cord wrapped around neck of baby in utero, stroke or a near drowning event. “When parents hear CP, they immediately picture a wheelchair bound, drooling, not functional child. If the anoxic event covers the entire motor cortex, then yes. But, more often CP deals with specific muscle groups. Some just have an issue with a few toes. CP is a spectrum.” She explained how cerebral palsy a common malpractice suit. “If your baby has cerebral palsy, call us to sue your Ob/Gyn. It is not always the obstetrician’s fault. 70 percent of events are thought to be prenatal.” 50 percent of CP cases have a history of prematurity. “Interesting the advances in prenatal care have not improved the incidence of CP.”

[John Edwards, the 2004 Democratic VP nominee, had a pre-Senate career as a plaintiffs’ lawyer suing physicians in cerebral palsy cases, At trial he would channel the words of the unborn child for the jury’s benefit. Expert witnesses hired by insurance companies defending these lawsuits would explain that there was no scientific basis for holding the obstetrician responsible, but the juries would often award millions in damages. Attempts to set up funds to compensate all cerebral palsy victims, not just the ones who sue, have been fought by trial lawyers. Edwards was a candidate for the 2008 Presidential election, but his campaign was impaired when a former campaign worker gave birth to his child and funds needed to be diverted to keep the new mother quiet. (She could have sued for child support in North Carolina, but the revenue obtainable through conventional family law is limited compared to in California or Massachusetts.) Edwards was criminally prosecuted by the U.S. Department of Justice for this diversion of funds to Rielle Hunter, but a month-long trial resulted in a mistrial on most counts.]

Our orthopedist lecturer showed a before-and-after video of her 10-year-old patient with cerebral palsy. The child initially had limited mobility, walking on his toes with a scissors gait. “Everything was tight. I was giving regular Botox injections, but those were having diminishing effects. I performed an adductor tendon release and transfer.” After the surgical intervention and physical therapy, the class could not discern any gait abnormality. “This child will not be able to compete in sports, but he’ll live a relatively normal life. Remember that cerebral palsy does not spread; we call it a static encephalopathy.” Several classmates were astonished about the tendon transfer surgery. Jane: “We can do that?”

She concluded with some career advice: “Do not assume children with physical impairments have mental impairments. Just because their body is failing them does not mean their mind is failing them too. And when you choose a specialty, think whether you are improving the quality of your patient’s life, or just prolonging their suffering.”

Our third lecturer: a surgeon specializing in nerve reconstruction presents on upper extremity nerve injuries. Type-A Anita, an aspiring Ob/Gyn, exclaimed in horror about nerve injuries during delivery: “That happens? We are barbaric!” Erb’s and Klumpke’s palsies occur if the infant’s head is placed in extension or if the infant’s arm is placed into abduction (away from body), respectively. “If the kid regains elbow flexion in three months, there is a good prognosis that he or she will fully recover.” The surgeon explained that it is possible to do nerve transfers. “We can get back elbow flexion and shoulder range of motion. Animation of the hand and wrist are still extremely difficult.”

Gigolo Giorgio ask about the potential role for nerve scaffolds in the future. “It is here! We use it today, keratin scaffolds, pig submucosal, cadaver scaffolds. And some people are starting to use nanotechnology to implant growth factors and such. That’s above me, I’m just the mechanic!”

Two sports medicine physicians held workshops on common musculoskeletal injuries using X-rays, CTs and MRIs. “Knee dislocations used to be caused only by severe trauma such as a football injury or car accident. We now are seeing low-velocity knee dislocations. An obese individual will step off a curb, and the momentum of the body on a fixed tibia will posteriorly dislocate the knee. Really no good surgical repairs for that so far.”

After lecture I attend the weekly “quarterback” meeting where rotating students air concerns and complaints about the curriculum to the block director. Students complain that lecturers get off-topic following questions from unprepared students. Mischievous Mary and Geezer George cited infractions from students who did not know the anatomy of the brachial plexus (nerves innervating the upper extremity). “I do not go to lecture because of it. It is more effective for me to use that time studying in the library.” George: “There is something wrong when some of the best-performing students do not go to lecture.” Several students tried to show their maturity relative to others in the class. A student recommended that two or three lectures be highlighted each week that require preparation. Mischievous Mary and Geezer George lept on it saying “we are not kids, if you did not prepare just shut-up during lecture.”

Wednesday morning, our sixth lecturer: a 50-year-old orthopedic surgeon lectures on bone diseases. Osteoporosis, and its precursor osteopenia, are diseases of disordered bone deposition resulting in decreased bone mass density [BMD]. “Your bone mass density peaks in your late 20s, and continues to decline thereafter. Moderate weight-bearing exercise is the most effective way of to raise your peak BMD, and to decrease the decline of BMD after your glory days. Moderately overweight individuals actually have stronger bones because they load their bones with more weight.” (He may be taking his own advice here; Pinterest Penelope described him as “tubby.”)

Why is osteoporosis bad? “The weak bone from osteoporosis is prone to fracture from normal weight-bearing activities and falls. People with osteoporosis can spontaneously fracture their vertebrae with no injury at all. Someone who falls on their butt or side should not get a fracture. One-year mortality after a hip fracture is 30 percent. This is not something you just put a screw in it and be done with. Yet, our medical system does not think about bone health. I see so many patients who have been on glucocorticoids on and off for asthma. [chronic steroid use causes osteoporosis.] They have terribly weak bones in their 50s. Frankly, there is nothing to do about it now.”

Thursday morning the whole class turned out to hear the last orthopedist lecturer, Hot Shot, a spine surgeon known for being one of the most highly compensated surgeons at the university.

“When the spine is injured, it shuts down. This is called spinal shock. Reflexes will be absent, even if the connections are not broken. You cannot assess the spinal cord injury level until spinal shock is over [2-3 days].”

Hot Shot explained why he choose Ortho: “I never wanted to do a rectal exam again. Boy, was I wrong. As a junior resident — that’s the guy in ER — my attending would tell me every single trauma case gets a rectal. If you do not do it on the patient, I will do a rectal exam on you.” He explained that every trauma patient should have a bulbocavernosus reflex test to assess the spinal cord integrity. This reflex is elicited by applying pressure to the glan penis or clitoris (or tugging on a Foley catheter), and feeling for increased anal sphincter tone.

Gigolo Giorgio asked whether spinal shock could be shortened by steroids. “We do not know what causes spinal shock. Like most things in medicine, our understanding is observational.”

After lunch, two state health department epidemiologists lead a workshop on an example hepatitis C outbreak. The senior epidemiologist begins describing the case: “I got involved after two or three calls from EM physicians diagnosing acute hepatitis from a new hepatitis C infection.” Hepatitis C is reportable disease in most state, meaning every physician must report the case to the health department. She scheduled a private meeting in a McDonald’s parking lot with one patient, a 25-year-old male college student. “Fast food parking lots are a good meet-up location. People want to remain anonymous.” (This is apparently an occupational hazard; the 55-year-old woman weighed at least 180 lbs.) The patient reluctantly explained that he visited a nearby college for an Ultimate Frisbee competition and “raging” party. Alcohol, cocaine, marijuana, IV drugs were all used. The patient explained, “There were a few tattoo artists hooking people up. I got a small one. I do not even remember it, I was so wasted.”

The junior epidemiologist, a 40-year-old with pink and purple hair, interviewed two other patients, including a married graduate student who had sex with several partners at the party. This patient provided contact information for one of the tattoo artists. The tattoo artist was an herbal medicine enthusiast in her 40s who claimed to use a homemade needle-cleaning machine. After interviewing 10 people (providers and patients), the epidemiologists completed their case report, estimating that, between tattoos, sex, and IV drug use, 200 people were exposed to hepatitis C.

[If the Editor were qualified to work in a state health department, the report would read “People spent 85 percent of their time at the party having sex with strangers, getting tattoos while too drunk to remember, and injecting recreational drugs. They wasted the rest of their evening.”]

We go to our small groups. Straight-Shooter Sally: “[The epidemiologists] seem so cynical.” My facilitator, a 45-year-old EM physician who stopped practicing seven years ago after she gave birth to children, but is trying to study for her boards now: “Everyone who works in the ED becomes cynical. Part of it is your job training, you are supposed to see the worst in everyone to not miss anything. Part of it is just who you are dealing with. Some people just think different. No shame in taking advantage of the system. For example, I had a patient with a connective tissue disorder who would keep coming to the ED every few days. He would purposely dislocate his shoulder to get Dilaudid (hydromorphone). In residency we had this homeless couple who would come in once a week, matter of factly state they were contemplating suicide knowing they would have to be admitted. They would get ‘two hots’ [warm bed, warm meal]. The male was a registered sex-offender so he was not allowed to go to homeless shelters. Instead he was surrounded by children in the ED.”

Straight-Shooter Sally gives a 20-minute presentation on tobacco cessation. She presents the findings of a “landmark study” (“A Randomized, Controlled Trial of Financial Incentives for Smoking Cessation”, NEJM, 2009) in which people who could receive $750 over a one-year period were three times more likely to quit. All of us have

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In a comment to “Judge Kavanaugh dust-up shows that Republicans need to abandon white men?” I wrote

Imagine for a moment that Amy Coney Barrett had been appointed. A cisgender man sends a letter to a senator saying that she tried to force him to do something sexual 30 years ago. He has been in therapy ever since he was attacked by Ms. Coney, a high schooler with raging hormones. The therapist will corroborate that the victim shared his painful memories well before the nomination of Mrs. Barrett. Would anyone believe this or care?

Is it possible that the nomination of Kavanaugh was a clever door-in-the-face maneuver to get the Senate to breathe a big sigh of relief and approve Amy Coney Barrett?

[Separately, if Kavanaugh is rejected and goes back to his regular job, the necessary logical conclusion will be that Americans are content to have a rapist on the United States Court of Appeals for the District of Columbia Circuit, but they can’t tolerate a rapist on the Supreme Court?]

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We attended a birthday party in our suburb recently for a 1st grader. I asked the hostess what she was up to lately. She said “Physical labor.” It turned out that what she meant by “physical labor” was caring for two healthy children, both of whom were the responsibility of the government/taxpayer from 7:15 am to 3:15 pm on weekdays (1st and 6th graders). She does no work for wages. Her house is not especially well decorated or organized. The four food groups that I’ve seen her serve: microwave, frozen, wine, and takeout. Perhaps she was the source for Bill Burr’s “The most difficult job on the planet” ?

[Separately, her personal situation provides a good micro example of the macro economic shrinkage to the U.S. from our family law system. She and her to-be-former husband are embroiled in divorce litigation. Massachusetts is a winner-take-all state and both she and her husband are seeking to become the winner. Both have decided not to work during the roughly three years that the case is expected to last. Each litigant hopes to be declared the “dependent spouse” and “primary parent,” which would entitle that person to live off the other for at least the next 17 years (until the youngest child turns 23). Although there are alimony guidelines intended to limit the duration of alimony as a function of the length of the marriage, if one litigant can convince the judge that he or she cannot work, alimony could be extended until the death of the payor. What’s the twist here? One litigant holds an MBA from an Ivy League business school. The other litigant is a fully trained attorney with experience in one of the hottest and best-paid areas of law. Both previously earned more than the salary of a judge in Massachusetts and both will be testifying that it is impossible for them to find work, even as they drive past 50 restaurants with “help wanted” signs on their way to the courthouse.]

Readers: What’s the most epic description of hardship you’ve heard from a suburban parent lately?

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From our anonymous insider…

Genetics week is taught by a 53-year-old pediatrician specializing in complex genetic diseases. Jane described her as “brilliant, but slightly awkward.” She began: “You all know when you walk by someone, say at the grocery store, who just doesn’t look normal. We are going to develop a systematic exam and language to explain these features.” We scrolled through slides of patients with various syndromes. “We’ll start with severe dysmorphic characteristics, and then use the same analysis on less severe phenotypes.” We look at kids with low set ears, flat nasal bridge, presence of epicanthal folds (skin flap covering lacrimal duct in lower nasal corner of the eye), smooth philtrum, and a high interpupillary distance. The geneticist: “You would be surprised how many terminologies in genetics have had to be changed over the years because they are no longer politically correct. We’ve changed simian crease to single palmar crease. We no longer use the term Mongoloid to describe upward-sloping eyes.” (Most people have two palmar creases.)

After the 12 PowerPoint images, we play “Is it Normal?” in groups of six. Each group rotates through 15 stations, where we analyze an image and decide if it is normal or abnormal. The geneticist explained this is the same game they play at conferences: “Whenever we go to the annual genetic disease conference, the main lecture is preceded by a game where each geneticist in the audience tries to beat the computer in identifying genetic diseases from pictures. The computer gets better and better each year. Humans still win though.” Straight-Shooter Sally: “I cannot wait until we have this technology in the office. I won’t have to memorize this stuff.”

[Editor: the Google AlphaGo team trained a computer to screen medical images. See “Development and Validation of a Deep Learning Algorithm for Detection of Diabetic Retinopathy in Retinal Fundus Photographs” (Gulshan, et al. 2016; JAMA). Maybe they will start selling ads for medical school loan refinancing next to the results?]

She concluded by explaining linkage analysis studies using VNTRs (variable number of tandem repeats). These regions exist on each chromosome and are passed through generations. “VNTRs provide a genetic fingerprint of each individual. I practiced in the age of patents on inheritance tests for specific genes. A family I worked with had autosomal dominant polycystic kidney disease (AD PCKD). The father needed a kidney, and his daughter wanted to donate. We needed to ensure the daughter did not have AD PCKD, but a patent troll had purchased the polycystin gene patent and raised the price to $10,000. Instead of paying the troll, we determined that she did not have the disease using an older technology linkage analysis of the family. We found a VNTR associated with the polycystin gene of the deceased father. We were able to clear the daughter based on her lack of this VNTR.”

Gigolo Giorgio: “How do people think of this stuff?! Not many people can do what she does. She has a special skill.” Lanky Luke: “I want each of my future children to go see her for a check-up. Make sure there is nothing wrong with them.”

After lecture, we debate ethics cases in groups of 10 while a licensed genetic counselor and pediatrician rotate. For each case, we divided into 2 subgroups of 5 to take each side of the debate. Frustratingly, we never learned an authoritative resolution of any of these issue. [Editor: perhaps it varies by state?]

Case 1: Huntington’s disease testing for a minor. A mother wishes to test her 8-year-old child whose father died from Huntington’s disease. Anticipation is a phenomenon in certain genetic diseases where the onset and severity of the disease increases as the disease is passed down through generations. For example, a grandfather may get Huntington’s at age 45, the mother at age 40, and child at age 30. Straight-Shooter Sally: “The mother is violating the future autonomy of the child. We should wait until he is 18.” The pediatrician added: “We also need to consider if this test is indicated. Would the answer change treatment?” Jane: “Does the mother have a right to know if her child has the disease? Perhaps she could get the test, and withhold the results from her child until he is ready to make a decision.”

Case 2: Adoption of a child at risk for Fragile X syndrome, an inherited disease characterized by moderate mental retardation and dysmorphic features. Rebecca, a 14-year-old with Fragile X syndrome, is raped and becomes pregnant. The rapist is imprisoned. The family places the child on the adoption list, but declines amniocentesis testing for the child. The family requests you, the physician, withhold the 50 percent risk of the child having Fragile X syndrome from the adoption agency to improve chances the child gets placed into a “good” family. Should the patient be required to get tested via an amniocentesis? Do you inform the adoption agency or withhold the information even if requested? Pinterest Penelope: “I don’t think you can force a mother to get a test she does not want. Amniocentesis is not without complications.” Straight-Shooter Sally: “I understand that, but an adoption agency should have the right to decline to list the child then.” Lanky Luke: “It would violate the trust in the adoption system. Fewer families would be willing to adopt a child if they risk not knowing the health of the baby.” Jane: “There are families that are actually seeking to adopt special needs children.” Lanky Luke: “These are interesting dilemmas, but I do not believe it is doctor’s role to decide what, from their perspective, is the right course of action. We should have started by studying the laws.”

[Editor: The same-sex couple that ministers to the spiritual needs of the Millionaires for Obama in our Boston suburb has two special needs children, neither of whom has any genetic connection to either father. A handful of deeply closeted Deplorables in our town occasionally grumble about the cost to the school system of providing for these voluntarily adopted children of the pastor and his husband.]

Case 3: A pregnant alcoholic heroin user refuses to enter rehab and stop abusing these teratogenic compounds (those that can disturb the development of the embryo or fetus). My EM facilitator commented, “This happens much more than you can imagine.” Can you force her to receive addiction treatment or counseling? Jane: “This is child abuse.” Lanky Luke: “Is this not a double standard? If you assume the fetus has a right to not be harmed by teratogens, would not this argue against abortion after some age?” We discussed Wisconsin’s 1997 Unborn Child Protection Act, whose constitutionality was still being argued 20 years later (see “Supreme Court allows Wisconsin to enforce ‘Unborn Child’ law” (Wisconsin Gazette, August 11, 2017). Type-A Anita became passionate on the subject of preserving abortion rights: “You need to educate the mother. I wouldn’t consider [daily heroin consumption] child abuse.” (The mom is unaware that heroin and alcohol are bad for kids?)

Breaking from the genetics theme, on Thursday we had three hours of lecture on back pain. A soft-spoken orthopedist with a Southern accent explained, “Doctors hate dealing with back pain. Ironically is is also the number one cause of office visits and 4 out of 5 malpractice lawsuits are related to back pain.” His example of a typical case: “I fell while working at Walmart, and I want to sue Walmart for hurting my back. I want to get opioids and a check every month.”

He continued: “Real back pain is debilitating though. Always ask the patient to show you where the pain is. A lot of people say back pain, but the issue is in the SI (sacroiliac) joint, the hip, or the kidney.” How to tell the difference between real and malingering? Start with Waddell’s sign: push on spine and ask to rotate hips. “My favorite is to ask patients who come in limping to limp backwards. No one ever practices limping backwards.” He added, “Be cautious though. They will immediately know that you know they are FOS [“full of sh*t”]. Makes rest of the visit a little awkward. My advice is to refer any back pain patient to orthopedics. We are trained to handle the real ones, and the FOS ones. I always ask how patients make the pain less. Most people with real back pain have found a way to lessen the symptoms. The exception is a herniated disk. Someone with a herniated disk has trouble finding comfort anywhere.”

“We’re the Microwave generation,” said our 45-year-old orthopedist. “Patients with a chronic condition expect immediate relief from one office visit. Our main cure is time, however. 8 out of 10 patients with back pain will be better in 3 months with none to limited therapy; 9 out of 10 people will be better in 6 months. It is tough to ask someone to be in this excruciating pain for three months though.”

That afternoon, a geriatrician gave a lecture on dementia and then we broke into small groups to practice mental status exams, including the MoCA (Montreal Cognitive Assessment), recently taken by President Trump. Anita projected a picture of Rear Adm. Ronny Jackson, the physician who “stamped” Trump’s exam. Anita: “There is no need to worry guys, our Commander in Chief is smart.” The Hillary-supporting students proceeded to trash Dr. Jackson’s credentials. Straight-Shooter Sally: “I am shocked that Trump scored 30/30.” A handful within our group matched the President’s score, but most of us lost 2-3 points on short term memory. Type-A Anita, looking at her near-the-bottom score, concluded: “Trump lied. Doesn’t it amaze you how he can lie so easily and so much?”

Our patient case: Connor, a 6’4″ 59-year-old CPA presents on his wife’s urging for forgetfulness. Family history reveals his grandfather and father had dementia in his 60s. (Lifetime risk of developing Alzheimer’s is 10 percent, but the risk is 25 percent when a first-degree relative has Alzheimer’s and the correlation is stronger for early-onset dementia.) Connor: “My wife and I grew up together as neighborhood friends from kindergarten and started dating in high school. She saw my family deal with my father’s dementia. He would walk out of our house and get lost for hours until the police picked him up. He got very aggressive in his 70s before he died.” (Connor was speaking to us three years after his diagnosis, but he remained intelligent and articulate.)

Martha, who had been a stay-at-home wife, took over: “I started noticing things years before he was diagnosed. He would come home later and later from work. Things would take him longer. He was having to stay much later every day to finish the same amount of work, until 8:00 or 9:00 pm in the office. He lost his sense of time.” Connor was diagnosed with early-onset Alzheimer’s in 2014 and retired from his accounting job.

Martha: “One conflict was about our taxes. I know nothing about finances. He was adamant about continuing to do them. This became a crisis in 2016. He kept saying he would be able to do the taxes. The deadline was approaching and he still had barely started it.” Connor was ashamed about having to file an extension and asking for help from a CPA friend: “I just couldn’t get all the papers together.”

Students asked Martha how her typical day had changed. “We talk about something, and ten minutes later he forgets. It can be infuriating. He’ll forget where we are driving to; he’ll forget to pick something at the store that I told him ten times. I try to be more patient. I pray every day for the strength to be patient.”

What other changes had she noticed? “He has some balance issues. He used to love playing basketball with our grandchildren. He fell one time and has had to stop. He has the same preferences. He likes the same food.” Ambitious Al asked about intimacy. Martha: “He

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Christine Blasey Ford is facing some challenges in making it to Washington, D.C. “Kavanaugh accuser says GOP trying to ‘bully’ her” (Politico):

The GOP has been told that Ford does not want to fly from her California home to Washington, according to the Republican senator, which means she may need to drive across the country to make the hearing. Ford has reportedly told friends she is uncomfortable in confined spaces, indicating a physical difficulty in making the trip by plane.

From “Claire McCaskill, Elizabeth Warren describe their #MeToo stories of sexual harassment” (Washington Examiner):

One of the stories — elicited in response to the social media #MeToo campaign — came from Sen. Claire McCaskill, D-Mo., who said a senior state lawmaker told her decades ago that she may need to trade sexual favors for passage of legislation.

“I cautiously approached the very powerful speaker of the Missouri House of Representatives” McCaskill said. “He looked and me and paused and said, ‘Well, did you bring your knee pads?'”

“I do think he was joking, but it was shocking that he would make that joke to a colleague,” said McCaskill, who has previously opened up on the incident.

McCaskill owns a Pilatus PC-12. Suppose that she were to demonstrate her passion for the #MeToo era by sending the crew and plane out to the Palo Alto airport. Rather than be confined in a five-seat automobile for five days, or endure the suffering of domestic First Class airline travel, Dr. Ford would be able to spread out in this massive executive 11-seater (2 pilot seats plus typically 8 seats and a restroom in the back) as she made her way to Washington, D.C. to testify.

[How do we know that McCaskill owns a PC-12? “McCaskill repays nearly $300,000 for unpaid taxes on plane” (CNN):

Sen. Claire McCaskill, D-Missouri, acknowledged Monday that she failed to pay nearly $300,000 in personal property taxes owed over the last four years for the partial ownership she and her husband have in a private plane.

McCaskill, a vocal supporter of reform and transparency in the Senate, described the failure to pay taxes as unintentional and said she will sell the plane.

McCaskill’s acknowledgement comes shortly after Politico reported that she used tens of thousand of dollars from her Senate office budget to cover the costs of chartering the plane for Senate business. After the story broke, McCaskill repaid the U.S. Treasury $88,000 for 89 flights.

McCaskill said the disclosure had created a “perception” problem and the “appearance of impropriety.” She sought a full accounting of her use of the plane which revealed the failure to pay taxes.

Did she sell the plane? Seven years later, “McCaskill admits to using private plane for part of RV tour”:

A campaign aide confirmed to CNN that the plane used during the tour is different from the one McCaskill had in 2011.

“Clearing The Air On Senator “Aire Claire” McCaskill’s Use Of An Airplane”:

In a political stunt, she demanded her husband “sell the damn plane.” But shortly after her reelection, the senator and her husband bought a new, more expensive plane.

Technically, the plane is owned through TLG Aviation LLC, a McCaskill-owned business entity valued at over $1 million. It’s all detailed on the senator’s personal financial disclosure form for the fiscal year 2016. Aero Charter, the company hired by Senator McCaskill to operate the 2009 Pilatus PC-12/47E [N5346M], wrote to the Federal Aviation Administration (FAA) earlier in April 2017 to ask for the tracking information on the plane to be blocked from the public.”

If you do try to track this plane on FlightAware, it says “This aircraft (N5346M) is not available for tracking per request from the owner/operator”.

How does a senator pay for an airplane that costs $5 million new? “Claire McCaskill’s wealth comes into focus” (St. Louis Post-Dispatch, 2011):

In 2005, months after McCaskill announced her candidacy for Senate, [ex-husband] Exposito was fatally shot in a hardscrabble neighborhood across the border in Kansas.

By then, McCaskill was married to developer Joseph Shepard, whom she met at the birthday party of a mutual friend. Their union meant that the details of Shepard’s vast business enterprise had to be revealed under disclosure rules for elected officials and their spouses.

Shepard has made a fortune investing in affordable housing, an industry that employs complex investment vehicles and intricate tax credit swaps. Shepard’s holdings, according to forms filed with the U.S. Senate, are divided among dozens of limited partnerships, from Abilene, Kan., to Zephyrhills, Fla.

So it turns out to be tax dollars that ultimately paid for the plane. “Businesses linked to McCaskill’s husband get $131 million in federal dollars” (Kansas City Star):

Businesses tied to U.S. Sen. Claire McCaskill’s husband have been awarded more than $131 million in federal subsidies since the Missouri Democrat took office in 2007, an analysis by The Kansas City Star found.

Joseph Shepard’s personal income from his investments in those businesses has grown exponentially during his wife’s two terms in the Senate.

The federal payments don’t go directly into Shepard’s pocket. Most of the money goes toward operating costs for government-subsidized housing projects Shepard is invested in. Those companies then distribute the profits to Shepard and other investors.

In 2006, the year before McCaskill entered the Senate, her husband’s personal income from those investments was between $1,608 and $16,731, according to the senator’s financial disclosure forms.

In 2017, five years into McCaskill’s second term, Shepard personally earned between $365,374 and $1,118,158 from investments in housing projects that received federal subsidies, the disclosure forms show. Disclosure forms only provide ranges of income.

Shepard (the rich guy) was previously married. That wife sued for divorce and, during the litigation, filed for a restraining order alleging domestic violence (police report and Petition for Order of Protection). Having married a man who was accused of assaulting a woman, McCaskill could offer to join for the trip and talk with Dr. Ford about the circumstances under which it should be #BelieveTheSurvivor.]

 

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I upgraded an iPhone X to iOS 12 earlier this week. The best feature is that Google Maps will work via Apple CarPlay.

The software is terrible at figuring out when to use WiFi calling. With full-strength 75 Mbits symmetric WiFi and 1/2 to 1 bar of service (the only thing that the Millionaires for Obama hate more than Trump is cell towers) the phone decides “well, let’s just keep using that quality Verizon mobile network”.

iMessage has been reconfigured for teenagers. If you want to send a photo you have to go through a screen in which you are prompted to take a new photo (selfie?) before you can tap on an obscure button to get to the taken-an-hour-earlier-or-whatever photo that you actually want to send. Worse, this “instant camera” app has the “old photos” icon in the top left corner, not to be confused with the “regular camera” app in which the “review old photos” is in the lower left corner.

Summary: a weak effort for suburbanites; due to the incompetently handled WiFi calling situation, the phone is barely usable as a phone.

Related:

• Is “data scientist” the new “programmer”? (all the people who could have made iOS 12 functional and consistent are working as data scientists)

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