Medical School 2020, Year 1, Week 18

From our anonymous insider…

Exam week covered cardiopulmonary physiology, anatomy and clinical skills. Pharmacology remains the most dreaded topic. Despite this universal struggle, two-thirds of the class appear comfortable with the pace. We know what to expect. We realize that the exams are meant as a stop-safe. If one of us fails the exam, typically a score less than 60%, it is a wake-up call that we are not on-track for the final judgement: Step 1.

The other third of my classmates are nervous wrecks. They are so concerned about what they need to know that they forget about learning. Four percent of the class failed and will have to retake the exam next week. Most of these individuals had adhered to Anita’s strategy of focusing on “High Yield” material, defined as material frequently included on the Step 1 exam and therefore in McGraw Hill’s First Aid for the USMLE Step 1. The First Aid summary figures are worth reviewing the day before the exam, but it seems that “High Yield”-minded individuals quickly forget a substantial amount of the information. These individuals go blank during discussion of some aspect of the patient case that was in the previous block, for example, an enzyme involved in a urea cycle disorder.

As soon as the exams were done, classmates were able to reflect on their experience. We agree that the tested block was much more enjoyable than our first block, which was devoted to clinical applications of molecular pathways, many of which students were exposed to in pre-med required courses and MCAT studying. The tested block was our first foray into predominantly “clinical” material: physiology and pathophysiology. We also got to use our stethoscopes!

After my second exams, a few things I wished I knew on day one:

  • find a good textbook
  • learning begins after lecture
  • study early, study consistently, repeat

Most of the class reads the suggested Costanzo’s Physiology (“I have a date with Costanzo tonight,” is a common inside joke), but I preferred the more in-depth Medical Physiology (Boron and Boulpaep).

Twenty percent of the class no longer goes to lectures because they find it less efficient than independent study. I continue to go to hear the clinical vignettes. Some lecturers are down to an attendance rate of less than 30 percent. Maybe medical school costs could be cut considerably; Jane and and I agree that we could learn everything besides anatomy and clinical exam skills using Web-based and library resources.

The job of a medical student is to study. Many of us got through undergraduate exams by cramming the night before. This purge-in, purge-out mentality does not work in medical school. Curiosity becomes the most valuable asset in medical school. The depth and breadth of information requires constant dedication to translate understanding into retention. My search for immediate answers to questions is challenging for classmates because I don’t have a smartphone right now. Jane suffers the most with my endless questions: “My ankle evertor muscles are sore. What muscles are those?” (Fibularis brevis and fibularis longus)

Statistics for the week… Study: 35 hours. The library was still packed when I left at 10:00 pm most nights this week. Sleep: 8 hours/night; Fun: Learning on Saturday that I’d passed!

More: http://fifthchance.com/MedicalSchool2020

Full post, including comments

Stocks for the long run: GE since 2001

Boston Magazine has an article on GE CEO Jeff Immelt. They note that the stock price has gone down from $40 per share to $29 during the 16 years that he has run the company. Adjusted for inflation, that’s nearly a 50-percent decline ($40 in 2001 is equivalent to about $55 today).

A Google Finance chart of GE versus the S&P 500 confirms the dismal performance of this stock.

What do readers think? Was GE just so crazily overvalued, even after the Crash of 2000, that the stock had nowhere to go but sideways? Revenue in 2001 was $126 billion and earnings per share were $1.41 (annual report). The 2016 annual report shows $113 billion in “industrial segment revenues” and $1 in “continuing EPS” (GAAP measures) and $103 billion in revenue and $1.49 using non-GAAP techniques. So the company’s performance has become incomprehensible to laypeople in the intervening years, but revenue and profits do seem to have stagnated. How can this be in a world that is ever-more-friendly to the biggest companies?

[Not everyone is suffering. Boston Magazine notes that shareholders paid Immelt $21 million last year. He spent a full four months of salary on a modest dwelling: a $7.5 million Back Bay townhouse.]

Related:

  • 2003 Slate article on GE executives underperforming
  • Stocks for the Long Run, the investment classic that my money expert friend says can lead to infinite wealth. If you are in fact sure that stocks will outperform bonds over the next 10 years, for example, you can work with options and futures to pick up guaranteed risk-free cash. (This is in case you don’t want to get infinitely rich by starting a company with a 100-percent female workforce, which Hillary Clinton and Elizabeth Warren say will do the same work at much lower cost than what your stupid competitors are paying their workers who identify as male.)
Full post, including comments

Car and Driver is more convincing than Thomas Piketty

Thomas Piketty presented 704 pages about how rich the world’s rich bastards are and therefore it was time for the pitchforks (see Book review: Piketty’s Capital). We have a household member who, despite being 13 years shy of being able to drive, is fond of Car and Driver magazine in hardcopy. From the June 2017 issue, in a review of the $3 million Bugatti Chiron:

Bugatti by the numbers:

42: number of cars owned by the average Bugatti driver

870: number of miles the average Veyron [previous version of the car] accumulates in a year

(This is in an inset box that is missing from the online version.)

Full post, including comments

New York Times discovers that it is expensive to live in Boston

“How Homeownership Became the Engine of American Inequality” (nytimes) advocates for a seemingly sensible economic policy (getting rid of the mortgage interest deduction), but I can’t see how the cited stories support the author’s argument. Here’s my published comment on the piece:

Affecting stories. And of course subsidizing unproductive investments in housing is a sure way to kill per-capita GDP growth (a worker who lives in a larger and nicer house does not get more work done), so it is hard to imagine a more counterproductive policy for an indebted government (which needs economic growth to pay off $20 trillion in debt) than the mortgage interest deduction.

That said, the author picked people who live in one of the world’s most expensive housing markets (Boston area) and they have kids and they want to have each child in a dedicated bedroom. Absent fellow taxpayers (many of them childless working drones) giving them subsidized housing, how was that ever going to work unless one parent had a high income?

There are some Americans who can afford to have kids with a moderate-income co-parent and a comfortable-sized house/apartment. There are some Americans who can turn a moderate income into a comfortable-sized house/apartment in a high-cost area. What this article shows is that the intersection of these two groups is non-existent without an ample helping of tax dollars contributed either by (a) those who have a higher income, or (b) those who don’t have kids.

Readers: Can you see a way in which eliminating the mortgage interest deduction would make housing in prime urban areas more affordable for low-income people who want multi-bedroom units? If killing the deduction slowed construction of new housing, wouldn’t the price of existing housing actually go up? And how does the mortgage interest deduction have a significant effect when we have (1) a growing population (due to immigration), (2) a demonstrated inability to construct new urban environments that are attractive?

[Separately, if you bought a house in Detroit or Cleveland 15 years ago you’ll be pleased to learn from the NY Times that “homeownership … is a proven wealth builder”]

Full post, including comments

Watching TV is not a good way to learn about reality

From the local school…

Dear Parents & Guardians,

Supporting the mental health and well-being of our students is a priority for all of us as a community. It has come to our attention that some of our middle school students have been talking about and/or watching a popular new Netflix series that presents an inaccurate and graphic portrayal of suicidality. The series, based on a book by Jay Asher, entitled 13 Reasons Why, portrays a high school student who commits suicide after leaving audio recordings for her peers to listen to after her death. The purpose of this letter is to make you aware of this series and the concerns of the suicide prevention experts. We encourage you to have conversations with your child if they have watched this series or have heard about it from friends. Having accurate information and talking points will support your conversation with your child. While all students require support with these discussions, students who may already be vulnerable are at greater emotional risk.

In addition, please be advised, mental health professionals are concerned with the graphic depiction of suicide and sexual assault contained within this series.

——- from the attachments…

On the surface, 13 Reasons Why might come across as a show that discusses mental health, however the issues of mental health or illness are never explored in the show. While a varied number of issues were presented in the show (e.g., sexual assault, sexual orientation, sexting, etc.), for Hannah they seemed to generally manifest themselves as shaming and harassment. The overwhelming message seems to be centered on the oft-cited but misleading narrative that bullying ultimately leads to suicide. The storyline espouses that the simple solution to Hannah’s struggle – indeed the cause of most of her strife – was the unkindness, and in some scenarios, the downright cruelty of her friends. While this is an important theme to explore, causal links between bullying and suicide are simplistic and as such, problematic.

Suicide is not a common response to life’s challenges or adversity.

When you die you do not get to make a movie or talk to people any more. Leaving messages from beyond the grave is a dramatization produced in Hollywood and is not possible in real life.

Hannah’s tapes blame others for her suicide. Suicide is never the fault of survivors of suicide loss. There are resources and support groups for suicide loss survivors.

I think is a good illustration of our culture of victimhood that one can now be a “survivor” as a consequence of someone else’s suicide.

Full post, including comments

Invitation to two lectures (tomorrow) at the New Economic School

Russian-oriented folks:

I’m giving two talks tomorrow (Friday, May 12) at the New Economic School here in Moscow. The first is from 11-12 and covers the American start-up world, open-source software, and some lessons on management and working with big customers (speaker notes/handout). If you’d like to attend, here is an official sign-up page. The second talk is from 17-18 (5 pm in American parlance!) and is titled “U.S. Family Law: What happens to an economy when having a baby is more lucrative than going to college and working?” (notes; best guess: the economy shrinks by about 3 percent). It is geared more to graduate students in economics planning their research projects, but if you’d like to attend please add a comment to this posting and perhaps it will be worth setting up an official sign-up page for that as well.

Full post, including comments

Can we measure value of American health care and pharma by exports?

One of my money expert friends refuses to believe that we are being bilked by the health care industry. Sure we spend 18 percent of GDP and Singapore spends 4.5 percent and we spend more than twice as much per person in dollars as do the richer European countries. However, American pharma and healthcare are way better than in those other parts of the world where they spend less.

Life expectancy statistics suggest that American health care is not better, but we can argue about lifestyle, accidental death rates, etc.

How about a new measure: exports of our purportedly superior products and services.

There are plenty of upper-middle-class and richer people all around the world. We can assume that their desire to be healthy and alive is as strong as ours. If our pharma is so great and the new patented drugs so much more effective than older generics, are foreigners happy to import these new drugs and pay U.S.-style prices for them? If our hospitals and procedures are more advanced, do we see planeloads of upper-middle-class French and Germans, for example, coming to hospitals in the U.S. for treatment? There is no debate that we charge 5-10X more and that they’ve already paid for insurance over there, but if we really do a better job wouldn’t at least a sizable number be willing to invest $800 in a plane ticket and whatever we are charging for procedures? What’s more valuable to a wealthy French or German citizen than health?

What do readers think? Is this a good metric?

Related:

  • my health care reform proposal from 2009 (pretty much the opposite of what was done with Obamacare! I advocated for universal coverage at a predictable and budgeted cost. Obamacare leaves out tens of millions of Americans and nobody can say what the cost will be.)
  • Book review: Bad Pharma (do new drugs work better than old drugs?)
Full post, including comments

Flying the Corsair from a World War II aircraft carrier

From Norman Hanson’s Carrier Pilot:

The [Corsair] fighter had originally been ordered by the US Navy for carrier use to replace the Grumman F4F, the Wildcat (Martlet to the Royal Navy); but it had proved to be such a handful in Fleet trials—particularly in deck-landing—that the new Grumman F6F—the Hellcat—had been adopted instead. The F4U—the Corsair—could now go to the shore-based squadrons of the US Marine Air Corps; and to the Royal Navy, if they wanted it. The Royal Navy accepted it willingly. The only alternatives in sight were the Seafire and Sea Hurricane—RAF production models fitted with arrestor hooks—and these just weren’t carrier material.

What was it like to fly a Corsair? It is no easy matter to describe it to someone who has never handled a fast aircraft; who has never known the thrill of three-dimensional high speed. Once tasted, that thrill remains with a pilot for the rest of his life. He climbs up on the high wing of the Corsair and lowers himself into the cockpit. The seat is a concave bowl of steel, designed to fit a packed parachute on which he sits. Between his backside and the parachute itself is a one-man dinghy, carefully stowed into a canvas case and attached to the parachute harness by a webbing lanyard. He straps himself, first, into the parachute harness, then into the safety harness. Now he dons his helmet and goggles and connects the R/ T lead and oxygen pipe. He’s ready to start up. In front and to either side are ranged the controls, levers, switches, dials—in all, about 110 of them. He goes through his check-off list … Magneto switches off. Control locks off; and check, too, that rudder, elevators and ailerons are all turning ‘the right way’ in response to movement of the controls. (They have been known to have been reversed, with dire consequences.) The wing-lock lever is in neutral and the manual lock engaged. Tail wheel unlocked. … The propeller control is in fully fine pitch. The angle of attack of the blades on the air is adjustable hydraulically; fully fine pitch, offering least resistance to the air, gives maximum horsepower and is always used for take-off. Once in flight, the coarser the angle, the lower the speed, the less wear and tear on the engine and the more economical its petrol consumption. (Consumption, as a matter of interest, is about 60 gallons per hour at cruising speed and no less than 100 at operational speeds.) Mixture control to full rich, to give the engine plenty of petrol to get her started. Elevator and aileron trimming tabs in neutral. Six degrees of right rudder trim. At maximum horsepower the engine torque is enormous and will try to tear the aircraft round to port. The pilot’s own strength on the rudder pedal would be insufficient to resist that force and the trimming tabs help him to overcome it. Cooling gills, round the front of the big radial engine, oil coolers and intercoolers open. Petrol cock turned on to main tank. This large container, holding 350 gallons, is surrounded by self-sealing material and is positioned immediately in front of the cockpit, behind the engine. All this sounds quite a handful. In fact, it took only a few seconds. Now the pilot confirms to the fitter, standing to one side below him, that the magneto switches are off. The fitter grasps the propeller blade nearest to him and rotates it once or twice ‘the wrong way’, blowing out; tough going, this, against the compression of 18 cylinders. Now he moves back and looks towards the pilot who turns on the master electrical switch, rendering all systems ‘live’. He gives the priming switch two or three short but decisive squirts, injecting a shot of neat petrol into the cylinders. Again he looks to his fitter, who signals to him that no one is standing within range of the great propeller. The pilot turns the magneto switches to ‘on’ and presses the starter switch, firing the Koffman starter which ignites a slowly expanding gas to hit the pistons under enormous pressure. The starter has a deep-throated tiger’s cough. It jerks the propeller into life, back-fires once, then settles into the comforting roar which signifies a good, clean, fire-free start. He moves the mixture control to auto-rich and advances the throttle to give 500 revs per minute on the rpm indicator. He leaves it there until the oil pressure gauge awakens and climbs to normal. Whilst waiting, he has another look around. Hydraulic pressure is normal. Oil temperature is rising to normal. The blind-flying ‘artificial horizon’ is dancing around slightly, showing that it, too, is awake and healthy. He switches on the radio and the crackling and unintelligible natter from miles away tells him that the set is functioning satisfactorily. At last the oil temperature and pressure gauges show normal. He opens up the throttle steadily to 1,000 revs and, keeping an eye on the rev counter, turns off one of the magneto switches. The revs drop by 50. He switches back to ‘Both’. A pause; then he turns off the other. Now the drop is only 30. Both are acceptable, for anything up to a loss of 100 is safe. Everything is OK for him to move. He throttles back and crosses and re-crosses his hands before his face. The fitter and rigger nip below the wing and behind the lethal propeller to pull away the wheel-chocks. The fitter gives a ‘thumbs-up’ sign. The pilot advances the throttle a little and taxies out to the downwind end of the airfield runway.

Today there would be at least a month of transition training before a pilot moved into a different aircaft. Back then?

After the Sabang operation, Joe Clifton from Saratoga and I exchanged aircraft for a local flight. It was my first experience of the Grumman Hellcat and, despite my fanaticism for the Corsair, I was certainly enamoured of it. Its cockpit was similarly roomy and efficiently laid out. Its performance, too, was much the same but in landing particularly I found it a lot safer and easier to handle largely, I think, because of its superior visibility and better stall characteristics.

Imagine an F-15 pilot just jumping into an F-18 for a $100 hamburger ($10,000 hamburger?) run!

Hanson does not describe anyone having qualms about killing enemies, even when an individual, such as a flak gunner, was targeted by strafing. War, it seems, came naturally to this group of young men.

We were searching out ahead, weaving all the time like bastards, when tracer flew past us, fired from astern. There in my mirror was an Oscar—it looked as though it was sitting on my elevators—with guns flashing along its wings. I had time neither to shout nor to break before it dived beneath us, only to reappear in a split second, pulling up in front of us, the length of two cricket-pitches away. We all heaved back on our sticks and gave it the works; no need for gunsights. The silly bastard was half-stalled, sitting there like a broken-down old whore. Its port aileron took off and sailed over our heads. What looked like a section of flap fell away to our right. Someone must have hit the engine. The aircraft fell, smoking, down on the port side and Matt Barbour must have nearly flown through it. God knows how he missed it. I yelled and did an aerobatic turn to port where another fighter—a Tojo?—was boring in. No—it was another Oscar. We gave it a long burst, tearing chunks out of the back end of the fuselage and tail section, and it sheered off to starboard. Jesus! Business was brisk and we were tearing around like frustrated virgins!

It must have been about 1630 as we crossed the town, flying at about 8,000 feet. Glory be! There was a parade ground! What was more, it was pretty full with all the licentious soldiery drawn up in serried ranks. One of the Corsair’s drawbacks as far as the enemy was concerned was that the exhaust roar from its 18 cylinders was all behind it. There was virtually no noise from the engine apparent until the aircraft was almost overhead. It was said that the Japanese called it the ‘whispering death’ for this reason. So when I decided to attack this juicy target, they broke formation only when it was too late for most of them to find cover. There were three possible angles from which to attack, only one of which was dangerous. After an afternoon of sheer frustration, monumental stupidity born of weariness and a touch of ‘twitch’ chose for me the route which in normal and more carefree times would clearly have indicated—‘ A sticky death this way’. In my eagerness to get in amongst it without losing the invaluable element of surprise, I gave the boys no warning at all. I banged the stick over to the right and down, leaving them to follow as best they could. It was providential that I did so, for had I led them down in an orderly formation, at least two of them would have bought it. As it was, they had scarcely made their move to follow me down when they realised that I had made a hash of things, giving them time to alter their own approach to something much safer and more airmanlike. Certainly I wrought a bit of death and destruction, there was no doubt about that. With that enhanced, falcon-like vision which fiercely pumped adrenalin produces at moments of high excitement, I could see soldiers fairly bouncing away from the sledgehammer impact of the .5 shells. It needed only a touch on the rudder-bar to cover square yards of the parade ground and there was a fair number of bodies lying motionless as I levelled out and pulled away. And then I saw it. Rising sharply from the back of the military area was a sheer cliff-like eminence which I had completely missed in my haste to get to ground level. Now, as I approached it at 300 knots, it looked like the North Wall of the Eiger. Taking my life in my hands I pulled on the stick for all I was worth. I can only remember thick streamers springing from my wingtips before I blacked out good and true. The black-out hit me like pentothal—there was no greying-out, no fuzziness. I went out like a light. When I recovered I was out at sea, climbing gently at about 150 knots, safe and sound. The others had formed up on me again and were gazing at me with uncomprehending eyes. Well they might. They had all been enthralled by the spectacle of their senior and most stupid bastard of an officer busily trying to kill himself.

Hanson crashes into the ocean during a landing mishap and is rescued by a destroyer. This turns out to have been common:

John Winton, in his book The Forgotten Fleet, now regarded as a classic history of the operations of the British Pacific Fleet, counts the casualties suffered by the Fleet Air Arm in the two operations [against an oil refinery in Indonesia]. Forty-one aircraft were lost from the four carriers: 16 in actual combat, 11 in ditchings near the Fleet and 14 from deck-landing crashes. As Winton says, this works out at roughly one aircraft for every ten sorties flown; and he adds his own significant commentary: ‘a casualty rate which would have made even Bomber Command flinch’. Against these losses, it was estimated that we had destroyed 68 enemy aircraft—38 on the ground and 30 in the air, not taking into account several ‘probables’. Palembang, whilst not completely destroyed, was effectively put out of the war for a long time to come.

Why don’t fighter pilots do a lot of damage by pressing the wrong buttons? It turns out that they do…

Coming in to land for the second

Full post, including comments